Our institution has previously reported on the Program to Enhance Relational and Communication Skills, a simulation-based educational paradigm designed to help health care personnel from many disciplines engage in empathic conversations with patients and families about difficult medical situations.1–5 Such training addresses 3 of the Accreditation Council for Graduate Medical Education core competencies as follows: interpersonal and communication skills, patient care, and professionalism.6–11 Intrinsic to this program are trained simulated patient (SP) actors representing patients and family in conversations with trainees. Extending this work to our Boston Children’s Hospital Simulator Program, we have also incorporated these actors into a number of mannequin-based high-fidelity medical simulation courses. For reference, the Program to Enhance Relational and Communication Skills program (focusing on empathic conversations) conducted 42 workshops during the 2012–2013 academic year, each using 2 to 5 actors for some portion of the day. The Boston Children’s Hospital Simulator Program conducts mannequin-based sessions, and actors are incorporated into approximately a third of these, totaling approximately 16 hours per month.
Professional, trained actors work in our program as SPs, representing patients, family members, or friends, in both mannequin-based and non–mannequin-based scenarios. Beyond simply enacting a role, however, these individuals are incorporated deeply into the fabric of the program. They are involved in the design, implementation, and revision of our offerings and contribute to ongoing growth and refinement of the program. Skilled actors add emotional and social context to scenarios and intensity to simulations beyond that provided by peer role play and, in so doing, facilitate suspension of disbelief 12—a critical step to engage participants fully in experiential learning. Training individuals to work effectively as SPs is a lengthy process, discussed in detail elsewhere.13,14 This article summarizes our more than 10 years’ experience with this process to provide a brief, practical, “how-to” guide to recruiting, auditioning, hiring, training, and mentoring SP actors for simulation programs.
Recruiting, Auditioning, and Casting
The first challenge for any program is recruiting qualified individuals capable of performing within the unique environment of real-time simulation and high-stakes debriefings. Sources might include organizations of professional actors, local professional and community theater companies, and colleges and universities with performing arts programs (Table 1). The training and use of standardized patients in Objective Structured Clinical Examination (OSCE) programs and in other medical education programs are well described in the literature,15–18 and medical school databases of these individuals might serve as another source—with certain important caveats. In particular, one must consider the primary goals and objectives of the specific simulation-based activity—evaluation vs. education. Evaluation requires standardization—in an examination setting such as the OSCE, all participants should be presented with the same scenario, with little or no variation on the part of the standardized SP, to enable a fair assessment of the participants’ knowledge and skills.19 In contrast, if the focus of a course is on teaching effective and empathic communication, standardization takes a secondary role to the immediacy of unscripted, spontaneous interactions between the SP actors and the learners.20,21 We hope to lead our participants to moments of insightful understanding—learning epiphanies—which are only possible in the context of genuine interpersonal relationships. Thus, SPs in dynamic, highly realistic simulations with an educational focus on communication or relational learning require the nuanced, interactive, and improvisational skills central to the acting profession.13
Performing Arts Consultant
Given how central actors and acting skills are to our work, we have employed a performing arts consultant (PAC), an actor with health care education and management experience and access to the regional theater community. The PAC creates a link between the simulation program and the acting community, providing key assistance in obtaining appropriate acting resources for the educational needs of the program. The PAC meets with senior members of the simulation staff; participates in scenario and overall program development; advises on the feasibility of proposed courses; recruits, auditions, and trains SP actors; and assists in ongoing evaluation and review of our course offerings. The PAC casts, schedules, supervises, and facilitates feedback to SP actors; maintains a resource database; and arranges for substitute personnel as necessary.
The Audition Process
When suitable candidates are identified, they are invited to audition. Auditions are scheduled periodically, depending on the needs of the program; these needs should be anticipated well in advance to ensure that the best candidates can be available and to allow time for casting and training. The audition team should include the PAC and several members of the faculty and staff who are involved in the simulation program. Individual auditions are scheduled at approximately 15-minute intervals.
