Simulcast Journal Club November 2017 – Sticks and Stones

Introduction :  

Simulcast Journal Club is a monthly series heavily inspired by the ALiEM MEdIC Series.  It 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.  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! 

Copy of Journal Club (3)

Title :  “Sticks and Stones 

The Case : 

Joe jumped at the sound of the tree branch crashing and his son’s scream, but Nimali had somehow managed to pick him up off the ground before Joe could even assess what was going on.  She glared at him with maternal rage.  The beer can in his hands wasn’t doing great things for his image. 

“How’s his arm?” he asked meekly. 

“Hopefully fine.” Nimali said hotly.  “No thanks to your parenting.  I saw you paying more attention to getting another beer than watching our 6 year old climb a tree, and I’m concerned you don’t comprehend he could break his neck up there.  Any thoughts on that?” 

“Don’t A.I. me in front of our kids.” he growled.  Being married to a Simulation Instructor had been mystifying at first, but 6 years into their marriage he was pretty comfortable with the lingo. 

“I just don’t understand how little concern you have for his safety!” snapped Nimali. 

“I care about him just as much as you do!” he snapped back.  “But you think you can protect him from everything!  I have a duty to let him learn to take some risks too.  Every kid should climb a tree in their childhood.  And anyways,” he said, “I need him to know I’m not going to be there to catch him every time.” 

Nimali paused.  Her son’s tears were drying and she felt her heart rate slow as he quietened down. 

“That’s true too.” She said, “I just think he learns better when he knows we’re there for him.”. 

Joe lifted his son from Nimali’s arms and ruffled his hair affectionately.  “Then let’s all go climb that tree together.”.  He reached out a conciliatory hand towards his wife and grinned.  “Rapid Cycle Deliberate Practice is more effective anyways, right?”. 

“Oh God.” Nimali smiled.  “That’s the sexiest thing you’ve ever said to me.”. 

The Article : 

Rudolph, J., Raemer, D. and Simon, R. (2014). Establishing a Safe Container for Learning in SimulationSimulation in Healthcare: Journal of the Society for Simulation in Healthcare, 9(6), pp.339-349. 


Discussion :  
In our final article for 2017, we look at a pivotal paper in simulation literature and medical education.  In 2014, Rudolph et al created the analogy of ‘the Safe Container for Learning’ and outline strategies to create a safe learning environment for simulation participants. 


The principles outlined within the article are critical learning points for all simulation educators and for many of us this has been a transformative article.  Three years since publication however, has the simulation community potentially misinterpreted what psychological safety means to these authors?  While Nimali’s concerns for her son’s supervision are valid, is there also truth to Joe’s belief in the inherent dignity of risk? 


To our journal clubbers, what has this article meant to you?  How has it changed your practice?  How does your simulation team approach psychological safety?  What have been some pitfalls you’ve identified? 


References : 

Rudolph, J., Raemer, D. and Simon, R. (2014). Establishing a Safe Container for Learning in SimulationSimulation in Healthcare: Journal of the Society for Simulation in Healthcare, 9(6), pp.339-349. 

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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42 thoughts on “Simulcast Journal Club November 2017 – Sticks and Stones

  • Melanie Rule

    Great case Ben. As a parent & a sim educator, your case made me laugh out loud. I think, like parenting, developing psychological safety for your learners starts from your first interactions with them. As a clinician/educator this includes how you act outside the sim room. Do you support them well in the clinical environment? Do you have their trust as a clinician and as a simulation educator? I think if you have this trust then you can push your learners out of their comfort zone in a simulation whilst still maintaining sufficient psychological safety. If you don’t have their trust, there may be a benefit to starting gently with less challenging cases and earning their trust before you start to push them into more challenging situations. This is similar to the parenting concept of “Circle of Security” where having a secure base allows the child to explore further away from their place of safety as they increase their confidence. Trust in the facilitator forms the secure base that encourages safe exploration & risk taking in more challenging simulations.

    I agree that this article is a must read for all simulation educators. I really liked the appendix where they describe safe & unsafe behaviours of the facilitator. I will be looking to be mindful of these in my own practice in future.

    • Ben Symon Post author

      Thanks Mel, I’m glad you enjoyed the case. It’s interesting being a parent and a sim educator, hey. I notice in your teaching at work that you draw a lot of parallels between the two, and now that I have a 3 year old I note I’m often doing the same. I think a lot about how far to push my son and also my learners, and I think especially in Paediatric Emergency a lot of consultants are guilty of overprotecting their trainees to the point where they’re really only independently making decisions the first night they’re on the floor as a consultant. I’m still trying to improve that balance of supervision vs control on the floor in my practice, and I think I have a long way to go.

      I really like the idea you suggest of the learner’s “circle of security” being similar to a toddler’s, and I guess it highlights a point that Steph brings up below regarding in situ sim, that sometimes we rely on the departmental culture to set some of our prebrief for us.

      • Derek Louey

        Is finding the ‘safe zone’ more difficult if the educator and the student are unfamiliar with each other and what implications does this have when running hospital-wide sim sessions or alphabet courses?

  • Derek Louey

    HI Ben,

    Simulation is certainly the trendy modality of Med Ed and has many potential theoretical benefits. I have previously been engaged in a peripheral and casual manner but as a recently qualified APLS instructor, I feel I really need to understand it at a deeper level.

