When they walk in the door here [university], they’ve come to learn medicine. When they leave, they’re going to treat patients [Male SP]
Simulation is increasingly being used in health care to create a learning environment in which students can practice and develop confidence in a range of skills1,2 and to ensure that they “do no harm” to patients.3 Simulation-based medical education, which encompasses any educational activity that uses simulation aids such as task trainers and high-fidelity manikins and to present patient problems authentically, also includes simulated patients (SPs).4 An SP is broadly defined as a lay person trained to realistically portray a real patient with a specific condition.5 As students generally engage with SPs before they meet real patients, SPs should be able to comment on students’ developing professional identities.
During the past few years, a wealth of literature has emerged on medical students’ professional identity development,6–14 a process that involves their socialization into the “culture” of the profession as they journey from being students to becoming doctors.9,11,15 An individual’s professional identity therefore comprises a set of attributes, beliefs, values, and experiences by which he or she will define himself or herself within the profession. Professional identity formation is, however, a complex, dynamic process that is socially constructed at the level of the individual through ongoing interactions with other individuals or groups within and outside the professional context.7,16 As students progress through their medical studies, developing the knowledge, skills, and behavior society expects of a doctor, they will encounter various teachers and trainers, health care professionals, and patients, each of whom will undoubtedly contribute to shaping their emerging professional identities.6,8,10,13
The extant literature on professional identity formation appropriately describes the process from the student’s perspective. It is, however, the behavioral and attitudinal manifestations of these developing identities that members of the broader society witness and upon which they are able to comment. A large study was designed not only to explore students’ perceptions of their journey to becoming doctors but also to document these developing professional identities through the lenses of different teachers and trainers (i.e., SPs, problem-based learning facilitators, registered nurses, and faculty members). This article describes students’ professional development from the perspective of SPs who may engage with students across all 5 years of the undergraduate program as SPs (during training) and often as standardized patients (during assessment). The intention of the study was not to offer generalizations about the relationship between SPs and students’ professional identity but rather to explore an area about which little has been documented. In addition to using a different lens through which to view professional identity development, this article further adds to our understanding of identity formation because it describes what SPs believe they contribute. Two broad research questions thus framed this study:
- What do SPs perceive influences medical students’ professional identity development?
- Do SPs contribute to medical students’ professional identity development, and if so, how do they contribute?
We have chosen to explore SPs’ views from a social constructionist perspective,17 a framework which broadly offers a conceptual space to explore how phenomena are perceived and constructed by others. Such an approach assists in developing a general view into the societal expectations of medicine. Although a social constructionist perspective often considers the larger sociometric level with discourses and rhetoric within institutional and organizational contexts, it is, however, the microconstructionist level that is of particular relevance to this study because it is conceptually located within smaller contexts such as everyday interactions.18 In addition to the social constructionist framework, theories about identity are also relevant. An example would be Moscovici’s social representation theory, which asserts that because knowledge is socially and culturally shared, it is not a representation of reality but is based on subjective experience.19 In line with the assertion of Moscovici,19 we can assume that each SP holds his or her own expectations of a doctor’s role and behavior in society, which might then impact his or her expectations of medical students. It is these assumptions and conceptions that we believe enable SPs to assume a position through which they can frame their observations of and interactions with medical students, thereby enabling them to express an opinion about developing professional identities. Both theoretical perspectives (social constructionism and social representation) are therefore relevant to our inquiry in the light of SPs’ regular interaction with students, the longitudinal opportunities for observing student development and the roles they play.
The study took place at an Australian university, which admitted its first medical students into its undergraduate program in 2005. Years 1 to 3 comprise the preclinical (on-campus) phase of the curriculum, whereas years 4 and 5 are the clinical (off-campus) phase.
