The Benefits and Risks of Being a Standardized Patient: A Narrative Review of the Literature

Comparison of real and standardized patients in Degree in Medicine: a randomized controlled intervention study

INTRODUCTION

Simulated clinical scenarios allow students to learn in a safe environment. Although it is recommended that standardized patients (SP) participate in these scenarios, few studies compare the impact of SP and real patients (RP) on medical education.

METHODS

Forty medical students per course (4th, 5th, and 6th) were selected and randomly assigned (1:1) to two groups: a scenario with RP or SP. The students and the external observer were unaware of the type of patient participating in the scenario. The students completed questionnaires on perceptions and knowledge, and the responsible professors and external observer completed questionnaires on perceptions. Qualitative information was collected through focus groups with the students.

RESULTS

No significant differences were found between both groups in perceptions and acquired knowledge, but there was a significant difference in the probability of correctly identifying the type of patient (p < 0.001): most students in the scenario with SP identified it as RP. No differences were found between groups in the professor and external observer questionnaires. Students were more prepared and involved if they believed they were facing a RP and considered the patient's feedback enriching, regardless of the type of patient.

CONCLUSIONS

Medical students do not differentiate SP from RP in scenarios and evaluate them similarly. Given the difficulty of having PR with diverse pathologies and severity levels, SP is a good alternative for training medical students.

Application of Large Language Models in Medical Training Evaluation-Using ChatGPT as a Standardized Patient: Multimetric Assessment

BACKGROUND

With the increasing interest in the application of large language models (LLMs) in the medical field, the feasibility of its potential use as a standardized patient in medical assessment is rarely evaluated. Specifically, we delved into the potential of using ChatGPT, a representative LLM, in transforming medical education by serving as a cost-effective alternative to standardized patients, specifically for history-taking tasks.

OBJECTIVE

The study aims to explore ChatGPT's viability and performance as a standardized patient, using prompt engineering to refine its accuracy and use in medical assessments.

METHODS

A 2-phase experiment was conducted. The first phase assessed feasibility by simulating conversations about inflammatory bowel disease (IBD) across 3 quality groups (good, medium, and bad). Responses were categorized based on their relevance and accuracy. Each group consisted of 30 runs, with responses scored to determine whether they were related to the inquiries. For the second phase, we evaluated ChatGPT's performance against specific criteria, focusing on its anthropomorphism, clinical accuracy, and adaptability. Adjustments were made to prompts based on ChatGPT's response shortcomings, with a comparative analysis of ChatGPT's performance between original and revised prompts. A total of 300 runs were conducted and compared against standard reference scores. Finally, the generalizability of the revised prompt was tested using other scripts for another 60 runs, together with the exploration of the impact of the used language on the performance of the chatbot.

RESULTS

The feasibility test confirmed ChatGPT's ability to simulate a standardized patient effectively, differentiating among poor, medium, and good medical inquiries with varying degrees of accuracy. Score differences between the poor (74.7, SD 5.44) and medium (82.67, SD 5.30) inquiry groups (P<.001), between the poor and good (85, SD 3.27) inquiry groups (P<.001) were significant at a significance level (α) of .05, while the score differences between the medium and good inquiry groups were not statistically significant (P=.16). The revised prompt significantly improved ChatGPT's realism, clinical accuracy, and adaptability, leading to a marked reduction in scoring discrepancies. The score accuracy of ChatGPT improved 4.926 times compared to unrevised prompts. The score difference percentage drops from 29.83% to 6.06%, with a drop in SD from 0.55 to 0.068. The performance of the chatbot on a separate script is acceptable with an average score difference percentage of 3.21%. Moreover, the performance differences between test groups using various language combinations were found to be insignificant.

CONCLUSIONS

ChatGPT, as a representative LLM, is a viable tool for simulating standardized patients in medical assessments, with the potential to enhance medical training. By incorporating proper prompts, ChatGPT's scoring accuracy and response realism significantly improved, approaching the feasibility of actual clinical use. Also, the influence of the adopted language is nonsignificant on the outcome of the chatbot.

An e-Learning Intervention for Professionals to Promote Family-Centered Cancer Care When a Significant Caregiver for Children Is at End of Life: Mixed Methods Evaluation Study

BACKGROUND

Families are often unsure how best to prepare dependent children for the death of a significant caregiver with a poor cancer prognosis and seek guidance and support from health care teams. Health and social care professionals (hereafter referred to as professionals) often lack educational opportunities to gain the desired knowledge, skills, and confidence to provide family-centered supportive cancer care. e-Learning has positively impacted access and reach, improving educational opportunities in health care.

OBJECTIVE

We aimed to evaluate the acceptability, usability, and effectiveness of an evidence-based, theory-driven e-learning intervention to equip and promote professionals' self-efficacy to deliver family-centered supportive cancer care when a significant caregiving member for dependent children is at the end of life.

METHODS

Guided by the "person-based approach," a mixed methods outcome evaluation was used. To determine the effect on self-efficacy, participants completed a validated pretest and posttest 12-item self-efficacy survey. The use of one-on-one, remote semistructured interviews and single-item questions determined the usability by professionals of the e-learning intervention and the acceptability of perceived learning in clinical practice. To generate enhanced insights, quantitative and qualitative data were integrated through a 4-stage, modified pillar integration process.

RESULTS

Overall, 158 participants completed the pretest survey for the e-learning resource, with 99 (62.7%) completing the posttest survey. Semistructured interviews were conducted with 12 professionals at least 1 month after the intervention. Findings highlighted a statistically significant improvement in posttest self-efficacy (99/158, 62.7%; P<.001). Usability of the e-learning intervention was positive, with participants reporting that it was clear and organized (mean 4.84, SD 0.373), the layout was appealing (mean 4.71, SD 0.539), the language was easy to understand (mean 4.71, SD 0.407), and graphics and media were purposeful (mean 4.76, SD 0.495) and engaging (mean 4.67, SD 0.703). Determining acceptability, participants considered that the intervention would positively impact practice (mean 4.60, SD 0.589) and increase knowledge (mean 4.56, SD 0.677), with appropriate practical examples to support learning (mean 4.58, SD 0.610). Following engagement with the e-learning intervention, professionals reported preparedness to deliver supportive adult-professional end-of-life cancer care, when an adult with significant caregiving responsibilities is dying. Findings demonstrated transferable learning to additional contexts, such as other close adult-child relational bonds (grandparents) and to life-limiting conditions.

