Simulated patients (SPs) (also referred to as simulated participants or standardized patients) are well individuals who portray human roles (patient, family, learners, healthcare professionals, confederates) in education and assessments of health professionals and students.1–4 Simulated patients have become increasingly involved in health professional education programs in recent years.1,4,5 The benefits to simulation-based education (SBE) are well established,6–9 and high-quality evidence supporting SP involvement in health professional education is available.10–12
The scope of practice of SPs who portray patient roles is increasing in complexity.13 This can include working in scenarios that require learners to practice basic clinical skills (eg, vital signs, physical examination), participation in hybrid simulations where the SP is aligned with a task trainer for procedural skills development (eg, urinary catheterization, intramuscular injection) or exploration of complex multisystem clinical histories. Furthermore, SPs may be required to achieve varying levels of “standardization” in portrayal, portray similarly over many repetitions, seize opportunities to respond “in the moment,”14 or share their experiences with learners after the scenario via “in-person” feedback or written feedback in rating forms.
It is known that SPs themselves are significantly impacted by their work.15,16 Simulated patients typically enjoy their work and personally benefit from it (increased confidence, empowered in personal health-related behaviors).17–22 However, SPs also experience unwanted negative impacts of their work, such as anxiety, shame, pain and discomfort from palpation, sustained postures or concentration, psychological disturbances, fatigue, and irritability.15,16,23 Researchers have explored the impacts of portraying roles with SPs in attempts to provide resources and knowledge for educators to minimize unwanted impacts.16,21,23 Schlegel et al24 investigated SPs perspectives on work satisfaction and concluded that if educators considered SPs' perspectives, and in particular, their motivations, SPs were generally satisfied. A checklist was developed by the researchers for educators to use when organizing SP interactions, and training sessions were developed that outline examples of practices that might support SPs (eg, create an appreciative atmosphere, write down a development plan for every SP).24 Informed by focus groups with SPs exploring the impacts of portraying patient roles, Bokken et al16 suggested that educators conduct more frequent training, give regular breaks, and vary role assignment.
Standards for practice13,25 and practical guides1,5 have also been published in recent years that aim to support educators in operationalizing safe, effective, and sustainable SP programs. However, although expert educators have been consulted in the development of these publications, the perspectives of SPs (despite being key stakeholders) are less prominent.26 One of these publications, the Association of Standardized Patient Educators (ASPE) Standards of Best Practice (SOBP) for SP educators13 may have represented SPs' perspectives, given Bokken et al16 and Schlegel et al24 were published some years prior, and because some educators have also been SPs in their own career trajectory. Feedback from SPs may also have been incorporated into individual SP programs via quality assurance projects. However, a gap in SP methodology literature still exists relating to SPs' direct perspectives and experiences of the ways to best operationalize SP programs. Direct exploration of SPs' perspectives on their practice might enhance the safety and effectiveness of SBE programs and could inform practice guides. Therefore, the research question for this study was “what are the practices, experiences and perspectives of SPs who work in health professional education?”
This study was underpinned by an interpretivist research paradigm.27 Specifically, we contend that SPs have constructed knowledge about their experiences through social interaction with others (SPs, educators, students, and others) that this knowledge is subjective in nature, and multiple interpretations of realities might exist among SPs. Therefore, an inductive qualitative approach was chosen, aligning with interpretivism and enabling exploration of SP practice that is driven by SPs and co-constructed by the researchers.28
Our research team was comprised of 1 male (S.A.P.) and 4 females (J.K., F.B., T.D., and D.N.). The primary researcher (S.A.P.) is a physiotherapist and health professional educator who also has experience as a simulation educator, as a SP, and as a learner in SP-based education. Before this study, SAP had limited experience in qualitative research methods. T.D. trained and worked as an osteopath but has more recently worked in health professional education including direct involvement in SP programs, and has experience in qualitative research methods. J.K. has a physiotherapy background and more than 30 years of experience in health professions education and research and has experience in qualitative research methods. F.B. has a physiotherapy background and more than 15 years of experience in health professions education and research, including direct involvement and leadership of SP programs. F.B. has experience in qualitative research methods. D.N. has a sociology background and more than 30 years of experience in health professions education and research, including direct involvement in and leadership of SP programs. D.N. has considerable experience in qualitative research methods.