Year 1 students range in age from 17 to older than 45 years. Although largely Australian residents or citizens, cohorts are culturally diverse, reflecting the broader Australian population, that is, ±27% born overseas.20 This diversity is increased if one considers students’ previous learning (eg, bachelor and postgraduate degrees) and professional experience (eg, health, engineering, law). About one third of students has studied (but not qualified) at a tertiary institution or has a health professional qualification (e.g., nurse, physiotherapist, pharmacist).
The SP Program
The university’s SP program began in 2005, with SPs recruited largely by word of mouth and paid for their services. A faculty member (one of the authors, P.G.) oversees their initial and ongoing training. It is important to note that our SPs are lay individuals from a range of backgrounds, in line with the definition of Cleland et al.5 In year 1, during their weekly interaction with students during history-taking, they realistically portray patients, adapting their responses to students’ questions and interviewing style. A number of SPs also assist with procedural and physical examination skills training (weekly in years 2 and 3). In year 3, SPs are involved in simulation scenarios (eg, hospital wards, emergency department) to prepare students for year 4 clinical rotations. Some SPs also serve as standardized patients during formative assessment sessions, as well as during the summative Objective Structure Clinical Examinations at the end of each semester and academic year. At the time of the study, 17 lay men and women, ranging in age from their early 20s to early 70s but with the majority being older than 50 years, were regularly involved in communication skills training (weekly from semester 1).
In line with the literature on professional identity, interview questions were developed by the research team for the broader professional identity study. Questions were refined following the analysis of year 1 to 5 student interviews. The largely open-ended questions were framed around the 2 research questions, allowing in-depth exploration of issues, particularly for research question 2, the relatively unexplored area of SPs’ perceived role (Appendix). Each team member reviewed the questions to ensure comprehension, clarity, and inquiry logic.
SP Recruitment and Interviews
After approval from the university’s human research ethics committee was obtained, the 17 regular SPs were invited by the principal investigator (M.M.) to attend an information session about the study. An information sheet and a consent form were distributed. Simulated patients had the opportunity to ask questions. They were informed that they would be reimbursed for travel costs. Of the 17 SPs, 14 (82%; 8 women, 6 men; Australian citizens; age range, 30–70 years) consented to participate. They agreed to interviews being audio-recorded and were assured that data would be deidentified. They were offered the opportunity of individual interviews, paired interviews, or a focus group of 4 to 5 SPs. Eight chose individual interviews, and six chose paired interviews (n = 14).
The principal investigator conducted the interviews. As a new academic with no previous contact with the SPs, she is able to declare no authority over the individuals who volunteered. Interviews, which lasted about an hour, were transcribed verbatim by a professional transcriber and then deidentified. After a preliminary analysis of the transcribed interviews by the research team, it was decided to conduct a follow-up focus group to validate common themes or issues raised and to further explore the “positioning” identified during analysis. Seven SPs (4 women and 3 men) participated in the follow-up focus group.
The transcripts were analyzed using template analysis, often used to code a series of transcripts on topics that may have already been researched and within which certain themes might be expected to arise.21 Template analysis is therefore a way of formalizing the analysis of identified previous assumptions and ensures that these assumptions are systematically addressed. The a priori themes therefore act as a template to analyze all transcripts. Template analysis does, however, allow for the emergence of new themes, as was the case for research question 2.
Each team member familiarized herself with 2 transcripts, documenting initial thoughts and identifying emerging issues and points of interest. After discussion, a set of a priori themes (labels that indexed transcripts, e.g., age, sex, previous health care experience), which aligned with our first research question (possible factors influencing identity development), were developed. These themes formed the template for transcript analysis. Several meetings were held to validate the theme content and, where appropriate, add new themes as well as identify supporting data extracts. The second research question allowed for themes to emerge about SPs’ perceived personal contribution to professional identity development.
Ensuring Research Quality
The rigor and transparency of the qualitative methodology was ensured by (1) regular discussions of the research team during data collection and analysis to reach consensus, (2) all researchers taking a reflexive stance (definition discussed later) and, (3) triangulating data through a follow-up focus group to confirm and further explore the views SPs had articulated during the interviews.
