Healthcare professionals are in the business of healing and helping patients cope and recover from the effects of ill health. Inherent in this ethos is the medical tenet of primum non nocere: “first, do no harm.” Healthcare professionals are accountable by ethical, professional, and institutional codes and processes to uphold this across all healthcare domains. Consequently, a vast literature describes numerous approaches for promoting patient safety during care delivery, with primary focus on the patients. This patient-centric model has been translated into clinical education where a learner-centered approach is encouraged and also privileges learner experiences and outcomes. By extension, such an approach also prioritizes their physical safety and psychological well-being. In healthcare simulation-based learning, the “safe container” construct1 has been proposed to create and maintain an environment that is safe to learn in all phases of simulation activity. Centered on patient/learner safety, its key parameters may be represented as a succinct 4-petal model (Fig. 1).
Recently however, advocacy for improved physical and psychological safety in different types of simulation modalities has emerged, increasing awareness of its homology with clinical safety and quality improvement paradigms.2–6 In the course of delivering patient-centered healthcare, carers and healthcare workers may be at risk to breaches in safety, for instance, and experience vicarious trauma as a “second victim” from adverse patient events.7,8 In the same way, clinical education facilitators of learner-centered simulation activities are vulnerable to adverse events during their instruction. Facilitators and faculty may inadvertently make errors or mistakes, which endanger them and compromise their own physical and/or psychological safety. Numerous industrial domains (ie, fields/spheres of activity) deliberately use different simulation constructs (ie, cognitive processes, physical or situational devices, or equipment made or adapted for a particular purpose) at different phases to maintain participant safety during simulation scenarios. An example in Australian healthcare simulation is the common practice for simulation participants to use “safe words” to terminate the scenario in the event of a perceived safety breach.
The goal of this commentary is to describe the case of an unexpected “simulation adverse event,” provide a reflective analysis of the unintended effects upon participants and their facilitators, and from lessons learned, propose an extended conceptual model for simulation safety that also encompasses simulation facilitator health and well-being.
The event was an open simulation workshop planned by the Human Dimensions in Simulation Committee (HDSC) of Simulation Australasia and nested in the proceedings of the 2016 cross-industry Australasian simulation meeting in Melbourne, Australia. The HDSC is an interindustrial group with simulation expertise in the healthcare, prehospital care, military, transportation, naval engineering, building, and theatrical arts domains. In previous conferences, this group had safely and successfully conducted workshops exploring these nexuses.9 Participating learners were conference attendees, participating via self-selection from the overall paying conference, and comprised an interindustrial delegate cohort with the healthcare sector well represented.
The workshop was designed to further explore the notion of the “safe container.” Although the Healthcare Simulationist Code of Ethics10 was, as yet, not published and did not form a part of the foundation of the activity, all participants were aware that they would be participating in a live simulation exercise, supporting the aspirational values of the code of integrity, transparency, and mutual respect.
The workshop's intended learning outcomes were to demonstrate and discuss the potential physical and psychological dangers of simulation-based activities, with opportunity to practice mitigation and management strategies for safety issues when they arose. At this time, the “safe container” construct was well known by all healthcare domain–affiliated HDSC members. The planned activity was a live simulation exercise to enable learners to consider the differences and similarities of safety approaches between the interindustrial domains. Two trained building industry simulation confederates were embedded in the exercise to provide planned examples of unexpected physical and psychological participant responses to the simulation event. Debriefers were allocated without a commonly shared debriefing model being planned, although the experienced healthcare debriefer used an advocacy-inquiry framework.11
A participant overview and presimulation briefing were provided, which included an explicit warning that, through exploration of the “safe container” concept, it was possible that their own psychological safety may become inadvertently challenged. All participants were aware that they would be participating in a live simulation exercise where physical safety was maintained. A clear description and illustration of the “safe words” (“STOP! STOP! STOP!”) was also included in the prebriefing without checking for a shared understanding of the practicalities of this process with all facilitators and participants. All of those present chose to remain and participate. Both trained building industry simulation confederates were not introduced to the learners.
