Constructing Safe Containers for Effective Learning: Vignettes of Breakdown in Psychological Safety During Simulated Scenarios ( ) Anna Maria Carrera1, Anjum Naweed2 ✉ , Elyssebeth Leigh3, Teresa Crea4, 5 6 Ben Krynski , Kevin Heveldt , Marc Lyons7, Cameron Knott8, and Sanjay Khetia9
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Department of Anaesthesia, Pain Medicine and Hyperbaric Medicine, Royal Adelaide Hospital, Adelaide, South Australia 5000, Australia 2 Appleton Institute for Behavioural Science, Central Queensland University, Adelaide, South Australia 5034, Australia
[email protected] 3 FutureSearch, Tempe, New South Wales 2044, Australia 4 Centre for Creative, Australian Capital Territory, University of Canberra, Canberra 2617, Australia 5 Real First Aid Pty Ltd., Victoria 3182, Australia 6 Royal New Zealand Navy, Auckland 0744, New Zealand 7 Building Leadership Simulation Centre, Victoria 3205, Australia 8 Austin Health and Bendigo Health, Victoria 3084, Australia 9 QinetiQ Ltd., Hampshire GU14 0LX, UK
Abstract. This paper reports on work completed to date comparing a range of approaches to using simulation in industry settings. We document, share and compare across psychological and physical ‘safety’ dimensions in each of our domains, and describe how these are managed in different contexts. The concept of simulation as creating, and then existing, within a ‘safe container,’ a term is used as a metaphor for the context of simulation in action. In this paper we first reprise work undertaken during 2015 to develop baseline comparisons of key simulation factors across our disciplines/activities. Each approach is described separately, then we use the data to extract key points of similarity and difference. Next, we consider what ‘safety’ is in the context of a simulation in action and explore how users can learn with, and from, each other about selecting appropriate strategies to both support and challenge the notion of ‘safety’ in simulation-based learning contexts. The paper does not include a complete consideration of all uses of simulation, however our approach to collecting data, sharing and considering the implications of the emerging array of information is proving to be useful for developing a broader scope with which to consider the issues of safety and learning which are central to the uses of simulation that we are exploring. Keywords: Simulation · Training · Psychological safety
© Springer International Publishing AG 2018 A. Naweed et al. (Eds.): SimTecT 2016/ISAGA 2016, LNCS 10711, pp. 1–15, 2018. https://doi.org/10.1007/978-3-319-78795-4_2
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Introduction
The power of simulation is mainly vested in experiential learning and the debriefing process that follows which should encourage reflective thinking and enrichment of the lived experience. Learning in an environment that is deemed safe and allows the learner to “fail” without catastrophic consequences to the systems and/or outputs should be the absolute aspiration of training. In this context, simulation is invariably considered a “safe” learning environment, but if the concept is re-framed and the focus becomes the simulation participant rather than the system or output in which the participant must become proficient, then simulation is anything but safe. In reality, simulation can be a confronting and very vulnerable setting for participants as they agree to expose their knowledge, or lack thereof, to instructors and in certain circumstances, to their collea‐ gues and peers. Consequently, there are broadly two categories of need to be addressed in the design and execution of simulations, i.e. physical and psychological safety. 1.1 Physical and Psychological Safety For the context of this paper, the physical safety of simulation participants will be taken to mean the hazards inherent in the environment and any hazards associated with the “tools of trade” used in the various domains. Additionally, simulation will be restricted to modalities that involve the participant to actually interact with their environment and/ or co-participants and that are experiential in nature. Case based and/or “passive” modalities will not be considered. High fidelity simulations seek to recreate the physical environment that the learner will confront in reality; therefore, it is probable that environmental hazards will be recreated in the simulated environment either by design or through chance occurrence. If simulation is in-situ then a comprehensive array of hazards inherent to the natural setting including obstacles, placement of furniture, normal workflow will be clearly evident and need to be managed. In interprofessional or multidisciplinary simulations, care must be taken to ensure that participants maintain situational awareness at all times so that they do not put themselves or others in potential danger. In addition to environ‐ mental hazards there are tools of trade that need to be handled with care. The psychological hazards present in any simulation are largely unknown and as varied (and potentially vast) as the sum of the experiences of all the participants. Simu‐ lation is confronting and weaknesses and doubts in participants’ perception of their skills and expertise are unmasked. Unresolved issues with a similar past experience or being challenged with situations that produce acute stress may also cause problems. Partici‐ pants may appear outwardly calm but have many underlying issues of which they may or may not be aware. As we are simulating workplaces, it more than likely that hazards inherent in normal working environments will be common across all domains, however, each domain will have its own unique challenges. Physical risks like trip, slip, and fall hazards will probably be found in most if not all work environments. Similarly, some psychological hazards like acute distress, self-doubt, flashbacks to previous lived experiences with poor outcomes and other stressors may be common. Participants can also feel threatened by unplanned events or accidents that may occur
