Confederates in Health Care Simulations: Not as Simple as It Seems

Confederates in Health Care Simulations: Not as Simple as It Seems

Clinical Simulation in Nursing (2014) 10, 611-616 Featured Article Confederates in Health Care Simulations: Not as Sim...

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Clinical Simulation in Nursing (2014) 10, 611-616

Featured Article

Confederates in Health Care Simulations: Not as Simple as It Seems Debra Nestel, PhDa,*, Bonnie L. Mobley, RNb, Elizabeth A. Hunt, MD, MPH, PhDc, Walter J. Eppich, MD, MEdd a

Professor, School of Rural Health, HealthPEER, Faculty of Medicine, Nursing and Health Sciences, Monash University, Churchill, Victoria 3842, Australia b Lecturer, Medical Education, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA c Associate Professor of Anesthesiology, Critical Care and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA d Assistant Professor of Pediatrics and Medical Education, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA KEYWORDS confederate; simulated health care professional; embedded actor; scenario design; immersive simulations; simulated patient

Abstract: Confederates often enrich immersive health care simulations. In this commentary, we raise issues for consideration when working with confederates. We define the term ‘‘confederate,’’ describe their purpose, scope of practice, commonly encountered challenges for participants and confederates, and make recommendations for practice. We posit that Simulated (Standardized) Patient methodology offers valuable insights to working with confederates. A systematic approach to training for role portrayal drawn from Simulated (Standardized) Patient methodology is likely to improve confederate portrayal. Although the inclusion of confederates in simulations might seem simple enough, there are many considerations to ensure educational or research goals are achieved and confederates unharmed. Cite this article: Nestel, D., Mobley, B. L., Hunt, E. A., & Eppich, W. J. (2014, December). Confederates in health care simulations: Not as simple as it seems. Clinical Simulation in Nursing, 10(12), 611-616. http:// Ó 2014 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.

Immersive health care simulations are often enriched by the role of ‘‘confederates.’’ In this commentary, we raise issues for consideration when working with confederates that are based on our experiences of immersive simulations in health professions education across continents and over many years. We have each had experiences of confederates * Corresponding author: [email protected] (D. Nestel).

being inadequately prepared or feeling unsafe. In writing this commentary, we hope to encourage reflection on contemporary practices of confederates. There is surprisingly little published research on confederates given their centrality to many simulation practices. Even the most comprehensive books on health care simulation make little reference to confederates. A recent and notable exception to understanding the work of confederates is by Sanko,

1876-1399/$ - see front matter Ó 2014 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.

Confederates in Health Care Simulations


Shekhter, Kyle, Di Benedetto, and Birnbach (2013) who draw on performing art theories to achieve effective involvement. We start by defining the term, ‘‘confederate’’ and then describe their purposes and practices in simulations. Drawing on our experiences and those of our professional community, we articulate commonly Key Points encountered challenges for  The role of confederconfederates and make recates in immersive ommendations for managing simulations is importhese challenges drawing on tant for many reasons Simulated (Standardized) Pabut is often oversimtient (SP) methodology. We plified with uninuse examples from different tended consequences health care professional for confederates and disciplines because of the learners. interprofessional nature of  Careful scenario many confederate-based simdesign is important to ulations. We offer directions quality assure optimal for research to improve contributions from confederates’ important conconfederates in immertributions to health care simsive simulations. ulations. Throughout the  Systematic approaches article, we use the term to training simulated ‘‘participant’’ to describe (standardized) patients any type and level of learner. can inform the preparation of confederates for their portrayal in immersive simulations. The Discourse of

