Medical simulation and emotions

Dr Lucas Opitz

CHU Nice, France

What are emotions?

emotion (n.) 1570

- "a (social) moving, stirring, agitation," from middle French Emotion (16c.), old French emouvoir "stir up" (12c.), latin emovere "move out, remove, agitate"

- assimilated form of ex- "out" + movere "to move" = MOVE OUT = Sense of "strong feeling" deriving from one’s circumstances, mood, or relationship with others

- first recorded 1650s; extended to any feeling by 1808

What are emotions?- James’s (1884): still unanswered (but interminably asked) question…

- Brain modes, actions or action tendencies, reflexes, instincts, attitudes, cognitive structures, motives, sensations, feelings?

- Biologically fixed modules (and hence reducible to biology)

- Socially constructed roles (and reducible to sociology)?

- Discrete categories or bipolar dimensions?

- Cognitive, precognitive, or postcognitive?

- Mental states or mental-behavioural processes?

- Same class as sensations, beliefs and desires

Emotions

Behavioural reactions

Emotional regulations

Extrinsic reactionsinteractions

Management

Emotions during simulation exercises

• Anxiety: unknown: DANGER• Pressure:

– Performance– External observers– Discussions, analyses - critics?

• Relief

Changed from: Dis Mon 2011;57:700-705

Stress

Stress

• Definition: Appears to arise whenever there is a departure from optimum conditions which the organism is unable, or not easily able, to correct

• Imbalance between demand and the organism’s capacities• Importance of failure: the demand must be considered as

important by the concerned person: performance, social(Stress and performance, A. T. Welford, Ergonomics 1973, vol 16 n°5 567 - 580)

CapacitiesDemandsEnvironmentSocial situation

Physiological reactions to stress

Emotive-cognitive:• Sensation of impotence• Panic, anxiety• Angriness, irritability• Confusion• Sadness• Sensation of guilt• Sensation of being vulnerable• Loss of interest

Physiological reactions to stress

Difficult to control:– Blushing– Bloc respiration– Trembling– Cold hands– Face expressions

How does the the trainee feel?

• “What do they want from me?” incertitude• “Am I able to respond to their expectations?” performance• “I don’t like them watching me!”• “How can I avoid to show them I do not know all of it?”• “I should have read the latest recommendations. Still, I must prove I

am a good professional”• “This here is just not real, reality is completely different”• “I have always worked in my way and never had any problems”

• Protection or vulnerability according to team• After more than some hours, days: getting more relaxed• At the end: relieved: no further damage has been inflicted…

The trainee: Possible attitudes:

• Withdrawal, abandon• Aggressivity• Mockery (situation, self)

• Playing the game• Missunderstanding the signals• Wanting to be recognized

PROTECTION

Trainees prototypes, or parallel communication

• Dominant• “Recessive” = timid, • Indifferent• Aggressive• Enthusiastic• Manipulative

- Simple or well-learned tasks: - linear relationship- improvements in performance as arousal increases

- Complex, unfamiliar, or difficult tasks:- relationship between arousal and performance becomes

inverse - declines in performance as arousal increases

Emotions and performance

Neural Plast. 2007;2007:60803.The temporal dynamics model of emotional memory processing: a synthesis on the neurobiological basis of stress-induced amnesia, flashbulb and traumatic memories, and the Yerkes-Dodsonlaw. Diamond DM1, Campbell AM, Park CR, Halonen J, Zoladz PR

Yerkes-Dodson law (1908):

- Performance increases with physiological or mental arousal, but only up to a certain point

- When levels of arousal become too high, performance decreases.

Emotions and performance

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The trainer’s emotions

• “Do I cover all the possible events?”• “Do I know/master all the possible clinical events?”• “No technical incident?”• “We had this teaching goal but now they focus on

something else, irrelevant..”• Confrontation with some trainee• “Why does the trainee always justifies himself?”

Defense mechanisms

Fragility Resources

DenialCleavageProjectionAggressiveness

CancellationDenialJustificationRationalizationObsessionsIsolation

SublimationCreativity

Theory of adaptation

STRESS

balance

imbalance Resource mobilization

Resource mobilization

• Not equal for everybody• Adaptation:

– Time– Individual

• Need to be enhanced, emphazised, coached

Effects of simulation on real-life stress

• Medical simulation decreases the physiological and psychological effects of stress experienced by participants

• Diminishes its effects on decision making and skill degradation and improves overall medical performance to a simulated anesthesia emergency

• Jeffrey A. PhD, CRNA; Hogan, Gerard T. DNSc., CRNA Medical Decision Making Under Stress-Evaluating the Impact of Medical Simulation Instruction on Affective LearningGroom, Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare: Summer 2006 - Volume 1 - Issue 2 - p 99

• Impacts on BP, HR• ScenarioMorris Kharasch, MD, FACEP, Pam Aitchison, RN, Christopher Pettineo, BA, Laura Pettineo, MA,

Ernest E. Wang, MD, FACEP: Physiological Stress Responses of Emergency Medicine Residents During an Immersive Medical Simulation Scenario Disease-A-Month, November 2011 Volume 57, Issue 11, Pages 700-705

