Graduate students' experiences with standardized patients as adjuncts for teaching pelvic examinations

Standardized Patients in Medical Education: A Review of the Literature

The concept of standardized patients (SPs) was first introduced in the 1960s by Dr. Howard Barrows of the University of Southern California and has been applied in medical school education since that time. This practice has allowed medical students to practice skills on live persons who are teachers rather than on real patients, who may be endangered by their emerging skills. Previous studies supported the use of SPs but did not measure whether they improved clinical competence or students' confidence in their skills. This literature review evaluated whether current medical education literature supports or refutes the use of SPs compared to other modalities such as simulated patients (SiPs) and virtual reality (VR) in the improvement of student confidence, clinical performance, and interpersonal communication skills. The research questions posed for this review were as follows: do medical students in their first two years of education who have practiced skills using SPs have more self-confidence in their ability to perform skills on real patients than those students who did not use SPs, do medical students in their third and fourth years of medical school have higher clinical competency with sensitive patient examinations after using SPs in their first two years of medical education than those students who did not use SPs, and do medical students who have used SPs for discussing sensitive issues have better interpersonal skills when they encounter real patients in the clinical setting than those who have not used SPs? The methodology for this descriptive, systematic review of the literature was organized using a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart to describe how articles were collected and synthesized to evaluate the variables under study. The results of this study revealed that students learned the most when SPs were used because they were able to teach students the skills that they needed in a safe learning environment. Medical students performing sensitive patient examinations with SPs learned not only how to perform the examinations but also how to improve their communication with patients. Students and residents reported increased confidence and clinical competence when performing new skills with SPs rather than with peer practice, virtual reality, or real patients in a clinical setting. Although the utilization of SPs has been studied in multiple ways and found to be a powerful tool in the education of undergraduate medical students and interns, there is still much study to be done to address the human needs of real patients. Gaps in this literature included small sample sizes, a lack of standardized assessment tools, and the need to include a multidisciplinary approach that addresses cultural awareness and appreciation. The authors found limited studies analyzing the effect the coronavirus disease 2019 (COVID-19) pandemic had on the use of SPs in medical school education. Continued scientific inquiry in post-pandemic medical education is an essential component for dissemination as most schools have reintroduced the use of SPs, which strengthens the concept that their use is superior to the other simulation methods used when SPs were not available.

Content and characteristics of evidence in the use of standardized patients for advanced practice nurses: A mixed-studies systematic review

OBJECTIVES

The use of Standardized Patients (SPs) as a supplement to traditional clinical experience is of interest in the advanced practice nursing curriculum. Yet, evidence exploring this area is limited. This systematic review aims to consolidate and synthesize findings on the available evidence of using standardized patients (SPs) on advanced practice nurse (APN) students' learning and assessment experiences.

DESIGN

Mixed-studies systematic review.

DATA SOURCES

PubMed, EMBASE, Cochrane Library, CINAHL, Scopus, PsycINFO, and ProQuest Dissertations and Theses from the inception of each database to May 2022.

REVIEW METHODS

Quantitative, qualitative, and mixed-method studies involving the use of SPs for education and assessments among APN students were included in this review.

RESULTS

Twenty studies were included. Three themes were identified through thematic synthesis: (1) Benefits associated with standardized patients, (2) Uniqueness of standardized patient experience, and (3) Preference and way forward. Overall, these students benefited from refining knowledge, clinical skills, and communication skills, and perceived a boost in confidence in their nursing competencies through SP simulations. More studies with rigorous methodology are needed to ascertain the causal relationships between SP simulations and APN students. Future studies should evaluate the cost-effectiveness of SP, especially in low-income countries. Inter-professional SP simulations and hybrid simulations should be explored further. Considerations for improvements include allocating more sessions for multisource feedback, offering dyadic or group support, and providing assessments that are more formative during simulations.

CONCLUSIONS

SP simulation can complement traditional clinical experience in providing APN students with the knowledge, clinical skills, and communication skills in the real-world context.

