‘Safe, not soft’ – hitting the sweet spot for simulation-based education

By Victoria Brazil(@SocraticEM) and Eve Purdy (@purdy_eve)

Learners in simulation-based education are at risk. They may be deceived, judged or ‘shown up’ in front of their colleagues, and dread returning to the sim lab. But equally they risk wasting time in simulation – if faculty are ‘too nice’ or fearful of offering performance critique. So how do we find a ‘sweet spot’?

Consider two hypothetical case studies. In the first, learners arrive at their simulation session without any preparation, are thrown into a stressful scenario, tricked by faulty equipment or performance sabotaging ‘confederates’, and then berated in front of their peers for their poor performance. Clearly problematic.

In the second example – learners have a pre-briefing before their simulation, including an instruction from the facilitator that ‘it’s a safe space here’. They perform barely adequately in the scenario. They are reassured in the debrief that ‘they did really well’, and the facilitator offers explanations for their deficits, and assurances that they will do better next time, without offering any critique or suggestions for ‘how’. The learners exacerbate the charade by offering a performative debrief using words they know the facilitator expects – like ‘closed loop communication’ and ‘clear roles’. The simulation has become ‘hyper-real’, and arguably lost touch with clinical reality.

Which activity has actually done more harm for learning? Have either justified the considerable resources that are required for design and delivery of simulation-based education.

Psychological safety is critical for learning and improvement, but a little misunderstood….

As Amy Edmonson describes it, psychological safety is “a shared belief that’s its ok to take interpersonal risk” in a group/ workplace/ learning environment, and is a strong influence on the performance of work teams. Ideally, it can accelerate learning – allowing us to push boundaries, fail, and extend ourselves. But psych safety is not just ‘being nice’, offering appreciation, or ignoring poor performance. Courtesy and candour can co-exist.

Creating a ‘safe container’ for learning has received a lot of attention in healthcare simulation due to the evaluation apprehension that many simulation participants feel, as well as memories of experiences like the first example described. Psychological safety is created slowly, consistently and by actions as much as words.

In situ simulation has highlighted a new issue – what level of psychological safety do real world healthcare teams (including facilitators) bring into their simulation-based learning?  Faculty can’t suddenly ‘create’ psychological safety in education if healthcare teams have dysfunctional hierarchies and poor relationships in their real clinical (or other) work.

Of course, we also hope that the psychological safety supported in simulation sessions is transferred back into those real world clinical environments. If so, this may be one of the more powerful impacts of simulation training on healthcare teams – working on the relationships and culture in the workplace.

What does this mean for the simulation educator, especially those delivering in situ simulation?

  1. Aim for ‘safe, not soft’ in design, delivery and debriefing of simulation.
  2. Be mindful of the dynamics teams bring into simulation sessions, including your relationships with them.
  3. Look for opportunities to explicitly explore psychological safety in simulation sessions – in language that is meaningful to those teams.
  4. Encourage discussion on practical transfer of psychologically safe conversations and behaviours to the workplace, including the barriers to that.
  5. Stay tuned for more in this area from our research team that is busy exploring the bidirectional impact of psychological safety in simulation and workplaces for real-world teams.

Happy simulating….