Monday, 27 January 2014

Book of the month: Just culture: balancing safety and accountability by Sidney Dekker (2nd edition)


Last month, when I was looking for a picture of the book cover for "Just culture" I noticed that there was now a second edition. What to do? Having spent many hours reading and taking notes on the first edition I didn't want to start all over and I didn't have the time to read another book. So I decided to post my  comments on the first edition, buy the second edition and comment on that this month.

What's New?

5 years after the first book, Dekker wrote this second edition, which he claims is more logical and addresses the needs of organisations who continue to struggle in the creation of a Just Culture. He has also added some material on ethics and on caring for the second victim. A number of new narratives have been added which provide a good intro for the ensuing argument. Dekker also makes a good claim for the importance of stories; stories are often told from one point of view and take on a life of their own, e.g. "The doctor as a murderer" (p.119) Whichever story is more believable or acceptable or promoted will prevail.

What's good about this book?

Dekker does concentrate more on the organisational requirements of a Just Culture. Headings such as "Responding to Failure: The Organization"(p.6) and "Ask What is Responsible, Not Who is Responsible"(p.12) explore the problems faced by organisations. He has also written a new section on what a successful reporting system looks like (voluntary, non-punitive, protected) (p.58) The re-organisation makes the book easier to read and the argument more logical. The additions Dekker has made strengthen his case that safety and accountability must be balanced.
Dekker's addition of the second victim material (p.76-78) is timely. He explains how failure can be devastating to the professional involved and that criminalisation is neither just nor logical.

What's bad about this book?

Dekker's arguments around utility and utilitarianism (p.2) are simplistic. In essence, he argues that utilitarianism would support the removal of a supposed unsafe worker as this would benefit the majority and harm only one person. However utilitarianism does not mean short-termism and the removal of the worker would be considered within a longer-term "greater good". Utilitarianism then would probably not support the removal of this worker for a supposed infarction for all the reasons that Dekker discusses in this book.

Final thoughts

This is a better book than the first edition. It is more logically organised and the writing is clearer. The additions are useful and little has been removed (the book is now 13 pages longer). Should you buy the second edition rather than the first? Yes. If you already have the first edition should you buy the second? Probably not, although you might want to loan it from your medical library.

Tuesday, 21 January 2014

Constructive Alignment in Simulation: Why we don’t simply replicate what happened in the resus room last week (Dr Al May, Educational Co-ordinator)


I have met many people in the simulation world.  Some have been just starting off their journey and some have many years of experience under their belts.  Something that often comes as a surprise to many of those people is my idea that there is more to writing a scenario than it first seems.  Everyone is obsessed with how to debrief and often the scenario design and running itself is considered easy (or not considered at all!).  I would like to use this months blog to try and explain why I think what I think about the importance of scenario design and running. 

-Debriefing isnt the only tricky part

Learners learn

The first thing you may have noticed is that I have used quotation marks.  The reason for this is because what I am going to talk about is applicable to any of the activity part of simulation, which wont always be an immersive scenario.  Everything comes down to Constructive Alignment (Biggs, J. Tang, C. (2011) Teaching for quality learning at university, Fourth Edition, Open University Press).  The Constructive part comes from constructivist theory; learners use the activity they participate in to construct learning as interpreted through their existing schemata.  One of the reasons that simulation can be so efficient, stems from the ability of the simulation faculty to have tight ultimate control over the activity of the learner. 

-Controlling the activity in simulation by specific design and running of a scenario gives the opportunity to (potentially!) control the resultant learning.

Start with the Learning Objectives

The Alignment part refers to aligning teaching and assessment to intended learning outcomes.  Applying this to simulation, alignment should apply to the entire simulation based learning event.  This means that the learning objectives are integral to the design, running and debriefing of the simulation.  The debriefing conversation could be likened to formative assessment in terms of observation of a performance gap and facilitated discussion around how to close that gap.  Ideally, this should be a facilitated self-assessment by the learners. A skilled debriefer will be able to direct the developmental conversation towards the intended learning objectives and this is much easier, and occurs more naturally when the entire activity has been designed around learning objectives. 

-Everything needs to be directed to achieving the learning objectives

Finish with the Learning Objectives

At SCSC, we almost universally use Take Home Messages as an assessment of the debriefed simulation we have delivered.  This final step of the learning event should answer the key question all educators must ask themselves Did my simulated learning event deliver the learning outcomes I intended?  We simply ask something like So what have you learned that you are going to implement tomorrow? at the end of each debriefing.  This is at the heart of constructivist theory; we only know what the learners have learned if we ask them (or test them!).  At this point, if they dont say the learning objectives you intended back to you (in some form that demonstrates theyve got it) then you havent done your job.  Something, somewhere along the line has gone wrong.  Either the scenario wasnt designed around the objectives, or you didnt run it tightly enough, or you didnt manage to facilitate the debriefing conversation to cover the objectives.  If they havent got it at the end, its too late, there is no point in telling them what you think they should have learned from your simulation and debriefing.  If you are going to do that, why not just save a lot of time and money and just tell them stuff in a classroom.  This is similar to The Design Focused Evaluation Approach (Smith, C. D. (2008) Design-Focused Evaluation Assessment & Evaluation in Higher Education, 33(6), 631-645), which seeks learner feedback on the efficacy of the alignment between the intended learning outcomes and the teaching and learning activities students engage in during a course of study. 

-Use Take Home Messages to assess whether you have done your job

So how do I do it?

The first step in designing any scenario should be to set learning objectives appropriate to the target learners.  Although scenarios will often eventually resemble an actual real life scenario, it is important to resist the temptation simply to replicate the real event using simulation.  By setting learning objectives first, the simulated scenario can be designed efficiently and effectively without including any of the extraneous content that is not aligned to the objectives.  One way to do this is to design each state of the scenario around one simple learning objective.  The scenario is then run according to a set plan, moving through scenario states that are mapped to learning objectives.  The learner is guided through the scenario in a realistic way with prompts to help them perform.  The prompts are minor physiology or faculty actions aimed at moving the scenario on, in the direction you have pre-planned without breaking the immersive psychological fidelity.  The transition trigger for moving from one state to the next will be something that the learner must do in the scenario, which is often an action that is closely aligned to a learning objective.  If your participants think they are managing a patient with an allergic reaction for the whole scenario, it will be quite difficult and appear strange for you to try to debrief around managing a patient with concealed haemorrhage, which was what the learning was supposed to be about!  Avoid getting in to those situations by actively designing, driving and guiding the scenario along the lines it needs to go to cover the learning objectives. 

-Designing and Driving is an active process


This is why I think what I think about simulation design and running.  What do you think?
(Dr Al May, Educational Co-ordinator (Faculty Development))