Engaging young people as simulated patients: a qualitative description of health professional educators’ perspectives

Abstract

Background

Real patients in clinical placements are important for learning and may well be the ‘gold standard’. However, simulated patients (SPs) are a viable alternative in the absence of this opportunity. While adult SPs contribute to health professions education, child and adolescent simulated patients (CASPs) are less common. This research aims to explore the perspectives of healthcare educators regarding the engagement of young SPs, specifically the identification of barriers and enablers to involving CASPs.

Methods

We used an interpretive paradigm of qualitative description. Thirteen interviewees, all educators involved in SP programmes, participated in semistructured interviews. Data were transcribed verbatim and analysed using an inductive thematic approach.

Findings

Not all participants saw value in engaging CASPs. A number of barriers and enablers to involving them were acknowledged in six themes: challenges and concerns; logistical barriers; benefits of CASPs; overcoming challenges; an ethical minefield; and child safety. Opinions differed with respect to feasibility and necessity for involving CASPs, particularly in the hospital setting where real patients are accessible. All participants articulated the critical importance of ensuring adequate support and adherence to ethical principles if CASPs were involved.

Conclusions

The involvement of CASPs in health professions education is a divisive issue. CASPs’ ability to provide a realistic option for supporting learning is recognised yet perhaps not wholly perceived as a feasible alternative to real patients. Their engagement raises critical ethical, practical, logistical and financial challenges.

Key messages.

What is already known on this subject

• The involvement of child and adolescent simulated patients (CASP) in health professions education is sporadic.

• CASP engagement in both teaching and assessment is seen as valuable to health professions education.

• Practical considerations are key in the discussion about CASP involvement.

What this study adds

• The perspectives of health professional educators can determine whether CASPs are engaged.

• There are a number of enablers and barriers that either perpetuate or preclude their involvement.

• Key concerns are related to ethical considerations and the potential for harm.

Introduction

Caring for young people can be challenging. From birth to late adolescence, the extent of change in communication, growth, development, illness presentation and treatments necessitates a breadth of knowledge and skill acquisition. Young people may not always present to paediatric-specific healthcare settings, so even in generalist degree programmes learners should have some exposure to opportunities that encourage development of core skills including communication and assessment. The opportunity provided for learners to develop the knowledge and skills to provide safe care with respect to paediatrics is often minimal in entry-level health professions education curricula. When present, it is often lean in terms of content and duration with practical learning occurring largely at the bedside with real patients.

Although this access to real paediatric patients is perhaps the ‘gold standard’, it would be remiss of health professions education to leave the learning of practical skills until clinical placement, or worse still, to employment. This places already vulnerable paediatric patients and their families at risk of exposure to unprepared learners delivering potentially unsafe care. This is particularly relevant in high-acuity settings and in situations where parents have the power to restrict or refuse learner access to their unwell child.

Since the 1980s, there has been involvement of adult simulated patients (SPs) in health professions education. SPs are people who have been carefully coached to simulate an actual patient so accurately that the simulation cannot be detected by a skilled clinician.¹ In paediatric education, there is evidence of adult SP engagement as parents; proxy providers of clinical information in the absence of a child patient.^{2 3} This may meet key learning outcomes in relation to interviewing the parent of a sick child, a skill that will enhance preparation for clinical placement. However, it does not provide the opportunity for learners to immerse themselves into the real world of caring for children.

Children and adolescents also contribute to the teaching and assessment of learners through SP roles. Research suggests they have been effectively involved, particularly in medical education.⁴ This engagement remains sporadic with concerns extending from more practical issues such as recruitment and training, through to far more serious apprehension regarding well-being and the ability of education providers to acknowledge and adhere to relevant ethical principles.^{5 6}

Child and adolescent simulated patients (CASPs) are ideally placed to support development of communication skills, physical assessment techniques and health education/promotion interventions. Learner engagement associated with the realism offered by well-trained CASPs can enhance learners’ knowledge and confidence, enabling them to apply theory in simulated practice without harm to real patients.⁷ Green et al ⁶ extol the power of CASPs by identifying it is their feedback that has most impact on learner outcomes. Adolescent SPs are able to realistically portray roles, some of which are highly emotive, with sufficient credibility and consistency to enable their participation in training and assessment.⁸