CONCLUSIONS

The systematic and iterative person-based approach optimized the acceptability of a novel e-learning intervention, having the potential to promote family-centered supportive end-of-life cancer care. This accessible e-learning intervention makes an important contribution to the recognized global gap of educational interventions in this field. Equipping professionals with family-centered supportive end-of-life care improves self-efficacy and preparedness to engage in challenging conversations, with the potential to promote better outcomes for affected adults and children and mediate adverse outcomes for adults and children before and after bereavement.

Experiences of Simulated Patients Involved in Difficult Conversations With Undergraduate and Postgraduate Health Professionals

INTRODUCTION

Simulated patients (SPs) are trained to simulate real patient scenarios for health professionals' education and training. The value of including SPs in simulated scenarios, particularly in relation to difficult and complex conversations, has been studied in various contexts, with a focus on learner experiences and outcomes. What has not been as extensively explored is the impact of difficult and complex conversations on the SPs. The aim of this study was to explore the perspectives, motivations, and experiences of SPs, particularly regarding difficult or complex conversations.

METHODS

A qualitative approach was taken to gather and interpret SP experiences. Open-ended interviews were the primary means of obtaining data. Thematic analysis guided the interpretation of interview data to generate key themes that encapsulated the SP experience.

RESULTS

Twelve participants shared their experiences of working as SPs in scenarios that involved difficult or complex conversations. From these data, 4 major themes were determined: Care for Students , Pedagogical Focus , Emotional Regulation , and Organizational Environment . The importance of empathy and safe design and support for simulations was apparent.

CONCLUSIONS

This study presents insights into the experiences and perspectives of SPs regarding difficult and complex conversations. Participants highlighted the necessity of uniformity in standards of practice in simulation and the need for advocacy for awareness of simulation-based practices.

Standardized patients' experiences of portraying characters in difficult communication scenarios: Narrative inquiry

BACKGROUND

There are limited studies that explored the preparation and challenges faced by standardized patients (SPs) in portraying characters in difficult communication scenarios, and the strategies used to overcome these challenges. The purpose of this study was to understand the experience of SPs in interpreting difficult communication situations and the learning needs of performing similar scenarios. And it allows the researchers to explore the meaning, beliefs, values, and aspiration associated with their role as SPs. The findings could shade light on the significance of their experiences and provide valuable insights for the development of future SP training programs.

METHODS

The design of this study is framed by a narrative inquiry, using semi-structured guidelines to conduct in-depth interviews with 11 SPs who have participated in the performances of difficult communication situations. Research data were analyzed by Polkinghorne narrative analysis, and Riessman's four criteria were used to establish rigor.

RESULTS

Analysis revealed the following five themes: scenarios to real life connections, process of preparing for a performance, methods to detach from character, obtaining unexpected rewards, and needs for performance training. There are two to three subthemes that are subsumed under each theme.

CONCLUSIONS

To strengthen training in difficult communication for healthcare professionals, the use of SPs to interpret challenging difficult communication scenarios will continue to increase. Educators need to ensure that SPs are fully prepared physically and emotionally before, during and after their performance. Offering of continuing education and training in feedback techniques are crucial to extend the tenure of SPs, reduce their frustration, prevent attrition, and ultimately, reduce training costs. In the future, SP training should also include detachment and feedback techniques to alleviate SPs' stress.

The Evolution From Standardized to Virtual Patients in Medical Education

Standardized patients (SPs) are widely used in medical education to teach clinical skills and provide assessments. SPs allow students to practice history taking, physical exams, and communication in controlled settings. However, SPs have limitations such as fatigue, performance variability, and the inability to simulate certain conditions, which virtual patients (VPs) can address. VPs can address these limitations and offer consistency, scalability, and adaptability. Although VPs are being implemented in research settings, they have the potential to be powerful medical education tools. Advancements in immersive technologies such as virtual reality, haptic feedback, and artificial intelligence (AI) will allow the creation of hyper-realistic, interactive training environments that mimic the complexity of real patient encounters. Medical students will be able to engage with VPs in fully immersive settings, complete with haptic feedback and AI-driven dialogue, allowing for more lifelike diagnostic and procedural experiences. The wider availability of such technologies through web services has implications for global medical education and assessment.

Faculty standardized patients versus traditional teaching method to improve clinical competence among traditional Chinese medicine students: a prospective randomized controlled trial

BACKGROUND

Standardized patients (SPs) simulation training models have been widely used in various fields, the study of using SPs in Traditional Chinese medicine (TCM) is still a new filed. Previous studies have demonstrated the effectiveness of occupational SP for TCM (OSP-TCM), which has an increasingly problem of high time and financial costs. The faculty SPs for TCM (FSP-TCM) simulation training model may provide a better alternative. This study aims to test and determine whether FSP-TCM simulations are more cost-effective than OSP-TCM and traditional educational models to improve the clinical competence of TCM students.

METHODS

This study was a single-blind, prospective, randomized controlled trial conducted between February 2023 and October 2023. The participants were randomized into FSP-TCM group, OSP-TCM group and traditionally taught group (TT group) in the ratio of 1:1:1. The duration of this training program was 12 weeks (36 credit hours). Formative and summative assessments were integrated to evaluate the effectiveness of teaching and learning. Three distinct questionnaires were utilized to collect feedback from students, SPs, and teachers at the conclusion of the course. Additionally, analysis of cost comparisons between OSP-TCM and FSP-TCM were performed in the study.

