The ‘Safe Container’ Rules, OK?

Here we discuss the seminal simulation article by Rudolph et al [PMID25188485]. Originally published as a PDF supplement on the Simulation Podcast back in December 2017, as part of their monthly Journal Club. I highly recommend reading the journal club summary and listening to the podcast at Simulcast Journal Club Podcast 10 & November Wrap.

Rudolph JW, Raemer DB, Simon R. Establishing a safe container for learning in simulation: the role of the presimulation briefing. Simul Healthc. 2014;9(6):339-49.

I felt a bit “vomity” when I started writing this “expert” response. It might have been the saccharine geek-speak in the dialogue of the trigger scenario… though the helicopter parent analogy was ‘sweet as’, Ben!… Or, maybe it because this is THE ‘Safe Container’ article… After all, if you know someone who is serious about simulation-based education, chances are they were taught by one of the Yodas (whoops, authors) of this article… Privileged I am, among them to be. So yes, I now get to play the role of a Sunday Schooler critiquing the Bible’s Ten Commandments. I’ll apologise in advance to Robert Simon for failing to heed the advice he gave me on my first sim course: “just don’t f#@k up!”.

Fortunately, unlike me, Ben Symon has written a succinct summary of THE article that really cuts to the chase. His summary of the online journal club interchange is spot on too. Read them. What follows next is my take; you have been forewarned.

OK, we all know that the debrief is where the learning really happens (or, at least, where it really takes off). BUT, for the debrief to work – for people to talk openly and honestly about what they did and why, to be challenged and to challenge one another, and then be able reflect on it all – we have to have this magical thing called “psychological safety”. It’s kind of like a seatbelt you strap on to stop you breaking bones as you carom off everyone else in a demolition derby. Click clack, front and back… Hmm, if only it were that easy.

The focus of THE article is how to construct a prebrief that conjures up this psychological safety magic, how to construct the hallowed Safe Container. I, like you, live by the Rudolph-Raemer-Simon commandments. I do introductions, I demonstrate my belief in ‘The Basic Assumption’ (“you’re all AWESOME!”), I negotiate confidentiality (“what goes on in sim, STAYS in sim…”), I’m explicit about assessment (“this is NOT a test”), and I figuratively sign everyone up to a fiction contract between facilitators and learners (“let’s keep it REAL…”), before orienting everyone to the sim environment, the sim process, and finally, the case at hand… Yes, like you, I’m well trained (did I mention I had great teachers?) and I have guzzled down plenty of the ‘prebrief’ Kool Aid.

Let’s face it, there is much that is great about this article. It is written by truly expert experts. I’ve seen them all in action (mostly Robert and Jenny… I watched Dan Raemer on YouTube once) and I’ve read many of their works over and over. They’ve got undeniable Street Cred. Importantly (though I’m not sure I could emulate exactly what they did from the description in the article), they’ve gone to lengthy lengths to dig up diverse literature from otherwise disconnected fields to build their case… and, oh, how I’d love to have read all of the listed references! Many great ideas come from a confluence of thought from disparate fields of study and the Safe Container is a case in point.

Enough of that. I want to go back to what Ben Symon and Mary Fey have each said in their own ways and make something clear: if you think psychological safety is about group hugs, singing Kumbaya, getting your feet massaged, and keeping it all cuddly-feely at all costs; you are wrong, profoundly wrong. Wrong like a Trump presidency. Wrong like Brexit. Wrong like a lot of other really wrong things. The Safe Container is not about creating a comfortable space, it is about making it OK to be uncomfortable. This is important because Ericsson tells us that expertise is forged from repetitive practice at the edge of, or beyond, our comfort zones (Ericsson, 2004). Psychological safety helps convert the Threat of socio-evaluative stress into a Challenge, so that we no longer worry about being embarrassed or having our Identities dismembered, and so that we can do things that help us learn despite the discomfort.

All this has got my ‘Amy Edmondson neurons’ twitching (her book ‘Teaming’ is a MUST read) and I find myself asking, “Is this a spanner which I see before me?”. You see, in the context of teams, Edmondson has defined psychological safety as “the shared belief that the team is safe for interpersonal risk taking” (Edmondson, 1999). Importantly, she states that this is a tacit belief borne out of a climate of interpersonal trust and mutual respect and that the essence of team psychological safety is not altered by making this belief explicit (Edmondson, 1999). So how does saying ‘the right stuff’ in a prebrief create psychological safety? Well, it doesn’t… Psychological safety is not something you say, it is something that grows from what you do. Actions speak much louder than words. Indeed, Jenny Rudolph has said similar things in podcasts on Debrief2Learn and Simulcast. Like me, you may have worked with people that ‘talk the talk’ but if they don’t also ‘walk the walk’, then trust and respect go up in smoke.