Reflexivity refers to the identification of researchers' beliefs and assumptions, and acknowledgement of researchers' relationships to a topic and participants, in the process of conducting qualitative research.29,30 Consideration of these influences on research findings must occur in all stages of the qualitative research process.30 Relevant considerations for this research are described in each subsection.
Participants and Sampling
We approached SP program administrators from 2 SP program databases in Victoria, Australia, to seek expressions of interest from SPs to participate. Simulated patients' programs local to the research team were approached to enable face-to-face focus groups that were logistically feasible.
An e-mail containing study information and rationale, an explanatory statement and consent form, information about the researchers, and an online survey that captured participation interest and demographic information (age, sex, experience as a SP, acting background, focus group availability) was sent to all potential participants by SAP, who had not had prior contact with SPs.
Purposive sampling31 informed the assignment of 18 of 45 respondents to 3 focus groups. These groups were broadly balanced for age, sex, domain of practice, years of SP experience, and acting background, in an attempt to enable heterogeneity across focus groups. Simulated patients opted to be paid or compensated with a gift voucher, equivalent to their usual payment rate (approximately US $75 – 3 hours at US $25 per hour).
Focus groups were chosen as a feasible means of bringing participants together to address the research question. Focus groups capture discussion about specific topics, interpretations of phenomena, and interaction between participants.32–34 The method seeks to enable rich data collection as participants explore topics in their own vocabulary and clarify and expand on their points of view with others.34,35
Focus groups were conducted in rooms familiar to the SPs at both universities, consistent with an interpretivist approach where data collection and knowledge generation might occur in the “natural environment” of the participants.27 A topic guide (Appendix 1) encouraged discussion about SPs' perspectives on their practice and included focused prompts for exploring nature of work as a SP, development of expertise, recruitment, training, portraying roles, feedback, implications of playing roles, and open prompts to elicit additional stories and topics of importance to SPs.1,2,36 Experienced facilitators led 3 focus groups (T.D. – 2, D.N. – 1) in the presence of SAP. Facilitator assignment to focus groups ensured that each facilitator had not previously worked with the SPs in their respective groups, to encourage open discussion. Facilitators periodically summarized their impression of the main points shared by participants throughout the focus groups to seek informal respondent validation. Focus groups were audio recorded using a digital voice recorder, then transcribed, and deidentified by an external agency before being checked for accuracy by S.A.P. Memo writing was performed by the facilitator (T.D. or D.N.) and observer (S.A.P.) of each focus group to capture immediate thoughts and reactions to what was discussed and encourage reflection on assumptions and presuppositions researchers were making about the data before analysis.
Inductive thematic analysis was conducted in the 6 phases as described by Braun and Clarke.28 Three researchers (S.A.P., T.D., D.N.) familiarized themselves with the data by independently reading and re-reading all transcripts multiple times (phase 1). S.A.P., T.D., and D.N. independently coded interesting features of the data in a systematic fashion, before collating codes into potential themes (phases 2 and 3). S.A.P., T.D., and D.N. then met to discuss and seek agreement on the codes and initial primary themes. Discussion, note taking, and reference to the memos written immediately after each focus group facilitated reflection and articulation of the researchers' underlying assumptions and highlighted the impacts that these might have on theme refinement. This team then reviewed the themes, whereby SAP re-read all transcripts to confirm illustrative quotes and nuances of conceptualization and articulation of 2 themes, and T.D. and D.N. completed the same process for 1 theme each (phases 4 and 5). S.A.P. then read all transcripts with the overall thematic map to confirm illustrative quotes, and through iterative e-mail and face-to-face discussion with T.D. and D.N., and refined the specifics of each theme and subtheme in preparation for report writing (phase 6). Research team members F.B. and J.K. were consulted for higher level discussion of themes, to check for negative and alternative cases, and for opinion on illustrative quotes matched to themes in this phase.
Institutional ethical approval was granted for the study (Monash University Human Research Ethics Committee Project Number CF12/1999-2012001095).
Of 18 participants, 11 were female and 7 were male. Ten (56%) had an acting background. Ages spanned between 21 and 75 years (mean = 44 years, median = 44 years). Simulated patients experience spanned 1 to 30 years (mean = 7 years, median = 5 years). Five had worked in 1 SP program; 13 had worked in 2 or more (median = 3 programs). Thirteen participants had worked with pre-registration students only; 5 had worked with both students and clinicians (no participants had worked with clinicians only). Eight had worked in medicine only, 1 in medicine and allied health, and 9 in medicine, nursing, and allied health.
