Dawn Taylor Peterson
© Springer International Publishing Switzerland 2016
V. J. Grant, A. Cheng (eds.), Comprehensive Healthcare Simulation: Pediatrics, Comprehensive Healthcare Simulation, DOI 10.1007/978-3-319-24187-6_8 D. T. Peterson ()
Office of Interprofessional Simulation, Department of Medical Education, University of Alabama at Birmingham, School of Medicine, Birmingham, AL, USA
e-mail: [email protected]
Simulation Pearls
• It is important to determine if a standardized patient or a simulated patient is necessary to accomplish the learning objectives of the scenario.
• The structure and type of training required for a standard- ized patient or (or family member) depends on the learn- ing objectives of the case and whether or not the simula- tion is part of a high-stakes summative assessment or is simply designed for educational purposes.
• Careful considerations must be made, and safeguards must be put into place, when children and/or adolescents are used as standardized patients or simulated patients.
• Simulated patients and family members can be an effec- tive tool for teaching communication skills as well as delivering bad news and facilitating difficult conversa- tions.
Introduction
The use of standardized patients in medical education origi- nated in 1964 [1] and has been growing in scope and impact over the past 60 years. While some educators believe that standardized patients are currently underused in healthcare education [2], the integration of standardized patients into the education and evaluation of healthcare professionals has increased dramatically over the past 20 years [3].
According to a 2012 survey distributed by the Council on Medical Student Education and Pediatrics, 35 % of pedi- atric clerkship directors surveyed reported using standard- ized patients with their students. These respondents also re- ported using children and adults as simulated patients 60 % of the time [4]. The use of standardized patients in medical education has also been determined to be a best practice for
teaching communication skills, interpersonal skills, and fa- cilitating difficult conversations [5].
Historically, simulation centers and standardized patient programs have been divided geographically with separate operational structures under the university, academic, or hos- pital umbrella, resulting in two separate staffs and two dis- tinctly different training programs. Recently, however, many simulation centers have combined programs under one um- brella, which integrates high-fidelity simulation programs along with standardized patient and simulated patient pro- grams [6]. The result has proven to be an effective structure for training standardized patients and educating healthcare professionals from any area or discipline.
Common Terms and Definitions
Standardized patients are now considered a unique disci- pline [7] and are being recognized as a specific occupation in countries all over the world [8]. As the field of standardized patients becomes more robust and formalized, it is impor- tant to clarify common terms and definitions. The term SP is commonly used to make reference to a standardized patient, a standardized participant, or a simulated patient [9], and in some settings, it is intended to reference a simulated client or patient instructor [8]. However, recent studies have made a distinction between the two terms [10, 11]. In accordance with these studies, this chapter will refer to a standardized patient as one who has been rigorously trained to display symptoms in a consistent, sequential, and unchanging man- ner for multiple learners in a high-stakes summative assess- ment. Standardized patients are also trained to rate students and clinicians using rubrics and checklists and to deliver structured feedback based on performance.
Simulated patient are trained to portray a patient for for- mative assessment purposes and may or may not provide feedback to the learner. The focus of the simulated patient is not necessarily on the standardization of the symptoms but more on the authenticity and believability of the performance.
Simulated patients typically spend more training time on character development, background stories, interpersonal relationships, and reactions to difficult conversations. One of the key challenges in the field is the lack of standardized terminology, which can often times cause misunderstanding or miscommunication in the training and implementation of these individuals into a simulation scenario [11]. For this reason, a list of common terms and definitions used through- out this chapter is provided in Table 8.1.
The Association of Standardized Patient Educators (ASPE) is an international organization committed to sup- porting best practices in the field of standardized patient edu- cation. This group of simulation educators aims to enhance the professional knowledge and skill set of its members as well as promote research and scholarship in standardized patient methodology and education. In 2014, ASPE drafted a document outlining best practices for standardized patient teaching and evaluation in six different areas. These areas include standardized patient safety, quality assurance, case design, standardized patient training, standardized patient feedback, and professional development. At the time of writing this chapter, these standards were still in draft form.
