Concepts and Commentary

Establishing a Safe Container for Learning in

Simulation
The Role of the Presimulation Briefing
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6djQAP8j+9DuXs2BAKNxvEpjpuVC5KrsY/ container. Establishing a safe logistic details, and (4) declaring
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4 Summary Statement: In the to engage actively in simulation respecting learners and concern for
Downloaded from absence of theoretical or empirical plus debriefings despite possible their psychological safety. As
http://journals.lww.com/simulationinhealthc agreement on how to establish and disruptions to that engagement instructors collaborate with learners
maintain engagement in instructor- such as unrealistic aspects of the to perform these practices,
are by
led health care simulation simulation, potential threats to their consistency between what
zUK86yfDRr9Hy+m9uzx8+xwNEfWBlglTy debriefings, we organize a set of
a professional identity, or frank instructors say and do may also
promising practices we have impact learners’ engagement. (Sim
Jenny W. Rudolph, PhD; Daniel identified in closely re lated fields discussion of mistakes.
Establishing a psychologically safe Healthcare 9:339Y349, 2014)
and our own work. We argue that context includes the practices of (1)
B. Raemer, PhD; Robert certain practices create a Key Words: Debriefing, Prebrief,
clarifying expectations, (2)
psychologically safe context for establishing a ‘‘fiction contract’’ Psychological safety, Realism,
Simon, EdD learning, a so-called safe with participants, (3) attending to Education
Copyright * 2014 Society for Simulation in Healthcare
DOI: 10.1097/SIH.0000000000000047

other similarly entitled epoch occurring before a

S imulation and postsimulation debriefing have long
been appreciated as linked steps in generating insights
simulation has long been part of practice.10,11 However,
the elements, rationale for each, and predicted
effectiveness have not been blended into a set of
and clari fying lessons in experiential learning promising practices, and we wish to do that here.
situations.1Y4 In the experiential learning cycle, simulation One crucial aspect of engagement in health care
can serve as an experi ence or experimentation period, simulation and debriefings is risk taking in the service of
and postsimulation debriefing is an opportunity for learning. This focus on risk taking in the service of learning
reflection, allowing learners to make a sense of the is guided by a diverse set of research findings that stress
experience and determine how to apply lessons learned a willingness of the learner to go to their social and
to future clinical performance.2,5 Yet, there are a variety of intellectual edges with a positive attitude.12 Manifestations
threats to learner engagement in simulation and of this engagement are what Edmondson13Y15 calls
debriefings, which can weaken the effectiveness of the learning-oriented behaviors: these include reflection on
experiential learning cycle. Learning can be impeded action, feedback seeking, speaking up about what one
when (1) learners do not ‘‘buy in’’ to the simulation thinks, asking for help, testing ideas that might or might
endeavor,6 (2) they find the fidelity of the simulation not be right, and reflecting on results. Engagement also
problematic, (3) they feel exposed by the simulation and includes what March16 calls experimentation and Elliot
debriefing in a way that threatens their professional
and Dweck17 call learning orientation, which both refer to
identity,7 (4) they feel defensive discussing performance
the willingness to try and err at the edge of expertise or
that falls short of a standard.8,9 capacity, where knowledge and skills may or may not be
So what can instructors do to help create a safe sufficient to avoid mistakes. The edge of expertise is
container, an environment where learners face similar to the ‘‘zone of proximal develop ment’’ where
professionally meaningful challenges and are held to high instructor assistance is needed to help the learner move
standards in a way that engages them but does not to the next level.18 These studies suggest that participants
intimidate or humiliate them? willing to experiment and who hold a learning orientation
We suggest that establishing an environment where can (1) tolerate practicing at the edge of their ability, within
learners can enter a deep level of connection to their an unfamiliar and possibly confusing environment; (2)
motivations, each other, and the instructors begins before appreciate comprehensive feedback in the context of
the simulation starts. The notion of a thoughtful demanding profes sional standards; (3) willingly reflect on
prebriefing, introduction, orientation, or problems and skills that are new or challenging to them;
(4) correct and repeat actions; (5) contemplate and learn
From the Center for Medical Simulation (D.B.R., R.S., J.W.R.), Massachusetts
from mistakes; and (6) tolerate not knowing the exact
General Hospital (D.B.R., R.S., J.W.R.), Harvard Medical School (D.B.R., R.S., answers to complex questions.
