Simulating Turbulence

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From the Center for Medical Simulation in Boston to our periphery, we bring you a conversation with Jenny Rudolph, Executive Director at the Center for Medical Simulation in Boston Massachusetts. Jenny is a master at team building and leadership and a natural and effective turbulator. The discussion of Leadership is so often focused on individual strengths and skills. Jenny offers us a framework for how individuals combine to create effective teams.


Simulating Turbulence

Rob Brodnick:  Welcome to the Positive Turbulence Podcast: Stories from the Periphery. Here we journey to the edge to talk to turbulators about their experiences creating positive change. Hi, I’m Rob Brodnick.

Karyn Zuidinga: And I’m Karyn Zuidinga. In sharing these stories, these perspectives on innovation, creativity, change, and leadership we hope to generate some positive turbulence for you. Thank you for joining us.

Rob Brodnick: From the center for medical simulation in Boston to our periphery, we bring you a conversation with Jenny Rudolph Executive Director at Center for Medical Simulation in Boston, Massachusetts. Jenny is a master at team building and leadership and a natural and effective turbulator.

Karyn Zuidinga: The discussion of leadership is so often focused on individual strengths and skills. What Jenny offers us is a framework for how individuals combined to create effective teams. And that to me was magic. Because, what good is a leader without a great team?

Rob Brodnick: Through the lens of the work she does in the world of health professions, simulation. Jenny guided us in the ways to transform high performing individuals into highly functioning teams.

Karyn Zuidinga: The lessons learned here are fantastic ideas to apply to teams and pretty much in any setting. Coming up. Jenny provides a masterclass and team building and leadership, both the theory and modeling how it’s done. She’s a practical genius.

Rob Brodnick: Jenny’s been a great provocateur and stimulus. Anytime she comes into a session, like people think differently right there, Jenny there’s people in the world that have the us magical gift, and you’re one of them when you show up, it changes the dynamic in a really positive way. And that’s a great form of positive turbulence. So when we were thinking about guests, I said I know the essence of positive turbulence and, , she, manages the Center for Medical Simulation. And so Karyn said let’s go. So that’s how we all got here.

Karyn Zuidinga: And if we call you a turbulator it’s a good thing. 

Jenny Rudolph: Thank you I will embrace my turbulence, creating capabilities. Many people close to me would find that quite unsurprising. 

Rob Brodnick: Tell us a little bit about the Center for Medical Simulation, how you landed there and what you all do.

Jenny Rudolph: I’ll start with what we do, which may surprise you because with a name like the Center for Medical Simulation, you might think about mannequins, or you might think about screen-based simulations, or you might think about predictive analytics and scenario planning. But the heart of what we do is really the connection within a healthcare team, taking care of a acutely decompensating patient in the operating room. How does the team quickly come together, decide what to do for this patient and then execute. The other big thing that we do is culture creation and culture repair, and simulations where people come together to take care of a patient is like a microscope that allows us to see what are the micro interactions between duets and trios. What is the type of conversation that people are having? And we’re very interested in those micro conversations because we see each of those building up to create the culture in the unit in the broader hospital. So that’s a bit of what we do. 

Karyn Zuidinga: Fascinating. I know a little tiny bit about medical simulation and I’m glad you mentioned that it’s not just about mannequins or some sort of VR headset or something, but I didn’t get the whole culture piece until just now.

Jenny Rudolph: Speaking of culture, I will just say that even though, again, our title Center for Medical Simulation we were founded 27 years ago. We tend to prefer to use the word now, health professions, simulation, or healthcare simulation, to be as inclusive as possible of the multiple professions, whether it’s nursing, physical therapy, respiratory therapy. There’s so many things that come together to allow us to take care of complex patients in this day and age. So I just wanna make sure that we’re talking about all kinds of professions within healthcare. 

Rob Brodnick: Yeah, that’s good. I, the world at large, I think you say medical and people think doctor, And it’s just us like a, a reflex and there’s a vast number of medical applications. I like that switch to health professions. What’s one of the strangest places where you’ve done work and not necessarily a location, but in, in the whole domain of health professions. I can imagine you’ve worked with hospitals and emergency rooms and doctors, but what are some of those other places where you’ve done some work 

Jenny Rudolph: I’m not sure this rises to the level of strange or odd, but I think it might be something different than people expect. So a hospital asked us to work with the anesthesia techs who manage the equipment that allows anesthesiologists and the rest of the team to, for example, address a difficult airway. So when you can’t intubate a patient in the normal way, you might need other adjuncts like a GlideScope or a fiber optic scope or other things, or if you suddenly have to resuscitate a patient often that involves increasing the amount of blood volume or any volume in their veins. And that requires putting blood or other volume increasing products like the different things they use into a pressurized thing that basically pumps that volume into your body. So you think everybody knows how to set that equipment up and manage that equipment. And indeed they do. 

Under stress, you can think about how you drive when somebody’s rear-ended you, just how your heart rate goes up with something as simple as that, and your brain stops working as well. So often people come to us and ask us to help their professionals manage their equipment. The pivot that we make in that situation is we say, Hey, yeah, they need to know how to turn it on and turn it off and set it up and take it down. But honestly, the biggest challenge is again, how do they connect with the other humans while doing so, and specifically also, how do the other humans, the other clinicians invite those people into this space to help them. And so one of the things that we do is we constantly pivot the problem as presented to us as an equipment problem. And we say, yes, it’s equipment in context. And these three people have to work as an ensemble to use that equipment. And those people have to feel psychologically safe, which means they feel comfortable to ask for help or admit they don’t know in order to use that equipment. And so then we try to design an experience that makes a temporary container where people can experiment and get better at using the equipment and talking to each other and using their brains and strengthen the psychological and emotional connections among them. 