In exploring the perspectives of SPs, 3 primary themes were identified that characterized different elements to SP practice. Theme 1, becoming and being a SP, broadly encompasses SP practice. Themes 2 and 3, preparing for a SP role and performing a SP role, relate to specific simulation scenarios. Illustrative quotes are embedded throughout the article as evidence illumination of each theme.
Theme 1: Becoming and Being a SP
Simulated patients shared their motivations for becoming and being a SP, their beliefs on what it means to identify as a SP, the attributes of SPs, and the impacts of being a SP.
Simulated patients became involved in health professional education through personal referral and advertisements. Desires for acting work, enjoyment, personal development (confidence building), and a sense of fulfillment and reward from contributing in a positive way to society motivates SPs.
I knew I kind of needed to up my confidence skills, so I saw it [SP work] as a confidence booster. That's how I got into it. (FG1)
I actually go home thinking that I've done something good and that I'm contributing to society more than what some people think just an actor does. (FG2)
Simulated patients believe that they are experts at their work and that all SPs should be committed to taking their work seriously. Simulated patients believe that they hold a unique and professional role in health professional education. Simultaneously, they seek to authentically stand as a proxy for health care seekers, consider educational principles informing student learning, and feel responsible for assessing aspects of students' competencies to practice (such as communication and empathy). Simulated patients believe that they portray the perspectives of health care seekers, which are different to those of health professionals. From SPs' perspective, the patient perspective is essential to student learning and assessment. However, SPs felt that educators may not seek the patient perspective from the SPs who see it as an important view to share.
We're sending doctors out into the community, they're going to be treating our children, this is not just play, it really isn't... I don't see it as an acting job... I owe it to them to give the best possible performance that I can do… do not underestimate what a simulated patient does. (FG1)
I have seen sometimes the examiners do a role play that was very awkward for everyone in the room, because it's become about the examiner's personality and wanting to model something which I, as a simulated patient, and in discussion with other sim patients afterwards would never do in that situation… it became a bit about the teacher showing their knowledge rather than giving an example of a useful simulated patient scenario. (FG2)
Attributes associated with high-quality SP practice included intelligence, time management, a willingness to undertake professional development, and professional skills, such as availability, punctuality, and commitment to preparation. Simulated patients believed that being “willing to respond emotionally” was important, an absence of which may preclude someone's suitability for this work. Prior acting training was not considered a prerequisite, although connections between actors were a referral source and motivation for SP practice.
I just think you have to be someone who's willing to respond emotionally … if I was sitting in that situation how's this making me actually feel, and let that come out in your eyes and your mannerisms, your body language. (FG1)
I know a number of simulated patients who don't have a lot of professional acting training who are very good at what they do. (FG3)
Simulated patients shared experiences of increased confidence to engage in healthcare as a result of their work. Conversely, SPs' physical health (musculoskeletal discomfort) and mental health (depressive mood, generalized anxiety, hypochondria) can be negatively impacted as a result of their practice. The content of the scenario most significantly influenced the nature and intensity of the impact. Scenarios that were similar to a SP's own personal life tended to have more lasting and significant impact.
I've found it's helped me to become a far more assertive patient in my own life and advocating for my kids… it just gives you confidence with your health. (FG3)
I did depression so well that I actually ended up at a myotherapist. I thought it was because I was running. She said, “what do you do for a job” and I'm like “oh, no, that wouldn't be it” and then I realized I'd sat hunched like this [stooped] for 8 hours of the day. (FG1)
Theme 2: Preparing for a SP Role
Developing the Character
Upon receiving a written role, SPs adapt information into a “character” with a “backstory” (personality traits, history, and emotional tendencies) before considering other scenario specific information detailing why the character is in the simulation. Facilitators of character development include receiving detailed information in a clear, easy to follow and sensible structure, having sufficient time to consider the role, previous experience from a similar real life or simulated scenario, and discussions with other SPs and educators. Barriers to character development include excessive medical information and jargon, and “confidential” roles that are not able to be provided to SPs until the day of the simulation.
Participant: You develop a back story. You create a character.
Participant: Who are you and what's happening?
Participant: Who, why, where, when, whatever.
