By: Beth Hallmark
The history of using a live person to portray a patient dates back to 1963, when Dr. Howard Barrows from the University of Southern California introduced a simulated patient to his neurology students. Dr. Barrows was able to create a patient case from a real patient situation he had treated. Using this direct method of observation, he was able to identify areas of improvement in both communication and exam techniques. Since 1963, the use of what we now refer to as Standardized Patients (aka: confederates, embedded actors, role player, actor, or simulated person) is a standard part of medical education. The Society for Simulation in Healthcare (SSIH) defines standardized patient (SP) as “an individual who is trained to portray a real patient in order to simulate a set of symptoms or problems used for healthcare education, evaluation, and research” (Lopreiato et al., 2016, p. 35).
No matter how hard we try using manikin-based simulation, talking with a manikin will never be the same as talking to a real person. Looking into the eyes of a live person, seeing real emotion, placing a stethoscope on real skin, listening to the patient’s story…this makes it real! The lack of realism, along with limitations such as space and portability of the manikin, make using a standardized patient a very attractive option.
Standardized patients have been used sporadically in nursing education, with an upward trend in the use of actors to portray both patients and family members in simulated educational events. Many schools of nursing are integrating SPs into simulation and the feedback is very positive. Some have included standardized patients in the feedback and debriefing period, allowing students to ask the actors how they felt during the scenario.
What Doesn’t Work
While manikins are very costly, using paid professional can also represent a financial and time investment, and many of our programs are on very tight budgets. One solution is to use the theater students on campus, but training SPs is a full-time job. Developing theater students as SPs requires a well-developed program, and all parties involved must be committed to make it work.
At some schools theater students are used on a volunteer basis to gain experience; other schools give credit toward required community service hours. However, these approaches are not entirely successful in terms of student commitment and attendance. I interviewed faculty at two schools that paid their theater students. They found that when students had academic responsibilities, they often did not show up or showed up very late. The two schools offered very different rates of pay. One paid the rate of a student worker ($7.25/hr) while the other paid ($20/hr). A faculty member told of having to “drag” her administrative assistant into the bed to be the patient!
What Can Work
Even with these difficulties, using theater students can be very effective in terms of the portrayal of the role. Theater students are committed to the role and are very “believable,” adding to the realism of the scenario. It is important that the theater student have the script before the simulation, along with coaching or training to fulfill the expectations of the simulation. Barriers to this type of an arrangement surround issues involved in training and the time required of staff.
Two schools have designed an interdisciplinary course where theater students receive academic credit. The students receive training from theater faculty in role development and improvisation, and as part of the course they participate in simulations. The students are then evaluated by their faculty in terms of how they fulfilled the theater course objectives. One center proposed videotaping the theater students for future use in their professional portfolios. Unfortunately, neither of the two schools has been able to launch the course.
An important consideration is following standards developed by the Association of Standardized Patient Educators. These standards provide best practices and should be followed to ensure the best student outcomes.
Using theater students as SPs is an exciting prospect. The most important thing I have learned is that it takes commitment to make this work, with someone to schedule and train students to ensure they are prepared and present when needed and to follow up as necessary. This is not unlike all other SP programs, which require a significant commitment from the university to ensure success. There is no doubt that the evidence supports the use of SPs in nursing education … now we just have to make it work!
Lopreiato, J. O. (Ed.), Downing, D., Gammon, W., Lioce, L., Sittner, B., Slot, V., Spain, A. E. (Associate Eds.), and the Terminology & Concepts Working Group. (2016). Healthcare simulation dictionary.