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in simulation from time to time. Participants may feel as if they had been set up to fail if simple things like equipment malfunction occur during the course of a simulation. In all cases the skilled facilitation is paramount. 1.2 Aims and Objectives The overarching aim of the paper is to draw on and extend the “safe container” metaphor about creating a psychologically safe context for learning (Rudolph et al. 2014) in order to compare and contrast the common core features associated with the safety of the simulation participant across our domains. The authors of this paper are members of the Human Dimensions in Simulation Special Interest Group (HD_SIG) of Simulation Australasia, thus the domains are confined to those affiliated with this cohort. They consist of: – – – – – – –
Transport (Rail) Health (Anesthesiology) Business (Management/Social education) Drama (Theatre) First Aid Training Navy (Maritime Engineering), and Construction (Management)
Whilst this paper does not provide a definitive report on safety in simulation, it starts the discussion about how to recognize and identify risks associated with physical and psychological harm to simulation participations. In the spirit of iterative research, this paper collects the thoughts and experiences of experts working in simulation, and repre‐ sents the first step in an engaged research agenda within the broader simulation community. This paper collates the authors’ industries and specific contexts in several ways. The first section provides vignettes where discrete simulator scenarios show the interplay with the user experience as an exemplar of their domain. These stories, and their accom‐ panying reflections are used to illustrate the breakdown of psychological and/or physical safety in each domain towards clarifying the relevancy of the “safe container” concept. The vignettes convey scenarios in the first or the third-person (using pseudonym’s where appropriate) that have been shared by participants, or observed first-hand by the substan‐ tive author, or inferred as a common scenario in their domain. These vignettes extend the aims of the paper by illustrating a scenario and then explaining the context. The last section summarises the relative physical and psychological hazard, and in doing so, dimensionalises the key constituents that need to be considered when constructing “safe containers” in these domains and broadly generalisable settings.
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Vignettes of Breakdown in Psychological Safety During Simulated Scenarios
2.1 Transport (Rail) Vignette. “Jimmy has 2 years of experience driving passenger trains. Today he has a competency evaluation. He comes into the training center – ah, there it is – the full motion simulator he’s heard so much about. He’s a good driver, never had any trouble, never had a SPAD. The instructor gives him a safety briefing about climbing the steps and holding onto the rails when he boards the capsule. Always, three points of contact. He sits down in the chair. It looks exactly like the real thing. The screen comes on. That’s a bit cartoony but cool all the same. The session starts and he drives, dropping and picking up passengers at the stations. It’s a routine task but after 20 min the novelty is still there. He doesn’t feel sick, they told him he might, but he feels all right - what the?! The signal in front has just changed to red. What-… he hasn’t got time to stop. He applies the emergency brake, dumping all the air. The train lunges forward and the wheels scream. His heart jumps into his throat. He hears the groaning of the coupling as the passenger cars bunch together. The large red orb whizzes past him on the screen. He’s still moving with no sign of stopping. At last it stops. He opens his eyes. He can’t quite focus. What just happened? What does he do? He’s gone over the points. Has he derailed? Somehow, the phone is in his hand and he’s dialing the Controller. ‘Driver G-H24, you’ve just run a red light at danger – remain where you are’ says the instructor’s voice. A Signal Passed at Danger… he’s had a SPAD. He laughs a little but his hands are shaking. The instructor talks to him and says things, but Jimmy doesn’t really hear them. How could he have done that? His hands are still shaking when he is debriefed and leaves the training center.” Reflection. In rail transportation, work activities are highly rule-based and subscription to the rail-driving task is about adhering to rules and applying them correctly. In the context of simulation-based the training, there are different learning outcomes. For maintaining competencies, the general aim is to gain an understanding of actions and behaviours, and test the driver’s knowledge. This may also happen in a scenario critical for safe driving, or scenarios, which carry high stress potential such as a signal passed at danger incident conveyed by the vignette. This is where the signals, which govern where a train may move, are breeched (like a car going through a stop light). These types of scenarios, by their very nature, have a startle component and may involve some deception so the User is not alerted to their presence. The psychological safety of the User in a train simulation is not really considered in the design of scenarios, under the ostensible assumption that the physical safety carries over to every possible dimension. A signal passed at danger event is one of the more debilitating scenarios that a train driver can experience in the real world. It raises ques‐ tions of competency and perceived threats of job security, with corresponding impact on their health after the fact. In the real world, the incident is often experienced as an acute stress response and has psychophysiological form (release of noradrenaline),