Participant: You give them a character, and then I've got a whole list of date of birth, sex, marital status, favorite color, favorite food, are you allergic to anything, everything, horoscope, favorite movie, what kind of animal are you? (FG3)
Sometimes the writers of the cases have their medical context, and the language just does not ring true. (FG2)
Understanding the Learning Context
Simulated patients seek to understand the learning context and situation in which the character is located. Knowing the desired student learning outcomes, expected competencies of students, and logistical arrangements for the session or examination enables SPs to adapt the character's motivations and passions to the learning context. Understanding the learning context also enables SPs to provide feedback to learners and examiners about their experience.
It's really helped me when I've read the instructions for candidates. You see “oh, they've got that much of the information, I've got some of that information and not more”… you don't want to give them information that we're not supposed to give them, but sometimes it can clarify why they ask the first question they ask. (FG2)
It's all about context, what are they learning and why and how long do they have… sometimes you can do a lot and sometimes you can't do a lot. (FG2)
Considering the Health Issue
Finally, SPs deeply consider the health issue that their character is experiencing in this learning context. Simulated patients acknowledge that their own experiences might not be relevant to the health issue; the desired portrayal is clarified and tailored through viewing demonstrations, discussion, rehearsal and feedback, and personal research. Educators' guidance to SPs on considered health issues was described as helpful at times and unhelpful at other times.
It's similar to being an actor with a director, so they can look at literally what you're doing, give you quality time, one on one, bit to the left, bit the right, whatever it is and tweak it until you get it right, until you feel really comfortable with it. And we go away and just get so familiar with that that we can just step back into it once we're in costume and tubed up. (FG3)
I found it helpful having a video, except the role play was played by a doctor who wasn't a very good actor so it was very sterile… doing your own research is what being a good sim patient is all about… if you're doing your job properly you'll actually go and seek it out. (FG1)
Theme 3: Performing a SP Role
Getting Into Character
“Getting into character” occurs immediately before the portrayal is required and in the initial performances. Activities such as rehearsals, discussions with educators, reflecting on personal life experiences, receiving feedback from educators, adopting postures of the role, and using props (glasses, scarf, dressing) support SPs in their readiness for performing a SP role. Simulated patients continue to get into character as they start performing, at times influenced by the performance of the student.
Last year in the women's health ones, I was 16 which is kind of close to my age, so I feel I can relate to what she was going through a lot more and get into the role easier. (FG3)
They [the student] regurgitated from the book the worst case scenarios. I found it easier to get into the zone when they were saying that because I was like “oh my goodness, if someone was saying that to me I don't think I'd be able to cope with that.” (FG1)
Simulated patients shared experiences of feeling unprepared for the simulation. Despite being described as a helpful activity in preparing a role, formal training and preparatory activities are inconsistently provided. Simulated patients reported not knowing important aspects of a scenario and not knowing where to seek help to clarify them. Simulated patients' strategies for dealing with unpreparedness included discussions with other SPs about their concerns and questions, and seeking feedback from educators. Simulated patients also shared instances of needing to continue to perform despite feeling unprepared.
I think the worst thing that can happen is not knowing an important aspect of the case, but even worse than that is not being able to find out about it… I've disgraced myself a few times by wanting some pivotal information but being unable to get it and being told that it would be dealt with on the day during the training. Well the training is 20 minutes during which the examiners are briefed. (FG3)
When we come back for the first tea break we're all saying ‘this person asked this and that wasn't expected, what did you do? Did you have something like that?’… so we actually learn from each other. (FG2)
Navigating Challenges and Constraints
Short duration examinations and restrictive performance instructions are constraints that limit SPs' ability to perform as a patient would. The high cognitive and energy demand of some performances, prescriptive influence of educators, nonbelievable environments, and safety concerns are challenges that can make performance difficult. Preparing well and drawing from acting skills were strategies offered by SPs to navigate the challenges.
If it was said to me in a normal setting I would not have reacted well to it… but you think ‘it's not part of my role, it actually said you are not emotional’ and it's like there's no way in a real setting I would not be emotional at this stage and react… you just know that you can't. (FG2)
It's being in character when you present and being prepared to work off the script, listening is so important, you're in the moment constantly that's why it requires an enormous amount of energy. (FG3)
Getting out of Character
Simulated patients finish their performance by actively “getting out of character” as a strategy for minimizing the negative impacts of performing a SP role. Strategies to reconnect with aspects of their own lives included leaving the simulated environment, debriefing, humor, and offering mutual support to other SPs.