Upon arrival, the candidate is welcomed, simple introductions are made, and contact information is exchanged. A brief review of the goals of the program and the expectations for the audition is provided. The candidate should be expected to provide a “headshot” (Table 2) and resume summarizing their experience in stage, film, video, medical, and commercial venues, including an outline of their training and other relevant experience (eg, work in education, improvisation).
Auditions are based on familiar, well-established scenarios germane to the SP role for which the individual is auditioning. The candidate is given time to review the scenario, to ask background questions, to understand their character, and to prepare to present the character in an honest and open fashion. The depth and detail the candidate puts into this preparation may be a good indication of the planning they will bring to their role if hired. It is particularly important to be sure that the medical information is understood and is as clear and unambiguous as possible (see scenario development later). The scenario is then enacted, with the candidate portraying the role of patient or family member and program staff playing the roles of health care personnel. The audition scenario runs for 3 to 5 minutes, followed by a short debriefing during which the candidate is asked to provide constructive feedback on the overall exchange and on the performance of the program staff. In this way, the audition samples not only the candidate’s ability to portray a character but also the equally important ability to contribute to debriefing by providing specific, appropriate, and effective feedback. Auditions run back-to-back during the course of several hours.
Following auditions, the program staff review and compare the candidates, coming to consensus as to whether and how an individual might fit the program’s needs (Table 3). The team must consider not only the candidates’ “performance”—the ability to portray a realistic and compelling character—but also their interpersonal skills and ability to provide feedback (a vital skill for debriefing). After team discussion, our PAC, who knows the program’s needs and can match an individual’s skills and talents with the requirements of specific scenarios, makes final hiring decisions. A candidate might be thought not well-suited for the auditioned scenario but ideal for another. If there is uncertainty, a candidate might be invited to participate in one workshop on a trial basis, with a mutual understanding that this is a trial and that further employment is not guaranteed.
The interplay yet distinction between actor and character is a complex process—one of understanding and being intimate with the character without actually becoming the character—playing a role “as if” the actor really were the character but always maintaining the distance provided by the “as if.”13,22,23 Of note, an individual’s personal experience with an illness or situation might enhance or constrain their portrayal in a simulation. For example, an individual who is the mother of a 3-year-old might not be able to distance herself sufficiently to work in a scenario as the mother of a critically ill child of similar age. Before final casting, therefore, it is important to insure that the SP actor/educator feels able to comfortably, safely, and effectively portray the character, especially if the scenario is highly emotionally charged. A casting error of this sort can lead to an ineffective or unpredictable scenario or even to an individual’s inability to continue working with the program.
Character and Scenario Development
Scenarios are derived from actual clinical events occurring in the hospital or health care organization; this optimizes relevancy and realism for staff. Educators, clinical content experts, and simulation specialists collaborate in scenario development; an experienced actor and a family representative with extensive personal experience with the medical system are typically included in the process. The draft scenario is given a pilot “run through,” using program staff as participants, offering an opportunity to make needed adjustments to assure that the scenario has clinical and emotional realism and accurately represents the experiences of patients and families.
Table 4 summarizes elements found to be useful in the development of characters and scenarios. Emphasis on clinical versus relational elements is adjusted to the goals and objectives of the specific experience. If the focus of a scenario is on communication and relational skills, it is important to ensure that the clinical content is straightforward and unambiguous. Alternately, if the focus is more clinical or technical, then there may be greater allowance for clinical variability and complexity as encountered in actual patient care. Lack of medical clarity is a particular handicap for the SP actors who cannot (and should not) easily or believably improvise medical facts that an actual patient or family member would know. Rehearsal time should be provided and used to ensure that SP actors understand all pertinent information about symptoms, laboratory results, and the disease process being simulated.
