Fifty years ago, Barrows and Abrahamson1 described the need for a new patient-oriented method for testing medical students in the domain of clinical skills. This was because real patients in student examinations always introduced variation into the assessment, making students' competencies difficult to compare. The “programmed patient” was thus devised to provide a more standardized test for students. The new method involved the standardized simulation of a neurologic disease by a healthy person trained to present the history and behavior of an actual patient. Later, the method was renamed “the simulated patient method,” and its use was no longer restricted to neurologic diseases.2–4
Since its start, the standardized patient (SP) method has developed considerably. Although the original emphasis was on portraying a patient only, in the early 1970s, SPs' feedback after a student encounter also became important: students were given feedback on their interviewing skills.2 In the 1980s, the use of SPs in assessment became common, for example, in the Objective Structured Clinical Examination (OSCE). The term standardized patient instead of simulated patient became a generally accepted term for SPs,5 at least in the United States.
Over the years, the requirements for SPs have become more difficult and demanding. Now, there are SP trainers who are responsible for supervising and supporting SPs in manifold competencies,6 for example, in portraying a patient according to a standardized role script, in observing students' behavior, in recalling the encounter for a feedback checklist, and in giving feedback on the students' diagnostic questioning.7 The quality of SP role-play and feedback has become more important, and appropriate evaluative instruments have been developed.8–10
The use of SPs in assessment and teaching in medical education has grown worldwide,11 as have SP training programs. Increasing SP professionalism, in turn, raises questions as to what effects stricter requirements and higher numbers of SPs per SP program have on the SPs in the programs involved. In a more demanding working world, a further question is how much SPs are committed to doing their current work. Work satisfaction and an appropriate workplace relationship are determinants of organizational commitment,12 and employees with high work satisfaction are willing to accept high demands when necessary.13 Sempane et al14 describe work satisfaction as people's assessment of their job in terms of the issues and concerns that matter; the feelings and emotions involved in work will have considerable influence on a person's work attitude. Unfortunately, there is a lack of specific research analyzing SPs' work satisfaction and workplace relationships, although research focused on work satisfaction and relationships in general is very common. Findings indicate that the social factors of work, that is, interaction, friendships, and emotional support, are even more important than autonomy task variety and the significance of work.15 Other studies show that social factors and the surrounding environment play an important role in work satisfaction.16 Chang12 concluded that, after investigating a sample of 400 nurses, good relationships lead to a sense of belonging and help to improve nurses' job satisfaction.
A correlation between motivation and work satisfaction has also been suggested. Altruistic motivations such as wanting to improve health care personnel interactions with patients or wanting to help in health professional education as well as more mundane motivations such as financial rewards or new acting opportunities can lead people to become an SP.17 However, Luthans18 argues that personal motivation should not be seen as the only justification for individual work behaviors, which are also derived from the surrounding social environment. Even though SPs are generally employed part time or hired by the hour, the need for social relationships at work does not change.19
Positive work satisfaction linked with good work relationships15 leads to positive work engagement. Schaufeli et al20 state that work engagement is a positive, affective-motivational state of fulfillment that is characterized by vigor (a willingness to invest effort in a job), dedication (a strong involvement in work), and absorption (characterized by time passing quickly). Engaged workers, be they full time, part time or hourly, work better because they are intrinsically motivated, are prepared to face new challenges, show prosocial behavior, process gathered facts better,20 and are recognized by their high-quality performance and high retention rate.21,22 High-quality performance and high retention rate are welcome in the training of medical professionals for both patient safety and budget reasons. The purpose of this research was to investigate SPs' current perspectives on workplace satisfaction, work-related relationships, and engagement in light of the current demands placed on SPs, focusing on the key elements of today's state-of-the-art requirements7,23,24 for being an SP. Knowing and understanding this perspective is important not only for SP trainers but also for SP coordinators because they are responsible for recruitment policy as well as SP welfare and hospitality.6 With this knowledge and understanding, SPs should get enough support to devote effort to achieving the SP program's objectives and remain with the organization.