The working definition of “being reflexive” is “to explore the ways in which a researcher’s involvement with a particular study influences, acts upon and informs such research” (p 228).22 With backgrounds in nursing (P.G., P.J.), medical education (M.M.), and psychology (S.S.), research team members acknowledged that they may have been drawn to or paid less attention to certain aspects of the data, depending on their previous knowledge and experience. Frank discussions about such predispositions at the regular meetings thus allowed for consensus in terms of legitimate observations and assumptions during analysis.
Research question 1: What do SPs perceive influences medical students’ professional identity development?
We have chosen to discuss our findings under 2 headings, namely, Age, Maturity, and Life Experiences and Authenticity of Experience (ie, previous health care experience and exposure to real patients).
Age, Maturity, and Life Experience and Professional Identity Development
In terms of the demographic factors we had identified a priori as possible factors influencing professional identity development, SPs almost unanimously singled out “age,” but as part of a complex theme, that is, an older age (vs. 17 years entering directly from school) was generally associated with being more mature and having had more life experiences. Based on their almost weekly interactions with first-year (history taking) and second-year (history taking, physical examination, and procedural skills training) students, SPs perceived older, hence more “mature” students to have better interpersonal skills and to be more socially adept. In their view, life experiences, such as dealing with sick children or other family members, engendered maturity and a better understanding of the role of the doctor as well as patients’ experiences of illness. Conversely, a 17- or 18-year-old entering medicine directly from school was generally perceived as being less mature, with little life experience and so generally less able to relate to people.
- Well, the older ones have more life experience… These young kids. I find some of them have never been sick before… And, the older ones are “Oh, we know what that is.” But, it is about life experience [Female SP]
- The maturity of the student will perhaps show in the way they can relate to people because they’ve had more life experience than someone that’s 17 and just left school and doesn’t know how to talk to somebody in their 50s and 60s [Male SP]
Authenticity of Experience: Previous Experience as a Health Professional and Professional Identity
For SPs, previous experience in health care as a professional was an important contributor to professional identity development. Simulated patients told us that from early in the medical program, they were generally able to identify students who had had worked in health care. In particular, those with a nursing background were often identified as having better physical examination and procedural skills as well as interpersonal skills (ie, more personal, empathetic, better communicators).
- I can always pick up if somebody’s done a profession previously, like a physio[therapist] or nurse. It’s just the way they approach what they’re doing [Male SP]
- Nurses have a lot more empathy and get better responses from you than the people who have no hands-on experience [Male SP]
SPs, however, identified that an existing professional identity may interfere with developing a new identity as a future doctor. They described incidents in which, for example, some nurses had found it difficult to switch from being a nurse to being a medical student. Simulated patients spoke about these individuals as having to “unlearn” and start again on the journey to becoming a doctor. Although most students with nursing backgrounds were perceived to adopt a mentoring approach with younger colleagues, SPs also described how some “took over,” often intimidating younger students.
- Some of them, it’s almost like [the University] has to break them down and start again. It takes them a while to realize that the things they thought they knew, maybe they didn’t know them as well as they thought they did and there’s an awful lot to learn [Female SP]
Authenticity of Experience: Interactions With Real Patients and Professional Identity
Almost without exclusion, SPs identified exposure to real patients as an important experience contributing to students’ developing professional identities. They described the marked professional changes that they observed and experienced among the year 4 and 5 students with whom they interacted either when students returned to the medical school for clinical sessions or during assessment or in a private capacity, as patients or as a patient’s family member at local hospitals. Emerging from this interaction with real patients were perceived constructs relating to patient-centeredness, a sense of humanism, and students being well advanced on their journey to “becoming” doctors.