J.W.R.), Boston, MA. Importantly, psychological safety may not completely
Reprints: Jenny W. Rudolph, PhD, 100 1st Ave, Suite 400, Boston, MA mitigate feelings of interpersonal risk. Rather, it tends to
02129 (e<mail: [email protected]).
The authors declare no conflict of interest.

Vol. 9, Number 6, December 2014 339 Copyright © 2014 by the Society for Simulation in Healthcare. Unauthorized
reproduction of this article is prohibited.
of learning from expe rience does not mean completely Working on the premise that
involve containing or reducing avoiding the negative emotions research findings and theory
feelings of insecurity and threat associated with mistakes, from domains closely related to
while nurturing feelings of well- which, in limited doses, can simulation plus debriefing
being and possibility.19Y22 With help motivate learning.29 logically transfer, we identified
origins in psychoanalytic Being observed by others and synthesized findings,
disciplines, the metaphor of a usually increases physiologic constructs, and theory from
safe container in which learners activation. This activation can aviation simulation, clinical
feel secure enough to be enhance performance via a learning and teaching,
uncomfortable or trust that they number of mechanisms 30 formative assessment, adult
will have help managing difficult including social facilitation a learning, experiential learning,
feelings and anxiety has come process by which people organizational learning, de
to be rec ognized as an perform better under scrutiny. liberate practice, and the
The physiologic activation cognitive, emotional, and behav
6djQAP8j+9DuXs2BAKNxvEpjpuVC5KrsY/ important feature of nurturing
23,24 associated with being observed ioral bases for mobilizing
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4 can also degrade performance change in
a5XcIBfoH3i0NdJnVWASOqTp6kvXqx0xe Furthermore, reducing threats
to professional and social when such scrutiny triggers adults.1,5,10,13,25,35Y38
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identity is increasingly evaluation apprehension or is Consistent with a nascent set
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P recognized as the sine qua non viewed as a threat.31Y33 of recommendations on how to
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of learning in groups. 13 Although psychological safety
http://journals.lww.com/simulationinhealthc has been extensively studied synthesize complex ev idence,
Our literature review suggests
we used a systematic, but
are by
that psychological safety is a as a predictor of learning in
zUK86yfDRr9Hy+m9uzx8+xwNEfWBlglTyacrucial concept in determining groups, few studies have nonprotocolized literature
create a setting where learners whether a safe container has looked at the variables that review.39,40 We read and hand
feel safe enough to embrace been created. If one feels create psychological safety. searched through references in
being uncomfortable. It creates psychologically safe, then one Leader inclusiveness, articles related to debriefing,
a setting where learners can feels that the current behaviors such as inviting input reflective practice, and learning
practice new or familiar skills environment is conducive to and listening to and in groups; we then asked 2
interpersonal risk taking; acknowledging subordinates’ experts each in debriefing, psy
without the burden of feeling
that they will be shamed, learners feel that they will be ideas (or at least not shutting chological counseling,
humiliated, or belittled. viewed positively even if they them down), has been posited organizational learning, clinical
make mistakes. Psychological as a pre cursor to psychological and general education, and
safety has been demonstrated safety.14,15 There are, we adult behavior change to
RATIONALE FOR A to be a precursor to learning- hypothesize, practices such as provide 1 to 5 references that
oriented behaviors such as these that are within an they thought relevant for
STRONG
asking questions, sharing one’s instructor’s control and might creating a context for learning
PRESIMULATION thinking, and asking for contribute to psychological and change. From these
BRIEFINGVTHE ROLE help.13,15 Psychological safety safety. sources, we were able to
OF PSYCHOLOGICAL helps avert defensive be identify key words and search
SAFETY The presimulation haviors triggered by feelings of METHODS FOR terms that we provided to
briefing (synonymous with the personal threat such as medical and social science
IDENTIFYING
terms introduction, orientation, obstructing and withdrawing; it PROMISING librarians at our university. The
and prebriefing) for a simulation can reduce elaborate false librarians helped us adapt
session or entire simulation explanations known as ‘‘fancy PRACTICES We have these to different clinical and
25
course sets the tone for all that footwork’’ and ego defenses identified and structured social science databases and
follows. Building on work in the such as mocking or denigrating practices useful in find additional articles and
field of organizational be havior the simulation activity. 26 presimulation briefing through 3 books. We read these articles
that finds that the climate set by Psychologically safe simulation inputs: (1) a synthesis of and, through citation tracking,
group leaders has a significant exercises are friendly to risk existing theory and research in pursued additional references
impact on group member fields closely related to sim that, in our judgment, seemed
taking in the service of learning; ulation and debriefing; (2) from rele vant. This process led to
engagement, we believe a well- people feel that it is ac
crafted introduction in which the exercise of developing an 78 articles we initially reviewed
ceptable, even desirable, to for this article (Appendix 1).