The study was conducted using a qualitative research design to understand the reactions, values, and perceptions that underlie and influence SP behavior. Qualitative research focuses on answering “why and how” and explores “real-life” behavior, enabling research participants to speak for themselves.25 This leads to a broader understanding of the SP point of view, providing insight and information for practical implementation.26 To illuminate the research question of what makes SPs engaged, the methodological approach of Grounded Theory was used to provide a detailed, rigorous, and systematic method for data collection and analysis.
As workplace satisfaction and workplace relationships are very personal topics, semistructured individual in-depth interviews (IDIs)27 were conducted, allowing participants to feel comfortable and talk openly. Another advantage is that IDIs can be conducted in various places,28 including via the Internet,29 and can be more convenient and less threatening to interviewees.
To cover SP perspectives from more than 1 SP program, a total of 15 SPs from 8 different nursing and medical schools in Switzerland were asked to participate. This was arranged purposely because SPs in different programs may have divergent work-related norms, practices, and expectations.30 The participating schools are different locations and curricula and are autonomous. Each school has its own SP program, SP coordinator, and SP trainers. All schools conduct OSCEs and also have formative SP-student encounters, where SPs give oral feedback to students after the encounter. As any patterns emerging from the IDIs need to be confirmed or refuted by subsequent interview data, a purposeful sampling approach31 was chosen, using SPs who were knowledgeable and experienced and had the ability to communicate experiences and opinions in an articulate, expressive, and reflective manner. Initially, 10 SPs, 6 women and 4 men, aged 24 to 72 years with more than 1 year of SP experience participated. Four were certified actors, and 6 were lay people. Two were employed full time by their school; the others, by the hour. Through constant comparative analysis of data gained, theoretical sampling was used for a better understanding of the pattern that was evolving. Based on the need to collect more data to examine categories and their relationships, we conducted 5 more IDIs with SPs from the French-speaking part of Switzerland, 3 women and 2 men.
Topic Guide for Semistructured IDIs
The topic guide (Table 1) shows the key elements of SP practice as well as elements of the Utrecht Work Engagement Scale,20 a validated instrument that showed good internal consistency and test-retest reliability, and the Andrews and Withey Job Satisfaction Scale, which significantly correlated with job performance, organizational commitment, and turnover intentions.32 Both instruments served as guidance for the semistructured IDIs with the SPs. We chose these instruments because their content best matched the purpose of this study. The topic guide was open ended and therefore allowed respondents enough scope to talk about their opinions on a particular subject. The topic guide was piloted first, but few modifications were necessary after piloting. An experienced moderator led the 1-hour face-to-face, semistructured IDIs, each 1 hour, in the presence of an observer. It was important that the moderator and observer were independent and did not know the SPs. The topic guide encouraged discussion of SPs' experience in the many elements of their practice. The semistructured IDIs were audio recorded and transcribed by an external assistant.
The transcripts were then read line-by-line by 2 researchers and constantly compared while the data were collected. Data were compared with data, statements with statements, story with story, and incident with incident. This allowed early analytic insights and conceptual ideas to shape the subsequent data collection. Findings that were unanticipated or that might represent a compelling area for further exploration were followed up in the subsequent interviews, as recommended by Watling and Lingard.26
The transcripts of all 15 interviews were read line by line, to elicit “what's happening here.” This was important in order to become familiar with the ideas, patterns, and stories of early participants. Notes on ideas were made as they emerged from the data. The constant reading and comparing of the transcripts resulted in the establishment of initial codes or categories. Initial codes were defined, and inclusion and exclusion criteria were formulated. A second researcher independently confirmed the initial codes.
In a second cycle, the initial codes were reorganized and reanalyzed. Axial coding extended the analytic work from initial coding, determining which codes were dominant and which were less important, and the data were reorganized accordingly.33 Similarly, coded data were sorted and relabeled into conceptual categories. No qualitative coding software was used because of the small sample size of 15 IDIs.