Karyn Zuidinga: Wow. You just completely shifted my perception of simulation just now. I get the whole thing just shifted wildly over. And I kept going back to other workplace situations where that whole problem of, I don’t know, I need help. You’re stressed and you’re feeling whatever something’s going on with you. And so you get snappish maybe that’s of course never happened to me of course. But I understand that happens to other people. Just saying. Tell me a little bit about that dynamic. I came to you, I have this piece of equipment I’m like, oh, help me learn to use this piece of equipment and you say great. Yes. And we’re gonna also teach you how to work with your team and how does that go? Do people expect that outcome?

Jenny Rudolph: No, they do not expect that outcome. Part of what we do is help them appreciate why that change of perspective is important. And the simplest way we do that is to help them focus on the risks, and the vision that they have for if this went well. An example would be, I wanna set up a. Thing that’s gonna allow me to get volume into the patient more quickly. One of the products that’s used is called Belmont. And I have to put a big bag of, this liquid of some sort in there. And I have to attach an IV to the patient and I have to get that to flow through to the patient. One of the things we do is we say, okay, if this goes badly, what are the risks to the patient? And this is always so obvious to them. They almost look at me like, are you stupid? The patient won’t do well there. Resuscitation might not happen. They don’t have enough volume, their blood. Pressure’s gonna go down. If their blood pressure goes too low, their heart won’t work, you I write all those things down. And then I say, if this goes badly, what are the risks to you or the other team members? And they often haven’t thought about that as much. and so then we talk about how bad they might feel, how guilty they might feel, how ashamed they might feel that they weren’t able to get that right. And their team members saw them not get it right.

Or more importantly, they feel they’ve harmed the patient. That sometimes comes under a formal term in health professions called moral distress. So they’re gonna have some moral distress and what’s the risk to the department or the unit. If that goes badly, obviously it degrades confidence across the department and it might diminish the reputation of the department or the unit in some way, once we dial up the heat a little bit on this thing, that seemed Like it was nothing more than how do you set up the Belmont? How do you set up this piece of equipment? And we say, if this goes badly, these are the things that are gonna happen. And then we flip to, if this goes well, which we could talk about more, if we wish here among us. all of a sudden they start getting a lot more interested in what we talk about as collective competence. How do we do this together? And so that’s part of how we manage that flip, Karyn. 

Rob Brodnick: Sounds like an aha moment. Like what and you probably repeat this with multiple clients and customers over time, it’s, it makes me think about sociotechnical systems and most people focus on the technology, and that, but that’s 10% of the problem. And most cases, 90% of it resides with people, how the people interact sometimes how they use the technology. But I love that. 

Karyn Zuidinga: I presume you’re working with people who are both, still training students but also professionals coming back learning some new piece of equipment or some new thing that they’ve gotta get their head around. I’m. I’m so enchanted by this idea of training teams, right? That it’s not just about training an individual about training a team together. And that we invest in the success of it together. And by first understanding, what failure looks like, and how we feel about failure. I think that’s a, that’s a wonderful idea. Ooh. I wonder if we could apply that other places immediately, but I’m also now curious about those outcomes. So this one team comes in and trains with you and they learn about the, you call it the Belmont. Is that right? 

Jenny Rudolph: Yep. That was the machine that helps us get volume into a patient more 

Karyn Zuidinga: And now that team has trained together. Do they work better on other places too? Now?

Jenny Rudolph: That’s a really great question Karyn and something that people are researching more and more in the healthcare simulation space. Really interesting research in the last couple years from colleagues in Australia Vic Brazel and E Purdy have looked at how repeated training of trauma teams influences the level of comfort. We use psychological safety often. And psychological safety is my sense that this immediate environment is safe for interpersonal risk taking such as saying, I don’t know, or asking for help, et cetera. When trauma teams train together repeatedly once a month, for example, that knowledge of each other’s tasks, the ability to create a shared goal and the repeated seeing of people practicing and getting better practicing making mistakes and recovering from that and respecting each other nevertheless, leaks out into the environment of actual traumas and how they’re run. Part of what we try to do in simulation is create a temporary safe space, I use the word safe container where we can do , that work. But what we’re increasingly appreciating is how people come into that space, how psychologically safe they feel as they come in. And then what we do in the space influences then how psychological safety or other team connection, feeling of connection, leaks out the other side. So we were consciously trying to influence those ins and outs. 

Rob Brodnick: Do have any metrics on it? I’m just curious, measurements of feelings of safety or communication, I’m sure there’s a whole bunch of different constructs that play into it. 

Jenny Rudolph: Yeah. Yeah. So a couple different ways that we’ve measured that is using an psychological safety instrument developed by Amy Edmondson who’s the protagonist of psychological safety from Harvard Business School. And it’s a wonderful, simple, six item measure that can be done in about three minutes. We sometimes measure that. The other work that I just referred to, they used a wonderful tool by developed by Jody Hoffer Gittel at Brandeis University called the Relational Coordination M etric. And that measures a variety of things such as: my knowledge of other people’s tasks, my sense of mutual respect with others, et cetera. So we can measure those things. 

