Establishing a Safe Container for Learning in Simulation

The Role of the Presimulation Briefing

Abstract

Summary Statement 

In the absence of theoretical or empirical agreement on how to establish and maintain engagement in instructor-led health care simulation debriefings, we organize a set of promising practices we have identified in closely related fields and our own work. We argue that certain practices create a psychologically safe context for learning, a so-called safe container. Establishing a safe container, in turn, allows learners to engage actively in simulation plus debriefings despite possible disruptions to that engagement such as unrealistic aspects of the simulation, potential threats to their professional identity, or frank discussion of mistakes. Establishing a psychologically safe context includes the practices of (1) clarifying expectations, (2) establishing a “fiction contract” with participants, (3) attending to logistic details, and (4) declaring and enacting a commitment to respecting learners and concern for their psychological safety. As instructors collaborate with learners to perform these practices, consistency between what instructors say and do may also impact learners’ engagement.

Simulation and postsimulation debriefing have long been appreciated as linked steps in generating insights and clarifying lessons in experiential learning situations.^1–4 In the experiential learning cycle, simulation can serve as an experience or experimentation period, and postsimulation debriefing is an opportunity for reflection, allowing learners to make a sense of the experience and determine how to apply lessons learned to future clinical performance.^2,5 Yet, there are a variety of threats to learner engagement in simulation and debriefings, which can weaken the effectiveness of the experiential learning cycle. Learning can be impeded when (1) learners do not “buy in” to the simulation endeavor,⁶ (2) they find the fidelity of the simulation problematic, (3) they feel exposed by the simulation and debriefing in a way that threatens their professional identity,⁷ (4) they feel defensive discussing performance that falls short of a standard.^8,9

So what can instructors do to help create a safe container, an environment where learners face professionally meaningful challenges and are held to high standards in a way that engages them but does not intimidate or humiliate them?

We suggest that establishing an environment where learners can enter a deep level of connection to their motivations, each other, and the instructors begins before the simulation starts. The notion of a thoughtful prebriefing, introduction, orientation, or other similarly entitled epoch occurring before a simulation has long been part of practice.^10,11 However, the elements, rationale for each, and predicted effectiveness have not been blended into a set of promising practices, and we wish to do that here.

One crucial aspect of engagement in health care simulation and debriefings is risk taking in the service of learning. This focus on risk taking in the service of learning is guided by a diverse set of research findings that stress a willingness of the learner to go to their social and intellectual edges with a positive attitude.¹² Manifestations of this engagement are what Edmondson^13–15 calls learning-oriented behaviors: these include reflection on action, feedback seeking, speaking up about what one thinks, asking for help, testing ideas that might or might not be right, and reflecting on results. Engagement also includes what March¹⁶ calls experimentation and Elliot and Dweck¹⁷ call learning orientation, which both refer to the willingness to try and err at the edge of expertise or capacity, where knowledge and skills may or may not be sufficient to avoid mistakes. The edge of expertise is similar to the “zone of proximal development” where instructor assistance is needed to help the learner move to the next level.¹⁸ These studies suggest that participants willing to experiment and who hold a learning orientation can (1) tolerate practicing at the edge of their ability, within an unfamiliar and possibly confusing environment; (2) appreciate comprehensive feedback in the context of demanding professional standards; (3) willingly reflect on problems and skills that are new or challenging to them; (4) correct and repeat actions; (5) contemplate and learn from mistakes; and (6) tolerate not knowing the exact answers to complex questions.

Importantly, psychological safety may not completely mitigate feelings of interpersonal risk. Rather, it tends to create a setting where learners feel safe enough to embrace being uncomfortable. It creates a setting where learners can practice new or familiar skills without the burden of feeling that they will be shamed, humiliated, or belittled.

RATIONALE FOR A STRONG PRESIMULATION BRIEFING—THE ROLE OF PSYCHOLOGICAL SAFETY

The presimulation briefing (synonymous with the terms introduction, orientation, and prebriefing) for a simulation session or entire simulation course sets the tone for all that follows. Building on work in the field of organizational behavior that finds that the climate set by group leaders has a significant impact on group member engagement, we believe a well-crafted introduction in which instructors collaborate with learners to set goals and expectations can enhance participation and learning, minimize later complaints and disengagement, and reduce potential participant defensiveness and resentment during the simulation and debriefing.

