Older people’s views and experiences of engagement in standardised patient simulation

Abstract

Background

The last two decades have witnessed initiatives aimed at improving the care of older people, including educating nurses so that they are equipped with the skills to care for older people with frailty and complex multimorbidities. It has been suggested that involvement of older service users in nurse education can facilitate the development of nurses’ caring skills by promoting understanding of the reality of older people’s situations. One method of involving older service users is standardised patient simulation (SPS). While some recent studies have acknowledged the importance of considering standardised patients’ experiences and perceptions of simulation, to date few have focused specifically on the experiences of older people.

Methods

In this qualitative study, data were collected via focus groups, whereby older people were invited to discuss their views and experiences of involvement in SPS. Data were analysed using open coding.

Findings

Four themes emerged from the data, demonstrating that involving older people in SPS may be beneficial for their well-being. The four themes were: ‘using personal experiences to improve care’, ‘having a sense of purpose’, ‘preparation and support for SPS’ and ‘feeling appreciated’.

Discussion

While most participants reported that they enjoyed the SPS activities, engagement appeared to have had a much deeper significance for them. Many participants’ responses suggested that involvement assisted them to ‘make sense’ of their experiences of illness and healthcare, and also gave a sense of purpose, of belonging and of being valued.

Conclusion

Findings support the need for nurse educators to consider developing SPS programmes that involve older people.

Introduction

The last two decades have witnessed a number of initiatives aimed at improving the care of older people.^1–5 Despite these initiatives, recent high-profile reports have highlighted that the quality of care for older people is still questionable and, at times, unacceptable.^6–8 Key organisations have responded to these documents by recommending strategies to improve care. Strategies include educating nurses so that they are equipped with the requisite skills to care for older people with complex multimorbidities, frailty and end-of-life care needs.^9–12 It has been suggested that involvement of service users in nurse education can facilitate the development of nurses’ caring skills by promoting understanding of the reality of service users’ situations.^{10 13–16} With this in mind, a UK university developed a module that is delivered in the third (final) year of the preregistration adult nursing curriculum to equip nursing students with the knowledge and skills to provide quality care for older people. Service-user involvement is integral to session development and delivery and is achieved by three approaches:

• Narrative approaches whereby older people discuss their experiences of illness and use of healthcare services.

• Older people discussing their participation in well-being initiatives.

• Standardised patient simulation (SPS) whereby older people role-play patients in acute inpatient settings and multidisciplinary team meetings.

In order to gain insights about these innovative teaching approaches, the teaching team undertook a research study that aimed to explore service users’ views and experiences of their involvement with these teaching methods. This paper reports specifically on service users’ perceptions of their involvement in SPS. The simulation session is based on one clinical situation that is explored at three different points in the patient journey: inpatient on a hospital ward, multidisciplinary team meeting and home visit prior to discharge. ‘Moulage’ makeup is used to simulate injury. The students visit each station for 40 min—20 min simulation and 20 min debrief. Cohort sessions run twice a year. There are approximately 200 students in each cohort, and group sizes are eight students per station (ie, 24 stations, twice a year). There are nine service users in the SPS team. Depending on their availability, service users facilitate between 0 and 6 sessions per cohort. Four service users involved in SPS were initially recruited from the university’s invigilation team. These service users recruited two others via word-of-mouth, and this ‘snowball’ method has been (and continues to be) used successfully to recruit on an ongoing basis. Prior to undertaking SPS, service users undertake training sessions facilitated by module staff during which they are provided with information and training about their simulated character, including medical, social and personal history. They also receive training in debrief strategies and feedback provision. In addition, they have access to a video on which the simulated clinical situation is demonstrated. Service users new to the team are required to observe sessions with experienced service users before taking on the roles themselves.