Hybrid simulation of pediatric gynecologic examination: a mix-methods study of learners' attitudes and factors affecting learning

BACKGROUND

Children and adolescents with reproductive health issues may require immediate or emergency care, however in many countries availability of the pediatric and adolescent gynecology (PAG) service is low. That being said, teaching PAG examination to OBGYN, pediatrics and emergency medicine residents seems reasonable, and cannot be underestimated. In order to provide residents with opportunity to learn PAG examination, a high-fidelity hybrid simulation workshop was implemented in our institution.

METHODS

The study aimed to investigate learners' attitudes towards the high-fidelity simulation (HFS) hybrid model as compared with task trainer-SP (simulated patient)-voice model in the HFS environment and the factors connected to learners' attitudes towards the hybrid model that could influence learning in high-fidelity simulation (HFS). The concept of attitude was used as the theoretical framework and the mixed method approach to study design was utilized with simultaneous collection of quantitative (original questionnaires) and qualitative data (semi-structured interviews).

RESULTS

Residents valued the HFS hybrid model higher over task trainer-SP-voice model in regards to all three attitude components: cognitive (95%), affective (87.5%) and behavioral (83.7%). Analysis of qualitative data revealed six themes important to learners and informing learning of PAG examination in HFS. Further analysis of the themes allowed to develop a conceptual model, in which six factors connected to attitude components influenced learning. These factors were: task difficulty, attention, emotional realism of the simulation, patient's emotions, physical realism of the simulation, and technical issues.

CONCLUSIONS

Participants of our study appreciated learning experience with the HFS hybrid model more, based on attitude questionnaire. Moreover, findings revealed that multiple, various factors connected to attitude may influence learning of PAG examination in HFS with hybrid model, and we propose a conceptual model illustrating relationships between those factors.

Does medical students’ gender affect their clinical learning of gynaecological examination? A retrospective cohort study

Introduction

Medical graduates should be competent in gynaecological examination as well as associated skills including speculum use and swabbing. Male and female medical students may have different opportunities to practise these skills in clinical environments, potentially impacting on confidence and competence. This study explores this further via reviewing students’ learning experience in genitourinary medicine (GUM) and obstetrics and gynaecology (O&G) clinics.

Methods

Cross-sectional study of 759 year 4 and year 5 University of Birmingham medical students via an online questionnaire. This explored degree of participation, impact of gender and self-reported confidence.

Results

Overall response rate was 31% (233/759). Students of either gender who observed an examination being performed by a clinician were more likely to perform the same examination. Female students reported more opportunities to practise gynaecological examination and associated skills. Female students were more likely to be granted consent to perform speculum examinations, vaginal swabbing and vaginal bimanual examinations. Sixty-five per cent of male students felt that their gender affected their learning experience with female patients. Despite this, there was no significant difference in self-reported confidence level in performing gynaecological examinations between genders at the end of placement.

Conclusion

The majority of male students perceived that their gender impacted their clinical experience in O&G and GUM. Self-reported confidence levels were unaffected, which could reflect varying approaches to competence between genders. The link between observing examinations and subsequent opportunities to practise is key. This could demonstrate students developing rapport and trust with patients, and clinicians’ roles as gatekeepers.

Clinical simulation with dramatization: gains perceived by students and health professionals

Objective:

to identify in the literature the gains health students and professionals perceive when using clinical simulation with dramatization resources.

Method:

integrative literature review, using the method proposed by the Joanna Briggs Institute (JBI). A search was undertaken in the following databases: Latin American and Caribbean Health Sciences Literature, Web of Science, National Library of Medicine, Cumulative Index to Nursing and Allied Health Literature, The Cochrane Library, Scopus, Scientific Electronic Library Online.

Results:

53 studies were analyzed, which complied with the established inclusion criteria. Among the different gains obtained, satisfaction, self-confidence, knowledge, empathy, realism, reduced level of anxiety, comfort, communication, motivation, capacity for reflection and critical thinking and teamwork stand out.