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including increased heart rate, constricted blood vessels, change in blood pressure), and emotional irregularity (disbelief, fear, panic anxiety) and threatens the performing capacity of the driver by manifesting cognitively (e.g. daze, narrowed attention, confu‐ sion, distraction, impaired judgment, disorientation, partial amnesia), and musculoske‐ letally (e.g. shaking, muscular agitation, delayed response) (Naweed et al. 2015). Based on data I have collected, SPAD scenarios in the simulator can have the same effects. Given that this type of scenario may not be briefed ahead of the experience, there are questions of user welfare. However, briefing the User, may compromise the whole point of experiencing the scenario. On the other hand, the attitude of the user is a key factor, largely because train drivers equate train driving with motion and route knowl‐ edge. Thus, if the route is not a duplication of a real route, or if the train driving does not feel right, the plausibility of the scenario for the end user is affected and may diminish their investment in the experience. 2.2 Health (Anesthesiology) Vignette. “Tania is an anesthetist who has worked in a large public hospital for 4 years.” She and a colleague, Bill, come to the sim lab because they are rostered on for simulation based anesthetic crisis management training. In the first scenario she takes the lead confidently and effectively leads the team to a successful outcome for a patient in serious trouble on the operating table. In the second scenario she is called in to help Bill who has just put a patient under general anesthesia. Once the patient is paralyzed, their airway collapses and Bill cannot intubate the patient by direct laryngoscopy, nor can he mask ventilate effectively. Tania tells the team that she will have a go at intubating the patient. Alarms keep going off, the oxygen level keeps falling and the carbon dioxide level keeps rising. Tania is distressed when Bill says they have to do a surgical airway. She wants an Ear, Throat & Nose (ENT) specialist called and wants to try bag masking again. Alarms keep going off, patient’s oxygen, carbon dioxide levels and heart rate worsen. Bill insists on making a surgical airway and starts preparing for it. He hands Tania a scalpel pack and she drops it. The scenario is terminated. In the debriefing process Tania is visibly distressed and reveals that she was called to a similar emergency a few weeks earlier. A junior ENT trainee had nicked a major blood vessel in the neck while making a surgical airway and the patient died. Reflection. In our Department, we teach crisis resource management to consultant anesthetists. The aim is not only to improve non-technical and decision-making skills but also to increase resilience by exposing clinicians to highly stressful situations. In each session, 2 consultant anesthetists are confronted with managing a patient who has spiraled out of control and needs to be rescued very quickly. Although the “Can’t Intubate Can’t Oxygenate” scenario is not common in the course of normal anesthetic practice, it can happen, especially in emergency surgery. Rescue techniques are either a cannula cricothyroidotomy and/or a surgical cricothyroidotomy. Both techniques have serious risks and potential complications for the patient. There‐ fore, they should only be used in life threatening situations. Surgical airways require a high level of skill as the potential for serious adverse events, such as nicking the major
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arteries in the neck, is high. Anesthetists are not typically trained in surgical airways but may be confronted with the need to do one if a suitably trained clinician is not available in time. In our simulations, we create a reasonably flat hierarchy by having 2 relatively senior anesthetists participate in our sessions. This so that the focus is on communication, especially sharing of mental models; decision making and ensuring that the best person in terms of skill and confidence is assigned and supported to perform a highly stressful task. Apart from the usual hazards e.g. trip, slip etc. the patient environment may also have other highly visible hazards such as scalpels and defibrillators that may be essential for patient survival. In anesthesia the psychological hazards can be well hidden and have the potential to cause emotional distress to participants. A good facilitator and debriefer will recognize the signs and have access to a range of people such as welfare officers or others who can help the participant cope with past psychological trauma. 2.3 Business (Management/Social Education) Vignette. “The occasion is a weekend workshop on group dynamics and social cohe‐ sion. Jim and Toby – respectively boss and 2IC of a small company – spend the day at the event and decide to stay on for the evening activity, a simulation about group dynamics during mergers and acquisitions. They join a five-member ‘team’ with family roles of father, mother, teenager, pre-teen and grandparent. Jim elects to be ‘mum’ and nominates Toby as ‘dad’ saying it is a “good chance to experience problems of leader‐ ship.” Elsewhere Rosy, arriving late, is assigned the role of “Dad’s girlfriend” - in a family whose ‘grandparent’ is the parent of an ‘absent’ mum and unhappy with the idea of a ‘girlfriend’! The simulation occurs over two rounds. For the first 30 min, teams fit all five members into a 3-bedroom dwelling, by ‘furnishing their home’ using scissors and paper. Then, abruptly, half of the families are told their house is repossessed and they have 15 min to move in with neighbors, who must accept the newcomers. Jim and Toby’s family are paired with Rosy’s family. Deciding they are ‘better out of there’ Toby and Rosy ‘elope’ to a nearby lounge to observe. The debriefing reveals Jim as a bossy ‘mum,’ leaving Toby feeling completely henpecked. Rosy is criticized by the grandparent, and not supported by the ‘dad’. These, and related issues of family and organisational dynamics, are explored by the whole group. On their way home together, Jim and Toby recall their experience when Toby notes that his experience parallels his experience working with Jim. Since Jim considers himself to be a collaborative and team-oriented boss the earlier revelations had been shocking enough – but now this! Sitting in the car until 2 am on a very cold night they build an entirely new working relationship, delightedly informing the facilitator about this later the same day.” Reflection. Management, and related social education arenas, use simulation to repli‐ cate social problems that human beings may experience in particular settings. The simu‐ lation described above, is called “Furnishing Your Home” and was designed as a means of learning how to bring together the three faiths that had decided to merge to become