Although learning is often seen primarily as a cognitive task, it has deep psychological and emotional foundations as well. The psychological foundations of learning from experience involve containing or reducing feelings of insecurity and threat while nurturing feelings of well-being and possibility.^19–22 With origins in psychoanalytic disciplines, the metaphor of a safe container in which learners feel secure enough to be uncomfortable or trust that they will have help managing difficult feelings and anxiety has come to be recognized as an important feature of nurturing experiential learning.^23,24 Furthermore, reducing threats to professional and social identity is increasingly recognized as the sine qua non of learning in groups.¹³

Our literature review suggests that psychological safety is a crucial concept in determining whether a safe container has been created. If one feels psychologically safe, then one feels that the current environment is conducive to interpersonal risk taking; learners feel that they will be viewed positively even if they make mistakes. Psychological safety has been demonstrated to be a precursor to learning-oriented behaviors such as asking questions, sharing one’s thinking, and asking for help.^13,15 Psychological safety helps avert defensive behaviors triggered by feelings of personal threat such as obstructing and withdrawing; it can reduce elaborate false explanations known as “fancy footwork”²⁵ and ego defenses such as mocking or denigrating the simulation activity.²⁶ Psychologically safe simulation exercises are friendly to risk taking in the service of learning; people feel that it is acceptable, even desirable, to work at the edge of their expertise or capacity where mistakes are likely. The importance of this psychologically safe container is amplified by the fact that core professional skills closely associated with the construction of professional identity^24,27,28 are in view with live observation and subsequent video. Paradoxically, creating a psychologically safe container does not mean completely avoiding the negative emotions associated with mistakes, which, in limited doses, can help motivate learning.²⁹

Being observed by others usually increases physiologic activation. This activation can enhance performance via a number of mechanisms³⁰ including social facilitation a process by which people perform better under scrutiny. The physiologic activation associated with being observed can also degrade performance when such scrutiny triggers evaluation apprehension or is viewed as a threat.^31–33

Although psychological safety has been extensively studied as a predictor of learning in groups, few studies have looked at the variables that create psychological safety. Leader inclusiveness, behaviors such as inviting input and listening to and acknowledging subordinates’ ideas (or at least not shutting them down), has been posited as a precursor to psychological safety.^14,15 There are, we hypothesize, practices such as these that are within an instructor’s control and might contribute to psychological safety.

METHODS FOR IDENTIFYING PROMISING PRACTICES

We have identified and structured practices useful in presimulation briefing through 3 inputs: (1) a synthesis of existing theory and research in fields closely related to simulation and debriefing; (2) from the exercise of developing an assessment of health care simulation briefing and debriefing³⁴; and (3) the authors’ collective experience in conducting more than 6000 debriefings, hundreds of presimulation course briefings, as well as roughly 2000 instances of coaching other simulation instructors on the flow from prebriefing to simulation to debriefing.

Input From a Literature Review

Working on the premise that research findings and theory from domains closely related to simulation plus debriefing logically transfer, we identified and synthesized findings, constructs, and theory from aviation simulation, clinical learning and teaching, formative assessment, adult learning, experiential learning, organizational learning, deliberate practice, and the cognitive, emotional, and behavioral bases for mobilizing change in adults.^{1,5,10,13,25,35–38}

Consistent with a nascent set of recommendations on how to conduct literature reviews to synthesize complex evidence, we used a systematic, but nonprotocolized literature review.^39,40 We read and hand searched through references in articles related to debriefing, reflective practice, and learning in groups; we then asked 2 experts each in debriefing, psychological counseling, organizational learning, clinical and general education, and adult behavior change to provide 1 to 5 references that they thought relevant for creating a context for learning and change. From these sources, we were able to identify key words and search terms that we provided to medical and social science librarians at our university. The librarians helped us adapt these to different clinical and social science databases and find additional articles and books. We read these articles and, through citation tracking, pursued additional references that, in our judgment, seemed relevant. This process led to 78 articles we initially reviewed for this article (Appendix 1).

Structure From Developing a Behaviorally Anchored Rating Scale on Briefing and Debriefing

We also used the organizing structure provided by developing a behaviorally anchored rating scale on briefing and debriefing.³⁴ Element 1 of the 6-element Debriefing Assessment for Simulation in Healthcare (DASH)⁴¹ assesses what instructors do or fail to do in a presimulation briefing to establish an engaging environment for learning (Table 1 and Appendix 2). In the following sections, we use the dimensions (subparts) of DASH Element 1 as the organizing rubric for the proposed practices.