RESULTS

The study comprised a total of 90 students, with no dropouts during the research. In the formative evaluation, students assigned to both the FSP-TCM and OSP-TCM groups demonstrated higher overall scores compared to those in the TT group. Notably, their performance in "physical examination" (Pa = 0.01, Pb = 0.04, Pc = 0.93) and "comprehensive ability" (Pa = 0.01, Pb = 0.006, Pc = 0.96) significantly exceeded that of the TT group. In the summary evaluation, both SP-TCM groups students outperforms TT group in the online systematic knowledge test (Pa = 0.019, Pb = 0.04, Pc = 0.97), the application of TCM technology (Pa = 0.01, Pb = 0.03, Pc = 0.93) and real-time assessment (Pa= 0.003, Pb = 0.01, Pc = 0.93). The feedback questionnaire demonstrated that both SP-TCM groups showed higher levels of agreement for this course in "satisfaction with the course" (Pa = 0.03; Pb = 0.02) and "enhanced TCM clinical skills" (Pa = 0.02; Pb = 0.03) than TT group. The SP questionnaire showed that more FSPs than OSPs in "provided professional feedback" (FSPs: strongly agree 30%, agree 50% vs. OSPs: strongly agree 20%, agree 40%. P = 0.69), and in "gave hints" during the course (FSPs: strongly agree 10%, agree 30% vs. OSPs: strongly agree 0%, agree 10%. P = 0.42). It is noteworthy that FSP-TCM was significantly lower than the OSP-TCM in overall expense (FSP-TCM $7590.00 vs. OSP-TCM $17415.60), and teachers have a positive attitude towards the FSP-TCM.

CONCLUSION

FSP-TCM training mode showed greater effectiveness than traditional teaching method in improving clinical competence among TCM students. It was feasible, practical, and cost-effective, and may serve as an alternative method to OSP-TCM simulation.

The effects of introducing virtual reality communication simulation in students' learning in a fundamentals of nursing practicum: A pragmatic randomized control trials

AIM

This study was conducted to examine the effectiveness of a virtual reality communication simulation (VRCS) in teaching communication skills in fundamentals of nursing practicum.

BACKGROUND

Effective communication skills are an integral part of the nursing profession and the foundation of high-quality nursing care. Effective communication not only addresses the needs of patients but is also necessary for maintaining patient safety. Many studies have reported the inadequacy of nursing students in communicating with patients. Nursing students often experience stress due to their lack of adequate skills to communicate effectively with patients and their family members.

DESIGN

A pragmatic randomized controlled trial research with four within-subjects assessments (at the baseline (T0), 1st week (T1) and 3rd week (T2) of the clinical practice and 1 week after the end of the clinical practice (T3)) and between-subjects assessments.

SETTINGS AND PARTICIPANTS

Eighty-four nursing students at a university of Science and Technology in central Taiwan.

METHODS

The students were randomly assigned to an experimental group (n = 42) and a control group (n = 42). The experimental group received a VRCS, whereas the control group received the nurse-patient communication teaching video. The data were collected from April 2022 to August 2022. The Kalamazoo Essential Element Communication Checklist, Communication Self-Assessment Scale, Learning Satisfaction Questionnaire and Stress Scale for Nursing Students in Clinical Practice were used for data collection.

RESULTS

At baseline, the control group had higher scores on communication ability and confidence compared with the experimental group (t = -3.91, p <.001; and t = -2.35, p =.021). In the first week of clinical practice, the experimental group had significantly higher mean scores for communication ability compared with the control group (β = 15.99, 95 % confidence interval [CI] 13.79, 18.18) and communication confidence and learning satisfaction compared with controls at T1, T2 and T3 of the clinical practice (all, p <.001). The clinical practice stress scores of the experimental group were significantly lower than those of the control group at T1, T2 and T3 of the clinical practice (all, p <.05).

CONCLUSIONS

The newly developed VRCS is acceptable and worthwhile for training nursing students to develop communication abilities. This study suggests that VRCS practice should be arranged as early as possible in fundamentals of nursing practice courses and before the fundamentals of nursing practicum so as to facilitate the learning of effective communication. Follow-up research is needed to evaluate the long-term effects of virtual reality education in nursing practice.

An Exploration of Diversity, Equity, Inclusion, and Antiracism in Standardized Patient Simulations

A trending topic in pharmacy education is the importance of educating and exposing student pharmacists to topics of diversity, equity, inclusion, and antiracism (DEIA). Incorporation of diverse patient populations is one emerging learning opportunity for students in the DEIA space. This commentary presents the findings of seven pharmacy programs reporting similarities and differences in standardized patient (SP) recruitment and training, and their use in DEIA simulation learning activities. Common barriers of DEIA-centric SP activities in pharmacy programs were also identified and included recruitment of diverse SPs, lack of faculty knowledge for implementation of DEIA-focused simulations, and emotional protection of SPs involved. While no best practices or standardized processes exist, the authors provide suggestions for addressing barriers, and make a call to action for further research to determine best practices related to recruitment, training, and utilization of diverse SPs in simulation activities in pharmacy education.

Family dyads, emotional labor, and holding environments in the simulated encounter: co-constructive patient simulation as a reflective tool in child and adolescent psychiatry training

BACKGROUND

Patient simulation has been used in medical education to provide a safe and supportive learning environment for learners to practice clinical and interpersonal skills. However, simulation involving pediatric populations, particularly in child and adolescent psychiatry, is rare and generally does not reflect the child-caregiver dyad or the longitudinal aspects of this care, nor does it provide learners with an opportunity to engage with and reflect on these dynamics.

METHODS

We organized as an educational opportunity a series of seven observed patient simulation sessions with a cohort of a dozen child and adolescent psychiatrists (eight fellows approaching graduation and four senior educators). In these sessions, we utilized the co-constructive patient simulation model to create the simulation cases. We included the use of at least two patient actors in most sessions, and two of the case narratives were longitudinally followed across multiple simulation sessions. We approached the data collected during the simulations and their respective debriefings by using thematic analysis informed by a symbolic interactionist approach.

RESULTS

Based on data from the debriefing sessions and longitudinal narratives, we identified four overarching themes: (1) Reflecting on dyadic challenges: role reversal and individuation; (2) Centering the child, allying with the parent, and treating the family system; (3) Ambivalence in and about the parent-child dyad; and (4) Longitudinal narratives and ambivalence over time.

CONCLUSION

The emotional experience of the simulations, for interviewers and observers alike, provided an opportunity to reflect on personal and professional experiences and triggered meaningful insights and connections between participants. These simulated cases called for emotional labor, particularly in the form of creating holding environments; in this way, the simulated encounters and the debriefing sessions became dialogic experiences, in which the patient and provider, parent and child, and learner and instructor could co-construct meaning and foster professional development as reflective practitioners.

