Considerations when using standardized patients in EMS simulation
The use of live humans as part of a simulation activity enhances realism by allowing a more realistic communication exchange that includes nonverbal cues. EMS has long used “actors” to portray an illness or injury during a simulation.
Many of us can remember our paramedic school instructors often stepping in to play the part of the patient. Embracing standard language from the Healthcare Simulation Dictionary, actors come in many forms based on the need of the simulation activity: embedded participant, role player, simulated person and standardized patient.1
Standardized pateints are defined as “a person who has been carefully coached to simulate an actual patient so accurately that the simulation cannot be detected by a skilled clinician.
In performing the simulation, the standardized patient presents the gestalt of the patient being simulated; not just the history, but the body language, the physical findings, and the emotional and personality characteristics as well.”1
The addition of the integrated out-of- hospital scenario to the National Registry of EMTs Paramedic Psychomotor Exam has increased the need for and use of standardized patients in EMS simulation activities.
This column will focus on the best practice of using standardized patients in simulation activities that will improve validity and reliability.
History & Challenges
The use of standardized patients in medical education programs can be tracked back to the 1960s.2 Over the years, standardized patient programs have been refined to provide better safety for the standardized patient and a more accurate experience for the participants.
Standardized patients are primarily used in medical schools to evaluate common competencies such as communication, clinical reasoning and diagnosis.3
They are also often used in summative objective structured clinical exams, which are used when determining the progression of a medical resident.
Today, healthcare education is seeing a broader application of standardized patients, as the importance of assessing human factors, crisis communication and patient dialogue has become invaluable for improving patient safety.
Identifying the optimal way to integrate a standardized patient into a simulation activity isn’t an easy task. Simulation activities with standardized patients are typically more challenging to design due to the numerous variables that exist when using human participants in a scenario.
The standardization of behaviors and presentations that’s essential for valid and reliable assessments is particularly tricky given human nature—and the possibility for extemporization (i.e., improvisation) by the standardized patients.
As educators, it’s imperative that students are provided with a fair, valid, and realistic learning and evaluation environment.
Given the amount of research on the value of SP use, embracing the evidence is the next best step of our evolution in simulation education.3
The Association of Standardized Patient Educators (ASPE) has compiled the evidence and has identified four domains of best practice: 1) safe work environment; 2) case development; 3) SP training; and 4) program management.4
Safe Work Environment
This is achieved by developing policy, procedures and standards that define expectations related to standardized patient involvement within the program.
Outlining clear parameters up front avoids many issues, and more importantly, maintains safety for all involved in the activity. General policies should address the following (although this is not necessarily a complete list): recruitment, formal training, operations, assessment, opting out, confidentiality, respect and quality assurance.
Once policies are established, recruitment of the SP candidates can begin. standardized patients can be recruited in a variety ways, such as local theater groups, nearby EMS agencies, drama clubs and civic associations, to name just a few.
Using minors as standardized patients should be done with caution because of parental consent issues and the higher likelihood of exposing educators and programs to legal risks. Further, the EMS environment is probably not an ideal situation for them to be exposed to.
As with other simulation activities, utilizing standardized patients begins with a needs analysis and identifying the learning objectives of the activity. The case design must be medically probable, reproducible, allow for ample time to evaluate the interaction with the standardized patient, and be appropriate for the level of learner completing the activity.
The standardized patient should be given adequate time and training to assimilate the role.
There should be a pilot test of the activity, allowing educators to ensure the standardized patient is portraying and conveying the proper information reliably, and that this portrayal is reproducable for each and every learner encounter.
It’s imperative to provide the standardized patient with a well-designed script that includes cueing for the standardized patient, as they may have different life experiences or views than what needs to be portrayed.
Faculty colleagues may be a great resource to rehearse the simulation activity, where they can assess the validity and reliability of the standardized patient by looking at the activity through the “eyes” of the learner.3
Before standardized patients can participate in an activity, they need to be trained. Simply finding the first person who’s available and giving them a script the day of the activity is certainly not best practice, and will result in poor validity or reliability of the learning activity or assessment. Training is paramount if the assessment is a summative (i.e., pass/fail) situation.
Training the standardized patient on realistic presentation and guiding them so that they avoid “overacting” is important for clinical decision-making progression.
Community colleges and universities that offer health profession education have medical resource librarians who can be a great resource to assist standardized patients with research related to a realtistic presentation of a specific illness or injury.
If a program is capturing assessment information from the standardized patient, or if the standardized patient will be participating in the debriefing, training to appropriately and accurately assess and provide feedback during debriefing also needs to be provided.
Program management actually begins with establishing the policy and procedures, but then evolves to include quality improvement and engaging with content experts to assist with the development of your standardized patient program.
Collecting feedback from not only the standardized patient, but also the learners, can be invaluable in identifying areas for improvement. This feedback should help refine and improve the standardized patient performance, program performance and learner experiences.
When deployed using these best practices, standardized patients are a valuable tool for the EMS educator to utilize to enhance the learning and evaluation process.
It’s essential for standardized patients and learners to be embedded in a safe learning environment and that the scenario can be reproduced reliably multiple times.
This is especially true when the simulation activity is part of a summative assessment, where the stakes are high, and passing might mean the difference in whether or not the learner will graduate from a program or pass the National Registry exam.
2. Palaganas JC, Maxworthy JC, Epps CA, et al., editors: Defining excellence in simulation programs. Wolters Kluwer: Philadelphia, 2015.
3. Levine AI, DeMaria Jr S, Schwartz AD, et al., editors: The comprehensive textbook of healthcare simulation. Springer: New York, 2013.
4. Lewis KL, Bohnert CA, Gammon WL, et al. The Association of Standardized Patient Educators (ASPE) standards of best practice (SOBP). Adv Simul (Lond). 2017;2:10.