Karyn Zuidinga: Wow that so cool. That’s so very cool. I have two feelings that I’m getting I’m I was thinking, wow. So you have this team that trains together and they learn about each other and they get better. And then. Maybe one of them leave, maybe someone gets married, has a baby life changes. Yeah. so they run off to California and start riding their bike all the time. I don’t know anybody who’s done that. Rob so how does that, how disruptive is that? Does the whole team have to go back to the beginning and train again? How do you bring everybody along? And then I, the other piece that I think is that if I expect that if enough smaller teams have had this training and are really working together, then culturally the place must have quite a sea change, a shift where a new person coming in quickly gets assimilated is my guess. Is that true?

Jenny Rudolph: Yeah. I would think about this in three ways, Karyn, and maybe we could take them, piece by piece, depending if they’re continue to be of interest. One thing I think about is what are the underlying values I think about it as the jazz chart, I’m gonna give you the key, I’m gonna give you, we’re gonna kind of work through these measures. The piece of music we’re gonna play is gonna be about that this long there’s something around values. And I’d love to talk about that. Then there’s sub teams, how do they interact and how do they fail to interact? And then the third thing is skills. So just starting with the values, one of the things that we’ve focused on at the Center for Medical Simulation is what we call the basic assumption, which is I’m going to assume that you are intelligent, capable, trying to do your best and you wanna improve. That sounds perhaps a little Pollyanna-ish, but what we’ve found is if my starting place with everybody I’m interacting with is that even if I’m interacting with Rob in a meeting and he does something that, my first reaction is, Ugh, that’s so annoying. I have trained myself and the culture supports the idea that I’m gonna think Rob’s intelligent, capable, trying to do his best, wants to improve.

Let me find out what he’s thinking. Let me find out where he’s coming from. So a core value of assuming the best of each other, assuming innocent until proven guilty can make a huge difference in the portability of how we can move across teams. Part of the way that healthcare simulation I believe is changing the culture of healthcare more broadly is to the extent that the norms of assuming the best of people who are putting their skills on display in this simulation, to the extent that value is carried into the unit or carried back to the, OR carried back to the community nursing or disrupts the mean girls club that is sometimes used to characterize some nursing training programs. That it’s a little causes, a little alchemy where people can come to each other from a stance of curiosity and respect rather than abuse, belittle criticize. That starts making team functioning much more portable and transferable. So that’s part one I would think. 

Karyn Zuidinga: And I just wanna jump in and go. Yes. And wow. I saw that just this past week where I was working with Rob on a thing, I overslept things just went sideways really quickly that day. And instead of, Rob showing up like Karyn, what the hell he was really cool. And it makes a huge difference on how on like that, that tiny little thing. Just assuming that, Hey, it’s I wasn’t being a jerk because I wanted to be a jerk life happened and that’s okay. Makes a massive difference. Doesn’t it.

Jenny Rudolph: Yeah.

Karyn Zuidinga: how everything goes. 

Jenny Rudolph: it. does end. If they may say it’s a discipline, it’s a practice. A number of

Rob Brodnick: it’s hard to sustain. It really is, over time consistently. And especially when things get crazy, 

Karyn Zuidinga: yeah. 

Rob Brodnick: it’s hard to do.

Karyn Zuidinga: Yeah. Super hard. You can. It’s easy when you’re not stressed. Super easy to be chill when you’re not stressed. Really hard to be chill when you are feeling 


Rob Brodnick: Yeah I just can’t the image of the car crash is stuck in my head and it was a great way Jenny, to open early in our conversation because it immediately, I can go back to that and think about, yeah, stuff’s flying around the inside of the vehicle, time has slowed, my, my brain is not functioning normally, but yet I still need to perform. And not only do I need to perform, I need to care about other people right now. So that’s like the ER situation or the, code blue situation when someone’s it really in trouble so that the metaphor helped me. 

Jenny Rudolph: And to that point, Karyn you had asked about if somebody left a team and how do we keep the team performance going, or if I shifted from one team to another, how do I keep the team performance going? so one of the things I think is important in that is having some shared values and assuming the best of each other and being able to have a commitment to resetting my self, to assume the best of the other person is part of that, I think.

But Rob, to your point of my brain not functioning well, my, my amygdala being triggered or I’m really anxious and my autonomic nervous system is kicked in. One of the challenges across teams, Karyn that we try to work with explicitly in healthcare simulation is the negative assumptions we tend to make about other tribes or professions. And one of the things I know as a social psychologist is there’s a phenomenon called the Fundamental Attribution Error, which is if you Karyn and make a mistake, and I see it, it’s because of your bad character. If I Jenny make a mistake, it’s because of the circumstances around me. So if you cut me off in traffic, it’s because you’re a jerk, But. the next day, if I cut you off in traffic it’s cuz I was late for my meeting. 

So part of what we have to do in healthcare simulation is when we have subteams, my group works a lot with teams in the operating room, so we might have a surgical team, we might have an anesthesia team, we might have a nursing team. And when people don’t understand each other’s tasks. They can easily make unfair attribution, that is. Make unfair assumptions about the reasons why somebody else is doing it. You’re lazy. You’re late. You’re a jerk versus, wow you have five orders that have just come at you circulating nurse two from the surgical team two from the anesthetic team and you can’t execute on all of them right away. That’s why you haven’t gotten me that instrument I need right now. Not because you’re lazy and incompetent. Part of what we do in simulation is we can press pause on those moments either explicitly during the simulation or by looking at a video and ask people, what were they up against at that moment? What were they thinking at that moment? And one of the biggest ahas for these subteam is, wow. I never realized that the scrub tech has to protect all the instruments at that moment while everybody else is, let’s say we’re having to resuscitate the patient, everybody else is trying to resuscitate the patient, she’s keeping the instruments clean so that if, and when we can start the surgery again, they don’t have to be decontaminated. We have to get a whole new set. And I never knew that. So those are the, the kinds of things we try to surface.

