- http://orcid.org/0000-0001-9680-0464Jill Steiner Sanko1,
- Tonya Schneidereith2,
- Amy Cowperthwait3,
- Rachel Onello4
- 1 University of Miami School of Nursing and Health Studies, Nursing, Coral Gables, Florida, USA
- 2 University of Maryland College of Nursing, Nursing, Baltimore, Maryland, USA
- 3 University of Delaware College of Health Sciences, Nursing, Newark, Delaware, USA
- 4 University of South Carolina, College of Nursing, Nursing, Columbia, South Carolina, USA
- Correspondence to Dr Jill Steiner Sanko, Department of Nursing, University of Miami School of Nursing and Health Studies, Coral Gables FL 33124, USA;
Background Terminology describing humans’ roles in simulation varies widely. Inconsistent nomenclature is problematic because it inhibits use of a common language, impacting development of a cohesive body of knowledge.
Methods A literature search was completed to identify terms used to describe roles played by humans in simulation-based education. Based on these findings, a survey was created to explore the terminology used by simulation educators and researchers to describe human roles in simulation and the perceived need for a consistent nomenclature.
Results Results demonstrated wide variability in terminology, including terms such as standardised patient, simulated patient, simulated participants, confederate, embedded actor and scenario role player.
Conclusion Creation of a cohesive body of knowledge for human roles in simulation requires use of common terminology, yet findings suggest a complex landscape of terminology. Building consensus on the terminology describing human roles in simulation can clarify understanding of best practice and allow for advancement in the research and state of the science in simulation-based education.
- standardized patient
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Simulation, as a teaching methodology, has been used for hands-on application of didactic content, demonstration of critical thinking and opportunities for independent decision-making.1 Simulation encounters can be designed to include manikins, humans or a combination of both (hybrid simulation). There is wide variability in the application of manikins within simulation encounters, including high-technology simulators to replicate physiologic processes and low-technology task trainers for skills-based practice. Similarly, there is wide variability in the use of humans in simulation scenarios, including portraying the role of patient, healthcare provider, family member or as someone who helps to keep learners on track.2–4
Terminology used to describe humans’ roles in simulation-based education (SBE) has broad variation in the literature. Terms that appear throughout the literature, in standards of practice and professional dictionaries include standardised patient,5–7 simulated patient, 6–8 simulated participants,6 confederate, 4-7 9 embedded actor,5 6 9 embedded participant 5–7 10 and scenario role player 5 6 9 to name a few. In fact, >16 distinct terms were identified throughout SBE literature completed by the research team. Further complicating matters is the region-specific use of terminology that appears within the literature from varying geographic regions. What may be termed a simulated patient in one country may be identified as a standardised patient in another. This discrepancy in terminology introduces significant variability when understanding the roles, purposes and best practice of humans in SBE, as well as communicating about simulation within the community when disseminated research findings.
This dissimilarity and variability is problematic for several reasons. First, the evidence-based International Nursing Association for Clinical Simulation and Learning (INACSL) Standards of Best Practices: Simulation11 and Association of Standardised Patient Educators (ASPE)12 Standards of Best Practice documents, require a cohesive body of literature from which to draw best practices; however, inconsistent nomenclature inhibits accumulation of evidence. Second, a reliable, organised body of literature with consistent terminology provides guidance and clear communication that is reflective of shared knowledge and values within a field.6
Finally, for those who include humans in simulation, a lack of shared language creates miscommunication. For example, what is a simulated patient to one educator may conjure up a different role to another educator, creating a negative learning experiences related to misinterpretation of the language. Continuing to use erratic and varied terminology is, at the core confusing, and promotes a system of potential misinformation among those who teach and learn from SBE. Moreover, inconsistent terminology also undermines research efforts to generate new knowledge related to human roles in teaching and learning. Variations in conceptual definitions threatens validity and weakens the ability to engage in important translational research. The absence of shared meaning is a significant barrier to advancing the state of the science of healthcare simulation.
