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Concepts and Commentary

Engaging Children as Simulated Patients in Healthcare Education

Budd, Natasha PhD; Andersen, Patrea PhD; Harrison, Penny BA; Prowse, Nycole PhD

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Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare: June 2020 - Volume 15 - Issue 3 - p 199-204
doi: 10.1097/SIH.0000000000000452
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The value of simulation-based education (SBE) in healthcare is well established.1–3 Although definitions of what constitutes “simulation”4 vary, there is a clear recognition by academics and health professionals of the need for SBE, where students learn by doing and reflecting on their experience. Essential to SBE is the role of the simulated patient (SP). The term SP is defined in the Healthcare Simulation Dictionary as “a person who has been carefully coached to simulate an actual patient … the history, body language, the physical findings, and the emotional and personality characteristics.”4 Recent research2,5–7 has drawn attention to the role of SPs, asserting their effectiveness in creating realistic clinical experiences.

In middle childhood, between the ages of 6 and 12 years, children have an increasing desire to act independently and make decisions relating to their everyday life. When children access healthcare services, healthcare professionals must negotiate care with both the child patient and their parent/guardian. The complex care relating to middle childhood patients is rarely practiced in the simulation suite, and yet, it has been found to be of significant benefit for nursing students who must learn to meet the needs of both the middle childhood patients and their families.8 Simulation with middle childhood SPs allows the key pediatric-based principles of family and child-centered care to be trialed in a safe learning environment. This is significant as pediatric simulations generally emphasize interactions with parents but neglect interaction with the child patient.5

Simulated patients afford unique opportunities for the development of “soft skills,” including critical thinking, problem solving, and patient–healthcare professional communication. Child SPs are well positioned to offer perspectives that provide a nuanced focus on the healthcare needs of children.5,9 Despite the specific needs of children, instances of simulations using child SPs are limited. A potential reason for this is the range of challenges posed by engaging children in SBE, including ethical and practical considerations.10 These are significant challenges that demand attention if children are to receive equitable care in the healthcare system. In arguing for further research to support more widespread inclusion of child SPs in education and training, this article will first review the evidence for child-focused simulations, discuss the benefits for learners and longer-term benefits for child patients, and conclude by identifying some ethical and practical considerations and guidelines. It offers commentary on current SBE and puts forward a case for engaging middle childhood child SPs in this rapidly growing area of healthcare education. In addition, it highlights the need for further research in the area, so healthcare professionals can better meet the specialist needs of middle childhood care.11

The Benefits of Child Focused Simulation for Learners: A Review of the Evidence

Bogo et al12 provide a scoping review of simulation and child welfare training, pointing to a wide array of literature that evaluates an increasing volume of SBE to prepare health practitioners. They argue that simulation is an effective method for delivering complex information in training child welfare workers for challenging interpersonal situations.12 Bogo et al12 find, however, an overall paucity of empirical evidence concerning child simulation training methods. In their work on pediatric emergency training programs, Cheng et al13 call for more nuanced research on simulation-based training in child healthcare. They state a need for the development, integration, and evaluation of a simulation-based, acute care curriculum into pediatric emergency training programs, and conclude that further research is needed to assess educational outcomes related to nuanced and unique learning strategies. More broadly, Sarver et al15 identify the need for and importance of further developing pediatric simulation training in nursing education.14 Healthcare provision in the outpatient setting is increasing. This confounds that the already challenging task healthcare educators have in providing learners with pediatric learning experiences; thus, Sarver et al14 call for a more focused use of simulation to provide realistic alternatives to pediatric clinical experiences.

