Jenny W. Rudolph

On the Receiving End: Sensemaking, Emotion, and Assessments of an Organizational Change Initiated by Others

This study focuses on the interpretations and experiences of change recipients, those who carry out organizational interventions initiated by others. Based on the ways nurses experienced a shared governance initiative implemented in their hospital, the authors investigated change recipients’ sensemaking about organizational change through their ascribed meanings, emotional responses, and perceptions of its impacts on them. Survey data demonstrated how nurses subjectively assessed their gains and losses from the change initiative. Participation in the initiative increased the experience of gains, as did membership in a unit where change was implemented more fully. Textual analysis of open-ended responses to the survey indicated that gains were linked with interpretations of the change initiative and pleasant feelings and that there was considerable emotional contagion within work units. Such effects are particularly likely in employee empowerment initiatives as experiences are linked to interpretation and mood among change recipients.

Debriefing as Formative Assessment: Closing Performance Gaps in Medical Education

The authors present a four-step model of debriefing as formative assessment that blends evidence and theory from education research, the social and cognitive sciences, experience drawn from conducting over 3,000 debriefings, and teaching debriefing to approximately 1,000 clinicians worldwide. The steps are to: 1) note salient performance gaps related to predetermined objectives, 2) provide feedback describing the gap, 3) investigate the basis for the gap by exploring the frames and emotions contributing to the current performance level, and 4) help close the performance gap through discussion or targeted instruction about principles and skills relevant to performance. The authors propose that the model, designed for postsimulation debriefings, can also be applied to bedside teaching in the emergency department (ED) and other clinical settings.

Teaching residents the two-challenge rule: a simulation-based approach to improve education and patient safety.

Introduction: Residents train in a historically hierarchical system. They may be compelled to question their teachers if they do not understand or disagree with a clinical decision, have a patient safety concern, or when treatment plans are unclear. We sought to determine whether a debriefing intervention that emphasizes (1) joint responsibility for safety and (2) the “two-challenge rule” (a rubric for challenging others) using a conversational technique that is assertive and collaborative (advocacy-inquiry) can improve the frequency and effectiveness with which residents “speak up” to superiors. Methods: In a simulated operating room, anesthesiology trainees were presented with opportunities to challenge coworkers (eg, orders to administer a relatively contraindicated medication). Opportunities to challenge the attending faculty anesthesiologist, attending faculty surgeon, and nurse (all confederates) were presented. When debriefed, subjects were taught the two-challenge rule and a communication technique that paired advocacy (stating trainee’s observation) and inquiry (request for the other’s reasoning). A second scenario offered new opportunities to challenge. Video recorded scenarios were evaluated by two investigators and trainee use of the prescribed advocacy-inquiry language was rated on a 5-point scale. Results: Forty subjects participated. Overall use of the two-challenge rule and advocacy-inquiry increased after debriefing. The debriefing and instruction specifically improved the frequency and quality of challenges directed toward superordinate physicians, without improving resident challenges toward nurses. Conclusions: This instructional intervention improves “speaking up” by residents to other physicians during simulated obstetric cases. Providing increased opportunities for resident learning, sharing responsibility for patient safety, and overcoming communication barriers within the medical hierarchy may improve teamwork and patient safety.

Which Reality Matters? Questions on the Path to High Engagement in Healthcare Simulation

With heart racing, sweaty palms, and tightness in her throat, the code team leader takes a deep breath and tries to remember the next step of the new Advanced Cardiac Life Support algorithm.As the needle pops gently up through the tissue and he secures the knot, the surgical resident notes with sati

Establishing a safe container for learning in simulation: the role of the presimulation briefing.

Summary Statement In the absence of theoretical or empirical agreement on how to establish and maintain engagement in instructor-led health care simulation debriefings, we organize a set of promising practices we have identified in closely related fields and our own work. We argue that certain practices create a psychologically safe context for learning, a so-called safe container. Establishing a safe container, in turn, allows learners to engage actively in simulation plus debriefings despite possible disruptions to that engagement such as unrealistic aspects of the simulation, potential threats to their professional identity, or frank discussion of mistakes. Establishing a psychologically safe context includes the practices of (1) clarifying expectations, (2) establishing a “fiction contract” with participants, (3) attending to logistic details, and (4) declaring and enacting a commitment to respecting learners and concern for their psychological safety. As instructors collaborate with learners to perform these practices, consistency between what instructors say and do may also impact learners’ engagement.

Debriefing Assessment for Simulation in Healthcare: Development and Psychometric Properties

Introduction This study examined the reliability of the scores of an assessment instrument, the Debriefing Assessment for Simulation in Healthcare (DASH), in evaluating the quality of health care simulation debriefings. The secondary objective was to evaluate whether the instrument’s scores demonstrate evidence of validity. Methods Two aspects of reliability were examined, interrater reliability and internal consistency. To assess interrater reliability, intraclass correlations were calculated for 114 simulation instructors enrolled in webinar training courses in the use of the DASH. The instructors reviewed a series of 3 standardized debriefing sessions. To assess internal consistency, Cronbach &agr; was calculated for this cohort. Finally, 1 measure of validity was examined by comparing the scores across 3 debriefings of different quality. Results Intraclass correlation coefficients for the individual elements were predominantly greater than 0.6. The overall intraclass correlation coefficient for the combined elements was 0.74. Cronbach &agr; was 0.89 across the webinar raters. There were statistically significant differences among the ratings for the 3 standardized debriefings (P < 0.001). Conclusions The DASH scores showed evidence of good reliability and preliminary evidence of validity. Additional work will be needed to assess the generalizability of the DASH based on the psychometrics of DASH data from other settings.