Noteworthy are the recent publication of the Society for Simulation in Healthcare’s Simulation (SSH) Terminology Dictionary6 and the INASCL Standards of Best Practice: Simulation: Glossary11 and ASPE Standards of Best Practice.12 While these efforts aim to provide consistency, they do not fully capture the variety of terms used to describe human roles in simulation and fail to take into consideration the potential cultural and professional influences on human role terminology.
The first step in the development of the global simulation survey included a comprehensive literature search to identify terms used for human roles in simulation-based learning. The literature search used scholarly databases including MEDLINE/PubMed, PubMed Central, the Cumulative Index to Nursing and Allied Health, Google Scholar, Scientific Citation Index, Scopus and Education Resources Information Centre (US Department of Education). The initial search included terms commonly used by the authors and others found in the SSH Healthcare Simulation Dictionary.6 The final list used in the survey is found in box 1.4–7 9 13 Terms included: actor, confederate, embedded standardised participant, simulation actor, simulated patient and standardised patient. Additional terms found in the literature were then used to expand the search. Examples of such terms that were found after the initial literature search were: embedded actor, embedded simulated person, embedded simulated participant, standardised participant, scenario guide, simulated person.
Term choices for each item
Embedded actor5 6 9
Embedded simulated participant5–7
Embedded simulated person9
Embedded standardised participant*6
Scenario guide5 7 9
Scenario role player5–7 9
Simulated person6 9
Other—term not listed
One term (simulation actor) was not found in use in the literature, but was a term in use among the research team so it was included for completeness.
Based on these findings, a survey was developed to: 1) explore the current use of terminology, and 2) identify a single term that could encompass all live roles in a simulation encounter. The survey consisted of 11 items (online supplementary appendix A). Demographic data were also collected and included professional environment, healthcare discipline and geographic location. Respondents were polled to identify terms that best described a: (1) healthcare provider, (2) family member, (3) patient (formative and summative) and (4) person embedded to keep learners on track when conducting a SEB exercise.
Supplementary file 1
The final questions in the survey were developed to assess if a single term should be used to encompass all live roles in simulation. These questions asked respondents to determine: 1) if a common term should be used to encompass all live roles in a simulation encounter and 2) which listed term would be the most appropriate. Finally, an open-ended question provided an opportunity for respondents to share ways in which live roles were used in their daily simulation encounters.
Prior to survey distribution, Institutional Review Board approval was obtained and permission from leading healthcare simulation organisations was granted. Survey distribution was made through listservs of the following organisations: Association for Simulated Practice in Healthcare, Australian Society for Simulation in Healthcare, INACSL, International Paediatric Simulation Society, Latin American Association for Clinical Simulation, Pan Asia Simulation Society in Healthcare, Sigma Theta Tau, ASPE, Society in Europe for Simulation Applied to Medicine and SSH in the Special Interest Groups (SIG) listservs for the Nursing Section, the Directors SIG and the Interprofessional Education SIG. Additionally, conference attendees at International Meeting on Simulation in Healthcare 2017 were solicited to participate in the survey via a paper flyer posted on the community board. There was significant emphasis on ensuring the survey was circulated to a global audience. The survey was open for a total of 16 weeks from October 2016 until January 2017. Reminders were not made, but rather posted a single time per listserv, staggered across organisations to avoid overlap and optimise distinct participant involvement.
Descriptive data analysis was used with SPSS V.22.0.14 Performance of the descriptive data analysis (non-parametric tests: Χ2, Fischer’s exact test), required data to be dichotomised based on profession and location. Due to the considerable number of terms found in the literature, item choices (dependent variables) were also reduced by combining the bottom percentiles of choices into a single category called ‘all other terms’. A cut-off of a <5% selection rate before being separated by profession or location) was used as a determination of inclusion in terms to be reduced into the ‘all other terms category’. For example, for the question: "What term would you use to describe a person who plays the role of a family member?” The top five terms were retained as individual variables (actor, confederate, scenario role player, simulated participant, standardised participant), while the remaining terms (embedded actor, embedded simulated participant, embedded simulated person, embedded standardised participant, scenario guide, standardised person, simulation actor, simulated patient, simulated person, other) were combined to form the new variable (all other terms).