    I am particularly interested in its relationship to the Yerkes-Dodson stress-performance curve and Sweller’s Cognitive Load Theory.

    Psychological safety is an important concept in any learning encounter but I wonder if what a student can tolerate (or consider ‘safe’) with a positive learning benefit is related to the degree of stress or cognitive overload they can manage.

    It is interesting to witness on courses how the same scenario can produce different and unpredictable impacts on different individuals. What we don’t have is a reliable measure that allows us to know when to ‘turn up the heat’ and ‘when to back off’.

    • Ben Symon Post author

      Thanks for joining the journal club Derek, it’s great to see you online after meeting you at GIC last year!
      I haven’t really consciously thought about the relationship between Psych Safety, the Yerkes-Dodson performance curve and Cognitive Load specifically. It’s an interesting point that you raise. How do you see them interacting?

      • Derek Louey

        Hi Ben

        Psychological safety, if defined as the ability to speak and act without fear of negative consequence self-image, status, or career; is somewhat a fiction. Simulation is not just a parlour game with an agreed contract between impartial participants. Although the mannequin is not real, it represents real patients that we can actually harm from our mistakes. They need to be included in this interpersonal dynamic.

        About 20 years ago, I attended a Simulation seminar when the concept was still in its infancy and was mainly a teaching tool for anaesthetists. I remember the speaker emphasise that they never have the mannequin ‘die’ even if the decisions would have led to that. They found that participants would be psychologically devastated as if it was an actual event. Whilst it is possible to escape the judgement of others, it is still difficult to evade the judgment from our own conscience and professional standards.

        So going back to my comments about cognitive load and stress we may not induce effective learning if we make things too easy. It can be so safe that it isn’t real and therefore there are no stakes. Conversely, a realistic but highly complex simulation where a participant is pushed past the limit of what they can manage might could just result in confusion and disempowerment.

        You mention an important concept in your article, risk. Life has risks and so does clinical medicine. This is an equally motivating factor for learning, not just safety. Children don’t learn much about trees or exercising better judgement just by climbing household furniture. But neither should they begin on skyscrapers.

        A timely editorial

        Live or Let Die: New Developments in the Ongoing Debate Over Mannequin Death
        Calhoun, Aaron W. MD; Gaba, David M. MD

        Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare: October 2017 – Volume 12 – Issue 5 – p 279–281

        • Ben Symon Post author

          Thanks for sharing so much of your thoughts Derek, it’s been so great to have you engaging in Journal Club.
          I disagree with you though about Psych Safety being somewhat of a fiction. I think it is achievable, but to do so takes nuance, and as you mentioned in your earlier post, the same strategy might not work for every learner.

          I agree that there is conflict within the sim community about what psychological safety means, and I think in many ways we have oversimplified and misinterpreted Rudolph et als article. The safe container is probably meant to be ‘the safe enough container’. Safe enough that you can take risks. Safe enough that you can allow yourself that vulnerable.

          While the article outlines a number of ways to achieve this, in particular the importance of the prebrief, being consistent in your behaviours POST prebrief (ie there’s no point telling them they’re safe and then criticising them brutally), and maintaining a stance of genuine curiosity. But what I love about Sim is how much some of this stuff is still alchemy. You can try and incorporate all those elements and still miss the mark, or have the wrong strategy for a specific group or learner. I do think it’s achievable, but it’s 1 part science and 1 part an intricate dance.

          • Derek Louey

            “An intricate dance”

            With a wide range of reactions among individuals that are not entirely predictable. Back to Yerkes, we could take a pharmacological analogy – stress is a dose and response is a learning benefit. The alchemy is because have no reliable means of gauging the outcome purely on the outward reactions of an individual in the short time frame of a simulation session.

            For instance, I found the GIC course last year extremely stressful and highly scrutinised (even with a friendly faculty) but I would still consider that I obtained a positive (and ongoing) learning outcome of having gone through it. I also witnessed candidates who despite successfully passing the APLS provider course (along with myself) mentioned they were glad it was over.

  • Steph Barwick

    Love the case Ben and like Melanie it made me laugh out loud!! The challenge is in finding the exact right amount of psychological safety. We don’t want learning environments that are safe but don’t challenge our learners nor do we want learning environments that are challenging but not safe.
    I really loved that this was the article this month, because I have been thinking a lot of late about the creation of psychological safety in In Situ Sims as these are the type of simulations I am typically involved in. Running simulations in the clinical environment adds a layer of complexity in creating a psychologically safe learning environment which is very different from the Simulation Centre.
    When I read the article I started thinking about the idea of pre briefing in the In Situ environment and what we do in our organisation to prepare our learners. We can usually do an pre brief with the initial team in the simulation but don’t often get that opportunity with the resuscitation team who respond if we are running a deteriorating pt simulation. One of the things that we have been doing is a ‘pre brief’ before the debrief .. i.e. thank learners for participating, acknowledge the time they have taken out of their busy day, convey respect, clarify objectives of sim and debrief, explain confidentiality rules and notify them of length of debrief. The other thing that our organisation has been doing is talking about the In Situ Sim program in orientation especially medical orientation and doing a general pre brief at the beginning of their rotations. These things along with a few others have seemed to be helping but I am not sure if we have hit the ‘sweet spot’.
    The layer of complexity also comes from the fact that we have to ensure psychological safety not only for staff who participate but also for the patients and visitors who are exposed to our In Situ Sims. This is an area of research I am interested in and the article made me think of pre briefing practices for our patient and visitor population and how we can use some of the principles suggested for them.
    I am always looking at ways to improve the psychological safety of ISS for both participants and patients/visitors, so would be really keen to hear if anyone else faces this challenge and what they do to overcome it?

