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The Sim Cafe~
The Sim Cafe~
Mastering the Art of Debriefing with Dr. Jenny Rudolph: Fostering Psychological Safety and Learning in Healthcare
Discover the transformative power of communication and learning as we welcome Dr. Jenny Rudolph to Sim Cafe, a pioneer who has redefined the art of debriefing in healthcare. This episode promises to take you on a journey from the athletic fields to the cutting edge of medical simulation, offering practical wisdom and insights that could revolutionize your approach to clinical education. Through tales of her own experiences, Dr. Rudolph unveils the significance of psychological safety and vulnerability in fostering trust and educational growth, and how these can be nurtured through the mastery of debriefing skills.
Our enlightening discussion also ventures into the delicate interplay of cultural influences on feedback and learning. Dr. Rudolph introduces the innovative 'preview, I saw, I think, I wonder' technique, shifting the focus of debriefing from internal emotions to observable outcomes, and reinforcing the importance of including one's perspective to enrich the learning process. As we contemplate the future of AI in simulation training and its potential to balance with human interaction, this episode not only equips you with the tools to enhance individual competency but also to contribute to the development of a positive organizational culture that values continuous learning and improvement.
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Disclaimer/ Innovative Sim Solutions Ad/ Intro:Welcome to The Sim Cafe, a podcast produced by the team at Innovative Sim Solutions, edited by Shelly Houser. hos De Taube a c Jer Join our host, Deb Tauber, and co-host Jerrod Jeffries as they sit down with subject matter experts from across the globe to reimagine clinical education and the use of simulation. So pour yourself a cup of relaxation, sit back, tune in and learn something new from The Sim Cafe. Tune in and learn something new from The Sim Cafe.
Deb Tauber:Welcome to another episode of The Sim Cafe, and today we are so fortunate to have Dr Jenny Rudolph with us. Welcome, Dr Rudolph, and you mentioned we could call you Jenny, so we will do that.
Jenny Rudulph:Glad to be here. Deb and Jerrod thanks for inviting me.
Deb Tauber:Thank you so much, and why don't you? For any of our listeners who may not be familiar with you, why don't you tell us about your journey into simulation and about yourself?
Jenny Rudulph:Sure, I am a lifelong athlete and that brought me into simulation. I love practicing, learning from both my successes and mistakes and getting better. And so when I was a young recent college grad, I rode crew on the US team and we would practice on the water and we would simulate rowing on rowing ergometers and in a tank indoors and we'd video it. And we'd look at our videos just like you do with basketball games and analyze them. And when I wrapped up that process I thought, wow, it would be so cool if I could actually do something like that that really had an impact in the world and really made a difference beyond sports. And so I started looking around for things and, fortunately, when I started my doctoral dissertation studies 10 years later, I fell into clinical simulation because I was interested in learning from accident and error.
Deb Tauber:And how did you actually fall into it? Why don't you just walk us a little bit closer to how you started the program and where you are now?
Jenny Rudulph:Sure. So I started with an interest in industrial safety. Actually, I had been doing research with one of my mentors on learning from accident and error in nuclear power and chemical processing and he knew that I really wanted to study clinicians and medical error. And fortunately healthcare is pretty safe overall and so error is pretty rare. And one day when I was hanging out with him in his office at MIT, when I was hanging out with him in his office at MIT, he tossed a proposal across the table to me and he said hey, this guy, David Gaba, sent me this proposal. It's about something called medical simulation. Why don't you take a look at it?
Jenny Rudulph:And I looked at it and I thought, oh, this is so cool. And, as luck would have it, I was able to visit David Gaba's lab. He showed me what he was doing. I discovered that Jeffrey Cooper and Dan Raymer had a similar lab in Boston, which is where I was working, and in those days pretty much everybody referred to simulation centers as simulation labs. I'm dating myself and I went over and I chatted with Dan Raymer and I said, hey, I'm really interested in this thing called fixation error, where you decided on a diagnosis but then you cling to it despite mounting cues that you're on the wrong track. Could we study that in simulation? And he immediately started laughing and he said, oh my gosh, yes, we have several situations like that. And so I was able to write a dissertation proposal to study fixation error during surgical emergencies and I looked at how did anesthesiologists either get stuck or get unstuck trying to solve problems in their decision-making Fascinating.