The roles that were explored included healthcare provider, family member, patient (summative and formative) and those in a simulation to keep learners on track. Responses were examined based on profession (nursing or non-nursing), location (US or non-US) and work area (academic institution, hospital, prehospital, other) to determine any differences in the terms used to describe persons portraying live roles in simulation.
A total of 307 people responded to the survey. Based on the largest simulation organisation’s membership numbers (SSH; n=3700 at the time of distribution of the survey), we estimate that there was an 8% response rate. Respondents were mostly nurses (47%) from academic institutions (68%) and based in the USA (80%) (table 1). All analyses were found to have moderate effect sizes. Cramer’s Phi was used to determine effect size, with 0.1, 0.3 and >0.5 demonstrating a small, medium and large effect size, respectively.15
Influence of profession on terminology
Of the role portrayals explored, two (role of a family member and role of a healthcare provider) displayed statistically significant differences in the terms used based on profession. The differences in the term used among nursing and non-nursing respondents to describe a person who portrays a family member, χ2=14.38, df=6, p=0.024, Ø=0.25 (table 2).
For a person who portrays a healthcare provider, p=0.003, Ø=0.30 (table 3).
Among nurses, the term confederate (18.9%) was the most frequently used term to describe a family member, with the terms scenario role player and standardised participant (11.7%) tying for the second most frequently used term. Among non-nursing simulation educators, simulated participant was found to be the most commonly used term (19%), with confederate as the second (15.7%).
Those respondents indicating that they were in the nursing field used the term confederate to describe a person playing the role of a family member or a healthcare provider during simulation encounters. Respondents describing themselves as non-nursing more often used the term simulated participant to describe the role of a person playing a family member, but used the term confederate to describe a person playing the role of a healthcare provider
Influence of work setting on terminology
Of the role portrayals explored, one (role of family member) displayed statistically significant differences in the terms used based on work setting. The term used to describe the role of a family member was statistically different depending on the type of work area, χ2=15.96, df=5, p=0.027, Ø=0.37. If the work setting was indicated to be an academic institution the term most often used was confederate, but if the setting was a hospital, the term most often used was actor. Half of the respondents who indicated that they work in a prehospital setting also used the term actor to describe a person portraying a family member. Finally, if the setting was listed as other, two terms (actor, scenario role player) were used most frequently (table 4).
Influence of location on terminology
Of the role portrayals explored, statistically significant differences were noted based on location (US or non-US) for the role of standardised patient who provides learner evaluations. The term most used among both US-based and non-US-based respondents to describe a person who portrays a patient and also provides learner evaluation, p=0.003, Ø=0.26 (table 5) was found to be standardised patient. However, a disparity was found among non-US- based respondents where over 55% of respondents also used another term. This finding was in stark contrast with the US-based group, of which 66% use the term standardised patient to describe someone who plays the role of a patient and also provides learner evaluation.
In addition to the examination of the specific terms used to describe specific role types, a question was asked regarding the opinion of adopting a single global term to describe all live roles in a simulation encounter. If respondents thought that a single term should be adopted, a second question asked respondents to select the preferred term.
Findings showed that 68% of the respondents were in favour of a global term, with the largest percentage (19%) of the respondents in favour of the term simulated participant as to describe live roles in general (figure 1). There were no statistically significant differences noted in preference of global term based on location, profession or work area.
To explore the various terminologies used by educators and researchers to describe human roles in simulation, a global simulation survey was conducted. This article reports the impact of location, work area and profession on the terminology used and supports the fundamental need to establish a more uniform nomenclature.
This survey sought to describe the varied nomenclature used for human roles in simulation. While the aim was to clarify the terminology, findings suggest that there is a much more complex lexicon than previously realised. These findings support the notion that, although many healthcare educators employing SBE consider standardised patients to be humans portraying patients in a healthcare setting, there is a substantial proportion of other healthcare educators working in simulation who use a variety of terms to describe all the other human roles used in simulation-based encounters to add realism, provide situational context or to keep learners on the appropriate track.
