Simulcast Journal Club September 2019

Introduction :  

Simulcast Journal Club is a monthly series that aims to encourage simulation educators to explore and learn from publications on Healthcare Simulation Education.  Each month we publish a case and link a paper with associated questions for discussion.  Inspired by the ALiEM MEdIC series, we moderate and summarise the discussion at the end of the month, including exploring the opinions of experts from the field. 

The journal club relies heavily on your participation and comments and while it can be confronting to post your opinions on an article online, we hope we can generate a sense of “online psychological safety” enough to empower you to post!  Your thoughts are highly valued and appreciated, however in depth or whatever your level of experience.  We look forward to hearing from you. 

Title :  “Broken Trust 

The Case :  

Nitin held Nimali’s gaze, silently searching for a hint of what emotion lay beneath.  Suspicion, certainly… but there was something else he couldn’t quite grasp.  In the dim light he slowly reached for her hand but withdrew at her involuntarily shudder.  His heart broke quietly in that moment.  “It’s a uniquely awful experience.” He ventured. “To lose the trust of the person who first taught you the Basic Assumption.”. 

Nimali’s eyes flickered. 

“I’ve lied to you.” He acknowledged.  “I’ve lied to everyone here since my arrival.  I’ve had to spin half truths and falsehoods through every conversation we’ve had.  But Nimali, I’ve never lied about loving you.”. 

Nimali winced as if she’d been struck.  “I’m afraid, Nitin, that our fiction contract has expired.” 

“I’ve wanted to tell you.” He said honestly.  “I’ve wanted to for the longest time.  But I can’t.  You’ve got to believe me Nimali, I’m trying to protect you.  You and this centre.  I need you to trust me, we’re all in very real danger.”. 

“You want trust?” countered Nimali.  “Trust is built longitudinally.  On a foundation of shared vulnerability, of integrity, of mutual respect… and from role clarity.”.   She advanced on him, fearless and stern. 

“What role are you playing, Nitin?”. 

Tachypnoea took hold as Nitin frantically weighed his options : lose his cover or lose the woman he loved.  His voice shook as he went to speak, and in that moment he finally recognised what he’d seen in her eyes besides fear.  Affection.  A remnant maybe, threatened and weak, but present nonetheless, with just a hint of positive regard.  A kernel of their past maintaining the tiniest of openings into her heart.  It was going to take a leap of faith. 

He took a deep breath. 

“I’m a spy, Nimali.  A foreign agent recruited by your Government, and if we don’t stop this murderer soon, it won’t be just psychological safety I’m worried about.”.

The Articles : 

Kolbe, M., Eppich, W., Rudolph, J., Meguerdichian, M., Catena, H., Cripps, A., Grant, V. and Cheng, A. (2019). Managing psychological safety in debriefings: a dynamic balancing act. BMJ Simulation and Technology Enhanced Learning, pp.bmjstel-2019-000470. [Currently open access thanks to BMJ STEL]

Ng, S., Kangasjarvi, E., Lorello, G., Nemoy, L. and Brydges, R. (2019). ‘There shouldn’t be anything wrong with not knowing’: epistemologies in simulation. Medical Education

Discussion :  

This month we’re looking at different papers that reflect upon psychological safety.  The first, by Michaela Kolbe et al provides an update on thoughts regarding the Safe Container and in particular a focus on nuance and advanced moves at repairing a perceived psych safety breach. 

In the second paper, Ng et al look at psychological safety with a different lens.  Asking if perhaps medical culture remains so hierarchical that espousing the goals of psychological safety may not be enough to create a truly safe space for higher learning. 

A questions for this month to start the conversation : 

  • How do you think these papers change your approach to maintaining or repairing a sense of psychological safety in your teams? 

References : 

Kolbe, M., Eppich, W., Rudolph, J., Meguerdichian, M., Catena, H., Cripps, A., Grant, V. and Cheng, A. (2019). Managing psychological safety in debriefings: a dynamic balancing act. BMJ Simulation and Technology Enhanced Learning, pp.bmjstel-2019-000470. 

Ng, S., Kangasjarvi, E., Lorello, G., Nemoy, L. and Brydges, R. (2019). ‘There shouldn’t be anything wrong with not knowing’: epistemologies in simulation. Medical Education

About Ben Symon

Ben is a Paediatric Emergency Physician at The Prince Charles Hospital in Brisbane and a Simulation Educator at Lady Cilento Children's Hospital. He currently teaches on a variety of paediatric simulation based courses on paediatric resuscitation, trauma and CRM principles. Ben has a growing interest in encouraging clinical educators to be more familiar with simulation research.

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10 thoughts on “Simulcast Journal Club September 2019

  • Eve Purdy

    Ben, as always thanks for the entertainment and the smile!

    I find the Kolbe paper an awesome way to think about psych safety in and out of the simulation experience.I found the aspect of the paper about salvaging psychological safety to be particularly helpful. Even when you’ve done your best to build the container it just might leak. How can one stop it from bursting completely or maybe even patch the hole?