Participants began with group activities that involved planning an emergency evacuation simulation. This transitioned to an actual simulated building evacuation, triggered by a reported collapse of an external wall. An interruption by the first confederate prompted participants to evacuate the room. During this simulated evacuation, this confederate enacted a medical emergency (“physical collapse”) while a second confederate simulated a contemporaneous psychological emergency (“anxiety attack”). One facilitator was appointed to try to calm the first confederate while a second facilitator was to end the simulation by shouting “Stop, Stop, Stop!” and escort everyone back to the debriefing room. Although participants were expected to remain in a state of uncertainty about whether the second medical emergency had been real, some agitation was expressed by healthcare participants when the safe words did not evoke the accepted response of stopping the scenario. Some participants challenged the facilitators, insisting on knowing whether the anxiety attack was real. The coordinating facilitator quietly informed them that the panic attack had not been real. The entire group then returned to the original room for a debrief, some with knowledge that the scenario had ended, whereas others remained uncertain as to whether it was continuing.
During debriefing, most time was consumed in the reactions phase where strong feelings were expressed by both facilitators and participants. This was followed by a facilitated panel discussion incorporating simulation feedback with psychological safety considerations, which included the second confederate re-entering the room, no longer in character, confirming that the anxiety attack had been enacted. Experiences and feelings were exchanged during debriefing to create a shared understanding of events. It became evident that the effect of the scenario preparation, delivery, and perceived deceptions was more profound than had been anticipated. The workshop concluded with the vulnerability of everyone exposed in an unanticipated way.
Adverse Event Review
As the workshop seemed to close with unresolved emotional issues for many present, it was subsequently likened to an adverse clinical event. Facilitators debriefed as part of a facilitator-only session after the event, with their evaluations evolving into an adverse event review for the entire faculty. One attendee, a volunteer participant, agreed to an invitation to a later participation in this process because of their own interest in facilitation. This group deliberated and, after ethics approval was obtained from the Human Research Ethics Committee of Central Queensland University (Approval No. 0000020938), agreed to share thoughts and feelings in written personal reflections (ie, data) to understand the unexpected psychological safety issues raised. Further subjective and objective examination of the event, informed by adverse event literature,8,12–15 occurred from these collated reflections. The following analyses extend the application of the “safe container” from its present focus on solely the learner group of simulation-based activities to its facilitators.
REFLECTIVE ANALYSIS OF THE ADVERSE EVENT
One Participant's Reflection
Chronologically, and in terms of the initial briefing, the reflecting participant indicated that mutual acceptance of the presented fiction contract was seemingly agreed by all participants: “The effect of the prebrief warning that our safety might be compromised was that there was a shared sense of camaraderie, anticipation and excitement among the group as to what the facilitators had planned for us.”
When the initial contravention of simulation safety rules occurred around the safe words, the participant recalled “the source of stress then became much more around the crisis itself, with a fear of the unknown - what's happening?” Asking everyone to return to the briefing room without a definitive end to the scenario was confusing but also constituted a second potential safety breach, in relation to the implications of the unknown and vulnerability of the situation. The participant noted an incongruity between faculty and learners: “I think that within the framework of a fictional [sic] contract, there is an assumption that there is a beginning and end to a fictional [sic] situation. This assumption was presumed by participants, and may or may not have been presumed by the educators.”
The participant described heightened stress among attendees: “I remember raised voices, along with participants questioning both the authority of educators, and their own role and sense of responsibility in the real-world.” In this context, the question of trust between educators and learners became evident: “they were asked to delegate their real-world clinical expertise to others in a situation where they knew it was in the patient's best interests to continue their management – they had clearly lost trust in the educators in that moment.”
During the debrief, the participant described everyone's contribution to the heightened emotion in the room: “… the educators themselves seemed to have mixed responses and distress levels which added to the ambiguity and perceived lack of safety for all.”
Though implicit in the described intended learning outcomes of the briefing, deception was also identified during the simulation and questioned as a key issue in the way the workshop was designed and undertaken: “… with consideration to both individual and team psychological safety, is [deception] something that should be used in the simulation domain in order to teach?”