Terms used to describe the roles of family members and healthcare providers were far more diverse than those used to describe patient roles, suggesting even greater disagreement within the community for what to call this role. Ten terms, including simulated participant, standardised person, scenario role player, embedded actor, comprised most of the survey responses used for describing the role of a family member. The variation used to define family member roles is challenging when collaborating with colleagues who use different terminology and may contribute to confusion. Using divergent terminology for identical concepts severely restricts the potential of high-quality simulation-based research.16
Describing the role of healthcare provider also highlights the wide disparity of terms used among healthcare educators employing SBE. Whereas a quarter of respondents used the term confederate to describe a person playing the role of a healthcare provider, the remaining three-quarters of responses were split between the other 15 terms listed as choices, with simulated participant, representing the second most frequently used term (12.7%). This finding is concerning because of the low frequency of agreement, and it raises important questions about the connotation and meaning behind terms used by simulation professionals. The literal definition of simulated participant is an imitation of a person who takes part in something, suggesting the individual playing the participant is not real!7 Some would argue that the human playing a role is quite real and are truly taking part in the scenario, however the term does not reflect this. Even more confusing, the term simulated participant is treated as a synonym for both simulated patient and standardised patient in SSH’s own dictionary for simulation.
The variability in terminology across survey questions was pervasive and unexpected. Due to the wide range of responses, collapsing the 10 terms used least frequently into an ‘all other terms’ category was essential to meet the requirements of Χ2 analysis. However, the constellation of terms that comprised the ‘all other terms’ category varied by item, meaning that no single term was used the least across any role (patient, family member, provider, etc). Furthermore, terms used most frequently were also far from representing a predictable pattern. While 18% of the survey respondents referred to the role of a family member as a confederate, 82% of the respondents used other terms including scenario role player, standardised person or another term not listed among the 16 choices. Similarly, 26% of respondents called the role of a healthcare provider a confederate, but over 10% indicated that they used a term other than the 16 options. The most commonly used term for both family member and healthcare provider was confederate. This generic term, for two very different roles that require varying levels of training, preparation and likely involvement in the scenario, was not expected. These findings highlight the prevalent lack of agreement within the simulation community. These findings demonstrate gross variability in terms, and illuminate the potential for creating confusion.
The only term that most respondents agreed on was the term used to describe a person playing the role of a patient and focused on learner evaluation. Sixty-two per cent of the survey respondents used the term standardised patient to describe this role. However, when asked about the term used to describe a patient when there is no learner assessment (ie, a patient who focuses on teaching), respondents failed to reach agreement. Thirty-nine per cent of respondents continued to refer to this role as a standardised patient, but 21% shifted to using the term simulated patient, and almost 10% used a different term. This variability represents approximately a 23% difference in terms used solely based on the presence or absence of an evaluation component as part of the role. These results, especially given the high frequency of new terms being introduced beyond those listed as options, suggest a significant lack of clarity and uncovers a previously unknown pool of ‘homegrown’ terminology not found in the researchers’ review of literature.
The survey findings also suggest support (67%) for a global term that could be used as an ‘umbrella term’ for all human roles in simulation. However, when asked what that the global term should be, not surprisingly agreement breaks down, with the highest frequency of respondents (19%) selecting simulated participant as their term of choice. Standardised participant (14%), standardised patient (13%), confederate (9%) and simulation actor (9%) were found to be close behind in preference.