Stress in simulation to help to lower stress in real-life

• Medical staff reported that error is important but difficult to discuss and not handled well in their hospital

• Barriers to discussing error:– denying the effect of stress and fatigue on performance– differing perceptions of teamwork among team members– reluctance of senior theatre staff to accept input from junior members

• But: Research in aviation shows that individuals can be trained to recognise stress as an error inducer

• BMJ. Mar 18, 2000; 320(7237): 745ñ749.PMCID: PMC27316Error, stress, and teamwork in medicine and aviation: cross sectional surveysJ Bryan Sexton, doctoral candidate,a Eric J Thomas, assistant professor,b and Robert L Helmreich, professora

Psychology of communication

- Signals that we give one to another contain several concurrent messages, which can be of very different weight

- Explicit - implicit- Non-verbal messages

- Sender and receiver believe different messages of the signal to be the most important for them

Psychology of communication

• 4-ears-model• Which ear are you talking to?• With which ear are you listening?

Psychology of communication

1. Factual information (which I am informing about) blue2. A self-statement (what I show of myself) green3. A relationship indicator (what I think of you and how

I relate to you) yellow4. An appeal (what I want you to do) red

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Psychology of communication

• Sender and receiver: not the same package• The knowledge that each signal contains various

messages, as well as the ability to receive signals with 4 ears, are the best guarantee that misunderstandings can be minimized in communication between people

Psychology of communication

If a problem in communication has arisen, the receiver should go through the following check-list:

1. What are the messages in the signal? 2. Which was the main message? 3. Does the signal also contain implicit messages? 4. Was the signal congruent or incongruent? 5. What was expressed on the level of

metacommunication? (the "that-is-what-is-meant" part of the signal)

6. Have I picked up the signal with 4 ears or with only one?

Linus Geisler: Doctor and patient - a partnership through dialogue†† © Pharma Verlag Frankfurt

http://www.linus-geisler.de/dp/dp06_speech.html

Psychology of communication: example

• “This baby breathes badly”– Factual:

• SaO2 83% at room air• Expiratory moaning

– I made the diagnosis before anybody else• (see I am a good clinician)

– You should have realized earlier• (I have a moral authority on you)

– You should put him under CPAP• (I am ther leader, your boss)

“This baby breathes badly”: reactions

– I know, I have realized as well– Why do you say this in this tone, do you think you are

better than me?– Do not tell me what I should have done because I know

what to do, but I wanted to check other parameters first– Do not give me orders, you are not my superior

“This baby breathes badly”: reactions

– Yes, she/he is right– She/he will help me in this difficult moment, she/he

knows what to do (submission)– I realize I have insufficient capacities (anxiety is

raising)– Tell me what I should do so I shall not be blamed

(abandon of proper initiative)

“This baby breathes badly”: reactions

The question of…

- Leadership- “Fighting” for leadership in a group- Switching leader

- Search for recognition

- Abandon/submission- Silence- Inactivity- Loss of initiatives

Metacommunication

• "When I send a signal, I also send (whether I want to or not) a message about how this signal is meant to be received" (F. Schulz von Thun)

• "We shall be pleased to see you”:Tolstoi's "Anna Karenina" dismisses the young Ljewin in a cool and dry tone to the words: is experienced as a classical example of implicit metacommunication.

• A message always contains means of interpretation:– Non-verbal: attitudes, movements, mimics– Verbal: reformulations, oratory precautions, tone of the

voice etc.

Signal, Metacommunication

Interpretation according to receiver’s sensitivityNeutral position when you elaborate

About signals

Hearing the signalNeutral position when you receive

Neutral feed back

excessive insufficient

Sender-receiver

• Thought is not said• Said is not heard• Heard is not understood• Understood is not wanted• Wanted is not being able• Being able and wanted is not done• Done is not memorized(Paul Watzlawick)

Sender-receiver: catalysing debriefing Hebel

• Thought is not said• Said is not heard• Heard is not understood• Understood is not wanted

• Wanted is not being able• Being able and wanted is

not done• Done is not memorized

Make them speak out

Be able to listen with the right ear

Make sure everybody understands(double-check)

“Play it again!”

Subtle advocacy

Debriefing

• Relationship of confidence: coaching, facilitating• Feedback or not feedback, and how much?

– Positive: yes– Negative: no, but…– Neutral: promote self-assessment

• Feedback through questioning• Express your thoughts when asked

• Facilitator’s task:– Give hints– But: Monopolizing: the other(s) will disconnect, be subordinated

to the speaker and therefore enter in phase of (relative) passivity

Debriefing

• Students learn better in a safe supportive learning environment, one which is challenging but not intimidating (WHO/IER/PSP/2009.3S)

• Errors in health care: focus on learning and fixing errors instead of blaming those involved(Leape 1994)

The essentials

• Simulation deals a lot with human psychology and communication

• Understanding feelings and stress means being able to anticipate them and to create constructive dynamics

• Parallel ways of communication exist and should be taken into account:

– Promotion of free expressions– Neutral, positive kindness– “Nourishing feedback”