Monday, 17 April 2017

Translating simulation into clinical practice: Psychological safety

At our sim centre, safety is a key concern. When people mention safety in the context of simulation, the first thought is often the safety of the patient. Simulation is safe for patients because, in the majority of cases, lack of patient involvement means that no patient is harmed. Perhaps the second thought regarding patient safety is that this is one of the reasons we carry out simulation in the first place.

Safety is not just about the patient however, but also about the simulation participant. In terms of physical safety, at our sim centre we have had sharps injuries, slips and trips, as well as a defibrillation of a mannequin while CPR was in progress. So, physical safety is important.

However, we think that the psychological safety of the participants is as important as their physical safety. Psychological safety “describes perceptions of the consequences of taking interpersonal risks in a particular context such as a workplace” (Edmondson & Lei 2014).  When people feel psychologically safe they will be more willing to speak up, to share their thoughts, and to admit personal limitations. This means that psychological safety is important not just in simulations but also in clinical practice.

The psychologically safe simulation environment is not self-generating, it must be created and sustained by the facilitator and participants. Creating this environment is not a cryptic, mystical feat which is only achieved by the expert few, but rather a set of behaviours and actions which can be learned. This means that the lessons learnt from creating psychological safety in simulation can be translated into clinical practice. Key concepts are:
  • Flatten the hierarchy
  • Prime people that mistakes will be made
  • Set an expectation of challenging observable behaviours/actions
  • Stress confidentiality

Flatten the hierarchy

A hierarchy is evidenced by a power distance or authority gradient where certain people are placed “above” others usually as a result of additional training or skills. A hierarchy, with defined leadership, is essential for safe care. However when the authority gradient is very steep those lower down are less likely to challenge behaviour. In aviation this has contributed to a number of well-publicised crashes including the Tenerife disaster. In healthcare it results in leaders making fatal (for the patient) mistakes without members of their team speaking up to correct them.

Flatten the hierarchy:
            In the daily brief by:
            Ensuring everyone introduces themselves
Ensuring everyone introduces themeselves by their first name
Admitting to personal fallibility
Setting the tone of expected respect

During the day by:
Gently correcting colleagues who use your title to refer to you by first name
Protecting those at the bottom of the authority gradient from bullying, harassment or other demeaning behaviour by others.

Prime people that mistakes will be made

In the simulated environment mistakes are almost guaranteed due to the planned crisis nature of the experience. In clinical practice mistakes cannot be guaranteed but it is unlikely that no mistakes will happen during a typical day. (Where research has been carried out, in paediatric cardiac surgery, there were approximately 2 major compensated events and 9 minor compensated events per operation. (Galvan et al, 2005)) It is therefore essential to prime people at the beginning of the day that mistakes are likely, that this is “normal” and that they should be looking out for them.

Set an expectation of respectful challenge to observable behaviours/actions

You have made it clear that people will make mistakes. You can then therefore set an expectation that others will challenge any behaviour or action which they are unsure about, which they think is a mistake or which they think threatens patient safety. Warn people that when their behaviour or action is under scrutiny that they will feel uncomfortable and perhaps threatened. Reassure people that when they are having these feelings of discomfort that they are experiencing a "learning moment". Either the person raising the concern is correct and a mistake is being averted or they are correct and the person raising the concern can be thanked and the action clarified.

Stress confidentiality

In the simulation environment, with very few exceptions, we can guarantee that the experience will remain confidential with respect to the facilitator (i.e. we will not talk about participant performance after the simulated event is over) and that we expect the same from the participants. In clinical practice a similar promise can be made. Of course errors, particularly those which may recur in other situations, must be reported using the appropriate system in order to help the system learn. However this does not have to be on a naming and shaming basis but rather a collective effort to explain how an error happened, how it was dealt with and how it may be prevented in the future. In addition this is an opportunity to stress that you will not talk about any mistakes behind people's backs or use the reporting system as a weapon to punish people.