The development team should identify learning objectives for the scenario and then build the scenario to best attain those objectives. Characters must be developed sufficiently in the scenario outline to provide SP actors a solid foundation or “back story” on which to build. A “character development tool” (Appendix) was developed to streamline and consolidate the definition of each character. Two versions of a scenario are prepared, one to be shared with all workshop participants and a second specifically for the SP actor. This second version includes all the information in the first but provides considerably more details about the medical condition, the emotional context, and the character to be portrayed; specific information about the character’s medical or social history, not provided to the participants, may be included as well. This background information allows the SP actor to understand and develop the character in a manner consistent with the learning objectives and to realistically portray the range of affect, behavior, and concerns of the patient or family member.
Training and Mentoring
As with any group of professionals, actors have varying levels of experience and expertise and welcome opportunities to challenge and expand their capabilities. The opportunity to explore and expand improvisational skills24,25 in a mentored setting with constructive feedback from colleagues is not commonly available. The PAC, with input from the program faculty, oversees this mentoring process and serves as “coach” for new SP actors and new scenarios, ensuring that desired teaching objectives are reached, rehearsing and modifying the performances or the scenarios as needed; the process is much like the theatrical process of directing.14 The consultant should observe new SP actors in their first scenarios, conduct video debriefing sessions with them initially and periodically thereafter, and provide oversight, feedback, and suggestions to help them as they refine their work. This process, fashioned after the Kolb cycle of learning,26 serves to support and further educate the SP actors, adding value and enhancing the program’s ability to retain them over time.
To maintain consistency, we have found it preferable to have specific SP actors work repeatedly in specific roles/scenarios/programs. An individual scenario develops its own rhythm, and important details become clearer and more evident over time. Simulated patient actors discover details, which may not have been apparent at first but unfold during the course of multiple enactments to become significant from the patient and family perspective. They become emotionally invested in the perspectives of patients and families in difficult situations and will often conduct research to develop a better understanding of their character and the character’s responses. Through this process, their character development becomes enriched and more textured over time. As new individuals join the program, they are paired with SP actors seasoned in particular scenarios. The experienced “mentor” can help prepare and orient the new individual, modeling the role and demonstrating techniques for (1) titrating the degree of difficulty and complexity to the participants’ level of expertise, (2) maintaining scenario tempo within a predetermined time frame, and (3) the provision of feedback during debriefings.
Our SP actors allow the enacted conversations to unfold with striking realism. As an illustration, consider this anecdote, related by one of our actors:
“I actually ran into one of the doctors, probably 2 or 3 months after a program that I had done, at a restaurant when I was there with my kids. I went over to say hello, and I found it very amusing because he recognized me, [and] when I introduced myself to his wife as an actor who had worked with him in a class, he was so relieved, because he said he had been watching me, and he knew he recognized me, he knew we had had a very intense conversation, but he couldn’t recognize my kids, so he was very confused about how he knew me! … It had really seemed totally real to him at the time … he remembered me as a parent of a patient, and I remembered him because he was really excellent”.
Typical courses are interdisciplinary, including physicians, nurses, social workers, chaplains, medical interpreters, and other health care personnel as learners. The learners’ specific disciplines and experience should be a factor in guiding SP actors’ decisions, interactions, and performance. Before a session, faculty members meet briefly with the actors to set specific goals for that day’s learners. Suggested adjustments to character portrayals (using the character development tool—see Appendix) might be made to address the needs of different learners; for example, a new resident typically has different learning needs than an experienced nurse.