Helping without harming: the instructor's feedback dilemma in debriefing--a case study.

Introduction Simulation instructors often feel caught in a task-versus-relationship dilemma. They must offer clear feedback on learners’ task performance without damaging their relationship with those learners, especially in formative simulation settings. Mastering the skills to resolve this dilemma is crucial for simulation faculty development. Methods We conducted a case study of a debriefer stuck in this task-versus-relationship dilemma. Data: The “2-column case” captures debriefing dialogue and instructor’s thoughts and feelings or the “subjective experience.” Analysis: The “learning pathways grid” guides a peer group of faculty in a step-by-step, retrospective analysis of the debriefing. The method uses vivid language to highlight the debriefer’s dilemmas and how to surmount them. Results The instructor’s initial approach to managing the task-versus-relationship dilemma included (1) assuming that honest critiques will damage learners, (2) using vague descriptions of learner actions paired with guess-what-I-am-thinking questions, and (3) creating a context she worried would leave learners feeling neither safe nor clear how they could improve. This case study analysis identified things the instructor could do to be more effective including (1) making generous inferences about the learners’ qualities, (2) normalizing the challenges posed by the simulation, (3) assuming there are different understandings of what it means to be a team. Conclusions There are key assumptions and ways of interacting that help instructors resolve the task-versus-relationship dilemma. The instructor can then provide honest feedback in a rigorous yet empathic way to help sustain good or improve suboptimal performance in the future.

Naturalistic Decision Making and Organizational Learning in Nuclear Power Plants: Negotiating Meaning Between Managers and Problem Investigation Teams

We explore the linkages between naturalistic decision making, which examines decisions in context, and team and organizational learning, which examines how feedback from decisions affects context. We study 27 problem investigation teams in three nuclear power plants, a setting that combines complex team decisions with organizational learning. Further, managers who commission the teams and receive team reports are a key aspect of context for the teams and a critical conduit for organizational learning and change. Questionnaires were given to both team members and manager recipients of written team reports, and team reports were coded for qualities of their analyses and recommendations. We find that team members value reports in which the team discovered causes or lessons that could be used in other contexts, whereas managers appreciate reports with logical corrective actions from teams with investigation experience. Teams with managers or supervisors as team members are better able to reach shared understanding with their manager customers. Teams with more diverse departmental backgrounds produce deeper and more creative analyses. Teams need access to information and analytical skills in order to learn effectively, but they also need management support and boundary-spanning skills in order to diffuse their learning.

Improving Anesthesiologists' Ability to Speak Up in the Operating Room: A Randomized Controlled Experiment of a Simulation-Based Intervention and a Qualitative Analysis of Hurdles and Enablers.

Purpose The authors addressed three questions: (1) Would a realistic simulation-based educational intervention improve speaking-up behaviors of practicing nontrainee anesthesiologists? (2) What would those speaking-up behaviors be when the issue emanated from a surgeon, a circulating nurse, or an anesthesiologist colleague? (3) What were the hurdles and enablers to speaking up in those situations? Method The authors conducted a simulation-based randomized controlled experiment from March 2008–February 2011 at the Center for Medical Simulation, Boston, Massachusetts. During a mandatory crisis management course for practicing nontrainee anesthesiologists from five Boston institutions, a 50-minute workshop on speaking up was conducted for intervention (n = 35) and control (n = 36) groups before or after, respectively, an experimental scenario with three events. The authors analyzed videos of the experimental scenarios and debriefing sessions. Results No statistically significant differences between the intervention and control group subjects with respect to speaking-up actions were observed in any of the three events. The five most frequently mentioned hurdles to speaking up were uncertainty about the issue, stereotypes of others on the team, familiarity with the individual, respect for experience, and the repercussion expected. The five most frequently mentioned enablers were realizing the speaking-up problem, having a speaking-up rubric, certainty about the consequences of speaking up, familiarity with the individual, and having a second opinion or getting help. Conclusions An educational intervention alone was ineffective in improving the speaking-up behaviors of practicing nontrainee anesthesiologists. Other measures to change speaking-up behaviors could be implemented and might improve patient safety.

EXPRESS--Examining Pediatric Resuscitation Education Using Simulation and Scripting. The birth of an international pediatric simulation research collaborative--from concept to reality.

Over the past decade, medical simulation has evolved into an essential component of pediatric resuscitation education and team training. Evidence to support its value as an adjunct to traditional methods of education is expanding; however, large multicenter studies are very rare. Simulation-based researchers currently face many challenges related to small sample sizes, poor generalizability, and paucity of clinically proven and relevant outcome measures. The Examining Pediatric Resuscitation Education Using Simulation and Scripting (EXPRESS) pediatric simulation research collaborative was formed in an attempt to directly address and overcome these challenges. The primary mission of the EXPRESS collaborative is to improve the delivery of medical care to critically ill children by answering important research questions pertaining to pediatric resuscitation and education and is focused on using simulation either as a key intervention of interest or as the outcome measurement tool. Going forward, the collaborative aims to expand its membership internationally and collectively identify pediatric resuscitation and simulation-based research priorities and use these to guide future projects. Ultimately, we hope that with innovative and high-quality research, the EXPRESS pediatric simulation research collaborative will help to build momentum for simulation-based research on an international level.