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International Journal of Healthcare Simulation
Healthcare simulation terms: promoting critical reflection

Article Type: Editorial, Article History

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Words are the means by which our community shares its practices, reveals its values and develops future practitioners. Words are fundamental to our professional culture. As a new international healthcare simulation journal (International Journal of healthcare Simulation – IJoHS), we want to flag the role of critical reflection on the use of terms.

We believe that healthcare simulation is hampered by terms that are not fit for purpose. While phrases such as non-technical skills, non-verbal communication and standardized patients are part of the lexicon across the healthcare simulation community, these terms are often inaccurate, redundant and oversimplified. The ramifications of the continued use of these terms have been described [1,2]. Here, we note a compelling quotation from Brian Friel’s play Translations that exemplifies the problem: ‘remember that words are signals, counters. They are not immortal. And it can happen […] that a civilisation can be imprisoned in a linguistic contour that no longer matches the landscape of … fact’ [3]. Applying this to healthcare simulation, we need to ensure that our words do not imprison our practices in a linguistic contour that does not reflect contemporary healthcare values.

Our argument in this editorial is for critical reflection of the words we use as authors to describe our practices. While we have preferred terms, we do not propose to mandate them, they are simply our preferences. We are more concerned with progressing language to ensure that it is fit for purpose and respectful. We believe that the term non-technical skills is unhelpful not least because of the deficit model of description [1,2]. Deficit models usually convey lesser value to the object that is ‘non’. What is a non-technical skill (NTS) – a skill that does not involve technique? Is it then a non-skill, if such a thing exists? Clearly, a more accurate description is required. If, for the sake of argument, technical skills involve the use of technology, be it a syringe, a blood pressure monitor or an ultrasound probe, then behavioural skills refer to the complexities involved in the associated social interactions, be they healthcare professionals (HCPs) interacting with patients or with other HCPs. Both types of skill involve techniques that are manifestly different from each other, but they are nonetheless used in conjunction and are essential to effective health care. Our preference is to name the skills for what they are rather than what they are not.

Non-verbal communication is also a limited phrase, as it inherently prioritizes verbal communication. Gestural communication is a more useful phrase that conveys the complex detail involved in facial expressions and hand gestures that are integral to effective communication. It is important to remember too that there are paralinguistic features of spoken words – pace, volume, emphasis, stress, pitch and register amongst other features that add further nuance to verbal communication . Gestural and verbal communication evolved concurrently, with the origins of language being highly complex and arguably multicausal [4]. It is as well then to recognize the complexity involved in these two interlinked modes of communication and describe them accurately in order to better understand them.

The phrase – standardized patient has increasingly become outmoded as it fails to recognize that patients, who are people, cannot be standardized as machines can be standardized [1,2]. What values are we conveying by standardizing patients? The culture of standardizing patients as in Objective Structured Clinical Examinations (OSCEs) can condition candidates to adopt behaviours that are not suited to real-world clinical encounters and are not person-centred [5]. While we recognize and promote the essential role of simulated patients in health professions education and the importance of standardization for assessments, we prefer to write of standardizing the portrayal rather than the patient [6]. This is a nuanced difference but an important one. A professional society for educators working with simulated patients (Association of Standardized Patient Educators) acknowledges the value of the umbrella term – simulated participant – in its standards document [7] but continues to use the standardized patient term in its own communications (https://www.aspeducators.org/) even when the wider term would make more sense. Critical reflection is challenging. Change can be hard!

We note that confederate is among the list of terms no longer recommended for use by the Society for Simulation in Healthcare (SSH) Dictionary with the following terms recommended instead: actor, embedded participant, simulated patient, simulated person and standardized patient [8]. The SSH Dictionary editors do not share the reason for decommissioning the term. We suspect that it is likely to do with the cultural politics of the term. In the United Kingdom and in Australia, for example, the term confederate is relatively innocuous, but in the United States of America, the term is fraught with connotations of racial conflict specific to the history of that country. We applaud the critical reflection of the SSH Dictionary editors in making this decision. It is this act of critical reflection that we believe is the responsibility of our community in shaping our future. While the editorial team at IJoHS will not always be aware or sensitive to local meanings, we seek to be inclusive and to promote respectful communication and we will always welcome feedback.

Returning to Friel’s play, Translations is instructive here focussing as it does on the cultural politics of language. Translations is set during the first ordinance survey of Ireland at a time when Ireland had the contradictory status as both a colony of the British Empire and a part of the United Kingdom. The play charts the dilemma faced by a schoolteacher, Hugh as to whether he should continue teaching his students in Irish or to accept the inevitability of teaching English as the vernacular due to the overwhelming military, economic and cultural influence of the British Empire. Hugh’s son, Owen, has served as an intermediary for the British ordinance survey officials who have blithely transposed English-sounding words for local Irish placenames with no regard for the etymology or cultural specificity of those names. Owen later regrets his complicity with the obliteration of his local culture, whereas Hugh adopts an attitude of grim pragmatism regarding the anglicization of Irish placenames: ‘We must learn to make them our own. We must make them our new home’ [3].

So, language has always been fraught with politics and meaning is radically contingent on context. Our words have meaning and impact on those with whom we interact; therefore, it is incumbent on all of us to choose our words wisely. Because words have enduring power, we will prompt authors to critically reflect on the words they use in their manuscripts. And, in the spirit of acceptance and being respectful of different ways of doing things, we will not, for example, be adopting ‘US’ or ‘UK’ spelling or mandating spelling (e.g. manikin vs. mannequin). Authors are welcome to use whatever works in their environment. Again, we prompt critical reflection and encourage consistency within manuscripts!

In closing, language is unique in evolutionary terms and has enabled human beings to evolve at a greater rate than any other species [9]. The kind of change that would have taken aeons to occur in biological evolution now occurs in a fraction of that time due to cultural evolution. Language allows us to understand each other’s perspective, a phenomenon that is a cause for delight for the philosopher Merleau-Ponty: ‘Whether speaking or listening, I project myself into the other person, I introduce him [sic ] into my own self. [...] The speaking ‘I’ abides in its body. Rather than imprisoning it, language is like a magic machine for transporting the ‘I’ into the other person’s perspective [10]’. We share Merleau-Ponty’s delight in language and the affordances it provides to not only understand how we can use objects in the world around us but also how we engage in inter-subjective encounters between us. At IJoHS, we are excited to be part of this evolution of our healthcare simulation community.



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