Artificial Intelligence Supporting the Training of Communication Skills in the Education of Health Care Professions: Scoping Review

BACKGROUND

Communication is a crucial element of every health care profession, rendering communication skills training in all health care professions as being of great importance. Technological advances such as artificial intelligence (AI) and particularly machine learning (ML) may support this cause: it may provide students with an opportunity for easily accessible and readily available communication training.

OBJECTIVE

This scoping review aimed to summarize the status quo regarding the use of AI or ML in the acquisition of communication skills in academic health care professions.

METHODS

We conducted a comprehensive literature search across the PubMed, Scopus, Cochrane Library, Web of Science Core Collection, and CINAHL databases to identify articles that covered the use of AI or ML in communication skills training of undergraduate students pursuing health care profession education. Using an inductive approach, the included studies were organized into distinct categories. The specific characteristics of the studies, methods and techniques used by AI or ML applications, and main outcomes of the studies were evaluated. Furthermore, supporting and hindering factors in the use of AI and ML for communication skills training of health care professionals were outlined.

RESULTS

The titles and abstracts of 385 studies were identified, of which 29 (7.5%) underwent full-text review. Of the 29 studies, based on the inclusion and exclusion criteria, 12 (3.1%) were included. The studies were organized into 3 distinct categories: studies using AI and ML for text analysis and information extraction, studies using AI and ML and virtual reality, and studies using AI and ML and the simulation of virtual patients, each within the academic training of the communication skills of health care professionals. Within these thematic domains, AI was also used for the provision of feedback. The motivation of the involved agents played a major role in the implementation process. Reported barriers to the use of AI and ML in communication skills training revolved around the lack of authenticity and limited natural flow of language exhibited by the AI- and ML-based virtual patient systems. Furthermore, the use of educational AI- and ML-based systems in communication skills training for health care professionals is currently limited to only a few cases, topics, and clinical domains.

CONCLUSIONS

The use of AI and ML in communication skills training for health care professionals is clearly a growing and promising field with a potential to render training more cost-effective and less time-consuming. Furthermore, it may serve learners as an individualized and readily available exercise method. However, in most cases, the outlined applications and technical solutions are limited in terms of access, possible scenarios, the natural flow of a conversation, and authenticity. These issues still stand in the way of any widespread implementation ambitions.

Children and young people as simulated patients: recommendations for safe engagement

Adult simulated patients (SPs) are now embedded in health professions education, prompting the development of practice standards. The comparatively sparse involvement of children and young people as simulated participants in education may account for the absence of standards to underpin their safe practice. Research suggests that children and young people who fulfil simulated participant roles have specific requirements not covered by existing standards. This paper offers recommendations specific to the safe engagement of simulated participants in health professions education that align with published guidelines for working with adult simulated patients. These recommendations include: Practical considerations, safe work environment, scenario development, training for role portrayal, feedback & completion of assessment instruments, parental responsibility and ethical considerations. We hope these recommendations are valuable for anyone working with children or young people in simulated participant roles.

Standardized patient experiences study on clinical performance evaluation of nursing college students' ability: A qualitative study

BACKGROUND

Nursing students' direct exposure to patients is limited, thus affecting their performance in practical clinical settings in the healthcare field, including hospitals or communities. Therefore, various clinical situation scenarios, using standardized patients trained to act like real patients (i.e., simulation practice), are applied in nursing education.

OBJECTIVES

This study examined the experiences of standardized patients, who were acting majors and had experience in acting, as patients for nursing students' education.

DESIGN

A qualitative research.

SETTINGS

A university in J city, South Korea.

PARTICIPANTS

Participants were 29 college students majoring in acting with experience of participating as standardized patients. The snowball technique was used for the recruitment of participants.

METHODS

Data were collected using focus group interviews from November 20, 2017, to February 2, 2018. The duration of each interview was 60-90 min, and they were analyzed using content analysis.

RESULTS

The final theme was 'becoming a partner of nursing education'. The participants' experiences were identified in four subthemes: 'beginning with worries', 'requiring thorough preparation', 'growing together', and 'becoming immersed in the duties undertaken'.

CONCLUSIONS

It is necessary to recognize the role of standardized patients as partners in simulation practice in nursing education. Further, developing a systematic education program is vital to nurture patients by understanding their experiences.

Quality in Standardized Patient Training and Delivery: Retrospective Documentary Analysis of Trainer and Instructor Feedback

Background

An important aspect of developing and maintaining a high-quality standardized patient (SP) program is incorporating quality assurance processes. Trainer and instructor feedbacks are considered critical in achieving these goals. The aim of this study is to determine programmatic and systematic issues in the scope of quality assurance and improvement through trainer and instructor feedback on SP performance. We also presented a logic model based on a synthesis of the current literature to ensure the development and maintenance of a quality management culture in the SP program.

Methods

A retrospective analysis of SP scoring was conducted, and written feedback forms completed by trainers and instructors in a large Canadian university’s SP program were collected. The previous six years (2014-2020) of SP feedback forms in the scope of quality assurance were reviewed and analyzed. Descriptive statistics were utilized to analyze the ratings. Thematic analysis was conducted on the data gathered from the written feedback.

Results

A total of 138 feedback forms were reviewed and analyzed in the study. The mean ratings given by the trainers for feedback and professionalism were 4.27 ± 1.29 and 4.77 ± 0.8, respectively. The mean ratings given by the instructors for knowledge of case information, appropriate responses, and affect were 4.84 ± 0.64, 4.86 ± 0.35, and 4.71 ± 0.76, respectively (from a range of 1 to 5). Four key themes emerged from the written feedback: nonverbal behaviors in simulation activity or feedback sessions, providing feedback from the patient perspective, consistency between role portrayal and scenario, and adapting easily to changing situations.

Conclusions

Component scoring on SP performance did not discriminate individual issues, but the qualitative comments identified certain specific issues. Further research is needed to establish standards of continuous quality improvement (CQI) within an SP program.