Psychological safety and mistakes

Staff psychological safety will improve patient health
One of the concerns that people may have is that the “psychologically safe” unit/team/department will be more tolerant of error and therefore make more mistakes.  In 1996, Amy Edmondson looked at eight hospital units and, with the help of a survey instrument and a blinded observer, rated their psychological safety with respect to medication errors. She found that the more psychologically safe the unit was, the greater the number of errors reported. However, she also found that the more psychologically safe the unit, the fewer medication errors the staff actually made. Units which were not psychologically safe not only reported fewer errors but made more.

Final thoughts

Words shape our thinking and we struggle to discuss a concept if we don't have a name for it. It is time that the term "psychological safety" escapes the confines of the simulation centre and enters clinical practice. We all deserve psychological safety at work and you can help make this a reality by using some of the above tips.


1)   EDMONDSON, A. C. & LEI, Z. 2014. Psychological safety: The history, renaissance, and future of an interpersonal construct. Annual Review of Organizational Psychology and Organizational Behavior, 1, 23-43.

2)   GALVAN, C., BACHA, E. A., MOHR, J. & BARACH, P. 2005. A human factors approach to understanding patient safety during pediatric cardiac surgery. Progress in Pediatric cardiology, 20, 13-20.

3) EDMONDSON, A. C. 1996. Learning from mistakes is easier said than done: Group and organizational influences on the detection and correction of human error. The Journal of Applied Behavioral Science, 32, 5-28.

Thursday, 15 September 2016

Book of the month: Bounce by Matthew Syed

About the author
Matthew Syed (@matthewsyed) is a journalist and was the English number one table tennis player for almost ten years

Who should read this book?

Anybody involved in education and training will find something useful in this book.  Although there are a few problems, they are more than outweighed by the readability of this book and the transferability of the acquired knowledge into practice. Syed talks about the myth of innate talent, deliberate practice, expertise, motivation, the benefits of standardisation, the training of radiologists and inattentional blindness.

In summary

The book is divided up into 3 Parts and 10 Chapters:

Part I: The Talent Myth. Here Syed effectively destroys the myth of innate talent. He tells us what you need is opportunity, deliberate practice with feedback and luck. 
  1. The Hidden Logic of Success
  2. Miraculous Children?
  3. The Path to Excellence
  4. Mysterious Sparks and Life-Changing Mindsets
Part II: Paradoxes of the Mind. In this part Syed look at how our beliefs can help (or hinder) us.
  1. The Placebo Effect
  2. The Curse of Choking and How to Avoid It
  3. Baseball Rituals, Pigeons, and Why Great Sportsmen Feel Miserable after Winning
Part III: Deep Reflections. This part is less obviously related to the preceding parts (see "What's bad about this book?" below)
  1. Optical Illusions and X-ray Vision
  2. Drugs in Sport, Schwarzenegger Mice, and the Future of Mankind
  3. Are Blacks Superior Runners?

What's good about this book?

This book is well-written and very easy to read. As someone who has "been there" Syed does a great job of debunking the talent myth (or the "myth of meritocracy" (p.7)) He references a few of the other writers in this field including Malcolm Gladwell (p.9) and Anders Ericsson (p.11)

Syed explains why the talent myth is bad, in part because it means we give up too quickly because "we're just not good at it". The talent myth also means that "talented" people are given jobs which they are not suited for, this may be a particular problem in government.

This book is relevant to the acquisition of skills (technical and non-technical): Syed refers to Ericsson when he says tasks need to be "outside the current realm of reliable performance, but which could be mastered within hours of practice by gradually refining performance through repetitions" (p.76) In addition, mastery of skills leads to automaticity and a decrease in mental workload.

As mentioned in previous blog posts, failure is an important element of improvement and in order to improve we need to push ourselves (and our learners). Are your sessions set up in order to make the best possible use of the learners' time? Syed also explains that it is not just time (cf 10,000 hours) but the quality of the practice that is important.

