GLOBALIZATION OF HEALTH CARE SIMULATION
Globalization, resulting from advances in transportation, communication, and information technology, has specifically affected the Asian health care education system. For example, since the health care education reform movement in Korea began 15 years ago, several factors have led to the growth and use of immersive and simulation-based learning (SBL).1 Schools reformed curricula to aim for more immersive and experiential learning, and the national examination authorities integrated simulation-enhanced clinical skills evaluations into their licensing process. As a result, health sciences education schools started focusing on the development of clinical skills laboratories and dedicated more clinical clerkship time for students to prepare for licensing examination. These reforms were triggered by the increasing numbers of health sciences education schools and the recognition by the Korean government that it was critical to prepare highly educated professionals for an increasingly knowledge-based society and competitive global markets.1
Similar health care education reforms have occurred in other Asian countries.2,3 This is evident by the recent Asia-Pacific Meeting on Simulation in Healthcare held in Hong Kong.4 This meeting attracted 501 attendees from 27 nations. Some of the countries are now establishing formal academic societies to build momentum for the further integration of SBL in health care education.5,6 Once these infrastructures are in place, leaders will be challenged to develop faculty for the most effective use of SBL. One of the challenges that could be encountered is cultural differences, as has been discussed extensively in the aviation domain.7 Our hope with this article is to raise awareness of the cultural differences and stimulate work to make progress in this regard.
DEFINITION OF CULTURE
Although culture can be defined in many ways,8,9 one particularly useful conceptual framework is that proposed by Hofstede et al,10 who examined culture under the rubric of symbols, heroes, rituals, and values. Symbols are words, gestures, pictures, or objects that carry a particular meaning that are recognized by those who share the culture. Heroes are persons who possess characteristics that serve as models for behavior. Rituals are collective activities that are technically unnecessary to the achievement of desired ends but that within a culture are considered socially essential. Values are broad tendencies to prefer certain states of affairs over others and as such represent core elements of culture. Culture may impact all aspects of SBL. The debriefing phase during a simulation session is likely to be an interesting indicator for culture because it is a collective activity aimed at reflection and partly changing of values.
Some challenges of the process of promoting learning outcomes could depend on the following examples:
- What are the target learning group professions (eg, physicians vs. nurses vs. midwives vs. other allied health professions), disciplines (eg, anesthesia, dentistry), or stage of career (eg, beginning students, senior students, postgraduate professionals with various degrees of experience)?
- What is the learning or outcome objective of the program (eg, technical-medical skills vs. nontechnical, human factors–oriented aspects)?
- On which underlying “learning assumptions” is the simulation activity built (eg, drill and practice of procedures vs. insightful change of attitudes)?
- Or what are the written and unwritten rules, interacting with each other, the mannequin and the equipment that are enforced during SBL (eg, do all that is possible not to leave marks on the simulator as expensive piece of equipment vs. using it hands-on risking that it looks and smells used)?
Again, values might be seen as the heart of a culture. For this reason, we focus our discussion around debriefing.
SIGNIFICANCE OF DEBRIEFING FOR LEARNING
Simulation-based learning can provide learners with a structured experiential component followed by reflection on the experience, thus facilitating changes in the learners’ knowledge, skills, and attitudes in practice.11 Debriefing plays a critical role in facilitated reflection on simulation after the experiential component of SBL. The importance of its role in SBL is described in 2 systematic reviews,12,13 and descriptions of the role, practice, and theory of debriefing are presented in previous reviews.11,14 Several studies have described the debriefing process as beneficial for learning:
- Anesthesia residents’ nontechnical skills failed to improve if they were not debriefed.15
- A multimodal training method comprised of audiovisual feedback and immediate debriefing improved cardiopulmonary resuscitation (CPR) performance.16
- A debriefing intervention using CPR quality data from actual in-hospital cardiac arrests improved CPR performance and initial patient survival.17
To ensure a successful debriefing process and learning experience, participants need to be able to share their experiences in a frank, open, and honest manner.18 Recent studies on debriefing emphasize the creation of a psychologically safe learning environment as an absolute prerequisite for effective debriefing19,20 and have offered suggestions on how to create an environment in which trainees feel psychologically safe to engage in reflective learning. Instructors can create this safe learning environment by avoiding emphasis on errors and mistakes, ensuring that the errors are not ridiculed, or giving compliments before and after a criticism.
All studies of debriefing cited stem from Western cultures and may thus generalize only partly to other cultures. Many of the approaches may be more difficult for trainees who come from cultures where the motivation to defer to authority outweighs the choice to disclose views that may seem to contradict those of the instructor.21 What is seen as good communication in a Western culture might be different from what is seen as good communication in a non-Western culture. Moreover, the way to communicate about communication is likely very different.