So, in a one-off sim session, your wider reputation as an instructor and how you behave during the prebrief is all you’ve got to create the Safe Container. If you do sim in the workplace (like Stephanie Barwick and Clare Thomas do), or have repeated interactions with the same group of learners, then things might be different. If you’re a day-to-day d!ckhe@d in the workplace, you can’t expect to wave the ‘Safe Container’ wand and turn from toad to prince as you step into the sim room — people will know you for who you really are. Even worse, even if you are an all-round ‘Good Guy’, even the best Safe Container strategy will be devoured if the pervading workplace culture is toxic. This harks back to Peter Drucker’s apocryphal saying: “culture eats strategy for breakfast”, only so much can be achieved with even the best prebrief strategy if the wider culture is a hungry psychologically unsafe monster. Of course, the pervading culture is even more important if you’re one of those intrepid educators who unleash unannounced ‘Guerilla sims’ in situ… Who dares wins? Not always.

Now, here’s a paradox for you to ponder. When I think of the most profound learning experiences in my working life, those that are seared indelibly into my cortex, a collection of colossal cock-ups come to mind. These are things I felt really bad about, in some cases things that really threatened my self-identity as a competent doctor. I don’t remember there being much ‘positive regard’ at those times. Yet I think they changed me, forced me to build new mental models, and made me strive to do better. How do experiences like this reconcile with the ‘Safe Container’? Or am I just a poster boy for survivor bias spuriously validating a “what does not kill you makes you stronger” mindset?

Also, on re-reading THE article I discovered that the premise, derived from economic theory, that people are ‘intendedly rational’ was something that bugged me. This is because people like Daniel Kahneman and Dan Ariely argue that much of our behaviour is actually “irrational”, and driven by a bundle of heuristics and cognitive biases of which we may not be aware (Ariely, 2009; Kahneman, 2012). These are typically adaptive in the right circumstance but can be maladaptive in others. This makes me wonder… Are we really privy to the mental processes that direct our behaviour? How much of what we hear in a psychologically safe debrief actually involves involuntary post hoc rationalizations rather than insights into what was really happening in someone’s mind at the time?

Another question for you, how important is the fiction contract? It centers on a belief that participants will learn more the greater their immersion in the unfolding simulation. Is this really true? Perhaps not, so long as the learning experience is ‘authentic’ (i.e. can be translated into the real world). For instance, low physical fidelity simulators can teach uroscopic procedures effectively (Matsumoto, 2002) and in some circumstances, observers of simulations can learn as much as participants (Stegman et al, 2012). What do you make of this?

Finally, as believers we are left with another confronting question, how do we really know if the Safe Container works? Does the Safe Container lead to better patient care or better patient outcomes, or even improve participant behaviour and performance in the real world? If the studies that answer these questions with definitive proof exist, I’m abashedly ignorant.

Having said all this, despite the caveats, I can’t see myself wavering from the script anytime soon. This is an outrageously important article and a valuable guide to anyone who steps foot into the sim arena. The Safe Container rules, OK?

References

1. Ariely D. Predictably Irrational: The Hidden Forces That Shape Our Decisions. Harper, 2009. [google books]
2. Edmondson A. Psychological Safety and Learning Behavior in Work Teams. Administrative Science Quarterly. 1999; 44(2):350-383. [article]
3. Edmondson AC. Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge Economy. Jossey- Bass, 2012. [google books]
4. Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Academic medicine. 2004; 79(10 Suppl):S70-81. [pubmed]
5. Kahneman D. Thinking, Fast and Slow. Farrar, Straus and Giroux, 2011. [google books]
6. Matsumoto ED, Hamstra SJ, Radomski SB, Cusimano MD. The effect of bench model fidelity on endourological skills: a randomized controlled study. J Urol. 2002; 167(3):1243-7. [pubmed]
7. Rudolph JW, Raemer DB, Simon R. Establishing a safe container for learning in simulation: the role of the presimulation briefing. Simul Healthc. 2014;9(6):339-49. [pubmed]
8. Stegmann K, Pilz F, Siebeck M, Fischer F. Vicarious learning during simulations: is it more effective than hands-on training? Medical education. 2012; 46(10):1001-8. [pubmed]