The participant described no medium- or long-term deleterious impacts from the experience but did disclose feelings of considerable personal growth and learning around the way in which participant responses may impact facilitators themselves.
There was a description of newfound positive insights into the training of educators, “it has changed the way that I educate educators” with respect to self-care. With the benefit of hindsight, there was recollection of “several past incidents where fellow faculty have been negatively impacted by an activity they delivered. For example, where there was inadequate consideration as to the experience of the learners, such that faculty felt ill-prepared; or with respect to not recognizing preexisting hierarchical relationships within the learner group, such that there was a derailing of the activity when learners felt compromised by poor performance in front of their peers.”
Lastly, there was acknowledgement that in the workshop, “facilitators of the activity faced uncertainty about their learners in the context of a multisector conference where participant attendance was ad hoc on the day, without provision of data around their background, goals, or experience level.”
Each of the 7 workshop facilitators also undertook their own written reflection of workshop events as part of their own reflective evaluation. A common flaw identified was the fundamental design of the activity in terms of a lack of shared understanding of how the safety conventions, described in the prebriefing, were applied across their different simulation domains. For example, “… I was unaware of the seriousness and significance of [the ‘words’] “Stop! Stop! Stop!”
Facilitators collectively described a switch in the hierarchical control or mitigation structure during the activity: “I did not in any way feel part of the control structure of the scenario.” This extended to a reduction in perceived personal safety: “I know I personally felt very intimidated” and continued through debriefing: “we were unable to create the required level of control to steer the [learner] group out of the simulation phase.” As a result, there was little to no resolution of the issues that had been raised: “I felt that we had done the ‘what,’ but I never got the opportunity to move us to the ‘so what?’” There was also little indication of personal preparedness for the events: “I had no real management or mitigation strategies in my mind as we dealt with the scenario aftermath.” This was also accompanied by shame: “I felt embarrassed and overwhelmed in trying to manage the highly volatile debriefing scenario.”
The reactions phase undertaken between faculty members contained a profound and enduring effect with some lingering stresses attributed to the event, along with a progressive change in the understanding of the event. For 6 months after the event, one facilitator said that “the meaning of such complex emotions and dynamic scenarios continue to have ramifications for me.” These effects extended vicariously to those who had not participated in the workshop: “It was interesting for me that, 2 days later, people who had not attended the sessions were talking about it [at the conference].” A number of faculty also perceived their psychological responses to have stayed with them: “I still have a ball in my stomach even now,” and transitioned to complex avoidance behaviors, for example by “not wanting to acknowledge that it was a visceral response to the workshop.”
CONCEPTUAL ANALYSIS OF THE ADVERSE EVENT
The workshop breached accepted safety protocols for healthcare simulation-based learners in a cross-domain learner group to explore the notion of the “safe container” with respect to interindustrial simulation. In keeping with the key aspirational values espoused by the Healthcare Simulationist Code of Ethics,10 the focus of this discussion is to highlight the vulnerability of participants toward maximizing safety and minimizing psychological risk akin to a critical event analysis, such as a root cause analysis.
In explaining the chaotic response of learners and facilitators, a key underlying factor was the varied perceptions of what defines simulation safety breaches. These variabilities were related to differences in agreed simulation safety conventions across the diverse faculty contexts. The extent of the safety breaches (seen in hindsight by some facilitators as untenable but by other facilitators as acceptable, when taken in context) formed the basis of the emotional response of those present. This encouraged the expansion of our understanding of the “safe container” concept beyond participants to the facilitators themselves.
Although the experiences around such an event will vary across individuals, the single participant reflection captured here provides a description of the events that occurred in a chronological way from the learner perspective and, in the case of this participant, highlight an individual sense of positive learning without long-term negative impact. Contrarily, the facilitators' reflections, canvassed through an agreed process of intellectual candor,13 imply a long-term, ostensibly more injurious response to the planned activity.
