SSH Article Response: SPs and Confederates: Similar but Still Different?

By Kris Slawinski

A recent article in the Journal of the Society for Simulation in Healthcare, “Establishing a Convention for Acting in Healthcare Simulation: Merging Art and Science,” underscores the many similarities between using SPs for healthcare education, and using confederates in simulation, and brings up some questions as well about how similar, or different, we really are from each other.

I believe most SP educators would agree that the use of the “confederate” so completely mirrors that of SPs that the acronym “SP” could substitute for the “confederate,” as “simulated participant,” that is the focus of this article. So I was rather curious to find that, although the simulation-based field of SP educational methodology is now some five decades old, there were no SP educators enlisted as consultants for the work reported on. Additionally, while the References include material related to acting, there is nothing specific to training SPs.

The authors state that due to “gaps in knowledge, training and skills of many simulation confederates, we chose to explore theatre arts and acting in healthcare to develop a guide that would assist in the closing of the gaps.” However this article largely addresses the elements that must be taken into consideration for an effective encounter or simulation event, or standards of practice. While “[p]oor acting is often underappreciated in its potentially negative effects on the learning outcomes,” what we get is a fairly comprehensive list of preparations, many outside of training of participants, to ensure the success of any simulation event, including:

  • Professionals should write and/or review scripts & roles: doctors should write/review the doctor role, nurses the nursing role, etc.
  • Appearance of participants & setting should be authentic & believable.
  • The confederate/SP must know their situation/purpose.
  • All participants should know the who/what/where/why of the encounter, mirroring the “Door Chart” /  “Student Instructions” of the typical SP encounter.
  • Simulated participants must know the learners’ level of training & performance.
  • The event must be based on specific learning objectives.
  • Simulated participants must expect the unexpected from the learners, and be prepared to improvise.
  • Simulated participants must practice the encounter/event with coaching.
  • Simulated participants must have empathy for the situation, their role, and the learners.
  • Simulated participants must avoid conveying unintended messages referred to in the article as “negative learning,” also known in medical education as the “hidden curriculum.”
  • Simulated participants must present themselves professionally at all times.
  • All participants must expect, allow for and accept that it’s OK for errors to occur in the simulation.
  • Simulated participants must not “help” when the intention is for the learners to recognize and act on challenges.
  • Video review can be “anxiety provoking” but invaluable to train the simulated participant.

The authors state that their next focus is to develop a valid “assessment tool for acting in simulation in partnership with scholars in acting and simulation. The tool will establish a rubric for the evaluation and improvement of acting in simulation.” I suspect what they really desire is a checklist of tasks required for a well-designed simulation event, which any of us SP educators, as specialists in simulation event design and coordination, could provide.

My suggestion to the authors is to replace references to acting with a focus on the educational aspect of simulation event design: as Rachel Ellaway told us at our conference in June, “All health professional education is simulation.” Whether it involves expensive equipment or an SP, a manual skill or communication challenge, is formative or summative, you must design well, troubleshoot, practice, and debug, until your protocols are established. Skimping in any of the setup is a recipe for mediocrity, if not a full-blown disaster.

 “Establishing a Convention for Acting in Healthcare Simulation: Merging Art and Science,” published in the Vol. 6, Number 4, August 2013 issue, Journal of the Society of Simulation in Healthcare. Jill Sanko, MS, ARNP-BC; Ilya Shckhter, MS, MBA; Richard Kyle, Jr., MS; Stephen Di Benedetto, PhD, David J. Birnback, MD, MPH.


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