Debriefing is an essential component of simulation-based learning in health professions education.1,2 Although simulation debriefing methods run the gamut from self-guided to facilitator led, the most common format involves the facilitator guiding the debrief after the learning event.3 Because debriefing aims to help learners gain insights from exploring and analyzing aspects of a performance, the interaction between facilitators and learners is the “heart and soul”3 and “cornerstone”4 of the simulation experience. A variety of postevent facilitator-guided debriefing approaches5 and debriefer assessment tools6,7 have been developed, and they highlight the importance of creating and maintaining a collegial, nonthreatening learning environment during debriefing. Conversely, a stressful, intimidating environment is a perceived barrier to learning from simulation.8 Rudolph et al9 argue that establishing a psychologically safe environment, where learners feel that they will be viewed positively even if they make mistakes, is important for active learner engagement. Facilitators play a significant role in creating a collegial, nonthreatening, psychologically safe learning environment, and it seems that the positive rapport between facilitators and learners contributes to such an environment. However, there is no established theoretical framework to guide facilitators in rapport management (RM) during debriefing.
Rapport Management10,11 is a potentially useful theory for this purpose. Based on previous work within Brown and Levinson's politeness theory12 and Goffman's sociological concept of face,13 the RM model was proposed by Spencer-Oatey to analyze the relational aspect of social interaction. She defines “rapport” as people's subjective perceptions of (dis)harmony and identifies three distinct but interconnected fundamental bases to rapport: face sensitivities, sociality rights and obligations, and interactional goals. Although the first component, face, has to do with concerns about personal/social value, the second component, sociality rights and obligations, has to do with concerns about personal/social entitlements. Face is associated with issues such as respect, honor, status, reputation, competence, etc. and is closely related to a person's sense of identity as an individual and/or as a group member. Based on legal/contractual agreements but more frequently on conventionalized behavior, sociality rights and obligations are related to one's expectations of the behavior of others in terms of two broad aspects: entitlement to consideration from others (eg, being treated fairly) and entitlement to appropriate levels of social involvement with others. Although threats to face could lead to shame, infringement of sociality rights and obligations might lead to annoyance. The third component, interactional goals, refers to specific tasks and/or relational goals that people may have during interaction, failure to achieve which might lead to frustration. These three components in the RM model are interconnected in the sense that they can affect rapport either independently or interdependently. However, they are distinct in the sense that they are separate concepts with different consequences when threatened. Sociality rights are not treated as face issues in that an infringement of sociality rights may simply lead to annoyance rather than a sense of face loss—although it is also possible that infringement of rights may lead to both shame and annoyance depending on the situation. Spencer-Oatey11 argues that each component needs to be taken into account when managing rapport because any behavior that mismanages these components will affect the relational dynamics between interactants. Depending on context, culture, and individual differences, people may also give different emphases to the components and conceptualize or interpret them differently.
The RM model has been used to analyze intercultural business negotiations and workplace interaction.14,15 In healthcare, Campbell16 applied the concepts of face and sociality rights from the model to the interaction between physicians and patients to help explain how physicians succeed or fail to build relationships with patients based on their verbal communication. By providing examples from medical interviews, Campbell16 suggested communication strategies for physicians to manage patients' face sensitivities (eg, showing interest in patients, using in-group markers, seeking agreement) and/or sociality rights (eg, listening, questioning, or hedging) in various situations. In health professions education, RM has been used as a framework to show how failure by the student chair in a Problem-Based Learning group to manage rapport effectively can influence the quality of group learning.17 For example, although one of the roles of the chair is to encourage everyone to participate by singling individuals out, students preferred to contravene their role as chair by avoiding this behavior to protect others' face, thus potentially affecting the quality of learning. The authors showed that face threats can be reduced if the person making the face-threatening maneuver has a legitimate right to do so and suggested, among other recommendations, making obligations and rights explicit as well as revisiting them throughout the period of group development.
The RM model is applicable to postevent facilitator-guided debriefing as all three components may be threatened in an interaction between facilitators and learners, depending on the context, culture, and/or individual differences. For example, learners' face can be threatened if feedback is given disrespectfully during a debriefing. If adult learners expect more autonomy in their learning,18 their sociality rights and obligations may be threatened when facilitators do not meet these expectations. Both face and rights may also be threatened if learners are asked to contribute to the discussion when they are not prepared or do not expect to be asked to do so. Learners' interactional goals for the debriefing can be threatened if there is a misalignment of goals for the debriefing between them and the facilitator. Their interactional goals may also be threatened if misalignment is perceived by the learners because the goals of the debriefing are not clarified (eg, learners are unsure what the facilitator hopes to achieve by asking them a series of open-ended questions).
