The effectiveness of unannounced standardised patients in the clinical setting as a teaching intervention

A Scoping Review on the Use of Experiential Learning in Professional Education on Intimate Partner Violence

Purpose

Intimate partner violence (IPV) involves any form of emotional, physical, and sexual abuse including controlling behaviors by an intimate partner. Front line service workers such as social workers, nurses, lawyers, and physicians are often the first professionals to come into contact with individuals experiencing IPV but are often inadequately prepared to respond appropriately as IPV education is highly variable. Experiential learning (EL), also known as learning by doing, has gained much attention from educators; however, the extent and type of EL strategies used to teach IPV competencies has not yet been explored. Our aim was to extract what is known from the literature about the use of EL strategies to teach IPV competencies to front line service providers.

Methods

We conducted a search from May 2021 through November 2021. Reviewers independently screened citations in duplicate using pre-determined eligibility criteria. Data collected included study demographics (publication year, country, etc.), study participants, and information about the IPV EL.

Results

Of 5216 identified studies, 61 were included. Medicine and nursing represented the majority of learners in the included literature. Graduate students were the targeted learners in 48% of articles. Low fidelity EL was used most frequently in 48% of the articles; and role play was the EL mode most frequently utilized (39%) overall.

Conclusions

This scoping review provides a comprehensive overview of the limited literature on how EL is used to teach IPV competencies and identifies significant gaps related to the lack of intersectional analysis within educational interventions.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10896-023-00552-4.

Which Violence Against Women Educational Strategies Are Effective for Prequalifying Health-Care Students?: A Systematic Review

Gender-based violence (GBV) is a global public health issue which disproportionately affects women. Health-care providers have an important role in recognizing and addressing GBV in practice, yet research suggests that the issue remains underrecognized, with many qualified professionals reporting lack of confidence and a sense of unpreparedness. Prequalifying GBV educational strategies are inconsistent in both quantity and quality worldwide, and to date, there has been no comprehensive review of those programs' effectiveness. This internationally focused literature review aimed to identify best educational practices in GBV for prequalifying health-care students. A systematic search of six databases yielded 17 studies meeting the inclusion criteria, with all studies examining one or more educational intervention. Quality appraisal was undertaken and data were tabulated to capture relevant information. Thematic findings suggest that interactive educational strategies yield better results than didactic approaches. Similarly, interventions with a focus on practical application of learning are generally preferred over strictly theoretical approaches. Courses of longer duration seem to be more effective in instilling attitudinal changes. Lastly, gendered differences were noted in a number of studies, with female students consistently outperforming males. However, more research is needed before conclusions can be drawn about the effectiveness of single- versus mixed-gender audiences. This review makes a useful contribution to the literature of health education, supporting many findings from previous studies and identifying knowledge gaps to be explored in future research. There are implications for both educators and practitioners in creating discernible change for women in their care.

Use of standardised patients in optometry training

Clinical relevance: The ability to articulate clinical findings to patients through effective communication is a key skill in all health-care professions.Background: Unannounced standardised patients (SPs) are successful in measuring quality of clinical care provided by qualified optometrists but have not been used in optometry training. Final-year undergraduate optometry students examine members of the public during primary care clinics observed by visiting clinical tutors (VCTs) who provide individualised feedback, highlighting areas for improvement. This pilot study investigates whether unannounced SPs can be used as an additional resource providing enhanced feedback on communication skills in undergraduate optometry education.Methods: Two SPs received intensive training on reporting on students eye examinations and communication skills through completion of pre-designed checklists for each patient encounter. Each SP presented 16 times as an unannounced patient for routine eye examinations. SPs' comments on communication skills of 32 students during 32 examinations was compared to feedback from 10 VCTs. SPs' performance was monitored to ensure consistency. Evaluation of differences in quality and quantity of feedback provided by SPs and VCTs was performed using thematic analysis and chi-squared tests. Student feedback on the use of SPs was obtained on completion of the study.Results: Qualitative thematic analysis revealed six overarching themes emerging from 64 sets of feedback. SPs gave significantly more feedback, both positive comments and comments with recommendations, than VCTs for the (a) total number of comments for each theme (p = 0.0000) and (b) detail and depth of these comments. Students reported that SPs commented on aspects of communication (e.g., establishing rapport and body language) not noted by VCTs.Conclusions: Unannounced SPs can provide enhanced feedback on communication skills to final-year undergraduate optometry students. Students greatly valued VCTs feedback; however, they felt SPs commented on elements of communication not noted by VCTs.