instructors collaborate with assessment of health care
work at the edge of their
learners to set goals and simulation briefing and Structure From Developing a
expertise or capacity where
expectations can enhance mistakes are likely. The debriefing34; and (3) the Behaviorally Anchored Rating
participation and learning, importance of this authors’ collective experience Scale on Briefing and
minimize later complaints and psychologically safe container in conducting more than 6000 Debriefing
disengagement, and reduce is amplified by the fact that core debriefings, hundreds of We also used the organizing
potential participant defensive professional skills closely presimulation course briefings, structure provided by de
ness and resentment during the associated with the as well as roughly 2000 veloping a behaviorally
simulation and debriefing. construction of professional instances of coaching other anchored rating scale on
Although learning is often seen identity24,27,28 are in view with simulation instructors on the briefing and debriefing.34
primarily as a cognitive task, it live observation and flow from prebriefing to sim Element 1 of the 6-element
has deep psychological and subsequent video. ulation to debriefing. Debriefing As sessment for
emotional foundations as well. Paradoxically, creating a Simulation in Healthcare
Input From a Literature Review
The psychological foundations psychologi cally safe container (DASH)41 assesses

340 Safe Container for Learning in Simulation Simulation in Healthcare Copyright © 2014 by the Society for Simulation
in Healthcare. Unauthorized reproduction of this article is prohibited.
in Appendix 2Videntified encounter, they may make the evaluation of whether the
through re search for the DASH common and natural mistake of learner has achieved expected
behaviorally anchored rating assuming that the learners see milestones and may de termine
scaleVare emblematic of some it the same way.44 Explicitly whether they advance in their
of our own as well as other clarifying learning program of learning.38 How and
people’s errors and good if performance in the simulation
practices; they reflect 2 ends of bears on the learner’s
the variance in practice that we advancement in a training
have observed in our instructor TABLE 1. DASH Element 1 and program, licensure process, or
courses. Dimensions maintenance of certification are
DASH Element Element Dimensions likely to influ ence the climate
objectives, actively exploring of the debriefing because many
PROMISING learners’ objectives, explaining learners feel that summative or
6djQAP8j+9DuXs2BAKNxvEpjpuVC5KrsY/ PRACTICES FOR or demonstrating the properties formal evaluation is a threat
of the simulators, explaining the rather than an aid.49,52 Thus,
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4 PRESIMULATION process and timing of the
a5XcIBfoH3i0NdJnVWASOqTp6kvXqx0xe trust can be built by being
BRIEFING Creating debriefing or other clear, consistent, and
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psychological safety is an postsimulation analysis transparent about the sort of
h2IizZcirgc6P9fEp2HRA4QQRZBPUKN3 abstract goal that in structors
P activities, and creating shared evaluation that will be taking
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http://journals.lww.com/simulationinhealthc collaboration with their learners regarding the role of instructors Confidentiality/Privacy?
are by through a set of discrete, and learners are helpful in The boundaries regarding who
zUK86yfDRr9Hy+m9uzx8+xwNEfWBlglTyaconcrete activities. The specific bridging this gap.10,43,45,46 might observe or be in formed
practices we have identified Furthermore, to the extent that about learner’s performance in
what instructors do or fail to do
within a presimulation briefing clearly stated goals are the simulation and debriefing
in a presimulation briefing to
establish an engaging are setting clear boundaries, inspiring for the learners, they can impact simulation behavior
environment for learning (Table expectations, and goals; can trigger the positive affect and debriefing conversation.