Simulated Patients for Competency-Based Undergraduate Medical Education Post COVID-19: A New Normal in India

The conventional medical curriculum in India needed more focus on explicit teaching and assessment of interpersonal and communication skills, professionalism, team-work and reflection for prevention and better management of increasing incidences of violence against doctors by building good doctor-patient relationships. Increasing number of seats in Indian medical colleges, decreasing hospital stay of patients, and decrease in faculty requirements will hamper adequate supervised authentic clinical experiences of undergraduates for developing clinical skills. The recent COVID-19 pandemic has led to a significant decrease in student-patient encounters. Simulated patients are being used in many countries to address many of these issues. To make the Indian medical graduates competent to function as primary physician of first contact, competency-based medical education along with guidelines for use of skill-lab and simulation has been introduced from 2019. The current review is focused on the need and use of simulated patients; their advantages, limitations and role in students’ teaching and assessment. It also gives a brief outline of their training process. Simulated patients should be used to supplement day-to-day learning, help in transition to attending real patients and also save enormous faculty time in the post-COVID-19 new normal. However, simulated patients are unlikely to completely replace real patients’ experiences.

Using the Higher Learning Commission's Assessment Culture Matrix to Support Continuous Quality Improvement of a Simulated Patient Program

The purpose of this commentary is to advocate for the use of the Higher Learning Commission's Assessment Culture Matrix to support continuous quality improvement (CQI) of simulated patient (SP) programs. We will share examples from our program demonstrating our maturation as it relates to leadership, shared mission and vision, faculty, and resources. While we are at the beginning stages of engaging students, we continue to make progress accessing and systematically using assessment data. We anticipate that sharing our process for utilizing this matrix may help other institutions as they conduct CQI with their SP programs and in other areas of their assessment portfolio.

Nothing about me without me: a scoping review of how illness experiences inform simulated participants' encounters in health profession education

Background

Person-centred simulation in health professions education requires involvement of the person with illness experience.

Objective

To investigated how real illness experiences inform simulated participants' (SP) portrayals in simulation education using a scoping review to map literature.

Study selection

Arksey and O'Malley's framework was used to search, select, chart and analyse data with the assistance of personal and public involvement. MEDLINE, Embase, CINAHL, Scopus and Web of Science databases were searched. A final consultation exercise was conducted using results.

Findings

37 articles were within scope. Reporting and training of SPs are inconsistent. SPs were actors, volunteers or the person with the illness experience. Real illness experience was commonly drawn on in communication interactions. People with illness experience could be directly involved in various ways, such as through conversation with an SP, or indirectly, such as a recording of heart sounds. The impact on the learner was rarely considered.

Conclusion

Authentic illness experiences help create meaningful person-centred simulation education. Patients and SPs may both require support when sharing or portraying illness experience. Patients' voices profoundly enrich the educational contributions made by SPs.

Engaging Children as Simulated Patients in Healthcare Education

STATEMENT

The value of "simulation" as a learning strategy is well established among healthcare professionals (Educ Prim Care 2015; 26(4):242-7). The use of "simulated patients (SPs)" to present real-world scenarios provides opportunities for students to develop "soft skills," including interpersonal communication, critical thinking, and problem solving. These skills are particularly relevant in pediatric care, where healthcare providers must consider the patient's cognitive development, emotional state, and familial context. This article focuses on middle childhood (6-12 years) a distinctive developmental stage between 2 major developmental transition stages: infancy and adolescence. Middle childhood is associated with compulsory school attendance, developing skills in self-discipline, conflict resolution, and decision-making. Child SPs can play an important role in healthcare education providing direct insight into this unique period of development. They can contribute to the design and delivery of simulations to increase fidelity and provide meaningful real-time feedback to learners on children's experience of the healthcare system. Despite children's expertise and particular care delivery needs, documented simulations using child SPs are limited. This article considers the role of child SPs to support a case for further research into the value of engaging middle years children in the development and delivery of "simulation-based learning experiences". It addresses the gap in child-focused education, the challenges inherent in working with children and outlines strategies and guidelines for effective practice.

Engaging young people as simulated patients: a qualitative description of health professional educators’ perspectives

Background

Real patients in clinical placements are important for learning and may well be the ‘gold standard’. However, simulated patients (SPs) are a viable alternative in the absence of this opportunity. While adult SPs contribute to health professions education, child and adolescent simulated patients (CASPs) are less common. This research aims to explore the perspectives of healthcare educators regarding the engagement of young SPs, specifically the identification of barriers and enablers to involving CASPs.

Methods

We used an interpretive paradigm of qualitative description. Thirteen interviewees, all educators involved in SP programmes, participated in semistructured interviews. Data were transcribed verbatim and analysed using an inductive thematic approach.

Findings

Not all participants saw value in engaging CASPs. A number of barriers and enablers to involving them were acknowledged in six themes: challenges and concerns; logistical barriers; benefits of CASPs; overcoming challenges; an ethical minefield; and child safety. Opinions differed with respect to feasibility and necessity for involving CASPs, particularly in the hospital setting where real patients are accessible. All participants articulated the critical importance of ensuring adequate support and adherence to ethical principles if CASPs were involved.

Conclusions

The involvement of CASPs in health professions education is a divisive issue. CASPs’ ability to provide a realistic option for supporting learning is recognised yet perhaps not wholly perceived as a feasible alternative to real patients. Their engagement raises critical ethical, practical, logistical and financial challenges.

"This Is Me!" Perceptions of Older Adult Simulated Participants in an Aging and Injury Simulation Experience

BACKGROUND

Older adults played the role of frail and prefrail geriatric trauma patients in a frailty-focused communication workshop for nurses. Although subjects played a role (acting) as simulated participants (SPs) for simulation, workshop content and role-play also applied to them personally. We aimed to explore the effect that learning frailty-focused content, scripts, and portrayal of prefrail and frail older adults has on older adult SPs.

METHODS

Qualitative focus group. Participants included older adults older than 70 years (N = 6).

PROCEDURE

Focus group questions pertained to (1) the SP experience, (2) thoughts and emotions throughout the SP experience, and (3) applicability of workshop content and SP experience to personal life. The focus group lasted 90 min, was digitally recorded, and transcribed verbatim. Authors independently coded transcripts to identify categories and supporting quotations. Categories and subcategories were condensed and modified through iterative discussions. Descriptive content analysis was utilized for data analysis.