According to the Swiss ethics committees on research involving humans, research studies reporting perceptions of employees do not require approval. Through a written informed consent, the study participants were made aware that the participation was voluntary, that they could freely choose to stop participation at any point in the study, and that their participation had no effect on their employment. The participants were assured that the interview transcriptions and the statements were anonymous.
The analyzed data encompassed statements collected from 15 interviews. The results are presented according to the themes in the topic guide for the semistructured interviews.
Being an SP
Altruistic reasons were the motivation most often cited for being an SP. The general opinion was that being an SP is an important job because it contributes so much to student outcomes, health care, and society. Standardized patients are confident that students can benefit from their work. They feel needed and think that they are important in students' clinical training. Some SPs have had negative personal experiences themselves with doctors and nurses, especially with respect to doctor-patient communication; by being SPs, they hope to contribute to better patient-nurse/doctor communication.
“Students can take something with them on their way to becoming (medical) professionals from my efforts as an SP. That's one of the most important things and gives me a good feeling.”
“One of my main motivations is that they get on with their patients as well as possible, that they and their patients feel comfortable.” (IDI 3)
Another SP motivator is learning about illnesses and diseases, which helps SPs in their own future medical consultations. Apart from this, being an SP is challenging, because encounters with students are not predictable. In addition, working with students who cannot cope with the method or do not take the learning opportunity seriously is difficult for SPs. They try hard to motivate students to take advantage of the opportunity provided by simulation and have difficulties to understand that some students reject this.
Standardized patients believe that their work is important for the professional development of health care students.
“There are some students who have trouble with this method. It's hard for me then. So I tell them that they can only benefit from these settings, and sometimes, that helps.” (IDI 2)
Therefore, in some cases, SPs believe they did not perform well, especially when students do not react as predictably as desired. In such situations, feedback from the SP trainer plays a key role in clarifying possible misunderstandings and providing an immediate and objective response to how the performance was perceived by students.
“For me, it is important to get feedback from the SP trainer in such situations because I'm uncertain then myself.” (IDI 5)
Feedback and performance feedback from the SP trainer are expected during the role play and feedback training as well as after the encounter. This allows SPs to reflect on their own performance and gain self-confidence and motivation for future tasks.
“Sometimes I don't get any feedback on my performance. That's hard for me because then I'm not sure if I did everything correctly.” (IDI 10)
For the role play training, the SPs expect the SP trainer to provide information about the illness they have to portray. Most of the SPs assume that the more information they have about the signs and symptoms they need to simulate, the better they can understand and identify with their role.
“I had to play a patient with a colostomy. Since I received no information from the SP trainer about why a person has to have a colostomy, I found it completely weird to imagine that someone had to have it. It affected me strongly, and I couldn't get into the role.” (IDI 4)
Information, feedback, and a sense of security seem to be motivators in workplace engagement. If these elements are correctly addressed and present throughout their work, SPs look forward to new inputs and challenges. The essential information needed contains symptoms and other characteristics of the disease or illness they have to portray, students' level of training, faculty they are cooperating with, and the educational goals of the training. Standardized patients are strongly involved in their work if they know the context in which they are performing.
Standardized patients appreciate working with the same SP trainer over a longer period. Doing so enables SPs to be more familiar with their trainer, which is perceived as a situation of less anxiety, security, and trust.
“I have known the SP trainer for a long time and am always glad to attend her training sessions. With every session, I learn something new, and she helps me if I don't understand the role or have problems with the feedback training.” (IDI 8)
“I am really looking forward to my next assignment because the SP trainer trains in a very appreciative way and mistakes are allowed.” (IDI 1)
A trusting, appreciative workplace relationship and environment, with an emphasis on feedback and security, not only helps the SP to handle growing requirements but also motivates them to invest effort in being an SP.
Standardized patients like to be treated with respect. They like to be called by their names and greeted by faculty and SP trainers. In some places, SPs receive special catering during their deployment, which is very much appreciated. A satisfying workplace relationship leads to involvement and commitment, accompanied by feelings of enthusiasm and significance. Longer hours and rising requirements do not affect SPs as long as they experience gratitude. Appreciation seems to be more important than pay. However, professional actors think they should earn more than laypersons. Some laypersons do not feel comfortable being trained with professional actors because it triggers feeling of inadequacy. In this case, a respectful and team-oriented attitude from the SP trainer is appreciated by the SPs, so all can concentrate on the training and feel satisfied.
