Standardized/Simulated Patient Integration

Introduction #

Welcome to the standardized/simulated patient module! This module will be different from the others, as the focus is less on the creation of a task trainer, and more on the integration of actors into your training and education sessions.

Definitions and Uses #

What is a standardized/simulated patient (SP)? 

• A Standardized Patient is a healthy individual trained to portray a clinical problem or situation for the purpose of testing or teaching specific skills in the field of health care professionals. (University of British Columbia, n.d.) 

What are SPs typically used for? 

• SPs are often placed in an acting role where significant emotionality, conversation, and/or range of motion is required to appropriately convey information for the assessment and/or case. 

• Examples for assessment may include: health history, healthy physical assessment, musculoskeletal assessment, neurological assessment, skin assessment, point-of-care ultrasound, and reproductive assessment (breast examination, digital rectal exam, etc.). Please note that extra care, structure, and compensation is needed for the last category to ensure the physical and psychological safety of the SP. 

• Examples for cases may include: behavioural/aggravated patient, preventative health discussions, chronic health discussions, birthing practices, overwhelmed family member, patient experiencing withdrawals, end of life/palliative discussions, and more. 

How can an SP be used instead of a manikin or task trainer?

• SPs, compared to manikins and task trainers, can get up and move around. This may be integral for key body language findings, or practicing key assessment or interventional skills such as range of motion assessments, de-escalation, restraint application, and more. 

• SPs can also show a broader range of facial expressions compared to manikins, and their voice and intonation can match the facial expression, compared to being the ‘voice of the manikin’. SPs can also elicit an emotional response in learners. By having realistic voice and body language, for example the ability to cry, scream, reach out, pace, etc., learners are more immersed in the emotionality of the scenario. This can be integral for complex conversations, such as a person escalating in behaviour, entering into end of life care, or an expectant mother entering into active labour. 

• SPs also have actual human tissues and organs. Sometimes, nothing quite beats like the real thing. When performing healthy physical assessments, or point of care ultrasound skills, seeing or hearing live feedback of actual organs at work can be incredibly meaningful for understanding placement of equipment and the position of the patient. 

How can an SP be used alongside a manikin or task trainer?

• SPs can be used for hybrid cases or assessments. A hybrid simulation is where you combine one or more modalities of simulation together to get more learning out of the whole process. This could be combining an SP with a task trainer, or starting with an SP then moving to a manikin (or vice versa). 

• Some examples of this could include combining our wound care module [LINK] to an SP to have a discussion on chronic health or wound care management. You could also place our ultrasound IV module on an SP to have a discussion on consent and insertion. 

Safety Considerations #

What are key physical safety considerations for integrating in an SP?

• SPs are healthy participants (or have a managed, stable chronic condition). Therefore, it is very important their safety is at the forefront of designing the assessment or case. Consider all the supplies that would be required for a real life assessment/case and then consider how those supplies would be a potential risk to a healthy person. The examples below are a good start, but are not considered an exhaustive list. 

• General rules: A safe word should be established for the SP to stop the simulation or skill should there be a risk for physical injury. This safe word should be introduced at the beginning of the session to everyone participating in the simulation or skills station. Ideally, one instructor/facilitator should be assigned to observing all actions on and around the SP to specifically ensure the SPs physical & psychological safety and stop learner action as required. 

• A safe word is a word that does not belong anywhere in the simulation/assessment (i.e. Pineapple, Fishcakes, etc.) that can be easily caught by learners, SPs, and faculty to pause the simulation to assess for safety.

• Key tips & tricks for keeping the SP safe, and your simulation space safe can be found at the following website: https://healthcaresimulationsafety.org/  

• Sharps safety: Sharp safety should be taken seriously during training events as you would in regular clinical practice.  Consider avoiding sharps when possible (e.g. syringes without needles), when training with SPs unless necessary to meet the specific learning objectives. 