The Emotional and Behavioral Impact of Delivering Bad News to Virtual versus Real Standardized Patients: A Pilot Study

Phenomenon: Virtual standardized patients (vSPs) are becoming increasingly common in medical education, though one limitation of vSPs is the artificiality of computer-based simulators. Past research on the use of vSPs has not clearly established whether learners have different emotional responses to real SPs (rSPs) compared with vSPs; however, understanding learners' emotional responses to vSPs is important in providing realistic learning experiences and establishing the validity of this teaching and assessment tool. This study compared the emotional experiences of individuals who interacted with rSPs and vSPs. Approach: Sixty medical students at a medical school in the southeastern United States participated in the study. Participants were randomly assigned to deliver bad news to an rSP or vSP. The vSP for this study used a hybrid intelligence model that allowed a person to "inhabit" the vSP. Salivary cortisol and a self-report measure of mood-the Profile of Mood States, Second Edition (POMS 2)-were gathered before and after delivering the bad news. The SP and 2 independent evaluators rated the behavioral performance of each participant in real and virtual conditions. Participants also rated the performance of the SP. Findings: Participants in both conditions reported increased negative emotionality on the POMS 2 following the SP interaction. There were no significant between-group differences on the POMS 2 or salivary cortisol concentration following the SP interaction. Ratings by the SP and independent evaluators indicated that participants performed similarly on most interpersonal dimensions, except tone of voice. Participants perceived the vSP as less realistic than the rSP. Insights: These results suggest that medical students may have similar emotional and behavioral responses when delivering bad news to a vSP when compared to an rSP. These findings provide support for the continued use of vSPs in training learners to deliver bad news and other communication-based skills and to assess their performance on these tasks.

Understanding the impact of simulated patients on health care learners' communication skills: a systematic review

CONTEXT

Effective communication skills are at the core of good health care. Simulated patients (SPs) are increasingly engaged as an interactive means of teaching, applying and practising communication skills with immediate feedback. There is a large body of research into the use of manikin-based simulation but a gap exists in the body of research on the effectiveness of SP-based education to teach communication skills that impact patient outcomes. The aim of this systematic review was to critically analyse the existing research, investigating whether SP-based communication skills training improves learner-patient communication, how communication skill improvement is measured, and who measures these improvements.

METHODS

The databases Medline, ProQuest (Health & Medical Complete, Nursing and Allied Health Source) and CINAHL (EBSCOhost) Education Resources Information Centre (ERIC) were searched for articles that investigated the effects of SP-based education on the communication skills of medical, nursing and allied health learners.

RESULTS

There were 60 studies included in the review. Only two studies reported direct patient outcomes, one reporting some negative impact, and no studies included an economic analysis. Many studies reported statistically significant third-party ratings of improved communication effectiveness following SP-based education; however, studies were unable to be pooled for meta-analysis because of the outcome collection methods. There were a small number of studies comparing SP with no training at all and there were no differences between communication skills, contradicting the results from studies reporting benefits. Of the 60 studies included for analysis, 54 (90%) met the minimum quality score of 7/11, with four articles (7%) scoring 11/11.

CONCLUSION

SP-based education is widely accepted as a valuable and effective means of teaching communication skills but there is limited evidence of how this translates to patient outcomes and no indication of economic benefit for this type of training over another method.

Enhancing the connection between the classroom and the clinical workplace: A systematic review

INTRODUCTION

Although medical students are increasingly exposed to clinical experiences as part of their training, these often occur parallel with, rather than connected to, their classroom-based learning experiences. Additionally, students seem to struggle with spontaneously making the connection between these spheres of their training themselves. Therefore, this systematic review synthesized the existing evidence about educational interventions that aim to enhance the connection between learning in the classroom and its application in the workplace.

METHODS

Electronic databases (AMED, CINAHL, EMBASE, ERIC, Medline, RDRB, PsycINFO and WoS) were screened for quantitative and qualitative studies investigating educational interventions that referenced a connection between the classroom and workplace-based experiences within undergraduate, graduate or postgraduate medical education.

RESULTS

Three types of interventions were identified: classroom to workplace interventions, workplace to classroom interventions, and interventions involving multiple connections between the two settings. Most interventions involved a tool (e. g. video, flow chart) or a specific process (e. g. linking patient cases with classroom-based learning content, reflecting on differences between what was learned and how it works in practice) which aimed to enhance the connection between the two settings.

DISCUSSION

Small-scale interventions can bring classroom learning and workplace practice into closer alignment. Such interventions appear to be the necessary accompaniments to curricular structures, helping bridge the gap between classroom learning and workplace experience. This paper documents examples that may serve to assist medical educators in connecting the classroom and the workplace.

The Relationship Between Experience With Standardized Patient Examinations and Subsequent Standardized Patient Examination Performance

Standardized patient (SP) exams are becoming an important part of testing clinical skills. The dynamics of this test format warrant exploration. This study is designed to measure the relationship between experience with SPs and performance on a SP examination. A general linear model is used to determine if a relationship exists and the pattern of that relationship as experience increases. There is a linear association between increased experience and better performance in technical domains. In interpersonal skill domains, there is a curvilinear association between experience and performance with improved performance with moderate levels of experience but not in the most experienced group. Different levels of experience with SPs are associated with differences in performance. The varied pattern of associations suggests a possible practice effect or test-taking behavior. Additional studies are needed to assess this potential effect on SP exam validity.

