Can We Destigmatize Healthcare Cultures Through Fostering Psychological Safety in Undergraduate Studies?
Author: Christoffer Ericsson, PhD Student, MSc, MHc, Director – Arcada Patient Safety and Learning Center, E-mail: christoffer.ericsson
On the beautiful morning of February 1, 2003, the Space Shuttle Columbia was reentering Earth’s atmosphere when it unexpectedly exploded into parts, killing the entire crew of seven and effectively putting a hold on all funding for space programs and the ISS constriction for a foreseeable future. The underlying reasons for this fatal incident, one of many in the field of space exploration, has been studied rigorously since and although no single reason has been pinpointed as the fault, with technical, non-technical, leadership and organizational issues accounted for, one concept has been raised as at least a remarkable contributor to allowing it to happen; psychological safety [1].
When teams and members express mutual trust and respect in each other, it leads to a culture of lower interpersonal risk-taking on personal credibility. This is called psychological safety [2]. In essence, people in such environments are not as afraid to speak up, present their ideas and potentially fail as consequence, if they feel they will not be pointed out and even ostracized due to person-level discrepancies or cultural norms (such as those contributing to the above Columbia incident). In such environments, participants will dare to be innovative, creative and questioning set realities, something Google realized from a 2-year study on team performance, where the single most common denominator in high-performing teams was, you guessed it, psychological safety [3].
In healthcare contexts, the concept of psychological safety has been shown to have wide-reaching impacts on team performance [4] with specific associations to, among others, personnel burnout levels (lower burnout prevalence correlates to psychologically safer environments) [5] and patient safety issues, stemming from individual culpability, failure to speak up and raise issues of concern [6]. Concurrently, in the healthcare educational sector, active-reflective training modalities, like medical simulation, which require student participants to perform and be “on stage”, is today a proven learning method. Specifically, but not exclusively, within the field of simulation, being aware of the concept of psychological safety is of utmost importance for student learning to occur in a positive environment and safe container [7, 8]. This is a core idea all faculty personnel at Arcada Patient Safety and Learning Center, the medical simulation center of Arcada, are well aware of and strive to uphold.
While we absolutely can agree that undergraduate students learning and patient safety issues are uncontestably relevant (healthcare has own its fair share of Columbia-like incidents), an equally important factor to consider is the issue of healthcare provider wellbeing. This is an especially pertinent issue today, when the healthcare sector, ranging from paramedics, emergency wards, intensive care, general practices to public health professionals, are all battling the global foe of Covid-19, resulting in doctors and nurses working well above their own limits for almost a year now. And yet, another problem has existed far before this coronavirus emerged; the stigmatization of mental health issues in healthcare. Healthcare, especially the acute and emergency care settings, has long hold the burden of stigmatizing doctors’ and nurses’ burnout and fatigue [9], turning it into a norm, alt times even worn as a badge of honor, all the while showing negative implications on healthcare workers’ compassion fatigue, burnout and compassion satisfaction and consequently, career lengths and sick days [10]. Although the raging Covid-19 pandemic clearly has brought some daylight to this thru open and safe discussions, debriefing workshops and systematic changes, we are not yet out the woods regarding this “virus” either.
Reducing stigma is by far no easy feat, it requires a vast cultural and value-based shift. Like changing the course of a cruise ship, we should not expect such a shift to happen overnight (or even over a pandemic) and it is not a one-click solution. However, what we as undergraduate educators can, and absolutely should, do is to teach the next generation of healthcare professionals (nurses, paramedics, midwives and public health nurses) to reflect on the implications and effects of studying and working in a psychological safe environment and thus enable them to go out and educate, develop and lead that cultural shift. This doesn’t even require much of us. I believe we, as simulation instructors, are already doing the groundwork; every time our students perform simulated exercises and debriefings, they see the idea of working, reflecting and speaking up in environments, “containers”, they feel safe in. That is a first step. And what could we, as educators and simulation facilitators, do to enhance this learning?
- Make It Explicit: By signposting, talking about, the concept of psychological safety, we can emphasize the existence of the idea for the students, awakening something they probably already intuitively “feel” but cannot explicitly verbalize. Then they will learn to also notice the less safe environments, which they undoubtedly will encounter.
- What Do You Feel: Dare to bring up questions and issues of personal internal reflections in simulations as a way to open up and talk about That Which Should Not Be Mentioned; those pesky feelings. When we do that with intention, we also implicate the right to open up and discuss them, something their future workplace might not be ready to do.