1 and Appendix 2). In the establishing a fiction contract; shown to stimulate increased Whether the exercise takes
following sections, we use the attending to logistic details; and openness to new ideas.47,48 place in situ or in the simulation
di mensions (subparts) of conveying respect for the Creating the conditions for this laboratory, instructors can
DASH Element 1 as the learner and interest in their positive affect and openness is further define the pa rameters
organizing rubric for the perspective. a boon when simulations plus of the learning environment and
proposed practices. debriefings are designed to build trust by informing learners
Clarifying Objectives, stimulate reflection and the whether visitors, researchers,
Environment, Roles, integration of new knowledge, colleagues, patients,
Input From Our Own preceptors, or students will or
Confidentiality, and ideas, or perspectives.
Experience
We have created, erred Expectations Formative Versus Summative will not be privy to their
Educational and psychological Assessment? performance. The principle is
(sometimes significantly), and that maximizing trans parency
modified our presimulation research agree that when Absolute clarity about how and
if performance during the about what and with whom
briefings during a period of 20 learners have a sense of information about simulation
years in the course of control and clarity about what is session will be evaluated is
expected of them and what to vital to establishing a safe performance will or will not be
delivering hundreds of clinical shared builds trust (not that
expect from those in container for learning during
crisis resource management
authorityVprovided it is debriefing. Learners may worry confidentiality alone is the only
courses for a variety of
benignVthey are more likely that mistakes will openly or way to build trust53).
specialties, interprofessional 10,42,43
engage. Clarity about surreptitiously be held against
teams, and levels of training
what is expected in a them. Formative assessment, Establishing a ‘‘Fiction
from nursing and medical
simulation and debriefing also often known as evaluation for Contract’’ With Participants
students through advanced
practice professionals, primarily increases learners’ ability to learning, is the process of Engaging in a simulated
meet those expectations. 10 identifying the learner’s current learning environment poses a
in the United States. In
Because the simulation assets or deficits with respect unique challenge, that is, acting
addition, we have obser ved
to specific learning objectives as if things are real.6 To
the variance in the prebriefs of etiquette, norms, and roles may
be unfamiliar to learners, it is and helping learners remediate immerse themselves into a
hundreds of simulation
incumbent on simulation the deficits and leverage the scenario, learners must often
instructors-in-training from 49Y51 Summative
North America, Oceania, instructors to clarify them. assets. be willing to play an active role,
Europe, South America, Although instructors may have assessment, also known as pretending to take care of real
Central America, and Asia. The a clear vision about the goals of assessment of learning, is patient in a simulated setting
prebriefing behaviors captured the simulation and debriefing usually a higher-stakes where their professional skills
1. Establishes an engaging learning environment. and understanding their perspective. Rather than assuming participants will
Clarifies course objectives, environment, are on display. The skilled instructor, or must accept the simulated
confidentiality, roles, and expectations.
Establishes a ‘‘fiction contract’’ with participants.
like a novelist or playwright, attempts to environment, Dieckmann et al6 have
Attends to logistic details. create a fictional environment en suggested that instructors must create
Conveys a commitment to respecting learners gaging enough to draw people in.6,54

Vol. 9, Number 6, December 2014 * 2014 Society for Simulation in Healthcare 341 Copyright © 2014 by the Society for Simulation in
Healthcare. Unauthorized reproduction of this article is prohibited.
ingness to participate as fully same simulation fidelity. Thus, are playing fair with re spect to
as possible. realism is a property of the fidelity and realism, they are
Building on the work of learner’s perception rather than more likely to focus on the
Dieckmann et al,6 we propose a property of the simulation. learning objectives at hand and
a model of how the fiction Based on their subjective to willingly reflect on their own
contract, along with the other perception of realism, we practice.
practices we describe, impacts propose that an individual’s
learner engagement. In this willingness and ability to Attending to Logistic Details
model, the fiction contract engage in the learning To help participants focus on
moderates and influences experience varies. Moreover, the demands of the sim ulation
learners’ willingness to engage the willingness to engage is exercise, they need to know
despite perceived lapses in affected by the ambient what to expect logisti cally.
realism (Fig. 1). Dieckmann et psychological safety of Simulation instructors can
6djQAP8j+9DuXs2BAKNxvEpjpuVC5KrsY/ al argued that health care
the whole education encounter easily focus on the content or
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simulations have 3 kinds of of which the fiction contract is technical aspects of the
4 an important part.