However, the organization hopes to publish the standards by the end of 2015 [8].
Recruitment and Training General Information
The integration of standardized patients and simulated pa- tients into simulation scenarios requires specific preparation, planning, and training. It is important that the SP enriches rather than disrupts the scenario and that the individual un- derstands not only his or her role in the simulation but also the overall purpose and objective for the educational session.
Regardless of whether the SP is a trained or untrained actor, structured training is necessary [6]. The coaching required to train SPs has evolved over the past 20 years to include sce- narios that are not necessarily standardized but focused on difficult conversations and communication skills. Educators must recruit, audition, and select persons who will enable the learners to meet the learning objectives of the scenario [7].
Recruiting Standardized and Simulated Patients Recruitment can be one of the most challenging aspects of securing SPs. It is important to cast the right individual to portray patient and family roles so that the realism of the case is not affected. Even experienced actors can have diffi- culty portraying certain patients, especially if they have had personal experience with medical problems in the past. It is also important to choose SPs who are able to control their emotions [12].
SPs can be recruited from a variety of places. Some simulation centers choose to pursue professional actors [7, 12, 13], while others look to volunteers to fill the role of SPs [14]. Outside agencies such as AARP (formerly known as the American Association of Retired Persons), newspa- pers, health-related support groups, volunteer organizations, schools of performing arts, and referrals from existing SPs are also resources for recruiting additional people to the pro- gram [7]. If volunteers or family members of actual patients are being utilized as SPs in hospital simulation programs, it is important to properly screen candidates before selecting the best one. While family members of actual patients can add to the authenticity of a simulation, it is very important to place them in scenarios that do not kindle emotionally trau- matizing events [14].
Regardless of how SPs are recruited, it is important to consider the ethnicity, gender, and age of the individual with respect to the learning objectives of the case. While the age of the SP does not have to be the exact age of the patient being portrayed, it is important that the SP closely resembles the age of the patient. Some cases may be acceptable for a male or a female to portray. However, allowing male and female SPs to portray the same case for a high-stakes sum- mative assessment could potentially cause variation for the
Table 8.1 Common terms and definitions Standard-
ized patient or simulated patient
The terms standardized patient and simulated patient are often used interchangeably to refer to a non- clinician who has been trained to portray a patient with a specific set of symptoms or psychological issues [3, 9, 52]
Simulated family member
A person who is trained to act as the family member of a patient in a simulation scenario. Simulated family members can also be referred to as embedded simulation persons [52]
Simulated client or unan- nounced standardized patient
A person who is trained to present as a real patient in a health clinic setting in order to observe and assess the clinician’s decision-making skills. Clinicians are unaware that they are being observed by the simulated client [25]. In the USA, these individuals are typically referred to as unannounced standard- ized patients
Hybrid
simulation When two or more modalities of simulation (i.e., task trainers, simulators, or standardized/simulated patients) are combined for a simulation session [9, 52]. In this chapter, a hybrid simulation refers to the combination of a high-fidelity simulator and a stan- dardized or simulated patient or family member Formative
assessment Assessment for educational purposes; formative assessment includes observation of the learners and feedback based on their actions [52]
Summative
assessment Assessment for evaluation purposes; summa- tive assessments are measurements of a learner’s proficiency and competency in a specific area;
summative assessments are typically high-stakes evaluations [52]
learners due to the fact that gender differences can and often do impact patient and clinician interaction as well as history taking [7, 15].