Conclusion:

the evidence demonstrates the great possibilities to use dramatization in the context of clinical simulation, with gains in the different health areas, as well as interprofessional gains.

Hybrid simulation compared to manikin alone in teaching pelvic examinations: a randomised control trial

Introduction

Performing a pelvic examination is a core skill for all medical undergraduates. The use of hybrid simulation, manikin with patient actress, to attain technical and communication skills competencies and to improve the quality of care we offer women, has not been compared to other teaching methods before. Outcome measures were technical skills, communication skills and confidence in completing a pelvic examination.

Methods

A cluster randomised control trial was conducted over an academic year. Forty-eight medical students who completed an 8-week obstetrics and gynaecology attachment were recruited. Clusters were randomly assigned for initial training on hybrid or manikin only models and attended an end of attachment Objective Structured Clinical Assessment.

Results

Outcome data were received for 43/48 students (89.5%). Following the objectively structured clinical examination, the hybrid trained cohort had higher technical scores (mean 23 (95% CI 20.1 to 25.8) vs 16.7 (CI 14.7 to 18.6); mean difference 6.3, CI 3.0 to 9.6) and communication skills scores (mean 22.6 (CI 21.2 to 23.8) vs 15.9 (CI 14.4 to 17.3); mean difference 6.7, CI 4.8 to 8.5) compared to the manikin only trained participants. Confidence in undertaking future pelvic examinations were similar in the control and intervention groups; (p=0.10, r=0.18).

Conclusions

This study demonstrates the value of hybrid simulation compared to manikins alone in improving the short-term acquisition of competence in simulated pelvic examinations at an undergraduate level. Future research should focus on whether hybrid models lead to long-term acquisition of skill and comparison of these models with other innovative methods such as clinical teaching associates.

The effectiveness of gynaecological teaching associates in teaching pelvic examination: a systematic review and meta-analysis

CONTEXT

An increasing number of graduating students are unable to competently and confidently perform a pelvic examination. Gynaecology teaching associates (GTAs) teach technical and communication skills and offer immediate feedback. The objective was to perform a systematic literature review to assess whether teaching pelvic examinations using real women who are trained to give instructions on technique and feedback improves the competence, confidence and communication skills of trainees when compared with traditional teaching methods.

METHODS

MEDLINE, EMBASE, the Cochrane Library, CINAHL and the ISRCTN Register of Clinical Trials were searched using selected terminology. No language restrictions were applied. The selection criteria were randomised clinical trials (RCTs) and controlled studies that investigated the use of GTAs to teach students or health-related professionals the pelvic examination. Data evaluating study outcomes, along with methodological details, were extracted in duplicate. The outcomes measured were: self-reported confidence, assessed competence and assessed communication skills. The standard mean difference (SMD) was derived for each study where possible and heterogeneity across studies was quantified using the I(2) statistic. In the presence of substantial variation, the data were pooled using a random effects model.

RESULTS

Eleven studies with 856 participants were included: five RCTs and six observational studies. GTA training improved competence compared with other teaching methods and the finding of enhanced competence was consistent when the pooled analysis was restricted to RCTs. Communication skills were also improved with GTA teaching, but to a lesser degree, whereas no effect on student confidence was observed. Statistical heterogeneity was present for all outcomes when data were pooled.

CONCLUSION

Our findings suggest that GTA-based teaching of pelvic examination is associated with improvement in the competence and communication skills of trainees. However, further larger-scale studies with standardised relevant educational outcomes are needed to confirm these findings.

Standardized Patient Encounters Improved Athletic Training Students' Confidence in Clinical Evaluations

Context

Researchers have reported that interacting with standardized patients (SPs) is a worthwhile and realistic experience for athletic training (AT) students. These encounters enhance students' interviewing skills, confidence as a clinician, clinical skill development, and interpersonal communication.

Objective

To determine how SP encounters impacted students' confidence in performing clinical evaluations.

Design

Pretest-posttest survey design.

