Introduction

The Psychological safety of the participants is vital for maximum engagement and learning in medical simulation. Although research is limited on the components that increase the likelihood that a participant feels safe, there is at least general agreement among simulation experts on practices that facilitators can employ to support the creation and maintenance of psychological safety. This article reviews the components and practices that contribute to psychological safety in medical simulation. One such critical element is confidentiality regarding the performance of individual learners outside of the simulation exercise. The practice of establishing a confidentiality agreement helps to build trust between participants and with the facilitator. This shared agreement among participants and the facilitator is one of the methods that help establish and maintain a psychologically safe environment for risk-taking. When the participant feels psychologically safe, they are more likely to adopt behaviors that enhance learning, such as willingness to practice at the edge of their abilities, sharing their thought process, and discussing and learning from mistakes. In this article, we are also going to discuss, how to identify the breaches in psychological safety and strategies to establish a safe environment during debriefing.

Function

What is psychological safety, and why is it important?

Psychological safety is a shared belief held by members of a team that the team is safe for interpersonal risk-taking.[1][2] Medical simulation, particularly immersive simulation and debriefings, are risk-taking processes of learning.[2] It is common and often desirable for participants to practice at the edge of their abilities and to take risks to maximize learning. In these circumstances, mistakes can occur. Psychological safety is essential for participants to feel safe enough to practice at the edge of their abilities and to analyze mistakes to identify and mitigate learning gaps. Even when participants in medical simulation meet a high standard of performance, psychological safety is still relevant in their ability to discuss clinical reasoning in the face of uncertainty and within the hierarchy of medical training.[3] When learners feel psychologically safe and are not worried about being humiliated or shamed, they are more likely to adopt behaviors that enhance learning (learning behaviors), such as seeking feedback, talking about errors, and experimenting.[2]

Issues of Concern

The following are components and practices that have the potential to increase the likelihood of establishing and maintaining psychological safety in medical simulation: 

• Familiarizing participants with the physical environment and equipment: Before starting the simulation exercise, the participants should be provided with information about the environment, such as the location of the restrooms, water, and refreshments (if available). An introduction and, at times, demonstration of the equipment in the simulation space can reduce the stress of the participants. A general overview of how much time will be spent in various phases of the simulation and when to expect breaks shows respect for the participants' other commitments.[2] Ways to exit the simulation area in case of an emergency should be reviewed along with the location of emergency equipment. This information helps the participants to acclimatize to the simulation environment and shows care for their safety and comfort.

• Welcoming participants into the simulation space and team-building: An introduction from the participants before or during the pre-briefing helps the group to get acquainted and builds rapport.[4] In an observational study by Amy Edmondson, team members mentioned that sharing a small amount of personal information about oneself helps develop mutual trust. Team development also contributes to establishing and maintaining a safe environment during the simulation exercise. Bruce Tuckman described that team development happens in five stages; Teams are forming, storming, norming, performing, and adjourning. During the initial forming stage, the members of the team are unclear about their roles, rules, and expectations. In the storming stage, participants are competitive and have conflicts regarding roles and personalities. Norming is the stage, where they get to know each other, form a shared mental model, agree on team goals and objectives, and get ready to work together. Successful team development depends on how quickly the team goes through the first three stages of team development. Team-building, teamwork, and team behaviors (facilitative or obstructive) are interdependent. Team facilitative behaviors include mutual respect, trust, commitment, accountability, seeking feedback, and the opposite of these are obstructive behaviors. Disruption in team building leads to the development of the ego, fear of conflict, and team members that focus on individual accomplishments rather than the common purpose, thereby disrupting the psychological safety in the team.[5]

• Confidentiality: It is standard practice in the pre-briefing to have the participants and faculty agree to confidentiality with regards to discussing individual performance and information about the simulation scenario outside the event. This contract can be completed by signing a confidentiality agreement or with a verbal agreement. This contract includes the guidelines that need to be followed by the facilitator and participants. Confidentiality and reporting breaches of confidentiality are essential in establishing and maintaining psychological safety. Groups who have a strong confidentiality agreement are more likely to discuss and analyze actions within the debriefing without having a fear of ridicule outside of the event. Maintaining confidentiality about the simulation scenario content and theme also allows faculty to reuse the same scenario for other groups of learners. It should be revealed before the simulation occurs if performance is going to be shared with others after the event. 

• Purpose of assessment: Learners might be worried that the mistakes made during simulation will be held against them in their real-time practice or be used to decide if they advance in the course or program. Whether the purpose of the evaluation is for formative or summative assessment should be clear to the participants during the pre-briefing or before the event. Uncertainty regarding the purpose of the assessment can erode a safe learning environment.  In general, most simulation experiences are formative. Formative assessments are learner-centered, and the main goal is to promote further learning by helping learners remediate deficits and leverage assets. Summative assessments are achievement centered and assess whether the participant has achieved expected milestones.