Syed extols the benefits of standardisation. He spent two months perfecting his stroke so that it would be identical "in every respect on each and every shot" (p.94). This meant that now he could introduce small changes and he would be able to tell if these were improvements or not as the rest of the stroke remained the same. There is a strong argument for similar standardisation or reduction in variation within healthcare. Currently it is extremely difficult to see whether a change is an improvement because of the variation in the system.

"Feedback is the rocket that propels the acquisition of knowledge (p.95-96). Syed again refers to Ericsson when he discusses how the training of radiologists and GPs could be improved by giving them access to a library of material where the diagnosis is already known (e.g. mammograms for radiologists, heart sounds for GPs). Because the participants are given immediate feedback on their diagnosis they can learn very quickly from their mistakes. Could your skills or simulation centre offer something similar?

Syed also deplores the lack of adoption of purposeful practice outwith the sports arena. He quotes one business expert: "There is very little mentoring or coaching... and objective feedback is virtually non-existent, often comprising little more than a half-hearted annual review" (p.103). How many of our workplaces can identify with this?

Syed's final chapter "Are Blacks Superior Runners?" is a very well-written argument that it is economic and social circumstances that result in more black people being motivated to take up sport and excel in it. The false belief that black people have sporting talent, but are intellectually inferior, is part of a wider culture of discrimination, where for example people with 'black'-sounding names are less likely to be invited to a job interview.

What's bad about this book?

Syed commits the same mistake as Gladwell (which is nicely refuted by Ericsson here) that "(w)hat is required is ten thousand hours of purposeful practice" (p.85) or that it takes 10,000 hours to "achieve excellence" (p.15) 

Syed changes Ericsson's "deliberate practice" to "purposeful practice". Although he does explain his reasoning, this change does not improve our understanding of what the term stands for and is an unnecessary variation.

Syed states that "some jobs demand deep application... nurses are constantly challenged to operate at the upper limits off their powers: if they don't people die."(p.72) Unfortunately this is not the case. Most nurses (and most healthcare workers) do not work at the upper limits of their powers and patients do die. Healthcare currently neither rewards nor encourages excellence. Healthcare rewards, if not mediocrity, then not being noticed for the wrong reasons.

Although applicable to sports, Syed's writing on the dispelling of doubt, does not translate well into healthcare. "Positive thinking" must not turn into the cognitive trap of "false positivism" and a degree of doubt is necessary for safe care.

Part III: Deep reflections consists of 3 chapters which seem to have been added, slightly ad hoc, to the end of the book (perhaps it wasn't long enough?) Syed's argument in Chapter 9 that a policy of "regulated permissiveness" would be better than the current doping ban does not hold water. It is more likely that everybody (who can afford it) will then be on the permitted drugs and the cat-and-mouse game between the dopers and the doping agencies would continue with the illegal drugs. With respect to the Haemoglobin-boosting drug EPO, Syed states: "It is only when [the haematocrit] is elevated above 55 per cent that the risks begin to escalate..." (p.226). When it is more likely that there is no safe limit for the haematocrit. In the same vein Syed states: "Moderate steroid use improves strength and aids recovery without significant damaging side effects" This begs the question: "Why are we not all taking a moderate amount of steroids?"

Final thoughts

Syed argues that standards are spiralling upward in a number of fields because "people are practising longer, harder (due to professionalism), and smarter." He also talks about coasting (driving car) and unfortunately this is where many of us end up. Once the exams are finished we neither push ourselves nor are we pushed.

If we "institutionalised the principles of purposeful practice" (p.84) as Syed encourages us to do, our training would be more effective, healthcare workers more qualified and patients safer.

Thursday, 8 September 2016

Harnessing the Power of Mistakes (by Vicky Tallentire)

Mistakes are an inevitable aspect of any system that involves decision-making; healthcare is no exception.  For better or for worse, the mistakes that we make over the course of our careers define, to some extent, who and what we become.  In the early days they often influence career decisions.  Subsequently, they shape our approach to work, subtly impacting on our communications with patients, our investigative decisions and our willingness to discharge people home.  For many nearing retirement, the timeline of a career is a haze of professional satisfaction, punctuated by incidents of avoidable harm recalled with the clarity of yesterday.  

