A total of 35/300 nurses, 20/60 registrars, 14/50 consultants, and 3 nurse educators completed the surveys; this reflects a response rate of 17.4%. EP conducted 19 interviews (9 nurses, 9 registrars, 1 consultant) with a mean duration of 17.6 min (7:14–33:53 min). Interviews were with staff at varying experience levels and length of time working at GCUH.
We explored the bidirectional impact of simulation on psychological safety and psychological safety on simulation (Fig. 1) at the individual, team, and organizational levels.
Individual
At the individual level, participants found simulation was both impacted by and had real impacts on confidence, a known key individual difference in mediating psychological safety [16].
A small group of participants were very confident and keen to participate in simulation. One nurse said she was “Stoked [to be picked for simulation]. [I] Enjoy the challenge and take it as a great learning and training opportunity”. This growth mindset, as a starting place, well positioned some participants to engage with the interpersonal risks of simulation. Most other participants fell into the category of feeling some anxiety around simulation but to a degree that did not necessarily prohibit learning. Like one registrar who said, “[simulation makes me] anxious because they are quite high stress but also look forward to it as always great learning” or another nurse who was “nervous but excited to be challenged”. This group often commented on the efforts that the facilitators took—such as distributing pre-readings and thoughtful pre-briefings—as helpful in making the transition from anxious to engaged. A much smaller but important proportion of participants had a pathologic degree of anxiety related to simulation that likely impaired their ability to take any interpersonal risks during simulation. Some in this group described visceral reactions including diarrhea or nausea. Others purposefully scheduled the days of simulation off work. Many in this group could describe in vivid detail a negative experience related to simulation from early in their training. This spectrum of individual confidence in skills and with simulation presents a challenge for simulation facilitators.
Simulations also had the ability to impact real-world psychological safety through the development or destruction of confidence in personal knowledge and skills. For example, registrars shared that simulations “improve clinical skills and confidence in managing critical patients” and serve as a “major confidence booster when dealing with high acuity problems.” One nurse described feeling “more confident using the airway equipment” after participating in a simulation as the airway assistant. At the same time, we saw examples of where design, delivery, and debriefing decisions negatively impacted confidence with real-world consequences. For example, one nurse commented on how being put into a role that she would not usually be in, negatively impacted her confidence.
They put me in the drug role position and I wasn’t even familiar with that role. It was totally negative because everybody was having fun except for me…I was out of my depth and I knew it…I gave drugs that I wouldn’t usually be giving and it made me feel stupid.– Nurse (interview 1)
Similarly, a registrar shared how such a negative experience could impact their experience in the workplace.
If I felt I did poorly in a sim it would affect me for the rest of the day and sometimes multiple. I felt like I was mentally and emotionally overwhelmed and wasn’t able to concentrate for the rest of my shift. Registrar (survey)
Team
At the team level, psychological safety both impacted simulation experience and was impacted by the simulation experience—a bidirectional effect largely driven by familiarity. Pre-existing familiarity with the team members participating in the simulation modulated the learning for some but more dramatically was a key outcome of the simulation for participants. Leader familiarity, leader behavioral integrity, and inclusiveness were also important outcomes of the simulations for teams.
For example, one nurse described his learning experience in simulations as being different depending on the level of familiarity he had with the other participants he entered the simulation with.
You may learn better from the scenario because you are not thinking, ‘I haven’t worked with this person before’ and trying to build that relationship. There is only so much you can comprehend. – Nurse (interview 18)
He went on to describe that for complex scenarios having a team that you know well allows you to engage in problem solving more fully whereas for more simple scenarios an unfamiliar team may be acceptable because there are fewer interpersonal challenges to navigate. Other participants highlighted the importance of the nature of the pre-existing relationships and familiarity with the simulation faculty as particularly relevant to their learning experience both positively and negatively.
The impact of simulation on the development of familiarity with team members and team leaders was the most central finding of our study as it relates to how simulation impacts psychological safety on the floor. Simulation was an incubator of familiarity and acted as a magnifying glass on leader behavioral integrity. It was clear that participants viewed simulation as a place where relationships are forged, with both positive and negative consequences. Many described feeling more empowered to take interpersonal risks on the ED floor after working with medical staff in simulation. Like this nurse who wrote,
I felt that I could be open with my colleagues in this scenario [geriatric patient with bradycardia] and would have been able to speak up had I felt that intubation was not in the patient's best interests. I believe this simulation strengthened my relationships with the registrars involved and it confirmed that they would respect my opinion in a similar scenario. – Nurse (survey)
The impact on familiarity seemed particularly relevant for new hires and those training in new roles. They worried about it negatively impacting their reputation but also recognized it as a potentially positive space to build meaningful relationships. One registrar (interview 12) who was new to the department said, “there’s a lot of fear about being out of my depth and not really knowing what to do and that being on display for everyone I work with.” While a nurse new to the hospital highlighted how it enabled her to become more familiar with her team, “I’ve come to a new team and it gives me an opportunity to see how they work, how they want me to work, and what works best.”
In particular, and quite specific to the context of our simulation program, registrars felt that it was a place that they could build credibility with the nursing staff. For example, one registrar said, “[it’s an opportunity to] instill faith in your team and make sure that they know that you know what you are actually doing…” (interview 11). At the same time, nurses found that it was a place that they could get to know the leadership styles of the registrars. Taking it even further a more senior nurse saw it as their opportunity to prospectively shape registrars’ leadership approaches.
Sometimes we might just assume the registrars are always really good, but it’s good to support the junior doctors as they step up. You can see their growth….and build a connection with those registrars you are working with. – Nurse (interview 4)
But along with the potential positives for psychological safety at a team level comes a real risk of negative consequences. There were not many, but some important examples, of when simulation negatively impacted real-world relationships. One nurse responded, “the simulation I was involved in was a horrible experience…we were not respected by the team leading doctor” or another who shared, “if I make a mistake during simulation it sets a negative tone for the rest of the shift.” Though we were not able to interview these participants to learn more, it is reasonable to extrapolate that such negative experiences, or similar that risk being underreported in our sample, have important consequences for teams on the ED floor.
Organization
Organizational factors influence psychological safety entering the simulation. Rostering choices impacted the ability for some to participate which created tension and hierarchy between some staff. Even worse in rare occasions without appropriate cover, simulation was perceived to potentially negatively impact patient safety on the ED floor. One nurse wrote, “daily checks weren’t complete and surrounding team members weren’t supported on the floor.” More positively, at the organizational level the simulation program was seen as living evidence of an organizational commitment to continuous improvement and safety culture. One registrar suggested,
“It’s the feeling that we are trying to push the envelope…like the getting to CT simulations and improving the times of getting trauma patients scanned…it feels nice, like you are working somewhere that does something good.” – Registrar (Interview 3)
Though not directly related to the ED simulations that were the focus of this study some participants did comment on how interdepartmental simulations increased their understanding of other departments’ roles and improved relationships across traditional organizational lines. We heard from participants that simulation modeled how to have conversations about improvement which some started incorporating into performance conversations with colleagues on the floor in the form of after-action reviews or hot debriefs.
The simulation program has greatly improved my own teamwork skills. I have developing awareness for higher order communication strategies that incorporate team briefings…and the use of hot debriefing techniques. – Consultant (survey)
These types of comments reflect that the simulation process itself magnifies important organizational values related to continuous improvement and teamwork.