November 6, 2013By Lance Baily

Lessons on Debriefing From Documentary Film-Making

Even having visited countless simulation centers around the world that have the latest equipment and an established staff still inherently miss some of the greatest opportunities inherent with teaching or training with through Healthcare Simulation.

Consider: Is the real purpose of an $80,000 manikin and a $1,000,000 Sim Lab to simply teach skills, or is their a greater opportunity to teach something significantly beyond? Continuing last week’s discussion on How To Overcome Camera-Shy Simulation Learners, this week we share deeper lessons from the world of documentary film-making – a place where closer relationships provide greater access to shared learning. Warning: This article may change your perspective!

The Facilitator, aka the ‘Documentary Film-maker’

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I learned first hand at film school that in great documentary filmmaking, a director’s real job is to capture footage that represents the reality of people in a given place, community or situation. If the director has no relationship with this community, they must spend time and energy building relationships in order to gain access to that inner world. At very minimal this director will have to convince the target individual and/or their group to provide permission for the subjects to be filmed. In other words, only once a trusted relationship has been built can the director receive permission to bring a camera into a normally private affair.

When the  filmmaker develops a close and personal relationship with the subject, the subject will feel safe and will be willing to open up and reveal more about themselves and their view of the world. With this kind of relationship, the filmmaker will be able to ask deeper questions that might previously have been considered too personal. With this depth of space in a relationship, a greater story is revealed through an unfiltered access into a subject’s greater reality. In other words, access to record a delicate performance comes with the proven trust to honor the subject’s story and respect the retelling of that story.

While filmmakers have some choice with the selection of their documentary subject, facilitators of medical simulation have very little choice as to the learners in the session on the sim day. Thus, those who debrief should take extra time and effort to create a safe space for learners to reveal their own personal “performance.”

Really Imagined

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Countless times I have been in the sim lab control room and overheard clinical facilitators yell to themselves, “I can’t believe this! I taught them better than that! Unbelievable!”. Where should the finger really be pointed in this situation? Let’s look to documentary film-making again where interviewee respect is a primary concern. If a film director does not respect the subjects they are filming the production will end with frustration and mixed emotions on both sides. And in the end, the director will not “get the shot” they need to tell the film’s story. Likewise, shouldn’t a simulation facilitator respect their students enough to know that mistakes are going to happen, and isn’t that the whole point of simulation is for the mistakes to happen in the sim lab safely aware from real patients?

If facilitators falter in front of the group and ‘lose their cool,’ they will reveal their judgment of learner stories and thus jeopardize the entire educational process. I believe that in order to be a successful facilitator, one must be able to see the student’s perspective and remain free of judgement. Yes, learners will make mistakes but at the core we must remember again this is the point of simulation!

Learners would not make mistakes if they remembered and connected all the pieces of information we have sent their way. Simulation is the way to help students connect the dots in a safe and stress free environment.

Your Risk vs. Their Reward

Some may think the prize of Simulation is knowledge gained. Perhaps though knowledge is only a small part of the potential benefit simulation has to offer. Knowledge is editable information that can change based on additional experience from more time and different places. Consider how many reiterations general CPR has gone through in terms of “best practices” in the last fifty years. With the right education, almost everyone can be expected to pass a CPR test based on a lecture, hands-on workshop, manuscript, video presentation or audio recording.

Isn’t the real opportunity from Simulation the chance to permanently modify a learner’s behavior? Why would behavior-change be more rewarding for learners to gain? Ask yourself: Would you rather hire a person for their knowledge or for their behavior? Wouldn’t we all agree that with the right behavior that almost any knowledge can be taught?  Contrast that with someone who has the knowledge but inexcusable behavior. How much can that kind of individual work effectively as part of a team or be open to learning new things?

In my opinion, behavior is much more difficult to transform because it is closely linked to a person’s sense of identity. For instance, if a learner does not know the correct knowledge, the education/educators can ultimately be blamed and held responsible for that outcome. Conversely, there is no other person/place/thing that can easily be blamed for a learner’s inappropriate behavior. If a learner exhibits a bad behavior that they learned a long time ago, they may continue that behavior even though they have new knowledge.

Of course, you can see how discussing someone’s behavior can quickly become a very touchy subject.  If someone close to a learner (like a parent) taught them an inappropriate behavior, the learner may associate requests to change that behavior as an attempt to alter their personal attachments, and thus their sense of self.  And so to have a conversation about a learner’s overall behavior, a facilitator must be willing to communicate at a much more intimate level.

Usually I have seen clinical educators more interested in the daily feeling of superiority gained from “I told you so” finding a methodology transition into Healthcare Simulation just too challenging. As, even thinking “I can’t believe they just did that” chisels away at the dedication necessary to building trusting and respectful facilitator/learner relationships.

When facilitators can “believe the learner just did that”, then they can move on to more important questions such as “How do I help these learners to see a better perspective?”. And those who have witnessed this shift in a learner’s perspective can attest that the reward is worth the wait. “Watching a learner gain a higher awareness of themselves is beyond words” I have heard some Healthy Simulation Champions say.

How specifically does Healthcare Simulation provide an opportunity to educate a learner about their behavior?

Being videotaped and analyzed in the workplace is not something many individuals are required to undergo. It can be an uncomfortable process, even without the stress to perform adequately and professionally. Haven’t most of us found we sound and look different than we imagined when captured on video? Add a potentially stressful situation and peer evaluation to the mix and you can have a seemingly risky situation on your hands. However, when provided with a safe space, learners will be given an opportunity through Healthcare Simulation to witness themselves fully engage in a workplace situation, perhaps for the first time in their entire life. When that happens, learners can be shocked to realize all of the elements of communication they have unconsciously let slide by their control.

How learners think they present themselves to fellow learners, classmates, coworkers, supervisors, subordinates, and patients versus how they actually present themselves can be two very different things. Video provides learners with an opportunity to see behaviors unfold that they potentially have never been made aware of or acknowledged before. For instance if they grimace when looking at an infected wound, or roll their eyes when a certain supervisor enters the room, or tap their foot when a coworker is talking. These are critical moments that will not come without providing learners a space to witness themselves without being judged.  Video will tell the truth, but only to those who are willing to acknowledge it!

In debriefing a simulation, the more developed a relationship with your learners the more trust they will give you to guide them to a path of self-discovery. With experience, facilitators can educate learners that the camera is not a condemning prosecutor, but instead an impartial witness. And when facilitators themselves offer the judge’s seat to the primary learner, then that individual is provided an opportunity to self educate themselves like never before.

A changed behavior never needs testing, as it is always present. Watching this shift in understanding is not only the purpose of Medical Simulation but as well the real joy!

How can you provide the ultimate learning opportunity through Healthcare Simulation?

Videotape your own debriefings and sit down with a fellow facilitator to become aware of your own process.  Partaking in the video recording yourself will provide endless examples to you about your own imagined perspective of an engagement versus the expanded, impartial and more realistic perspective of that same session. Then you too can be educated through expanded awareness of the process – and your behaviors will change right before your very eyes!

Leave us a comment and share your perspective.

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