• General rules: if sharps are deemed absolutely necessary, they should be new, unused, and non-expired. The sharps must meet local institutional policy for safety features. There must always be a sharps bin within reach/close proximity. Learners must have already been oriented to sharps safety principles and safe disposal principles. The area must be prepared if a sharp stick injury does occur which includes first aid supplies, a sink for rinsing, and incident/accident forms. 

• For cases: the SP should not be exposed to any sharps on their person. Cases can become chaotic by their nature, and the facilitator/instructor may not be able to observe every learner’s actions. To ensure SP safety, administration of sharps, if necessary should be done to a task trainer off to the side (i.e. IV insertion, medication administration, etc.), and this should be explained in the pre-brief [LINK]. Sharps such as IV spikes, etc. can still be present provided they will not be linked to direct SP contact.

• For assessments or procedural skills: if sharps are not necessary to complete the assessment or procedural skill, then they should not be present to minimize risk. If the sharp is deemed necessary, the SP must be equipped with a task trainer that has a very broad width and depth to ensure a significant margin of error for the learner to complete the skill or assessment, with a puncture proof base (rigid plastic or equivalent). The learner must be oriented in advance to where they will perform the skill or assessment, and should have been oriented in advance to insertion/puncture depth considerations for safety. A facilitator should observe at all times to ensure SP physical safety.  

• Simulated medications & fluids: 

• Injection IV/IM/SubQ administration: the SP should never be at risk for being administered medication (expired or non-expired) at any point. All simulated or real medication must be removed from the learning space to avoid confusion. 

  • Ideally, no medications (simulated or real) should be administered during the case or skills station. If possible, the participant should practice the medication administration with empty vessels. This will limit all risk of the SP receiving something unintended during the case or skill. 

  • If medication administration/reconciliation is an absolutely necessary skill that require fluids to properly calculate dosage or mixing, the following principles should be followed:

    • Non-expired normal saline vessels should be used and have applied an easily identifiable FAKE medication label (https://www.sim.ucla.edu/sophie/ (Free sign-up)) that only has the necessary information to draw up the fluid. The vessel should have the ‘Not for Human Use’ sticker prominently displayed. 
    • The simulated medication should be administered into an injection pad or line that is off to the side or away from the SP. Learners must be oriented to this location and all safety rules during the pre-brief. 
    • This exception does not apply to in-situ simulations, where bringing expired or not for human use medications should be avoided. This is because of the risk that the medication may be mistaken for real medication and used in an emergency scenario on a real patient if misplaced in the real patient environment. 

• PO administration: the SP should never be at risk for being administered medication (expired or non-expired) at any point. All simulated or real medication must be removed from the space to avoid confusion.

  • Should one of the objectives be to convince a SP to take oral medications, the instructor can have a Tic Tac or like-container with Tic Tacs or like-candies with a FAKE medication label that only provides the medication name and dosage (https://www.sim.ucla.edu/sophie/ (Free sign-up)), and has the Not for Human Use – Educational Purposes Only sticker affixed. This process needs consent of the SP beforehand to assess food allergies and willingness to take the candy. The learners must be oriented to this process in advance. Immediately following the case or skill, the label is to be torn off the Tic Tac or like-container. 
  • This exception does not apply to in-situ simulations, where bringing expired or not for human use medications should be avoided. This is because of the risk that the medication may be mistaken for real medication and used in an emergency scenario on a real patient if misplaced in the real patient environment. 

• Exposure safety (electricity and radiation): 

  • Under no circumstances should the SP ever be at risk of having electricity exposure during the case, skills station, or assessment. If delivering electricity is a required learning objective, the pads should be placed on the SP by the faculty and hooked up to nothing (the faculty should literally hold up the unconnected line beside the SP. The two options for practice can include:

    • 1. The learners simulate administering electricity by simply stating out loud the anticipated actions. No electricity is ever delivered. 
    • 2. The learners can have a defibrillator with a ShockLink or equivalent [https://laerdal.com/ca/products/skills-proficiency/defibrillation-cardiology/shocklink/] which dumps the electricity into a device. During the pre-brief and each shock the learners will do their all clear checks and also declare ‘NOT CONNECTED’ so that the instructor can also confirm the SP is not connected before dumping the electricity load. 

