What simulation has taught me about being a trusted leader

When I was a little girl, I would often complain about having to practice the piano. My mother would quote the oft-repeated mantra that “practice makes perfect.”  Legendary NFL coach Vince Lombardi applied more critical thinking on the subject when he said, “Practice does not make perfect. Only perfect practice makes perfect.” Successful sports teams follow his advice. They don’t just practice; they apply best practices – including scrimmages, where they simulate actual game conditions as closely as possible.   

Clinicians follow a similar approach when they’re in training. For example, a student in residency who’s preparing to place a central line for the first time will go through specific steps to learn the procedure, practice the skill in simulation, and perform the procedure with another instructor before she “gets in the game” and places a central line in a patient without supervision.    

That said, what we don’t practice enough in medicine is the art of effective communication. In 2015, the Joint Commission cited lack of effective communication with patients or administrators as the third leading root cause of sentinel events, which are unexpected episodes in healthcare settings that result in major injuries.

Excellent communication by both leaders and clinicians is key to decreasing errors, innovating, and learning in today’s complex healthcare environment. In her book Teaming, Amy Edmondson, PhD, professor at Harvard Business School, defines the following skills and behaviors needed to compete in today’s volatile, uncertain, complex, and ambiguous world: awareness, communication, trust, cooperation, and a willingness to reflect. However, opportunities for clinicians and leaders to learn and practice these skills and behaviors are lacking in most institutions.

Simulation as an approach to learning

Simulation is an organized event that uses technology to represent real-life scenarios and help people achieve their education goals through experiential learning. I've been able to see the remarkable difference healthcare simulation has on caregivers’ ability to learn and retain new skills. 

I love what Chinese philosopher and politician Confucius says about learning: “Tell me, and I will forget. Show me, and I may remember. Involve me, and I will understand.” And that is exactly what we try to do at the Intermountain Healthcare Leadership Simulation Center. Not only do we learn specific skills from participating in simulation exercises, but we also learn from the way simulation experiences are structured. 

Debriefing is a critical step in simulation

Debriefing after a scenario allows the learners to review and analyze their performance to translate lessons learned into future practice. Debriefing after the simulated scenario is an essential component of simulation and is the "lynchpin in the process of learning," says Roxane Gardner, MD, MPH, DSc, in a June 2013 article in Seminars in Perinatology. The quality of the learning experience in a simulation directly correlates to the quality of the debrief. The underlying approach is for the facilitator to create a constructive environment for the debrief so real learning can occur. For leaders, participation in a debriefing is one way to hone, polish, and improve their communication skills. 

You might be able to recall a time where a leader or instructor used a less-effective approach for providing feedback. One way to give feedback is a judgmental approach, which uses shame, blame, and chastising comments to influence performance. This approach can be humiliating and can affect one’s willingness to participate and speak up. Another method is the use of non-judgment, which is an effort to help without harming by hiding constructive feedback in a compliment. Both styles have low rates of success.  

There is a better way. An article in the June 2007 issue of Anesthesiology Clinics, “Debriefing with Good Judgment: Combining Rigorous Feedback with Genuine Inquiry,” by Jenny Rudolph, et al., promotes a debriefing approach that uses reflective practice to understand the assumptions, beliefs, and values that are taken for granted and which underly behavior and actions. In simulation, we call this approach “debriefing with good judgment using advocacy and inquiry.” This approach assumes everyone is acting with good intent. Just as simulation experts strive to create a positive and constructive environment for learning, we as leaders benefit from using this approach as we practice advocacy and inquiry in our interactions.

How do I use advocacy and inquiry?

Adopting advocacy and inquiry in giving feedback increases a leader’s effectiveness. It demonstrates a strong character base and shows our desire to become more competent. This approach leads to trust and inspires others to engage their best efforts in the challenging but noble cause of healthcare.  

Here are three steps to effectively use advocacy and inquiry:

  1. State the facts. When you approach a problem, it is paramount to understand the unbiased, non-editorialized facts. Stating the facts helps you share what you know about the situation. Facts aren’t based on your judgments or values. Facts stand alone.

    Example: Emily, I noticed you’ve been absent at our last three team meetings.

  2. Share your stance. Sharing your stance is one of the most difficult and overlooked steps. Both parties need to know what your concern is. Your concern comes from your frame of reference. What’s your stance on the facts you presented?  While communicating your concern, it’s important to share your feelings on the situation from your perspective.

    Example: We’ve covered some good things in our meetings, and I’m concerned you may not have all the information to follow through with the project and your coworkers will need to spend more time catching you up on what you’ve missed.

  3. Get curious. Success lies in the assumption that the other person is a skilled, capable, intelligent, and valuable team member and may have a different perspective. Assuming best intent and assuming you have something to learn will de-escalate the situation. The goal is to uncover the viewpoint and values of the other person so you can understand why that person acted in a specific way. Finding where you’re not aligned is a process of discovery. This approach requires a blend of curiosity and respect.

    Example: I’d like to understand your situation better. Can you tell me what might be happening for you?

    Emily’s response: I’m sorry this has caused a conflict. It just so happens these meetings have all fallen at the same time as the clinical program’s quality council where I’m expected to present.  

Now that you’ve discovered and explored each other’s point of view, you can apply these insights to collaborate and develop an action plan that works for everyone involved.

Incorporate these ideas into your leadership style

Using this approach to gather feedback in simulation and leadership communication pays dividends by uncovering unintended misunderstandings and errors. Here’s how to apply these skills to your leadership practice.

  1. Recognize opportunities. Start looking for opportunities to use advocacy and inquiry in your life. Situations will present themselves with coworkers, bosses, direct reports, at the store, with your neighbors, and at home.
  2. Practice. Vince Lombardi’s quote rings true. First, you need to practice, then you need to perfect that practice. Do not hesitate to role play and map out what you would say and how you’d say it. Come up with quality questions that help you learn about the other person’s frame of reference.

Implementing the communication skills of advocacy and inquiry will develop more trust in your relationships. It will strengthen your personal leadership skills and others will benefit from how you approach crucial conversations. The reality is, we don’t know what the other person is thinking, but we can perfect the practice of how we respectfully approach situations and foster trust, good will, and accountability.