In healthcare, learning is seen primarily as a cognitive task, but decades of research in developmental psychology, classroom teaching, infant studies, change management, and sustained behavior change highlight the crucial importance of relationship in learning. The quality of connections between people mediates the cognitive aspects of learning. Eng et al's article poses a refreshing challenge to us in the simulation community: carefully consider the role of rapport in simulation-based training and debriefing. Ignore rapport at our peril.
Eng et al1 present the concept of rapport management in debriefing, a topic on which the simulation literature has largely been mute. The Spencer-Oatey Rapport Management Model (RMM) is a conceptual framework to analyze and guide social interactions that can be applied to simulation-based debriefings.2,3 Rapport is a noun describing a friendly and harmonious relationship.1 When present, rapport supports the educational goals of debriefings in that it provides mutual understanding and empathy that facilitates communication of ideas and concepts. When rapport is supported, learners are “in sync” with other learners and teachers.
This work is a great example of using existing theory from other disciplines to inform educational practices and can be used as a foundation for educational research involving simulation. We hope that this work will encourage others to embark on simulation scholarship and/or research through a transdisciplinary approach to facilitate innovation in our field.
The Spencer-Oaty Rapport Model presented by Eng et al provides concrete, granular guidance on how to build rapport: meet the learner where they are with respect to their identity, their expectations, and their goals.2,3 “Face sensitivities” are about perceptions of how one is honored or valued. Shame is the result of violations. “Sociality rights” relate to expectations. For example, participants feel entitled to be treated fairly, to not being tricked. Sociality rights are met when facilitators are clear about rules and expectations. Violations may result in anger and frustration. “Interactional goals” relate to the learners' tacit or explicit objectives and purposes. Learners may feel disrespected or disregarded if their goals are not taken into account. When rapport is neglected or mismanaged in debriefing, learners may feel shame (ie, lose face), feel annoyed because expectations have not been met (ie, sociality rights), and/or feel disregarded (ie, because their goals were not taken seriously).
The summary of evidence in Eng et al's article supports the importance of rapport as a key component of effective experiential learning that should be considered in all debriefings. Managing rapport can enhance participation and engagement of learners and minimize defensiveness and withdrawal. Psychological safety, trust, and rapport are different faces of social learning that can reduce feelings of insecurity and threat and pave the way for connection, vulnerability, and risk taking in the service of learning. Importantly, this work presents evidence from the educational, organization, and psychology research fields demonstrating that reducing threats to professional and social identity is a key ingredient in interprofessional training or education. Rapport management is consistent with other literatures in feedback and facilitation skill development that focus on the importance of building relationships.4
The importance of the Eng et al article goes beyond the feel-good value of rapport; it shows us how to leverage rapport to enhance learning. There are implications for debriefing, interprofessional practice, teamwork, and healthcare provider education within and outside of simulation. In simulation, violations of RM components lead to degradation of the tacit unspoken expectations or psychological contract between learners and facilitators.5
Although facilitators can work to manage rapport between themselves and learners, they must also be aware of the dynamics between learners and work to manage interlearner rapport appropriately. In our experience, this requires the use of advanced facilitation skills with techniques such as validation, normalization, and silence to manage difficulties as they arise. For example, facilitators analyzing and thinking about the professional identity issues, the expectations, and the goals of each group could help colleagues from different disciplines prepare for and adapt to different perspectives shared during a debriefing. Rapport management in debriefing can help to repair interprofessional misunderstandings learners may have experienced previously in the clinical setting. Alternately, rapport management in debriefing might demonstrate and develop interprofessional communication skills that could be applied later to reinforce respect and curiosity across tribal boundaries.
Within debriefings, the rapport between learners is influenced not only by their previous experiences but also by how discussion is facilitated and managed during debriefings. For example, in a simulation, a physician learner can make a statement that embarrasses a nurse learner (ie, threat to face in RMM), and this can impact the experience for other learners and the facilitator. Disharmony between team members can have a disruptive effect because it raises anxiety, which in turn increases cognitive load, and moves the focus away from the learning tasks at hand. In this scenario, the comment by the physician leader could also threaten the face of a facilitator that is a nurse. Managing these threats to identity is another distraction from learning. These threats can be rooted in the training of the different professional “tribes” and/or be related to previous personal experiences.