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fidelity, where fidelity describes simulation environment and ig
how accurately reality is By making explicit faculty’s nore or minimize the logistical
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represented and we have interdependence with learners details of the exercise. An
h2IizZcirgc6P9fEp2HRA4QQRZBPUKN3 on buying in to the simulation, important part of creating
P adapted their terminology.57
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Physical fidelity is the degree to the fiction contract also plays a engagement is ‘‘student-
http://journals.lww.com/simulationinhealthc which the simulation elements vital role in mitigating the centered design’’ where
are by are sensed as approximating occasional shame or clinician learners know how the
zUK86yfDRr9Hy+m9uzx8+xwNEfWBlglTyavisual, tactile, auditory, and ol humiliation learners may feel if structure of the session
factory reality. Conceptual they do not perform well in front interfaces with their other
an explicit and collaborative
of others. By revealing their professional or edu cational
agreement with participants, in fidelity is the degree to which
the simulation proceeds in a own vulnerability in setting the commitments.59 Attending to
which both instructors and
causally plausible manner. fiction contract, the instructor logistics can prevent the
learners have commitments.
invites collaboration: for
The fiction contract is a form of When the patient’s physiologic, dissatisfaction that results
pharmacologic, or emotional example, ‘‘I have done when care and comfort issues,
psychological contract that
everything I can to make this as also known as ‘‘hygiene
describes what instructors and responses make sense for a
real as possible, but in the end, factors,’’ are handled poorly.60
learners owe each other and given intervention, this is
it is not reality; I have to
should expect of each other to conceptual fidelity. As trivial as these issues may
depend on you. I ask you to do
have a successful encounter.55 Emotional/experiential fidelity is your best to act as if this is real seem, covering appropriate
To create a fiction contract, the the degree to which the so that the time we have
details such as the starting and
instructor typically offers to do simulation generates the together is used to our best
stopping time of the session,
what can reasonably be done feelings learners would expect advantage.’’ Without this, breaks, how to handle pages,
to make the situation as real as in a similar real situation. How learners who feel they have not texting, e-mail, social media,
possible but acknowledges the the simulation unfolds to telephone calls, transportation,
limitations (eg, man nequin develop realistic time pressure, done well in the simulation tend refreshments, whether they will
stress, happiness, or relief to blame the simulation for have enough time to get to their
patient’s skin color does not lapses in perceived realism as next class or shift, and so on
change or does not feel or look would be a property of
real; invasive procedures emotional/experiential fidelity. a way to combat the identity prevents distraction and worry
For a given participant in a threats7,58 they feel when they and helps learners focus on
cannot be performed on
standardized patients). The simulation exercise, the 3 kinds do not perform as well as they issues within the curriculum.61
instructor seeks a voluntary of fidelity combine to produce a would like. They may feel that Demonstrating sensitivity to the
commitment from the learner to perception of re alism for that these ‘‘unfair’’ (unrealistic to logistic constraints of
do what he or she can to act as individual. One person may them) qualities of the simulation participants’ other dutiesVby,
perceive a certain degree of prevented their performing
if everything is real6 and for example, asking about
realism, whereas another may better. themVsends a subtle message
conveys that the quality of the Conversely, we have found in that
experience a very different
learning experience depends,
degree of realism, both with the our own simulations that if
in part, on the learner’s will
learners feel that the instructors

FIGURE 1. A model of fidelity, realism, and educational engagement in simulation. 56

342 Safe Container for Learning in Simulation Simulation in Healthcare Copyright © 2014 by the Society for Simulation
in Healthcare. Unauthorized reproduction of this article is prohibited.
give weight to the role of their together will always enhance presimulation briefing begins
own thoughts and emotional engagement, but they are the process of creating a safe
processes to improve future supported conceptually by container for learning that
performance.62,63 previous research and theory, allows learners to tolerate and
Second, working on the our primary research on how to welcome direct and critical
premise that people are assess precourse briefings and feedback, create opportunities
actively constructing a view of debriefing, and our experience to ‘‘redo’’ a skill, work outside
reality, experimental economics in health care simulation. We their comfort zone, accept and
finds that people are generally have found them to be useful in deal with surprises, change
‘‘intendedly rational’’; they are structuring our own their current clinical practice,
trying to accomplish a valued presimulation briefings. recast their current ways of
goal given their current per The promising practices we thinking, and validate
ceptions and analysis of the have proposed can be adjusted themselves as professionals.
