International Journal of Healthcare Simulation

To the Editor-in-Chief,

We read with great interest Murphy and Nestel, Healthcare simulation terms: promoting critical reflection [1]. Throughout, the authors encourage critical reflection on the language used within simulation-based education – and subsequently within published literature – with particular comment on the terms non-technical skills and non-verbal communication.

The authors’ state: ‘We believe that the term non-technical skills is unhelpful not least because of the deficit model of description. … 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?’. As facilitators with clinical backgrounds and simulation experience in psychiatry, we agree with the authors’ views regarding this terminology. This language, and the widespread use of the term NTS, infer that almost every skill that a psychiatrist utilises is non-technical. We argue that the skills that are learnt during psychiatry training, such as conducting a detailed psychiatric interview, assessing for psychopathology and undertaking a detailed risk assessment are highly technical. With recognition of this, we, therefore, suggest that the term behavioural skills does not fully capture the true complexity of these skills, given their technical nature. Perhaps the distinction comes between a skill which involves equipment and one that does not. Should a skill involving equipment be called a procedural skill to allow the distinction?

Regarding the phrase gestural communication in place of non-verbal communication, we agree that this is more useful to convey other complex communication seen within the simulation. However, this struggles to encompass unconscious processes and the communication of these within simulation. These terms, and their development, draw on broader psychodynamic theory considering transference and countertransference. These are communicated during any clinical interaction and are an important consideration within all specialties.

Overall, the language of simulation-based education has evolved following its early adoption by acute hospital-based specialties, which often focuses on emergency medical situations. While we welcome this discussion around terms used within simulation-based education, we think this needs further consideration. Perhaps this can be enhanced by the expertise and involvement of specialities such as Psychiatry and General Practice which have more recently become involved in simulation-based education.

Sincerely

Catriona Neil and Kenneth Ruddock