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the Uniting Church in Australia. Its framework parallels the kinds of events that may emerge when two or more separate entities decide to merge. Whatever the logic or financial benefits of such a decision, it will have potentially serious consequences for all those involved. Such simulations can help by allowing individuals to experience the impact in a small, relatively safe, environment ahead of implementation of the decision. On the occasion described here the simulation was being run as an example of such designs, rather than with any intent to deal with real issues. However, in choosing and managing such simulations, facilitators must always be aware that any number of unknown and unknowable factors may be at work as the activity unfolds. I was not yet a skilled facilitator and Jim and Toby provided me with a profound experience whose lessons have stayed with me. People will do what they want to, in a simulation, and their actions will parallel real life – often in unexpected and surprising ways. Individual deci‐ sions for action will have an impact on others that can be harmful, however unintentional, and such outcomes need to be addressed at the time they emerge. During the debriefing Toby and Rosy’s experience was explored more in relation to the impact on individuals in real situations. For Rosy that was the end of it. For Jim and Toby (aliases) the outcome had a much more profound impact. They were delighted with the outcome of what had become a very problematic set of conditions, and were clearly skilled enough to manage the fallout. As I was entirely unaware of these dynamics during the simulation and afterwards, I was initially appalled that my choice of activity had generate such potential for continuing difficulties for them. I was relieved to learn that my work during the debriefing had supported a positive outcome. I was also shocked to realize how much the events of the simulation had so precisely re-created their real-life experiences. Since that long-ago night I have run hundreds of simulations in all kinds of contexts around the world and each time the eloquent reminder from Heraclitus that ‘you can never step in the same river twice’ (because the water you stood in has flowed on and gone) is with me. I know that what I am about to create and invite participants to enter is the ‘container’ of a new simulation in a new context. No matter how often I may have presented a particular design these participants have never worked together in this way before, and will not do so again, even when they continue to work together. This expe‐ rience will change them in some small or major way. Thus, simulations of these kinds will always have the potential to generate interpersonal stressors, may recall (pleasant or unpleasant) events from personal life histories and instigate individual insights of both positive and negative kinds. With regard to environmental issues, most such designs are conducted in the relative safety of conference or classroom spaces but even these have potential for unanticipated impacts. In short – like life –simulations are both safe and potentially not so. And like life, they offer learning opportunities of rich and varied hues, requiring facilitators to develop skills including situation sensitivity and the capacity to fail and recover–repeatedly. 2.4 Drama (Theatre) Vignette. “Nicole nervously makes her way to the first day of rehearsals for a new Australian play soon to be premiered at a local arts festival. The rehearsal room is abuzz
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with excitement as she greets her colleagues - many of whom she has worked with before. The director calls everyone to order, roles are allocated and the ensemble embarks on their first reading of the play scenario. After, over lunch, the group discusses the main themes, examining the motivations behind the main characters and their actions. The work delves into the secrets of a remote community - secrets comprising violence and domestic abuse. In the afternoon, the director suggests they do some improvisational exercises to explore different portrayals of domestic violence. They gather some rudimentary props and costumes - a jacket, an apron, a kitchen table - and set about re-enacting (simulating) a range of different family scenarios. Nicole draws on an acting technique which utilizes memory recall to evoke incidents of violence that she has witnessed in the past to inform her responses during the improvisation. But Nicole has herself been a victim of violence in real life, and as much as she hangs on to her acting technique and tries to separate the two realities, the re - enactment suddenly becomes psychologically ‘real’ for her and she breaks down sobbing.” Reflection. Theatre is amongst the oldest of crafts to use forms of simulation and reenactment, and over time has evolved a vast repository of different techniques to facil‐ itate role-play. In conventional theatre1, the work of the actor is particularly emotionally taxing. Actors draw on a range of methodologies - from psychological analysis and memory recall, to physical and vocal exercises - in order better understand their character and back story, and ‘get into the role’. Actors