Adding to the complexity of the topic was an interesting relationship between the profession and term used. Nursing professionals most commonly used the term confederate to describe a person who plays the role of a family member, whereas all other professions used the term simulated participant. This statistically significant finding (p=0.024) suggests that some aspect of professional training or culture may influence terminology use. There was a similar influence of geographical location. Respondents in the USA most frequently referred to the role of family member as confederate, while respondents outside the USA used the term actor (p=0.003). This geographical difference may be attributed to the classical US and British English definition of the term. The term confederate is commonly used in the psychology literature as ‘an assistant, ally or accomplice',17 18 but does not fully explain the geographic differences.18 Additionally, and interestingly according to 2014 commentary by Nestel et al on the use of confederates in healthcare simulation, the origin of the term is uncertain, but likely to derive from the role of ‘plants’ in experimental psychology.2
Based on the findings of this study, the research findings supports several recommendations. First, with the lack of consensus on the terminology and the increasing integration of human patient roles in high stakes exams linked to graduation, licensure and certification, the researchers recommend that a more purposeful effort to establish single and consistent terms to describe live roles in simulation be made. Building consensus on a common terminology can clarify understanding, improve collaboration and allow for advancement in the research and science of simulation.
Next, the researchers support establishment of a global lexicon for all roles that include humans in SBE guided by evidence and or expert consensus. Finally, with the recent release of ASPE’s first edition of the Standards of Best Practice for Standardized Patients (SPs) there has been the endorsement within this body of work to use the global term12 simulated participant to describe any role a human would play in simulation.12 While this effort can be viewed as a first step towards clarity and consistency, caution is warranted in selecting simulated participant as the global term given the findings of this work which was completed prior to the release of the standards demonstrating that only 19% of the respondents surveyed agreed that simulated participant should be the global term. To combat potential issues, perhaps a term should be integrated into the SSH Dictionary pointing all identified alternates to a single established term. Then once established, the global community of practice should also be encouraged to incorporate the established term into all published literature, presentations and conference abstracts. Modelling will be important for the change to be effective and a shift to occur. Finally, influencers in the simulation community including the journal, organisations and thought leaders will need to be vocal and consistent about accepted terms.
Although this study had several limitations including the possibility that responses may have captured a response bias, whereas only those individuals interested in the topic of nomenclature answered the survey. Furthermore, this study sought to provide a global perspective on the use of human roles in simulation, voluntary participation in the survey limited the findings to those who were willing to participate and could also read English. The survey did not fully capture the non-US viewpoint. Many countries were either under-represented or not represented at all.
Additionally, given the relative low response rate of approximately 8% it is possible that the findings of this study do not fully capture the true nature of the problem, thus this study may only represent preliminary evidence from which to base a conversation and initiate efforts towards tightening up the language of healthcare simulation. Other important limitations to highlight is the descriptive nature of the survey itself and the need to dichotomise data to be able to compare term usages. This dichotomise while necessary to statistically compare terms also represents a statistical limitation that may have potentially impacted the findings.
Finally, it is important to note that these findings present how healthcare educators employing SBE currently use terminology, rather than how it should be used. Additional work is needed to more fully understand the most appropriate terminology for each role. Despite the noted limitations, this work represents the first efforts to use research to characterise the nature and extent of a problem in healthcare simulation term usage; certainly it provides enough evidence that a problem exists and the importance of solving it to ensure the continued growth of the field.
The findings of this study highlight the need for thoughtful consideration of the meanings and connotations of the words adopted for use within the simulation community. The findings underscore a need to build consensus around terms used to describe human roles in simulation. If simulation is to continue to build momentum, produce significant and impactful research and share best practices, a common language must be established. Failure to adopt a common language may put the discipline at risk of becoming hampered by its inability to fully communicate both within and beyond the community, repeating the 1920’s scientific community’s zeitgeist, which was staunchly isolationist.19 It is up to the community of leaders currently engaged in healthcare SBE to move this agenda forward through the promotion and modelling of common simulation language. The publication of the simulation dictionary6 by SSH, the INACSL Standards of Best Practice: Simulation: Glossary11 and ASPE12 represent a strong start, but it is clear there is more work to do towards building real consensus.
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Contributors Each author made substantial contributions to the design, data collection, analysis and/or writing, revising the manuscript. Each author has given final approval of the version to be published and is in agreement as to the accuracy of the data presented.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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