Confederates For health care simulation, definitions of confederate include, ‘‘an individual other than the patient who is scripted in a simulation to provide realism, additional challenges, or additional information for the participant’’ (IERC & AHC Simulation Center University of Minnesota); ‘‘experienced healthcare professionals who act as team members during a simulation activity’’ (McMaster University); or ‘‘a person assigned a role in a simulation encounter to help guide the scenario. The guidance may be influential as positive, negative, or neutral or as a distracter, depending on the objective(s), the level of the participants and the scenario. Although the embedded actor’s role is part of the situation, the underlying purpose of the embedded actor is not identified to the participants in the scenario or simulation’’ (The INACSL Board of Directors, 2011). In health care simulations, the origin of the term is uncertain but likely to derive from the role of ‘‘plants’’ in experimental psychology (Asch, 1955; Milgram, 1961). For some individuals, the term has negative connotations, particularly in the United States with respect to the images and implications evoked by ‘‘Confederate’’ since the U.S. Civil War. However, the lower case and capitalization of the first letter changes the meaning. Simulation is based

on shared meanings of symbols, and the Confederate States of America’s symbols remain controversial as symbols of slavery and racial segregation. Despite this discord, the term confederate is used internationally although not universally in health care simulation. Dictionary definitions include reference to both ‘‘accomplice’’ and ‘‘citizen’’ reflecting the different values attributed to the word. Alternative terms include simulated health care professional, simulated relative, and embedded actor. These terms may have emerged in response to the discord or simply as precise descriptors of the role. However, for the purposes of this commentary, we maintain the use of confederate.

Practices of Confederates Confederates usually play the role of a health or social care professional or a patient’s relative and are often ‘‘alone’’ in the scenario. That is, they are immersed in the scenario as an agent of the simulation educator or researcher as opposed to one of the participant group. They may also play the role of visitors, first responders (e.g., police, firemen) or witnesses (e.g., passerby at a motor vehicle accident). Confederates are most commonly colleagues (e.g., simulation educators, clinicians, research associates, and so forth) or actors employed for this specific role (Kassab et al., 2010). Sometimes, participants other than the intended learner group are recruited as confederates, whereas in some simulations, a fellow participant may be asked to take on this role. The practices of confederates in simulation education and research are summarized in the Table. Confederates can serve several key functions in a scenario. They can engage participants, enhance realism, and augment or maintain the educational integrity of the learning encounter through information they provide explicitly as well as the affect they present. A wellprepared confederate helps keep simulation participants oriented from the outset of the scenario as participants transition from the ‘‘here and now’’ (Dieckmann) to the reality of the scenario by providing key information up front or as information is requested. Confederates can also provide appropriately timed prompts to help compensate in manikin-based simulation when simulator fidelity is insufficient to provide relevant clues for clinical decision making. It can be helpful to think of the educative function of the confederate on a spectrum from almost none (e.g., presence adds to reality, keeps participants safe) to directing and adjusting the scenario according to participants’ responses, pausing for discussion, and participating in debriefing and evaluation. That is, confederate roles can have little direct educative function through to that of a ‘‘role-playing’’ instructor or facilitator. Confederates can also provide essential triggers that form the basis for desired actions on the part of the participants. When understanding or acceptance of the

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Table Summary of the Practices of Confederates in Simulations  Guide learners B B B B B

Orientate learners to the scenario Help learners work in an unfamiliar simulation environment Prompt learners at specified pointsdverbal and material/ task Guide learners to meeting learning objectives Offer feedback at preplanned teachable moments

 Offer safety B B

Provide physical safety for learners Protect simulators from damage

Challenges for Participants

 Add realism B B


Demonstrate appropriate emotionsdsad, happy, cooperative, anxious, and arrogant Provide relevant cues to compensate in simulator fidelity (e.g., an infant’s mother states, ‘‘he is so sleepy’’ or ‘‘his hands are so cold!’’) Increase learners’ engagement in the scenario by selectively increasing participants’ cognitive load

 Bridge between faculty and learners B B B

Respond to audio or other cues from faculty during scenarios Communicate with ‘‘control room’’ during scenarios Offer insider experience during debriefing and/or evaluation

 Facilitate research B


difficult and may also pause scenarios and offer feedback at teachable moments. Confederates can play an invaluable role during research simulations. They can collect data that cannot be observed from a control room or video, and they can standardize the manner in which information is conveyed to the subject and ensure research protocols are followed. The ‘‘lifesaver’’ role of the confederate described previously is particularly important for research simulation scenarios where keeping the simulation on track may be essential to avoid systematic bias and possible internal threats to validity, thus maintaining the integrity of the study design (Cheng et al., 2014).