    Thanks for the article and case Ben!

    • Ben Symon Post author

      Thanks for joining the conversation Steph, it’s exciting to get your perpsective as an in situ expert.
      I had never thought of doing the pre brief post the simulation, but that strategy intrigued me as it seems like a viable ‘next best’ strategy for dealing with the fact that we often spring in situ simulation on teams. How have you found the pre debrief prebrief goes?
      I think doing a formal prebrief or simulation orientation at the start of the medical term is a great strategy for getting at least some of the components in this article in early, and setting them not just as a sim expectation but acknowledging sim as part of workplace culture.
      What sort of things do you discuss in the organisation orientation?

      • Stephanie Barwick

        I’ve been having good results with the pre debrief pre brief. I find it helps them to understand purpose of simulation and reorientates them to the idea of the debrief being a learning conversation filled with curiosity and respect – that’s how I see it anyway, I hope our learners feel the same. I do see some evidence in that we have some really valuable conversations in this context even when we haven’t been able to do an official pre brief to everyone before the sim.
        So far the when we speak about in situ sim in the medical orientation we cover what the program is, its objectives, their roles and expectations and that it is apart of our learning culture. We also talk about some of the organizational improvements that the program has facilitated and that they can have a real impact in organizational change in sharing their experiences in the debrief in relation to any systems issues. It is very brief and we are working on ways to get it into all orientations so it is still a work in progress. One of the things we have been able to achieve is that our program is now included in policy as one of the ways we train people in responding to medical emergencies so in situ sims are becoming more of a norm and there is a general understanding of their overall objectives which I think helps with clinicians seeing it’s value despite it being a little disruptive at times. I still think we have got a way to go in ensuring consistent psychological safety in such a challenging context and are always thinking of ways to make it better.

        • Clare Thomas

          Hi Steph
          it was very useful to read your comments as I too, conduct in-situ simulations and establishing a safe container takes time and thought, and is very different to when I do sims in the lab. great idea to make it part of the orientation and I would like to try the same.
          what I have been doing is contacting the team prior to the simulation exercise and giving them the heads up of what is happening. It takes a bit from the surprise element, they get prepared for example. But then I figure we should always be prepared if we are on a emergency team anyway. so the pre-brief is a phone call to all which takes considerable time but I can find out what their level of experience is with simulation and I find this information incredibly helpful especially in running the sim and debrief. I don’t know if it is ideal and unlikely sustainable. This journal club has given me thought to review and ask for feedback on this process.
          I also do a mini pre-brief in the post brief simulation. I use it as an opportunity to lay down the ground rules of showing respect to co-participants in our comments.

  • Rowan Duys

    Thanks again everyone for the case and contributions. My 2 cents worth would be just to highlight some of the influences of psychological safety over which we have very limited control:

    1. Previous exposure to sim. The majority of our learners are ‘sim-for-learning’ naive. They’re still stuck in the mindset of their last summative assessment from days in undergrad training from several years back. And, in our setting, most of those seems to have been almost deliberately traumatic 🙁 Its difficult to undo that in one ‘pre-brief’ but I hope that, with time and repeated exposure, we start to re-create safety.

    2. The established safety within the group. We recently ran a sim with a group of learners that had been an extremely tight study group for the best part of a year as they prepared for their final college exams. We pushed them hard, and the whole group, including observers, were emotionally charged by the sim. But they had created such a safe container before we got our hands on them, that they were able to debrief and share and support effortlessly. I don’t think we as faculty could’ve changed that situation much.

    3. The socio-evaluative stress. My ‘feeling’, and I’d be interested in opinions or references to support of refute this, is that our learners are most stressed or challenged by the fact that there are observers watching them perform. It’s difficult to get away from having observers during our ISS, particularly since we’re trying to promote the vehicle, but it really creates threat. Again, I’m hoping that as ISS becomes the norm, and more and more people have been exposed, that this becomes less of an issue.

    In the meantime, I still wake up in a cold sweat thinking about debriefing a sim for the first time in front of one of my virtual mentors.

    • Ben Symon Post author

      Thanks for your comments Rowan, astute as always :p
      Your story about the exam group who supported themselves through the sim and debrief echoes Jenny Rudolph’s comments in her Psych Safety Podcast where she suggested doing a team building exercise at the start of the day to create safety through a sense of belonging.

      • Cathy Grossman

        This is a great discussion – another part of creating the safe bucket – is trying to get your hands around the perceptions regarding simulation exercises/culture at your institution. Then working to nudge peoples frames..

        When we started doing our interdisciplinary cardiac arrrest simulations 8 years ago for whatever reason many people thought they had been chosen to come for a “poor performance” reason, and this was just for the doctors. But that was not the case by any means. We started to explicitly state that participation was not a remedial task, and that we strive to create (or at least try to ) an experience that will challenge everyone from different professions. These clarifications of known perceptions in our local prebriefshave changed our debriefs and participation only for the better.

