Simulation-based education encompasses a wide variety of training methods for healthcare professionals. Methods include computer-based virtual environments, high-fidelity mannequins, task trainers, and standardized patients. This article will focus on the use of standardized patients (SPs), individuals who are trained to portray patients, family members, and even colleagues. This modality is widely implemented in simulation throughout the world and for a variety of healthcare providers at all levels of learning. SPs can be useful in a variety of simulation activities, from communication-based scenarios to observed structured clinical exams (OSCEs).
SPs can get recruited from a variety of sources; local theater or acting troupes, theater schools, or even hidden talent in someone who did not know they could act. Individuals who portray nurses often get recruited from pools of retired nurses or other healthcare professionals. Method of compensation varies widely from SPs considered to be volunteers to those who receive pay as regular staff or independent contractors. The use of SPs should be distinguished from role-playing. Role-playing is when co-learners portray a role other than themselves, with resultant loss of sociological fidelity.
Training SPs is often decided at a local level. However, the Association of Standardized Patient Educators (ASPE) has published a document that outlines best practices. ASPE has outlined key values to ensure the physical and psychological safety of the SPs and the learners while providing the best possible learning: safe work environment, case development, program management, professional development, and feedback and assessment methods. A safe working environment, confidentiality, and respect for each other, and the learners ensure that psychological and physical safety are maintained. When training SPs for their role, every opportunity should be made for the SP to interact with the faculty in a rehearsal setting so that nothing is left to interpretation when interacting with the learner(s). This process allows the SP the opportunity to ask questions about the case and demonstrate the necessary physical findings ahead of the live performance to ensure accuracy.
Some institutions request that SPs provide feedback to the learner, either written or verbal, and meetings should occur to review the associated instruments. The level of role portrayal requires weighing against the use of a feedback tool by an SP; when an SP is called upon to do too many things, the level of fidelity may suffer, causing the potential for a negative experience by the learner. One recent study surmised that SPs might provide more accurate feedback on a validated tool as that individual is more attuned to the content of the scenario.
Facilities should also provide opportunities for reflection of performances and ongoing professional development and continuing education opportunities. Script templates, completed by the faculty, that SPs can utilize is crucial, along with elements that discuss emotional states, must use phrases, critical actions, information that should be held back until a learner inquires. This information assists with calibrating the performance by the SP and ensures that the utmost attention gets paid to maintain fidelity. While literature shows that SPs find value in providing training opportunities for learners of all levels, the satisfaction of providing their service is incumbent upon the proper training so that reacting and adjusting to learner skill, maintaining the proper level of emotion, and remembering all of the pertinent facts of a scenario are maintained. Ensuring the accuracy and validity of an SPs performance is crucial. When SPs are used for summative and high-stakes assessments, performances must be standardized equally amongst all SPs recruited for a session(s) so that there is the removal of any measure of subjectivity.
A growing body of literature shows the positive impact that SPs have on the education of healthcare providers. The use of simulation enhanced by incorporating an SP supports adult learning theory, especially the principle of self-efficacy of motivation. Further, a recent meta-analysis demonstrated achievement of gains in three of Bloom’s taxonomy domains: affective, psychomotor, and cognitive. Primary care providers were more likely to remember to incorporate various screening tools into a visit based on simulated patient encounter experience, even months beyond the training initiative. When using SPs for scenarios that are rooted in clinical decision-making skills, learners rated the scenarios as more realistic, and they also scored higher in evaluations following participation when compared to scenarios using mannequins.
While a multitude of nursing and medical schools implement SPs into their curricular activities, associated costs of training and managing them can be prohibitive in some instances. As a result, other methodologies come under scrutiny; however, learner outcomes get enhanced when utilizing SPs. By and large, learners appreciate the ability to interact with SPs for a variety of crucial skills, from history and physical skills to communication skills dealing with delicate topics. Complex medical conditions, such as movement disorders, cerebrovascular accidents, and other nuanced neurologic conditions, can be accurately and believably portrayed by SPs with the right training and practice.
SPs can be implemented in hybrid simulations. For example, an SP can play the family member of a mannequin, either adult or pediatric/neonatal. Wearable technology can also be donned by an SP to simulate abnormal findings; tabs that link SPs to software with abnormal ultrasound pathology or heart and lungs sounds that can indicate murmurs, crackles, or dysrhythmias.
Some SPs are trained to serve as models for procedures such as genitourinary exams and ultrasounds. These particular exams often pay more due to their invasive nature. Programs that utilize SPs for these psychomotor skills attribution should have policies and procedures in place should abnormal findings be discovered. A faculty member should screen these SPs before a learner’s examination to ensure that nothing abnormal is discovered incidentally by a learner and that any anatomical differences noted do not detract from learning.