Henry Marsh (1) describes the impact of mistakes on his professional demeanour: “At the end of a successful day’s operating, when I was younger, I felt an intense exhilaration. As I walked round the wards after an operating list… I felt like a conquering general after a great battle. There have been too many disasters and unexpected tragedies over the years, and I have made too many mistakes for me to experience such feelings now…”(p.33)  Dealing with one’s own failures is, I think, the most challenging aspect of a career in healthcare.  How does one balance the inevitable sorrow and guilt with the need to hold one’s head high and continue to make high-stakes decisions?

Medical school lays the foundations for a career in medicine.  The thirst for knowledge is unparalleled.  As Atul Gawande (2) says, “We paid our medical tuition to learn about the inner process of the body, the intricate mechanisms of its pathologies, and the vast trove of discoveries and technologies that have accumulated to stop them. We didn’t imagine we needed to think about much else.”(p.3)  And yet we do.  At medical school I was introduced to the abstract concepts of error, unintended harm and, God forbid, mistakes.  But I didn’t understand them concretely, like I do now.  That I will make mistakes, I will cause harm, inflict distress and compound misery.  That one day I would be crouched on the floor beside a patient, with the hateful glare of a relative fixed on the back of my head, uttering “I’m sorry”.

Don’t we, as a profession, have a duty to better prepare our future doctors to deal with their own failings?  Shouldn’t we augment the vast knowledge of pathophysiology with self-awareness, emotional resilience and the language of professional but meaningful apology?  The challenges are great, but so too are the rewards. 

Immersive simulation is a tool that facilitates rehearsal of high-stakes decision-making in emotionally charged situations. Mistakes are more than likely in such contexts.  The debrief allows participants to reflect on their actions, off-load emotionally and discuss the possible consequences of alternative choices.  That journey of self-discovery and emotional development is, in my mind, what underpins the power of immersive simulation.  The challenge now is how that journey can be continued, and supported, in the workplace.

  1. Henry Marsh. Do No Harm: Stories of Life, Death and Brain Surgery. Published by Weidenfeld & Nicolson, 2014.
  2. Atul Gawande. Being Mortal: Illness, Medicine and What Matters in the End. Published by Profile Books Ltd, 2014
About the author:
Vicky Tallentire is a consultant in acute medicine at the Western General Hospital in Edinburgh.  She has an interest in the training of physicians, and has held a number of roles in the Royal College of Physicians in Edinburgh.  Vicky has a particular interest in simulation based research and completed a doctorate at the University of Edinburgh in 2013 using simulation as a tool to explore decision-making and error.  She is keen to develop the research profile of the centre and would like to hear from anyone, from any professional background and at any level, who is interested in undertaking research projects in the field of simulation.

Friday, 29 April 2016

Book of the month: The Invisible Gorilla: And Other Ways Our Intuitions Deceive Us by Christopher Chabris and Daniel Simons

About the authors
Christopher Chabris (@cfchabris) is an associate professor of psychology and co-director of the neuroscience programme, Union College, New York. Daniel Simons  (@profsimonsis a professor in the department of psychology and the Beckman Institute for Advanced Science and Technology at the University of Illinois. Chabris and Simons ran one of the most famous experiments in psychology, the "invisible gorilla" (video). A blogpost discussing the conclusions to be drawn from their experiment and related ones is available here: Inattentional blindness or "What's that gorilla doing there?".

Who should read this book?

Anybody with an interest in human performance limitations will find this book an interesting read. In addition, many of the concepts are useful to gain insight into how people perform within a simulated environment and in clinical practice.

In summary

The book is divided up into an Introduction, six chapters and a Conclusion. The six chapters are:
  1. "I Think I Would Have Seen That"
  2. The Coach Who Choked
  3. What Smart Chess Players and Stupid Criminals Have in Common
  4. Should You Be More Like a Weather Forecaster or a Hedge Fund Manager?
  5. Jumping to Conclusions
  6. Get Smart Quick!