The ability to modulate emotion and adapt to last-minute changes is a strength of professional actors, whose training emphasizes flexibility and spontaneity; these characteristics are essential for SP work, particularly in an educational (rather than evaluative) session. Adjustments can be made by the SP actor to titrate the emotional intensity of the scenario, modifying the level of anger, anxiety, guilt, or grief expressed. Simulated patient actors may be asked to incorporate specific challenges the participants have identified in their practice, such as de-escalating a crisis situation or rebuilding a family’s trust. We have sometimes used the character development tool as a group exercise before simulations, allowing participants to specify the “personalities” of the patients or family members they are about to meet. The experience is thus tailored to the interest and educational needs of that day’s learners. Such adjustments make the learning self-directed, experiential, relevant and practical, as well as enjoyable and motivating for actors and learners alike—all consistent with the principles of adult learning theory.27
Simulated patient actors portray the family or patient realistically by reacting naturally to the conversation as it unfolds. They act as “ethical understudies,” representing the thoughts and emotions of patients and family members.1 They may become upset if participants provoke them with poor word choice or insensitivity, or they may be reassured and comforted if they are well supported. Emotional responses, outbursts, pacing, and crying are to be expected, as are expressions of relief or even laughter if a supportive or empathic connection is achieved. At all times, the learners should feel that their interaction with the SPs is genuine, real, and believable. To the extent possible, the SP actors let the conversation flow naturally, permitting topics to progress or vary as they might in everyday health care conversations.
When learners are struggling with a difficult but important issue, have difficulty initiating topics or finding the right words, or find it challenging to address the “elephant in the room,” skilled SP actors are able to recognize the block and guide the discussion to open up that issue in the moment while remaining in character. The SP may direct the conversation by asking for clarification of a past statement or by asking frank, outright questions. Examples include “Could my child die?” “Doesn’t that mean that the cancer has come back?” “So there’s nothing else you can do?” This technique of redirection brings the learner to a deeper level of interaction while keeping the dialogue as true to life as possible. As the conversation flows, the SP actors take mental note (still staying in character) of the clinicians’ tone of voice, position, physical or nonverbal expression, directness of information given, and clarity. By observing such features of the learners’ communication style, the SP actors develop material that may be of use educationally during the subsequent debriefing.
Our approach leverages Vygotsky’s concept of the “zone of proximal development,”28 encouraging learning by participation in active problem solving followed by a discussion and reflection with peers and facilitators. Simulated patient actors are coached to portray their characters with a degree of realism, complexity, and intensity that keeps participants on the edge of their learning curve. Learners are challenged not to follow a memorized script but to respond from their own humanity, allowing them to recognize that humanity to be central to their interaction with the patient or family.20,21,29 This process can be stressful. Creation of a safe environment, where learners are secure in knowing that their participation is valued and that feedback will be offered in a sincere, honest, confidential, and constructive manner, is essential.
Actor Contributions to Debriefing
During team debriefings, SP actors provide feedback akin to how patient and family members might respond to the scenario. They are coached to listen carefully to the learners’ first impressions of the encounter and to use these as a springboard for the ensuing discussion. To best represent real family reactions, we ask them to speak in the first person: “When you said ...., I felt ....” versus “When you said ...., my character felt ....”. This technique serves to ground the conversation between learner and patient or family member, rather than between 2 people playing a role. Our SP actors typically lead with positive comments highlighting the learners’ strengths and then move on to areas needing reflection or improvement. Common observations include (1) the manner in which the learner introduced him or herself, (2) the quality of attention and listening, (3) nonverbal behaviors, and (4) the use of medical jargon. The SP may recall specific moments in the conversation that held significance for them and explain why those moments stood out.
Simulated patient actors’ comments can illuminate moral and relational nuances fundamental to successful interactions.1 Because of the shared experience between them and the learner during the enactment, learners generally appreciate and accept feedback provided by SP actors. The actors’ observations reflect a personal experience fed from emotion rather than medical knowledge; this may be more compelling and meaningful to the learners. It is important that this feedback be clear and well presented to insure that the learner feels he or she is learning from the experience rather than being judged by it. We coach our SP actors to base their comments on their actual experience in the scenario that day, rather than to discuss “general principles” that, although perhaps important, are less meaningful to the learners if they do not directly relate to the events of today. Although not necessarily using a formal “advocacy/inquiry” style of debriefing,30 SP actors are asked to frame their comments in a specific, reflective, and nonjudgmental fashion. If negative comments or challenges arise during debriefing, the faculty can depend on the partnership and skill of the SP actors to respond honestly but gracefully, addressing the concerns but sparing participants humiliation. These skills of listening, understanding, and interpreting are invaluable contributions professional, experienced actors can make, either directly as active SPs or indirectly as consultants to the simulation program.