TABLE 1: DASH Element 1 and Dimensions

Input From Our Own Experience

We have created, erred (sometimes significantly), and modified our presimulation briefings during a period of 20 years in the course of delivering hundreds of clinical crisis resource management courses for a variety of specialties, interprofessional teams, and levels of training from nursing and medical students through advanced practice professionals, primarily in the United States. In addition, we have observed the variance in the prebriefs of hundreds of simulation instructors-in-training from North America, Oceania, Europe, South America, Central America, and Asia. The prebriefing behaviors captured in Appendix 2—identified through research for the DASH behaviorally anchored rating scale—are emblematic of some of our own as well as other people’s errors and good practices; they reflect 2 ends of the variance in practice that we have observed in our instructor courses.

PROMISING PRACTICES FOR PRESIMULATION BRIEFING

Creating psychological safety is an abstract goal that instructors can move toward in collaboration with their learners through a set of discrete, concrete activities. The specific practices we have identified within a presimulation briefing are setting clear boundaries, expectations, and goals; establishing a fiction contract; attending to logistic details; and conveying respect for the learner and interest in their perspective.

Clarifying Objectives, Environment, Roles, Confidentiality, and Expectations

Educational and psychological research agree that when learners have a sense of control and clarity about what is expected of them and what to expect from those in authority—provided it is benign—they are more likely engage.^10,42,43 Clarity about what is expected in a simulation and debriefing also increases learners’ ability to meet those expectations.¹⁰ Because the simulation etiquette, norms, and roles may be unfamiliar to learners, it is incumbent on simulation instructors to clarify them.

Although instructors may have a clear vision about the goals of the simulation and debriefing encounter, they may make the common and natural mistake of assuming that the learners see it the same way.⁴⁴ Explicitly clarifying learning objectives, actively exploring learners’ objectives, explaining or demonstrating the properties of the simulators, explaining the process and timing of the debriefing or other postsimulation analysis activities, and creating shared agreements with learners regarding the role of instructors and learners are helpful in bridging this gap.^10,43,45,46

Furthermore, to the extent that clearly stated goals are inspiring for the learners, they can trigger the positive affect shown to stimulate increased openness to new ideas.^47,48 Creating the conditions for this positive affect and openness is a boon when simulations plus debriefings are designed to stimulate reflection and the integration of new knowledge, ideas, or perspectives.

Formative Versus Summative Assessment?

Absolute clarity about how and if performance during the session will be evaluated is vital to establishing a safe container for learning during debriefing. Learners may worry that mistakes will openly or surreptitiously be held against them. Formative assessment, often known as evaluation for learning, is the process of identifying the learner’s current assets or deficits with respect to specific learning objectives and helping learners remediate the deficits and leverage the assets.^49–51 Summative assessment, also known as assessment of learning, is usually a higher-stakes evaluation of whether the learner has achieved expected milestones and may determine whether they advance in their program of learning.³⁸ How and if performance in the simulation bears on the learner’s advancement in a training program, licensure process, or maintenance of certification are likely to influence the climate of the debriefing because many learners feel that summative or formal evaluation is a threat rather than an aid.^49,52 Thus, trust can be built by being clear, consistent, and transparent about the sort of evaluation that will be taking place.

Confidentiality/Privacy?

The boundaries regarding who might observe or be informed about learner’s performance in the simulation and debriefing can impact simulation behavior and debriefing conversation. Whether the exercise takes place in situ or in the simulation laboratory, instructors can further define the parameters of the learning environment and build trust by informing learners whether visitors, researchers, colleagues, patients, preceptors, or students will or will not be privy to their performance. The principle is that maximizing transparency about what and with whom information about simulation performance will or will not be shared builds trust (not that confidentiality alone is the only way to build trust⁵³).