Deb Tauber:Now you wrote the article led the charge on. There's no such thing as nonjudgmental debriefing. Why don't you tell us a little bit about how you guys came about starting that work and about that?
Jenny Rudulph:I think one of the biggest problems that we all struggle with is how do I give straightforward feedback or how do I share a critical insight without ruining the relationship with the other person? And let me just ask you a little bit, because I know you've been an educator for a long time you're a podcast interviewer what are some of the things that you kind of either struggle with when you have feedback conversations or enjoy when you have feedback conversations, and then maybe we can build on that together.
Deb Tauber:Yeah, thank you. What I enjoy when I'm having conversations with people is being sure that I've understood what they're trying to communicate to me.
Jenny Rudulph:So the words they say may or may not reveal their underlying feelings or their thought processes, or tell me a little more about what makes you feel unsure.
Deb Tauber:Just to make sure that they're comfortable enough to speak up.
Jenny Rudulph:So it's the psychological safety part, the feeling like it's safe for them to let you know what they're really thinking Correct. How do you know what are sort of the signs and symptoms that you've gotten there? What lets you know when you feel like you can trust that you've created or co-created that environment with people? And I'm asking because I feel like if we can sort of get these ideas on the table, then you and I can kick them around a little more and I can talk about debriefing with good judgment in relation to challenges that I think you would recognize and other people would recognize.
Deb Tauber:I think, generally when they say something vulnerable, if they say something that is vulnerable to me, then I will know that they feel comfortable to tell me more and help me, to help them clarify what they might be thinking, so that we're all on the same page and we can make some good decisions.
Jenny Rudulph:Okay, thank you, Deb, that's so helpful.
Jenny Rudulph:So, circling back to there's no such thing as a nonjudgmental debriefing and debriefing with good judgment.
Jenny Rudulph:I think the heart of what we were trying to accomplish with the debriefing with good judgment was how do you create an environment that is simultaneously psychologically safe enough for people to either admit mistakes, talk about something they're not entirely proud of, share their true feelings, and also for the feedback conversation leader or the debriefing conversation leader to take the risk to be open and honest about their insights, about the other person's actions or performance.
Jenny Rudulph:And the problem that we were kind of trying to solve with debriefing with good judgment was exactly this, which is most of us so value relationships that we kind of sugarcoat bad news because we don't want to hurt the other person's feelings or, even more, we don't want to hurt the relationship between us. But when I sugarcoat or I'm indirect about my insights, then it's harder for you to learn my conversation partner, to learn from the things that you might have a blind spot on that I actually saw. On the other hand, though, I think we really want to be able to help our colleagues in, especially, health professions and maybe people who are direct reports and even people we report to be the best that they can be at their jobs, and so we have standards that we want people to meet. We have insights that can help them do better, and so we need a way to be straightforward while also maintaining the relationship.
Jerrod Jeffries:Yes, yes, and Jenny, I think that a lot of that really resonates with me, because I mean, to your thing of sugarcoating, you always want to be their friend but also make sure that you're the leader and coaching them, but then at the same time, you don't know how direct or deep to go on certain situations. So I think what you're getting at is so it hits me hard. But I also think that a lot of our listeners can really relate to it in regards to saying I've been in that same situation, either being the person who's actually leading the debriefing, or the learner or the participant within it, Because I think there's just so many times that we're faced with that, you know you almost I don't want to say daily, but definitely weekly even in personal relationships, not only just within the simulation training.
Jenny Rudulph:Yeah and Jerrod, I don't know if it's something that comes to mind for you like an example or a feeling, or I was really struck by your phrase. It hits you hard, what hits you hard, or what is that about?