Observe actions and collect data not otherwise able to collect unobtrusively, for example, a nurse confederate would be able to observe dose of medication prepared by pharmacist before administering it Standardize manner in which information is conveyed to study participants (e.g., laboratory data, physical signs and symptoms, whether the patient has a known allergy, and so forth) to limit variability, minimizing risk for bias

simulation is threatened, confederate prompting can help ensure the integrity of the planned scenario. Indeed, Dieckmann, Lippert, Glavin, and Rall (2010) discuss scenario lifesavers that help keep scenarios on track; of these, role-playing confederates ‘‘on the inside’’ of the scenario help maintain the educational integrity of the encounter by helping keep the participants focused on the objectives. Similarly, effective confederates promote engagement by helping titrate the participants’ cognitive load in a variety of ways. For example, confederates may add or delete elements to the scenario in a preplanned manner such that the scenario becomes more or less

Without proper scenario design and character introductions, participants may not be aware of the role of the confederate and so may exclude the confederate from the scenario. This is an important point because it can show that participants may have limited situational awareness that they are not managing their resources wisely or have not fully engaged in the simulation. Because the role of confederates is not to trick participants, then orienting them to the simulated environment (including the people they may encounter) is important. Participants who already know the confederates (e.g., their instructors, supervisors, other colleagues) may face some ambiguity accepting them in their simulation role. Although a full briefing can address this challenge, it remains important to acknowledge the complexity of participants seeing their instructors, supervisors, or peers in a role other than the one they expect.

Challenges for Confederates The introduction of confederates into simulations needs careful consideration by the scenario authors, simulation directors, and the confederates themselves. For example, accomplished clinicians may be asked to take on the confederate role of an inexperienced professional from within their own clinical specialty. Although this might seem simple, it can be challenging for expert clinicians to authentically perform as a novice because their clinical decision making, management, and other clinical skills have become tacit. For example, asking an experienced surgeon to handle instruments as a junior can be difficult because of the physical automaticity associated with their expertise. It is well documented that some experts have difficulty describing their performance to others so it may be that they also have difficulty ‘‘performing’’ as a novice (Clark et al., 2012). This can result in an awkward, clumsy, or an ‘‘over-acted’’ performance. Similarly, less experienced clinicians may be asked to portray someone much more senior to their experience whose fluency of movements and language is beyond their current grasp.

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Confederates may also find it difficult to separate their personal role from their performance role in the scenario leading them to intervene thereby unintentionally misdirecting learning. For example, a confederate who is an experienced pediatric nurse may have difficulty not responding to the deteriorating signs of a child manikindeven momentarily stepping outside his or her role may compromise the educational value of the scenario for the participants. In a research setting, this compromises the quality of the simulation by adding what may be unhelpful variability and thereby confounding the data. Not all confederates have the ability to ‘‘act.’’ When confederates are clinicians, they may have considerable challenge taking on the role of another health professional. It is easy to make assumptions that they understand the substance and nuance of this role. However, the wide need for interprofessional education suggests that this assumption may not hold true. Confederates may be asked to portray a stereotyped clinician with somewhat negative connotations. For example, a nurse may be asked to perform a role that reinforces unhelpful stereotypes of nurses. Of course, the purpose of the scenario will determine whether the stereotypic performance is justified, and the debriefing should explicitly examine the intended purpose of the said stereotype. Failing to do so can leave the individual clinician who took on the role feeling disrespected. Similarly, medical students who have aspiring careers in a particular discipline may feel personally challenged playing the role of a poorly performing or unhelpful clinician in scenarios involving their future colleagues. When confederates are junior colleagues (and they often are), it is important that they do not feel pressured into performing. When actors are employed to take on the role of health care professionals, it is important to remember that the health care roles and settings in which the simulations take place are often quite alien. They may need significant investment in simply appreciating the professional role they are taking on and the environment in which they will work. This is one reason why health professional colleagues often assume these roles. Significant levels of support need to be offered to actors (nonclinicians) in appreciating social and technical elements of the role and the workplace.