Rob Brodnick: That pressing pause is amazing. And I’m thinking about positive turbulence and one, one way we look at it is you can bring turbulence. You can be the turbulator and try to produce positive outcomes. Another view of it is, Hey, there is turbulence, right? It’s all around us. And how do we keep it positive? How do you keep the turbulence positive? But you gave me an insight and it’s pressing pause on the turbulence, which is a rare thing. Like you can’t pause the car crash, right? It’s happening. But as a learning and training moment, to be able to pause the turbulence and just have a moment of reflection, I imagine the next time you’re in a turbulent situation that you can’t pause, you might do things differently. And so I don’t know. It’s an insight I had help me validate that. Is this real, or am I just making things up here a little bit? Or is this part of the magic of CMS and what you do? 

Jenny Rudolph: Yeah. I like to think it’s part of the magic of The Center for Medical Simulation and many healthcare simulation programs, which is we do have the luxury of pressing pause. The other thing we have the luxury of doing, back to your question about how do we keep the teams functioning, Karyn is clinician leaders or clinicians who are leading a small team can create a sort of pause even while, for example Addressing the needs of a deteriorating patient or having a conversation with a family of a critically ill patient. That’s a very difficult conversation. How do you press pause in the middle of that? 

 What people are able to do is sometimes do what Marcus Rawle call take 10 seconds for 10 minutes. And what they do is they say, okay, let me just pause us for a moment. Keep doing the chest compressions. Let’s just assume we’re, I’m doing a cardiopulmonary resuscitation. We wanna keep those chest compressions going, but I’m going to describe what we’ve done over the last five minutes and I’m going to describe what we’re gonna do in the future. And we have a process that we call name, claim, aim to help teams do that, where I’m gonna name the fact that we’ve given the epinephrine. We’ve done two minutes of chest compressions. We’ve got a secured airway. So I’m naming the situation we’re in. I might assign different roles that need to change claiming those different roles. And then I might say so in the next two minutes, we’re gonna keep up the chest compressions. We’re gonna give another dose of epi and we’re just gonna keep ventilating the way we are. What that does Rob, regarding the turbulence, is it names, things, what we found is this actually comes from the psychotherapy literature to some degree, name it, to tame it. When you can name difficult things that are going on, it reduces people’s anxiety. It reduces their cognitive load because they understand what’s happening. And they also feel, oh, Jenny or whoever is naming it has got this. So again, we’re creating that container, that temporary container where people can help their anxiety be born, can trust others to do the work they need to do and can trust themselves to do the work. I don’t think we can always pause turbulence, Rob, but we can reduce its emotional impact by being able to name it is what I think. 

Karyn Zuidinga: Yeah, that’s crazy cool. So we talked about underlying value. We talked a little bit about sub teams just there. But we haven’t talked about skills yet.

Jenny Rudolph: Yeah. I’m gonna just say one more word about sub teams and positive turbulence, and then I’ll switch over to skills. My colleague, Chris Russin at The Center for Medical Simulation has been very interested and been able to map and document what are the micro climates in larger team. And in a larger team of say 10 people, there. might be three or four subteams.

And within each subteam people might feel quite psychologically safe and be able to quickly exchange information with each other and trust each other and believe each other have their back. But across those subteams, there might be a much chillier environment. I’m sure that either both of you have had the experience where you’re maybe in a corporate meeting or there’s a something planned and a certain person walks into the room and the entire temperature in the room just goes down, or you can just see everybody’s shoulders go up. 

That is a new entry to the team that changes the subteam dynamics and reduces the subteam psychological safety. Part of the work of, again Karyn, being able to help us perform across teams from situation to situation is how do we build in practices that make each team. Feel more safe. And so that’s where I’m gonna get to the topic of skills. 

Rob Brodnick: Awesome. I gotta say, I had a small amount of self pride about my ability to ask multiple part questions, but Karyn just knocked it out of the park. I’m now I’m now the student, because this has been a sustaining three part question. That’s genius. So you two rocket go 

Jenny Rudolph: all right. Thanks Rob ex Rob look at what a good trio we are here, guys! Just to be, to make an analogy for a moment, cuz this is live right in the moment. So let’s assume we all hold the basic assumption about each other, which I think we do, but we’ve quickly assembled a trio. That’s an ensemble that’s working together to produce, we hope a relatively interesting conversation.

We’re doing that by using our skills of turn-taking. We’re using that by using our skills of listening, we’re creating this conversation by paraphrasing back and following up. And so even though we’ve never been together as a trio before we have some common values, some common skills, some common things that we’ve brought together in order to produce this trio right now. 

So extending our trio into the healthcare team space, the things that we’ve started finding is that allowing healthcare providers to narrate what is happening is a key teaming skill. What people tend to wanna do when they’re taking care of a patient, which is very good for you and me is like, get down to business start assessing the patient, looking at them, head to toe, palpating, different parts of the body, or listening to heart sounds or breast sounds or whatever, or doing intervention such as giving a medication or whatever it might be. And not thinking aloud about the process of what is happening there. So what we’ve found is it’s very socially abnormal for people. People find it awkward and unintuitive to name the process that they’re entering, but of the biggest teamwork skills we work on is helping people do that. So for example, 

Karyn Zuidinga: Oh, 

Jenny Rudolph: we run a simulation. yeah, Sorry, go ahead, Karyn. 

Karyn Zuidinga: So suddenly I, oh yeah. I can totally feel how awkward it would be, but that when someone does it, the tension is released.