  • Under no circumstances should the SP ever be at risk of radiation exposure. Portable X-rays can be mimicked with OR lights, cardboard set-ups [https://www.youtube.com/watch?v=DuSkIxZgCdI] or other devices. The objective of situating an SP for an X-ray should not be overturned by the risk of radiation exposure to both learner and SP. Spacing and positioning can be replicated without the real-life device. Free medical image files can be obtained at https://radiopaedia.org/ to display on a laptop/monitor for the simulation. 

• Restraints: 

  • Restraint application can be psychologically stressful and physically unsafe with incorrect application (Crisis Prevention Institute, n.d.).

    • Learners should be shown a video for demonstration, and instructed on manikins or a perfectly-still SP on restraint application prior to the SP applying resistance or conducting a full case. 
    • Instructors should be right beside the SP to ensure their safety and ensure correct application by learners. 
    • Ensure that the SP is always able to vocalize their safe word as required. 

• Additional considerations:  

  • Slips, trips, and falls: inform SPs in advance of what equipment may be in the room so they know to anticipate potential trip hazards if mobile (i.e. IV lines & cords, oxygen tubing, crash cart, etc.). Tape down any wiring and remove trip hazards as much as possible prior to the case. 

What are key psychological considerations for integrating in an SP? 

• Performing certain assessments or cases may be psychologically taxing on either the SP or the learner. Certain questions or phrases may unknowingly trigger SPs or learners to a point of becoming psychologically unsafe. 

• Guidelines                                      

• Establish a safe word to pause or stop a simulation should the case or assessment become psychologically unsafe. This word should be distinct and not related to any part of the case or assessment. Have this word introduced to the SP during training and the learners during the pre-brief. 

• On intake of the SP, provide a clear description of the objectives of the case/assessment and the anticipated actions they will be expected to perform. Allow the SP to opt out during this point should they feel they are unable to safely fill this role. 

• During the training of the SP, provide a script and description of expected learner actions. Allow them time to voice concerns they may have about fulfilling the role, and work through additional accommodations or safety protocols that may make the case or assessment safer for them and/or the learners. 

• Create a non-judgemental space where learners and SPs feel safe to pause the simulation to take a breath and resituate themselves. Have an area for SPs separate from learners to take breaks and prepare. More info here [Lewis et al., 2017]. 

• If the SP is to participate in the debrief, provide coaching on what topics may be approached and how their feedback may be useful to guide/inform the learners. Allow the SP to have an exit strategy should the debrief be overwhelming. NOTE: debriefs can also be empowering or psychologically beneficial to SPs as it provides them insight into the learners frame of reference, and further shows the value of the patient lens in informing future professional practice (Block et al., 2018). 

• If either the SP or the learner does feel triggered or overwhelmed by the experience, allocate time to have a one-on-one debrief for emotional release. Have further contacts (mental health hotlines) if a full debrief cannot occur or the consult is outside your scope. 

Recruiting, Hiring, and Training Considerations #

What are key administrative considerations for integrating in an SP? 

• Recruiting 

  • Look to your local universities and colleges to see if they already have an SP program established. If they do, there may already be a running list of individuals interested and trained in providing SP-related work that you can email or call. 
  • If your location does not have a local university or college (or associated branch), work towards advertisement. Advertise in areas that people would typically look for volunteer or job opportunities, or for community events. Ensure the poster/ad is brightly coloured and clearly indicates the profile/SP demographics, training and event time, date, location, objective, and compensation (if relevant) provided. Highlight where and who to contact for more information. An example of a poster can be found here [LINK]. 
  • Provide several weeks in advance to advertise, setting yourself up for time to interview, sign agreements/contracts, and schedule training. 
  • Know your community: if advertising online, in-person, via word of mouth, or other means will be more impactful, use these tools to your advantage. 