- It’s a much more sincere attitude. You get the feeling that the year 5s seem to actually care what you’ve got to say. Little things like washing their hands and just the way they dress [Male SP]
- In the early stages, they don’t see the patient as being important. Whereas as they go on, they realize that “perhaps the patient is the reason I’m doing this” [Male SP]
- They are able to talk to you in a conversation way rather than just asking questions one after another [Female SP]
Emerging from a question about what they thought changed most over time in terms of the students, SPs were unanimous: professionalism. Based on SPs’ descriptions, professionalism was not “something” that suddenly appears. Rather, it develops as students become increasingly exposed to more authentic clinical experiences and as they internalize their future responsibilities. Simulated patients expressed the belief that without exposure to real clinical contexts, without a conception of their future role, many students viewed themselves merely as “students” or at best, “medical students.” This, for SPs, translated into a perceived lack of “appropriate” dress and/or behavior (i.e., did not meet their expectations), which was particularly noticeable in the first 2 years of the program. Thus, for our lay SPs (representing the broader society’s expectations of what constitutes “being” a doctor), professionalism was the observable behavioral and attitudinal manifestation of “becoming” a doctor (i.e., developing a professional identity) upon which they were able to comment.
- I’ve noticed that in the senior year, possibly [also] in the third and fourth years, that [professionalism] seems to change. I think the interest, the confidence, the participation, the interaction, the seriousness, improves [Male SP]
- I’ve met them in hospitals…where our doctors have come through and they’ve been students and I would have to tell you, they’re very professional. Unbelievably professional [Female SP]
Research question 2: Do SPs contribute to medical students’ professional identity development, and if so, how do they contribute? Unanimously, SPs believed that they had a role to play in students’ developing professional identities. Two major themes emerged in this regard: SPs’ role in developing safe practitioners through feedback and realistic role-playing and SPs’ (including their bodies) availability for repetitive practice.
SPs’ Role in Developing Safe Practitioners Through Feedback and Realistic Role-Playing
Simulated patients believed that they provided a safe and supportive environment for students. They explained how they contributed to students’ professional development by providing constructive feedback aimed at improving skills. The “safe” aspect related to students being able to make mistakes under supervision, without fear of ridicule or causing real patients harm.
- When I’m asked to give feedback, I tend to work along “If you’d done this perhaps a slightly different way, you might have gotten a much more positive response from me” [Male SP]
Simulated patients also believed that they contributed to students’ professional identity development through their realistic portrayal of a patient narrative.
- A lot of time, we are just [role-playing] normal people with problems, but a lot of time, I am also doing the extra ones where I actually have to … if you’re in physical pain, I will act like I’m in physical pain. I won’t just say I’m in pain…You can change your voice and your tone [Female SP]
- I’ve done breaking bad news, and I try to convey all the right characteristics and the language associated with the particular case. Hopefully, I come across as a genuine patient to them [Male SP]
SPs’ (Including Their Bodies) Availability for Repetitive Practice
This theme related to SPs allowing students to practice physical examinations and taking a history, often repetitively, to enable them to hone their skills. Simulated patients, particularly those volunteering for physical examination and procedural skills, because it was more authentic than a manikin, were also acutely aware of their own vulnerability when they allowed students access to their often ageing bodies.
- “…putting our [old and no longer good-looking] bodies up there [Female SP]
- It is not that we have the best bodies, but we do it because we want to give them a tool to learn so that they make better doctors when they get out there and are more comfortable in their [clinical] environment [Female SP]
- The students would never get an interaction with a manikin. And the manikin’s [pulse] is always probably going to be in the same spot. My pulse is hard to find [Female SP]
- I think whether it’s as a PEP [physical examination patient] or a history-taking, it’s all part of us providing them a platform to develop their skills [Male SP]
Without exception, our analysis revealed a community of dedicated individuals who considered themselves as “professionals” who took their role of training students seriously. There were clear examples of SPs’ positive emotional appraisal of how they felt about their role:
- We love it, and I think that’s important…I intend to come here on a Zimmer frame [Female SP]
This study, which explored Australian medical students’ emerging professional identities through the lens of SPs, has provided us with rich insight into some of the factors that may have an impact on the development of their professional identities. In our study, SPs’ views represent 2 perspectives: (1) as trainers (“patients”) who had interacted with and observed students across the medical program in different contexts, and (2) as lay individuals representing the broader society, many of whom had encountered fourth- and fifth-year students in their private capacity as patients or a patient’s next of kin. Simulated patients were able to comment on how students conducted themselves (i.e., their professionalism), which was the “window” through which outsiders (i.e., general public, educators, and trainers) can view emerging professional identities.