I had to debrief with somebody, I had to debrief with people afterwards before I could actually drop the character, because there were lots of different levels and emotional, spiritual and psychological experiences going on inside. (FG3)
I walk out of the building, take a deep breath and call somebody. (FG1)
This study explored the experiences, perspectives, and practices of SPs, to enable the development of SP practice guidelines that are informed by SPs themselves. Analysis demonstrated that SPs have deep beliefs about their work and perspectives on helpful and unhelpful behaviors across the following 3 dominant themes of their practice: becoming and being a SP, preparing a SP role, and performing a SP role.
This is the first study, to our knowledge, that provides insight into SPs' perspective on their identities within health professions SBE. It may be surprising to some educators the extent to which SPs' feel responsible for assessing a learner's readiness to practice (historically an educator role), in addition to representing an authentic patient perspective. These dual identities seem worthy of reflection and discussion by educators at an individual program level to ensure shared understanding of roles and responsibilities.37 Furthermore, SPs' experiences of educators having good intentions to support SPs (ie, including SPs in teaching and facilitating preparation activities) but not understanding their preferences (eg, “I would never do that” – FG2) are also new, and worthy of reflective consideration by SP educators at a program level to ensure that the authentic patient perspective is included in the design of teaching activities.
The language used by educators involved in SP methodology is complex, yet important to consider, given that differences are observed geographically1 and that SPs are real people and not objects.37 Although only just over half of the SPs involved in this study (10/18) reported prior formal acting training, terminology inspired by the performing arts characterized the discussions. A case, or scenario, represented the outline or summary of the simulation interaction and the patient information provided to a SP. A character was the person that the SPs adapted the case information into, to enable learning of the role. A script was referred to by some SPs. Our choice to word the primary themes of preparing for a SP role and performing a SP role was deliberate and based on the language of SPs in this study. Simulated patient program practice guides refer to “training” SPs for a role1,13; SPs typically used “training” to represent the specific activities that are led by educators to assist them in preparing for a role. Several other activities that do not form part of formal “training” were also reported by SPs to contribute significantly to preparing for a SP role. Therefore, “preparing” was chosen as a more representative word. “Portrayal” of a SP role is also a common word that can describe what SPs do in simulations. Simulated patients in this study tended to describe what they do as “performances.” Simulated patients' use of the word performance seemed to represent the complexity of skills that are needed to enable it, including improvisation, memory and recall of “scripts,” emotional availability, physical adaptation of postures, and movements. Our experience as SP educators and scholars is that SPs are also commonly referred to as “actors.” In contrast, what SPs do in simulations represents many aspects that are not associated with theatrical acting, including understanding a learning context, providing feedback to students on their performances, and providing judgments on the suitability of students for independent practice.13 We encourage educators to embrace the complexity of skills practiced by SPs and adopt language that inspires and acknowledges these valuable contributions to health professional education.
Considering the SOBP
We referred readers to the ASPE SOBP13 in the introduction to this study and refer to it again to compare, contrast, and suggest points for consideration in future iterations that directly include SPs' perspectives.
Lewis et al13 contend that the scope of what actors do is different to what SPs do; achieving the objectives of a director and performing for an audience are different from achieving the objectives of an educational activity and serving learners. The SPs in this study aligned with these notions and added that they have objectives relating to representing an authentic patient perspective.
The SOBP recommends educators “screen SPs to ensure that they are appropriate for the role” (SOBP principle 1.1.3) but does not provide specific guidance for the recruitment of SPs into programs or for individual roles. Our results suggest that effective recruitment for individual roles is important to minimize the risk of negative impacts and to facilitate a high-quality portrayal. Ker et al,38 Cleland et al,1 and Pritchard et al39 provide further suggestions on how educators might effectively recruit and select SPs.
Case development for, and training of, SPs seems primarily educator driven in the SOBP, where educators are responsible for seeking subject matter experts and coordinating training activities. The involvement of SPs in case development (SOBP domain 2) might enable more effective resources and processes for SPs to prepare for and perform roles. For example, information for SPs that is presented in a clear structure (SOBP practice 2.2.5), where the person's character is outlined separate from their health issue, and the development of training resources that include video examples (SOBP practice 2.2.6) of real or simulated (where the SP is not an educator or clinician) patient interactions were suggested by SPs. Furthermore, confidentiality (SOBP principle 1.2) of role details until the day of the simulation was identified as a barrier to effective SP preparation and might be improved with the use of confidentiality agreements and earlier sharing of details.