        Lastly getting to the granular level for the individual participant the Robert Simon lines (or at least that’s who went through this at CMS when I went) of “giving yourself the benefit of the doubt and each other the same benefit -as sometimes we do something in simulation that we wouldn’t do in the real world”; following up with active acknowledgment to do so seems to at least introduce the idea of self compassion (nod to mindfulness) that is also a wonderful frame shifter for many.

        • Ben Symon Post author

          Thanks for your comments Cathy, I agree that longitudinal relationships and an organisations ‘cultural memory’ appear very effective at creating a stronger safe container.

  • Marrice King

    I see the difference between psychological safety in the case study and what we do in the simulation lab as fundamental to why we have simulation in the first place. In the case study the child is a live person, the tree is tall, and the ground is far down and hard. There is a real and potential chance for harm. If I simulated that case in the lab the standardized participant child would have a harness on the tree would be a manageable height with sturdy branches and safe twigs, and the floor would have a rubberized playground surface grass colored. The two simulation participants [parents] would have the chance to practice various parenting styles debriefing the results of their critical reasoning and judgments after each rapid cycle deliberate practice.
    This is my take on psychological safety: the participants [parents] in my simulation scenario have the chance to try what they learned from the curriculum; to see how it is works for them in 4 dimensions. It also gives them a chance “feel” the gaps and see the results of those gaps in their knowledge or understanding of the material in a situation where no real harm comes to the standardized participant [child]. Know matter what happens they will be supported in debriefing. They are not judged by the debriefers for the path they chose through the simulated learning experience. We will discuss what they were thinking about when they made the choices they did, and look at the areas they may want to try differently the next time.
    I want to say that no body gets hurt in simulation; but having been a participant in simulation and having killed a manikin or two in my time I know that statement is naïve. The times I had psychological safety, I still left mentally smacking myself for making such a stupid mistake. That mental smacking I gave myself worked though because faced with that situation again I did not make that same wrong choice. I had the other better choices explored to choose from. The times I did not have psychological safety, and was ridiculed and made fun of for my choices; I did not hear the what I could do better the next time, just that I was so stupid. When faced with that same situation in real life, I did not have the better choices information or the confidence to try anything at all and my patient suffered as a consequence.
    So that is my thoughts about psychological safety how I practice it in my simulation lab

    • Ben Symon Post author

      Thanks Marrice, I think your comments make a really important point. When you say “The times I had psychological safety, I still left mentally smacking myself for making such a stupid mistake. That mental smacking I gave myself worked though because faced with that situation again I did not make that same wrong choice. I had the other better choices explored to choose from. The times I did not have psychological safety, and was ridiculed and made fun of for my choices; I did not hear the what I could do better the next time, just that I was so stupid. When faced with that same situation in real life, I did not have the better choices information or the confidence to try anything at all and my patient suffered as a consequence.”.
      – to me I think that highlights the fact that even when we’re in a psychologically safe place, we might still feel uncomfortable or remorseful, but that we’re still in a place where we can hear the information needed to improve our clinical practice.

  • Mary Fey

    Hi Ben,
    Once again, a great topic. But, seriously, “the sexiest thing you’ve ever said”?? Geek love! Laughed my head off!

    One conversation I often find myself having related to psychological safety is about the conflation of psych safety with low stress levels. I posit that learners can be both psychologically safe and stressed during simulation. As has been pointed out, learners feel safe when they don’t fear humiliation or loss of professional identity by being made to feel like an idiot. A psychologically safe environment does not need to be free of stress; indeed, simulation is just the place to allow learners to perform under duress for the purpose of developing strategies to succeed in difficult situations. A safe environment is one in which the learners trust that the facilitator is not out to get them, and has their best interests at heart. In the context of this type of trusting teacher-learner relationship, they are willing and able to tolerate stress and discomfort in the service of learning.

    So we can challenge learners with difficult cases, including those in which we thoughtfully allow the patient to die. The key is to prepare them well for what they are about to experience and then to empathetically attend to the emotional reactions that are inevitable.

    • Ben Symon

      Oh Mary Fey, you have no idea how happy I get when you come to Journal Club :p
      One thing that I’m still having trouble with is that on some courses they really try and make people feel safe by naming Psych Safety. Over and over we go “We want you to feel safe, we want you to feel safe”, and then when the Sim makes them feel challenged or stressed, they throw it back at us, saying “You said we were gonna be safe!”.
      I think negotiating that line in the sand, where we tell learners we want them to feel safe enough to push themselves but that we want the process to be challenging, I find that a really difficult contract to make with them. Much more sophisticated and complex than the fiction contract, for example.
      Any tips?