CULTURAL DIVERSITY IN LEARNING
To better understand the effects that cultural differences between non-Western and Western societies can have on learning, we examine a case from the aviation industry.22 A Korean airliner crash in the late 1990s stimulated the airline industry to acknowledge the importance of cultural legacy in developing training programs that would contribute to a decline in airliner accidents. The accident was primarily attributed to mitigated speech (an attempt to downplay the meaning of what is being said) and other factors, such as minor technical malfunction, bad weather, and a tired pilot. Mitigated speech refers to a situation where you (according to cultural rules) need to be polite, where you are ashamed, or where you are deferring to authority. In the Korean airline case, the pilot tried to convey the urgency of the situation to the control tower in his own urgent manner, the “polite” way, but the manner of speech, such as the tone, language, and expression, was not conveyed as urgent to the personnel in the control tower.
Further exploration of the Korean culture reveals that its language has 6 different levels of conversation, depending on who is being addressed. Like many other Asian countries, Korea is “receiver oriented,” meaning that the listener is responsible to make sense of what is being said. This is contrary to Western communication, where it is the responsibility of the speaker to communicate ideas clearly and unambiguously. The crash occurred because the Korean pilots were not assertive and clear about the dangers, and the Western controller did not acknowledge or understand the cultural characteristics of “mitigated speech.” The Korean pilots were too “courteous” to the controller and did not convey the urgency of their message clearly.
The airline addressed the problem by acknowledging that cultural legacies mattered and accepting that when it came to airline safety, Korean pilots needed to accept changes although it went against their culture.22 The acceptance of such changes does not happen in a single training or experience. It is important for people with experience of the local culture to develop solutions that will be most effective for that culture. An outside consultant from a Western airline was able to find solutions that contributed to a decline in airline accidents in Korea, by learning and studying its culture and acknowledging its cultural legacy, before implementing any training programs that specifically addressed the challenges.22
Like the example from the Western airline consultant, understanding the values of the pilot was important in adapting a new paradigm into another culture. This also applies in SBL. For participants to engage in the reflective learning process of debriefing, facilitators need to understand the individual’s frame of mind, sometimes also called mental model.21 Frames contain the norms, values, and beliefs that a person holds regarding all aspects of their life and work. Those frames also contain cultural elements, which one might think of as a filter influencing how individuals perceive and interpret events and interactions. The framing concept can be used to investigate significant characteristics between non-Western and Western cultures that manifest themselves in substantially different teaching and learning practices. Although studies have demonstrated effective implementation of Western style training in a non-Western setting,23,24 challenges also arise from sociocultural discrepancies. Small group learning that encourages active participation can be limited:
- When non-Western students are more passive in a small group tutorial settings.25
- When teaching at the elementary and high school levels is influenced by preparing students for the national entrance examination, which emphasizes memorization over critical thinking. In this system, students usually do not have the habit and courage to challenge authorities.26
- When teaching Korean registered nurses who are accustomed to a style where students are expected to be relatively passive in their interaction with the teacher.27 Fear of incorrectly answering questions often causes their reluctance to participate.
This is also observed in a nursing study by Melby et al,28 where Western educators in Eastern Asia had difficulties in their experiences. The instructors found it difficult to reach out and understand the students by the usual methods of teaching and evaluation in the teacher’s role with which they were familiar.
These cultural differences are also being experienced in SBL throughout Asia. From the author’s (H.S.C.) experience and from discussions with other colleagues from Japan, Taiwan, and Singapore, there seems to be an unexpected gap between facilitator and learner expectations of the simulation activity. Although facilitator-led debriefing is common throughout the world, in Asia it is very difficult to get learners involved in debriefing discussions. This tends to make the facilitator provide answers and solutions to the learners, rather than participants actively participating and reflecting during learning. The challenges experienced during debriefing are even more pronounced when there are multidisciplinary or multigenerational groups of learners. Nurses tend to speak less than physicians, and junior providers are more passive than their more senior counterparts. When trying to address this issue, it is important to acknowledge special challenges when people from different cultures interact.
Why does this difference in debriefing styles occur? Is it because of individual personality, or is it professional culture developed from working? These differences cannot be explained solely by an individual’s distinct personality or professional culture. Rather, there are tendencies and assumptions passed down by the history of the individual’s community, and these influence the cultural traits of that person.29
Hofstede analyzed cultures and derived four dimensions of a national culture (Table 1).7 In “high power distance” country (a measure of interpersonal power or influence between superior and subordinate, as perceived by the subordinate such as Korea), subordinates are unlikely to approach or question their superiors directly. This is a challenge for a debriefing style that relies on free interaction between people. Furthermore, countries with high “power distance” often are also “high collectivism” (a trait that values the motivation to avoid disgracing the other group members with one’s weakness or failure), and this makes debriefing even more difficult. Therefore, in a group session, it is difficult for team members to speak about things that went wrong during the simulation.