Learning also occurs for CASPs. The development of communication and assertiveness skills, along with the increased ability to distinguish between good and bad doctors, can ultimately affect their own healthcare, education and employment choices.⁹ Children can also learn about the roles of health professionals in a supportive academic rather than what is sometimes a frightening hospital environment. This can serve to help allay their fears surrounding future healthcare interactions.⁶

The risk of adverse effects for CASPs has been reported.^{6 10 11} Although the nature of these risks varies, for young children particularly we cannot be sure they fully understand what they are being asked to do. The potential for fatigue is acknowledged, as is the possibility of children being unduly affected by the role they play. Adolescents who undertake risk taking or mental health roles are also at risk of displaying negative responses to their SP work; these can be transient and, when identified, may be ameliorated by adequate support and debriefing.^{5 12} This is not universal, however, as some roles do exert a negative consequence that can persist.⁵

CASPs may be a positive adjunct to other teaching methods. It is suggested that involving CASPs is motivated by both intrinsic and extrinsic factors, arising from the individual and the organisation. However, a conversation to identify and address these factors remains absent in contemporary literature.

Research aim

Despite the potential of CASPs for learning and consolidation of knowledge and skills in a realistic yet safe way, they do not have a strong presence in simulation programs. This research explores the perspectives of health professional educators regarding the engagement of CASPs. Of interest to this research is identification of the barriers and enablers that promote and prevent involvement of CASPs.

Research design

Methodology

This research rests on an interpretive paradigm where qualitative description was used to gain an understanding of reasons, opinions and insights into health professionals’ perspectives about engaging CASPs.¹³ Qualitative description is an empirical method of investigation aiming to provide a rich description of the informant’s perception and experience of the world and its phenomena.¹⁴

Recruitment and sampling

We sought participants who could provide detail about CASP involvement but as the pool of potential participants was relatively shallow, participants with known adult SP experience and at least one encounter with volunteer children in health professions simulation were included. Thirteen participants arose from both tertiary academic and healthcare settings where medical, nursing and allied health simulations occurred. All participants were involved in programmes that incorporated at least some paediatric/adolescent health curriculum (table 1). All were contacted by phone or email to ascertain initial interest in participating.

Table 1.

Summary of participants’ work and simulation experiences

Work setting
Hospital/health service	4
Higher education	8
Both	1
Role
Simulation coordinator/facilitator	2
Paediatric/child health and simulation	7
SP-specific coordination role	4
Discipline of learners
Medicine	10
Nursing	7
Allied health	3
Age range of SPs (years)
All ages (5–18)	3
Only children (4–7)	1
Only children (8–12)	3
Only adolescents (>12)	4
Children (4–12 years)	1
Children and adolescents (7–18)	1
SPs engaged for teaching/assessment
Teaching only	5
Assessment only	0
Teaching and assessment	8
Length of experience with CASPs
Minimal (less than 5 times)	2
<2 years	2
2–5 years	1
>5 years	6
Experience only with volunteer children (children who did not have a script to follow, participated in scenarios as themselves)	2
Currency of experience with CASPs/volunteer children
Current	9
Past	4

CASP, child and adolescent simulated patient; SP, simulated patient.

Data collection

Data collection occurred over 5 months in 2019 through semistructured interviews (40–60 min). AG conducted a pilot interview face to face, with the remainder of interviews conducted by phone or internet technology. These were audiotaped to enable verbatim transcription. Researcher field notes also formed part of the data collection process.

Data analysis

Analysis occurred concurrently with data collection until we considered data sufficiency was reached. Decisions around analysis and coding were made through a process of constant questioning of the assumptions made during interpretation and data coding. Themes were confirmed with the use of illustrative quotes and then refined iteratively by all three researchers.¹⁵

Reflexivity

Reflexivity recognises the researchers’ reflective engagement with the data throughout the analytical process. Their values, ethical stance, education and experiences can influence the research process.¹⁶ While personal perspectives can provide unique insights during the interview process, they may also lead to assumptions or neglect of content relevant to the research question. As a paediatric nurse, AG values the core principles of safe practice and child welfare. SP engagement without appropriate safeguards and supports challenges this notion and was difficult to ignore. DN and MB share similar perspectives. DN is a simulation practitioner experienced in working with adult and child/adolescent SPs. MB has past experience as an SP and has extensively taught SP methodology. Both MB and DN are experienced in qualitative research methods.