Setting

Athletic training simulation lab.

Patients or Other Participants

Thirty-five students from the junior (n = 20) and senior (n = 15) AT cohorts from a public liberal arts institution in the Southeast.

Intervention(s)

Athletic training students completed 2 SP encounters per semester throughout an academic year in the AT program, totaling 4 SP encounters.

Main Outcome Measure(s)

Each student completed a 17-item Likert scale (1 = strongly disagree, 5 = strongly agree) that rated confidence levels immediately before and after each SP encounter. The confidence rating assessed students' confidence regarding how the SP encounter affected their confidence in completing patient evaluations (eg, identifying history questions, interpreting results of special tests). We computed descriptive statistics for all items Wilcoxon signed rank tests determined differences in pre-encounter and should be postencounter confidence ratings.

Results

Overall, students from both cohorts reported that the SP encounter improved confidence in completing clinical evaluations. Specifically, students reported a significant increase from pre-encounter to postencounter confidence ratings after nutrition-based (Z = −2.991, P = .004), knee (Z = −3.261, P = 0.001), concussion (Z = −3.294, P = .001), psychosocial intervention (Z = −3.062, P = .002), and general medical (Z = −3.524, P > .001) SP encounters.

Conclusions

The authenticity and fidelity of the SP encounter provided the AT students a real-time clinical evaluation in a nonthreatening environment. Students reported that their confidence improved after each encounter. By providing these experiences, AT students can become comfortable interacting with patients in clinical evaluations.

Digital rectal examination skills: first training experiences, the motives and attitudes of standardized patients

BACKGROUND

Physical clinical examination is a core clinical competence of medical doctors. In this regard, digital rectal examination (DRE) plays a central role in the detection of abnormalities of the anus and rectum. However, studies in undergraduate medical students as well as newly graduated doctors show that they are insufficiently prepared for performing DRE. Training units with Standardized Patients (SP) represent one method to deliver DRE skills. As yet, however, it is little known about SPs' attitudes.

METHODS

This is a qualitative study using a grounded theory approach. Interviews were conducted with 4 standardized patients about their experiences before, during and after structured SP training to deliver DRE competencies to medical students. The resulting data were subjected to thematic content analysis.

RESULTS

Results show that SPs do not have any predominant motives for DRE program participation. They participate in the SP training sessions with relatively little prejudice and do not anticipate feeling highly vulnerable within teaching sessions with undergraduate medical students.

CONCLUSIONS

The current study examined SPs' motives, views, expectations and experiences regarding a DRE program during their first SP training experiences. The results enabled us to derive distinct action guidelines for the recruitment, informing and briefing of SPs who are willing to participate in a DRE program.

Learning in simulated environments: effect on learning transfer and clinical skill acquisition in nurse practitioner students

This research study examined whether a transfer of learning (i.e., growth in clinical competency) occurred from the simulation laboratory to the clinical bedside and if it did occur, how. The study design was descriptive research, using 14 acute care nurse practitioner students. Observations were done in the simulation laboratory with a standardized patient and then in the clinical setting with an actual patient. The results showed significant growth in overall clinical competency from the simulation laboratory to the clinical bedside (M(diff) = 0.08, SE = 0.02, t(13) = 3.03, p = 0.01, r = 0.64). A statistically significant correlation was noted between the overall competency scores of students in the simulation laboratory and the overall competency scores in the clinical setting, with r(12) = 0.63, p < 0.01. Three themes emerged from the students' responses regarding how the simulation experience affected their clinical competency.