ADAPTING DEBRIEFING TO CULTURE
Based on the Hofstede analysis, we can hypothesize different debriefing patterns to be functional throughout the world (Table 2). These assumptions could serve as a starting point when conducting simulation-based research on debriefing in different cultures. Simulation-based learning will likely have the best effect when it is able to connect to local traditions and culture—otherwise, it might remain a foreign element. Therefore, simulation activities, especially debriefing, should consider cultural differences and can be adapted to the different contexts.
Similar experience is noted from a problem-based learning (PBL) environment. The delivery of instruction in PBL involves active participation and engagement between the teachers and learners in an open communication style. Consequently, this may pose an apparent serious conflict with Asian communication styles generally dominated by “mitigated speech.” An article by Gwee30 describes the difficulties in implementing PBL into an Asian culture curriculum. Although cultural barriers do exist, creating a conductive and supportive learning environment for students can overcome these—the elements of such environments, however, may differ between the different parts of the world. Gwee concludes that Asian medical educators need to have a clear understanding of the PBL process, philosophy, and practice to optimize the educational outcomes that can be derived from a PBL curriculum—so that here, more metacommunicative elements might be needed to make PBL work. Based on previous experiences from the aviation industry and PBL, we can explore how cultural differences affect SBL and debriefing.
There is no doubt that students in Korea feel satisfied and enjoy learning with simulation methods,31 but in many Asian countries, a silent participant would not be considered “difficult,” but just “following the rules” and being a “good student,” whereas the “silent participant” is a classic “problem” during faculty development in Western countries. How can we teach Korean junior clinicians to speak up more in front of senior clinicians during debriefing? Should we aim to do so? What impact would such a change have for the persons involved, who work in a context that supports the “silent,” not the “talker.” How can we start changing culture? From bottom up, by having more and more participants change actions and request changes, or do we need to start top down and convince the leaders first? How can we combine both approaches? At the present, there are no definitive answers to these questions, but they need to be investigated with research programs about culturally sensitive debriefing. We need to consider culture-sensitive interpretations of SBL, so that we do not unintentionally lose valuable aspects of the local culture that will lead to more meaningful and sustained SBL by introducing Western style debriefings everywhere.
HOSTEDE’S THEORY AS ADAPTATION AID
The concept of four manifestations of culture, namely, symbols, heroes, rituals and values, may provide a framework to better understand this phenomenon. Except for values, the manifestations are visible to the outside observer, meaning that some adjustments can be made to find a balance between contrasting cultural styles. If we apply the 3 visible manifestations to SBL,
- Symbols could represent the terminology we use in simulation. Most of simulation terminology is derived from English. There is still confusion about translation and usage of the words. A first step is to localize the translation of terms that would be more relevant to the user’s culture.
- Heroes relate to the teacher’s role, and they need to investigate and find the best method for delivering SBL to students that is culturally balanced for the respective culture. One method to achieve this is to identify more opportunities to network and collaborate in multinational, multicultural research and projects.
- The ritual can be represented as methods of debriefing. The practice of debriefing will need to start with acknowledging and understanding the participants’ cultural background. Instructors need to clearly understand how a debriefing process can be integrated into varying cultural contexts, philosophies, and practices to be able to optimize the educational outcomes that can be derived from reflective learning.
By trying to adjust the 3 visible manifestations of culture, we might be able to find a possible solution for balancing the most inner core of a culture, which is the value of learning. Culture-sensitive faculty could thus create learning opportunities that allow to reflect on norms, values, beliefs, and actions to the extent that does not scare learners away.
DIRECTIONS FOR FUTURE RESEARCH
A recent article summarizes the process in developing research that addresses learner characteristics in achieving effective SBL.32 One could ask, for example the following:
- “Are there differences in learning motivation between 2 different cultures?”
- “What motivates Asian students to be active in SBL?”
- “What are the characteristics that distinguish Asian students from Western students, and are these domains specific or generalizable within the culture?”
- “What are the elements of a safe learning environment in different cultures?”
With regard to debriefing, we should try to find answers to research questions, such as the following:
- “What debriefing characteristics are most relevant to a particular group of learners with a specific cultural background?”
- “How do different methods of debriefing affect different cultures in SBL?”
- “What aspects of culture are ‘safety neutral,’ and what aspects may actually have effects (positive and negative) on patient safety and patient care?”
- “How do cultural differences impact faculty development in the different parts of the world?”
- “How can participants with different cultural backgrounds be best prepared for simulation activities?”
Although these are very challenging questions, we need to start finding the answers through multinational and multicultural research projects. In that way, SBL could truly benefit the global world we live in. Every simulation session conducted can thus become a piece in the puzzle, not only when the individual change is emphasized but also if faculty and learners commonly also reflect about national, professional, or departmental culture.
Simulation-based learning in health care has become a global standard of learning. Through this article, the authors tried to describe the importance of cultural diversity in learning and how we should consider the cultural values of the learners before implementing any structured programs. Thus, we hope that we have raised the awareness of cultural differences and stimulate work to make progress in this domain.
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