The success of failure

Sim centres around the world have routines for when participants first arrive. Perhaps a sign-in sheet, distribution of parking permits, directions to the nearest toilets, refreshments, etc.

Most sim centres will also have a period before embarking on scenarios which includes looking at (or setting) the learning objectives and talking about confidentiality. This period helps to create the safe learning environment which will allow the candidates to perform without fear of reprisal or ridicule.

During this "setting the scene" period I talk to the candidates about failure and say something along the lines of:

"We are all human. We all make mistakes. You will make mistakes today. That is alright. I have made some spectacular mistakes in my clinical practice which have resulted in patients being harmed. I have learned from these mistakes and am a better practitioner as a result.

We are all here to learn from one another and I'm sure you would much prefer to make a mistake here on a mannequin, who will not die or come to harm, than on a real patient."

The problem with participants... with all of us... is that we don't like failure. In fact, we actively avoid situations where failure is an option. Youtube has a plethora of "fail" clips. Cats failing to jump high or far enough seem to be a particular favourite. Although they can be humorous, perhaps the viewpoint should be that these cats are trying something, failing at it and then learning from it. And that persistence often pays off.

Perhaps there are still places where failure is not seen as failure? In this very readable Inc. article about cadets at the United States Military Academy at West Point, the author Jim Collins talks to some of them about failure. Their responses:

"It's better to fail here and have other people help you get it right than to fail in Afghanistan, where the consequences could be catastrophic"

"Here, everybody knows it's a learning experience"

Collins goes on to claim that repeated failure is built into the West Point culture. Currently our education system and our medical training system is not rewarding or encouraging of failure. Big summative tests at the end of periods of training allow you to advance (or not) to the next level. In terms of education and training, what would happen if there were a test on day 1, where everybody fails and then repeated tests throughout the year to show you how you are doing and where your strengths and weaknesses are?

In terms of the simulator I am not a believer in the idea that the participants must fail in order to learn. (This is the "they're doing really well, let's throw in an 'anaphylaxis'" school of thought.) I think if the participants shine then we can all learn from that. But perhaps we should be more positive about failure, build it into our simulation centre culture and show how failure can be a success if it makes you better. I leave you with two quotes. The first a youtube comment on one of the cat "fails" and the second from Tommy Caldwell, a rock climber who features in the above-mentioned Inc. article

"This is not a fail. This is an Epic try!" - Dio Rex

"(Failure) is making me stronger. I am not failing; I'm growing." - Tommy Caldwell

Book of the month: Crisis Management in Acute Care Settings (2nd ed) by St.Pierre, Hofinger, Buerschaper and Simon

The last two books reviewed here: "Why we make mistakes" and "Set phasers on stun" were light summer reading. "Crisis Management in Acute Care Settings" is the sort of book you need the rainy weather and darker evenings for; its 335 pages of densely packed text require concentration and persistence.

The four authors are: Michael St.Pierre (Anaesthetist, 'Oberarzt' at Erlangen University hospital), Gesine Hofinger (PhD, Cognitive Psychologist, Department of Intercultural Business Communication, Friedrich-Schiller-University, Jena), Cornelius Buerschaper (Researcher, focused on decision-making in crises, who unfortunately passed away in August 2011) and Robert Simon (Director of Center for Medical Education, Harvard Medical School)

Who should read this book?

This book is for the dedicated human factors and/or simulation devotee. Although an aim of the authors was to "formulate the text in an easy to read language" (p.ix) with a target audience of "nurses, technicians, paramedics and physicians" (p.ix) the language used is at times overly complex and the concepts require a more than basic understanding of human factors. This is not the book to give to people who have expressed an initial interest in human factors or simulation.

I haven't got time to read 335 pages...

The book is divided into four parts, so you can decide if there is one particular aspect you wish to explore:

1. Basic Principles: Error, Complexity and Human Behaviour (81 pages)
2. Individual Factors of Behaviour (111 pages)
3. The Team (81 pages)
4. The Organization (62 pages)

62 pages? That's still too much!