RESULTS

Six categories and 2 subcategories emerged, including (1) inevitability of aging: not playing a role (sub: inevitability of death), (2) shifting perceptions: how aging impacts thought and actions, (3) time as a factor: getting information sooner, (4) changing behavior/safety: mental recalibration, (5) attitude as a determining factor (sub: loss of independence), and (6) sharing information with others.

CONCLUSION

The study supports the use of frailty-focused communication with older adults to prompt contemplation of aging and frailty and eventual decline/death. Providing information earlier in the aging trajectory enables time for behavior change that can prevent and delay frailty and mitigate untoward outcomes (falls, hospitalizations).

Simulated Patients for Competency-Based Undergraduate Medical Education Post COVID-19: A New Normal in India

The conventional medical curriculum in India needed more focus on explicit teaching and assessment of interpersonal and communication skills, professionalism, team-work and reflection for prevention and better management of increasing incidences of violence against doctors by building good doctor-patient relationships. Increasing number of seats in Indian medical colleges, decreasing hospital stay of patients, and decrease in faculty requirements will hamper adequate supervised authentic clinical experiences of undergraduates for developing clinical skills. The recent COVID-19 pandemic has led to a significant decrease in student-patient encounters. Simulated patients are being used in many countries to address many of these issues. To make the Indian medical graduates competent to function as primary physician of first contact, competency-based medical education along with guidelines for use of skill-lab and simulation has been introduced from 2019. The current review is focused on the need and use of simulated patients; their advantages, limitations and role in students' teaching and assessment. It also gives a brief outline of their training process. Simulated patients should be used to supplement day-to-day learning, help in transition to attending real patients and also save enormous faculty time in the post-COVID-19 new normal. However, simulated patients are unlikely to completely replace real patients' experiences.

'It clarified a lot': GP trainees as peer role players in a formative Clinical Skills Assessment (CSA)

INTRODUCTION

The MRCGP Clinical Skills Assessment (CSA) is a high stakes examination which a significant proportion of candidates fail on first sitting. To address this, deaneries have introduced candidate preparation, such as formative CSAs (f-CSA). One way to maximise the gains from a f-CSA is to use GP trainees as peer-role players (VRPs) instead of professional actors. Our aim was to explore trainee experiences of, and educational gains from, the VRP role.

METHOD

This qualitative study used semi-structured interviews to explore 15 VRPs' perceptions of peer roleplay. Questions were generated from the literature and from informal discussions with f-CSA organisers. Analysis was inductive and thematic.

RESULTS

Analysis identified three main themes. Role play gave participants insight into the exam in terms of what to expect and how to approach the exam. They commented on learning the importance of communication skills and acknowledging the patient's perspective. Finally, there were gains in terms of professional development, particularly in terms of observing good feedback.

DISCUSSION

GP trainees who role played patients in a formative CSA reported increased confidence and educational gains from their experience. Whether these perceived gains will be transferred to their own CSA performance later in training remains to be seen.

Listening to young voices: The lived experiences of adolescent simulated patients in health professional education

BACKGROUND

Learners should be exposed to the core principles of adolescent specific communication and assessment frameworks as part of health professional curricula. How this is done can vary considerably, but the inclusion of adolescents seems an ideal and realistic option. However, securing their participation can be challenging. A viable option to adolescent patients may be adolescent simulated patients.

OBJECTIVE

This study describes adolescents' lived experiences of being simulated patients in health professional education.

DESIGN & SETTING

An interpretive phenomenological approach involving ten adolescent simulated patients from two health professional education programs in Australia.

METHODS

Consenting/assenting adolescents participated in semi-structured audio-recorded interviews. Data was transcribed verbatim and analysed using van Manen's phenomenological approach.

RESULTS

Adolescents offered unique insights and intimate knowledge of their lived experiences of simulated patient work. Adolescents reflected upon the often positive but sometimes challenging journey of simulated patient work. The identification of harm, largely unrecognized by adolescents themselves is the most concerning finding of this study.

CONCLUSIONS

The experiences of adolescent simulated patients can help to shape the future of their involvement. However, their experiences also reveal myriad challenges. The implications for ethical practice must be reviewed before inclusion of adolescents as simulated patients is a feasible option.

Simulated participant methodology in paediatric surgical training: Exploring contemporary practices

Surgical training is long and complex. At the core of clinical practice is communication. Voice is central to relationships of care. Communication and other person-centred competencies are well articulated in surgical training programs. Simulated participant (SP) methodology has seen significant development over its contemporary history. Most commonly in paediatrics SPs portray the roles of parents. However, children and adolescents as SPs are increasingly employed to support the development and assessment of the complex concept of voice. There are specific considerations in all phases of SP-based work, and these are heightened for children and adolescents. This article explores contemporary SP practices in health professional education with a focus on paediatric surgery training.

A Virtual Counseling Application Using Artificial Intelligence for Communication Skills Training in Nursing Education: Development Study

BACKGROUND

The ability of nursing undergraduates to communicate effectively with health care providers, patients, and their family members is crucial to their nursing professions as these can affect patient outcomes. However, the traditional use of didactic lectures for communication skills training is ineffective, and the use of standardized patients is not time- or cost-effective. Given the abilities of virtual patients (VPs) to simulate interactive and authentic clinical scenarios in secured environments with unlimited training attempts, a virtual counseling application is an ideal platform for nursing students to hone their communication skills before their clinical postings.

OBJECTIVE

The aim of this study was to develop and test the use of VPs to better prepare nursing undergraduates for communicating with real-life patients, their family members, and other health care professionals during their clinical postings.

METHODS

The stages of the creation of VPs included preparation, design, and development, followed by a testing phase before the official implementation. An initial voice chatbot was trained using a natural language processing engine, Google Cloud's Dialogflow, and was later visualized into a three-dimensional (3D) avatar form using Unity 3D.

RESULTS

The VPs included four case scenarios that were congruent with the nursing undergraduates' semesters' learning objectives: (1) assessing the pain experienced by a pregnant woman, (2) taking the history of a depressed patient, (3) escalating a bleeding episode of a postoperative patient to a physician, and (4) showing empathy to a stressed-out fellow final-year nursing student. Challenges arose in terms of content development, technological limitations, and expectations management, which can be resolved by contingency planning, open communication, constant program updates, refinement, and training.