Actor Retention, Compensation, and Development
Simulation-based educational offerings emphasizing communication clearly benefit from the continuity provided by retaining a corps of experienced and committed SP actors who are familiar with the program’s structure, requirements, and learning objectives. To this end, faculty are encouraged to make the SP actors feel welcomed, valued, and respected for their contributions; to allow them to expand their repertoire of skills; and to make working within the program as enjoyable and rewarding as possible. Through direct contributions to the scenarios, SP actors develop a sense of ownership of the program, improving actor retention and increasing the return on the investment made in training. We have had a number of professional actors stay with our program since its inception more than 10 years ago. Their partnership with clinicians in a team approach to a new kind of education can yield a sense of personal reward, social merit, and pride for all.
We have found that investment in our SP actors offers great return in the quality of acting, the caliber of debriefing, and our ability to retain a solid corps of exceptional SP actor/educators. In keeping with theater industry standards, our practice has been to hire and pay individuals for 4- or 8-hour blocks, with a set payment based on the typical compensation in our region ($200 per 4-hour block at the time of this writing). It is important to remember that scheduled breaks during the day are needed; particularly with emotionally intense content, a 10- to 15-minute break between sessions is critical to allow SPs to decompress, recharge, and refocus their energy on the next scenario. We maintain a database of those we have employed and their experience with us. We attempt to schedule individuals as far in advance as possible, so that actors working elsewhere can adjust their schedules accordingly. We have also found it essential to maintain a list of understudies—experienced SP actors who have indicated that they might be available on short notice to fill in if needed. Our professional actors consider our program to be a long-term “gig” that is supportive and financially worthwhile and often prioritize our program over other opportunities in an effort to maintain our long-term relationship.
We recognize that the use of professional actors and the hiring of a PAC may not be possible in all circumstances. If such actors are not available or are simply not feasible within the budget structure of a program, alternatives might be found in local community theater organizations or in college theater programs. Experienced SPs from traditional SP programs can be excellent candidates; we reiterate that experience and comfort with advanced acting techniques are important to successful enactments, particularly when the focus of the training is on interpersonal interaction, communication skills, and emotional content. The audition process is particularly important here. It may be necessary to hold “callbacks,” where a select group of applicants are invited back for a second audition. These candidates may be asked to enact several different scenarios, wherein their ability to portray the characters, to follow direction, and to provide appropriate, constructive feedback can be more intensely evaluated. Promising candidates can then be brought into a training program, where instruction, mentoring, repeated practice, and time will allow them to develop and refine the necessary skills.
Simulation-based training programs frequently incorporate SPs into their work, and SPs are called upon to represent patients or family members in a wide variety of situations. Professional actors have worked as SPs for many years, both in scenarios focused on clinical/medical issues and in those whose focus is more clearly set on communication skills, empathic interaction, ethical issues, professional behaviors, and the like. Simulated patients without an acting background can do the same, but experience and specific training in acting and communication techniques is essential for these individuals to work in emotionally challenging scenarios. Carefully selected and mentored, actors can add great realism, richness, and depth to simulation-based training programs, both by participation as SP actors and by sharing their acting skills and techniques with others who are developing those skills. The actors experience satisfaction from contributing to innovative educational programs of considerable social value. Their skill and improvisational talent allow programs to offer ethical and relational training, customized to a wide range of practitioners and adapted across a variety of health care conversations. Such learning opportunities can directly address Accreditation Council for Graduate Medical Education core competencies in preparing capable, confident, and empathic health care practitioners.
The authors would like to recognize the contributions of several individuals to this article and to their program: Ms Chantelle LaMountaine for her assistance in collating and organizing data; Mr Lewis D. Wheeler, a lead actor and contributor to the character development tool (Appendix); and Sigall K Bell, MD, for her thoughtful comments on the article.
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