Jenny Rudolph: exactly. So imagine your te a simulation that we run is trying to build people’s ability to work in an ad hoc team, just as we have with this trio, how do you quickly come together in a new team, that’s never worked together before that’s an ad hoc team? And because of COVID, so many people are now working in new spaces with new teams, with new equipment. We now understand the pathophysiology of COVID much better than we did two years ago, but imagine the pandemic, you’re constantly having to work in new teams and new situations. Healthcare has changed so dramatically also because of the pandemic, because we’ve lost so many providers who have decided to leave the profession.

And we have many, many new providers with patchy or uneven or different levels of skill. Part of what, what we’ve talked about before is we can’t rely on the fact that this new person has the same value set that I do or sees things the same way that I do. So these ad-hoc teaming skills become incredibly important.

So an example is you’re a team who’s in the emergency department and you’re working together on a shift for the first time, someone of, you know, each other, some of you don’t, and you’ve got a multi-casualty let’s say car pile up of say four or five patients coming into the emergency department and you need to plan to get ready. It’s very seductive and easy to just jump right into do we have this bed free, do we have that bed free, can the operating room take a patient when we need to send them up there? Who’s gonna do triage. Who’s gonna do this. Who’s gonna do that. It’s important. All that stuff has to happen, but the teaming skill that people need to build is to say, Hey, we are a team that is getting ready for these patients to come in. We need to just pause for a second and think about who’s gonna do each role and how are we gonna divide that? And then how are we gonna reset ourselves if we get off track? So those process oriented skills are things that work across multiple disciplines in multiple settings. And so we’re trying to make that more socially normal by having people practice it in simulation.

Karyn Zuidinga: I’m feeling you all the way along and I’m applying it in, in, my own worlds among multiple worlds that I work in where, all it would take would be a really easy, Hey, we’re a team for this, we’re doing this thing and this is how it’s gonna go. Oftentimes that, at least in the worlds I travel in, those things are assumed. They happen more or less, sometimes better, sometimes worse, but nobody, including me, stopped to say, Hey, we are a team. And our objective is that.

Jenny Rudolph: We could critique our trio if we wanted to at the beginning of the recording, or even before we started. I didn’t do this, but we could have said, Hey, we’re gonna be a trio today, recording, You’re both expert facilitators. So am I, what skills should we bring to this party today to make it even better than it might normally have been? And so that’s, that would be an example of that. 

Rob Brodnick: That’s Cool. Sometimes Karyn and I play, good cop, bad cop on these, but we it’s you’d be really nice. And I’ll ask tough questions today. We didn’t have a plan at all though. First Hey, it made me think a little bit, the way you started to talk about COVID. I know everyone’s business model shifted during the pandemic. Healthcare quite dramatically because so much of healthcare provision is literally hands on, right? It’s there face-to-face, person-to-person, and now we have this social distancing that’s occurred and all that. I imagine that your business, how you do what you do at Center for Medical Simulation changed, but how did the nature of your training change or the things that you do for your customers or clients over the last two years, just curious about that. 

Jenny Rudolph: Pretty much all the professionals across the globe who used to do in-person meetings or in-person trainings, almost everything we do now is available, online in some kind of online platform. And the main change that we had to make is for finding innovative ways to create challenging, realistic clinical simulations that still let people practice.

So the kind of thing that we can’t do now is going back to the original example of, we wouldn’t be able to have someone actually practice intubating a patient on Zoom or Skype or what a platform we’re on, but we can create a situation where the decision making around that needs to be done. And so the challenge for simulationists I think probably similar to all education lists right now is how do you bring the heat up? How do you make it challenging? How do you make it exciting? How do you make people’s heart rate come up a little bit when that’s a good thing to do. And so that’s, those are the kind of innovations that we’ve had to make. And just to give a simple example in the, OR for many anesthesiologists, if the patient’s vital signs start decompensating in a certain way, just getting worse in a certain way, as the patient’s heart rate and oxygen saturation goes down, or the heart rate, their heart rate goes up and the oxygen saturation goes down, the provider’s heart rate is going to go up. We can take advantage of those things even in this online space. So the turbulence of COVID for us, the positive turbulence, I think the thing that shook us up got us to rethink is where are the most important places to do in person work and where can we get a lot done remotely or working together, but remotely. And so we’ve given a lot of thought to, to that piece. 

Karyn Zuidinga: Yeah, 

Rob Brodnick: Yeah, it’s a puzzle everyone’s trying to figure out right now. And it’s quite a challenge for sure. you know, Life sort of happens, we float down stream. And it’s all smooth and easy, right? We know where we’re going the expected destinations in front of us, but inevitably something happens right. A little bit of white water. The raft gets jostled. We veer off into an eddy and we’re all of a sudden, either stuck in a circle or, you know, trying to pull our, our gear, our paddle up to get back on that path we were traveling and a lot of people think that those moments are disruptive and negative, but there’s opportunity in it. And I, I just wonder if Jenny if that ever happens in your world and what can you do about it?

Jenny Rudolph: Yeah, I love the analogy. Rob I confess to being really committed to seeing life as a people growing machine. And so you know, when the the raft gets a little upended or jilted or something happens in an interpersonal context, you’re in a meeting at work and somebody says something that really contradicts something you care about, or you get upset or you get triggered. I think what I’ve learned from simulation is any perturbation like that, any disruption like that is a marvelous opportunity to either press pause or switch to slowmo and think about what’s going on with me, such that I am triggered by that. How can I reset myself and interact with that other person better? And what we can do in simulation is we do the simulation, we record it with a video. Then we come back and we look at it in a debriefing, but what I think is exciting for all of us is as we build those skills, we can do them in real time. One of the things that I’ve been working on for several years is something that Susan, Eller from Stanford University Medical School taught me, which is when I’m thinking WTF or what the F that somebody else did. How can I flip that to, what’s their frame? What were they thinking? So WTF to WTF the other, the second one being, what’s their frame, what’s going on with them. And I love that application of debriefing. And debriefing we’re always interested in what is the other person thinking? What are people thinking?