Jerrod Jeffries:Well. So I think that you sugarcoat it and I think there's a lot of situations or times, you know, even in my relationship with my wife. We have a fantastic relationship, but we have a young child, you know, who's just under a year and a half, and it's like handling logistics around a small child, of course, is just, it's almost elementary of who's going to pick her up, who's going to make sure that that backs. But whatever it may be right, very minute, just easy things. But sometimes I think, when we are communicating, if the communication is too direct or if it's not led with appreciation, sometimes because of all the other things that everybody's doing, you sometimes can overlook or it seems like you're overlooking all the good things I've done.
Jerrod Jeffries:So back to you know the simulation practices. It's all the learning objectives or the scope of practice. They hit eight out of 10. And there's no mention of them doing a great job of those eight out of 10, but it's just like those two that you did were. They weren't severe, they were not critical errors, but those two learning directions they did not hit. If you just dive right into those and be like, well, this is just. Your teamwork was horrible. You guys didn't communicate. You skipped over this, I think the team or I'll put it in my personal experience I would think maybe, oh, that's the biggest focus, and they didn't see any of the good. So actually, my confidence was lowered and I don't feel as good going into the next sim or actually going into practice now. So it actually did the opposite of what it was intended.
Jenny Rudulph:Yeah.
Jenny Rudulph:So what I'm hearing us talk about now is the relational context of our debriefing conversations or our feedback conversations or our collaboration conversations with our partners or our spouses or our colleagues, and what I'm thinking about is essentially what is the culture that we want to create via these conversations? And I want to talk for a second maybe about the value of being valued, and then maybe we could pivot back to talk a little bit about the more critical insight conversations that often we also have to have. So Rick Hansen, who does research around resilience and learning, says our brains are like Teflon for good things that we have done and or good things that other people do, and Velcro for our mistakes and other people's mistakes. And part of what interested me so much and got me into the concept of debriefing with good judgment was what is the culture that we want to create?
Jenny Rudulph:Going back to that history of studying nuclear power plants, what John Carroll, my mentor, and I discovered studying plants over five years was that plants who were too harsh and too controlling created a culture that was kind of punitive and nobody wanted to talk about their mistakes, and plants where people had learned from that and decided they were going to be more open and kind. That succeeded. People were less afraid, but they weren't able to really dig into the mistakes that had been made because they didn't have the muscles to dig in in a way that was non-punitive and non-threatening. So they either had this sort of control what we've now come to call harsh judgment approach or they had kind of a fake nicey what we've now come to call harsh judgment approach or they had kind of a fake nicey what we've now come to call hidden judgment approach. And what the plants who learned the most did was what we in those studies called deep learning, which is where they were open and honest about what were the mistakes that had been made, but they assumed the best of other people.
Jenny Rudulph:And what we would now call that for debriefing and feedback conversations a good judgment approach, where you hold a high standard and yet you also assume the best, or you hold the learner or the employee in high regard. And the thing that you've directed us to Jerrod e , here, is the high regard piece. The team not only did eight things right and we need to recognize that. They need to kind of quote unquote get credit for that, because we humans like to get credit for doing things right, but as the feedback conversation leader or the debriefer, I'm creating a culture of appreciation and valuing the other people by acknowledging those things and what we can learn from that positive performance. So why I'm so passionate about debriefing with good judgment is not only the immediate conversation that we're having, that I'm being fair and caring and challenging, but that in the future you'll feel that the culture that we've co-created is one where you can be open and honest about mistakes, but also open and honest about successes, and you won't be afraid to bring up things in the future.
Jerrod Jeffries:This is wonderful. I'm loving this, Jenny. But one question about this is do you find the frequency of, say, hidden judgment or another, like we want to get to deep learning, we want to get to the best deep learning possible? Is the frequency of not getting there more prominent in any area that you see more likely, or even within the study?