According to the SPs, a medical student’s age (which implied level of maturity and previous life experience) impacts on professional identity development. To this end, younger students, usually those entering directly from high school, were generally perceived as less mature, with fewer life experiences and so were often seen to behave (e.g., inappropriate dress code) in a manner that provided little evidence of an acknowledgment of what would be required as a future doctor. At the opposite extreme, being older brought with it maturity and greater experience in terms of life’s uncertainties. Others have written about “mature” students were able to draw on their medical school and life experiences to transition more easily to the clinical environment from medical school.23
Although SPs perceived previous experience as a health professional to be an important factor contributing to professional identity development, they had witnessed how an existing professional identity (e.g., as a nurse) could impede the process. If the assertions of McKay and Narasimhan24 are correct that the role of doctors and nurses are inherently different, leading to negative stereotypes and confusion about roles and poor interprofessional communication, difficulties will inevitably arise when transitioning from being a practicing nurse to a medical student. We believe that our interactive “patient journey” involving an SP couple exposes our first-year students to the roles and responsibilities of individual health care professionals in different interprofessional teams. During this journey, students have to research and then role-play various health professionals involved in the care of an SP “patient” with a myocardial infarction as she and her partner move from the General Practitioner’s office, through to the emergency department, the cardiac catheterization laboratory, and finally to discharge.25
Early patient contact, widely acknowledged as providing medical students with “context” in their learning,26–28 is an important contributor to professional identity formation.6,8 It may, however, not always be feasible to provide regular, well-supervised patient exposure in the early years, due, in part, to an increased demand for clinical placements. Recent figures from Health Workforce Australia indicate that an almost doubling of medical students between 2003 and 2012, clinical placements are in short supply.29 Not only addressing such shortages but also recognizing the need to develop safe practitioners, SPs, through authentic role-playing, can assist students to develop students’ communication, procedural, and physical examination skills before they encounter real patients. Although our SPs identified areas where they believed they contributed to students’ professional identity development (i.e., safe learning environment, availability for practice, feedback), they did, however, acknowledge the pivotal role of real patient contact in contributing to students’ developing identities as doctors.
Because professional identity development is both social and relational,10,16 we believe that SPs have a role to play in medical students’ professional socialization. In describing their engagement with students, SPs told us that they pay attention to details in role-playing a “patient” script to ensure that students have realistic experiences and believe that honest feedback allows for improvement. These behaviors are certainly commensurate with the alignment of the microsocial constructivist approach, considering SPs’ regular and longitudinal interaction with a small cohort of students and in light of their focused attention on student performance and development.