The studies detailed previously reveal a growing demand for simulation methods that involve child SPs and acknowledge the overwhelming potential of such methods. A key factor in the growing interest in SP simulation generally is its capacity to increase the complexity and fidelity of simulation activities. Increased complexity and fidelity in SBE create rich learning environments that offer deep and sustained knowledge acquisition.6,9,15,16 Moule et al16 conducted a 2-phase study examining the experiences of both students and mentors and found that SBE afforded broader learning opportunities than the clinical environment. In particular, the use of simulation enabled students to rehearse and receive feedback on a range of clinical skills before consolidation in clinical practice.16 Furthermore, Moule et al16 affirm the collaborative potential of simulation “between higher education providers and clinical staff” and its “scope for interdisciplinary and interprofessional development.” Focusing on nursing students' experience of and reflection on clinical simulation, Nunes de Oliveira et al7 conclude that the use of SPs is critical to facilitating the integral training of students through experiential learning. This position is further supported by Arveklev et al's17 exploration of “nursing students' experiences of learning about nursing through drama,”—a study based on the premise that healthcare is grounded in universal humanistic values such as kindness, empathy, concern, and love for self and others—and Kaplonyn et al's6 emphasis on the impact of SPs on healthcare learners' communication skills.

The Gap in Child-Focused Education

Although a review of the evidence affirms the value of adult SPs in SBE, this article illuminates the valuable contribution child SPs can make and the current paucity of their inclusion. Studies by Crow18 and Fisher et al19 affirm the effectiveness of using SP simulations in creating “authentic” experiences for students in child health scenarios. Despite agreement on the benefits of children's inclusion, and persistent calls for their involvement in developing healthcare curricula,20 a gap remains in the area of SBE with child SPs. Although simulations using adult SPs in scenarios depicting adult health concerns are delivering strong outcomes,21 there are few recorded examples of child SPs being engaged to perform child specific roles. This omission reflects the marginal position of child-focused education in the health sector and highlights the need for research that addresses this marginalization.

Although sometimes seen as a specialist or postgraduate area, lifespan approaches to care are central to undergraduate education. This is addressed by Glasper and Richardson,22 who argue that studying adult care has traditionally been the priority in tertiary education institutions at the expense of child-centered care. Contemporary approaches to curriculum design seek to address a changing healthcare system by integrating broad learning competencies and using innovative teaching practices that prepare nurses for the varied environments they will encounter.23 While moving on from the more rigid focus on generic clinical skills, McNee et al24 identify that the specific requirements and care delivery needs of middle childhood children are not always highlighted in undergraduate training and remain secondary in the largely adult-centric curricula. For Moule,25 this partly reflects professional standards, which are generic and applicable to all areas of practice. Although newly graduated nurses can practice within the context of pediatric care, specialist preparation and qualifications remain in the postgraduate domain. The realities of caring for children and families, however, are markedly different from those of adult patients. Middle childhood patients have specific needs when they access healthcare services, whether in the community or within the acute care hospital model, and it is important for students to prepare and rehearse this complex layer of practice.26

The Benefits of Child-Focused Simulation for Patients: A Review of the Literature

Children, young people, and their families have the right to access quality healthcare and to have their opinions valued. Healthcare providers are required to acknowledge the importance of fostering partnerships between families and healthcare providers to ensure the best possible care for all patients.27 The involvement of middle childhood children in nurse training simulation assists this endeavor by creating a space for thoughtful engagement with child patients and their families; one in which children's needs are acknowledged and appropriately addressed.

Addressing children's needs can be challenging. Kim et al28 and Walsh et al29 both allude to key areas of concern with communication interaction in pediatric care, identifying healthcare providers' “fears” and “phobias” of specific child health issues. Randall and Hill20 report that undertaking research with children to better understand their experience of care can be an unpleasant experience for the child participants, “evoking hurtful memories and raising difficult issues.” Challenges exist from the perspective of both the healthcare provider and child client, which underlies the need for creative approaches. Experiential learning in the form of simulation with SPs provides an opportunity to play out areas of concern within a safe environment, with immediate feedback to the learner from the child SP.

The importance of providing an authentic child perspective is addressed in Randall and Hill's20 2012 study, which challenges commonly held assumptions about children's perceptions of the care they receive. For the child participants in this study, the priority was feeling safe in the hands of a competent professional who engages with them as people. Overly jovial and friendly approaches gave children a sense of unease and were, at times, viewed by the children as patronizing. This example highlights the importance of involving children in healthcare training. It underscores the disparity between intent and reception, and the need for skillful communication informed by the needs and perspectives of children. This approach to engagement engenders ethical and respectful communications with the middle childhood patient30 and fosters strong partnerships between healthcare workers, children and families.