Every chapter finishes with an "In a nutshell" section which provides an overview of the content. It may therefore be worthwhile reading the "nutshells" and then deciding which chapters warrant a more detailed look.

What's bad about this book?

There are a number of minor annoyances such as:

• Random use of italics e.g. "First, the majority of patients arrive at the ED rather unprepared..." (p.12)
• Obtuse sentences e.g. "Humans try to balance actual and nominal physiological conditions"(p.66) "The interpretation of sensory impressions tries to form them as good a good Gestalt (the law of "Praegnanz" - good form)."(p.93)
• Obtuse sentences which are also long e.g. "From an evolutionary point of view, the ability to rapidly produce workable patterns to understand of the environment seems to have been advantageous compared with a 100% scanning and consciously filtering important from unimportant information about the surroundings."(p.95) Including possibly the longest sentence I have ever read: "As complex situations are characterised by the interrelatedness of many system variables (on-scene situation, pathophysiology of the patient, main motives of the different providers and professional groups involved), there will be some goals which are in themselves justified but which are mutually exclusive - be it the parallel technical and medical rescue operation on site or the side by side of diagnostic and therapy during resuscitation of a trauma patient in the emergency room."(p.127)
• The use of distracting background pictures in diagrams which add nothing to the understanding of the text (p.90,p.188)

A more important oversight is the lack of any reference to our acute medicine and surgical colleagues whom I would consider part of the "acute care setting". With the advent of Non-Technical Skills for Surgeons (NOTSS), the development of courses looking at surgical crisis teamwork and leadership and courses for acute medical practitioners, I would like to see surgeons and acute physicians included in the third edition.

What's good about this book?

This book provides a detailed analysis of human factors and team psychology in a high stakes environment. The book also links the aforementioned with patient safety and so enriches the understanding one may have of how work in human factors/simulation can improve patient safety.

The "in a nutshell" section at the end of every chapter is a useful reminder of what has been discussed. Most chapters also have a "tips for clinical practice" section which may help to convert theory into practice and there is an extensive list of references provided for every chapter.

Most chapters are packed full of information and, once the convoluted language has been overcome (see above), they begin with a good overview of the concepts and then delve into the core of the matter, focusing on each piece in turn.
For example, Chapter 11: "The Key to Success: Teamwork" discusses and defines teamwork and teams, followed by a review of team performance. The latter is analysed by looking at the input into the team from: individual characteristics, team characteristics, characteristics of the task and characteristics of the environment. The authors then go on to discuss how teams are formed, how a "good" team performs and where teams can go wrong (communication, shared misconceptions, groupthink etc. etc.) The level of detail is extremely impressive and educational. The same detail is found other chapters such as chapter 3 which looks at the nature of error and chapter 9 which looks at stress (acute, chronic, coping mechanisms). 

There are also some great quotes such as:

• A situation does not cause emotions; your interpretation of the situation causes emotions (p.99) (with echoes of Jack Sparrow)
• "As an overall philosophy, it is wise to use good judgment to avoid situations in which superior clinical skills must be applied to ensure safety"(Attributed to Hawkins in Human Factors in Flight, 1987) (p.118)
• ...human factors should never be equated with "risk factors." Each time mindful healthcare professionals detect, diagnose, and correct a critical situation or an error before it has an opportunity to unfold, it is the human factors that prevent patient harm (p.15)
• The development of expertise requires struggle. There are no shortcuts (p.33)
• Practice does not make perfect; instead perfect practice makes perfect (p.33)
• Teamwork is not an automatic consequence of placing healthcare professionals together in the same shift or room (p.210)
• If you want to profit from a good team process in a critical situation, you need to rehearse team skills on a frequent basis. (p.216)
• You will not succeed if you do not talk! Talking is the way team members develop and maintain a shared mental model. (p.217)
• Teamwork seems to be the essential component in the pursuit of achieving high reliability in healthcare organisations. (p.324)

Final thoughts

Buy this book for your simulation centre. Set aside the time to read it. It is a great reference text and will inform your workshops, lectures, research, simulated scenarios and your clinical practice.