65Y69 Learners, even to match the demands of Creating and sustaining an
6djQAP8j+9DuXs2BAKNxvEpjpuVC5KrsY/ situation.
when they make mistakes, different simulation contexts engaging environment for
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4 and stable or changing learning relies on
a5XcIBfoH3i0NdJnVWASOqTp6kvXqx0xe usually fit this assumption.
When instructors indicate that participant composition. The understanding and
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they realize the learner was
P working toward a goal as best adjusted depending on whether psychologically safe
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73,74 If well
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he or she could in the moment it is for a once-a-year teamwork container.
http://journals.lww.com/simulationinhealthc given their current sense- training for medical flight or constructed, this container, like
are by making processes, level of retrieval medicine group, a the nonreactive crucible used in
zUK86yfDRr9Hy+m9uzx8+xwNEfWBlglTyaknowledge, level of stress, and twice-a-week simulation chemistry experiments,75
so on, they convey respect and laboratory within a prelicensure allows instructors and learners
the instructor is aware of and nursing course, or a monthly
cares about the learner’s interest in the learner’s to tolerate the ‘‘heat’’ of
perspective. For example, residency training program on participating in simulations and
competing commitments.
instructors could convey that interprofessional collaboration. debriefings to transform
Conveying a Commitment to mistakes are puzzles that will Different aspects of these practice through experiential
Respecting Learners and reveal valuable information practices could be covered at learning in a simulated
Understanding Their about learners’ meaning- different degrees of depth; a environment.8,9 Based on the
Perspective making process rather than a briefing might run from 3 to 5 theory, research, and
When instructors convey that crime to be covered up or minutes for a one-hour ses experience we synthesized for
they value the learner’s punished.4,62 sion, to 45 to 60 minutes for a this article, we believe that 4
perspective, it can have a Third, psychotherapeutic day-long training. For example, promising practices help
powerful impact on learning.62 theory, although it has differ ent first-time exposure to learners participate actively in
Three related theories from goals from debriefing, also simulation might involve a simulations, openly and
experimental economics, concerns itself with much longer discussion of rigorously analyze their
organizational behavior, and transforming thinking, skills, principles of formative performance in debriefing, and
cognitive anthropology are and attitudes. The role of assessment, more details of set the stage for improving
relevant to how in structors what is expected from both the clinical performance.
positive regard70 for other
convey respect and interest in peopleVassuming they are learner and the instructor with
learners’ thinking. First, capable of competent action
respect to the fiction contract,
learners are not simply doers of and self-transformationVinfuses and a more deliberate ACKNOWLEDGMENTS
correct or incorrect actions; the debriefing with a posi tive description of the progression The authors thank Michaela
they construct meaning about psychological tone. Recent of the exercise than would be
Kolbe, Walter Eppich, and
the world around them. research on the transformative required for repeat learners.
Learners, like the rest of us, features of evoking positive The presence of learners from JWR’s peer review writing
sample the stream of different specialties and group, ‘‘Fulton 214’’ for their
emotion indicates that its
experience around them and presence in debriefing can help disciplines who might be helpful comments on this
make sense of it, constructing unfamiliar to each other in an article.
spur learning.71,72
categories to label their interprofessional simulation
reality.63 This ‘‘sense session might merit a longer
64
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Vol. 9, Number 6, December 2014 * 2014 Society for Simulation in Healthcare 343 Copyright © 2014 by the Society for Simulation in
Healthcare. Unauthorized reproduction of this article is prohibited.