Recommended Practices for Working with Confederates Effective confederate contribution is based on sound scenario design with clear and concise instructions for participants and confederates. Learning or research objectives should guide scenario design and confederate tasks. Scenarios developed from real events are recommended to counteract participants’ ‘‘that would never happen’’ rejections. It is also important that a simulacrum effect does not occur (Bligh & Bleakley, 2006). That is, the theatrical drama of the scenario should not become more important than the

learning activity. By adopting the basic presentation principles of SPs when preparing confederates, many challenges may be avoided or minimized. We argue for this systematic approach although confederates may not have the professional training and extensive performance repertoire of SPs. Two examples of confederate preparation of actors to take on anesthetic roles in the operating room have been reported. Kassab et al. (2010) describe a 1-day training program for confederates whose purpose was to add realism. The training consisted of character development, personal and professional information (about the anesthetist), and technical elements of work in an operating room, particularly medical language (Kassab et al., 2010). Nestel et al. (2008) evaluated a training program for actors taking on the role of anesthetists in surgical simulations. As in the first study, the role of the confederates was largely to add realism. The program included a range of cognitive, experiential, and observational activities. Training material included a written guide to the role of anesthetists, the nature of the surgical procedure, photographs of the operating theater and equipment, links to Web sites on laparoscopic surgery, a character, and example verbatim cues and responses. The actors gained confidence after five operations with language, especially jargon being a significant challenge.

Training for Role Portrayal as Confederates In SP methodology, four major components comprise training for role portrayal. One approach is summarized in the Figure. The first component consists of developing the character and identity (back story) of the ‘‘person’’ to be portrayed (e.g., introverted, cooperative, social and work history, and so forth). That is, exploring ‘‘who’’ the person is outside the scenario. The second component relates to the learning event and includes sharing the learning objectives, description of the learner group, starting and finishing times, debriefing, and so forth. The third component is context. Why is this person (confederate) in this scenario? What is the likely process of the scenario? What is the likely outcome? What triggers, cues, and prompts are relevant? The final component is rehearsal, and based on the study by Nestel et al. (2008), five ‘‘run throughs’’ were necessary for actors taking on the role of anesthetists to feel confident. It is likely that clinicians as confederates may need fewer run throughs because of their greater familiarity with clinical environments, but it is important not to make assumptions.

Figure Phases for training confederates for role portrayal adapted from Simulated (Standardized) Patient methodology. Source: Adapted from Nestel, D. 2012, Module 4: Training methods for simulated patients. [Accessed May 4, 2014].

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However, clinicians may need more time in taking on other elements of acting such as consistency in role and emotional expression. Although not documented for use in training confederates, it is likely that other approaches to training SPs would also offer benefits with confederates (Howley, 2013; Szauter, 2014; Wallace, 2006).

Piloting Scenarios In addition, piloting and rehearsing the scenario with participants who are unfamiliar with the objectives will allow the scenario developers to identify areas that need further details to avoid unintended consequences. This is particularly important for any high-stake situations. For example, one of the authors had not piloted a scenario and a participant asked the confederate nurse to check the patient’s blood glucose level. The confederate spontaneously chose a very low value, which then prompted the subject to start addressing the hypoglycemia (low glucose) and moved the focus of the scenario away from the original study objectives. By piloting the scenario several times, missing items such as laboratory values, patient history, and allergies can be built into the scenario.