Findings

Using thematic analysis, we identified six themes that influenced engagement of CASPs:

1. Challenges and concerns.

2. Logistical barriers.

3. Benefits of CASPs.

4. Overcoming challenges.

5. An ethical minefield.

6. Child safety.

Challenges and concerns

Participants expressed views that challenged the need for CASP involvement, particularly where there was little emphasis on child and adolescent health in curriculum or placement activities.

I think the big prevention [for engaging CASPs] is the lack of curriculum around this—as in child and adolescent health—or simulations around that area. (Participant 6)

Participants solely involved in hospital-based education indicated CASPs were unnecessary.

I’m not sure what umm, which programs we’d need to cover off with paediatrics that we can’t do with manikins…we’ve got the paediatric ward for any experience with communication or interacting with children is done on the ward. Then we don’t need simulated patients for that. (Participant 11)

The need for CASPs was further challenged by participants who questioned whether a rationale existed to substantiate their involvement.

It goes back to the, what are you trying to achieve in your session? Are you just chasing the visual realism or the realism of the interaction, rather than chasing what are your learning outcomes? (Participant 8)

CASPs can be involved in assessment, yet this was an area of consternation for many participants. Participant 4 indicated that student assessments had routinely been undertaken with CASPs or children of faculty, but their lack of real signs and symptoms detracted from the learning experience. The realism offered by patients and the ability to safely repeat the assessment many times were key in decisions about engaging CASPs:

It was a decision by the academic team a couple of years ago to trial doing assessments on the wards instead with patients. And they found it was a much more robust exam …. I guess [the students] were able to kind of assess a bit more clearly and were able to differentiate the normal versus abnormal …. So they got more out of it. (Participant 4)

So, once we identified that if we had an adult informant and didn’t have the child present, then we had no issues repeating it. (Participant 3)

There were also concerns raised in relation to the involvement of CASPs in assessment. The first of which relates to the reliability and authenticity of CASP performances.

Obviously in those instances (complex cases) we don’t have children role-playing… we don’t feel that they can consistently do that in a way that would make it equitable for assessment. (Participant 13)

Although there is value in including CASPs in summative assessment, a second concern identified was a deep concern for their welfare and safety:

I think if you’re assessing someone’s competency and you’re not necessarily training them but there’s a summative assessment to train for them, then that would be very useful. But then I’d also worry that people say very odd things in exam settings when they’re under pressure, and so would it be worth the psychological safety of putting kids in that place as well? (Participant 8)

A further risk was identified if SPs were asked to take on a character that may trigger a painful memory or having children believe they really are sick.

I would worry that they’d take that to heart, or they wouldn’t disassociate from it later, or it would increase their awareness of something that perhaps they didn’t need to be aware about at that age. (Participant 9)

Recruiting suitable children and/or adolescents was challenging—even for those who worked with CASPs. The children of faculty were a common source. However, their participation was not always acceptable given the types of roles CASPs were sometimes asked to play and the potentially negative impact on faculty relationships should things go awry.

It was a child of one of my colleagues, and there were challenges that maybe he didn’t want to put them in a situation where they may feel uncomfortable. There may have been an element of protectiveness, I guess. So more aware of their involvement but using them I guess that’s probably something that I’m appreciating more that we shouldn’t be doing. (Participant 8)

Participants identified local schools, or drama/acting students as potential sources of recruitment, although these also had challenges.

It’s always a challenge to work with schools. Because it’s not just about the actual children, it’s about informing the parents and making sure that there’s enough supervision, it’s about transport getting to and from the University. When they’re here we want to make sure that they’re entertained… (Participant 7)

A key challenge beyond actual sourcing of CASPs is their availability. CASPs are often school students themselves, with competing school and external curricular demands limiting their involvement. While scheduling that coincided with school holidays or a weekend was an option, this was difficult to coordinate with academic timetables and as a result, the engagement of CASPs reduced or omitted.