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Healthcare. Unauthorized reproduction of this article is prohibited.
will determine whether you will up.’’ ‘‘fiction contract’’ with
be allowed to insert a CVL on & Explicitly describing the participants. The fiction
the unit.’’ instructor’s role: examples: to contract is a joint agreement
& Introducing and/or describing facilitate discussion; that debriefers and students
the simulators, an cillary commenting on performance create. In it, the instructor
equipment, location of supplies, based on expertise or acknowledges that the
role of actors/ embedded observing similar events or simulation cannot be exactly
simulated people, etc. simulations; acting as a like real life but agrees to make
& Discussing the origins of the resource on own area of the simulation as real as
cases, procedures, or events to expertise (e.g., New practice possible within resource and
be simulated and why certain guidelines, procedural steps, technology constraints. The
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http://journals.lww.com/simulationinhealthc & Explicitly stating expectations explaining why introductions learning contract. It is a better
are by for participants’ roles in the are not needed. & Not approach than unilaterally
zUK86yfDRr9Hy+m9uzx8+xwNEfWBlglTyasimulation course and mentioning objectives, roles, or decreeing that the learners
performance be handled? Will subsequent debriefing. expectations of the session or shall ‘‘suspend disbelief.’’
there be research conducted Example: ‘‘Act as yourself in describing them in a too-vague Positive, effective behaviors for
the simulations. Take care of or misleading way this dimension include: &
during the session?; To what
the patients using the skills you & Not explicitly addressing Explaining that the instructor
extent is summative and/or
formative assessment involved have. Don’t pretend to be a matters of confidentiality such and participants have to
different specialty or level of as who will be informed of collaborate to create an
in this course?
training.’’ participants’ per formance while engaging simulation and
Positive, effective behaviors for
& Requesting that participants in the simulation. learning environment
this dimension include: &
Introducing oneself and inviting engage in debriefing & Not explaining whether the & Stating that the instructor‘s
discussions and attempt to be
others to introduce themselves. goal of feedback is to im prove obligation is to do ev erything to
self-reflective. ‘‘One of the hard make the simulation as real as
& Sharing and inviting others to performance (formative
things about this course is
share information about their assessment); or that evaluation possible within resource and
reflecting on the thought technology constraints.
personal qualifications and has consequences for the
processes behind what you do & Asking the participants to do
experience, background, and learners’ advance ment
in the sim. I can help you with
interest in and goals for the (summative assessment). E.g. their part to act, as best they
reflective process. We can see
course. Student: ‘‘Does this matter for can, as if the simulation were
what you do, but not what you
& Presenting the session our grades?’’ Instructor: ‘‘We’ll real, acknowl edging that a
are thinking. Under standing participant will likely act
overview and learning see.’’
the relationship between your
objectives. & Addressing & Being vague or misleading in differently in the simulation
thinking and performance is environment than in the real
confidentiality explicitly. describing the simu lation or
one of the most interesting clinical environment.
Examples: ‘‘Your preceptors debriefing.
things about this course. I hope & Stating a fair and balanced
will (or will not) be getting a
you will engage with me in that & Ignoring or leaving no time or assessment of simulator
report of your performance opportunity for stu dent
process.’’ strengths and weaknesses.
here;’’ ‘‘What you say and do
& Stating etiquette rules for the statements or questions about An example that includes some
here stays hereVcan we all
simulation and debriefing: e.g. goals and ex pectation of the of the above behaviors is: . E.g.
agree to this?’’
to be respectful, curious about session. ‘‘We have done our best to
& Explaining assessment: E.g.
others’ thoughts and actions. & Making statements or using make the simulations as real as
‘‘There is no formal evaluation
& Explicitly encouraging people body language that ap pears to possible, but when all is said
in this course. We will provide belittle the learners’ goals,
to speak up and allowing for and done it is a simu lation and
you feed back on what we questions or concerns about
respectful disagreement. ‘‘I not exactly the same as real
observe only to assist you in de the session.
may say something you patient context. So I’m asking
veloping your skills.’’ Or ‘‘Your & Using language that implies you to meet me half way and
disagree with or have a
ability to follow the central
different perspective on. I wel that poor performance in the do your best to act as if it is
venous line (CVL) insertion simulation will be held against real. I know you will likely not
come hearing different
protocol will be assessed using
perspectives; so please speak the learner. Establishes a exactly the same as you
the hospital checklist and this

348 Safe Container for Learning in Simulation Simulation in Healthcare Copyright © 2014 by the Society for Simulation
in Healthcare. Unauthorized reproduction of this article is prohibited.
participants about logistical Conveys a commitment to out of the session today?’’