The results of this study also affirm the need for the detailed training practices of Domain 3 to be implemented across SP programs. However, educators might not be aware of the preferences of SPs for training activities or the additional activities that SPs feel are necessary to complete outside of formal sessions to prepare them or to help them get out of character. The results of this study provide educators with practical examples of activities suggested by SPs (see subthemes 2.1, 2.3, 3.1, 3.2, 3.3, 3.4). Furthermore, the SPs in this study described attributes that they feel are required to perform a role well (subtheme 1.3), which could further inform SP recruitment and training activity design.
Considering the Health and Safety Concerns of SPs
The results of this study suggest that work health and safety concerns continue to exist for SPs. Simulated patients in this study reported pain and discomfort arising from adopting abnormal physical postures, and prolonged stress, anxiety, and depressive moods from portraying emotionally demanding and traumatic roles. These experiences were unintended consequences of performing authentic roles. Though not new knowledge,15,16,23,39 our experience of presenting this work at national and international conferences is that some educators remain surprised and concerned at their incidence. Furthermore, given that knowledge about negative impacts spans more than 20 years,23 it is surprising that the SPs in this study still reported significant preventable negative impacts. It may be that with the proliferation of SP programs globally, there may be educators in the broader SP community who are unaware of the strategies that have been suggested by other authors.13,15,16,23
Considering Communities of Practice Theory
The “social aspect of being a SP” is considered an enjoyable aspect of this work,1 and it has been suggested that SPs represent a community of practice (CoP).40 Although the theory was not used a priori as a sensitizing concept for thematic analysis, we identified during manuscript preparation that our final themes relate to the theoretical notion of SPs as a CoP. Therefore, we have applied this theory post hoc to help interpret these data and generalize findings beyond our immediate setting.41 Wenger42 defines a CoP as a group of people who are unified by their practice, and having the features of mutual engagement (connections that exist between members and are necessary for practice), joint enterprise (a shared purpose negotiated by members), and a shared repertoire (resources for negotiating meaning; routines, words, tools, skills). These features were considered as a framework through which further meaning might be elicited. S.A.P. and D.N. assigned the themes, subthemes, discussion points, and illustrative quotes to features of a CoP (Table 1).
Mutual engagement of SPs was identified in each theme of SP practice; it was a vessel for SPs to begin engaging in this work (personal referral) and a positive factor prior, during, and after performing SP roles. Mutual engagement was the dominant strategy by which SPs navigate unpreparedness and minimize negative impacts of a role. Providing SPs opportunities to engage with each other in all aspects of their practice seems to be helpful for SPs.
Considering the feature of joint enterprise enables a view of SP work as a much richer activity than “an acting job.” Examples of SPs considering the learning context, seeking to be professional in what they do, and being motivated by altruistic desires to grow the healthcare workforce, reinforce the notion that SPs are co-educators who work with educators, rather than actors who are tools to be “used” by educators in their practice.4,13
Examples of a shared repertoire that has been developed and adapted by SPs enable a view of the many things that SPs do, to do their job well. These insights might be considered by educators in designing programs that are supportive of SPs. The chronological steps by which SPs prepare for, and then perform, a SP role might stand as a framework for the design of training, briefing, and debriefing activities for SPs. These practices give some practical examples for the standards of best practice for SP educators.13
Acknowledging and Valuing the Community of Practice of SPs
Considering the results from this study within the framework of a community of practice offers practical and insightful direction for educators on the complexity of SP practice.
Simulated patients' work seems to bring SPs together, characterizing a CoP defined as a group of people unified by their practice. However, the leadership that educators have within SP programs seems to have contributed to this community working at times in isolation, rather than as a collaborative and valued part of a SP program. Simulated patients are dependent on educators for work. However, educators are responsible for providing opportunities (eg, demonstrations, feedback, being available for discussion, providing detailed information about the role, learning outcomes, and competencies of students) for SPs to prepare for and perform a SP role (shared repertoire) and are the source of some of the barriers to SPs doing their work well (providing excessive medical information, poor demonstrations, and confidential roles).