are also assisted in this process by makeup, props and costumes - all of which act as sensory triggers to facilitate emotional identification. But as they strive to uncover the psychological truth of their character, there is a danger that they may lose psychological perspective and trigger unexpected or hidden emotions. The rehearsal period is therefore at once an exciting yet vulnerable phase of the development process whereby the actor works to deepen motivation and axes of char‐ acter conflict, key relationships and significant moments of the dramatic action. They are required to delve deeply into their psyche to find true emotions and ways of simu‐ lating these emotions in a manner that will be credible to an audience. That said, in conventional theatre, there is a tacit understanding between actors and audience that they are separated by an invisible ‘fourth wall’ that delineates the fictional space or simulation - represented by the stage - from the real world. But in the rehearsal room there is no fourth wall or curtain to delineate the fiction space from reality. It is the director who must act as the external eye and take the position of the audience. In this way s/he also ensures that any physical staging hazards and/or psychological hazards are mitigated should the actor become too immersed in the process. The director is at once a side coach, a facilitator and a guide, ensuring the actor stays focused, safe and in character, while maintaining technical and emotional control. It is up to the director to set and patrol the boundary between reality and fiction. Thus, the rehearsal period is also 1
Today many disciplines make use of theatrical and dramatic role-play practices for a variety of purposes including education, business training and therapy. For the purposes of this paper, our case study refers specifically to theatrical conventions commonly found in the entertain‐ ment industries.
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the time when all physical, emotional and psychological hazards are worked through such that the actor may feel confident and safe enough to re-enact their character’s journey - no matter how harrowing - truthfully every night, in front of an audience. In the above vignette, the director would have stepped into the simulation breaking the illusion of the fictional space, removed the actor from the scenario, and coached them back to the present utilizing a range of debriefing techniques from the removal of costumes and physical exercises, to group reflection and feedback. 2.5 First Aid Training Vignette. “Lucy has been a secondary school teacher for the last 15 years and through that time, required to complete First Aid and Cardiopulmonary resuscitation (CPR) refresher training regularly. This year the school decided to bring in a new provider who has promised to make the training more realistic and engaging. On the day of the training, the instructor asked for volunteers, and Lucy elected to participate as the first-aid responder. The Instructor along with the rest of the class left the room, leaving Lucy and two other ‘responders’ to ponder what they were about to face. Suddenly, 3 people burst into the room, agitated, frightened and panicked, and yell that someone has collapsed in the cafeteria. They grab Lucy by her jacket, yelling that they have to go quickly as “she is dying.” Running out the room and through the courtyard, Lucy’s vision collapses, color becomes less vivid and the distant screaming grows louder and nearer. The sounds are frightening and as she approaches her purple-tinged, unresponsive colleague lying on the floor of her cafeteria, flashbacks to her own father collapsed in her family lounge flash through her mind. And then she smells it – the overwhelming scent of vomit – the same odor from the lounge. It is all too real, the sounds from the inside, the sight of her friend, and the smell – its reeks of death. She bends over, closes her eyes and starts to hyperventilate. Within seconds, the Instructor realizes something is wrong and imme‐ diately ends the scenario, takes Lucy outside and sits her down. She remains nauseous and shakes with violent spasms. After 10 min or so, she calms down but the anxiety, nausea and shortness of breath are not so quick to go.” Reflection. As this vignette shows, we attempt to simulate first aid and other critical emergencies in our training organisation. Utilizing innovative, low-tech cost-effective solutions, the aim is to recreate the true emotions and sensations of a critical incident, then practice within that environment. Training in such a high-fidelity environment has clear physical and psychological hazards. Safety is arguably the responsibility of not only the instructor but of every student, however the challenge is that most of the partic‐ ipants within these courses have never participated in any form of immersive simulation before, and even though they are briefed on what they will encounter, they seldom understand what it means until they experience it for the first time. Furthermore, it is often the case that students do not understand how their body will react under stress until they are placed in such a situation. This limits our ability to identify those likely to experience an adverse emotional response. A comprehensive safety brief is discussed at the beginning of each session that focuses on both physical and psychological safety. Students are empowered to cease
