Psychological Safety

Debriefing in simulation drives learning.  An effective debriefing can help learners make sense of events and encourage knowledge transfer from the simulation to the practice setting. Psychological safety is an important component of debriefing; it means that people feel safe taking risks and being vulnerable with others. When applied to a virtual simulation in education it means that the learners feel free to speak up, share thoughts and ask questions without being embarrassed or worrying that peers will respond negatively (Edmondson & Lei, 2014). A skilled facilitator is able to create a sense of psychological safety in the group; achieving a balance between learners’ feelings of fear and defensiveness with a willingness to share, reflect, ask questions and discuss experiences openly (Kolbe et al., 2020).

Expert’s Corner: Evaluation and Psychological Safety

If a simulation will be graded for evaluation purposes, this will likely reduce learners’ sense of psychological safety.

Psychological Safety in Debriefing

While psychological safety is first established in the pre-briefing phase of a simulation-based learning experience (Chapter 3), Kolbe et al., (2020) describe recommendations for establishing and maintaining psychological safety during debriefings.

Establishing Psychological Safety

Setting the right tone at the beginning of the debriefing is an important aspect of psychological safety. To establish psychological safety, debriefers should:

• Explain the debriefing process – including roles of facilitators, learners, and potential observers.
• Explicitly invite active participation in debriefing and demonstrate appreciation for doing so.
• Commit to actions and behaviours that convey respect, curiosity, attentiveness, and understanding of the learners’ perspectives.

Maintaining Psychological Safety

Given the dynamic, and at times delicate nature of psychological safety in the debriefing context, even apparently minor disrespectful behaviours can negatively impact perceptions of psychological safety (Kolbe et al., 2020). To maintain psychological safety, facilitators should:

• Consider behaviours that contribute to psychological safety during debriefings (e.g., explicit behaviours – clarify expectations, use inclusive language, demonstrate active listening; implicit behaviours – arrive early, respect confidentiality, convey empathy)
• Be aware of indicators that suggest learners’ perceptions of psychological safety may be threatened, for example:
  • Engaged or conversant learners becoming quiet or reserved.
  • Closed body-language.
  • Defensive responses or comments.
  • Learners arguing or criticizing one another.
• Assume learners’ reactions reflect how they feel; reticence or defensiveness means learners do not feel psychologically safe
• Focus on facilitator behaviours (rather than the learners) when attempting to restore psychological safety, for example:
  • Convey a positive affect (open body-language, eye contact).
  • Validate, and normalize learner concerns.
• Debrief the debriefing by regularly reflecting on own feelings of psychological safety and the ability to convey psychological safety in the debriefing process.

Debriefing Emotionally or Psychologically Stressful Simulation Events

Simulation-based learning experiences have the potential to evoke psycho-social or emotional distress in learners (Harder et al., 2020). When simulation experiences involve known stressful events (e.g., patient death), debriefing should shift from focusing on clinical judgment and analysis of technical and nontechnical skills to addressing the emotional stress of the  experience. Harder et al. (2021) developed a debriefing framework for health care practitioners and learners who experience patient death within the simulation experience: the Trauma-informed Psychologically Safe (TiPS) debriefing framework.

The TiPS Debriefing Framework

The TiPS debriefing framework is based on the principles of trauma-informed care: safety, choice, collaboration, trustworthiness and empowerment (Harris & Fallot, 2001). The purpose of the framework is to help learners feel prepared for exposure to potentially traumatic events (Harder et al., 2021). The TiPS framework includes guidance for facilitators on establishing psychological safety prior to the debriefing and procedures to follow during the debriefing. The framework also outlines what to do following the debriefing such as observing for the signs and symptoms of normal and abnormal stress or trauma reactions. It also outlines the importance of frequent self-monitoring following an emotionally stressful simulation experience.

In this video, Dr. Nicole Harder provides insight into the TiPS debriefing framework.

Spotlight on Scholarship: TiPS

Read the paper, “Developing a trauma-informed psychologically safe debriefing framework for emotionally stressful simulation Events” by N. Harder, J. Lemoine, W. Chernomas, and T. Osachuk to learn more about the TiPS debriefing framework. https://doi.org/10.1016/j.ecns.2020.11.007. 

Potentially Sensitive, and/or Distressing Topics

Facilitators should have an awareness of potentially sensitive and distressing topics and consider additional steps to enhance psychological safety that include:

• Select an appropriate debriefing framework (e.g., TiPS).
• Provide information on counseling services.
• Adopt strategies to prevent emotional distress and re-traumatization in learners.

Sensitive Topics

• Death/dying/end of life
• Terminal illness
• Violence/Gender-based Violence
• Suicide
• Child maltreatment
• Racism
• Cardiac arrest/emergencies
• Natural disaster

Strategies to Prevent Emotional Distress, and/or Re-traumatization (Li et al., 2019)

Preventing emotional distress and re-traumatization is important. These are some preventative strategies educators can employ through the different stages of a simulation to minimize risk:

•  Preparation
  • Include detailed information about the potentially distressing content in the pre-brief.
  • Inform learners about symptoms of emotional distress/re-traumatization (e.g., difficulty sleeping, distressing dreams).
• Ongoing Assessment
  • Maintain an ongoing assessment of learners’ experiences throughout the simulation experience e.g., “check-in” at regular intervals.
• Respond to Disclosures
  • Supportively acknowledge learners’ disclosures as an educator/facilitator (not as clinician).
  • Introduce available and affordable counseling and support services (e.g., learner or employee health services).
• Titrate exposure to traumatic material
  • Use breaks or pauses to prevent learners from becoming overwhelmed.
  • Ensure traumatic material is dispersed throughout the course or learning experience.
• Give learners control over material
  • Inform learners of their right to engage with material at their own comfort level.
• Promote Self-care
  • Stress the importance of relaxation, recreation and play.
  • Encourage learners to seek support from family, friends and mentors/supervisors.