• Fiction Contract: The fiction contract is an agreement between the facilitator and the participants. In this contract, the facilitator is responsible for creating a simulated environment that is as real as possible. The participants agree to play an active role assuming the scenario is real even if certain aspects of the simulation do not match a similar real clinical encounter, such as facial expressions in the manikin and changes in skin color. Having a fiction contract helps to focus on learning objectives rather than blaming the simulation if learners feel they have not performed well. The facilitator invites collaboration with the learner when in the pre-briefing, they admit that although they have done everything they can to make the simulation as real as possible, it still is not perfect. I have to depend on you (the participant) to look past lapses in realism for the benefit of learning. This early collaboration helps to create psychological safety and sets the tone for the entire event.[2]

• Fidelity: Fidelity in simulation is described as how accurately reality is represented. If the participants perceive there is an issue with fidelity, they are less likely to feel safe and may even be confused by the simulation. Medical simulations have three types of fidelity. They are physical (an approximation of senses like tactile, visual, olfactory, and auditory), conceptual (patient's physiologic, pharmacologic and emotional responses), and emotional/experiential fidelity (happiness, stress, anxiety).[6] Participants' perception of realism in simulation depends on these three kinds of fidelity.  If there is an issue with any component of fidelity, it could affect the psychological safety of the learners. Participants' perception of realism, along with a fiction contract, decides the willingness and ability to engage.[2]  

• Cognitive load: If participants feel they are being presented with too much information, this can create stress and potentially erode psychological safety.  In an experimental study of training 1st-year medical students in simulation, the researchers observed the effect of cognitive load on emotions and learning outcomes. Processing too much information in less time leads to cognitive overload, thereby causing a stressful learning environment and reducing the learning outcomes.[7] Simulation exercises should be designed in a way to avoid cognitive overload and therefore maximize learning and maintain psychological safety.  

• Identifying psychological distress in high-intensity simulations: The facilitator's motive is to encourage the development of psychological safety, making participants feel safe enough when subject to uncomfortable situations (this enhances risk-taking behavior). Participants should still be subjected to stress to approximate reality. Facilitators should identify symptoms of severe psychological distress and, if needed, address them in the debriefing, after the event, or seek the advice of a mental health professional depending on the situation. The symptoms of psychological distress can be physical, cognitive, or emotional (like anger, anxiety, depression, fear, crying, etc.). In cases of severe distress, the facilitator can provide the contact of a specialist such as a psychologist. The psychological distress of one person could disrupt the learning of other participants in the team.[8]

• Conveying a commitment to respecting learners and understanding their perspective: During the simulation, the facilitator should express sincere interest in the participant's thought process and explore the factors that went into a particular action.  The facilitator's role is that of a detective that helps to reveal the internal meaning-making processes of the participant to identify learning gaps.[2] All participants should be viewed by the facilitator and fellow participants as intelligent, capable, and wanting to improve. This practice shows respect and holds the participants to high standards.

• Feedback: Giving and receiving feedback can be challenging. Maintaining psychological safety doesn't mean avoiding constructive feedback. Constructive feedback in moderation motivates learners to improve their skills. The feedback conversation should never be disrespectful. The main focus should be on things that can be improved and how they can be improved.[9] A psychologically safe environment helps participants:
  • Appreciate comprehensive feedback
  • Have a willingness to reflect on problems and skills that are challenging
  • Correct and repeat the actions until a level of consistency is achieved.

• Role of Facilitators: Facilitators play an essential role in creating a safe environment in medical simulation. Some of the vital facilitator qualities and actions are mentioned below:
  • Be welcoming, approachable, and empathetic.
  • Give clear insights into the simulation exercise, collaborating with participants to set goals and objectives.
  • The facilitator should cultivate trust and encourage participants to speak up and engage in interpersonal risk-taking learning processes.[1]
  • Show vulnerability by admitting and analyzing their mistakes. This practice encourages participants to act similarly and models that mistakes should be seen as mysteries to explore, rather than merely errors. 
  • Respecting individuals' opinions 
  • Identifying the symptoms of psychological distress and acting appropriately

Curriculum Development

Strategies to improve psychological safety: Rudolph et al proposed some explicit and implicit strategies to establish and improve psychological safety during debriefing

Identifying breaches in psychological safety

Clinical Significance

Facilitators in medical simulation who use practices such as confidentiality agreements, fiction contracts, understanding the learner's perspective, and being clear about objectives will be more likely to have safe learning environments and therefore improved learning. Improved learning and skills lead to improved patient care. It has also been shown that psychological safety in clinical teams increases the likelihood that members of the group speak up when they witness errors or quality issues. This willingness to speak up can avert errors before they cause harm to patients. The desire to speak up also improves safety reporting and can improve patient care through quality improvement.[10]

Enhancing Healthcare Team Outcomes

Psychological safety is essential in the function of interprofessional teams in medical simulation and the clinical setting. Interprofessional teams that are psychologically safe have improved communication.[11][12] Psychological safety also increases the chance members of a team speak up or report and issue when they see errors or quality improvement opportunities.[13] Both improved communication within health care teams and reporting quality issues within our healthcare systems are imperative in improving the quality of care we deliver to patients. Facilitators and leaders that foster psychological safety in medical simulation and clinical practice are involved with culture change that can improve patient care across an organization.