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any scenario by calling out “Stop Stop Stop!” in a loud voice if they see something unsafe that is about, has been, or is being performed. They are also encouraged to inform the instructor any point at which they feel uncomfortable and/or worried about anything they have been asked to do. Throughout the scenario, instructors constantly reassess the environment and observe the student’s body language for any signs indicating an adverse reaction. The main struggle in this context is prevention as many students do not fully understand how they will response emotionally or psychologically, or what flashbacks they may have to previous experiences until they are placed in that situation. 2.6 Navy (Maritime Engineering) Vignette. “Simbasics 4 kicks off as the facilitator hands over the shift to a novice team comprising an Engineer of the Watch (EOOW), and two additional operators, known as the 2nd and 3rd engineers. The team undertakes visual checks on the system mimic screens in the Machinery Control Room (MCR). The facilitator observes through the mirror window as the learning outcome of ‘Initiate a planned propulsion configuration change using the automated propulsion control system’ unfolds. The EOOW refers to the operating procedures folder in her lap and then sends the 3rd engineer to the local operating panel in another room to monitor key equipment. She notes that he follows the safety protocols and acknowledges his report over the phone when he arrives. The 2nd engineer switches to the process change over HMI and prepares to cross check. The EOOW notes this and then contacts the bridge to get permission to conduct the mode change. Approval is given, and she initiates the process start at her own HMI. At the local panel, the 3rd engineer inadvertently switches a pump to local control; he then quickly switches it back to remote. The EOOW has the phone to her ear speaking to bridge staff as the control system initiates an auto control failure alarm and the system freezes halfway through the changeover resulting in all three main propulsion engines connected and driving the ship. The EOOW drops the phone and her folder, leans over to pick them up, hits her head and while rubbing her temple, starts to flick between HMI screens to see what has happened. The 2nd grabs the breakdown folder, starts to read the emergency response checklist, stops, jumps out of his seat and picks up the Public Address (PA) system microphone. He calls the 3rd engineer back to the MCR and pages the senior engineer to come to the MCR. He then sits back down beside the EOOW and starts to read the breakdown checklist.” Reflection. This vignette of a low level procedural training scenario going off track may seem innocuous and easily rectified by resetting the simulation and starting over in order to meet the learning outcome. In our Domain however, this kind of incident is seen as a significant opportunity to build and enhance our particular context of a safe container. Our training paradigm has the safe container concept being framed as a basic assumption about operating in synthetic learning environments. That is; we are all here to learn, it is safe and, we are in this together. In order to achieve this, a number of supporting elements are in place. Scenario design and scripting must challenge
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participants to the appropriate level of dissonance in order for them to operate in their Zone of Proximal Development (Rudolph et al. 2014). Design must also encourage participants to “think” about their role, not merely “do” it (Stocker et al. 2014). Lastly and we believe most importantly, the environment must be psychologically and physi‐ cally safe. Physical safety for us is mandated and bounded by strict organisational processes. Psychological safety is more cultural coded and where we have the belief that interpersonal risk taking such as admitting mistakes or speaking up is permitted, and knowing that risk taking won’t be met by resentment, embarrassment or ridicule (Edmondson 2002). For our facilitators, the Vignette is an opportunity for authentic learning to take place. This is because our approach to learning in simulation is not about what’s happened but rather what happens next. 2.7 Construction (Management) Vignette. “Rick has always been a high achiever finishing in the top 4 of his Bachelor of engineering class. Upon completing his degree Rick landed a job in one of Australia’s largest construction companies, boasting projects ranging from $100 m to a staggering $1b dollars. In the 5 years since Rick has been at the company, he has risen to the position of senior site engineer and now been earmarked as a potential project manager within the next few years. Today Rick finds himself at the Building Leadership Simulation Centre attending a high-performance site leadership program. It is about 90 min into the program and Rick is being briefed into his first simulation session. Rick will soon be assuming the role of a site manager on a 120-million-dollar apartment project. He will be replacing the previous site manager at week 38 of the project, about half way through the build. Rick has been informed that the project is 8 weeks behind schedule and 3% over budget, and tensions on site are high. Rick confidently makes his way to his site office where he is greeted by Gerry, his general foreman. Gerry is 196 cm, 120 kg and clearly agitated, aggressively he demands that Rick stops today’s concrete delivery as an accident has delayed the formwork. At this moment the phone rings, it’s Vanessa from head office, she explains that they have just received a noise complaint from the local council. They have received reports of an explosive sound; she needs Rick to investigate and get back to her by 10 am. Becoming increasingly annoyed at waiting Gerry interrupts; he leans in aggressively over Rick’s desk; tell her you’re busy and cancel the concrete? Rick’s mind is inexpli‐ cably thrown back to his primary schoolyard where a bully made his life a misery for 4 years. Rick emotionally and physically withdraws; his facial expression and his eye are blank. His tone is quiet and slow; clearly distressed he exclaims I do not want to play anymore…Rick then breaks down crying.” Reflection. This vignette is an example of medium level construction management conflict resolution and problem-solving scenarios. The behavior of site personnel and office support staff has been modelled on stereotypical responses to pressure as identified by industry practitioners.