Signals and Audio Links

participants can be helpful so that all participants receive the same information while the confederate gains insight to potential sources of concern to participants. However, there may be occasions when the learning objectives may be compromised if the confederate is present during the briefing. For example, meeting the confederate ‘‘out of role’’ before the simulation may compromise their ability to perform ‘‘in role’’ during the simulation. It should also be made clear to the confederate whether they will be involved in debriefing the participants and what form this will take. Confederates may be asked to provide feedback to students of their experience from the perspective of the confederate. As with SPs, confederates are most likely to have a positive impact in the debriefing if they participate out of role. For example, an angry confederate is unlikely to offer valuable feedback while remaining in role. There may be benefits of including the confederate in debriefing to represent the thoughts and impressions of the role they were playing; being present in the simulation may offer different and valuable insights to observing from the outside. However, decisions about inclusion will largely depend on the learning objectives, preparation of the confederate, the skill of the debriefer and resourcing, and if the confederate is available to participate.

Debriefing Confederates

In most simulations, it is important to clearly signal the beginning and the end of the scenario. It is especially true where confederates are included. This can help to remove ambiguity of whether confederates are really part of the scenario or whether they have accidently wandered into the ‘‘scene.’’ It can be helpful for confederates to stay in character at the end of the scenario while the participants leave for the debriefing area. Depending on the technical sophistication and location of the scenario, a wireless audio link between an off-stage educator and a confederate may enhance the confederate’s ability to alter their comments and behaviors in response to the participants’ unexpected actions. This approach has been reported in preparing confederates for participating in education-oriented simulation research (Black et al., 2006; Kassab et al., 2010). However, this technical ‘‘fix’’ can distract confederates’ attention. It places significant cognitive load (van Merrienboer & Sweller, 2005, 2010) on the confederate listening to one instructive voice while synchronously participating in another conversation.

Confederates in Briefing and Debriefing with Participants

In our experience, debriefing the confederates (after the participant debriefing) is important for everyone contributing to the scenario. This might be a simple checking in with them that they have stepped out of role or as complex as part of the evaluation of the scenario. Asking confederates to note any issues in playing the role can result in the accumulation of scenario-specific information valuable for others taking on the role in subsequent simulations. This is an important quality assurance activity that can be used in conjunction with the evaluations from participants and other faculty. Confederates may need to be reminded to let go of feelings, part of deroling if they were asked to play a role that was emotionally demanding (Stafford, 2005). Although these preparation and debriefing activities all take time, they are likely to lead to improved learning experiences and safety for participants and confederates. Once accepted for their long-term payoff, such quality assurance activities can be integrated into most simulation practices. Finally, committing all this detailed information on the role of the confederate to a written format assists the process of thinking through the scenario in a deeper way and ensures documentation of the scenario as an enduring resource.

Suggestions for Future Studies The learning objectives determine if and how to include confederates in a scenario from briefing to debriefing. We have found that including the confederate in the briefing with

Most components of simulations are well researched, but the confederate role has received less attention. Working

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effectively with confederates is a rich area for research to improve health care simulation. We need to better understand how to prepare and care for confederates to ensure that learning is optimized, negative learning is minimized, and that confederates do not have unhelpful, frustrating, or disheartening experiences. Confederates have an important role to play in many health care simulations and therefore should not be seen as an afterthought. As we seek to improve the quality of the learning experiences and the integrity of the research we conduct through simulation, it is important to consider the recruitment, selection, preparation, and postsimulation care of the confederate. Undertaking this research will mean we can move from experience- and theory-based practices as we have shared in this commentary to evidence-based practice.

Acknowledgments We acknowledge our colleague Richard R. Kyle, Jr. MS, Instructor, Uniformed Services University, Bethesda, Maryland, USA (retired) for his invaluable contribution in the preparation of this paper. We also acknowledge all the participants in the panel discussion on confederates at IMSH 2013 on which this paper is based.

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