Implementing high-fidelity simulation in Canada: reflections on 3 years of practice

This paper explores our experiences in implementing and using high-fidelity simulation (HFS) over the last three years, in the context of the results of the Canadian Association of Schools of Nursing (CASN) health 2006 simulation survey, which explored the use of simulation across Canada in professional health education. Considerations for the practical implementation of simulation based on evaluations at the University of British Columbia School of Nursing are discussed. The rapid increase in the uptake of simulation-based education in Canada is due in large part to the belief that these techniques offer a safe environment for learners to improve competence. Students and teachers have identified positive learning experiences with high-fidelity simulation, particularly with respect to complex patient care scenarios, multidisciplinary team scenarios, student team work (i.e., team-based learning), and reflective debriefing. Despite these benefits there have been significant resource implications from adopting these technologies. The use of team-based learning and reflective debriefing appeared to be a focal area for emphasis in the planning of clinical simulation experiences. A team focused learning approach may also offer a more cost-efficient strategy for clinical simulation.

Patient involvement in teaching and assessing intimate examination skills: a systematic review

OBJECTIVES

There are recognised difficulties in teaching and assessing intimate examination skills that relate to the sensitive nature of the various examinations and the anxiety faced by novice learners. This systematic review provides a summary of the evidence for the involvement of real patients (RPs) and simulated patients (SPs) in the training of health care professionals in intimate examination skills.

METHODS

For the review, 'intimate examinations' included pelvic, breast, testicular and rectal examinations. Major databases were searched from the start of the database to December 2008. The synthesis of findings is integrated by narrative structured to address the main research questions, which sought to establish: the objectives of programmes involving RPs and SPs as teachers of intimate examination skills; reasons why SPs have been involved in this training; the evidence for the effectiveness of such training programmes; the evidence for measures of anxiety in students learning how to perform intimate examinations; how well issues of sexuality are addressed in the literature; any reported negative effects of involvement in teaching on the patients, and suggestions for practical strategies for involving patients in the teaching of intimate examination skills.

RESULTS

A total of 65 articles were included in the review. Involving patients in teaching intimate examination skills offers advantages over traditional methods of teaching. Objective evidence for the effectiveness of this method is demonstrated through improved clinical performance, reduced anxiety and positive evaluation of programmes. Practical strategies for implementing such programmes are also reported.

CONCLUSIONS

There is evidence of a short-term positive impact of patient involvement in the teaching and assessment of intimate examination skills; however, evidence of longer-term impact is still limited. The influences of sexuality and anxiety related to such examinations are explored to some extent, but the psychological impact on learners and patients is not well addressed.

Undergraduate students as standardized patients to assess advanced practice nursing student competencies

Evaluating clinical skills of students in an online distance education program can be challenging because of the diverse location of students. The authors describe a unique and cost-efficient method of using standardized patients to evaluate these skills. The project involved undergraduate students representing standardized patients for graduate advanced practice nurse students.

Patient Communication Simulation Laboratory for Students in an Acute Care Nurse Practitioner Program

Background Effective communication skills for clinical practice are essential for all advanced practice nurses. However, competence in these skills is not necessarily intuitive. Advanced communication skills should be taught in a way that is similar to the way other psychomotor skills in advanced nursing practice programs are taught.

Objectives To develop a patient communication simulation laboratory for the acute care nurse practitioner program at a major university and to evaluate students’ perceived confidence and communication effectiveness before and immediately as well as 4 months after completion of the laboratory.

Methods The communication simulation laboratory was developed in collaboration with faculty from the schools of nursing and medicine. Students participated in a didactic session and then completed a 2-hour communication simulation in the laboratory. Content and simulation concentrated on breaking “bad news,” empathetic communication, motivational interviewing, and the “angry” patient. Students’ self-reported confidence and perceived skill in communication were measured via a Likert scale before, immediately after, and 4 months after completion of the laboratory simulation. Students also evaluated the experience by responding to open-ended questions.

Results Compared with baseline findings (before the lecture and simulation), students’ confidence in initiating difficult conversations increased significantly both immediately (P&lt;.001) and 4 months after (P=.001) the laboratory simulation. Students’ self-ratings of overall ability to communicate were also significantly greater immediately (P&lt;.001) and 4 months (P=.001) after the simulation. Overall, students rated the laboratory simulation experience highly beneficial.

Conclusions The content and methods used for the simulation improved students’ confidence and perceived skill in communication in potentially difficult acute care situations.