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The construction industry is a melting pot of personalities and competing stake‐ holders. These personalities come together to perform work that can be inherently dangerous with tight margins and deadlines. The project workforces are mainly made up of contractors and consultants with competing interests working on increasingly complex and technical builds requiring specialist knowledge and skills. The leaders on these projects must bring these personalities together to coordinate, cooperate and collaborate if a project is to be successful. In order to provide effective leadership resilience, critical thinking and the ability to identify and adapt your communication is critical. Central to our training philosophy is the safe container, a place where participants can gain experience and build self-efficacy through real play practice and experimen‐ tation. As demonstrated above, you must always be aware that participants can experi‐ ence adverse reactions to stress and pressure in a high-fidelity simulation. Simulation can blur the lines between virtual and reality, connecting real memories that evoke feel‐ ings and emotions well beyond the simulation. In many cases this can occurs without warning and regardless of pre-simulation activities. It is extremely difficult to anticipate what will trigger these adverse reactions or who is vulnerable. Our focus to date has been to prepare our actors, observers and facilitators to better recognize the signs of psychological stress so they may intervene or cease simulations as soon as possible. In the above vignette our actor recognized the adverse reaction, and as instructed he immediately removed himself from the scenario. Our observer then proceeded to collect Rick and remove him from the simulation environment; he was then taken to a private space to compose himself. The decision to continue any interaction with the training is left to Rick. Regardless of his decision he is closely monitored and assessed for the duration of his training. 2.8 Summary of Hazards All of the vignettes presented highlight tangible threats to psychological safety. Although these examples feature across different domain and industry sectors, they all share common themes that highlight how difficult it is to screen out these variables, but at the same time how easily these issues may be triggered in the simulated scenarios. Table 1 lists the range of psychological hazards that may exist to varying degrees and may manifest to compromise and potentially harm the individual in the simulated scenario. Based on a consensus seeking exercise to identify and group the hazards, threats to psychological safety are likely to exist at the (1) interpersonal, (2) individual, and (3) historical levels. They may be broadly defined as follows: 1. Interpersonal hazards: Hazards typically associated with or relating to relationships or communication between people; 2. Individual hazards: Hazards of self-regulation and/or relating to a particular person; and, 3. Historical hazard: Hazards specifically associated with previous exposure or connected to past life events.
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Table 1. Summary of hazards. Domain
Interpersonal (psychological)
Individual (psychological)
Historical (psychological)
Environmental
Transport (rail)
Bullying Power differential (chain of command) Communication gaps
Competency issues Threat to job security Acute stress and/or anxiety
Prior experiences of conditions replicated in a design (may be positive or negative)
Slips, trips, falls Manual Handling/ heavy lifting Collision with trains
Business (management)
Bullying Harassment Differences in personal style Communication gaps
Lack of voice Stress Anger Frustration Fear of discovery of self-perceived inadequacies
Prior experiences of conditions replicated in a design (may be positive or negative)
Slips, trips, falls Physical contact jars/ jolts Animal/insect bites Allergies to pollen
Drama (theatre)
Lack of support from fellows Abuse from fellow performers Lack of preparation and adequate boundary setting (by director)
Emotional vulnerability Blurring of the line between acting and reality
Memory recall of stressful events Over identification with past
Slips, trips, falls Props (malfunction) Spills Falling objects
Health (anesthesiology)
Loss of face Exposure of weaknesses Exposure of skills gap
Lack of confidence Self-doubt Pressure of “test situation”
Past exposure to similar crisis with negative outcome
Electrical Slips, trips, falls Toxins Sharps
First aid training
Embarrassment in front of others Failure to perform in front of supervisors/ colleagues
Overwhelming emotional stimuli (leading to symptoms such as fainting, vomiting) Failure leading to mental and physical breakdown
Flashbacks from prior incidents
Slips, trips, falls Pyrotechnics Respiratory hazards (smoke) Spills Manual handling Unintended use of real weapons, drugs or devices
Navy (maritime engineering)
Loss of face Bullying/ harassment Exposure of weaknesses in front of work colleagues Skills gap exposure Power differential (chain of command)
Lack of voice Stress Anger Frustration
Past exposure to above Battle wounds and PTSD injuries Burns Biohazards/toxic gases Chemical Heavy machinery Slips, trips, falls Manual handling Electrical RADHAZ
Construction (management)
Loss of face Bullying/harassment Exposure of weaknesses in front of work colleagues Differences in personal style
Stress Anger Frustration Self-doubt Threat to job security Fear of exposure Claustrophobic
Past exposure to crisis Slips, trips, falls (flashback) Vertigo Recall of emotions Electrical from past stress/ trauma event
Each of these hazards has the effect of causing harm to the person in the simulation. As shown in Table 1, interpersonal hazards such as bullying/abuse, harassment and loss of face were common across the domains. Hazards in this category included harm arising
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A. M. Carrera et al.
