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Meeting the needs of simulated patients and caring for the person behind them?

2005; Wiley; Volume: 40; Issue: 1 Linguagem: Inglês

10.1111/j.1365-2929.2005.02375.x

1365-2923

John Spencer, Jill Dales,

Family and Patient Care in Intensive Care Units

The use of simulated (or, in North America, standardised) patients in health care education is widespread and increasing. Indeed, from the perspective of protecting patients from unnecessary harm, emulating other high risk industries such as commercial aviation and the nuclear industry, there is a strong argument for increasing the use of simulation in medicine1,2 including teaching and assessment of communication. Many advantages have been identified3 not least (as we tell our medical students) that role play with simulated patients (SPs) offers a ‘safe introduction to reality’. Other advantages include: opportunities for rehearsal with feedback; flexibility and customisation; and standardisation (i.e. reproducibility of roles), particularly important in assessment.3 However, what about the SPs themselves? What effects might participation have on the individual role player? A paper in this issue reports a study by researchers in Nova Scotia into the effects of being a young female adolescent standardised patient.4 Eleven 13–15 year-old girls were recruited from local schools, trained to portray risk-taking adolescents with medical conditions, and then interviewed with an SP mother by final year medical students. Focus groups and interviews were used to evaluate outcomes. There were no apparent adverse effects, indeed the adolescents reported benefiting from participation, corroborated by their real parents who were also interviewed. Students found the role players realistic and, although they had been told otherwise, some even thought that they were a real adolescent-mother pair! These findings add to a surprisingly small literature on this subject. Researchers in Israel, using 16–17 year olds (male and female) from a high school drama department in a CME session also reported no adverse outcomes.5 Hanson et al. in Toronto used adolescents, again both sexes, recruited from local schools to participate in 2nd year psychiatry objective structured clinical examinations (OSCEs) and came to similar conclusions.6 All this is reassuring. Other workers, however, have reported potentially adverse consequences. Rubin and Philp in Alabama found that SPs' perceptions of their own health care was significantly worse one year after participation in a 3rd year OSCE. They were unable to say whether this was due to changed expectations (which, they argued, could be seen as a positive outcome) or to variables specific to the OSCEs.7 Bokken et al. from Maastricht found ‘an unexpectedly high number’ of SPs involved in communication teaching in the Skillslab described stress symptoms, albeit mild ones.8 McNaughton and colleagues in Toronto identified a high proportion of SPs who experienced residual ‘psychophysiological effects’ after portraying emotionally intense roles, sometimes lasting several days. Unsurprisingly, perhaps, the precise nature of the role was an important factor.9 However, Woodward and Gliva-McConvey from McMasters reported largely positive outcomes, including a more balanced view of health professionals, better communication skills and greater tolerance of others,10 findings corroborated by Wallach et al.11 The general consensus seems to be that benefits outweigh any disadvantages. The authors of the three papers reporting effects on adolescent SPs all emphasise the importance of careful selection, training, and continuing support and debriefing, in line with ‘received wisdom’ on this subject.3 Blake and colleagues have described elsewhere the challenges of recruiting adolescents.12 Interestingly the SPs in their study unanimously chose to come out of role to discuss issues with the students, mainly because they wished to distance themselves from it and did not wish to be seen as a risk taker.4,12 It would have been interesting to know what their perceptions (and experience) of risk-taking behaviour were before they worked as SPs. However, concerns that young impressionable volunteers might be encouraged to adopt some of these behaviours seem to have been misplaced; the young recruits in Hanson et al.′s study were quite clear that their participation had if anything decreased the attractions of the behaviour to them.6 Careful attention to recruitment and selection, training, support and debriefing and de-roling should not be confined to adolescents, and are important when involving anyone in simulation13. In recruitment and selection, it is not only the individual's ability to ‘act’ that needs to be identified. In most instances simulation involves more than simply acting, demanding flexibility, ability to improvise and an appreciation that their role is as an educational resource. The reason(s) they have chosen to get involved in simulation may have a significant influence, both on how they portray the role, and how much the role may impact on them, and consequently, how effectively they are able to detach themselves from it. An individual with ‘baggage’ from personal experiences may need more support when de-roling, and, in our experience, may be unsuitable for SP work altogether. It is therefore important to explore, in confidence, personal issues with the person to avoid them being exposed to situations which, at best may be difficult for them to handle and at worst, potentially harmful. In training, SPs also need to be aware of potential emotional demands so they can develop appropriate coping strategies. Despite careful selection and training, however, SPs may still find a particular role difficult to leave behind ‘on the day’. Unfortunately, for many reasons, often related to practicalities of time limitations and/or the setting, de-roling of SPs may be given less priority than the preparation beforehand. It is not just the impact of the role that makes this important. The SP is also a potential or actual real patient themselves. How they are dealt with in the session may have a significant effect on their perceptions of the care they might receive as a real patient. The role play performance itself may have been perfectly satisfactory, but if not handled skilfully and sensitively by the facilitator, it may be much more difficult for the SP to detach. Equally, the context and how the facilitator (who may be a senior health professional) interacts with the learners may also impact on the SP's perceptions of health care. It is important that we understand all the possible factors that may influence the SPs' psychological and emotional well-being – not just the demands of the role but the impact of context, including the behaviours and attitudes they observe. We make the inevitable call for more research in this area.