And when I can get curious about what the other person’s thinking, It usually transforms my practice in the moment, cuz I find out, wow, that was, there was actually a really good reason they did that apparently extremely obnoxious thing. And wow, I need to really rethink myself. And that then strengthens my ability to do that sort of a reset and come to them from a stance of curiosity and respect over and over,. Which I think creates more connection and more peace among us.

And also, often increases improves performance in a team or something like that. 

Rob Brodnick: A little bit like empathy. Say to me,

Jenny Rudolph: Yeah. exactly. 

Karyn Zuidinga: Is it just a practice thing to be able to be good at that? Or is it is there something else there? So I found myself in a situation where I got triggered not too long ago and I got into a thing and it took me good 24 hours to kinda work my way through it. And I’m like, oh man, I showed up as a jerk. I was snippy and jerky, let’s be clear and oh, and that’s because I got triggered. Oh, and then I thought, oh, where were they coming from? Why did they show up the way they did? But it took me 24 flippin’ hours to get there, not the 10 seconds that it, you know, so I’m wondering, is it situ I’m sure it must be situational. Some things are gonna be bigger and harder than others, but also is there a practice thing in there and is there some kind of tip maybe to share to oh, how can I quickly get to understanding? Oh yeah. I’m not showing up very well. I’m being a bit of a jerk right now. Like there, and to switch what’s their frame? Is there something that you learned along the way that maybe helps our listeners.

Jenny Rudolph: I’m sure that all, everybody, most grownups have some sort of a trick when they feel triggered, that allows them to recognize that, accept that and reset themselves and then engage. For me, it’s been a practice of what I just said, recognize the that I am triggered, accept that I’m triggered is a really big part of it for me, rather than fighting with it. 

Rob Brodnick: Yeah. 

Jenny Rudolph: and by practice Karyn my experience is, I’ve been able to create more and more space between the reaction and the triggered state and what comes outta my mouth next. And so, you know, whether it’s breathing or counting to 10 or everybody may have their own thing. For me, I tend to label, I actually have a little acronym that I use. Which is RARE, which is what I just said, which is Recognize, Accept my reaction, Reset, and then Engage. My goal is to make it not too rare, but recognize, accept, reset, engage kind of helps me with that. I find WTF to WTF so humorous that it’s, a

Rob Brodnick: Yeah, 

Jenny Rudolph: it’s just right. I just use that, and because I’m often thinking WTF and then that, that in and of itself, that changes that Q routine reward, the Q is WTF.

The routine is reset and the reward is usually I find out something because of, as you said, Rob, and empathy and interest and curiosity, what’s going on with that other human that changes what I do.

Rob Brodnick: four steps in RARE they can’t go in another order. You actually have to process those is cuz if you don’t re reset before you engage you’re right back into that moment. I think Dan Goldman called that the amygdala hijack , when you get into those situations and, as an emotionally intelligent person, being able to even recognize it’s happening, that’s a huge leap for a lot of people, but I can only imagine when you’re training high performing teams that are under a lot of stress that they’ve gotta not only have been schooled in these techniques, but made ’em their own.

Jenny Rudolph: Yeah. In the transfer that we try to make, just to circle back to the beginning of our conversation is people often think they’re coming to, a training program to work on their clinical skills. And indeed they often do get to work on those, but using that react accept reset type skill to manage your emotional state and your team by naming the dynamic or narrating the situation or describing what has been done and what’s going to be done next. Those are all socially abnormal. In that we don’t generally talk about process in social context, but we’ve increasingly been able to normalize those and I think it’s the naming skill that really helps us calm ourselves down and connect with the other people on the team. 

Karyn Zuidinga: For sure. It gives you that sense that somebody’s in charge, somebody’s in control. This is not just wildly spinning. Somebody’s got off this thing and I can go, Ooh, I can breathe now. And now, okay. Now I can come back and do all the things. while the thing is spinning and you feel like it’s spinning, it’s really hard to take a breath.

Fantastic. I feel like it, it could this kind of thinking this kind of approach, culture’s so big right now in the corporate world, everybody’s talking about culture. Everybody’s scared about losing talent to other places. The great resignation is far beyond the medical world. It’s in every industry out there. It’s hard to hire people right now cuz you know, people are getting snapped up left right and center. Yet there does not seem to be a very at least in the wider world, a very conscious understanding of how to create culture and how to grow culture. We throw the word around, oh, we’ve got a great culture. And sometimes it happens. There are places that are wonderful. But it feels often accidental rather than intentional

Rob Brodnick: And there’s gonna be yeah, huge. The echo that, that follows and as you said, the great resignation, some people are calling it the great upgrade. The cultures that are gonna be either left or produced they’re gonna need some tending. And I think some of these mindsets perspectives and tools, Jenny makes me think about adjacent worlds, right? And you’re applying a lot of this to health, healthcare education, healthcare delivery, and all that. But boy, 90% of the world out there could use a lot of this, deep simulation where it’s team introspection, personal mastery of the ability to interact and work with tech. It’s not really about the tech so much anymore. So just has me thinking about, wow, there’s so many adjacent applications to what you do for 

Karyn Zuidinga: Yeah.