Children's cultural context, language skills, cognitive development, emotional state, knowledge, and confidence in navigating the healthcare environment all affect their ability to effectively communicate their needs and offer accurate medical information to healthcare professionals.25 The healthcare professional's understanding of these complexities and their level of interpersonal communication with the child patient can significantly impact both the effective delivery of medical care, and the child's experience of that care. Addressing middle childhood patient's needs in the healthcare system, therefore, demands a range of skills beyond clinical proficiency. The use of middle childhood SPs in SBE has the potential to play a key role in developing “soft skills” and embedding child-focused humanistic values into education that explicitly acknowledge children's needs in the healthcare system.6 Middle childhood SPs are uniquely positioned to offer enlightening and sometimes surprising learning opportunities in healthcare education by providing a child specific perspective of care. As Austin et al31 highlight, child SPs have the potential to bring an “air of authenticity” to simulations.

Simulation-based education with middle childhood SPs could be far reaching in its capacity to influence lifelong healthcare practice. The educational possibilities of simulation provide opportunities for the development of essential understandings of children and their experience of healthcare.31 They have implications beyond the context of pediatric care by focusing learners on whole families rather than individual patients. This approach to simulation asks learners to consider children's needs within a broader care context.31 Examples of this include situations in which children are present who are not themselves the patient, such as when a sibling or the child of an adult patient visits the healthcare environment. This type of scenario supports students' awareness of children's central position as members of families and the need for them to be considered in various healthcare contexts. Such refocusing can occur within the process of immersive simulation, where the educator designing the program can create whole family scenarios, allowing learners to negotiate and support the whole family in planning, goal setting, and decision-making.32

The benefits of engaging child SPs extends beyond student learning to the SP experience. In a 2016 review of current literature, Plaksin et al33 conclude that “the benefits of being an SP [including a child SP] appear to outweigh the known risks.” In 1999, Lane et al34 reported that the parents of SPs identified “no negative effects on the children,” and in 2017, Fu et al35 reported that 90% of child SPs involved in their study “liked taking part” and would do so again. These studies suggest that if practical and ethical issues are well managed, child SPs and their families can find participation in SBE personally rewarding.

Addressing the Challenges of Working with Child SPS

Educators and healthcare professionals globally are grappling with the challenges of implementing child-focused SBE. Cultural, social, and legislative frameworks vary widely and result in differing approaches and practices. In each context, the inclusion of child SPs presents a myriad of practical and ethical challenges for organizers, learners, and children, leading some researchers to advocate for technology-based approaches such as virtual humans and other forms of artificial intelligence.36 This rejection of live SPs is not surprising given reports of child SPs being subject to long work hours with few breaks, limited opportunities for active involvement, and the use of coercive remuneration practices by some educational institutions.36 However, although new technologies may be effective as tools in teaching clinical competence, they lack the capacity to engage in complex and authentic interpersonal communications, particularly in terms of feedback to the learner post simulation. The challenges then must be addressed if “soft skills” including critical thinking, problem solving, and communication competency are to be taught alongside clinical skills.

In their 2017 study, Khoo et al36 asked a group of experts to “consider the ethical issues that arise when minors are asked to act as SPs in medical education.” Key issues identified were possible coercion by parents and organizers; negative psychological and emotional effects on the child; the risk of being hurt or traumatized; the potential for children to become bored and thus not maintain consistency; and a lack of appropriately trained SPs. Effective strategies for mitigating these risks were also offered, at the core of each was the welfare of the child. Mitigation strategies included participation of the SP's family; opportunities for the child to give feedback; the use of child advocates and chaperones; and perhaps most importantly, a requirement for both consent and assent.