Background

While most research investigating SPS focuses on learner outcomes, a few recent studies have considered SPs’ experiences and perceptions. This literature has concluded that, in general, participation in simulation is a beneficial experience for SPs. For example, participants from a number of studies reported feeling that their contribution to the education of healthcare professionals is valuable.^17–19 Other studies have proposed that engaging in SPS sessions leads to increased knowledge and understanding of medical conditions, healthcare systems and health behaviours.^20–22 In addition, a few studies have found that engaging in SPS activities can enhance empathy for people with chronic diseases and mental health conditions.^{23 24}

Although overall SPS can be beneficial for those undertaking the activity, there are some risks. SPs can experience anxiety about their simulation performance,^{25 26} and they can become fatigued or exhausted during simulation activity.^{27 28} Furthermore, the medical knowledge gained by participating in simulation can result in SPs worrying about their own health.²⁴

Literature searches of CINAHL, Medline and Web of Science databases using the keywords ‘older people, older adults or elderly’, combined with ‘simulation or standard* patient’ and ‘views, experiences or perceptions’ found no studies to date that focused specifically on the experiences of older people who engage in SPS, yet this is an important area, as older people have particular vulnerabilities. The aim of this aspect of the current study was to explore older people’s experiences and perceptions of their involvement in SPS with a view to generating insight into their understanding of this experience.

Methodology and methods

As the study aimed to explore the complexities of perception and experience, a qualitative research approach was deemed appropriate. Denzin and Lincoln²⁹ proposed that qualitative methods yield rich, in-depth knowledge of how individuals think, experience and behave within given contexts. Approval to undertake the study was granted by the Faculty of Health and Life Sciences Ethics Committee, Northumbria University.

Twenty service users had contributed to the delivery of the module, and all were invited to take part in the study. Fourteen individuals agreed to participate—nine women and five men: four aged 60–69 years, five aged 70–79 years and five aged over 80 years. Individuals who agreed to participate were provided with information about the study, and if they decided to take part, they were asked to complete a consent form. Consent was revisited at all stages of the research process, and participants were able to uphold their right to withdraw from the study at any time. Participants were assured that their identity would remain anonymous throughout the study. They were allocated unique identifier codes, which supported anonymity of data. Data collection took place in university classrooms. All participants were familiar with these settings and felt at ease in these rooms.

Participants were invited to take part in two group interviews. All participants were invited to the first focus group interview (group 1), and 10 participants attended. This general discussion enabled participants to meet and share their diverse experiences. They were invited to discuss their motivations to participate in this curriculum innovation, their views on older people’s involvement in teaching, their experiences of their involvement and their views with regard to what worked well and what was problematic. In recognition that the participants contributed to the delivery of teaching in different ways, a series of second focus group interviews took place. Five group interviews were conducted, and these reflected the nature of the involvement of group members in teaching. There were two interviews with those involved in SPS (n=3 and n=2; three females/two males: two aged 60–69 years/two aged 70–79 years; one aged over 80 years). These discussions explored participants’ reasons for participation, what they considered would be the outcomes of their participation, challenges encountered with regard to participation and their reflections on their experiences.

Focus group interviews were audio-recorded. All data were transcribed verbatim and open coded by individual members of the research team. The data from the first group interview were then marked up to highlight the contribution by the SPS participants. Secondary coding of the initial interview was completed to explore if additional codes relating to SPS would be generated through this additional analysis.

To validate the coding, another team member independently recoded the SPS data, and outcomes were compared with original codings during a team meeting. Variations and similarities in coding were discussed, and this informed the process of collapsing codes into larger categories and development of themes. This allowed elucidation and description of participants’ experiences of SPS, while creating meaningful themes.³⁰

Results

This paper reports on findings that emerged from the whole group discussion (group 1) and the two SPS group discussions (groups 2 and 3). Four themes emerged from the data. These were ‘using personal experiences to improve care’, ‘having a sense of purpose’, ‘preparation and support for SPS’, and ‘feeling appreciated’.

Using personal experiences to improve care

Most participants stated that their primary motivation for becoming involved in SPS was to contribute to the improvement of care for older people. Many recounted care episodes that either they or relatives had experienced. Usually, these accounts were about what they considered to be poor care experiences. These participants felt that involvement in teaching enabled them to contribute to the development of students’ understanding of what older patients want and need when being cared for by nurses:

I think I explained I wasn’t quite happy about one episode. So if they (students) can come back here, and do roleplay with us, and try and introduce into the students a kind of a caring attitude towards older people…If we can accomplish a bit of that, you know…that would be fantastic (2:1).