from exposure of weakness and skills. Domains where chains of command-type struc‐ tures are common (e.g. Navy, Rail) included harm as a result of power differentials. Simulated scenarios in the managerial context (e.g. Business, Construction) included more subtle hazards such as differences in personal style. At the individual level, it is apparent that many latent issues may give rise to or augment the hazards existing at the interpersonal level. These include the lack of a voice, self-doubt, fear of discovery, and concerns for job security. Many also point to problems with emotional regulation such as anger, frustration, and anxiety. The risk of harm from hazards connected at the individual and interpersonal levels may be significant, given that the simulated scenarios are designed to place participants under situations that challenge these very psychological constricts. In some situations, it may be particularly difficult to manage these hazards, for example in the context of Theatre where emotional regulation is a feature of the work, and therefore may open up situations where the simulation and real world ostensibly overlap. In the historical category, the hazards all highlight that people are not unidimen‐ sional, but rather, are underpinned by a rich tapestry of experience that forms part of their make-up. Importantly, any previous experience of conditions that may be replicated within the simulated scenario can telegraph to the present and create significant risk of harm. This is shown very clearly in the First Aid Training exemplar, where a very dynamic simulation conjures flashbacks to previous traumatic memories at a highly sensory level. While some of these issues may be screened prior to the simulation, it is difficult to determine how much resilience individuals may have to these hazards. In this regard, all three levels of the psychological hazards intersect. Table 1 also lists the hazards associated with the physical safety of the participant, as illustrated in the vignettes, and more broadly within the type of scenarios in the rele‐ vant industry setting. Generally speaking, these hazards are associated with mobility (e.g. slips, trips, falls, physical contact) and the kind of things in each context that would be captured and mitigated by health and safety risk assessments captured in frameworks such as the hierarchy of hazard control system (Manuele 2008). These include collision with trains (Transport – Rail), malfunctioning props (Theatre), biohazards (Navy – Maritime Engineering), sharps (Health), and vertigo (Construction).
3
Discussion
The aim of this paper was to compare and contrast the common core features associated with the safety of the simulation participant across various domains by drawing on the “safe container”. Whilst the aim of many of the simulated scenarios in the represented industries is to create a safe environment for effective learning and development of specific skills, the identified issues indicate that, for the psychological dimension, a good baseline level of resilience and self-regulatory capacity is required to ward off risk. Clearly, it is difficult to screen some of these hazards; whilst some of the risk factors in the individual or interpersonal categories may be identifiable, by the assessor if not in self-reports by the individual, it is harder to identify hazards in the historical category because they may not be available for conscious introspection by the participant. There
Constructing Safe Containers for Effective Learning
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is a dramatic irony inherent to the safe container, which is that people need to develop effective skills so that they are better able to resist hazards in training situations that aim to develop effective skills. Thus, it is important to understand and to recognize the psychological safety profile as distinct from the environmental hazards more commonly associated with physical safety. This paper collects the thoughts and experiences of experts working in simulation, and represents the first step in an engaged research agenda within the broader simulation community. However, it would be very unwise to assume that professionals who run simulation have all the answers and insights to sources of physical and psychological harm. Thus, future ethically approved research activity should also take place with participants who have suffered some degree of trauma during a simulated event. This will then provide the feedback that simulation professionals need to design and build safe containers, which are comprehensive and have relevance to participants and prac‐ titioners across different industries. The psychological safety imperative related to the simulated scenarios identified in this paper makes a general argument for more resilience training in participants. This may be one of the ways in which we may be able to decrease the chance of the hazards actually causing somebody harm. Acknowledgements. At time of writing, all of the authors on this paper were members of the Human Dimensions in Simulation Committee of Simulation Australia.
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