An exemplar of these global concerns is the Australian context where SP research is being undertaken at the University of the Sunshine Coast (USC).37 In this research, children are subject to restricted work hours and employment conditions dictated by local and national legislation and policy (as an example, see Queensland Legislation Child Employment Act, 2006).38 Because of these restrictions, SBE takes place outside school hours and includes regular rest and food breaks. Beyond legislative requirements, well established processes drawn from the fields of community cultural development and youth arts are used to support children and their families.39 Such processes affect every aspect of the work from project design to recruitment strategies; SP training methods; simulation scheduling and delivery; and feedback and reflection mechanisms. Recruitment requires both child and guardian consent, and child-specific information and assent documentation are developed. Gaining guardian approval and informed consent from middle childhood SPs requires deep consideration of children's capacity to fully comprehend the scope and purpose of the simulation activity, including any future use of artifacts created in the process such as video and audio recordings. Additional time and expertise are required to care for children's physical and emotional well-being, and extra staff may be required to support children and their families, particularly those from culturally and linguistically diverse communities.

The additional demands placed on healthcare educators in child-focused education highlight the need for clearly defined principles and guidelines for engaging children in SBE; however, as Hilliard et al40 point out, there is minimal reference to children in medical school codes and guidelines. As a possible way forward, researchers have drawn analogies between SP participation in medical research and in educational settings and suggest that many of the same ethical issues apply.36,40,41 They propose that the ethics process undertaken by academic researchers might be applied to educators using child-focused SBE in their teaching. Hillard et al40 put forward a brief list of recommendations, while also pointing to the University of Oxford's guidelines for medical students examining children.

Findings from a 2014 investigation into children's participation in the performing arts39 were adapted and tested in a further study at the USC 2015-16, which investigated child-focused simulations in nursing education. One of the outcomes of the USC study was a set of guidelines for working with middle childhood SPs. The guidelines are intended for organizations engaged in the training of pediatric health care professionals and are designed to promote and facilitate SBE. They offer recommendations on working with children in simulation. The guidelines are premised on articles 12 and 24 of the United Nations Convention on the Rights of the Child.

Articles 12 and 24 of the United Nations Convention on the Rights of the Child

These 2 articles dictate children's involvement in issues of concern to them, in particular their involvement in healthcare education as it relates to the treatment of children (Table 1). The UN principles are embedded in the USC guidelines, which have been included here in truncated form.

Articles 12 and 24 of the United Nations Convention on the Rights of the Child

The guidelines are divided into 4 broad categories: safety and productive involvement; facilities and resources; recruitment and documentation; training, delivery, and feedback, and are included in Table 2.

Guidelines for Engaging Children as Simulated Patients

Guidelines for Engaging Children as Simulated Patients

The guidelines are adapted from Budd et al.39 Although the challenges to engaging children as SPs in healthcare education are significant, they are not insurmountable (Table 2). If practical and ethical issues are effectively addressed, middle childhood SPs can contribute unique perspectives and affective power to SBE. These attributes, when manifest in well-constructed simulation scenarios, can provide deep and sustained knowledge for learners.


This article considers the potential of SBE that engages middle childhood SPs in the development and delivery of “simulated-based learning experiences.”4 It outlines children's capacity to productively contribute to learning experiences that replicate the complexity of clinical practice and invoke the humanistic values on which healthcare is premised. It details the benefits of simulation as a learning strategy in a rapidly changing environment where critical thinking, problem solving, and communication competency are increasingly valuable skills. A paucity of examples in child-focused simulation is identified, and the barriers to children's involvement is outlined. Finally, the article affirms the benefits of child-focused SBE and offers strategies and guidelines for addressing the practical and ethical issues that arise when children are asked to perform the role of an SP in SBE. This article looks to the engagement of middle childhood SPs in healthcare education as a site of future research. Further exploration of the challenges and benefits will create a space for thoughtful consideration of child patients and their families, one in which children's needs are acknowledged and appropriately addressed.


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Simulation; middle childhood; education; healthcare; pediatric; simulated patients; standardized patients; children

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