As soon as potential SPs have been recruited, it may be necessary to hold an audition. It is helpful to hold multiple auditions on one day in order for simulation staff and cli- nicians who are involved in the scenario to be present [7, 13]. This also allows staff and clinicians to compare perfor- mances of potential SPs so the best selection can be made for the case [7]. The length of the audition will depend on the complexity of the case and on whether or not the SP is being trained for a high-stakes summative assessment with struc- tured feedback or for a formative learning session focusing on an emotional experience or a difficult conversation. Wal- lace suggests a 1.5–2-h audition for standardized patients who will be involved in summative evaluation [7]. Video recording auditions allows simulation center staff to build a database so that candidates can be reviewed if necessary at a later date. Pascucci et. al suggest holding auditions in 15-min intervals where the potential SP is given a scenario to review and then 3–5 min to audition or interact in the scenario fol- lowed by a short debriefing [13]. This type of audition is ideal for SPs who will be involved in formative assessments.
In addition to acting ability, it is necessary to determine the observation skills, self-reflection skills, and memory skills of anyone who is going to be recruited as a potential SP.
These individuals must also be reliable and willing to focus on standardizing their performance along with other SPs if necessary [7, 12].
Training for Summative Versus Formative Assessments
There is a distinct difference in training a standardized pa- tient for a summative assessment and training a simulated patient for a formative assessment. Before any training can begin, it is important to determine if the case is for evalua- tion (i.e., summative assessment) or for education (i.e., for- mative assessment). The goal in a summative assessment is to train the standardized patient with a focus in standardiza- tion and the ability to give structured feedback. Standardized patients must display symptoms in a consistent, sequential, and unchanging manner for multiple learners. In summative assessments, standardized patient performance is not about creativity. It is about consistency. All learners involved in the case must be presented with the same information with minimal or no variation [13]. If the simulation is designed to evaluate specific clinical objectives, standardization is a must. Intense training will be required for the standard- ized patients to systematically perform the same case for all learners [2].
On the contrary, if the simulation is purely for education and is considered a formative assessment, then standard- ization and consistency are secondary to the development of an authentic role where simulated patients can interact with learners in a realistic and unscripted manner. These types of educational scenarios require a significant amount of background information and social history in order for the simulated patient to develop his or her character [13].
The authenticity and believability of the performance is most important in training simulated patients. This does not mean that simulated patients choose the direction of the scenario. Some consistency and scripting are required to be sure that the scenario unfolds in a similar way for each learner.
Training Standardized Patients
True standardized patient training requires structured and specific training [7, 9, 12, 16, 17]. Wallace suggests a train- ing model of four training sessions and one practice session in order for a standardized patient to deliver a consistent and effective simulation encounter with structured feedback [7].
If standardized patients work in high-stakes clinical exams, authentic and precise performances are required [2]. De- pending on the complexity of the case and the amount of documentation and feedback required, training a standard- ized patient for a summative high-stakes assessment can take between 10 and 20 h [12]. Standardized patients can only be consistently accurate if they are well trained, regularly moni- tored, and given repeated feedback on their performance by a licensed clinician [7].
If multiple standardized patients are being trained to pres- ent the same case, it is most effective to conduct group train- ing [7, 12]. This can aid in standardization of the case and also allows the standardized patients to ask questions and learn from one another. It is also helpful to provide a video which emphasizes appropriate nonverbal behavior and emo- tion. Giving explicit examples of good and poor learner per- formances is beneficial for standardized patients when they are learning to give feedback [12].
If the summative assessment includes feedback delivered by the standardized patient, specific rater training is impera- tive. Rater training should focus on observations, judgment, and proper documentation [12] and is necessary to enable the standardized patient to effectively give feedback [7]. If physical findings are part of the simulation, it is important that clinicians are involved to help train standardized pa- tients on how to produce appropriate signs and symptoms.
Clinicians should also be involved in the final practice ses- sion before the standardized patient presents the case to the learners [16].
A comprehensive discussion on how to recruit, select, and train standardized patients is beyond the scope of this chap- ter. For more detailed information on recruiting and training standardized patients for summative assessments, please see Coaching Standardized Patients for Use in the Assessment of Clinical Competence [7] and Objective Structured Clini- cal Examinations: 10 Steps to Planning and Implementing OSCEs and Other Standardized Patient Exercises [12].
