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

•The role of confederates in immersive simulations is important for many reasons but is often oversimplified with unhelpful consequences for confederates and learners.•Careful scenario design is important to quality assure optimal contributions from confederates in immersive simulations.•Systematic approaches to training simulated (standardized) patients can inform the preparation of confederates for their portrayal in immersive simulations.•Given the importance of confederates in immersive simulations, all facets of their contribution are ripe for research.

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.