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Cultural Prototypes and Differences in Simulation Debriefing

Ulmer, Francis F., MD; Sharara-Chami, Rana, MD; Lakissian, Zavi, MD, MPH; Stocker, Martin, MD; Scott, Ella, RN, RSCN; Dieckmann, Peter, PhD

doi: 10.1097/SIH.0000000000000320
Empirical Investigations

Introduction Culture is believed to play a role in education, safety, and patient outcome in healthcare. Hofstede’s culture analysis permits a quantitative comparison between countries, along different culture dimensions, including power distance (PD). Power distance index (PDI) is a value reflecting social hierarchy in a country. We sought to explore the relation between PDI and self-reported behavior patterns of debriefers during simulation debriefings. We determined six culture-relevant debriefing characteristics and formulated six hypotheses on how these characteristics correlate with national PDIs.

Methods Low-PDI countries have a PDI of 50 or less, and high-PDI countries have a PDI of 51 or greater as defined by Hofstede. Interviews with simulation debriefers were used to investigate culture-relevant debriefing characteristics: debriefer/participant talking time, debriefer/participant interaction pattern, debriefer/participant interaction style, debriefer/participant initiative for interactions, debriefing content, and difficulty with which nontechnical skills can be discussed.

Results During debriefing, in low-PDI countries, debriefers talked less and used more open-ended questions and focused more on nontechnical issues than on medical knowledge and simulation participants initiated most interactions. In low-PDI countries, debriefers felt that participants interacted more with each other and found it easier to address nontechnical skills such as speaking-up.

Conclusions Our results supported our hypotheses. National culture is related to debriefing practice. There is a clear relation between PDI and debriefer-participant behavior patterns as described by debriefers. The higher the PDI of a country, the more the debriefer determines the course of the debriefing and the more difficult it becomes to address nontechnical skills.

From the Department of Pediatrics (F.F.U.), Insel University Hospital Berne, Switzerland; Department of Pediatrics and Adolescent Medicine (R.S.C., Z.L.), American University of Beirut Medical Center, Beirut, Lebanon; Department of Pediatrics (M.S.), Kantonsspital Luzern, Luzern, Switzerland; Sidra Medical and Research Center (E.S.), Doha, Qatar; and Copenhagen Academy for Medical Education and Simulation (CAMES) (P.D.), Center for Human Resources, Capital Region of Denmark, Herlev, Denmark.

Reprints: Rana Sharara-Chami, MD, FAAP, Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, P.O. Box 11-0236 Riad El Solh 110 72020 Beirut, Lebanon (e-mail:

The authors declare no conflict of interest.

F.F.U. and R.S.C. contributed equally to this article and are considered first authors.

Supported by institutional funds from The American University of Beirut Medical Center, Insel University Hospital Berne, and Kantonsspital Luzern.

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© 2018 Society for Simulation in Healthcare