I think mostly it comes down to time and money, and scheduling, because children have to work outside of school hours, in holidays when our uni [sic] students are on holidays themselves. (Participant 9)

Participants reported difficulty in justifying the financial cost of employing CASPs. Parents were often required on-site and this was an additional cost that had to be justified.

Participants who worked with CASPs identified that they can derail a simulation, compromising learning outcomes. Failing to adequately prepare, fatigue, inability to maintain consistency in an assessment or experiencing discomfort within the role were all voiced by participants.

The challenge is I think getting them to do what you want to do, because they might go a bit rogue if they're a child, some of your learning objectives might go out the window if the patient’s not doing what you want them to do, or they're not cooperating at all. I don't know how reliable it would be. (Participant 5)

Logistical barriers

Human resource (HR) requirements such as appropriate remuneration were a key barrier to employment. Documentary processes required for employment were time consuming and participants reported that parents did not view this favourably. While one option was to employ the parent rather than the child, this was also challenging as a result of potential tax implications. Most participants identified that children are given gift vouchers in lieu of money. For some, this may mean the involvement of CASPs either relies on children they know or it falls outside of HR policies. HR policies often mandated that the employee be spoken with directly which was complicated when this was a child. This did not detract from participant 2 employing younger SPs.

‘Well, you’re not the staff member, we need to talk to that staff member,’ and I’m saying, ‘Well, she’s 10 and she’s at school.’ (Participant 2)

Abiding with guidelines for employing young people in acting roles was also considered a barrier. A dedicated child-only space, provision of entertainment options and the need for a dedicated and trained person to look after the children were expensive. In many cases, this was deemed not worth the financial outlay, particularly to programmes where patients or manikins were available.

Parental involvement for young people under the age of legal consent was essential. Parents were asked to read outlines, consent to involvement, facilitate transportation and often remain present as their child’s support for extended time periods, often without financial reward. Parents who worked as SPs or were invested in their child’s SP work expected this; however, others with limited involvement, apart from signing a consent form, found it onerous and time consuming.

Benefits of CASPs

Creating an experiential learning experience in a safe space to support application of didactically imparted knowledge was considered important. CASPs were a key factor in achieving this goal:

It also takes away that lecturing at the student aspect, ‘This is how a child would feel, and these are words that a child wouldn’t understand.’ Here, you’re actually putting the kid there, so they can see how the child is feeling, or they’re seeing for themselves the words that the child does or doesn’t understand, without the lecturer dealing in the third party. (Participant 2)

CASPs were viewed as important to skills teaching that cannot be done with manikins or real patients. A manikin’s inability to mimic the behaviour and mannerisms of children limits their effectiveness, particularly for communication training, while ethical concerns related to learning with real patients problematise their involvement.

There is that capacity to make it much more realistic, particularly when you’re looking at how to get a basic assessment from them when they’re screaming at you, so that communication is much more realistic, and much more authentic, which is important in paediatrics, because your approach to a two-year-old, to a four-year-old, to a ten-year-old, to a fifteen-year-old is very different. (Participant 4)

Assessment in health professions frequently occurs with real patients in practice. Participants identified that CASPs could fulfil this role to protect already unwell patients from repeated examination. CASPs may also better meet the learning needs of students, providing a more consistent and equitable approach to assessment and ensuring patient safety.

The sky’s the limit at that level for areas where we know that students have some degree of difficulty or we’ve got reasonably good evidence to suggest these are the kinds of the ways that students are unsuccessful in clinical practice; that we could build up a repertoire of simulated practice for them before they go out there. (Participant 3)

For some participants, the involvement of CASPs was directly relevant to the adequacy of learner preparation for paediatric care.

Imagine how much care of children and possibly more adolescents is actually being avoided or not taking place because we haven’t adequately prepared people to do it. Simulation done in paediatric adolescent health-type subjects with manikins with parents or whoever playing a role doesn’t meet the clinical needs and the preparatory needs of students for placement. (Participant 3)

Participants alluded to a positive impact on learners’ experiences through provision of feedback from CASPs.

