Introduction

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 using standardized patients (SPs), individuals who have had the training to portray patients, family members, and even colleagues. This modality is widely implemented in simulation throughout the world and for various 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).

Recruitment

SPs recruitment can be from various 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. Methods of compensation vary widely from SPs considered volunteers to those who receive pay as regular staff or independent contractors.[1] One must distinguish the use of SPs from role-playing. Role-playing is when co-learners portray a role other than themselves, with resultant loss of sociological fidelity.

Issues of Concern

Training

Training SPs often occurs 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.[2]

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.[3] 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.[4]

Facilities should also provide opportunities for reflection of performances and ongoing professional development and continuing education opportunities.[2] 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 appropriate level of emotion, and remembering all of the pertinent facts of a scenario are maintained.[5] Ensuring the accuracy and validity of an SPs performance is crucial.[6] When using SPs for summative and high-stakes assessments, performances must be standardized equally amongst all SPs recruited for a session(s) to remove any measure of subjectivity.

Clinical Significance

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.[7][8] Further, a recent meta-analysis demonstrated achievement of gains in three of Bloom’s taxonomy domains: affective, psychomotor, and cognitive.[7] 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.[9] 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.[10]  

While many 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.[1] By and large, learners appreciate the ability to interact with SPs for various 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.[9][11][12][13]

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.[14]

Some SPs have the training 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 ensures that nothing abnormal is found incidentally by a learner. Any anatomical differences noted do not detract from learning.

The Future

There is the possibility that virtual SPs may become more prevalent over time; this is a trend that is continuing to receive coverage 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.[13][15]

Pearls and Other Issues

• 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.

Enhancing Healthcare Team Outcomes

A recent systematic review of the current research indicates that more research is necessary regarding utilizing SPs in interprofessional simulation activities.[6] Potential areas for future research could include communication and hand-offs, along with a team-based response to pre-arrest scenarios.