  • Jane Stanford

    Great to revisit this article and read views that are informed by experience of following the ‘safe container’ guidelines (and very helpful/practical appendix). I know many facilitators who see this article as a great guide for ‘harm minimisation’ when runnning simulations.
    I’m interested to know what facilitators think the ‘sweet spot’ looks like or how they have/will assess it has been reached? Personally, I wonder if we can know who is and isn’t ‘mentally smacking’ themselves after the session – when one of the aims is to have learners move to the edge of their capability/work outside their comfort zone. Marrice was not harmed, but would someone with less resilience/motivation be the same?
    Rowan’s examples of the study groups – fearing or embracing the simulation environment and then his own personal ‘cold sweat’ experiences demonstrate for me that at times we may need to accept that we don’t know the impact pre or post simulation training.
    Aside from developing the broader culture of safety with words, actions, behaviours, authenticity etc – is it enough to trust in the principle of respecting the learner?
    A recent article, using Realist methods to evaluate the UK consultant appraisal process, described mechanisms (tacit choices and abilities) that influence change behaviours. The study identified that dissonance (promoting reflection), denial (avoidance) and self-affirmation (positive regard and motivation to maintain status) were the ‘mechanisms’ affecting outcomes. The relevance I see to simulation training is 1) individual responses to the process and information received and 2) effect of receivers respect for the information/process.
    Brennan, N., Bryce, M., Pearson, M., Wong, G., Cooper, C., & Archer, J. (2017). Towards an understanding of how appraisal of doctors produces its effects: a realist review. Med Educ, 51(10), 1002-1013. doi:10.1111/medu.13348

    ..hoping we can have some more insight (potentially even from the authors) at ways they have evaluated their ‘safe container’ recommendations.

    • Ben Symon

      Thanks Jane, I’m looking forward to reading the article you’ve linked, it sounds fascinating! You asked what we think ‘ the sweet spot’s is. For me I think it’s when I can see a group is engaged in the scenario, showing growth focused behaviours, and who are actively encouraging each other to be vulnerable and seek feedback. I think I’ve failed the group if they are focused purely on praising each other as a protective mechanism to avoid or preemptively defend against anticipated critique. If I have truly created a safe container , I hope they’re more focused on giving each other feedback and exploring their learning objectives together.

      • Jenny Rudolph

        Hi Ben I wanted to reply to this gem of a comment by you. What you are saying is that the sweet spot is a place where people can engage in “reflective“ versus “deflective” routines. I think your comment is a gem because it highlights in plain English The empirical insight that Amy Edmondson found in her 1999 study. That psychological safety – the feeling that the environment is safe for interpersonal risk-taking – – leads to learning-oriented behaviors. So what I learned from your comment is that when the learners are successfully willing to look at their own behaviors, think about how to improve instead of trying to protect each other or themselves through defensive routines, we’ve done something right in terms of creating a safe environment for learning. You’re highlighting that moment where there’s almost a feeling of intimacy, vulnerability, and sharing and it’s about connecting and getting better. Ignacio del Moral, The director of the the Hospital Virtual Valdecilla talks about this special moment as instilling the ability to “get better at getting better“.
        Thanks, Ben, for moderating this marvelous discussion

        • Ben Symon

          Thanks Jenny for both coming along and writing the article in the first place :p
          Thanks for the term “reflective vs deflective” routines, it’s such a succinct summary of one of the things I find really challenging : a group’s tendency to protect each other from critique to the point they’re stopping themselves from learning.
          Your description of that moment as being intimate is so true. I think that intrapersonal intimacy and vulnerability is when I find learning through Sim so utterly intoxicating.

    • Derek Louey

      Hello Jane,

      We now meet in cyberspace! What I am struggling to come to terms with is achieving this mythical ‘sweet spot’.

      Each participant comes with their own experiences, cultural norms, preconceptions and ‘baggage’ unbeknownst to us (Rowan Duys comments), the instructor pre-briefs by creating a generic ‘safe container’ for the group and then tries to dynamically modify this during the sim and debriefing to optimise the learning experience. We make adaptations based on our fairly crude observations of how the participant performs in sim or post-hoc by their later reactions (Maurice’s ‘mental smacking’ or Ben Symons ‘cold sweats, Ruldoph’s reflective/deflective behaviours ) or group learning behaviours ( Ben Symon’s comments). The problem is that I can’t see Maurice’s brain flagellating itself, maybe Ben is anhydrotic and I am misinterpreting someone’s silence as disengagement or coldness but they just never liked public speaking and are more comfortable quietly reflecting.

      Meanwhile we have this tension between safety and stress, or safety and scrutiny. We talk about psychological safety as ‘safe enough’ which I take to mean removing extraneous cognitive load (worrying about what others think) and focussing on constructive solutions yet at the same time needing to create enough stress to stimulate learning (but not too much because they then get pushed too far over the Yerkes-Dodson Stress Performance curve and stop learning). But as Ben comments, a group seeking safety by protecting each other (deflecting) with empty platitudes is not the outcome he is seeking but being able to manage the provocative (and stressful) questions that need reflecting upon.

      But this is not a fixed entity because the response to the same stimulus dynamically alters over repeated exposures (Rowan Duys) such as seen in stress-inoculation training. And because Trainees know that their usual clinical experiences are not enough to respond to this, they deliberately subject themselves to sim to prepare themselves for testing in a non-safe container such as an examination. Essentially they are learning to prepare themselves for extremely stressful and unsafe situations. And that is not a bad thing in an exam or in real life. For we practice climbing with safety nets but then we eventually get rid of them.

