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.
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….
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 😉
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!
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.
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.
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.
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.
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.
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?
Hi Ben,
Thanks for your comments. Yes I think it’s about naming the elephant in the room and if not done well, perhaps it has the potential to escalate the situation rather than diffuse.
As a simulation academic at uni, my role is more around simulation program/curriculum design, developing and teaching simulation tutorials and in-services, training actors, patient case development and simulation research and evaluation etc. We generally employ clinical educators to guide students through Sim cases and then they run the debriefs in our Sim centre 🙂
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.
Oh Sonia, I think you have nailed it! The challenge of being primarily a clinician that also works in SBE with their clinical colleagues. It is complex to wear multiple hats within an organisation and currently I’m finding it super challenging…. the hierarchical nature of health care. I imagine my colleagues are also very confronted by me working in different spaces at different levels!
Thanks so much Sonia for such a well thought out critique of these papers. Sorry for the delay I replying but I wanted to reread the Ng paper with your thoughts in mind.
For me the Ng paper delights me for its central thesis that the culture we promote in Sim is asynchronous with the dominant medical culture we work in. It speaks to me so powerfully about the inconsistency and in some ways, hypocrisy that this dichotomy can present.
But I think you’ve pointed out very politely that the methods used to investigate that theory aren’t optimal. A sim to essentially practice a skill that involves correct interpretation of a sound as a specific heart murmur seems an explicitly perfect set up to encourage students to focus on what the ‘right answer’ is rather than deeper reflection on the clinical approach to cardiac diagnoses.
I’d also argue that med students are not necessarily the most familiar with all aspects of medical culture, and being at the start of their learning journey should appropriately focused on knowledge acquisition and the pursuit of basic skills. It makes no sense to me for them to be focusing on higher level reflection or clinical application so early in their careers.
Despite this I found the qualitative analysis and the themes and comments they reveal to be delightful and informative. As you allude to Sonia, there’s much brutal honesty there, and I think it stimulates an important reflection on what we tell ourselves as educators about just how flat the heirarchy really is.
A spy! Yet another twist I could never predicted!
Thank you for spotlighting these two papers. Though it has important messages, I honestly had a rough time getting through the Ng paper so I’m thankful for the comments thus far that helped break it down. The reminder that how we as facilitators/leaders conduct ourselves (both in and out of sim/debriefing)
The Kolbe et. al. paper is a resource that I will refer back to regularly. While it is framed around managing psychological safety in debriefings, many of the strategies/concepts apply to all sorts of interactions.
One of the things that I’ve been thinking about for a while is the idea of a “longitudinal pre brief” – much has been described about what to cover prior to simulation or immediately prior to debriefing. What about the days/weeks/months before a program (i.e.: post-clinical event debriefing or new in-situ program) is rolled out? Some of our most successful implementations have been after spending ample time to discuss what the program is (and isn’t), what to expect, etc during a grand rounds/town hall augmented by emails/posters. Reminiscent of the same moves done immediately prior/during a debriefing, the timing well-before events likely allows processing with a different level of extraneous cognitive load (h/t Michael Meguerdichian)
Hello Komal,
I love that you gave a name to the longitudinal pre-brief. I used similar techniques in the past when launching a new simulation program for nurses. At the time I thought of it as prep for those who did not have experience – or had negative experiences with sim in the past. I wish I would have had the language to think of it as an extended pre-brief.
Thanks for coming Komal! I’m missing your presence in Australia already !
Interestingly in a previous discussion on psych safety the Mater team noted that they do an institutional pre-brief at corporate orientation as a deliberate strategy to get the tone right early for as many staff as they can catch who might intersect with their pop up sims. It sounded like a very good idea!
I’m sure they’ll comment on that post curry tonight!
Thanks Ben and Simulcast crew for hosting such a rich discussion about psychological safety in debriefing. This is such an important topic! One of things I’ve struggled with personally is recognizing when psychological safety has been breached. What happens if the signs of the ‘breach’ are subtle, and you don’t pick up on them as a debriefer?
I remember one particular debriefing I was co-facilitating where learner came up to me after the debriefing to let me know how upset she was with the nature of discussion. I had obviously failed to pickup on the breach(es) of psychological safety during the debriefing ….. but it had me thinking, should we not be more pro-active and REGULARLY utilize many of the strategies described by Kolbe et al in our debriefings, as opposed to ONLY using them in a more reactive manner when breaches are obvious? Perhaps if we do this more regularly that will prevent potential breaches in psychological safety from occurring?
Keen to hear what people think about this…..
Adam
Hello Adam,
Your question about the subtle signs of the breach of psychological safety took me back to a clinical example. After many years of being an ED nurse, I had a patient come in who made a faint, but distinctive, sound in the back of her throat and I told my resident and attending to prep for intubation, as she was going to go into flash pulmonary edema. They looked at me like I had two heads, but sure enough, she started frothing within minutes – yes, we were prepped. I told them I had heard that sound only twice before, and I would never forget it.