CONCLUSIONS

The creation of VPs to assist in nursing students' communication skills training may provide authentic learning environments that enhance students' perceived self-efficacy and confidence in effective communication skills. However, given the infancy stage of this project, further refinement and constant enhancements are needed to train the VPs to simulate real-life conversations before the official implementation.

Patient involvement in health professionals' education: a meta-narrative review

More than 100 years ago, Osler inspired educators to consider health professions education (HPE) as intricately reliant on patients. Since that time, patient involvement in HPE has taken on many different meanings. The result is a disparate body of literature that is challenging to search, making it difficult to determine how to continue to build knowledge in the field. To address this problem, we conducted a review of the literature on patient involvement in HPE using a meta-narrative approach. The aim of the review was to synthesize how questions of patient involvement in HPE have been considered across various research traditions and over time. In this paper, we focus on three scholarly communities concerned with various interpretations of patient involvement in HPE-patient as teachers, real patients as standardized patients, and bedside learning. Focus on these three research communities served as a way to draw out various meta-narratives in which patients are thought of in particular ways, specific rationales for involvement are offered, and different research traditions are put to use in the field. Attending to the intersections between these meta-narratives, we focus on the potentially incommensurate ways in which "active" patient engagement is considered within the broader field and the possible implications. We end by reflecting on these tensions and what they might mean for the future of patient involvement, specifically patient involvement as part of future iterations of competency based education.

"Please let me know when I do not realize it myself": a qualitative analysis of senior simulated patients' experiences

BACKGROUND

Simulated patients (SPs), defined as being over 65 years old, are valuable partners in the training of health professionals related to the care of our aging population. Many senior SPs have been long-time members of SP programs. As SPs age, shifts in their abilities may be observed that, in turn, can affect the overall quality and effectiveness of their participation. It can be challenging and distressing for both the SP educator and the SP to acknowledge these changes and to respond in a compassionate, respectful, and ethical manner that ensures the safe and effective delivery of a simulation for all stakeholders. SP educators are looking for guidance. The aim of this study was to ask SPs from two countries (Switzerland and Canada) to identify the benefits and challenges of working as SPs as they age and to offer strategies to SP educators to accommodate and facilitate their participation.

METHOD

A qualitative thematic analysis research design was implemented to address the study aims. A semi-structured approach with a topic guide was used to individually interview 16 SPs (9 in Switzerland; 7 in Canada). Researchers iteratively compared their results until consensus was reached in terms of identifying the themes and subthemes.

RESULTS

Three main themes, with corresponding subthemes, were identified: giving and receiving value as senior SPs, recognizing challenges when working as a senior SP, and fostering meaningful involvement for senior SPs. Meaningful involvement focused on creating a sense of security, adapting to changing abilities, acknowledging contributions, and providing opportunities to stay connected to the program.

CONCLUSION

This study illustrates the importance of SP educators working with SPs to co-create a safe and effective work environment. Studies like this can serve as a model to provide practical strategies. Through this study, we have learned from senior SPs how we can best support them in their important work.

Three-dimensional needs of standardized patients in nursing simulations and collaboration strategies: A qualitative analysis

Simulation-based education using standardized patients is recognized as an effective education method from which students can learn in a safe and controlled environment, and instructors can provide consistent education. It has been reported that the level of standardized patients' satisfaction in the simulation experience positively affects to their case mastery and providing feedback to learners. This study aimed to explore standardized patients' lived experiences on nursing simulation using qualitative research to provide empirical resources to facilitate collaboration with standardized patients for efficacious nursing simulation. Study participants were recruited from simulation centers and had experience with nursing simulation education as standardized patients within the last 3 years. Focus group interviews were conducted to explore experiences of the 12 standardized patients in nursing simulations. The focus group interviews were conducted with structured four steps of opening, transition, key, and ending questions, from which additional questions and discussions followed. They were recorded electronically and transcribed for analysis. Qualitative content analysis was used to analyze the data. Two researchers read the interview transcripts several times to become familiar with the content, and then interpreted them systematically. From the qualitative analysis of standardized patients' experiences on nursing simulation, 23 codes, 10 sub-categories, 4 categories, and a theme were derived. It would be concluded that standardized patients have serving, learning, and interpersonal needs on their simulation, which may be related to their experiences in the simulation that affects learning outcomes of the students' as well. By facilitating positive experiences of standardized patients, quality of nursing simulation could be increased to provide more active and effective learning opportunities for students.

Using the Plan-Do-Study-Act (PDSA) Model for Continuous Quality Improvement of an Established Simulated Patient Program

Objective

To describe the use of a continuous quality improvement process for strengthening our simulated patient (SP) program and the initial steps that have been implemented.

Innovation

A workgroup that included five clinical faculty with significant experience working with SPs and a strong interest in improving the SP program was developed. The Plan-Do-Study-Act model was used as it allowed for incremental quality improvement changes, in order to ensure a high-quality SP program designed to optimize student learning. Data were gathered from students, SPs, and faculty. Opportunities for improvement were prioritized based on anticipated benefits and available resources. Changes related to planning, implementation, and evaluation and feedback have been executed.

Critical Analysis

Changes related to planning that were implemented included developing handbooks for SPs, faculty, and graduate student instructors, as well as material for students in order to better describe the program. SPs are now referred to as "simulated" as opposed to "standardized" as part of a broader effort to clarify the purpose of SP interactions to students. Streamlined rubrics have been piloted, including electronic rubrics for first year students. SPs are being trained on fewer cases, in order to improve the training program. When possible, activities now take place in one large classroom instead of many small classrooms to improve oversight. Finally, additional feedback has been obtained from SPs via a retreat. These changes have been well received by students, SPs, and faculty.

Next Steps

The collection of this data and initial quality improvement changes provided a basis for hiring a full-time employee who will: dedicate 50% of their time to programmatic assessment of the SP program, support faculty with logistics and training, and be the face of our program to the students and SPs. Further, formal quantitative and qualitative assessment of the SP program has begun.

Beyond catharsis: the nuanced emotion of patient storytellers in an educational role

CONTEXT

As health care organisations seek to cultivate patient and family-centred care, patient storytelling has emerged as a valued educational resource. However, repeatedly harnessing patient perspectives to educate health care professionals may have consequences. We need robust insight into what it means to be a patient storyteller in order to ensure ethical and appropriate engagement with patients as an educational resource.