I think the risk of anything is too powerful or could be depending on the age and the subtlety and diplomacy of which it’s delivered, but I think the power comes from the lack of subtlety and diplomacy. I think it’s more real and is a true feeling. (Participant 10)

Positive outcomes for children/adolescents provided an additional rationale for their involvement. Gains in self-esteem, confidence and opportunity to enhance communication skills were repeatedly cited. Adolescents nearing completion of secondary school also gain knowledge that may influence future career choices as well as some learning around actual health literacy (Participant 13).

Overcoming challenges

Perceptions related to the actual need to engage CASPs, along with logistical barriers and a genuine fear about the potential risks, can lead simulation programs to consciously avoid the employment of CASPs. A variety of preparatory and support strategies were implemented to reduce the potential for a scenario to go awry. Three participants commented on the nature of preparation and ensuring children had a clear grasp of the rationale for their participation.

We spent several weeks working in-depth with the children so that they understood that they had a job to do: they weren’t just acting a character, they had a job …. and if the nurses had had this training then that child was going to get a much better experience. (Participant 9)

All participants who currently worked with CASPs offered training, although variable in both duration and content. Attendance was noted as being important to support SPs, mitigate their anxiety and prevent unproductive or negative impacts for learners.

Training is three hours, but less for young children so they don’t get bored. We touch on why we do it, what it’s all about, open and closed-questions, how to go through the interview, how to respond, how much information to hand out to the students, how do you learn your scenario, what you should go through with this scenario. (Participant 2)

Using actor agencies was identified as time conserving as they held responsibility for screening, selecting and initial role preparation. Evaluating both child and family coping skills and ability of the family to offer support was an added benefit of agency recruitment.

…what we find is that when you go through an acting agency you probably sub-select from a population of actors who have a high level of that native skill. … in our suicidal teen case, there’s a point where the actor transitions from deliberately keeping the students at arm’s (length) to then moving into more profound sadness. And if they don’t have significant acting chops (ability) that shift can feel quite forced. (Participant 12)

Participant 12 invited CASPs to meet learners after the scenario as a way of indicating the role-play was overserving to decompress learners and CASP. It also offers SPs the opportunity to derole to avoid them being left with the residue of what may have been an intense psychological experience.

An ethical minefield

The final decision for employing CASPs rested on assessment of ethical concerns and the degree to which they could be mitigated.

There’s a general and broad group of ethical concerns around anything that objectifies a person that puts them in the centre of a situation and that may potentially expose them to risk. That might be around physical risk, it might be around psychological risk, it might be around reactivating them. (Participant 3)

The argument in relation to CASPs’ ability to provide informed consent was present across the data set. Participants with limited experience of CASPs seemed to hold the strongest views in relation to informed consent.

Are children being used for an educational benefit, and we can’t really explain that to them? (Participant 4)

Perhaps a child’s involvement in SP work correlated with their desire to make a parent or someone that they respected happy, and if the children get paid and the money goes to the parent, then is the parent putting their child in those situations to get an income? (Participant 8)

An additional concern related to the sense of self or the confidence young people have to acknowledge their discomfort. This could lead to adverse effects that may have long-term consequences.

…I worry about with children as SPs is the emotional maturity associated with being in a scenario—I remember a girl, I think she was only about six…, after running the whole thing, turned around to her mum and said, Am I going to be all right or do I need an operation? (Participant 8)

As identified earlier, some participants reported the involvement of faculty children as their availability encouraged inclusion in teaching scenarios. Although the children had more of an understanding, were more thoroughly briefed and debriefed by their faculty parent, the potential to negatively impact the child was raised.

…one of the children got quite upset that her dad (faculty) wasn’t around… when he came into the room, he came in character of a dad who’s anxious about… that his daughter had become sick; and sort of ramped it up and played it up. And as soon as she saw him in that sort of position, she started to cry. And we all looked horrified and went, ‘…what have we just done, what have we created.’ (Participant 10)

Recognising potential threats to safety and mitigating them was identified as costly; in some cases, prohibitively so.

What support structures—level of personal experience you have working with children and around children’s psychological safety and whether or not that would mean that you would also have to import consultants into the space as well. (Participant 3)

Although simulations in higher education were identified as potentially risky, exposing children/adolescents to live or in situ simulation was a far greater threat to both physical hurt and psychological well-being.