Assumed Simulation Conventions: Not All Simulation Domains Play by the Same Rules
In the described event, simulation faculty were drawn from a range of professional backgrounds, trained in various specific conventions and devices for simulation, including parameters around safety. Individuals had different approaches, understandings, and demarcation of boundaries in relation to safety in simulation contexts. Subsequently, they brought their own practices to the exercise with an assumption of consensus in underlying shared simulation rules.16
The safety device itself, an example of epizeuxis (a rhetorical device featuring immediate repetition of words for emphasis), was recognized common practice for most from the Australian healthcare simulation sector. This was subsequently found to be a device not necessarily known, nor explicitly practiced, by other cross-domain workshop participants, even after an attempt to prepare for its use in this event's prebriefing. A key insight we draw here might be that both static and dynamic variations in the facilitation of “safe simulation boundaries” seemingly occur within simulation cultures in different industries and there does not seem to be universally recognized safe simulation facilitation elements to ensure safe practice variations. For instance, in some live simulation modalities, particularly those using live rehearsals and role play (such as dramaturgical simulation), the delineation of boundaries between different spaces and conventions of where the simulation begins and ends are not necessarily the same.17
The contravention of this entrenched “cultural norm” of healthcare simulation was interpreted and repudiated by some as deceptive, whereas for others, it was an adequate execution of the intended learning objectives. Although deception may be “ethically justified and carefully implemented”18 to explore simulation safety as part of a lesson plan, our commentary lends narrative support around the effects on both facilitators and learners when the values of honesty and accountability in clinical simulation education are not maintained. The participant reflection suggested that it may have undermined the learner's perception of trust and, within the teaching team, caused a sense of deception.19–22 The emotional tensions around the differences of individual participant perceptions resonate with the theory of frame analysis,23 in that they may have also reflected the facilitators' inadequate dynamic modulation of the simulation-realism continuum to achieve the educational goals of the simulation event.24
We propose that there be explicit discussion and movement toward cross-context consensus for common principles and well-defined minimum-standard safe simulation practices for different industries. These should include the provision of transparent learning outcomes during prebrief and the establishment of an endpoint. Of particular importance is the development of a universally accepted term, phrase, or device for immediate simulation scenario termination for safety reasons. This is the dynamism of the “safe container,” echoing that “safety is a dynamic nonevent.”25
Keeping Facilitators Safe
Psychological safety of learners in simulation-based activities is well described. Given the extent of the education literature, there is comparatively little concerning the safety of simulation faculty. French26 describes 3 categories of teacher anxiety: fear of loss of control, fear of incompetence, and anxiety arising from student expectations. Each of these surfaced in the postevent reflections of facilitators.
A breakdown of the control structure was clearly expressed, with ensuing group anxiety that may have contributed to perceptions of compromised personal safety. In terms of a fear of incompetence, there was a heterogeneous interindustrial faculty presenting a health-based workshop to an experienced and largely health-based group of participants. Facilitators may have had less understanding of the underlying subject matter and were unable to dynamically adapt to learner needs, with this combination of factors contributing to perceived lack of psychological safety.
The facilitators perceived that the simulation attendees may have expected a level of facilitator-led omniscience in managing or mitigating event outcomes. This expectation mismatch may have been unreasonable given the expertise among event participants. The notion of peer-teaching and learning in health science tertiary educational programs describes a co-operative exchange between peers, where one student who may be more academically advanced than another assumes the “near-peer teacher” role to collaboratively lead learning.27,28 The workshop may be considered an exchange of ideas in keeping with a peer-assisted learning model, in that everyone, as attendees of a simulation conference, had some ostensible experience with simulation in their respective fields. The faculty may have held a perception that learners had unrealistic expectations and were dissatisfied with their level of learning—this may have further challenged their psychological well-being.
Compromised safety may occur when the responsibility between teacher and student is too blurry to hold and contain simulation safety. Finlay29 discusses the notion of the therapist as a contained container and concludes that they need to have sufficient robustness to avoid adding their own emotion to that of their clients while maintaining an openness that enables empathy. Thus, it may be alarming for a client to perceive their therapist as unable to cope with their own responses and feelings to situations being described or experienced. Certainly in the described event, the participant expressed the view that the educators seemed distressed during the simulation debrief.