Changes in Clinician Ability to Assess Risk and Help Patients Determine the Need for Hiv Testing

An estimated one of four people with HIV in the United States do not know they have the infection. The Centers for Disease Control and Prevention encourages HIV testing in clinical settings, but there is evidence that this is not done on a regular basis. The purposes of this study were to (a) compare two less traditional teaching methods with a classroom method to determine whether the less traditional methods resulted in greater improvement of clinician knowledge, skill, and willingness to perform HIV risk assessment as the basis for recommending HIV testing; and (b) find out whether there were significant differences in convenience, cost, learner preference, or learner acceptance that would make one method more desirable than the others. Findings from participants in the standardized patient interaction with facilitator feedback (FB) and the case-based self-study module (SSM) were not different from those of participants in the interactive classroom education method (CL). Generally, there were positive changes in knowledge, attitudes, and behaviors over time. Participants preferred standardized patient interaction (FB) and interactive classes (CL) to self-study modules (SSM).

Can simulation replace part of clinical time? Two parallel randomised controlled trials

CONTEXT

Education in simulated learning environments (SLEs) has grown rapidly across health care professions, yet no substantive randomised controlled trial (RCT) has investigated whether SLEs can, in part, substitute for traditional clinical education.

METHODS

Participants were physiotherapy students (RCT 1, n = 192; RCT 2, n = 178) from six Australian universities undertaking clinical education in an ambulatory care setting with patients with musculoskeletal disorders. A simulated learning programme was developed as a replica for clinical education in musculoskeletal practice to replace 1 week of a 4-week clinical education placement. Two SLE models were designed. Model 1 provided 1 week in the SLE, followed by 3 weeks in clinical immersion; Model 2 offered training in the SLE in parallel with clinical immersion during the first 2 weeks of the 4-week placement. Two single-blind, multicentre RCTs (RCT 1, Model 1; RCT 2, Model 2) were conducted using a non-inferiority design to determine if the clinical competencies of students part-educated in SLEs would be any worse than those of students educated fully in traditional clinical immersion. The RCTs were conducted simultaneously, but independently. Within each RCT, students were stratified on academic score and randomised to either the SLE group or the control ('Traditional') group, which undertook 4 weeks of traditional clinical immersion. The primary outcome measure was a blinded assessment of student competency conducted over two clinical examinations at week 4 using the Assessment of Physiotherapy Practice (APP) tool.

RESULTS

Students' achievement of clinical competencies was no worse in the SLE groups than in the Traditional groups in either RCT (Margin [Δ] ≥ 0.4 difference on APP score; RCT 1: 95% CI - 0.07 to 0.17; RCT 2: 95% CI - 0.11 to 0.16).

CONCLUSIONS

These RCTs provide evidence that clinical education in an SLE can in part (25%) replace clinical time with real patients without compromising students' attainment of the professional competencies required to practise.

Standardized patient outcomes trial (SPOT) in neurology

BACKGROUND

The neurologic examination is a challenging component of the physical examination for medical students. In response, primarily based on expert consensus, medical schools have supplemented their curricula with standardized patient (SP) sessions that are focused on the neurologic examination. Hypothesis-driven quantitative data are needed to justify the further use of this resource-intensive educational modality, specifically regarding whether using SPs to teach the neurological examination effects a long-term benefit on the application of neurological examination skills.

METHODS

This study is a cross-sectional analysis of prospectively collected data from medical students at Weill Cornell Medical College. The control group (n=129) received the standard curriculum. The intervention group (n=58) received the standard curriculum and an additional SP session focused on the neurologic examination during the second year of medical school. Student performance on the neurologic examination was assessed in the control and intervention groups via an OSCE administered during the fourth year of medical school. A Neurologic Physical Exam (NPE) score of 0.0 to 6.0 was calculated for each student based on a neurologic examination checklist completed by the SPs during the OSCE. Composite NPE scores in the control and intervention groups were compared with the unpaired t-test.

RESULTS

In the fourth year OSCE, composite NPE scores in the intervention group (3.5±1.1) were statistically significantly greater than those in the control group (2.2±1.1) (p<0.0001).

CONCLUSIONS

SP sessions are an effective tool for teaching the neurologic examination. We determined that a single, structured SP session conducted as an adjunct to our traditional lectures and small groups is associated with a statistically significant improvement in student performance measured 2 years after the session.