  • Derek Louey

    After having participated in a year long series of clinical simulations, a group of Trainees thought it would be fun to create a scenario for their Consultants to undergo. At the end of one particular session, they mentioned this idea to their Instructor. Her response was positive. She thought it would be a great way to engage her older and more sceptical colleagues on the benefits of Sim Training. Personally, she had no trouble with the proposal. With years of sim experience, she had learnt to create a safe, constructive and impartial environment that was enthusiastically embraced by her Trainees. During her many learning conversations she had the opportunity to also show her own vulnerability. Some of the most significant lessons that she was trying to convey came from errors that she had unfortunately committed in real life. Her humble admissions served only to impress her trainees even more of her great wisdom and insights. With cautious enthusiasm at the next Consultant meeting she mentioned the suggestion made to her earlier in the week. Their reactions were strangely uneasy. They were never impressed by the usefulness of sim. And now to think that the tables would be turned and that their actions would now be scrutinised by their sub-ordinates was a step too far. The Instructor left the meeting both disappointed and vexed. Psychological safety was considered to be a fundamental precept in Simulation. But how would this be possible if the mere mention of being subject to a simulation could cause these senior clinicians to feel threatened? The whole point of simulation was learning. What did they stand to lose?


    • Ben Symon

      Thanks for sharing your story Derek.
      I agree that engaging senior clinicians in simulation remains ‘the great white whale’ of simulation teaching.
      I can understand the senior clinician perspective in some ways, in that in many ways they have the most to lose from looking vulnerable, being at the top of their tribes hierarchy gradient.
      We carry a huge burden of responsibility for the patients under our departments care. In doing so I think many consultants believe they need their juniors to perceive them as impermeable and perfect in order to maintain their authority.
      Guiding them towards how beneficial it can be for their juniors to see them demonstrate vulnerability is really hard!
      I still don’t think you’re telling us everything though :p

      • Derek Louey

        Hello Ben,

        Maybe this is the answer you are looking for. I think Sim can be a great teaching tool but I think running one successfully is much more than creating Psychological Safety or establishing a plausible Fiction Contract. This article explains a bit more about more how multiple factors can add to the extraneous load.

        Being at both the receiving end and provider, I feel that it still remains somewhat ‘a game’ that you need to learn to play or ‘unlock’ much like having to perform short cases in an exam. In what situation would someone walk straight in to a room without more than perfunctory sentence briefing and introduction and proceed to examine a conscious, competent, verbal patient without the benefit of a history or the rapport-building process that comes with it. Similarly, there is a strange awkwardness of simultaneously interacting with a lifeless mannequin that is being infused with meaning by a third-person standing in the room that is simultaneous proxy-patient, assessor and narrator. There is still an artificiality that you need to overcome that allows you to perform well in it. I have seen some trainees who work quite effectively in a team resus or communication consultation but who find it difficult to make the translation to sim. This form of training is also now becoming part of ACEM Fellowship assessments and I worry that it may not be always a true indicator of a candidate’s ability.

        I think there are multiple aspects of Sim that are different from real life that one needs to adapt to, may impair importance and may influence the Instructor’s perception of what specific lesson/error arises from it. Extraneous load includes things such as previous negative experiences of Sim, natural aversions to public performance (e.g. public speaking, performing in front of a crowd), being able to demonstrate a continuous ‘think aloud protocol’ for sub-consious automated actions (You didn’t seem to check if the patient was breathing’), adjusting the timing of your responses when time seems to constantly dilate and contract as events progress and treatments are given (‘You forgot to measure the BP 30 seconds after giving the fluid bolus that went through in one minute’), interacting naturally with a ‘voiceless’ mannequin which shares the same vocal characteristics as the ‘voice of God’ that punctuates the session (talking to the mannequin or listening to the instructor).

        I wonder how many of these factors have to be addressed before one can get a true assessment of the candidate and what actual knowledge transfers needs to be achieved. Safety is but just one aspect to attend but achieving useful learning is the ultimate goal (germane load)

        PS the above story was largely fictitious (although speculative and plausible)

        • Ben Symon

          Thanks for your comment Derek, I feel like I’m now starting to understand better where you’re coming from. I’m just going to contemplate your thoughts for a while before I respond properly. Interesting things you bring up about the emergency college exams using SIM, it has created some blurriness in my workplace too as candidates treat a translational SIM as an opportunity to practice for the exam when they are two very different beasts.


    Thanks Ben

    Great article and great topic to finish 2017 journal club!
    And loving the discussion and thoughts posted
    These are some thoughts to share:
    • It is fascinating to see that psychological safety (definition /concept) has different interpretation amongst facilitators / participants. I really liked Mary Fay’s interpretation “that learners can be both psychologically safe and stressed during simulation “
    “A psychologically safe environment does not need to be free of stress” “A safe environment is one in which the learners trust that the facilitator is not out to get them, and has their best interests at heart.”
    Which translate to” We need to prepare our participants very well for the sim, respect them and honour our Sim agreement “

    • Here are some practical points that emphasize the importance of Pre-Brief and prepare the participants very well.
    – We should make it clear in our pre-brief “The WHY?” and the HOW?” of the current Sim session
    – The WHY? Why are doing this Sim today?
    Is it to identify gaps in the system? How we work as a team? to test new pathway? patient journey? To get better in what we do every day?
    – The HOW? Get the logistics out of the way early!
    – How many case /scenarios in this Sim session? how long roughly is the actual Sim and the debrief?
    What type of Sim we are doing today (traditional, pause and discuss or LDR )?
    Are we using Mannequin or SP?
    What resources are available (if it is ISS or in the lab)?
    – Sending an email the day before for the participants with (FAQ / or fact sheet of the coming Sim ) is also a good practice .