Baker30 has described the need to create a “safe contextual space to hold and nurture debrief conversations” that include “attending to the needs of perceived safety.”(p6) This concept is contained in many healthcare debriefing frameworks and resources31–33 where a “reactions phase” is described to enable learners to vent their thoughts and feelings before an “analysis” and “summary” of the actual events proceed.34,35 These frameworks could be translated to other interindustrial simulation contexts. In the setting of the highly emotive responses produced by this workshop, akin to those sometimes observed after clinical events,36 the facilitators who undertook the co-debriefing may have been unable to dynamically and adaptively create this safe simulation space. The resultant unmet learning objectives may induce dissonant responses for some participants.
Lessons Learned: Toward a New Safety Framework (From a Daisy to a Chrysanthemum)
In the context of the reflections reported, we propose that facilitators involved in simulation-based learning are equally vulnerable to breaches in simulation safety (physical or psychological) as their learners. We contend that the training of faculty around simulation-based activities (particularly with mixed faculty or learner groups) should encourage consistent consideration of physical and psychological parameters7,8,37 in equivalence to the learner experience.
In developing a framework for this, it is important to consider the specific practices of simulation briefing, which has already been identified to be important in ensuring the psychological safety of participants.9 To extend this work beyond participant-centric safety and reflect equivalent central safety for everyone involved in simulation activities, we propose that the represented parameters of Figure 1, if viewed as 4-petal “daisy” model, require further overlapping layers of interaction and complexity so they may be viewed more meaningfully as a complex “chrysanthemum” model (Fig. 2). This reconceptualization may include the same specific practices of prebrief applied to facilitators, but also feature some of the unknown aspects of the “safe container,” and include such things as: preexisting sector-specific social and cultural norms; uncertain interpersonal or historical relationships among those participating; the influences of simulated participants; or unanticipated environmental risks. Consideration of facilitator self-care,7 psychological first aid,38,39 open error disclosure, and restorative justice apology processes could evolve from structured assessment and role-modeling of best-practice responses to errors and mistakes in simulated environments.40 Adopting, exploring, and even adding to this multifactorial framework might enable safety culture development41–44 for everyone involved in the simulation-based activity, with extensions to the end-users of the industries and health services that these activities serve. Responding to adverse events with a more honest and upfront approach may help us address the unintended consequences of our educational activities in the most ethically appropriate way, encourage sharing of similar “stories from the trenches,” and ultimately assist in the overall evolution of the field.
Future Research Directions
The field of simulation is still in its adolescence, and it is important to reflect on issues of harm and personal responsibility so that others may be encouraged to do the same. To learn more about such events when they happen, and to explore our “chrysanthemum” model, further research and investigation using root cause analyses may have specific value here, especially as such approaches are underrealized in healthcare.45 However, in addition to such “what went wrong” approaches, the use of “what went right” approaches42 may also be a valuable philosophical simulation safety construct.
This commentary reflects our vigilance in reporting not only desired outcomes but also the potential unintended consequences of simulation activities. We have considered the personal reflections from participants at a workshop that explored safety in simulation and have articulated something that has not been previously discussed within the literature pertaining to simulation-based learning—the very real possibility that facilitators of such activities are themselves just as susceptible to harm as their attendees. We have also identified that the absence of a universal cross-sector safety device or mechanism is needed to terminate an unsafe scenario, and we propose a broader conceptualization of the safety container to promote debate and discussion of simulation safety.
The authors of this work were volunteer members of the Human Dimensions in Simulation Committee (HDSC) of Simulation Australasia at the time this work was completed. They gratefully acknowledge the contributions of other members, including Marc Lyons, Kevin Heveldt, Anna Maria Carrera, and Elyssebeth Leigh. The authors are also very grateful to the participants who took part in the workshop on which this commentary is based – without their input and support, this work would not have been possible.
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