Jenny Rudulph:That's a great question. So we only looked at five plants in that particular study, jared but we looked at tens of accident and error reports and corrective 300 reports, and so I can answer more about the stance of the people who were formally charged with causing learning from that event, and I've never actually thought about this before. So, as debriefers or feedback conversation leaders're the people charged with supporting learning in our organization. And so you asked me about the frequency simulation leader and instructor programs that we've done.
Jerrod Jeffries:I would say, well, more than half come into the program with a hidden judgment approach, because that's what we're all socialized to do Sure, and so just when you socialize to do, do you think that's specifically within the United States or do you see that even globally?
Jenny Rudulph:I'm not an expert on this interculturally that even globally. I'm not an expert on this interculturally, but when I was taught in Hong Kong, germany, australia, spain, most people, and especially in most Western countries, certainly prefer the polite, hidden judgment approach and in collectivist cultures that and many Asian cultures tend to be more collectivist there's a big emphasis on preserving face. But recent research I've read on this Jared and is interesting which is if you care about the collectivity more than you care about the individual, there's a huge interest in learning from accident and error. Yeah, it's possible that there might be some factors that make it easier for people to use good judgment rather than hidden, but again, this is not my area of expertise, so I'm speculating.
Jerrod Jeffries:No, I think that we could probably spend a whole hour just on this. And I'm blanking on the name. I don't want to say it's called the cultural war, but it's some sort of culture map that highlights different countries. And back to the collectivism versus individualism. It's a slew of I'm making this number up 79 other traits around the norm, cultural norms. So that was my question with the US, first Global. But from your first-hand perspective of teaching in so many different areas as well, I think that's fascinating.
Jenny Rudulph:For myself and others listening. I was just thinking you know how you kind of recap during a resuscitation like what have we done? Where are we? I think Deb asked a question, then you asked a question. I'm just trying to remind myself the topic area we're in. Was it creating culture via conversation? Was it the value of being valued? We've been over some interesting things. Anyway, I'm happy to follow you guys.
Jerrod Jeffries:I have one last question, maybe to wrap up. This one is what do you feel or what do you see as the most common errors? Is there any sort of pattern that has emerged that says this is what I anticipate, the probability of something going wrong? It's going to be X. And what would that X be?
Jenny Rudulph:You mean in feedback conversation skills or debriefing conversation skills? Yes, I definitely can answer that. I would say the most common thing that people like to skip is sharing their point of view. So, for instance, if we are helping people learn to preview what is the topic, let the learner or the other person know what they saw that was important about it and then share why it was important to them. It's that third piece that people tend to want to leave out, because it's the part that's the spiciest and they're worried that's going to land badly so often. The corrective thing that we offer there. And I'm just going to give an example.
Jenny Rudulph:Let's say we were in a debriefing in a healthcare situation and the situation was learning to manage parent presence during a pediatric procedure. And so in the debriefing, let's say the debriefer said something like this hey, I want to talk about the importance of managing parent presence during a procedure. I noticed that you turned your back on the mom in the middle before you placed the intraosseous line, and I'm worried about that because I think turning her back on her might've contributed to her becoming more anxious. How do you see it? So, right, there, I'm modeling one of the kind of conversational molecules that we use in debriefing with good judgment, which is preview, I saw, I think I wonder, and then I would listen for their answer.
Jenny Rudulph:The part about I'm worried about that because I think it might've caused the mom to become more anxious, is what people tend to leave out. And when we're working with people, there's a really important reframe that we have to help them with to be able to share their point of view directly and kindly, and that is to make it about something outside the person they're talking to. So it's the clinical consequence, or the social consequence, is usually not nearly as spicy as what they're thinking, which is something like hey, uh, student, I've taught you five times you can't ignore mom during the procedure. Of course she's going to become more anxious. What are you stupid? So they are feeling bad or angry or something.