This critical review aims to explore how various studies in the simulation debriefing literature, which describe postevent facilitator-guided debriefing approaches, can be viewed through the lens of the RM model, identifying which component of RM is usually considered and which might be neglected. Given that the RM model posits that rapport is threatened if any of its components is not managed, a secondary objective of this review is to uncover any positive learning outcomes of debriefing approaches that allude to the collective management of all three components of the RM model.
A critical review approach was adopted in congruence with the aim of the study. It follows Norman and Eva's19 description of a critical review as a critical synthesis of literature that brings together different types of literatures and, as a result, offers a new perspective. Given that there are no established methods of conducting a critical review, we adopted the stepwise methods of searching, selection, data extraction, and data synthesis.
Between May 2016 and August 2016, two databases PubMed and CINAHL were searched using the search terms: (simulat* AND debrief*) AND (rapport OR relation* OR facilit*). We included empirical research, commentaries, and review articles published in English without a limit to publication year. Records pertaining to simulation debriefing and rapport/relationships/facilitation in health professions education were retrieved. This generated 314 records through the databases. In addition, 16 other publications were identified through a “snowball” search, which was based on iterative internet searches, reference lists of retrieved articles, and recommendations. Duplicates were then removed.
Two reviewers (L.M.E. and C.K.) independently screened the titles and abstracts to select the most relevant articles for inclusion. Articles that were not primarily about debriefing were excluded. Full-text articles were retrieved and assessed for eligibility, and articles that do not describe the communication or interaction between facilitators and learners during postsimulation debriefing were excluded. Disagreement was resolved through discussions with a third reviewer (L.W.S.). An outline of the search and selection of included articles is provided in Figure 1.
A data extraction form was drafted and tested on a random sample of 10 articles and revised iteratively by the study team. The final form collected information pertaining to publication details, study design, objective(s) of study, population, location and setting, details of simulation, debriefing model, and in vivo quotes of phrases that alluded to the components of the RM model. We also collected outcomes of studies, which described debriefing approaches that alluded to all three components of the RM model. Two reviewers (L.M.E. and C.K.) independently read all studies that met the inclusion criteria and extracted the relevant data. Any uncertainty regarding extraction was resolved by discussion or adjudication by a third reviewer (L.W.S.).
In keeping with a critical review approach, articles reviewed comprised a broad genre ranging from empirical studies (descriptive/narrative reports, and qualitative and quantitative studies using both experimental and quasi-experimental methods), to reviews and commentaries. Given the diversity of materials reviewed, no attempt was made to grade the levels of evidence or perform a statistical synthesis; rather, we focused on a critical synthesis of the literature with the overarching aim of providing a fresh perspective, using the RM model to illuminate a nascent area that has not been extensively reviewed. Using the rubric described in Table 1, we identified the elements of face sensitivities, sociality rights and obligations, and interactional goals. For instance, an article is deemed to have alluded to the component of “interactional goals” when it highlighted the importance of a briefing/discussion where the purpose of the debriefing is explained. From this classification, we performed a quantitative frequency analysis of each component of the RM model.
A total of 34 articles were reviewed: 17 empirical studies,2,6,7,20–33 3 reviews,1,34,35 and 14 commentaries.4,9,36–47 Half of the articles were commentaries and reviews, which either discussed simulation debriefing in general or discussed a specific debriefing approach. The empirical studies included quantitative studies that validated debriefing assessment tools and qualitative studies that explored the perspectives of facilitators and/or learners. The “Debriefing with Good Judgment” model was the most frequently discussed debriefing approach with four corresponding commentaries4,36,41,43 and three empirical studies22,27,32 investigating outcomes of debriefing with this approach. Other debriefing approaches include SimTRACT,31 Health Care Simulation After-Action Review (AAR),44 Diamond,38 3D model,37 TeamGAINS,28 and PEARLS.42 Simulations involving mannequins were the most common simulation type in the articles reviewed. Although none of the articles explicitly used the RM model, one or more components of rapport from the model were alluded to in all the articles included.