• Hiring 

  • If recruitment is successful, you want to ensure you are hiring or bringing on someone who can successfully perform the task. Even if this is a volunteer position, key questions should be asked to ensure the success of the event.

  • Interview:  

    • Ensure availability – indicate expected training time and dates, if the training times are flexible or specific, and the expected start and end times of the exact date. Ensure the individual is available for all components 
    • Explain role – provide a detailed profile of expected learning objectives and SP tasks expected from the role/event. Ensure the potential recruit is comfortable and consents to these objectives & tasks, and provide clarity where required. 
    • Re-clarify compensation – indicate compensation (if training is paid, if all hours are paid, are volunteer hours signed for, etc.) and ensure no confusion. 
    • Establish a relationship – ensure the individual knows that this is for education and no advantage is present within the healthcare/medical community based on participation. Create distinction between therapeutic relationships, especially for remote communities. Check-in that the person is capable and willing to maintain confidentiality of performance. 

  • Contract 

    • Regardless if the position is voluntary or paid, a contract should be established between the institution/healthcare worker and the potential SP. An example of an SP template can be found here [LINK]. 

    • Contracts should address the following information:

      • Understanding of expectations of the role as an SP 

      • Potential risks associated with role (physical and psychological) and relinquishing/waiver of responsibility from institution (if relevant). 

      • Potential risk for unintended discovery (physically or psychologically) and next steps expected from healthcare worker/institution.

        • Unintended discovery may include assessment or diagnostic findings during a case relevant to the SP as a person rather than the role they are portraying. (For example performing an ultrasound workshop and an unknown lump is found). The recommendation from the simulation community is if an unintended discovery is made the SP be asked to go to their primary healthcare provider/come back later as a patient, for assessment rather than receive a full assessment or diagnosis during the simulation, as this can blend the therapeutic relationship, and confuse learners (source). An exception would be an emergent finding that requires immediate intervention (even in this case the person should be transported to an area where the intervention can be safely performed).  

      • Expectation for training from SP and institution/healthcare worker 

      • Expectation for arrival, scheduling, cancellation, and no-shows from both the SP and the healthcare worker/institution. 

      • Expectation for compensation/finances; and routine scheduling or guaranteed work

        • This section may not be relevant to all groups but an indication that none of these are guaranteed/granted should be present 

      • Confidentiality of the case/assessment and learner performance by SP (attach confidentiality agreement) 

      • Waiver for loss of personal property 

      • How to terminate agreement/contract 

• Training 

  • A time and location should be set-up for training of the assessment/case for the SP. Ideally this time should be flexible, and well in advance of the assessment/case, to adjust to the SP schedule. A content expert should be present. 
  • During the training, the first part should be a sit-down, table-top walk-through of the expectations of the assessment/case from all parties (SP, learners, and faculty). Then a brief explanation of the SP-specific roles and actions should be indicated. Videos and cognitive aids can help this section. A pause should occur at the end of this portion for the SP to ask any questions or pose any concerns. 
  • Afterwards, a walkthrough or dry-run of the assessment/case should commence. It may be helpful for the faculty to demonstrate first and then have the SP mirror the actions. Having multiple faculty present to play the role of learners can really establish the expectations of the event. However, this may not always be possible for rural/remote locations. During the walkthrough or dry-run, there should be pauses after every stage or key objective to allow the SP to ask questions or pose concerns. 
  • More time may be required to test out moulage/special effects, or to fit the task trainer specifically to the SP if this is required. 
  • The training should end with a debrief where the SP and faculty can discuss any questions that may have arisen from the training. Key safety concerns and boundaries should be established here, including the safe word. If the SP feels they cannot fill this role, this should be their final opportunity to opt out. 
  • At the very end, the SP should be provided with instructions (either emailed or paper copy) of expectations for showing up day-of (i.e. time, location, clothes to wear, general appearance, etc.) and contact information for day-of. 