Rob Brodnick: I didn’t frame that as a question. I’m sorry.

Jenny Rudolph: good. That’s good. Yeah. 

Karyn Zuidinga: Magic wand, if you could, would you and where? 

Jenny Rudolph: Where would we apply these things more broadly? I think one of the culture drivers that’s works in any setting is the idea that how we talk to each other each moment can, create a virtuous cycle or a vicious cycle. So if I start a meeting and say, our agenda’s this, and here’s what we’re gonna try to talk about today. I only have one perspective and I would really like to hear other perspectives, please speak up if you disagree, I’ll be inviting you to it’s cetera. And then somewhere in the middle of the meeting, someone speaks up and I say, Rob, when I want your opinion, I’ll tell you I’ve immediately. Suppressed the culture of speaking up in that meeting, because a, I said one thing and did another, which now makes you not trust me very much, but B suppressing, anybody sharing opinion has a, is easily amplified. and so what I’ve done there is I’ve started a cycle where

Rob’s not gonna speak up and other people saw me press Rob. They’re not gonna speak up. And as fewer PE fewer people speak up the norms about speaking up get weakened. And so we’ve created that vicious cycle of silencing and indirectness versus I invite everybody to speak up. And in the middle of the meeting, Rob says, Hey, I have a point of view on that. And I say, oh Rob, they, what is it? Let me hear it. Then you share it. And I say, oh, thank you so much for that, Rob. Does anybody else have a point of view on that now I’ve started creating a virtuous cycle of people trusting that if they speak up, it will be heard and it will be accepted the norms of speaking up, get strengthened. And I’m making a circle in the air with my hand right now. And those norms are our culture. They are part of our culture. And so that is how we drive culture through conversation. And what we try to do in simulation is sort of infect the rest of the culture with the stylized tools and processes that we use in simulation. 

But I think those kinds of norms of inviting, speaking up, supporting, speaking up that works in any industry in any context all the time, of course, there are certain moments where, we have to get something done really fast or something bad will happen to a patient or something bad will happen and that’s different, but. What we’ve learned from the research of Amy Edmondson and others is creating a context where those things can be shared. That’s applicable in any context, in my view, 

Rob Brodnick: Yeah, those moments are like grains of sand. The little catalysts that can turn a great something meeting performance, whatever it is in to that vicious cycle and, you know, recognize cuz it, the thing slip, right? You we’re all human. We make little mistakes, but recognizing that, Hey, something just destabilized. I’ve gotta recover this and I’ve gotta turn it back into the virtuous cycle. That’s a, that’s an art

Jenny Rudolph: right? And that’s a, that’s what in the family therapy literature and the couple’s therapy literature is called it repair attempt, or a bid repair bid. And another part of building culture in my view is accepting repair attempts. And building on repair attempts rather than deflecting repair attempts.

To your question, Karyn, I think all of this is applicable in many industries in many contexts. 

Karyn Zuidinga: Yeah. Yeah I completely agree. I was thinking about the leadership portion of that, that the repair attempt the being open, the inviting commentary, but I also thought about not so much lately, I haven’t seen it, but it certainly have seen it where you’ve gotta a bad actor in the room, a disruptor and not, not just disruptive, but damaging, disruptive. How do you respond to that? Do you see that in your world of medical simulation and how do you course correct? Beyond just modeling the good stuff? Somebody just is feeling like, oh god, I’m not gonna listen to 

Rob Brodnick: yeah. They don’t show up with those intentions that everyone else, should. and 

Karyn Zuidinga: for whatever reason they’re showing up, not their best self that day. How do you help them come out of.

Jenny Rudolph: Yeah, I think there’s a couple different things. One is before. So I have shifted from a point of view that I can train almost anybody to do anything to selection is really important. So I think that as you are trying to create teams that can work well as an ensemble picking people who are capable of assuming the best of others. For more complex conceptual work, picking people who understand that their thoughts are not the truth. That don’t equate what I think with reality, but recognize, I have thoughts that filter reality. I have to select for those two crucial things, because it’s much, much harder to change people and for people to change themselves if they don’t have the, those two attributes. The other thing, so there’s selection way in advance.

The other thing that we bring from simulation into our daily work often is this idea of a briefing or a pre-briefing where we create a set of agreements at the beginning of a meeting or the beginning of a project, how we are gonna work together. What are the expectations? What do you owe me? Karyn? What do I owe you? You can expect me once I’ve committed to do X by Y date that it will be done by Y date or. these are the ways that we’re gonna talk to each other. We’re going to not interrupt each other, or we’ll listen as an ally or we’ll invite other points of view. So we create those pre-agreements such that when there’s a disruptor in the middle, we can go back and invoke the pre-agreement that this was not something we agreed we were not gonna do is much easier to do than try to affirm the rule in the moment. And then lastly, again partially empowered by the fact that the, from the specialized world of simulation that I think we can also bring to other things is if I’m the uh, educator leading a simulation program, I have a sacred duty to make that environment as psychologically safe as possible. Now that we’re working with broaching race and racism and identity. As identity safe as possible. And sometimes that’s not gonna be possible it’s gonna be a space where people feel invited to be brave, but it’s my responsibility to manage that space. As the person who’s invited people there.

And I see that the same way in meetings, other things like that. If I’m the chair of the meeting, it’s my job to make sure that everybody can function, not just the disruptor. And so again, I’ve, you might call me harsh or ruthless or whatever, but I’ve become much less forgiving about disruptive behavior and uh, I’ll find ways to sequester that person or that behavior and get them out of the space of the thing I’m trying to do. 