Simulated patients' completion of independent research to support their preparation and impromptu support of each other after performances are 2 examples of ways that this CoP has overcome challenges associated with their dependence on SP educators (mutual engagement). The primary outcome of this tension in power is the impedance of SPs' mandate (joint enterprise) to authentically portray patient perspectives, for the benefit of health professional education. Given that SPs are dependent on educators for ongoing work opportunities, they might be reluctant to share feedback about their perspective and experience. We encourage educators working with SPs to reflectively consider their own practices that might enable or be a barrier to high-quality SP practice and consider the helpful practices identified by SPs that might enable high-quality SP practice.
Strengths and Limitations
The sampling strategy and analysis method are strengths of this study, as they enabled exploration of SP practices from the perspective of SPs with various backgrounds. The standards of reporting a qualitative research report43 informed report writing. A limitation may be that SPs were recruited from only 1 geographical area (Victoria, Australia). However, our findings were consistent with those articulated by articles published internationally, which strengthens confidence in transferability. Time-limited focus groups and a topic guide may have limited the amount and content of what participants shared. However, the open nature of the focus groups was successful in capturing the stories and experiences of SPs. We sought to investigate the factors SPs identify as important to various aspects of their work and this was achieved.
Simulated patients consider 3 primary aspects of practice and identified ways in which educators might develop supportive and high-quality programs. Simulated patients' practice aligns with the features of a community of practice, and implementation of communities of practice frameworks could benefit SPs in their work. Consultation with SPs throughout all elements of their work may lead to greater support of SPs in their practice and higher-quality educational experiences for learners.
1. Cleland JA, Abe L, Rethans J. The use of simulated patients in medical education: AMEE Guide No 42. Med Teach
2. Nestel D, Bearman M. Introduction to simulated patient methodology. In: Nestel D, Bearman M, eds. Simulated Patient Methodology: Theory, Evidence, and Practice
. Sussex: John Wiley & Sons Ltd; 2015.
3. Wind LA, Van Dalen J, Muijtjens AM, et al. Assessing simulated patients in an educational setting: the MaSP (Maastricht Assessment of Simulated Patients). Med Educ
4. Nestel D, McNaughton N, Smith C, et al. Values and value in simulated participant methodology: a global perspective on contemporary practices. Med Teach
5. Motola I, Devine LA, Chung HS, et al. Simulation in healthcare education: a best evidence practical guide. AMEE Guide No. 82. Med Teach
6. Dreifuerst KT. The essentials of debriefing in simulation learning: a concept analysis. Nurs Educ Perspect
7. Gaba D. The future vision of simulation in healthcare. Simul Healthc
8. Lasater K. High-fidelity simulation and the development of clinical judgement: students' experiences. J Nurs Educ
9. Nestel D, Groom J, Eikeland-Husebø S, et al. Simulation for learning and teaching procedural skills: the state of the science. Simul Healthc
10. Cook DA, Hatala R, Brydges R, et al. Technology-enhanced simulation for health professions education: a systematic review and meta-analysis. JAMA
11. Cook DA, Brydges R, Hamstra SJ, et al. Comparative effectiveness of technology-enhanced simulation versus other instructional methods: a systematic review and meta-analysis. Simul Healthc
12. McGaghie WC, Issenberg SB, Cohen ER, Barsuk JH, Wayne DB. Does simulated-based medical education with deliberate practice yield better results than traditional clinical education? A meta-analytic comparative review of the evidence. Acad Med
13. Lewis K, Bohnert CA, Gammon WL, et al. The Association of Standardized Patient Educators (ASPE) Standards of Best Practice (SOBP). Adv Simul (Lond)
14. Newlin-Canzone ET, Scerbo MW, Gliva-McConvey G, et al. The cognitive demands of standardized patients: understanding limitations in attention and working memory with the decoding of nonverbal behavior during improvisations. Simul Healthc
15. Plaksin J, Nicholson J, Kundrod S, et al. The benefits and risks of being a standardized patient: a narrative review of the literature. Patient
16. Bokken L, Van Dalen J, Rethans J. The impact of simulation on people who act as simulated patients: a focus group study. Med Educ
17. Abe K, Roter D, Erby LH, et al. A nationwide survey of standardized patients: who they are, what they do, and how they experience their work. Patient Educ Couns
18. Woodward CA, Gliva-McConvey G. The effect of simulating on standardized patients. Acad Med
19. Simmenroth-Nayda A, Marx G, Lorkowski T, et al. Working as simulated patient has effects on real patient life – preliminary insights from a qualitative study. GMS J Med Educ
20. Wallach PM, Elnick M, Bognar B, et al. Standardized patients' perceptions about their own health care. Teach Learn Med
21. Boerjan M, Boone F, Anthierens S, et al. The impact of repeated simulation on health and healthcare perceptions of simulated patients. Patient Educ Couns
22. Block L, Brenner J, Conigliaro J, et al. Perceptions of a longitudinal standardized patient experience by standardized patients, medical students, and faculty. Med Educ Online
23. McNaughton N, Tiberius R, Hodges B. Effects of portraying psychologically and emotionally complex standardized patient roles. Teach Learn Med
24. Schlegel C, Bonvin R, Rethans J, van der Vleuten C. Standardized patients' perspectives on workplace satisfaction and work-related relationships. Simul Healthc
25. Association for Simulated Practice in Healthcare (ASPiH). Purva M, ed. In: Simulation-Based Education in Healthcare - Standards Framework and Guidance
. UK: Association for Simulated Practice in Healthcare (ASPiH); 2017.