Establishing a “Fiction Contract” With Participants

Engaging in a simulated learning environment poses a unique challenge, that is, acting as if things are real.⁶ To immerse themselves into a scenario, learners must often be willing to play an active role, pretending to take care of real patient in a simulated setting where their professional skills are on display. The skilled instructor, like a novelist or playwright, attempts to create a fictional environment engaging enough to draw people in.^6,54 Rather than assuming participants will or must accept the simulated environment, Dieckmann et al⁶ have suggested that instructors must create an explicit and collaborative agreement with participants, in which both instructors and learners have commitments. The fiction contract is a form of psychological contract that describes what instructors and learners owe each other and should expect of each other to have a successful encounter.⁵⁵

To create a fiction contract, the instructor typically offers to do what can reasonably be done to make the situation as real as possible but acknowledges the limitations (eg, mannequin patient’s skin color does not change or does not feel or look real; invasive procedures cannot be performed on standardized patients). The instructor seeks a voluntary commitment from the learner to do what he or she can to act as if everything is real⁶ and conveys that the quality of the learning experience depends, in part, on the learner’s willingness to participate as fully as possible.

Building on the work of Dieckmann et al,⁶ we propose a model of how the fiction contract, along with the other practices we describe, impacts learner engagement. In this model, the fiction contract moderates and influences learners’ willingness to engage despite perceived lapses in realism (Fig. 1). Dieckmann et al argued that health care simulations have 3 kinds of fidelity, where fidelity describes how accurately reality is represented and we have adapted their terminology.⁵⁷ Physical fidelity is the degree to which the simulation elements are sensed as approximating visual, tactile, auditory, and olfactory reality. Conceptual fidelity is the degree to which the simulation proceeds in a causally plausible manner. When the patient’s physiologic, pharmacologic, or emotional responses make sense for a given intervention, this is conceptual fidelity. Emotional/experiential fidelity is the degree to which the simulation generates the feelings learners would expect in a similar real situation. How the simulation unfolds to develop realistic time pressure, stress, happiness, or relief would be a property of emotional/experiential fidelity.

FIGURE 1: A model of fidelity, realism, and educational engagement in simulation.⁵⁶

For a given participant in a simulation exercise, the 3 kinds of fidelity combine to produce a perception of realism for that individual. One person may perceive a certain degree of realism, whereas another may experience a very different degree of realism, both with the same simulation fidelity. Thus, realism is a property of the learner’s perception rather than a property of the simulation.

Based on their subjective perception of realism, we propose that an individual’s willingness and ability to engage in the learning experience varies. Moreover, the willingness to engage is affected by the ambient psychological safety of the whole education encounter of which the fiction contract is an important part.

By making explicit faculty’s interdependence with learners on buying in to the simulation, the fiction contract also plays a vital role in mitigating the occasional shame or humiliation learners may feel if they do not perform well in front of others. By revealing their own vulnerability in setting the fiction contract, the instructor invites collaboration: for example, “I have done everything I can to make this as real as possible, but in the end, it is not reality; I have to depend on you. I ask you to do your best to act as if this is real so that the time we have together is used to our best advantage.” Without this, learners who feel they have not done well in the simulation tend to blame the simulation for lapses in perceived realism as a way to combat the identity threats^7,58 they feel when they do not perform as well as they would like. They may feel that these “unfair” (unrealistic to them) qualities of the simulation prevented their performing better.

Conversely, we have found in our own simulations that if learners feel that the instructors are playing fair with respect to fidelity and realism, they are more likely to focus on the learning objectives at hand and to willingly reflect on their own practice.

Attending to Logistic Details

To help participants focus on the demands of the simulation exercise, they need to know what to expect logistically. Simulation instructors can easily focus on the content or technical aspects of the simulation environment and ignore or minimize the logistical details of the exercise. An important part of creating engagement is “student-centered design” where clinician learners know how the structure of the session interfaces with their other professional or educational commitments.⁵⁹ Attending to logistics can prevent the dissatisfaction that results when care and comfort issues, also known as “hygiene factors,” are handled poorly.⁶⁰ As trivial as these issues may seem, covering appropriate details such as the starting and stopping time of the session, breaks, how to handle pages, texting, e-mail, social media, telephone calls, transportation, refreshments, whether they will have enough time to get to their next class or shift, and so on prevents distraction and worry and helps learners focus on issues within the curriculum.⁶¹ Demonstrating sensitivity to the logistic constraints of participants’ other duties—by, for example, asking about them—sends a subtle message that the instructor is aware of and cares about the learner’s competing commitments.