    I got myself into a bit of a bind recently….I was facilitating a simulation activity for a group of participants who I did not know and who did not know each other – all sorts of high risk psych safety red flags. I was deliberate about building and fostering this during the pre-brief and felt I had been successful. I then picked participants for the simulation. About 2 minutes later I noticed that one participant was holding back and was a bit slow to get up when the team went outside. In fact, she was still in her chair while the rest of the group was at the door. I knew I had stuffed something up. Racking my brain about how to address this appropriately – not just to salvage psych safety with the participant but not destroy it with the rest of the group – was something that I felt a bit underprepared for in the moment. Fortunately Jenny Rudolph was in the session and seeing her across the room reminded me of this paper and though not outlined as an approach to build/maintain safety I wondered whether “advocacy inquiry” would work – not just to debrief effectively but to save the psychological safety situation – it was all I had to go on…so I thought, “well, here goes nothing.”

    “____, I notice that you are not joining the group, is there something you are concerned about? If so, I’m sure we can work through it together.”

    As it turns out, though their English was so good in the pre-brief that I didn’t think twice about language being a barrier to participation, they usually practices medicine in French, not English, and was particularly concerned about not having the medical language skills to go through the scenario smoothly.

    Together the group brainstormed a couple of options (from switching participants, to trading roles on the team etc.) but they were keen to participate and be the team leader with some support. Eventually we decided that we would pair them with an english speaking participant who could be her “dictionary” if needed.

    The scenario started and they didn’t turn to her dictionary once.

    This stands out in my mind because it highlighted how rapidly and unexpectedly the psychological safety of a situation can change. I was feeling pretty good about my pre-briefing and though we’d be smooth sailing until debrief time. It reminded me that recognizing and addressing threats to safety is entirely necessary to the integrity of the experience. This could have resulted in total disaster – not only for the individual but also for the group. Fortunately through the recognition of non-verbal cues, and literally having Jenny Rudolph in the room as a reminder about some implicit and explicit techniques to build, maintain, and salvage safety I venture that we might have even had a stronger foundation headed into the debrief.

    Perhaps the salvage done well is actually an opportunity to take psych safety to the next level….

    • Susan Eller

      Hello Eve,

      I agree – a salvage done well, is a way to enhance the psychological safety even further. I think it deepens the trust. You demonstrated your fallibility AND willingness to openly discuss how to make the situation better. Kudos.

      My own reflections later Ben – I didn’t forget 😉

    • Laura Rock

      You offer a lot of psych safety, Eve, in how you describe your own emotions – fear of “stuffing something up” and how you worked through with bravery and your skills!

    • Ben Symon Post author

      Thanks for starting the convo Eve! What I get from your story is in essence that psych safety is not a fixed, concrete foundation on which to build a house of learning, but instead a shared space we may continually rebuild, break and repair with our participants. It reminds me of some psych theories about the core of successful relationships being how we rebuild and repair rather than how great a couple might sync up in terms of matching characteristics. I remember Jenny in another Jclub mentioning psych safety being a conceptual space held by the group, not an individual.

  • Susan Eller

    Hello Ben,

    Like Eve, I liked the Kolbe et al. article as a resource for ways to think about identifying breaches to psychological safety, and then strategizing how to recover. In my earlier simulation career, I think that one of the things that I hesitated doing was naming the dynamic and have since found it a powerful tool.

    I had an interesting personal reaction when reading the Ng et al. article. I was very intrigued by the abstract, and agree that the dominant culture in medicine rewards certainty, and that is not the philosophy of so many simulation educators. We believe that simulation should be a safe place to make mistakes and voice uncertainties. When I started reading the article, my imposter syndrome was triggered a bit. In the first paragraph, they used epistemology (or some variation of the term) seven times. I am a PhD student, so familiar with the terminology – but I don’t use the word in every day sentences often. Definitely not seven times in one paragraph. I had a momentary thought of “maybe I don’t belong in academic medicine”. It was a fleeting response, and I got through the rest of the article and appreciated how the authors explored the learners’ desire for feedback from faculty. My internal struggle reminded me of the Kolbe article, where they outlined individual, group and organizational antecedents of psychological safety – one of which was a learning orientation versus a performance orientation.

    It was ironic to me that I was probably demonstrating one of the concepts that the Ng article explored: I wanted to be “right” or smart enough to be more comfortable with the terminology instead of being comfortable not knowing and learning – I am glad I persisted. I also reflected to my days as an ED nurse educator, because if I would have read the Ng article with the challenging terminology, I would have chucked it before getting to the qualitative study part. Their point of how the dominant culture conflicts with SBE ways of knowing would have been lost to me due to what I perceived as jargon.

    Having that initial moment of discomfort, and reflecting back to a time when it could have made me dismissive or defensive, was a poignant reminder to me to be aware of the learning environment that I have created – both intentionally and unintentionally.

    • Ben Symon Post author

      Hi Susan, sorry it took me a while to reply to you because I was too busy googling Epistemology. Thankfully I can now quote a definition but I still don’t get what it means ;p (I’m … not joking, Study of how we know stuff? Is that it?)