…an SP within in situ role, with safety and things like making sure that nobody overexcited puts an IV cannula into them and making sure that live defibrillators aren’t around them. (Participant 10)

With potential for both risk and harm, safe practice necessitates strategies designed to mitigate, reduce or remove the adverse effects of SP work. Participants identified a complexity in determining how a scenario may affect a young person over time and perhaps a sense of guilt ensued should they not identify when it may be having an adverse effect.

You’d discover that the performance felt incredibly believable because actually they’d seen this happen in their own home lives. And for some of our actors that was a really powerful helpful and therapeutic experience. They felt like they were taking charge of something that had been incredibly distressing by teaching people about it. And for others we realised that we had to divert them into a different scenario because it was taking an emotional toll. (Participant 12)

Child safety

Working across a range of ages (7–18 years), participant 2 suggested the presence of parents for young children is essential, while for older adolescents a support/contact person is invaluable. CASPs should be reminded they could withdraw from a station or a scenario at any time. Reducing the potential for children to be adversely affected by their experience and leave thinking this is the experience of being a patient can be traumatic, so reminding them it isn’t completely real, is important (Participant 12).

The role of simulation facilitators is essential; but the role of parents is equally important to ensuring child safety. Parents of under-age children have over-riding power of consent over whether they accept the offered roles. Although rarely refused, one participant identified a scenario in which an adolescent was offered a risk-taking role for which consent to participate was denied. Advising both parents and adolescents that they can refuse participation is an essential component of informed consent.

Either they feel pushed in something they don’t want to do or they feel like there’s been an attribution to them as the character traits of the role that they’re playing which may not be a particularly pleasant role; or that they don’t think that they’ve done the job very well and they’re sort of disappointed with their performance. (Participant 10)

Discussion

Our findings identify health professional educators’ perspectives about CASP involvement in health professions education differ quite considerably. These differences are predicated on a mixture of both internal and external factors, perceived benefits and anticipated barriers. This research showed that educators held different opinions with respect to feasibility and necessity, with much less emphasis on their importance in hospital settings where real patients are readily accessible. Although not all participants saw value in engaging CASPs, all could articulate the critical importance of ensuring adequate support and adherence to ethical principles when CASPs were involved.

Whether CASPs are fully engaged in simulation appears to rest on the perceived benefits and constraints. An intrinsic desire to involve CASPs as a means of providing more comprehensive and realistic education was a definite enabler. Constraints were numerous and again arose from intrinsic and extrinsic sources. Some participants had no hesitation in clearly expressing their lack of interest in engaging CASPs as it was an unnecessary and particularly arduous activity. Interestingly, for participants who did see value, a number of barriers were identified that challenged their ability to bring CASPs to the desired level. So regardless of the positive perspectives and beliefs extolled by some participants, extraneous influences had the most impact on whether CASPs were employed.

Constraints

Research suggests health professionals have insufficient training and skills to work effectively with adolescents, yet child and adolescent health is not usually a major component of curriculum.^17–19 Where the inclusion of child and adolescent health is negligible, clearly there is no need for CASPs. Yet even when child and adolescent health is included in the curriculum, some participants still did not support engaging CASPs, preferring manikins or parent SPs. Perhaps, as suggested, manikins and parents are just easier options that come without the challenges of potential harm and lack of repeatability associated with engaging young people. Participants offered a number of practical and logistical issues such as a lack of awareness of suitable recruitment options, HR policies and an increased financial cost associated with training and supporting young people as additional reasons for negating CASP engagement.

Cost extends beyond the purely financial, to include psychological, time and resource requirements. In relation to support needs, involvement of a parent or an adult SP is highly regarded^{20 21} while multiple studies suggest involving a mental health or child communication specialist when young children are involved or when roles are risk taking or stressful in nature.²² Time required for preparing training modules to suit the developmental spectrum of CASPs, ensuring the safety of the environment, incorporating appropriate distraction techniques and having ‘spares’ to reduce fatigue were also cost intensive. The need to pay parents who were not participating was also identified as problematic.

