A Different Way of Knowing: The 'Blink' Group
Drs. Leslie McKeon, Jill Oswaks, and Pat Cunningham (from left to right) practice simulation in their Patient Focused High Reliability Team Training (PHReTT) study.
The idea for the research program that Drs. Jill Oswaks, Leslie McKeon, and Pat Cunningham are developing occurred to Dr. Oswaks after one of her students experienced a traumatic event. The student was involved in a case where a patient died after a system error. After the event, administrative changes were made in the unit; however, there was no debriefing to determine what occurred based on all participants’ experiences. The situation became a dead-end catastrophic event, and no one learned from it. The student was traumatized.
Dr. Oswaks, Director of the Nurse Anesthesiology Option for the UTHSC College of Nursing, wondered, “Can we do better?” She approached Dr. McKeon, who has expertise in systems theory, and Dr. Cunningham, who, as a psychiatric nurse, has expertise in debriefing, to discuss the issues her student had confronted. There is a lot of stress in anesthesia practice, with acute stress response and long term adjustment—a high price clinicians pay for system failures.
The group agreed to work together to develop a way to change practice for the benefit of the provider and the patient. The change strategy would include understanding the theory-driven point-of-view of practitioners and of the current practice and systems.
Knowledge and wisdom emerged as the collaborators have worked together around their complex topic. Cunningham and McKeon acknowledged that they were primed by Oswaks; she encouraged them to read the book “Blink” by Malcolm Gladwell, which describes ‘intuitive knowing and the adaptive unconscious.’ Oswaks further encouraged the group to read other scientific literature outside of their regular sphere of exposure—to learn to value different ways of knowing. They moved from “Blink” to classic literature, including military literature about stress and decision making. The group adopted ‘Blink’ as their informal group name, and they are referred to by colleagues as ‘Blinkers.’
Dr. McKeon is credited with moving the project past the idea stage. She encountered a challenge when searching for an instrument to validate a method for effecting change. The group will use simulation as a context for behavior, so it’s critical to ensure that the simulation is valid and to eliminate the simulation itself as an impact on the outcomes. Simulation is currently used to teach skills, as when students role play using manikins. The ‘Blink’ research will factor in the behaviors and engagement of providers, for instance with a programmed manikin, to both evaluate and teach providers to manage emerging events and simultaneously perform standard tasks—just as airplane pilots learn to manage emerging events and simultaneously fly a plane. The research will focus on non-technical factors, called human factors, in healthcare delivery. Practicing clinicians have a core technical skill set, but in their work experience other human factors are in play, such as communication, vigilance, attention to detail, etc. The Blink group’s goal is a training intervention to serve as a safeguard for distracting events.
Training exists, but it is limited to specific environments that aren’t generalizable to all healthcare environments. What is needed is a valid measurement of effectiveness of simulation training on patient outcomes and of staff ability to manage system failure events. The desire is to teach providers skills to make early captures of events that are potential threats to patient safety. In the current health care culture, there is a tendency to want to eliminate human error altogether, which in other industries—such as aviation—is recognized as impossible. In environments where there is a lot of ‘noise’ and folks miss things because of distractions, it might be more realistic to honor different ways of knowing. In a schemata, there are patterns; we see things as we believe they ‘ought to be’ and may be blind to what we are missing that’s not in our schemata. Another issue in health care practice is an authoritarian power gradient; there is often an historical and unneeded deference to persons in authority roles. Healthy systems understand that all members of a team are in relationships and that all team voices are important.
Clinical practice problems are often related to system failures. To attain positive patient outcomes, people’s experience should be leveraged and in emerging situations, risk in taking action should be encouraged. Dr. McKeon developed a complexity science based theory to drive the processes of the Blinker’s research, named Patient Focused High Reliability Team Training (PHReTT). PHReTT includes elements of James T. Reason’s model for error, famously applied in the aviation industry, which explores occurrences, organizational policy, and various other created systems that all interact.
The ‘Blink’ collaborators are currently testing their simulation for validity to determine if it emulates real life and if it can be applied to practice. The simulation will not just involve manikins. Its fidelity requires it to look like practice and to capture system failures and behaviors actually practiced by providers. The simulation will measure the stress effect of constant exposure to the conditions of practice.
Stress inoculation (Grossman & Neisserbaum) involves a heightened awareness that does not situationally blind the practitioner; i.e., arousal, but not to a level where the person is so aroused by stress that critical thinking breaks down. Heightened arousal decreases situational awareness and adaptability. As an example, in a crisis situation where authoritarian communication is part of the system, during a rapidly changing event, often the approach is for the authority figure to blame someone: “What’s going on here?” Alternately, in less confrontational communication, an authority figure might approach a subordinate or a team and say, “Team, I see you’re struggling. Is there anything I can help with?”
The ‘Blink’ group acknowledges The College of Nursing for support, particularly for the seasoned mentored support from Dr. Mona Wicks—for her coaching and for being there to bounce ideas back during creative discussion sessions. They also acknowledge the challenges of having diverse backgrounds, expertise, and the demands of their regular faculty responsibilities. They work to maintain a commitment to keep their research moving forward, and Dr. McKeon is credited as a driving force in their progress to date. As the work proceeds, Drs. Oswaks’ simulation expertise and Dr. Cunningham’s debriefing skills will increasingly be demanded.
The group intends to identify barriers to successful practice amidst the constant systems-related environmental pressures a clinician operates in, and look forward to applying PHReTT to deal with power gradient and other issues as they relate to patient outcome and provider competence. Validation of the PHReTT method will require looking at simulation, assessing human factors, and conceptualization of environmental and situational factors. Complexity in healthcare environments require a multifaceted approach to understand the phenomena and interpret results; the Blink group’s varied expertise will be a welcome contribution to seeing things in a new light.
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