      I found your reflection very interesting in that I think what I’m hearing is that the complexity with which the Ng article is presented created a potential barrier to reader engagement, despite there being a lot of good stuff in there. And in doing so, it perhaps mirrored the way complex facilitator language, acronyms or terms not used in common vernacular can create a barrier to learner engagement by subtly reinforcing an expertise hierarchy so unbalanced that the identity threat to new learners prompts disengagement.

      Thanks so much for this, I will have to reflect on my own practice. I remember a good colleague reminding me that ‘frames’ is not a term that my non sim colleagues would know without explanation after feedback on a conference talk. It’s easy to slip into this space.

      • Susan Eller

        Ben – every part of your response – from googling Epistemology through using the term “frames” (I have done that too) – so eloquently and succinctly expresses my thoughts.

        Cheers mate.

  • Belinda Judd

    I read with interest the paper by Kolbe and colleagues. I was particularly pleased to be reacquainted by the technique of ‘naming the dynamic’. Susan Eller notes early in her career she was reluctant to name the dynamic and reflecting on my own approach, I certainly share some of this hesitancy, but am reinvigorated to work on it! Whilst not new to simulation, being directly involved in debriefing is not usually a large part of my role. I can see how the technique may be a great diffusing trigger when threats to psychological safety arise or a technique to restore it when it has been lost. I was also intrigued from reading the paper to consider the evidence on what may be the relationship between psychological safety and learner engagement in sim scenarios and debriefing? The assumption of course would be that when psychological safety is perceived to be high this may relate to high engagement, but it would be a nice study to empirically investigate the relationship of these constructs! The same would go for determining if low perceived psychological safety impairs learning?
    The Ng et al paper reinforces that faculty should be modelling an authentic appreciation of learning through experiences, errors and discovery. This is a good reminder about the explicit conversations to learners about this style of learning and non-consequential mistakes. I was somewhat frustrated that Ng and colleagues suggested that simulation may not indeed provide a safe container for learning due to faculty and discipline culture but didn’t appear to use the opportunity to ask Med students in interviews their perception on whether they felt they experienced a safe learning environment? Some of the participant responses appear to highlight that many did in fact feel they we in a safe container for learning. Concerningly, there was a strong theme of fear of humiliation amongst peers/colleagues and a sense of needing to be seen to be smart/correct.
    From quite different approaches, interestingly, both papers suggest psychological safety is best enhanced when faculty authentically embody and role-model a value for learning through trial and error. This is something that has provided some good food for thought for reflection.

    • Ben Symon

      Hi Belinda! Thankyou so much for your very considered comments and critique of both papers. It’s interesting to hear that both you and Susan were nervous or reluctant about naming the dynamic. What is it that makes you uncomfortable with it as a conversational technique? Is it the sheer fact you’re acknowledging an elephant in the room, or is it something else? I would say personally I have found it a remarkably effective technique, not just in debriefing but more frequently now in real life situations, particularly when facilitating meetings.
      You mentioned that you are not directly involved in debriefing a lot lately, how come?

  • Sonia Twigg

    All of my favourite genres now coming together; simulation literature, fantasy, romance and now spy novels! Perfect holiday reading!

    Kolbe’s paper was an elegant discussion of debriefing that goes beyond the facile assumption that psychological safety can be commanded and into the mud of what actually happens. I have felt breaches in safety before of course but have not had the language to describe it -or this list of clear strategies to restore it. I also liked the description of Naming the Dynamic. I have seen this done beautifully – but this paper helped clear up some of the mystery of how to do it.

    As for Ng’s article, well yes, it’s a relief to get brutally honest about the effect of hierarchy and dominant epistemologies in medicine. And thanks for introducing me to such delicious new vocabulary (took a bit of time to look it all up and think about it!) When I was a trainee participating in sim, I did find that while I appreciated the efforts towards creating safety, it felt ironic to be assured that what happened in the sim was confidential and my performance not assessed, but I knew my consultants in the room would inevitably form opinions about performance which could inform my term feedback.

    This misalignment of competing underlying assumptions is not all bad. We live in a complex world and regularly cope with competing epistemologies. For example, when I participate in simulation my race, gender, socioeconomic background, role and training level all interact in competing ways. Recognising all these interactions gives us more to reflect on in the debrief! I am encouraged that there seemed to be a role for the clinical teacher (facilitator) in setting the learning climate, and framing the approach to learning that challenged some of the dominant cultural messages and encouraged co-creation of knowledge.

    I did find the task given to the medical students of learning to differentiate cardiac murmurs to be an interesting choice. Perhaps I am accepting a dominant belief in emergency medicine that cardiac auscultation is a subjective skill – there is evidence that cardiologists themselves cannot reliably differentiate murmurs. (And note my affirmation of dominant medical culture that the task should be more objective!) This is also a quantitative query – had the students actually learned? Had their ability to auscultate a cardiac murmur improved? Or was this task simply an excuse for an excellent debriefing discussion? Perhaps the larger study from which this data is derived will tell.

    Thanks again Ben. I’ll go back and keep reading the papers until this intangible knowledge is embodied in my doing – running the next sim.