• Cancellations / No-shows 

  • It is entirely possible that even with well-established recruitment, hiring, and training practices that some individuals will have to cancel their SP role, or that there may be no-shows. Important note: cancellations and no-shows are extremely reduced when SPs are compensated vs. when the role is voluntary. 

  • In the event of a cancellation in advance: 

    • See if you can recruit from a list of SPs who also expressed interest. See if there is time for training, even if it is the morning of. 
    • If no SPs are available for recruitment, see if a fellow faculty or staff can take on that role, this should be the last option as it will take the learners out of the experience if it is someone they work with or holds authority over them. 

  • In the event of a last-minute cancellation or no-show:

    • See if a fellow faculty or staff can take on that role. This should be the last option as it will take the learners out of the experience if it is someone they work with or holds authority over them.
    • If there are no faculty/staff deployable to take on the role, the event may have to be rescheduled. Work to notify learners as soon as possible. 

• Re-contacting 

  • Some SPs may be well suited to fit into many different assessments or case scenarios. You can also cut back on training time if you bring back the same SP for the same assessment or case scenario that has a new group of learners.
  • A structure should be in place whereby you create an agreement that an individual can be re-contacted for additional SP opportunities with your institution/healthcare worker group.
  • When re-contacting, ensure the SP is informed if the assessment/case is the same or different, and re-establish the relationship as educational. Ensure if the assessment/case is different that the objectives are set-out so the SP can determine whether they can take on this new role. 

Key considerations for rural/remote locations?

• The hiring pool is smaller. It is important to set a wide timeline to hire the right individual for the role, and also to create flexible timelines & schedules to meet the SP where they are at. Where you can, ensure your case is adaptable to age, gender, ethnicity, and so forth to not limit your hiring pool or the feasibility of bringing the case to life. 
• There is a higher likelihood you will know the individual who you are hiring. It is important to establish the goals and relationship for this interaction compared to the usual therapeutic relationship. This is especially true in remote locations, where the education may be taking place in the only healthcare setting in the community. 
• Confidentiality is especially important to emphasize. Ensure the SP hired knows the importance of and is capable of keeping the performance of the learners confidential. Simulation is a space where learners can make mistakes and grow. However, if the small community learns that one of the few healthcare professionals working there has significant learning gaps, there may be panic or unrest in the community. 

Training #

How do I properly train up an SP for an assessment style scenario?

• Show a video or demonstrate on a co-worker what is to be expected during the assessment. 
• As required, perform a dry-run of the assessment with the SP prior to the event, which will help to increase recognition and reduce anxiety. 
• If the assessment involves a health history or interview, provide the SP with an SP profile [LINK] that provides them the necessary background information on the person they are portraying. Provide the SP profile at least 48 hours in advance so that they can ask any follow-up questions and have enough time to memorize necessary information. 
• Inform the SP what sort of clothing they will be expected to wear during the assessment. For example, a hospital gown, loose light-fitting clothing, or normal street clothes. Indicate whether a second set of clothes is recommended (i.e. in case gel or fluids accidentally ends of on the clothing). Gowns and clothes should be provided by the faculty/institution if expected damage/staining is expected or there is a high risk of this occurring. 
• If the assessment involves a skill, demonstrate or show a video of the skill. Explain what safety precautions, if any, are in place for the safety of the SP. Establish a safe word as required. 
• Ensure the SP has contact info for the instructor running the event day-of if there is any issues with accessing the facility, if they get lost, or if they can no longer attend (i.e. sickness, etc.). 

How do I properly train up an SP for a case-based scenario? 

• Provide an SP profile [LINK] that provides them the necessary background information on the person they are portraying including (but not limited to) - key demographic information, social history, health history, current presentation, motivations, etc. 

  • Provide the SP profile at least 48 hours in advance so that they can ask any follow-up questions and have enough time to memorize necessary information.

