Simulated Patient Methodology

Theory, Evidence and Practice

Debra Nestel, Margaret Bearman

• Publisher: Wiley-Blackwell
• Year: 2014
• ISBN:
  9781118760956
• Edition: 1
• Topic: Medicine
• Subtopic: Clinical Medicine

Simulated Patient Methodology is a timely book, aimed at health professional educators and Simulated Patient (SP) practitioners. It connects theory and evidence with practice to ensure maximum benefit for those involved in SP programmes, in order to inform practice and promote innovation. The book provides a unique, contemporary, global overview of SP practice, for all health sciences educators. Simulated Patient Methodology:
•Provides a cross-disciplinary overview of the field
•Considers practical issues such as recruiting and training simulated patients, and the financial planning of SP programmes
•Features case studies, illustrating theory in practice, drawn from across health professions and countries, to ensure relevance to localised contexts Written by world leaders in the field, this invaluable resource summarises the theoretical and practical basis of all human-based simulation methodologies.

Chapter 1
Introduction to simulated patient methodology

Debra Nestel and Margaret Bearman

Monash University, Clayton, Australia

Introduction

‘Simulation is a technique to replace or amplify real experiences with guided experiences, often immersive in nature, that evoke or replicate aspects of the real world in a fully interactive fashion’(1). This definition by Professor David Gaba, a pioneer of contemporary healthcare simulation, aptly describes simulated patient-based scenarios. A well-prepared simulated patient (SP) has the ability to draw learners into a scenario quickly, achieving deep engagement. Their mere presence usually prompts interactivity.

The terms simulated and standardized patients refer to largely similar simulation modalities, that is, a well person trained to portray a patient. The level of standardization varies according to the context in which the SP is placed. In learning settings, standardization is less critical and often its absence can be a feature. The tailoring of SP encounters can be used to meet the needs of individual learners, and also to introduce all the variation that characterizes human beings. In contrast, in summative or high-stakes (graded) assessments, SPs function as the examination question. Therefore, to permit a fair test, the SP must perform consistently within the character of the person they are portraying. Embodied in their role is factual information relevant to the clinical encounter. Whereas in Canada and North America the term standardized patient is commonplace, in the United Kingdom (UK) and Australia the commonly used term is simulated patient. In the latter tradition, simulated patients who perform in high-stakes assessments have their behaviour rather than their being described as standardized. These are nuanced differences and reflect historical practices. North America has witnessed a strong testing orientation of SP methodology whereas in the UK and Australia the origins are rooted in supporting learning(2). Hereafter, the abbreviation SP is used to refer to either! Several other terms are used to describe the work of SPs and these include expanding roles too (Box 1.1). Our focus is on the role of SPs, although some chapters consider elements of expanded roles and others consider the role of the SP practitioner.

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Box 1.1 Alternative terms used to describe simulated or standardized patients and expanded roles for SPs

• Role-player– Sometimes used interchangeably with the term SP and often includes medical, nursing or health professional students as patients.
• Clinical teaching associate– Describes SPs who teach specific physical examination (e.g. breast, rectal, vaginal). The focus is on supporting learners in developing psychomotor, communication and other professional skills. This is a highly specialized role.
• Trained patient– Sometimes used interchangeably with the term SP and may or may not include a person who is using their experience of a particular illness to play their role.
• Patient instructor– May be used interchangeably with the term SP and may include a person who is using their experience of a particular illness to play their role.
• Incognito or unannounced patient– An SP who enters real clinical settings (e.g. pharmacy, general practice) with permission but without being identified as an SP—enabling judgements of clinician performance in action.
• Volunteer patient– A patient who is sufficiently well to attend teaching sessions. They may simply be themselves in role-play activities (e.g. an Objective Structured Clinical Examination) or they may play the role of another patient.
• Hybrid patient– The combination of an SP and a simulator permitting the practice of procedural and operative skills. The concept was first reported by Kneebone et al.(15), who described the blending of simulation modalities as ‘patient-focused simulation’, and is now widely used internationally.
• Actor patient– Used interchangeably with the term SP, although it may refer to professional acting skills of the SP.
• Confederate– An individual other than the patient who is scripted in a simulation to provide realism, additional challenges or additional information for the learner (e.g. paramedic, receptionist, family member, laboratory technician)(16). The voice of manikins can also be considered as a confederate role.

Adapted from the Victorian Simulated Patient Network, Module 1: An Introduction to Simulated Patient Methodology.

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Although healthcare continues to draw on training and assessment practices in high-reliability industries, simulation is likely to become embedded in all stages of education for the healthcare workforce. In the UK, the Chief Medical Officer reported that simulation was one of the top five priorities of the National Health Service in the coming decade(3). With this sort of strategic and high-level vision, simulation is clearly here to stay.

The contemporary history of SP methodology has many drivers. These are well documented and originate from humanistic, educational and external issues(4, 5). The imperative of not causing harm to patients is a critical driver(6). However, we must also be aware of the risks to learners and SPs learning and working in this methodology. A theme throughout this book is the role of SPs as proxies for real patients. As such, they represent patient rather than clinician perspectives(7, 8). Several chapters identify ways in which this patient proxy role can be strengthened. Some contemporary SP practices constrain the voice of real patients, which limits their potential in offering patient perspectives. We promote approaches that offer authentic patient voices and thereby contribute to the development of patient-centred and safe care. Recent history is also witnessing better alignment of simulation-based education in health professional curricula, which means that SP practitioners are more likely to be working with other simulation practitioners. This creates exciting opportunities for practitioners of all simulation modalities to learn from each other.

Although the educational settings in which SPs work can vary widely, there are commonalities in simulation practice. Throughout the book, we refer to six phases commonly found in simulation-based educational activities. All are essential to creating effective educational experiences (Figure 1.1). This simulation framework has been adopted in a national training programme for simulation practitioners in Australia(9). The phases enable practitioners to share a common platform for designing and communicating simulation-based education. For the Preparation phase, we are referring to all the activities that take place before the session starts—recruiting and training SPs, database management, setting learning objectives, designing scenarios and so on. The Briefing phase refers to explaining the simulation process to all participants, including the scenario context, learning objectives and the approach to debriefing. Other activities during the briefing may include learners setting their own objectives, sharing prior experience and orientation to the learning environment. There are briefing activities for SPs too, such as checking that they know their role. The Simulation Activity is the next phase, and may take different forms, but is where the learner interacts with the SP. The Debriefing and Feedback phase follows, which complements the briefing. Learners' feelings are checked, objectives revisited, other perspectives sought and future learning is planned. During the Reflection phase, learners (usually individually) are encouraged to make sense of the simulation in the light of their own experience. Similarly, faculty and SPs are also encouraged to reflect on all facets of their contributions. The Evaluation phase ref...