Using unannounced standardized patients to assess residents' competency in asthma severity classification

OBJECTIVE

The aim of this study was to test the hypothesis that an educational intervention would increase the competency of pediatric residents in classifying asthma severity as assessed using unannounced standardized patients (SPs).

METHODS

Six SPs were trained to represent mild-intermittent, mild-persistent, moderate-persistent, and severe-persistent asthma. Data from a control group were obtained in 2002-2003. In 2003-2004, after an intervention, data were collected from an intervention group. The intervention consisted of a didactic session and posting the criteria for asthma severity classification. During precepting, faculty obtained a commitment from residents (N = 12) regarding the severity classification. Faculty and residents were blinded to the presence of SPs. The assigned severity of each SP was used as the criterion standard. Residents' severity classification was compared with the criterion standard. To test whether competency improved postintervention, we compared residents' performance by using intervention group versus control group and within-subject control comparisons. Bivariate analyses tested differences in proportions of categorical variables.

RESULTS

Fifty resident-SP encounters were analyzed. The intervention group performed significantly better than controls at each level of training in identifying persistent asthma: postgraduate year 3 (PGY3, 100% vs 71%), PGY2 (71% vs 50%), and PGY1 (50% vs 43%). They also performed significantly better in determining subclassifications of persistent asthma: PGY3 (87% vs 40%), PGY2 (67% vs 33%), and PGY1 (50% vs 33%). All had P < .05. Similarly, for within-subject control comparison, residents performed significantly better postintervention at identification and subclassification of persistent asthma than did the same residents at baseline.

CONCLUSIONS

An educational intervention resulted in significant improvements in the competency of residents in asthma severity classification.

Domestic violence: a national simulation-based educational program to improve physicians' knowledge, skills and detection rates

BACKGROUND

Although physicians are in a unique position to identify and report domestic violence (DV), detection rates are poor.

AIM

To develop a national DV experiential training program, based on standardized patients (SPs), to improve knowledge, skills and detection rates among physicians.

METHODS

The program was initiated by the Israeli Ministry of Health and took place at the Israel Center of Medical Simulation (MSR). Three one-day workshops for physicians were developed, each focusing on intimate partner violence, elder abuse or child abuse. Outcome measures were perceived capabilities, reported case management, and perceived intervention barriers, as obtained by self-assessment questionnaires at baseline and within a follow-up period of six months.

RESULTS

A total of 150 participants took part in 15 workshops. Perception of knowledge and skills, routine screening frequency and reported case management all demonstrated significant improvement. A clear trend to elevation in detection, evaluation and referral rates was found. Ranking of intervention barriers was compared with baseline values and lack of knowledge, lack of skills and psychological difficulties diminished significantly.

CONCLUSIONS

An SP-based experiential DV training program for physicians improved perceived capabilities and overall management of DV cases and reduced intervention barriers in a follow-up period of six months.

A randomized controlled trial using insinuated standardized patients to assess residents' domestic violence skills following a two-hour workshop

BACKGROUND

Residents feel inadequately trained to treat domestic violence victims.

PURPOSE

The purpose was to assess clinical skills of residents participating in a domestic violence workshop.

METHODS

Twenty-seven internal medicine residents were randomized to receive one of two workshops (domestic violence or control workshop). Standardized patients were trained to two domestic violence cases (depressed; injured). The two cases were randomized and insinuated into each resident's continuity clinic at either 1 to 3 months or more than 3 months after the workshops.

RESULTS

The domestic violence workshop residents did not identify the standardized patients as domestic violence victims any more often than residents participating in the control workshop; 16/25 (64%) versus 13/23 (56%), p=.86. However, domestic violence workshop residents were more likely to score 75% or higher on the domestic violence checklist items compared to control workshop residents; 9/25 (36%) versus 2/23 (9%), p=.04.

CONCLUSIONS

Once a standardized patient was identified in clinic as a domestic violence victim, domestic violence workshop participating residents demonstrated better clinical skills than a control group.

Meeting the need to train more doctors: The role of community-based preceptors

Community-based precepting is becoming a critical component of Canadian medical education. Calls from the public to train increased numbers of physicians have placed more students in community-based settings. Other countries are facing similar situations. Understanding the factors that make community-based practitioners decide to teach plays a significant role in recruiting and retaining potential preceptors. Ensuring that there are appropriate numbers of trainees and administrative supports, and that there is adequate recognition of these teachers, may be more important than financial incentives. A positive experience has been shown to reduce stress, enhance professional satisfaction and increase patients' perceptions of their physicians. Ultimately, a positive experience can influence a trainee to take root in a community-based setting. Recognizing the most common causes of preceptor burnout will help to protect this group of faculty. Some of the myths surrounding community precepting, including massive time commitments, significant financial impact and poor patient acceptance of medical students, are discussed. Providing a range of tools to further educate and support this group of medical teachers is critical, especially in light of the rapidly expanding number of training positions.