METHODS

Constructivist grounded theory was used to explore the experience of patients involved in a storytelling curriculum as part of hospital staff continuing education. All 33 storytellers were invited by e-mail to participate in the study. Twenty-six storytellers responded to the invitation, and 25 could be scheduled to participate. Using theoretical sampling, semi-structured interviews were conducted and analysed in a process that was inductive, iterative and comparative.

RESULTS

Participants described the central role of emotions in their storytelling experience, which varied from 1 to 25 tellings over a period of 1 month to 2 years. These emotions were shaped by the passage of time, repetition of storytelling and audience acknowledgement. However, emotion remained unpredictable and had lingering implications for storytellers' vulnerability.

CONCLUSION

The multiple storytelling experiences of our participants and ongoing educational nature of their role provides unique insight into how emotions ebb and flow across tellings, how emotions can be both a surprise and a rhetorical strategy, and how emotions are influenced by audience acknowledgement. These findings contribute to an emerging conversation regarding the power and politics of selecting and using storytellers for organisational purpose. Implications include how we support patient storytellers in educational roles and how we can sustainably integrate patient storytelling into health professional education.

The pillars of well-constructed simulated patient programs: A qualitative study with experienced educators

INTRODUCTION

The inclusion of simulated patients (SPs) in health professional education is growing internationally. However, there is limited evidence for best practice in SP methodology. This study investigated how experienced SP educators support SPs in providing SP-based education for health professional students.

METHODS

Experienced SP educators were identified via relevant professional associations, peer-reviewed publications, and peer referral. Semi-structured individual interviews were conducted via telephone. Data were analyzed independently by three researchers using principles of inductive thematic analysis.

RESULTS

Four themes were identified that represent the key structural components of SP programs considered by educators seeking to optimize learning for health professional students in SP programs: managing SPs by operationalizing an effective program, selecting SPs by rigorously screening for suitability, preparing SPs by educating for a specific scenario, and directing SPs by leading safe and meaningful interactions. Within these components, subthemes were described, with considerable variation in approaches.

CONCLUSIONS

Key structural components to SP programs were consistently described by experienced SP educators who operationalize them. A framework has been proposed to assist educators in designing high-quality SP programs that support SPs and learners. Future research is required to evaluate and refine this framework and other evidence-based resources for SP educators.

Older people’s views and experiences of engagement in standardised patient simulation

Background

The last two decades have witnessed initiatives aimed at improving the care of older people, including educating nurses so that they are equipped with the skills to care for older people with frailty and complex multimorbidities. It has been suggested that involvement of older service users in nurse education can facilitate the development of nurses’ caring skills by promoting understanding of the reality of older people’s situations. One method of involving older service users is standardised patient simulation (SPS). While some recent studies have acknowledged the importance of considering standardised patients’ experiences and perceptions of simulation, to date few have focused specifically on the experiences of older people.

Methods

In this qualitative study, data were collected via focus groups, whereby older people were invited to discuss their views and experiences of involvement in SPS. Data were analysed using open coding.

Findings

Four themes emerged from the data, demonstrating that involving older people in SPS may be beneficial for their well-being. The four themes were: ‘using personal experiences to improve care’, ‘having a sense of purpose’, ‘preparation and support for SPS’ and ‘feeling appreciated’.

Discussion

While most participants reported that they enjoyed the SPS activities, engagement appeared to have had a much deeper significance for them. Many participants’ responses suggested that involvement assisted them to ‘make sense’ of their experiences of illness and healthcare, and also gave a sense of purpose, of belonging and of being valued.

Conclusion

Findings support the need for nurse educators to consider developing SPS programmes that involve older people.

Transforming the Patient Role to Achieve Better Outcomes Through a Patient Empowerment Program: A Randomized Wait-List Control Trial Protocol

Background

In the patient-centered medical home model of health care, both health care providers (HCPs) and patients must understand their respective roles and responsibilities, view the other as a partner, and use communication skills that promote shared decision making. This is particularly necessary in chronic conditions where outcomes depend on behavior change and in underserved populations where the burden of chronic disease is high.

Objective

The objectives of this study are to determine if a Patient Empowerment Program (PEP) (1) is acceptable to patients and feasible across multiple clinical sites; (2) will increase patient preference for control in medical decision making, improve patient perceptions of patient-HCP communication, and increase patient activation; (3) is associated with an increase in diabetes self-management behaviors; and (4) has an effect on hemoglobin A _1c(HbA _1c) level.

Methods

This study recruited English-speaking adult patients with type 2 diabetes mellitus from three urban clinical sites in New York City and randomized them to an immediate intervention group that completed the PEP intervention or a deferred intervention group that served as a wait-list control and completed the PEP intervention after 3-4 months. The PEP intervention consists of two facilitated small group sessions. Session 1 focuses on defining HCP and patient roles in the medical encounter by introducing ideal communication behaviors in each role and by providing both positive and negative examples of patient-HCP encounters. Session 2 focuses on practicing communication skills by role-playing with actors who serve as standardized health care providers. After the role play, participants set goals for their own health care and for future interactions with their HCPs. Outcome measures include the Patient Activation Measure; Ask, Understand, Remember Assessment; Krantz Health Opinion Survey; SF-12v2 Health Survey; Diabetes Self-Management Questionnaire; and HbA _1c. These measures will be assessed at the time of enrollment, after the waiting period (deferred intervention only), and then postintervention at 1 week, 3 months, and 6 months.

Results

Study recruitment occurred from November 2014 to June 2015, with a total of 80 patients enrolled. To date, 45 participants have attended at least one session of the PEP intervention. Further intervention sessions and post-intervention follow-up are ongoing, with data collection set to be completed in April 2016 and results of data analysis available by June 2016.

Conclusions

From preliminary participant self-report data, our PEP intervention is acceptable to low-income, low–health literate patients and feasible to hold across multiple clinical sites. Participants have reported learning specific ways to change their behaviors at their next HCP visit (eg, stating their opinions, asking more questions). With the forthcoming quantitative data on participant attitudinal and behavior change, the PEP intervention may ultimately empower participants within the medical encounter and improve health outcomes.