Karyn Zuidinga: Before we run outta time, I’ve got one other thing I really wanna explore with you, which is the concept of failure. We talked a little bit about it at the top, where you were saying, if we don’t learn how to do this what are you gonna feel? In the worlds I travel in we like to say, the words fail fast to succeed in, all this sort of design thinking talk. But the reality is I haven’t met a person yet who feels good about failure. How do you, and I’ve been searching for a way to bridge that for people. How do you bridge it in your worlds? Okay. We’re gonna train for success and we’re gonna feel good about it, but what are, what other tools might be, might there be around navigating failure? Cuz your failure is way worse than mine, right?

Jenny Rudolph: I’m as a simulationist leading a simulation organization, I have super luxury, which is no patient is gonna be harmed when somebody makes a mistake in one of my simulations. And patients can be harmed if a similar mistake were made in real life. And that is very problematic for the patient and the provider and the institution.

However I’m very influenced by Amy Edmondson’s work in this space and her wonderful book, The Fearless Organization, which is how do we create organizations, where we can make mistakes and we can fail, and we won’t be humiliated and shamed, first of all, she to use the word sequester again, she separates out mistakes or adverse events that were caused by willful malfeasance or criminal intent or bad intent, there’s, that’s another whole One of the animating features of the basic assumption that I spoke about earlier that you’re intelligent, capable, trying to do your best and wanna improve is I have to apply that to myself because I, Jenny and each of the eyes in this room are listening here. We might feel guilty or ashamed when we make a mistake.

I, I certainly do, but I quickly try to slap down over myself. I’m intelligent, capable, trying to do my best and for whatever reason, my emotions at the time, my, my mental state at the time, whatever I was thinking propelled this mistake. And just as we talked about react, accept, reset, engage. I have to do that same thing around my failures and mistakes, which is I feel bad.

I have to accept that I made the mistake. Sometimes it takes me 24 hours. Sometimes I’ll feel terrible about it for a week, Karyn. Anybody with high standards does not like to make mistakes. At the same time, that concept of life is a people growing machine. It’s such a gift, there’s that wonderful book by rabbi I can’t remember his last name, The Gift of the Skinned Knee. When you fall down and skin your knee, you’re gonna learn something and you’re gonna get more resilient. I think failing fast, what I’ve taken away for of the work of Amy Edmondson on this, is the leaders and managers and everybody around and the person themselves has to have a sense of forgiveness and excitement about what are we gonna learn from this mistake? 

And it’s the follow up. Beyond the commitment that I think really shows the seriousness, like we could say fail fast. And then when you fail, everybody raises their eyebrows. That’s going to not make it possible to fail fast. But if you fail fast and you’re like, whoa, Karyn, that was awesome. Oh my God. Now 

Rob Brodnick: Let me give you a 

big hug, 

Jenny Rudolph: Now we know that’s not gonna work. I, those kinds of mini celebrations of mistakes and how are we going to learn from them? That actually makes it more credible I think . Okay, here’s the mistake. And here’s what we learned or here’s how we’re learning. I think makes it a lot more credible for organizations. 

Rob Brodnick: Wow. We’ve got such good stuff.

Karyn Zuidinga: Fantastic.

Rob Brodnick: awesome. What else Karyn? We got one minute 

Karyn Zuidinga: I don’t wanna stop without saying thank you so much. This conversation has been exactly that explore somewhere that you don’t know really much anything about. And new stuff will emerge for you 

Rob Brodnick: delight and surprise is 

what resulted 

Karyn Zuidinga: precisely that moment. So thank you so much for spending the time and sharing with us your wisdom and knowledge, because I’m gonna take this away. You’ve just changed my world. So thank. 

Jenny Rudolph: Thank you both for the opportunity. Really great to be here. 

Karyn Zuidinga: Hey, lovely listeners stay tuned to find out where Jenny goes to find some positive turbulence. First, a huge thank you to AMI who have nurtured us in developing this podcast, is the source of so many of our guests, and of course the founder, Stan Gryskiewicz is also the author of the original book, and dare I say, the George Washington of positive turbulence. 

Rob Brodnick: AMI as a pioneering nonprofit organization, comprised of committed individuals who foster and leverage creativity and innovation in organizations in society. AMI identifies leading edge innovation, shares experiences, sponsors, research, and recognizes innovation and creative processes. Find out more at

 And thank you to Mack avenue music group, our contributing sponsor for providing our podcast soundtrack, Late Night Sunrise.

 Let’s see where some of our guests go for their own positive turbulence. 

Jenny Rudolph: Two things. One is I do a lot of the same turbulence searching, which is I listen to a lot of different spiritual guiders, like Mark Epstein, the buddhist psychotherapist, or Michael Singer, the computer programmer reflection guru. They often have ideas that force me to take a step back, but in a way it’s inherently non-turbulent, cuz I do it all the time.

What I’ve started doing recently influenced by the book Range, which was about how the generalist thrives in a specialist society or something like that. The author of Range argues, we should be reading much more broadly, read in botany, read in horticulture, read in cooking, read in astrophysics.

So what I have found is I try to listen to either audio books or some podcasts in like areas that I know nothing don’t think are gonna be important to me. And they end up usually blowing my mind and pointing me in a new direction. So conceptual turbulence comes from that and and then like learning new ways to move.

I just started trying to figure out if I could play golf which I know is a very conservative sport, but it’s dang hard and it’s totally uh, getting me thinking in different ways about how do I move.