More than Simply Techniques: Standards of Practice in Simulation-Based Learning

By Kris Slawinski, Jennie Struijk, Val Fulmer, Dena Higbee, and Cathy Smith

Regarding the recent article in the Journal of the Society for Simulation in Healthcare, “Establishing a Convention for Acting in Healthcare Simulation: Merging Art and Science,” we write to thank the authors for underscoring the transferability of the SP (standardized/simulated patient/participant) educational methodology to all modes of simulation-based education, whether implementing a simulated participant (“confederate”) or not. The authors have reinforced the importance of standards of practice in simulation events, citing proper case development; authenticity of setting, roles and tasks; mental attitude and professionalism; identification of learning objectives; pitfalls of the hidden curriculum (“negative learning”), among other key elements of a successful event. Where the gaps are—screening the candidates, training protocols, etc—can be readily filled from research and scholarship in the practice of the SP educational methodology over the past several decades. Rather than simply a “technique” implemented for learning, this is a mature yet constantly expanding field of study and practice.

As SP educators who have worked in human-based simulation training and assessment for years, we caution newcomers to the field of simulation—with or without simulated participants—that all of this behind-the-scenes preparation requires a tremendous amount of planning and work, typically resulting in what appears to be a seamless and effortlessly put-together event. Thus you may find yourselves to be expected to put events together with just hours’ notice, and little to no training of participants!

While aspects of acting theory and practice can inform the design, training and performance of simulated participants, we also caution against the use of theatrical terminology for what is undeniably an educational purpose. Referring to the simulated participant as an “actor” or as “acting’ in the scenario can cause learners to be “turned off” to the process, as it magnifies perceived artificiality of the constructed event. “Nurse,” “patient,” “resident,” “medical student,” etc, should be adequate, as it correctly describes their role in the event and keeps other participants focused on its relation to reality. Also know that not all actors work well in simulations and that many non-actors can be excellent: careful screening, training of and practice with your “formerly known as confederates” (as the term “confederate” seems to currently be in flux) is vital to successful events.

There are professionals currently working within various modalities and hybrid simulation in which the SP training and evaluation tools are being used. The practice exists – perhaps we just need to do a better job of disseminating the presence of existing standards.

We wish to offer the assistance of the SSH SP Special Interest Group (SIG) for the development of the “rubric for the evaluation and improvement of acting in simulation,” which was announced as the authors’ next focus. We all have checklists and protocols, indeed, well-developed standards of practice, in place for our programs, for all types of events we are responsible for, and are happy to share. This is the purpose of the SP SIG—so why should SSH members have to reinvent the wheel?

Listed below are a number of publications that will further guide those wishing to use simulated participants in their events. We also welcome members to contact us through the SP SIG page on the SSH website.

  1. van der Vleuten, CPM, Swanson DB: Assessment of clinical skills with standardized patients: state of the art. Teaching and Learning in Medicine, 1990; 2 (2): 58-76.
  2. Colliver JA, Williams RG: Technical issues: test application. Academic Medicine, 1993; 68 (6): 454-463.
  3. Kneebone, R., Bello, F., Nestel, D., Yadollahi, F., & Darzi, A. (2007). Training and assessment of procedural skills in context using an Integrated Procedural Performance Instrument (IPPI). Stud Health Technol Inform, 125, 229-231.
  4. Levine, A. I., & Swartz, M. H. (2008). Standardized patients: The “other” simulation. Journal of critical care, 23(2), 179-184.
  5. Levine, A. I., Flynn, B. C., Bryson, E. O., & DeMaria Jr, S. (2012). Simulation-based Maintenance of Certification in Anesthesiology (MOCA) course optimization: use of multi-modality educational activities. Journal of clinical anesthesia, 24(1), 68-74.
  6. Khadivzadeh, T., & Erfanian, F. (2012). The Effects of Simulated Patients and Simulated Gynecologic Models on Student Anxiety in Providing IUD Services. Simulation in Healthcare, 7(5), 282-287.
  7. Scott, L. A., Maddux, P. T., Schnellmann, J., Hayes, L., Tolley, J., & Wahlquist, A. (2012). High fidelity multi-actor emergency preparedness training for patient care providers. American journal of disaster medicine, 7(3), 175.
  8. Luctkar-Flude, M., Wilson-Keates, B., & Larocque, M. (2012). Evaluating high-fidelity human simulators and standardized patients in an undergraduate nursing health assessment course. Nurse Education Today, 32(4), 448-452.
  9. Standardized Assessment for Evaluation of Team Skills: Validity and Feasibility.
  10. Wright, M. C., Segall, N., Hobbs, G., Phillips-Bute, B., Maynard, L., & Taekman, J. M. (2013). Standardized Assessment for Evaluation of Team Skills: Validity and Feasibility. Simulation in Healthcare.
  11. Siassakos, D., Bristowe, K., Hambly, H., Angouri, J., Crofts, J. F., Winter, C., … & Draycott, T. J. (2011). Team communication with patient actors: findings from a multisite simulation study. Simulation in Healthcare, 6(3), 143-149.
  12. Undre, S., Koutantji, M., Sevdalis, N., Gautama, S., Selvapatt, N., Williams, S., … & Vincent, C. (2007). Multidisciplinary crisis simulations: the way forward for training surgical teams. World journal of surgery, 31(9), 1843-1853.
  13. Kneebone R, Nestel D, Wetzel C, et al. “The human face of simulation: patient‐focused simulation training.”Academic Medicine. 2006 Oct;81(10):919‐24.
  14. Nestel D, Kneebone R. “Authentic patient perspectives in simulations for procedural and surgical skills.” Academic Medicine. 2010; 85(5):889‐93.
  15. Cantrell, M. J. & Deloney, L. A. 2007, “Integration of standardized patients into simulation”, Anesthesiol.Clin. vol. 25, no. 2, pp. 377-383.
  16. LeBlanc, V. R., Tabak D, Kneebone R, Nestel D, MacRae H, Moulton CA, “Psychometric properties of an integrated assessment of technical and communication skills.” Am.J.Surg. 197.1 (2009): 96-101.
  17. Moulton, C. A., Tabak D, Kneebone R, Nestel D, MacRae H, LeBlanc VR “Teaching communication skills using the integrated procedural performance instrument (IPPI): a randomized controlled trial.” Am.J.Surg. 197.1 (2009): 113-18.
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