Participants who had personal experience of nursing care reported that engaging in SPS could be an emotional experience:

I felt quite drained, you know, when you come out of character. You feel it’s like it’s a relief. Because you’re sort of…you do get so into it. And you could almost feel…you could get upset, really. You could get a little bit upset. Because you sort of remember, and think…‘there but for the grace of God go I’ (3:1).

Nevertheless, they said that they continued to take part in teaching because they viewed their involvement as integral to developing students’ caring behaviours and ultimately to improving care for older people:

You are a drained at the end of the day. I go home whacked out. In fact, (wife) has said once or twice, ‘Pack it in’, you know. But, no, I would never do that. But anyway, it’s, it’s quite a thrilling experience, really, to be able to do something like that…you can see it coming out (students’ caring behaviours) (2:1).

Other participants used their age status of being ‘older people’ as a means to enhance students’ learning experience. These participants proposed that because their age reflected that of the characters they were portraying, an element of realism was brought to the classroom:

It’s probably easier somebody closer to the age of the people who might be ill…they feel like we’re patients. And I felt that, you know, I was helping the students get an understanding of people that they were going to come across in their working lives in the hospital scenario (3:2).

Here, participants suggested that this authenticity within the learning environment enabled students to achieve a deeper understanding of older patients’ perspectives.

Having a sense of purpose

Participants acknowledged that they also benefitted personally from their involvement in this type of teaching. For example, many inferred that involvement in the SPS sessions afforded opportunities to engage in purposeful activity. For some, their purpose was to do something that was stimulating:

It gives you something to do. It gives you something to think about (3:2).

This individual highlighted the mental stimulation associated with preparing for and reflecting on the simulation sessions. Others viewed the activity as a means of continuing to engage in a kind of work occupation:

I didn’t want to retire. When I was 65, I didn’t want to stop working. But because the (employer) had the rule, I had to. It’s nice that I don’t have to stop working. I can get up and come and do things. For me, it gave me that (1:4).

This individual explained that growing older had not only marked the end to working life, but also the end to a previous role as a mentor for young people. For this person, engaging in simulation sessions provided an opportunity to reclaim that role:

It is lovely to see the young people. As I say, I’ve dealt with young people for most of my adult life, in one way or another. From being a guide captain to helping with air cadets. So it is nice. And my own children. So it is nice to still have that input, and still be able to give the students something (1:4).

For some participants, SPS sparked renewed interest in the activities and aspirations of their youth. For these participants, teaching was not a work substitute, but rather an opportunity to fulfil old ambitions that had been put on hold during their working and parenting lives. For example, one participant described how SPS afforded opportunities to realise a youthful aspiration for acting:

I never thought I’d get the chance to do this, quite honestly. I mean, a long, long time ago there was these drama groups going on, and I thought, ‘That’s great, that. I wouldn’t mind doing that’. But I never got round to it. But now I’ve fulfilled my ambition (2:1).

For other participants, SPS was about looking forward to the future rather than revisiting the past. These participants explained that in circumstances where the ageing process, chronic disease or disability were inhibiting their mobility, some of their preferred past activities had had to be abandoned. However, age was no barrier (and indeed was a prerequisite) to exploring and engaging with this new activity:

He’ll (partner) be off out walking somewhere – rain, hail, shine, whatever. Because he won’t sit in the house, you know. And I can’t do walking anymore, so this is really something I can do and enjoy (2:2).

Preparation and support for SPS

Most participants said that becoming involved in SPS was an impetus for learning and researching. For many, this learning was motivated by their desire to provide an education experience for students that was as ‘real’ as possible:

I did a bit of research on the internet…because obviously we’re not experts, you know. And the idea behind was to try and make it as realistic as possible for the nurse. So you’re trying to bring things into your role to make them aware of the problems that person would have (1:9).