• Provide an SP script – this script will provide a step-by-step walkthrough of the:

  • Starting set-up, SP location and their demeanour, 
  • Opening line for the SP, 
  • The expected learner actions at each stage, 
  • The expected SP responses to actions, 
  • Key triggers to change language/verbiage/body language/action 
  • Key if this = then this statements that cause case to change direction 
  • Key operator/faculty instructions (can be separate if it will overwhelm SP), 
  • How the case is expected to close, and 
  • Key safety considerations. 
  • Three templates for SP cases are available here [LINK]. Provide the SP case template at least 48 hours in advance so that they can ask any follow-up questions and have enough time to memorize necessary information. 

• Inform the SP what sort of clothing they will be expected to wear during the case. For example, a hospital gown, loose light-fitting clothing, or normal street clothes. Indicate whether a second set of clothes is recommended (i.e. in case gel or fluids accidentally ends up on the clothing).

  • Note: if clothing is expected to be damaged/stained/etc. during case then the institution/instructor should provide the clothing 

• Perform at minimum of a walkthrough with the SP, ideally a dry-run. During this time, clarify:

  • Key triggers, 
  • Check interpretations of phrases/body language from SP, 
  • Provide direction on what phrases or actions cannot be modified (i.e. standardized) vs. what can be improvised 
  • Review set-up and key safety considerations (i.e. fitting of task trainers, slip/trip hazards, location of instructor, etc.) 

• Create safety protocols for both physical and psychological safety. Establish a safe word. Review prebrief and ensure everything is mentioned to keep SP safe including considerations for sharps, electricity, and simulated medication. 

• If the case involves a skill(s), demonstrate or show a video of the skill. Explain what safety precautions, if any, are in place for the safety of the SP. Establish a safe word as required.

• If a hybrid SP/task trainer is used, ensure the SP is knowledgeable and comfortable with the task trainer, or the manikin they are interacting with. 

• Ensure the SP has the contact info for the instructor running the event day-of if there is any issues with accessing the facility, if they get lost, or if they can no longer attend (i.e. sickness, etc.). 

What are some key considerations for day-of SP integration? 

• Ensure the SP is oriented to the space. 
• Provide an opportunity for a dry-run in advance
• Provide time for application of make-up/special effects. 
• For hybrid cases, provide time to walk-through timing, or for application of the task trainer. 
• If the SP is to be involved in the debrief, go over the debriefing guide and expected goals/take-aways to ensure they are on the same page. 
• Consider including SP in lunch order or catering 
• Have a dedicated area for the SP to prepare for the case and for breaks/pauses in-between cases. 

Templates and Best Practice Resources #

Templates  #

• https://www.aspeducators.org/aspe-case-development-template 
• London Health Sciences Centre https://www.lhsc.on.ca/media/9428/download 

Where do I go to find more information on SPs?

• Association for Standardized Patient Educations (*membership required for some information): https://www.aspeducators.org/standards-of-best-practice
• Healthy Simulation https://www.healthysimulation.com/healthcare-simulation/
• International Nursing Association for Clinical Simulation and Learning (*membership required for some information):https://www.inacsl.org/healthcare-simulation-standards

References #

https://www.crisisprevention.com/CPI/media/Media/elearning/flex/PDF_NCI-Risk-of-Restraints.pdf 

https://www.med.ubc.ca/about/careers/standardized-patient-program/#:~:text=What%20is%20a%20Standardized%20Patient,Standardized%20Patients%20vs%20real%20patients 

 Healthy Simulation Standardized Patient | Healthcare Simulation | HealthySimulation.com 

Block, L., Brenner, J., Conigliaro, J., Pekmezaris, R., DeVoe, B., & Kozikowski, A. (2018). Perceptions of a longitudinal standardized patient experience by standardized patients, medical students, and faculty. Medical Education Online, 23(1), 1548244.

Lewis, K.L., Bohnert, C.A., Gammon, W.L. et al. The Association of Standardized Patient Educators (ASPE) Standards of Best Practice (SOBP). Adv Simul 2, 10 (2017). https://doi.org/10.1186/s41077-017-0043-4