There is the possibility that virtual SPs may become more prevalent over time; this is a trend that is continuing to be reported in the literature. Several studies have documented no significant difference between real and virtual SP encounters, especially those dealing with the assessment of communication skills.
Standardized patients can greatly enhance fidelity in simulation scenarios.
Planning and communication between the facilitator and the standardized patient before the educational exercise improves performance.
Learners are often more engaged when using standardized patients over manikins.
A recent systematic review of the current research indicates that more research needs to be conducted utilizing SPs in interprofessional simulation activities. Potential areas for future research could include communication and hand-offs, along with a team-based response to pre-arrest scenarios.
|||Hart JA,Chilcote DR, [PubMed PMID: 26926219]|
|||Lewis KL,Bohnert CA,Gammon WL,Hölzer H,Lyman L,Smith C,Thompson TM,Wallace A,Gliva-McConvey G, The Association of Standardized Patient Educators (ASPE) Standards of Best Practice (SOBP). Advances in simulation (London, England). 2017; [PubMed PMID: 29450011]|
|||Newlin-Canzone ET,Scerbo MW,Gliva-McConvey G,Wallace AM, The cognitive demands of standardized patients: understanding limitations in attention and working memory with the decoding of nonverbal behavior during improvisations. Simulation in healthcare : journal of the Society for Simulation in Healthcare. 2013 Aug; [PubMed PMID: 23584724]|
|||Dickter DN,Stielstra S,Lineberry M, Interrater Reliability of Standardized Actors Versus Nonactors in a Simulation Based Assessment of Interprofessional Collaboration. Simulation in healthcare : journal of the Society for Simulation in Healthcare. 2015 Aug; [PubMed PMID: 26098494]|
|||Jin HR,Choi YJ, Three-dimensional needs of standardized patients in nursing simulations and collaboration strategies: A qualitative analysis. Nurse education today. 2018 Sep; [PubMed PMID: 29945097]|
|||Rutherford-Hemming T,Alfes CM,Breymier TL, A Systematic Review of the Use of Standardized Patients as a Simulation Modality in Nursing Education. Nursing education perspectives. 2019 Mar/Apr; [PubMed PMID: 30789562]|
|||Oh PJ,Jeon KD,Koh MS, The effects of simulation-based learning using standardized patients in nursing students: A meta-analysis. Nurse education today. 2015 May; [PubMed PMID: 25680831]|
|||Irby JH,Anders ME,Beasley DA,Moretz J,Brunner B, Patient- and Family-Centered Care in the Preoperative Setting: Simulation Cases Featuring Standardized Patients for Anesthesia Residents. MedEdPORTAL : the journal of teaching and learning resources. 2017 Jul 21; [PubMed PMID: 30800806]|
|||Fallucco EM,James L,Smotherman C,Greco P, Impact of Experiential Training With Standardized Patients on Screening and Diagnosis of Adolescent Depression in Primary Care. The Journal of adolescent health : official publication of the Society for Adolescent Medicine. 2019 Jul; [PubMed PMID: 30879884]|
|||Alsaad AA,Davuluri S,Bhide VY,Lannen AM,Maniaci MJ, Assessing the performance and satisfaction of medical residents utilizing standardized patient versus mannequin-simulated training. Advances in medical education and practice. 2017; [PubMed PMID: 28765717]|
|||Block L,Brenner J,Conigliaro J,Pekmezaris R,DeVoe B,Kozikowski A, Perceptions of a longitudinal standardized patient experience by standardized patients, medical students, and faculty. Medical education online. 2018 Dec; [PubMed PMID: 30560720]|
|||Baylor C,Burns MI,Struijk J,Herron L,Mach H,Yorkston K, Assessing the Believability of Standardized Patients Trained to Portray Communication Disorders. American journal of speech-language pathology. 2017 Aug 15; [PubMed PMID: 28595263]|
|||O'Rourke SR,Branford KR,Brooks TL,Ives LT,Nagendran A,Compton SN, The Emotional and Behavioral Impact of Delivering Bad News to Virtual versus Real Standardized Patients: A Pilot Study. Teaching and learning in medicine. 2019 Aug 22; [PubMed PMID: 31437006]|
|||Friederichs H,Weissenstein A,Ligges S,Möller D,Becker JC,Marschall B, Combining simulated patients and simulators: pilot study of hybrid simulation in teaching cardiac auscultation. Advances in physiology education. 2014 Dec; [PubMed PMID: 25434018]|
|||Maicher KR,Zimmerman L,Wilcox B,Liston B,Cronau H,Macerollo A,Jin L,Jaffe E,White M,Fosler-Lussier E,Schuler W,Way DP,Danforth DR, Using virtual standardized patients to accurately assess information gathering skills in medical students. Medical teacher. 2019 Sep; [PubMed PMID: 31230496]|