    • I agree with Derek Louey’s point regarding using Sim as the assessment for the college exams. I personally don’t like to use Simulation for assessments or exams for multiple reasons (I can share them later in another discussion or post)

  • Ian Summers

    I am not sure what the link is between:

    “the sexiest thing you’ve ever said to me” and rapid cycle deliberate practice in your household but, ah, thanks for sharing….

    So, to this months ripper of an article and discussion and I’ve joined this one late which means that so many of the comments I read here I find myself nodding along to, in agreement. Much, in fact, like the original article “Safe container” which I remember reading in 2014 when it first came out. Did I mention I love it? This would be my desert island sim article, and a must read for anyone doing our trade. But, at the time of release it recorded was already being done in our centre, largely due to the huge influence and training of its authors, but also because much of it made intrinsic sense. It didn’t leave me changed by anything within.

    I would love to see a version 2 to explore the areas already identified by your contributors as the areas where safety zones are getting tested: assessment, guerrilla in-situ sim, “poor” behaviour in confederates to explore professionalism, deception, death and dying, allowing mistakes, gamification and level progression. I would like to see scenario design aspects covered too. In mature centres filled with immature simulatonists like me, there is a natural tendency to try things that are new, exciting, innovative and potentially at the border of the comfort of the sim staff (as opposed to the learners). We are humans too. We love trying new stuff. Part of a scenario design checklist should be a brake that includes the question “is it psychologically safe?”, Grant us the tools and wisdom to push that boundary too.

    And a final thought, as I swing wildly into a meta digression, is the appreciation of the risks of adding any thoughts to an on-line journal club and the skill with which you weave your moderation to encourage and question and (gasp) disagree with comments in an open forum inviting, by its nature, critique of the work of some of the legends of our sim world. Thanks!

    As ever, yours in psychological safety,


    ps. What sort of parent would ever put their child at risk? Surely not! Bubble wrap and cotton wool forever.

    • Ben Symon Post author

      Thanks Ian, I agree for an experienced debriefer this article might not be as transformative. I guess I view it as a critical foundational article upon which to build more fine tuned abilities when establishing a growth oriented environment.

      I too look forward to a safe container sequel that looks at more in depth strategies for in situ, multidisciplinary Sims etc. Although maybe we already have some of the answers in this discussion?

      Thanks for your compliments about the moderation. It is particularly challenging encouraging critique of a paper by SIM Superstars, but I keep telling myself that my experience with Jenny et al is that they are willing to allow themselves to be vulnerable too, and that the only way I can truly show respect is to be willing to give feedback or invite a different perspective. I have faith they’d expect no less from us.

  • NoSafeSpace

    Great article.
    My ward is a case study of what happens when a bully is made a Clinical Nurse Educator.
    There is no safe space. Ever.
    She exemplifies the worst: Those that can’t do, teach.
    Nursing staff are paralysed with fear in emergencies: Arrest teams comment on it!
    Staff do not feel safe to speak up about safety issues.
    Graded assertiveness? Minor deviation from a ‘ghost guideline’ = yelled at and performance management.
    The best, most motivated staff are belittled and targeted by unjustified monitoring and criticism of their work (they threaten the status quo).
    Critical thinking is mocked and discouraged e. g. Feeding a late prem baby… “that’s all covered by hypoglycaemia policy” 😕 (not true).
    “We don’t do that here” = a rationale.
    “You’ll have to dumb down to work here” = advice to new staff member.
    I made a formal complaint … Now know why people don’t complain…. Retribution, no change, concerns minimised by HR and upper management. Mediation can be a great forum for a bully to have another go, too…

    • Ben Symon Post author

      Thanks for your anonymous comment, it sounds like this is a situation you’re finding stressful and / or frustrating. While I’m keen to keep away from specific examples of individuals with whom we’re frustrated, I do want to acknowledge your comment.

      I think your example highlights an important point that Chris Nickson makes in his soon to be published expert opinion : “Psychological safety is not something you say, it’s something that grows from what you do.”

      Our educational roles and our behaviour on the floor are not separated. If we do not model psych safety in the workplace, it will not follow us into the SIM room.

      I don’t want to further discussion upon an individual’s behaviour though as this isn’t an appropriate format given the public nature of the discussion.