Jenny Rudulph:I'm exaggerating a little bit. What they're really thinking is hey, what's the matter with you? Why'd you turn your back on mom? So the reframe that lets people share their point of view, which is so valuable to the other person, is shifting it from their emotional point of view, like I feel upset or I feel threatened that you X, y, z, which could be important for another conversation, but for right now, the learning conversation needs to focus on those external factors. Right now, the learning conversation needs to focus on those external factors. So that's the piece, that two-step of like hey, your emotions are important, we'll come back to those, but for now, share your point of view about what was the consequence that dials down the heat for people so much that they're often able then to practice that and get better at it.
Jerrod Jeffries:And that one was preview, I think I saw. I wonder yeah, preview.
Jenny Rudulph:I saw, I think, I wonder, and we've often also talked about that as preview advocacy, inquiry. So it's what I see, what I think about it, and then I'm interested in what you think about it, or what's your perspective. What was going on with you, what?
Deb Tauber:you think about it or what's your perspective, what was going on with you? And I think that the reason that this particular debriefing model has had such an impact on me is that I worked for 25 years in the emergency department prior to any types of debriefing, where it was just the hierarchy of who's who in the pack and who's going to do what and say what, and you never really had an opportunity to speak up. So being exposed to your work early on in my simulation career just opened my eyes to some of the things that we were doing that weren't so wonderful.
Jenny Rudulph:Yeah, I'm a student and follower of the work of Amy Edmondson and I know so many of us probably are. Do organizational cultures in our clinical context move from a sort of personalities before principles or focusing on who's right more than what's right, creating a context where we can share what we need help with? And one of the things I wanted to connect to what you're saying, deb, and back to Jared's question about kind of essentially fairness, like when you're coordinating with your spouse to get out the door with your young child and who has the diaper bag and how could you have forgotten X, y, z?
Jenny Rudulph:A piece of work that I'm actually very proud of and I think is undervalued by all of us is a blog post called the Value of being Valued, and in that blog post we connected the debriefing skill that we all use of saying something that we might have seen and then exploring it with the other person, but having it focus explicitly on things you're doing.
Jenny Rudulph:That helped me, like I so appreciated, you know, appreciated before we went live, deb, you and me having a chance to connect more personally and learn a little bit about each other. And using that value of being valued algorithm, essentially, I tell you what we did and then I say and I really appreciated it, deb, because it relaxed me and it made me feel like you and Jared and I were really going to be able to have a comfortable conversation. So instead of the external impact, the value of being valued conversations can really focus on. Hey, I want to talk about how you helped me relax. Before the podcast, I noticed you helped us. We kind of chit-chatted. The impact on me was to relax me and allow me to be more authentic while I was here, thank you, and we do that so little for each other, and I think that's another thing we can do to really warm up and create an appreciative culture around ourselves.
Deb Tauber:Thank you so much. We really appreciate having you here today and we are going to start to wrap it up, but I would like to just ask you two more questions. One is what are you most proud of in your vast career? And then, following up into what do you see as kind of the cutting edge for innovation as you move into things you're doing now?
Jenny Rudulph:I think I'm most proud of the fact and of course, others will have to attest whether this is true.
Jenny Rudulph:My mission is to help people tap into their authentic voice and power, and including helping my own self tap into my authentic voice and power, and I feel like the formal practice of debriefing with good judgment, practicing getting there, learning how to know what you did see, learning how to know what you do feel and think, learning how to know what you do feel and think, learning how to consider your voice and your insights as worthy of being shared I feel like is a very profound, dare I say even spiritual, journey for many of us. How do I actually share what I care about, how do I use my authentic voice in a way that? And then the power part for me is not power over, but it's how do I have a positive impact on people around me? How do I advocate for myself in a fair and caring way? I like to think that the journey of learning something like debriefing with good judgment has helped a lot of people tap into their authentic voice and power. Thank you Regarding your innovation question, deb.