26. Nestel D, Roche J, Battista A. Creating a quality improvement culture in standardized/simulated patient methodology: the role of professional societies. Adv Simul (Lond)
27. Bunniss S, Kelly DR. Research paradigms in medical education research. Med Educ
28. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol
29. Flick U. An Introduction to Qualitative Research
. 5th ed. London, UK: SAGE Publications Ltd; 2014.
30. Ramani S, Könings KD, Mann K, et al. A guide to reflexivity for qualitative researchers in education. Acad Med
31. Patton M. Qualitative Evaluation and Research Methods
. Beverly Hills, CA: Sage; 1990.
32. Kitzinger J. The methodology of focus groups: the importance of interaction between research participants. Sociol Health Illn
33. Nestel D, Ivokovic A, Hill RA, et al. Benefits and challenges of focus groups in the evaluation of a new Graduate Entry Medical Programme. Assess Eval High Educ
34. Pope C, Mays M. Qualitative Research in Health Care
. Carlton: Blackwell Publishing; 2006.
35. Liamputtong P, Ezzy D. Qualitative Research Methods
. Melbourne: Oxford University Press; 2005.
36. Howley LD, Gliva-McConvey G, Thornton J. Standardized patient practices: initial report on the survey of US and Canadian medical schools. Med Educ Online
37. Nestel D, Clark S, Tabak D, et al. Defining responsibilities of simulated patients in medical education. Simul Healthc
38. Ker JS, Dowie A, Dowell J, et al. Twelve tips for developing and maintaining a simulated patient bank. Med Teach
39. Pritchard SA, Blackstock FC, Keating JL, et al. The pillars of well-constructed simulated patient programs: a qualitative study with experienced educators. Med Teach
40. Nestel D, Burn CL, Pritchard SA, et al. The use of simulated patients in medical education: guide supplement 42.1—viewpoint. Med Teach
41. Rees CE, Monrouxe LV. Theory in medical education research: how do we get there? Med Educ
42. Wenger E, Communities of Practice. In: Brown JS, ed. Learning in Doing: Social, Cognitive and Computational Perspectives
. New York, NY: Cambridge University Press; 1998.
43. O'Brien BC, Harris IB, Beckman TJ, et al. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med
Appendix 1 – focus groups topic guide
We’re interested in understanding your perspective, and what you think about what you do.
- Context / nature of work as SP
Development of expertise
- How long have you worked as a SP?
- Howmany days each year do you work as a SP?
- What types of learners have you worked with?
- In what contexts have you worked (teaching, examinations)
- How did you start SP work?
Perspectives on practice
- 6. How have you come to develop expertise as a SP?
Implications of playing roles
- 7. What are your experiences of SP training?
- 8. What training have you found helpful? Why’s that?
- 9. What training have you not found helpful? Why not?
- 10. What specific skills do you require for SP work?
- 11. If you were training someone to portray a SP role, what do you think would be important?
- 12. What resources have you found effective for this?
- 13. What are your experiences of portraying SP roles?
- 14. What things help you engage with the role?
Perspectives on feedback
- 15. What do you get out of this work?
- 16. Has anything changed as a result of you working as a SP?
- 17. What are your experiences of providing feedback as a SP?
- 18. What do you find hard about feedback? Easy?
Facilitator to provide short recap of key points, seek clarification
- 19. What are some of the most powerful experiences you’ve had as a SP?
- 20. Anything else you’d like to share?