Taking a step back, we believe that there are additional considerations with respect to the influence of rapport in simulation-based education. Establishing and building rapport between facilitators and learners often start before the debriefing. The interactions during debriefings are heavily connected to the prebriefing, the simulation event, and variables outside of the simulation event. An effective prebrief can help to ensure psychological safety and enhance rapport.6
Using the RMM within debriefing may have positive spill-over effects outside of simulation into the real clinical context. Consider the value of rapport management in the contexts of interprofessional education and practice. Often, different professions each have hidden assumptions about the goals and conduct of care that may not be known or shared across disciplines. When conducting an interprofessional and/or multidisciplinary simulation-based team training course, learners arrive from different “tribes” of healthcare, each with their own cultures, norms, and perspectives. Although the authors discuss the importance of ethnic/geographic cultural differences, their article's principles can also be extended to different cultures within healthcare. These tribes can be at the level of the discipline (surgical-medical fields) or profession (physicians-nurses).
Lastly, rapport management may be a necessary ingredient to quickly and confidently connect colleagues on emergent or ad hoc teams, which are increasingly the norm in healthcare. Contrast this to the natural rapport that can develop in stable, long-term teams. In a recent panel discussion on debriefing at an international simulation conference, a lead training administrator from NASA's simulation program noted that actively managing rapport is not a focus of their debriefings.7 This is because facilitators and learners have a strong shared organizational culture and have completed many hours of interactions that foster rapport and a “shared mental model” before starting simulation-based training. The simulation activities involve the same team and facilitator participating in months of intensive simulations. In contrast, in healthcare, simulation is a small fraction of the total training time and individuals participating may not have established relationships. NASA astronauts and their facilitators are bonded together with 1 common purpose, with the understanding that mistakes may lead to loss of life of a friend and a team member.
In healthcare simulation and debriefing, rapport management is necessary to bridge the different “thought worlds,” professional cultures, and practices each “tribe” brings to the management of a patient. Imagine an ad hoc interprofessional team that participates in an in situ trauma simulation. The clinicians may have limited interactions before the session. For these debriefings, rapport management could provide a clear pathway to the interprofessional jackpot of understanding; because even though each profession cares about the best outcome for the patient, they often unintentionally work at cross purposes. The Spencer-Oatey model could allow the facilitator to protect the identity of individuals from a specific profession, to explore and meet different expectations, and to ascertain the goals each individual learner was trying to reach.
Eng et al's article provides an introduction of RMM into the simulation community and sets the stage for future areas of research. The authors present some excellent strategies for rapport management that can be expanded and matched to the simulation context (in situ vs. center), objectives (team vs. psychomotor), consequences (formative/summative), and learner types (single profession/multiprofession, same level of learners/different levels). By publishing their thoughtful work, Eng et al have opened the door to future research that explores how RMM contributes to improving simulation-based education.
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3. Spencer-Oatey H. Culturally Speaking: Managing Rapport Through Talk Across Cultures
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4. Sargeant J, Lockyer J, Mann K, et al. Facilitated reflective performance feedback: developing an evidence- and theory-based model that builds relationship, explores reactions and content, and coaches for performance change (R2C2). Acad Med
5. Rousseau DM. Psychological Contracts in Organizations: Understanding Written and Unwritten Agreements
. Thousand Oaks, CA: SAGE Publications; 1995.
6. Rudolph JW, Raemer DB, Simon R. Establishing a safe container for learning in simulation: the role of the presimulation briefing. Simul Healthc
7. Huang L, Rudolph J, Roussin C. PANEL DISCUSSION 3—Multi-Industry Approaches to High-Performance Team Debriefing
. Paper presented at: International Pediatric Simulation Symposia and Workshops 2017; Boston, MA.