A workplace relationship based on trust and confidence offers autonomy and responsibility. Standardized patients like to have autonomy, and some of them have good self-management. They have strategies for identifying with the role they have to play and develop their own debriefing concepts. Besides autonomy, more experienced SPs like to take responsibility for the progress of their own learning. Having autonomy and responsibility motivates the SPs to invest effort in their job and the persistence to face difficulties.
Standardized patients in general like assignments that take several hours because some SPs come from far away, and the expense (time and money) of traveling should be worthwhile. They like to have their work scheduled as early as possible, so they can plan the rest of their time. If they are not scheduled for a subsequent assignment, they feel insecure because they do not know why they were overlooked.
“I did not know why I was left out. Perhaps, I am too old, or I did not do my last assignment well enough… When I called the SP trainer, none of these reasons were confirmed; it made me feel safe.” (IDI 9)
The workplace environment does not have to be state-of-the-art, but it has to be clean and warm.
“When I put my head on the pillow it smelled. I could not concentrate on my task because the pillow smelled, even though it was a clean pillowcase…” (IDI 5)
“During an OSCE, most students forgot to cover me up with a blanket after their examination. I was freezing because the room was not heated enough; this was very unpleasant.” (IDI 4)
Trustful working climates help SPs to honestly and transparently communicate about issues that disturb them during their performance. The prerequisite is that the SP trainer and coordinator are prepared to listen and take SPs' concerns seriously to create a trustful working climate, increasing SPs' motivation, engagement, and satisfaction.
The purpose of this research was to investigate SPs' perspectives on workplace satisfaction, work-related relationships, and engagement in the light of current demands on SPs. Our analysis provided insight into SPs' apprehension of being an SP and how they perceive their associated assignments. Based on the IDI statements, SPs in general were satisfied with their workplace and work relationships. Standardized patients felt motivated, engaged, and willing to invest effort in their task and did not mind increasing demands as long as the social environment was supportive. This finding leads us to the previously mentioned concept of work engagement,20 which is a positive, motivational state of work-related well-being characterized by vigor, dedication, and absorption.20 These motivational performance indicators are described as intrinsic rather than extrinsic work motivations, that is, motivations from inside an individual rather than from external or outside rewards.20 Intrinsic and extrinsic motives may coexist and need not be antagonistic.34 In the concept of work engagement, intrinsic motivation is of major importance because its presence facilitates higher work satisfaction, engagement, and performance.35 This also corresponds with Herzberg's two-factor theory,36 based on the assumption that there are 2 sets of factors that influence motivation in the workplace: hygiene factors, which are extrinsic and linked to compensation, working conditions, and so on, as well as motivators, which are linked to the intrinsic motivation of the job itself, including recognition, achievement, and opportunities for growth.
This investigation shows that SPs have a strong desire for recognition for performing successfully, ideally through feedback from the people they work for. Feedback enables individuals to develop intrinsic motivation and interest and is assumed to support feelings of competence.37 In addition, further attributes of feedback are concentrated on error correction and achievement change and have motivational effects.37 Instruments8–10 exist, which enable high-quality feedback to the SP. Therefore, to promote SP development, institutionalizing SP performance feedback in SP programs is recommended, thereby increasing both quality and the opportunity to learn and develop. Standardized patients can also take responsibility for their own development process by writing their own SP portfolio.
As the results showed, SPs are motivated to cope with demanding tasks provided that the SP trainer supports them in an encouraging way. Positive interventions can increase positive emotions and engagement, which enable SPs to advance to a higher level of performance. However, these increases are temporary rather than permanent.20 To keep SPs challenged and engaged, some SP programs offer advanced training, such as bringing more theoretical communication models into their training.