Enablers

While significant obstacles to CASP involvement are apparent, participants also offered equally compelling reasons why they should be involved. For some, CASPs were necessary for an engaging and meaningful curriculum while the ability to mimic reality creates a powerful learning experience that is only safely and ethically available in the academic setting by involving SPs. The power of feedback from young people also provides opportunities for learners to see the impact they are having rather than observe or read about it. There is increasing recognition that the child or adolescent’s voice should be captured to provide richer feedback to students and trainees.⁶ Study participants agreed with the sentiment that adolescent feedback should be encouraged, and those with the capacity to deliver direct, thoughtful and reflective feedback should be trained and encouraged to do so.

Ethics and harm

Every participant, regardless of their experience of working with young SPs, acknowledged ethical concerns as a barrier. Children lacking a complete understanding of what they were being asked to do challenged the notion of informed consent. Seeking consent where limited or no benefit ensued for the CASP was also identified as an ethical dilemma.^{23 24} Concerns about the harms associated with playing risk-taking or complex mental health roles were concerning despite research indicating this can have a preventative effect.⁹ Previous studies have recognised the possible detrimental impacts of intense scenarios and study participants concurred. Exposure to an illness they thought they might develop or to concepts previously unknown, such as a child dying, challenged the ethics of working with CASPs.²⁵ However, even for participants who described harms, most continued on balance to feel their involvement was worth the risk. They did recognise that with increased effort, harms can be mitigated by ensuring children/adolescents are adequately briefed, debriefed and deroled before leaving the simulation environment.²⁵

Standards for working with CASPs

The Association of Standardized Patient Educators (ASPE) Standards of Best Practice (SOBP), published in 2017, provides guidelines to underpin safe practice with adult SPs. These include five underlying values: safety, quality, professionalism, accountability and collaboration. Five domains of best practice (safe work environment; case development; SP training for role portrayal, feedback and completion of assessment instruments; programme management; and professional development) incorporate key practices that provide clear and practical guidelines for achieving desired outcomes and creating simulations that are safe for all stakeholders.²⁶ This research reveals that many of the participants’ perspectives align with at least three of the domains within the ASPE SOBP. Provision of a safe physical and psychological environment involves adequate screening, briefing, debriefing and providing strategies for mitigating or avoiding potential negative outcomes. Involving SPs in case development relates to ensuring SPs are offered information, training, briefing and guidelines about case-specific feedback. Domain 3 identifies the need to adequately prepare SPs for the roles they are assuming in the simulation experience; their case role and, in some situations, their role in assessment. Applying these in an appropriately modified form to CASP programmes would provide a framework that is perhaps missing in the CASP programmes of our participants.

Strengths and limitations

A strength of the study was the semistructured interviews. Although not all participants were deeply immersed in CASP practice, deep reflection on their experiences with SPs and/or volunteer children resulted in rich description of the complexities surrounding their involvement. A qualitative approach also provided multiple methods for data gathering in the form of interviews and researcher field notes.

Recruiting participants was challenging given the limited CASP engagement in simulation programs in Australia. Although there was an effort to recruit from programs associated with all health professions, only three participants engaged CASPs in allied health. Additionally, the majority of participants were from academic rather than healthcare settings. As the study was located in Australia, we acknowledge the applicability of the findings to other countries may be limited by legal, ethical and practical foundations of other national programs. This research explored the perspectives of Australian educators who work with CASPs, and although these experiences are important, further research could analyse these in parallel with the international perspectives and experiences of CASPs to offer a more balanced discussion.

Conclusion

CASPs can meaningfully contribute to health professions education, particularly where real patients are not easily accessible. However, this requires a concerted effort to identify the constraints and harness the enablers. The perspectives of health professionals are at times divisive with strong opinions underpinning arguments for and against CASP involvement.

Because their engagement does raise critical ethical, practical, logistical and financial challenges, acknowledging and analysing these is necessary for CASPs to be perceived as a feasible alternative to real patients.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. Individual participant data that underlie the results have been reported in the article after deidentification.

Ethics approval

This study was approved by the Monash University Human Research Ethics Committee. Participation was voluntary and each participant signed an informed consent form.