Jenny Rudulph:So I started out the conversation with you and Jerrod talking about my history of being an athlete and I think, because of my love of athletics, I've always had a passion for mastery, learning Like. I love trying and trying and making mistakes and learning from my mistakes and then getting better, and so one of the things that I've enjoyed most about getting to work with clinical leaders and educators for so many years is working on conversation excellence. Whether it's feedback conversations, goals of care, consent, debriefing conversations. We can treat those conversations kind of like algorithms to some degree, that there are steps that we can master and ways that we can improve our listening. So we've been working on different ways to help people master conversations, and our current work is thinking about how do we use a pre-trained generative AI to provide feedback to people when they're working on a conversation. So, for example, if you were working on a debriefing conversation, we could train the and we are working on this train both the brains and then avatars, if needed, to listen to you, respond to you as you debrief, and we can train them using, for example, something like the debriefing assessment for simulation and healthcare or other rubrics for the conversation, and then, once the conversation is finished, almost immediately you get feedback on what you said. You'll be able to see a transcript of the words you actually said and then you'll get some feedback based on the rubric.
Jenny Rudulph:So back to Jerrod's question. One of the things we're working on is training people to be able to do preview. I saw, I think. I wonder, because it's a powerful molecule at the center of feedback, debriefing, negotiation, consent conversations, because you have to be able to say what you think and you have to find out what the other person thinks so that you can find a way to collaborate. So we could train the AI to analyze the quality of the previous statement, quality of the I saw statement, the quality of the I think statement or larger parts of the conversation, and then provide immediate feedback.
Deb Tauber:So that's what we're working on right now, and I think the thing that's so fascinating about that is that if you get a response from AI, there can be no feelings associated with it.
Jenny Rudulph:Well, people are certainly studying that, deb, and many of us do feel less threatened and less judged. A colleague of mine, Kate Kellogg at MIT Sloan School of Management, has started looking at this, actually has an article we could put in the show notes about this in HBR. I can send you the Harvard Business Review. Some people are like who the hell are you AI? What do you know? So it kind of could vary.
Jerrod Jeffries:One question, last question for me Do you see the future of simulation being seeded or with AI and a lot of parts of within sim, like the whole process, not just debriefing or communication?
Jenny Rudulph:What I think about on that, Jerrod, is I'm very influenced by the work of my colleague, Chris Rusin on sim zones, which divides up the learning into stages. So zone one we're learning the basic. Zone two we're learning them in situations. Zone three is a lot of what all of us in the early part of the modern simulation era did, which is full field simulation with lots of a mannequin and lots of other people.
Jenny Rudulph:In my opinion, Jerrod, in zone one and zone two, when we're mastering the basics whether it's how to put in an IV, whether it's how to do an LP, whether it's how to take a history, whether it's breaking bad news those batting practice-oriented trainings, in my view, will be greatly assisted by AI. I still think there's going to continue to be an extremely important role for having to interact with the other humans in a realistic context, because we all tend to feel more socially awkward and also can feel more supported by having to interact with the other people and haptics and whatever else is in that environment. So what I see happening is a much more efficient use of how do we divide up our time, how do we get up the learning curve using that batting practice assistance that we can get from AI and then continuing to do the more complex simulations with the actual humans.
Deb Tauber:Thank, you, yeah, now. Are there any final words that you'd like to leave our guests, our listeners, with?
Jenny Rudulph:Thank you for the opportunity for that. Deb and Jerrod, Thank you for having me on. First of all, I think what I'd like to say is if we can see our work in simulation, both in how we pre-brief, invite people into the simulation space, listen to what they want to do that day or that session or that 20 minutes, and in our debriefings, create a context where people can really reflect on their thinking and feel psychologically safe doing so. I feel like we're creating a little engine of positive culture change when we do those things well. So it's not just the learning moment of that simulation, pre-briefing or debriefing, it's what we're modeling and showing as possible and kind of positively infecting other parts of our organizations with those norms.
Deb Tauber:Perfect, I love that. With that, I think that we're going to let you get onto your athletics.
Jenny Rudulph:Great.
Deb Tauber:Thank you. So thank you so much and happy simulating.
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