Even for highly motivated SPs, trainers should remember that the often highly emotional nature of simulated patients' roles can affect SPs. Several authors38–40 report that although symptoms such as stress, exhaustion, and dissatisfaction are reported by SPs, they are moderate and short-lived.39 It is suggested that great care be taken in the selection of SPs and that monitoring and debriefing are essential. Experienced SPs have their own strategies for leaving the character they were playing by taking a shower, dancing, or just opening the window and breathing fresh air. Regardless of those strategies, the SP trainer should be present and have an open and trustworthy manner so SPs are able to get advice or help if needed.
Information is what SPs appreciate and desire. Information about the patient case and the illnesses and diseases they have to simulate helps SPs to become involved in their work. The knowledge gained has further consequences, as SPs believe their medical knowledge is improved, which leads to a change in the way they deal with their own symptoms.41 This impact makes SPs feel competent and appreciated, thus promoting more self-confidence and awareness.41
Altruistic reasons are another intrinsic motivator for SPs. “Altruistic” describes someone who is concerned for the welfare of another, without any ulterior motive.42 Standardized patients would like to help students to become good communicators and health professionals and, thus, to contribute to health care and society. However, there are also hidden motives for becoming an SP, such as negative experiences with the health care system or a personal crusade concerning the health professions.6 In this case, instead of altruistic reasons, the literature mentions psychological egoism,42 which could also be a motivator for being an SP. Psychological egoism refers to the thesis that we are always deep down motivated by what we perceive to be in our own self-interest; in other words, there is an ulterior motive when we help others, one that tends to fly below the radar of consciousness.42
Regardless of the motivation, the recruiting and selection of SPs must be done with great care.43 Enrolling SPs with a hidden agenda, for example, those who cannot cope with their own illness or have a negative attitude toward the medical profession, into a medical school database might lead to situations that could be damaging to students6 or to the SPs themselves. Good supervision and interpersonal skills on the part of the SP coordinator or SP trainer are essential in such cases to find a satisfactory solution for both parties.
Working hours were also a topic SPs addressed during the IDIs. Some SPs who travel a considerable distance to work and are not compensated for their travel expenses would like to have an assignment that takes more than just a couple of hours. It is recommended that SPs should not portray a given patient role for more than 7 student encounters a day, including a 30-minute break after a few encounters, to reduce SPs' load.39
Extrinsic motivation such as work relationship, security, salary, and work environment are important and support people's work satisfaction when in place,15 but once extrinsic motivators are satisfied, the effect soon wears off, as this type of satisfaction is only temporary. Therefore, it is important that institutions understand that people are not “motivated” by merely addressing those needs.
This investigation shows that the behaviors of SP trainer and SP coordinators are crucial for the well-being of the SPs. They should be familiar with concepts such as work engagement20 and the two-factor theory of motivation36 and have expertise in the domain of engaging and working with SPs. Training and program staff should also be knowledgeable about the needs of SPs, possess interpersonal skills, and have experience in the development and advancement of SP education and research in the health sciences. Based on the results of this study and the concepts mentioned earlier, we designed a nonstatic and context-adaptable SP-oriented working spreadsheet (SOWSS) (Table 2). This is meant to support SP trainers and SP coordinators in planning and organizing training events from an SP-centric point of view. It constitutes a good basis for setting up and maintaining SP programs and conducting SP training sessions.
This investigation aimed to access the personal perceptions and motivations of SPs and is restricted by the following limitations. First, the research was conducted in Switzerland. Although cultural differences were addressed by investigating SPs from different institutions and parts of Switzerland (German and French speaking), the perceptions of the SPs interviewed may not be an accurate representation of the whole profession.
The question also arises whether a sample size of 15 SPs was sufficient or if a bigger sample would have resulted in different findings. Further studies should be conducted in various institutions and countries to determine if different cultures have different motivators for workplace satisfaction, work engagement, and work relationships.
Standardized patients manage their tasks and current requirements well when certain intrinsic and extrinsic motivators are considered. Therefore, SP programs and their management require concepts in which SPs' perspectives, particularly their motivations, have been considered.
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