Although such encounters between SPs and students may be part of the formal learning experience, contributing to the development of students’ self-image as future doctors, other (but probably not measureable) aspects (i.e., the informal or hidden curriculum) of students’ interactions with SPs are also likely to contribute to students’ professional development in terms of the relationships that may develop through longitudinal encounters. Because our SPs comprise a community of dedicated individuals who have been in this role for several years, they are familiar faces for students across the different years of the program. Again, the microlevel of the social constructivist framework is of relevance here, with the SPs interacting with students on 2 levels. The first level involves SPs playing the role of a patient while the student assumes the role of doctor. The conversation at this level is largely crafted by societal expectations at a macroconstructivist level (i.e., SPs as lay individuals). It is then made visible through discursive interaction in the practice educational session, becoming a smaller representation of the larger narrative of medical communication. The second level relates to the feedback and other friendly conversation to which SPs refer. In this way, SPs have another conversational window through which they can observe students’ emerging professional identities in the simulated context of SPs role-playing “real” patients. Our SPs’ position may be unique in that although they are involved as standardized patients in clinical examinations, they are not directly responsible for grading. This may allow them to foster a different relationship with students compared with clinical tutors and academic faculty who are both trainers and assessors. In addition, considering that SPs engage with students regularly and longitudinally across the curriculum and that they provide a safe learning environment in which students can make mistakes without retribution, some students will inevitably develop “relationships” with SPs. For Goldie,10 this integration of learners into social networks in medical schools as well as the provision of feedback is important for students to develop meaning about their future selves as doctors.
Cruess et al14 have recently highlighted the need to overtly identify educational strategies (intimately linked with professionalism) that contribute to developing professional identities and socialization. To highlight and foster this process, opportunities need to be created early in the curriculum to allow students to experience the “culture” of health care. Our “patient journey” in the first year25 enhances medical students’ understanding and appreciation of members of different health care teams and also hopefully contributes to their understanding of their future role and responsibilities as doctors. They have certainly identified it as such in their weekly feedback to faculty.
Although the SP lens yielded rich insight into identity development, limitations must be acknowledged. The boundaries imposed by transcript analyses obviously prevent researchers from analyzing nontextual forms of communication. This is, however, mitigated to some extent by the use of single and paired interviews and also by using a focus group to allow group interaction to mediate the discussion. The research team has acknowledged that some of the interview questions may have been subject to suggestibility during the course of the interviews. Given the subjective nature of qualitative research, this reinforced the need to be reflexive about our individual roles and acknowledge our own experiential, cognitive, and affect biases, which is considered good practice in qualitative research.
On a more conceptual level, another issue arose in that although the SPs had much to say about the students in various contexts, it was not always clear whether they were articulating their perspectives from their positions as “trainers” or were drawing on their experiences as patients. Further qualitative analysis of this phenomenon using narrative analysis, possibly underpinned by positioning theory, is currently in progress. The variable nature of simulation should be acknowledged. At many institutions, SPs are professional actors and are therefore focused on a professional craft that demands discrete cognitive appraisals and attention. The SPs in our study were not actors but lay individuals from various backgrounds (sometimes professional) whose cognitive focus may be different and who may then frame students’ attitudes and behavior differently.
As our SPs engage regularly and longitudinally with students, they can potentially provide an opportunistic “window” into the factors that may impact on students’ developing professional identities. We do, however, acknowledge the embedded complexities involving SPs as representatives of the broader society. Notwithstanding this, based on their accounts of student behavior and attitudes through observation and interaction, SPs identified that students start from very different places when they enter medical school, with age and previous experience in health care being 2 factors that can potentially impact on a student’s journey to becoming a doctor. Authenticity of experience, that is, doing the things that doctors do such as engaging with real patients, was a key factor perceived to accelerate the development of a professional identity. We concur with our SPs that by providing a simulated but “near-authentic” patient experience, they do contribute to students’ emerging professional identities. This study has identified the need for additional research focusing on the varied nature of SP work and how their backgrounds (e.g., professional actor or other occupational context) may impact on their perceptions. As well as considering SP occupational and pedagogic positions, several methodological possibilities, for example, reflective diaries, online data sourcing, and repeated-measures surveys, can add value to this relatively unexplored research area. We argue that a wider view through the SP “window” is necessary to understand and possibly develop their potential role in medical students’ professional identity formation. Our broader study canvassing a range of educators’ and trainers’ perspectives will provide us with perspectives through different sets of lenses.
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Interview Guide for the Broader Professional Identity Study Involving Students and Various Teachers and Trainers