It made me wonder, what are some of those subtle signs in debriefing? Are learners reactions so individual that it is hard to determine, or are there “sounds” of early warning that we can heed? Or is it the best practice to be more pro-active in using some of the strategies outlined in the Kolbe et al. article? Yes, I think that can prevent potential breaches, AND I think that there is constructive value to psychological safety when the participants can see facilitators successfully navigate the breaches that do occur.
Hmmmm! Early signs of psych safety breaches! Great thoughts Susan, I’m wracking my brains about things that instinctively tip me off. To me it’ll often be just something about an off handed comment, a subtle facial expression or poor eye contact reciprocity. Sometimes it will be hearing the same theme expressed from the same person in different conversations even though it doesn’t seem particularly relevant for that particular content, which suggests to me an unresolved psychological need.
Hi Adam, thanks so much for coming along!
Interesting points about our ability to detect participant distress during a debrief. I think your points about prophylactically utilising the strategies outlined as opposed to interventionally using them are very appropriate. It brings to mind to me a lot of Schmutz and Eppich’s recent publications/presentations on team inclusivity recently. My perspective would be that with appropriate anticipation around sensitive topics that are coming up, inviting candidates to express concern about the nature of the discussion may be useful as well. My thoughts would be that we sometimes have unrealistic expectations of ourselves when debriefing, that we have no psychic link with participants who are often very good at disguising their thoughts in front of any perceived authority figure. I’m wondering how we can delegate shared responsibility for the safe container.
Mater Curry Journal Club
Karen is our newest Sim team member and gave her perspective as the new kid on the block.
Karen felt the Kolbe et al article was very helpful for introducing concepts of psych safety to an experienced clinician but novice debriefer in the SBE space. Karen thinks it will end up dog eared as sh can see it’s benefit as a reference tool – easy to “doss up” if read on the eve /morning of a SBE event, refreshing concepts.
The group felt Figure 2 and Table 1 were well set out with a lot of information. Table 2 Dynamics deserves particular mention with “scripted” suggestions of how to approach challenges within the debriefing environment. The group readily agreed that an extended “phrase book” would be a useful tool for debriefers considering how many “lines” we have taken from Walter or Jenny over the years. Such a resource may be helpful at alleviating some the tongue tied-ness especially when debriefing is a new skill. It would be great to be formulated internationally; acknowledging that phrases are possibly centric to organisation’s or even geographic locations and the need to be mindful that phrases are not lost in translation.
Steph related to the difficulty of identifying breaches in psychological safety, and although we felt that as instructors we may be responsible for causing breaches, we also talked about other participants’ role in upsetting the safe container. We discussed how we build psych safety across the campus and loved the new term “longitudinal prebriefing” which we attempt to apply at in situ simulations, and the importance of experienced debriefers supporting those delivering simulation locally. This led into the discussion of how critical it is to Debrief the Debrief – to provide an opportunity for the educator to reflect on all the stakeholders: learner group, co- facilitator and the entirety of psychological safety.
As the naan was being consumed we moved to discussing the Ng article. Many admitted only reading the front and back page, and we agreed that there is a level of inaccessibility for clinician educators in the writing. Sarah admitted on her second read through she stopped reading and challenged herself to finding sentences with greater than 40 words – of which there are quite a few! We wished for more pragmatic example to explain the big words in the introduction!
But moving on from our admissions of simplemindedness, there is a very valid point to be made that there may be a conflict between the way beliefs underpinning education in SBE and in the clinical environment may be different. This could be a reason why many of us clinicians took years to develop as effective SBE debriefers!
Perhaps as most of us are not involved in undergraduate education, we felt that the title “there should be nothing wrong with not knowing” is perhaps a little misleading (click – bait perhaps?). Our focus on SBE is on application of knowledge, particularly in teams, and therefore, we agreed that not being able to apply knowledge effectively in the simulated or real world is common and should be viewed with curiosity. However, we were less in agreement that it was okay to not know and this led us back to a conversation about SBE use – not to impart knowledge but to apply it. Perhaps it is different in undergraduate SBE, perhaps this view is simply a reflection of our misunderstanding of what knowledge is and we are demonstrating our lack of academic credentials again!
Thanks Ben for introducing these articles – our minds were challenged, we had a great discussion, many laughs and very full bellies by the end of the night.
Thanks Karen and the mater curry club for such a wonderful summary! I really enjoyed all your points, but was particularly interested in what you meant at the end about ‘However, we were less in agreement that it was okay to not know’.
I’m interpreting that as an acknowledgment that actually in medicine we do have responsibilities to have an understanding of the principles we practice, and that there’s a balance of being open to human error but accountability for certain standards. Am I understanding it right?
Yes, we are responsible for knowing the basics of our craft, but acknowledge the application is often problematic! That’s where we focus our efforts in sim right? Doing vs knowing. Or am I thinking of this too simplistically????
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