The RM component of face sensitivities was referred to in one article43 and alluded to in 311,2,4,6,7,9,20,22–33,35–42,44–47 articles (94%). Most of the included articles highlighted the importance of creating a nonthreatening, nonjudgmental, psychologically safe debriefing environment. In such environments, learners feel respected and valued instead of being under attack.1,38 Correspondingly, facilitators manage face sensitivities if they are positive and interested in learners and do not use accusatory language or damage learners' sense of self-worth.1,23 In particular, Rudolph et al9 recommend conveying a commitment to respecting learners and understanding their perspective to establish a psychologically safe environment. Cheng et al45 recommend attending to transitions from one topic to another during debriefings so that learners do not feel undervalued. Debriefing assessment tools such as the Objective Structured Assessment of Debriefing (OSAD) (for surgery simulations)6 and Debriefing Assessment for Simulation in Healthcare (DASH)7 assess facilitators' concern for and ability to create a psychologically safe environment. Debriefing approaches such as SimTRACT,31 Health Care Simulation AAR,44 Diamond,38 3D model,37 TeamGAINS,28 and PEARLS42 emphasize the creation of a safe and nonthreatening learning environment. Rudolph et al43 mentioned “saving social face” yet providing constructive critical feedback as a main consideration when debriefing. Recognizing the two constraints of embarrassing the learner with a judgmental approach and sending confusing messages with a nonjudgmental approach, their Debriefing with Good Judgment approach is based on the presumption that the learner is operating with good will and is trying to do the right thing.
Sociality Rights and Obligations
We identified the component of sociality rights and obligations in 331,2,4,6,7,9,20–37,39–47 articles (97%). Most of the included articles highlight the importance of a learner-centered debrief where learners are usually encouraged to actively participate, self-reflect, and discover, alluding to the management of sociality rights and obligations if learners expect such a debriefing approach. Because sociality rights are threatened when people's expectations of being treated fairly and appropriately are not fulfilled, facilitators manage sociality rights and obligations if they are curious about learners' thought processes and do not impose their views on learners but share their views in the context of the learners' views.43 However, facilitators also manage sociality rights if they are directive when learners expect them to.31,42 Accordingly, facilitators manage sociality rights when they balance learner-centered and instructor-centered debriefing methods depending on learners' needs and the learning context.45 Debriefing assessment tools such as the OSAD and DASH assess facilitators' ability to encourage participation of learners and to provoke engaging discussion. Moreover, OSAD and DASH also assess whether facilitators clarify expectations at the start, a fundamental strategy for managing expectations, and by extension, sociality rights and obligations. Debriefing approaches such as PEARLS manages sociality rights and obligations when it guides facilitators to help learners know what to expect for the debriefing. In addition, PEARLS as well as other debriefing approaches such as the Health Care Simulation AAR, 3D model, The Diamond, SimTRACT, and TeamGAINS incorporate the advocacy and inquiry process where the facilitator seeks to uncover the thought processes that drive the actions of learners, instead of imposing the facilitator's views on learners.
Interactional goals are alluded to in 156,7,9,20,24,25,32,36,37,41–46 articles (44%). These included articles that highlight the importance of a briefing/discussion where the purpose or the concept of the debriefing is explained. Debriefing assessment tools such as the OSAD and DASH assess facilitators' ability to clarify debriefing objectives. Among the debriefing approaches, the Health Care Simulation AAR, PEARLS, and 3D model emphasize such a briefing for learners. In particular, PEARLS guides facilitators to do so through a script. Rudolph et al43 noted the necessity of preparing learners from certain cultures, where deferring to authority is the norm and disclosing views that contradict those of the instructor is not common, for the Debriefing with Good Judgment approach by explicitly explaining the goals and norms of the simulation and debriefing. In describing learner-centered methods of teaching, Cheng et al45 allude to the management of interactional goals when they recommend assigning priority to the learner agenda. On a similar note, Palaganas et al36 recommend finding out what learners would like to discuss during the debriefing, paving the way to managing interactional goals.
All Three Components of the RM Model
Among the 34 articles, 15 (44%) considered all three components of the RM model. Table 2 provides a description of these 15 articles and how they considered each component. Two debriefing assessment tools, the OSAD and DASH, and four debriefing approaches, PEARLS, the 3D Model, Healthcare Simulation AAR, and Debriefing with Good Judgment, were identified to have taken into consideration all components of rapport. Face, sociality rights and obligations, and interactional goals are also alluded to by four empirical studies20,24,25,32 and five commentaries9,36,41,45,46 that discuss debriefing more generally.