details and providing a respecting learners and un & Expressing interest in
physically comfort able derstanding their perspective. thought and emotional pro
environment helps them focus Participants often worry that cesses: ‘‘An important feature
on learning. simulations are designed to of simulation is that it allows us
Positive, effective behaviors for expose their weaknesses or to all to reflect on the thought
this dimension include: & humiliate them. To counter processes that drive our
Making sure that the learning these notions, instructors practice. Though I can see
space or conference room is should offer clear what you do, I can’t know what
clean. When available, chairs, alternative interpretations. One you are thinking or feeling. I’ll
tables, white board, video, alternative is to highlight the do my best to share my
simulation devices, or other difference in stress and thinking and I am also very
educa tional materials are cognitive load inside versus interested in yours.’’
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orderly, clean, and ready when outside the simulation; it is & Normalizing and clarifying the
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the participants arrive. easy to see what needs to difference in perspec tive inside
4 done when one is outside the versus outside of the
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& Briefing participants on
where the simulation will take simulation; much harder inside. simulation: ‘‘Research on
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place and how long it may last. A second alternative is for the cognitive load and stress tells
h2IizZcirgc6P9fEp2HRA4QQRZBPUKN3 instructor to convey that they us that it is often much more
P & Letting participants know
Downloaded from
about the availability of food assume the trainee has good challenging to be in the
http://journals.lww.com/simulationinhealthc and drink, transportation or intentions and are trying to do simulation; on the outside
are by logistical consid erations, their best but will likely make things may seem obvious and
zUK86yfDRr9Hy+m9uzx8+xwNEfWBlglTyalocations of bathrooms, etc. mistakes along the way Y the path way clear, but in the
which is perfectly all right sim it can be very challenging.’’
would if it were a real patient, & Informing participants about
when and where the simulated because this is a good place to Negative, ineffective behaviors
but we will still have lots of
talk about improving our include:
interesting things to discuss.’’ case, procedure, or event is
likely to be debriefed. practice. & Teasing, belittling, or ignoring
& Modeling the practice of
Positive or effective behaviors participants’ expres sions of
engaging with the simulated & Inquiring or stating provisions
in this dimension include: & anxiety.
environment as if were real by to make accommo dations for Stating that he or she
& Threatening to expose
talking to or taking care of a allergies (e.g. latex) or physical
understands that trainees are inadequate knowledge, values,
simulated patient during an disabil ities. Offering the
trying to accomplish something or skill
orientation. & Negative or opportunity to speak privately
positive, even when they make & Stating or implying that poor
ineffective behaviors include: with instructors about these mistakes. Could include a performance by trainees in the
& Trivializing the challenges issues.
comment like, ‘‘Mistakes are simulation is indicative of poor
students face in ‘‘buying in’’ to Negative or ineffective puzzles to be solved, not actual skills or will be held
the realism of the simulation. behaviors include: crimes to be punished.’’ against them.
& Stating or assuming that & Not orienting participants to & Expressing a commitment to
& Making demeaning
trainees should and will act the course logistics and the hold generous in ferences comments about a student’s
same way they would in the physical environment. about learners such as ‘‘We competence.
real clinical setting. & & Ignoring or making light of believe partici pants in our & Using a mean tone of voice
Insinuating or stating that it’s trainees’ concerns about courses are intelligent, capable, and message to under mine a
the student’s fault if the timing, location, or physical and are trying to do their best student’s aspiration to be a
simulation doesn’t seem real to needs. to learn and improve.’’ capable health care provider.
them. ‘‘We judge you level & Failing to address individuals’ & Stating that learners’ goals ‘‘You really aren’t cut out for
of commitment by your ability to potential challenges related to and interests are impor tant in this profes sion, are you?’’
suspend disbelief.’’ Attends to their particular physical the learning process: ‘‘Your
logistical details. circumstances (e.g., do they goals and interests are
use a wheelchair or other important. What are some of
Although it may seem
device, do they have a latex the things you would like to get
secondary, informing
allergy etc.)

Vol. 9, Number 6, December 2014 * 2014 Society for Simulation in Healthcare 349 Copyright © 2014 by the Society for Simulation in
Healthcare. Unauthorized reproduction of this article is prohibited.