Training Simulated Patients
When training simulated patients for formative assessments, typically, the authentic character and true-to-life reactions of the patient are more important than standardization. The focus of simulated patient training is on character develop- ment and not necessarily scripted reproducibility. However, it is still important to determine the minimum level of consis- tency required for the learner, and those elements can be em- phasized during training [18]. For some simulation scenari- os, variation in simulated patient performance will not derail the overall goal of the simulation, especially if the scenario is designed for formative assessment [2]. Zabar recommends a minimum of 2 h of training for a formative assessment, which may focus on content related to delivering bad news or engaging in difficult conversations [12]. Simulated patient training should focus on presenting a believable social his- tory, accurate symptoms related to the case, and authentic reactions in order for learners to gain the most from the simu- lation session. If the simulated patient encounter is part of a research study, it may be helpful to provide a template or script during training to help specify the role of the simulated patient. Cue cards or notes can also be provided for the simu- lated patient to use during the scenario. Video recordings of appropriate behaviors and reactions, along with pilot ses- sions, can also be beneficial for training simulated patients [19]. See Table 8.2 for a summary of considerations for train- ing SPs for summative versus formative assessments.
Children as Standardized and Simulated Patients While not an extremely common practice, children have been used as standardized patients and simulated patients for the past 20 years [20–26]. In 1995, Woodward conducted a focus group of seven children aged 6–18 who were routinely used as standardized patients to determine how the experi- ence had affected them [20]. Parents were present during the focus group and were asked to allow the children to talk as much as possible. The mother of a 6-year-old who partici- pated in the group said one emergency department simula- tion had frightened her child because the child overheard discussions that she might die. Although her child reported
that the simulation was fun and enjoyable, she had never thought about someone her age dying. Other young children in Woodward’s focus group reported needing additional time to sit and think before giving feedback to learners. After ana- lyzing the results of the study, Woodward determined chil- dren are at an increased risk than adolescents and adults of having negative effects following the experience of being a standardized patient.
Tsai conducted a review of the literature in 2004 to deter- mine the extent to which children were being used as stan- dardized patients and simulated patients. He concluded that successful child SP programs are limited because of ethical concerns; however, child SPs can be successful and effective for clinical assessment if careful attention is paid to selection and training [26].
In 2005, Brown reported using children as simulated patients for complex cases such as attention-deficit hyper- activity disorder (ADHD), depression, and anorexia. Chil- dren who were trained for these cases were recruited from local community theater or were children of medical fac- ulty. Cases were designed by a psychologist, a standardized patient educator, and a psychiatrist. Children attended two training sessions, each of which was 90-min long. In the first training session, children were provided with the details of the case and an explanation of the medical signs and symp- toms they were to display. In the second training session, children were able to practice being the patient. The children in this study were able to realistically interpret psychiatric disorders and were able to separate the activity as role-play- ing. Brown concluded that child SPs can be a very effective tool for residents and medical students to learn communica- tion skills surrounding pediatric psychiatric disorders [21].
Children can be used in some settings as unannounced SPs or simulated clients, but care must be taken to protect
Table 8.2 Summary of considerations for training SPs for summative and formative assessments
Summative assessment
(high-stakes evaluation) Formative assess- ment (educational experience) Type of
patient Standardized patient Simulated patient Goal of
training Standardization: scripted reproducibility with con- sistent responses enabling every learner to receive the exact same experience
Authenticity: realistic responses enabling each learner to have an authentic encounter based on their actions Length of
training 10–20 h Minimum of 2 h
Elements
of training Detailed script of responses, rater training for checklists and feedback, clinician oversight of practice ses- sions, video review, and pilot session
Description of role and character, cue cards, examples of authentic responses, video review, and pilot session