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Simulation: A Lab of Human Behavior and Cognition
By Lillian Su, MD, Stanford University
It is an exciting time in healthcare simulation. As the Medical Director for Simulation for the Heart Center at Lucile Packard Children’s Hospital at Stanford University and a part of the simulation community for over 14 years, I have witnessed an evolution in simulation’s impact on healthcare. What started as a form of education targeted to students and trainees has evolved into an essential component of patient safety.
My first encounter with simulation was during my training to become a pediatric cardiac intensive care physician which is my clinical role at Lucile Packard Children’s Hospital. I take care of children who are either born with or acquire heart disease when those children need intensive care therapies such as a breathing tube, a mechanical heart or continuous intravenous medications to keep their hearts pumping well. My training in cardiovascular intensive care included “mock codes” where the mannequins were my patients in a manufactured distress and we would be asked to “suspend disbelief” so we could immerse ourselves into the clinical scenario. Technology has increased the fidelity of such mannequins so the immersion can be immediate and automatic. Some simulation rooms are designed to be exact replicas of existing clinical space. Other times, the clinical spaces as used for “in-situ” simulations.
The attraction and fascination with the technology is understandable. As the mannequins become more lifelike, the tendency is to focus on simulation as a technology but that would be a mistake. Simulation labs are, in fact, labs of human behavior and cognition-- a place where we as healthcare educators, patient safety experts and anyone interested in how patient care is delivered can observe the behaviors and the cognitive processes of healthcare professionals. The field of human factors and ergonomics describe the gap between how work is imagined by administrators to how work is done on the “front lines” when those tasks are completed in the context of a time pressure, limited resources and the complexity that human interaction brings. As Safi Bah call so eloquently summarizes in his book Loonshots “The weak link in the chain of innovation is not in the supply of new ideas, it’s in the transfer to the field.” If you think about pharmaceutical development, you can imagine the millions of dollars that are invested in the research and development of the medication.
Healthcare is changing quickly and we must learn to adapt as robots start to assume more of the routine aspects of care
But since the goal of that medication is to improve the patient’s health, we must remember there are still steps in the path from medication creation to consumption by the patient. That path involves a team that includes pharmacists and nurses who interact with the medication. If we were to find that 75% of pharmacists and nurses who administer a medication draw up the wrong dose because of a confusing label, at some point we stop telling nurses and pharmacists to be more diligent and instead admit that the interaction of the medication’s label and a human is prone to error and we change the label.
Studying this delivery phase of medicine should also acknowledge that a lot of care, especially in the intensive care unit where I work, is delivered by a team. Often called a “soft science,” teamwork skills such as communication, coordination, leadership, and sensemaking , are underestimated in healthcare. There is a pervasive belief that “teamwork” is about being “nice” and something we should have all learned when playing nice in the sandbox. Instead as team science experts in Psychology and Organizational Behavior have long documented, team science and its associated study of team processes are as complex and nuanced as the human psyche and it must be taught and practiced. Zhike Lei, PhD, an Associate Professor of Applied Behavior Science at Graziadio Business School at Pepperdine University, calculated that an intensive care unit with 80 nurses, 8 residents, and 16 faculty has over 10.5 million combinations for an ad hoc resuscitation team composed of 3 nurses, 1 resident and 1 faculty. Each provider must be facile with the team processes that facilitate ad hoc team formation.
The strength of any simulation lies in the debriefing and this is usually allotted over 60% of the simulation event. Participants can reflect upon their actions and the cognitive processes that produced the resultant behaviors. My mentor, Mary Waller PhD, who is a Professor of Organizational Behavior at Texas Christian University, briefs participants in her simulations by framing the simulation as a form of personality test. Participants can learn more about themselves and how they are affected by various stressors such as a difficult diagnostic dilemma or a difficult team member. This can create a habit of reflecting and learning from everyday performance in both real and simulated events. Instead of limiting the discussion about how simulation allows healthcare providers to “practice “technical skills on mannequins, simulation leaders now discuss changing workplace culture by promoting this reflection in the everyday practice of medicine.
Healthcare is changing quickly and we must learn to adapt as robots start to assume more of the routine aspects of care. What will healthcare look like when our protocols serve as the blueprint for the programming of robots? What are the truly human elements of our care and how do we make sure we use technology to optimize them? Repeated practice creates muscle memory which is useful when speed on a routine task is needed. What happens when the task deviates from the routine?
Some healthcare teams adapt better to an unpredictable and complex challenge than others. We must strive to understand what team processes make those teams superior. If a dying patient needs an unexpected emergent surgery on a day when the operating schedule is full, the hospital must find ways to adapt to this challenge and most do in brilliant and creative ways. I believe that this extreme adaptive capacity of healthcare must be studied, examined and preserved as we attempt to make hospitals safer with protocols and checklists which may have the unintended consequence of making these systems less adaptable. Simulation can lead the way.