Ethical imperative of psychological safety in healthcare: in response to the Manifesto for healthcare simulation practice

Abstract

Psychological safety is valued in other high-risk industries as an essential element to ensure safety. Yet, in healthcare, psychological safety is not mandatorily measured, quantified, or reported as an independent measure of safety. All members of the healthcare team’s voice and safety are important. Calls for personal, physical or patient safety should never be disregarded or met with retaliation.

We read the Park et al ‘Manifesto for healthcare simulation practice’¹ with great interest and present this commentary to prompt continued discussion.

The effects of the pandemic are widespread throughout healthcare and health professions education. In the Manifesto, the authors implore simulationists to ‘adopt a commitment to comprehensive safety, to advocate collaboratively and to lead ethically’. They emphasise working remotely and fear that some simulationists’ ‘calls for safety are overlooked or even disregarded by their own institutions’. We emphatically agree that healthcare simulationists should inform clinical and educational leaders about safety, collaborative advocacy and ethics during the current pandemic and in its aftermath.

The article suggests that standardised patients (SPs) may not have an empowered voice to speak up if they feel unsafe in the learning environment and that SPs should have the same psychological safety as learners and patients. We agree with the authors that psychological safety for all simulationists, learners and clinicians is imperative to the health and well-being of learners and patients.

The quadruple aim of healthcare suggests a thriving, well-trained and fulfilled workforce provides better care for patients.² In this unusual time, there is an essential tension among the competing priorities of professional safety, service, duty and satisfaction. We simulationists have spent decades demonstrating how rigorous experiential education improves patient care outcomes. Our leadership actions and advocacy statements affect the health and well-being of the healthcare workforce and the patients we serve.

We acknowledge that psychological safety does not exist in either the clinical setting or in educational environments simply because we deem it so. The COVID-19 pandemic makes plain that frontline workers are not guaranteed psychological safety when reporting concerns. In fact, healthcare providers and public health officials have often been muzzled or experienced retaliation when voicing concerns.³

At the onset of the pandemic, clinicians who spoke out about the lack of personal protective equipment (PPE) in hospitals across the world were silenced. Dr Li Wenliang, the Wuhan whistleblower who expressed fears about the public health threat, was initially silenced then celebrated for his courage and sacrifice. Following public outcry, authorities apologised for silencing Dr Li’s concerns, recanting claims that he was ‘making untrue comments’ and ‘severely disturbing social order’ after his death from COVID-19.

We respectfully challenge the authors’ Manifesto position on two key points. First, SPs are non-essential to experiential healthcare education. The challenge of our new paradigm creates uncertainty about safety and autonomy. Educational leaders across the continuum, from kindergarten to higher education, face the same ethical challenge. We must abide by policies and protections of local institutions and public health organisations. We believe SPs should have decision-making autonomy. In fact, simulationists, learners and clinicians should all have agency to weigh the risks and benefits of participating in simulation activities with adequate PPE and safety precautions.

Second, we offer that PPE, social distancing and effective hand hygiene are essential tools to improve safety for the population, healthcare providers and learners. Accumulating evidence shows that precautions improve safety and that PPE works. Social distancing—keeping 6 ft apart, wearing high-quality medical masks or face shields when distancing is not possible—minimises the spread of SARS-CoV-2.⁴ Mandating face mask use in public is credited with a decline in daily COVID-19 incidence and has averted greater than 200 000 estimated COVID-19 cases in the USA since 22 May 2020.⁵

At the onset of the pandemic, healthcare leaders worked to preserve scarce PPE for frontline patient care providers. Now, however, restaurants, hair salons, professional sports teams and public spaces worldwide are operating with safety protocols in place. Clinical and simulation-based education is obviously more essential than these activities because healthcare education is necessary to maintain a well-trained workforce that can provide optimal patient care. Safe healthcare education is particularly important during a pandemic.

PPE should be reserved for direct patient care activities in places that have shortages. However, organisations with adequate PPE supplies can deploy resources to protect simulation educators and trainees to provide essential healthcare services.

This is a pivotal time in healthcare and healthcare simulation history. Our greatest concern is that, in its present form, the Manifesto may produce the unintended consequence of limiting the autonomy of SPs and other critical simulation personnel suggesting their face-to-face presence is non-essential. Simulation leaders must simultaneously ensure that simulation experiences are delivered safely, providing transparency and choice about potential hazards that cannot be eliminated.¹

Our work as simulationists provides a foundation to improve the health and well-being of society as we use education to advance patient care quality. During this pandemic, and in the future, as clinical leaders in simulation, we need to endorse and use scientific, evidence-based approaches including social distancing and PPE.

Calls for personal, physical or patient safety should never be disregarded or met with retaliation. Everyone’s voice and safety are important. We know that psychological safety to report concerns has been promoted in other high-risk industries as an essential element to ensure safety. Yet, in healthcare, psychological safety is not routinely measured, quantified or reported. We agree that SP, learner and clinician voices must be heard and valued as we move ahead. Psychological safety of all members of the healthcare team to report concerns must be a priority.

We thank the diverse group of Manifesto authors for their work and commitment to simulation education. We agree that safety, advocacy and leadership are core tenets of healthcare simulation. We affirm the importance of active stakeholder collaboration to achieve consensus and invite productive discourse and difficult conversations that increase the physical and psychological safety of all who contribute to improving the care of the patients we serve.

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