Studies With Outcomes of Managing All Three Components of the RM Model
Only two studies measured the outcome of using a debriefing approach, which we identify to have considered all three components of rapport. Cheng et al24 found that the use of a standardized debriefing script by novice instructors improved knowledge acquisition and team leader behavioral performance during subsequent simulated cardiopulmonary arrests. The debriefing script provides specific phrases according to the advocacy-inquiry approach for each key task, emphasizing respect for learners and promoting self-reflection and discussion, hence managing learners' face and sociality rights. The script also includes an introduction phase where instructors are guided to describe the purpose of the debriefing and the roles of the instructor and learners, hence managing learners' interactional goals as well as sociality rights. Morse32 found that the Debriefing with Good Judgment approach, which considered all three components of RM, resulted in a significantly higher rate of acute care nurse practitioner students' perspective transformation, specifically, the shifting of the nurses' professional perspective to include medical decision making.
Our critical review has demonstrated how the RM model by Spencer-Oatey provides a useful framework for understanding the critical components of RM during postsimulation facilitator-guided debriefing. Even though none of the studies explicitly mentioned the RM model, we found, inter alia, that many of the identified studies alluded to the individual components, albeit with less than half alluding to all three components and only two studies specifically measuring outcomes of a debriefing approach that we identified to have taken into consideration all three components.
Because debriefing, especially the giving of feedback during debriefing, could be face-threatening and face is a universal concern, it is unsurprising that most of the articles reviewed alluded to the management of face sensitivities. In cultural settings where people generally have a more collectivistic orientation (eg, Singapore), learners might be more driven toward not losing face, attributing face-losing situations to external causes compared with cultural settings where people have a more individualistic orientation (eg, United States) and learners are more driven toward gaining face before others, making internal attributions of success.48 Hence, facilitators could preserve the face of learners in collectivistic cultures by, where justifiable, acknowledging the external causes of mistakes. In addition, what is face-threatening in one cultural context may not be in another, for example, it could be more face-threatening for learners in collectivistic cultures to be singled out. Hence, for facilitators, especially those who are new to a culture, to manage face sensitivities, it is crucial that they understand the learner and the cultural context so that they use appropriate communicative strategies to mitigate face threats to learners. In particular, there may be certain culture-specific linguistic conventions for the use of terms and phrases in managing rapport. Adopting the premise that every learner is operating with good will and is trying to do the right thing as advocated by the Debriefing with Good Judgment approach, and conveying this commitment to respecting learners is a good starting point for facilitators in managing face sensitivities across cultures.
Similarly, managing sociality rights and obligations in postsimulation debriefing also requires an astute understanding of learner needs and expectations and the attendant sociocultural context. In a learner-centered debrief, facilitators typically manage the general expectations of learners to be treated with appropriate consideration and fairness by encouraging them to actively participate. However, this discursive approach may threaten sociality rights and obligations instead if such an approach is not the norm and learners are not used to participating actively during a debriefing session. Adopting a more directive approach may also be more appropriate in certain situations, for example, for learners with little relevant background knowledge or clinical experience. It is also important to appreciate underlying cultural differences when managing sociality rights and obligations. In Asian countries such as Korea, Japan, Taiwan, and Singapore, there seems to be an unexpected gap between learner and facilitator expectations.39 Learners from non-Western countries may not be used to participating actively during debriefing sessions and hence expect facilitators to be more directive. Hence, clarifying expectations, not only what is expected of learners but also crucially helping learners know what to expect from the facilitators, is fundamental to managing sociality rights and obligations.