  • Derek Louey

    Thanks Ben for moderating the forum. It’s been great seeing everyone’s responses and crystallising my own thoughts. Before it closes these are my final thoughts:

    On Psychological Safety for which I am in agreement:

    1) Without experiencing safety within any learning encounter, an individual’s ability to learn and engage is significantly curtailed
    2) A pre-briefing in sim (setting of the ground rules/rules of engagement) is an important component in establishing this condition

    What I feel may impact a person’s perception of lack of safety despite an adequate briefing:

    1) An overly complex simulation unsuitable for their ability/experience/mental resilience (‘You ambushed me’, ‘I just felt overwhelmed and deflated’)
    2) Extending the bounds of the ‘fiction contract’ by a poorly designed sim, an unrealistic scenario, instructor and confederate miscues/mis-steps/unrealistic actions that produces erroneous responses by the participant and later incorrect conclusions about their performance during the debrief (‘I didn’t do that because it didn’t seem how things would happen in real life’)
    3) A lack of familiarity with the ‘simulation game’ of stereotypical cues and stock responses that need to be demonstrated to ensure successful performance. (‘I’m not sure what you wanted from me at that point’)

    4) A scenario which contains negative stereotypes and caricatures of individuals for which the participants may identify with (‘The incompetent RMO’, ‘The unreasonable relative’, ‘The ignorant nurse’, ‘The arrogant surgeon’, ‘The obstructive radiologist’)

  • Ben Lawton

    Hi Ben
    Excellent case which has clearly prompted an excellent discussion. I want to come back to what Mel said at the beginning about the “circle of security”. My first thoughts when I originally read this paper were of the parallels between “the safe container” and John Bowlby’s “secure base” which forms the foundation of attachment theory with the idea that kids need to know they have a place of emotional safety (an attachment figure/secure base) from which to explore the world. So I think Mel’s focus on the importance of trust is spot on. I suspect this parallel between child development and simulation education may be deliberate as Donald Winnicott (another prominent developmental paediatrician) gets a reference in the paper. Winnicott thought we have “true selves” and “false selves” with the false self essentially being a defence mechanism/set of behaviours that comply with other people’s expectations (if anyone is really interested his Wikipedia page explains it quite well In that sense we probably all have something of a false self at work as there are some legitimate feelings that it’s not OK to share with patients and colleagues so it’s reasonable that working around those defence mechanisms in simulated clinical environments might need to be a learnt behavior for most of us. As Mel says I think the key to doing that is about trust in the facilitator and whether we can develop that is partly down to what we say, heavily down to what we do and also heavily influenced by the departmental/institutional culture.

    We are lucky to get to deliver simulation based courses in lots of different hospitals around our state, so lots of different clinical teams many of whom we don’t know and don’t know us. Some places I feel like it really doesn’t matter what we say as everyone is clearly there to learn and arrives assuming that everything is going to be safe, other places it feels more like the environment described by anonymous where establishing some kind of psychological safety with words feels like trying to chop wood with a butter knife. We start one of our courses with a case discussion involving a patient who got sub-optimal care and get participants to explore the reasons behind some of the CRM/communication failures that occurred during this patient’s journey. One of the main reasons for doing this is so that we can explicitly push the discussion towards exploring the frames of the characters in the case with positive regard rather than allowing attribution of blame or assumptions of incompetence in the hope that “actions speak louder than words” and we are role modelling the type of conversations we expect to have in the debriefs when the participant’s themselves become the subjects of those conversations.

    The other theme that has come up in this conversation that I struggle with is the conflict between sim used as a summative assessment and sim used for learning. Clearly the former does not allow the psychological safety that is essential to the latter. I find this really hard with the paediatric resuscitation courses that we run as there is this institutional need to “demonstrate competence” and an actual need to improve clinical care. Any course with a test at the end inevitably leads to participants (or at least some of them) being heavily focused on the pass/fail element of this throughout the course, often I think, at a real cost to meaningful learning. People are working in roles where a growth mindset is essential to optimal performance yet we force the values of a fixed mindset on them. Mastery learning is attractive as an approach to this where there is no such thing as failing but there is such a thing as not having passed yet. That context of sim being used as an assessment tool in other aspects of participants professional lives is clearly something we need to be conscious of when establishing the safe container, even if our own courses are almost exclusively devoid of such distractions.

    As a final point (because this is a journal club) I think the complexity of the methods in this paper highlight just how difficult an area this is to research and kudos to the authors for creating such an approachable roadmap through such wildly varying literary terrain.

  • Jenny Rudolph

    As we think about “establishing an engaging environment“ for learning, we can think about two amazing such environments created in part by Chris Nickson aka @precordialthump: The blog, Life in the fast lane and the conference SMACC. Both of these have fostered lively, argumentative, sharing, communities of practice that build knowledge, skills and commitments to just and fair practice. It seems to me they support collegiality, spicy discussion, and listening to other perspectives that are hallmarks of psychologically safe yet challenging environments. Looking forward to your commentary!

    • Chris Nickson

      Thanks Jenny!

      I feel like I’ve been skulking in the shadows watching the fantastic online discussion unfold on Simulcast. Soon I will have my say – and I hope to have heeded the final advice Robert Simon gave me years ago on the Harvard CMS course… 😉

      Jenny, your comments about LITFL and SMACC are very kind. Most of the good bits are just a manifestation of the communities that have driven their development. However, I pause to reflect that while I share your perspective on SMACC and FOAM as being psychologically safe and challenging environments, not everyone does. Indeed, there are individuals who I suspect would argue the opposite and feel both excluded and that if they said anything negative about SMACC/ FOAM they would be unfairly shot down. Over the years, I seen many teams and organizations where there was such a dichotomy. Perhaps we should anticipate this whenever we strive to create psychologically safe environments: it is in the eye of the beholder and not the same for everyone; we can’t always achieve what we want. Nevertheless, a worthy goal is worth striving for, and, when achieved, an environment where everyone feels psychologically safe is a wonderful thing.