Conveying a Commitment to Respecting Learners and Understanding Their Perspective

When instructors convey that they value the learner’s perspective, it can have a powerful impact on learning.⁶² Three related theories from experimental economics, organizational behavior, and cognitive anthropology are relevant to how instructors convey respect and interest in learners’ thinking. First, learners are not simply doers of correct or incorrect actions; they construct meaning about the world around them. Learners, like the rest of us, sample the stream of experience around them and make sense of it, constructing categories to label their reality.⁶³ This “sense making”⁶⁴ shapes how they perceive reality and, in turn, how they act. When instructors communicate—by inquiring into their perspective, for example—that they see learners as “meaning makers,” not simply doers of correct or incorrect actions, it reveals a deeper interest in the learner.⁶² When instructors show they value their students’ internal sense-making processes, learners will be more likely to give weight to the role of their own thoughts and emotional processes to improve future performance.^62,63

Second, working on the premise that people are actively constructing a view of reality, experimental economics finds that people are generally “intendedly rational”; they are trying to accomplish a valued goal given their current perceptions and analysis of the situation.^65–69 Learners, even when they make mistakes, usually fit this assumption. When instructors indicate that they realize the learner was working toward a goal as best he or she could in the moment given their current sense-making processes, level of knowledge, level of stress, and so on, they convey respect and interest in the learner’s perspective. For example, instructors could convey that mistakes are puzzles that will reveal valuable information about learners’ meaning-making process rather than a crime to be covered up or punished.^4,62

Third, psychotherapeutic theory, although it has different goals from debriefing, also concerns itself with transforming thinking, skills, and attitudes. The role of positive regard⁷⁰ for other people—assuming they are capable of competent action and self-transformation—infuses the debriefing with a positive psychological tone. Recent research on the transformative features of evoking positive emotion indicates that its presence in debriefing can help spur learning.^71,72

CONCLUSIONS

Through a review and synthesis of relevant concepts from literatures with bearing on presimulation briefings, we have proposed and discussed a set of promising practices that make up a sound presimulation course briefing and provide examples of these practices in Appendix 2. We cannot be sure that any one of the practices we have proposed or all of them together will always enhance engagement, but they are supported conceptually by previous research and theory, our primary research on how to assess precourse briefings and debriefing, and our experience in health care simulation. We have found them to be useful in structuring our own presimulation briefings.

The promising practices we have proposed can be adjusted to match the demands of different simulation contexts and stable or changing participant composition. The presimulation briefing would be adjusted depending on whether it is for a once-a-year teamwork training for medical flight or retrieval medicine group, a twice-a-week simulation laboratory within a prelicensure nursing course, or a monthly residency training program on interprofessional collaboration. Different aspects of these practices could be covered at different degrees of depth; a briefing might run from 3 to 5 minutes for a one-hour session, to 45 to 60 minutes for a day-long training. For example, first-time exposure to simulation might involve a much longer discussion of principles of formative assessment, more details of what is expected from both the learner and the instructor with respect to the fiction contract, and a more deliberate description of the progression of the exercise than would be required for repeat learners. The presence of learners from different specialties and disciplines who might be unfamiliar to each other in an interprofessional simulation session might merit a longer discussion of confidentiality to be sure that everyone is confident that those principles will be upheld. A simulation course with learners who have experienced simulation with the instructor in the same setting many times before might warrant just a quick reminder of the elements of psychological safety, fiction contract, confidentiality, and behavior.

We believe that a strong presimulation briefing begins the process of creating a safe container for learning that allows learners to tolerate and welcome direct and critical feedback, create opportunities to “redo” a skill, work outside their comfort zone, accept and deal with surprises, change their current clinical practice, recast their current ways of thinking, and validate themselves as professionals.

Creating and sustaining an engaging environment for learning relies on understanding and implementing the concept of a psychologically safe container.^73,74 If well constructed, this container, like the nonreactive crucible used in chemistry experiments,⁷⁵ allows instructors and learners to tolerate the “heat” of participating in simulations and debriefings to transform practice through experiential learning in a simulated environment.^8,9 Based on the theory, research, and experience we synthesized for this article, we believe that 4 promising practices help learners participate actively in simulations, openly and rigorously analyze their performance in debriefing, and set the stage for improving clinical performance.

ACKNOWLEDGMENTS

The authors thank Michaela Kolbe, Walter Eppich, and JWR’s peer review writing group, “Fulton 214” for their helpful comments on this article.