What I learnt this week: Are you calling for help for you or your patient? #WILTW

This is the 58th #WILTW

The second of our paediatric ED simulation days took place this week. The need for simulation is well summed up by Cliff Reid (I couldn’t let #WILTW go this week without a #smaccUS reference!)

There is always as much for the faculty to learn as the candidates and this was no exception. Simulation immerses health care professionals into familiar and unfamiliar situations. As technology has improved it has becoming increasingly possible to create high fidelity scenarios where participants often forget they are dealing with a plastic dummy. Even though team based simulation should not be a formal assessment of individual skills participants know they are being observed. There is no getting away from the fact if you make mistakes you feel you are judged in front of your peers. This creates anxieties and uncertainties and not everyone relishes the opportunity to get involved.

While the simulation maybe stressful for the candidates, it is the  debrief afterwards which causes me angst. I have a great deal to learn in the art of ‘debriefing’. It is a vital skill for simulation participants to experience if they are to gain the most out of this learning experience. Knowing that you need to tease out mindsets, challenge behaviours and support those sometimes are visibly emotionally struggling is a daunting prospect. The debrief aims to highlight communication and behaviour, by individuals and groups, which may or may not have been in the patients best interest.

Simulation

What stood out at for me at this weeks event was a reminder of a particular communication conundrum teased out by a fellow faculty member at a previous session. At times of stress individuals don’t always state the obvious in their concerns for another person’s decision. For example, a doctor choosing to to give a particular medication when the nurse feels another treatment may be better. Simple queries such as, “can you explain that decision to me?” become lost in either submission to hierarchy or a perception that their confusion represents a knowledge deficit. What compounds the problem is that the original decision-maker often fails to pick up on this (even when body language and tone make it blindingly obvious to everyone else there is uncertainty!). A route of this impasse is a suggestion to call for more help i.e “if you are not getting me the answer or information I need I will ask someone else.

I don’t think this is a dynamic solely confined to doctor and nurses as it happens in grades within professions and between specialities. It is also not just a process observed in education during a medical simulation. Looking to a third party to bypass an obstructive individual or someone not understanding your concerns happens in all team settings.

In healthcare crisis situations this additional call for help does have consequences. While often beneficial, a senior intervening effectively, it can have negative consequences. The skill set of the individual(s) arriving or their insight into understanding why they have been called may mean the original concern is not addressed. Obviously in a patient in cardiac arrest the reason is clear but this is only a small proportion of the total number of medical emergencies in hospital. Failure to clarify concerns also disempowers the original decision maker who may well have been grateful for the question to solidify their own thinking.

It fascinates me that the simplest phrase, “can you explain why you are doing that?” is something that health care professionals (and patients) often struggle with.

What did you learn this week? #WILTW

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