- Use Hidden Curriculums: The concept of hidden curriculum is defined as “the “unspoken or implicit academic, social, and cultural messages that are communicated to learners” [11]. We simulation instructors use them a lot, even unbeknownst to ourselves. We have that role-model, that “rude” stereotype, that “one problem patient”. So why not design these challenges into an intentional tool, a learning objective, to safely be able to discuss and reflect around those difficult situations..and those feelings.
The anecdote of Columbia from the beginning could easily be seen as an analogy of a patient case gone wrong. It could, however, also be viewed as a study of a healthcare provider’s slow progression towards a burnout and end of career, never recognized for what it was due to a culture of managing. As a flexible university of applied science in the Helsinki region with, more often, small-sized healthcare student groups (enabling reflection of difficult issues) and a core focus on ethical approaches and nursing sciences, Arcada is in a unique position to actively focus on enhancing our healthcare students’ and future professionals understanding of psychological safety and the implications of, among others, stigmata, burnout, compassion fatigue and incivility on providers’ mental health and performance. We can do this through easy implementations such as the above, through curriculum planning and even implementing masters-level research. The wide curriculum update we are undergoing offers possibilities to operationalize these core values to new ideas. Adding to that, the simulation center proudly bears the name Arcada Patient Safety and Learning Center. Both these core concepts; “patient safety” and “learning”, are implicit in making healthcare work more manageable for all our future nurses, paramedics and midwives, as “safety” stems from open and learning-centered cultures. So, why not make it explicit?
References
[1] Roberto, M; Bohmer, R M J; Edmondson, A C. 2006. Facing Amiguoys Threats. Harvard Business Review. November 2006. [www] Accessed on 22.11.2020: https://hbr.org/2006/11/facing-ambiguous-threats
[2] Edmondson, A C; Lei, Z. 2014. Psychological Safety: The History, Renaissance, and Future of an Interpersonal Construct. Annual Review of Organizational Psychology and Organizational Behavior. 2014 1:1, 23-43
[3] Delizonna, L. 2017. High-Performing Teams Need Psychological Safety. Here’s How to Create It. Harvard Business Review. August 2017. [www] Accessed on 22.11.2020: https://hbr.org/2017/08/high-performing-teams-need-psychological-safety-heres-how-to-create-it
[4] O’Donovan, R., McAuliffe, E. Exploring psychological safety in healthcare teams to inform the development of interventions: combining observational, survey and interview data. BMC Health Serv Res 20, 810 (2020). https://doi.org/10.1186/s12913-020-05646-z
[5] Vévoda, J; 1; Vévodová, Š; Nakládalová, M; Grygová B; Kisvetrová H; Grochowska Niedworok E; Chrastina J; Svobodová D; Przecsková P; Merz L. 2016. The relationship between psychological safety and burnout among nurses. Pracov. Lék., 68, 2016, No. 1-2, s. 40-46.
[6] O’Donovan, R; Van Dun, D; McAuliffe, E. 2020. Measuring psychological safety in healthcare teams: developing an observational measure to complement survey methods. BMC Medical Research Methodology, 20(1), 203. https://doi.org/10.1186/s12874-020-01066-z
[7] Turner, S; Harder, N. 2018. Psychological Safe Environment: A Concept Analysis. Clinical Simulation in Nursing. Volume 18, p. 47-55. https://doi.org/10.1016/j.ecns.2018.02.004
[8] Rudolph, J W; Raemer, D B; Simon, R. 2014. Establishing a Safe Container for Learning in Simulation – The Role of the Presimulation Briefing. Simulation in Healthcare. December 2014, Volume 9(6), p 339-349. doi: 10.1097/SIH.0000000000000047
[9] Sukhera, J. 2020. Stigma drives mental health of healthcare workers into the shadows. HealthyDebate. Opinion. June 5, 2020. [www] Accessed on: 22.11.2020 https://healthydebate.ca/opinions/mental-health-healthcare-workers
[10] Ramaci, T; Barattucci, M; Ledda, C; Rapisarda V. 2020. Social Stigma during COVID-19 and its Impact on HCWs Outcomes. Sustainability. 2020, 12, 3834; doi:10.3390/su12093834
[11] Brazil, V. 2019. What’s Your Simulation Hidden Curriculum?. ICE Blog. July 30, 2019. [www] Accessed on: 22.11.2020 https://icenetblog.royalcollege.ca/2019/07/30/whats-your-simulation-hidden-curriculum/