Chabris and Simons explore and explain a number of misconceptions we have about our own abilities. Each chapter focuses on a specific "illusion": attention, memory, confidence, knowledge, cause, and potential. Chabris and Simons are interested in the fact that, not only do we suffer from these illusions, but we also are unaware of them and are surprised when they are pointed out.

What's good about this book?

This book is well-written and very easy to read. Each chapter focuses on one topic and is peppered with everyday examples to illustrate concepts. These include motorcycle collisions, film continuity errors, a sense of humour, and lifeguards in swimming pools.

Not an effective way to change behaviour
In Chapter 1 the authors discuss why cars hit motorcycles (at times due to inattentional blindness) and they also explain why "Watch out for motorcycles" posters and adverts are not effective. They suggest that making motorcycles look more like cars, by having two widely separated headlights, would make them more visible to other car drivers. The same concept of "attention" also explains why the risk of collision with a bicycle or motorcycle decreases as the number of these forms of transport increase. The more often people see a bicycle on the road, the more likely they are to expect to see one and look for one.The authors also provide additional details about the various illusions. For example, eye-tracking experiments have shown that those who do not see the "invisible" gorilla spend as much time directly looking at it as those who do.

Chapter 2 looks at memory and uses persuasive experimental evidence to convince the reader that memory is fallible. In particular, contrary to popular belief, people do not have crystal clear memories of what they were doing during exceptional events such as 9/11 or Princess Diana's death. People think they do, because they think they should, and therefore are confident about these (unclear) memories.

Chapter 3 explores confidence. The first example used is a doctor who looks up a diagnosis and treatment, which makes his patient feel very uneasy. Isn't a doctor supposed to know this stuff? We encounter similar situations in simulation, with the tension between appearing confident and being able to admit ignorance often results in a less than ideal outcome. The notion of moving from unconscious incompetence to unconscious competence is also covered here, by referring to an article ("Unskilled and Unaware of It") which begins with a description of an inept bank robber.

Would you ride this bike?
Chapter 4 explains why we often think we know more than we do. The authors make this point by asking the reader to draw a bicycle and then to compare this against the real thing. (Italian designer Gianluca Gimini has created some interesting 3-D renderings of people's concepts of what a bike looks like.) This illusion of knowledge, they argue, played a part in the 2008 banking crisis as bankers thought they understood both the banking system and the extremely complex collateral debt obligations (CDOs). 

In Chapter 5 Chabris and Simons explore causation and correlation. While many people with arthritis think they can tell when the weather is about to change, researchers have found no correlation. It is likely that their pain levels fluctuate but if the weather changes they then ascribe their pain to the change in atmospheric pressure.

In Chapter 6 the authors debunk the Mozart Effect, which led parents to play Mozart to babies in the belief that it would make them smarter. Similar claims by Lumosity, a company which alleged that playing its games would delay age-related cognitive impairment, resulted in a $2 million lawsuit.

What's bad about this book?

There is very little to fault this book. Chabris and Simons call limitations in human performance "illusions" because, like M. C. Escher's prints, they persist even when you know what they are. The authors do a great job of explaining the illusions but do not spend enough time addressing the ways in which we might improve our ability not to succumb to them. 

Final thoughts

In terms of simulation, this book explains a number of behaviours that we witness in the simulated environment. For example, it is not unusual for participants to "lie" about something that happened. They may be adamant that they called for help, but the debriefer knows (and the video shows) that this was not the case. The participant is falsely remembering a call for help because they think that they would always call for help.

Again, in terms of the illusion of confidence, we find that those who are least able are often most confident because they lack the insight required to know how poor their performance is.

In terms of human factors, this book will provide a number of examples of human fallibility for workshops or other courses. It also reinforces the need for systems which help humans. As an example, changes in a patient's end-tidal CO2 (ETCO2) trace can suggest physiological impairment, but most machines do not make the clinician aware of these. A smarter monitor would alert the clinician to these changes instead of relying on his or her continued awareness.