Among the three components of the RM model, interactional goals seem to be the least mentioned in the articles reviewed. The interactional goals of learners, not entirely synonymous with learning objectives, refer to what learners hope to achieve during their interactions in debriefing sessions. With the notable exception of the OSAD and DASH, which specifically assess facilitators' ability to clarify debriefing objectives, most studies describing facilitator-guided debriefing approaches do not emphasize the management of interactional goals by recommending that facilitators clarify debriefing objectives with learners. The importance of clarifying objectives in RM cannot be overemphasized, because a misalignment of goals can lead to frustration and derail learning during the debriefing process. If learners, for example, aim to maximize their learning from the debriefing interaction but perceive that their interactional goals are not recognized or met, this might threaten rapport and hence undermine learning. Good practices in the articles reviewed include explaining the objectives and the concept of debriefing, either in a spontaneous or scripted manner, finding out what learners would like to discuss during the debriefing and assigning priority to the learner agenda. For example, facilitators who seek to use a discursive approach but are debriefing learners who aim to maximize their learning within a short debriefing time (interactional goal) and are used to a directive approach (sociality rights) can say something like this to manage both learners' interactional goals and their sociality rights: “I know we have limited time for the debriefing. Often lecturing is the most efficient way to get material across. However, because one of the goals of this debriefing exercise is to develop your tacit ways of thinking, I cannot do that without knowing what you are thinking. So we will need to have some discussions in which you share your point of view. Based on what I hear from you, I will be better able to accelerate your learning since I will be able to diagnose and help you change your current patterns of thought. Put another way, we can make your learning more efficient and get you up the learning curve faster if we take the time to discuss your views, not just mine. Would you be willing to do that?”
Given that the three interconnected components of the RM model can affect rapport either independently or interdependently, it is crucial that facilitators consider all three components during debriefing and manage them strategically. Table 3 summarizes how the components might be threatened and how they can be managed by simulation debriefers. In general across cultures, face sensitivities can be managed by adopting the premise that every learner is operating with good will and is trying to do the right thing; sociality rights and obligations can be managed by helping learners know what to expect from the facilitators; and interactional goals can be managed by explaining the objectives and the concept of debriefing, finding out what learners would like to discuss during the debriefing and assigning priority to the learner agenda.
This critical review identified two debriefing assessment tools (the OSAD and DASH) and four debriefing approaches (PEARLS, the 3D model, Healthcare Simulation AAR, and Debriefing with Good Judgment) to have taken into consideration all three components of the RM model. However, we uncovered only two outcomes studies, which reported that the use of debriefing approaches that we identify to have considered all three components of rapport, were found to have positive learning outcomes.24,32 Although this provides preliminary support for the use of a debriefing approach where all three interrelated components of the RM model are managed for effective debriefing, we recommend that more studies compare debriefings, in various contexts, that are guided by the RM model and debriefings that are not. In particular, the Sim-PICO template49 provides guidance for researchers to design studies to assess outcomes of debriefing.
In keeping with the methodological aims of a critical review, the literature search was not exhaustive. Nonetheless, we included the two databases that we felt were most pertinent to our study and supplemented our initial search with further iterative internet and reference list searches and expert recommendations, resulting in a more comprehensive overview of representative literature. In addition, data extraction and synthesis occurred in duplicate using clear definitions of key terms such as the individual components of the RM model. Future empirical studies could investigate how the RM model can be used to guide debriefing approaches in various cultural or learning contexts as well as clarify why or how these debriefing approaches work.50 The varying learning contexts may include debriefings after in situ simulations where rapport needs to be quickly established and participants may be observed by patients, simulation debriefings involving interprofessional learning where either or both the facilitators and learners are from different professions, and self-guided debriefings where the debriefing is conducted by the simulation participants themselves. Because the outcomes of a debrief may also depend on the interaction between learners and the learner-learner interaction may moderate facilitator-learner rapport, future work could also explore how the RM model can be applied to the interaction between simulation debriefing participants. Finally, how the application of the RM model can be usefully extended to the presimulation briefing, which sets the stage for learner engagement, could be explored.
This critical review showed that the RM model provides a lens with which to view studies in the simulation debriefing literature that describe postevent facilitator-guided debriefing approaches. By considering face and sociality rights, the RM model also provides a useful heuristic to create awareness of the importance of considering cultural contexts in the management of rapport in postsimulation debriefing. We found that less than half of the identified articles alluded to all three components of the RM model, with interactional goals least alluded to. There is very preliminary evidence that the management of all three components of the RM model during debriefing may contribute to improving short-term learning outcomes. The RM model is a potentially useful conceptual framework to guide RM during the debriefing process, enabling the identification of the interrelated components of face sensitivities, sociality rights and obligations, and interactional goals that, when managed collectively, create a non-rapport-threatening learning environment.
The authors thank the reviewers for their insightful comments that have helped us improve on an earlier version of the article. In particular, we would like to thank one of the reviewers for the example script used in the Discussion section.
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