Others were inspired to develop their knowledge base to a greater extent by engaging in personal study. For example, one participant developed a portfolio of research and information about a range of health issues including physiology, illness progression, and health and social care policy.

Participants indicated that in preparation for the classroom activities, they reflected on their personal experiences of healthcare to identify what care was good and could be built on and what was poor and required improvement:

I had a bad experience with my mother in hospital when she was dying and I just want it to be better, really (3:1).

These reflections could be painful, therefore the teaching team provided opportunities for the SPs to reflect on, and make sense of personal experiences, and to identify how their involvement contributed to enhancing students’ educational experiences, which could lead to enhanced care delivery and improved outcomes.

Feeling appreciated

A number of participants commented on students’ and staff’s appreciation of their engagement in teaching:

And then at the end, they (students) were very, very enthusiastic. And right at the centre of them were very…and thanked us for, you know, doing what we did (1:2).

This appreciation was regarded by participants as an indication that their contribution to teaching was worthwhile:

And the fact they appreciate it at the end shows that it is important for them (1:4).

Participants’ perception that their involvement was valuable was summed up by one participant: ‘You know, I feel like we’ve done good work’ (3:2). This belief in having ‘done good work’ led many to derive a sense of accomplishment from their involvement. They used words such as ‘achievement’ and ‘satisfaction’ to describe their feelings.

A few participants inferred that students’/staff’s appreciation of SPs had the consequent effect of leading to feelings of being valued as a person. For example, one participant commented: ‘It makes me feel quite special’ (1:9). Others commented that involvement led to a sense of belonging and comradeship. Indeed, one participant suggested that older age and retirement was a kind of exile, but engagement with the project enabled her to reintegrate with the world:

They treat us like a member of staff. Like a colleague, which is nice. We’re not treated like outsiders (2:2).

This participant’s allusion to work again suggested that involvement in SPS facilitated a sense of purpose (as discussed above).

A few participants expressed concern that older people might be perceived as a ‘burden’ on health services. Staff/students’ appreciation and valuing of participants’ contribution to the simulation sessions seemed to indicate to participants that their input was recompense for the care they received for health services:

And I feel as though I’ve given something back (1:4).

It’s the fact that you’re putting something back, you know. And you are acknowledged as doing that, and people appreciate what you do (2:2).

Discussion

Some of the benefits and risks identified in previous studies were apparent in this study. For example, participants suggested that the involvement of older people in SPS added authenticity and value to sessions, which they felt supported the development of students’ caring skills.^{17 18} The study found that engaging in SPS can lead to increased knowledge of health topics^{20 21} but that it can be fatiguing.^{27 28} However, the findings of this study also indicated that involving older people in this type of education initiative may be beneficial for their own personal well-being. While most participants reported that they enjoyed the SPS activities, engagement appeared to have had a deeper significance for them. Many responses suggested that involvement in teaching assisted participants to ‘make sense’ of experiences of illness and treatment within healthcare services. For example, some participants used their experiences of poor healthcare as an impetus to improve care for older people. They were able to demonstrate to students the impact of inadequate care on the individual and their family and to work with the students to develop positive caring behaviours. This was cathartic, enabling them to derive a sense of hope that they had contributed to the development of caring and compassionate nurses. For some, this wish to generate ‘good’ from ‘bad’ motivated them to continue to be involved, even though involvement could be a tiring and, at times, upsetting experience.

Gerontological research acknowledges that older people are likely to experience social losses. They may retire, losing their work identity as well as comradeship provided by work colleagues, and may experience reduced recognition for their contributions to society. They no longer engage in intensive parenting and may have lost their family role as provider or advisor. They are also likely to experience the death of significant others and are at increased risk of chronic illnesses and disabilities that impact on their abilities to participate in preferred activities. As a result, some older people are at risk of social isolation and lowered self-esteem.^31–36 Being involved in SPS enhanced the participants’ social network and engagement with what they considered a valued activity. These participants used the physiological presentation and their experiences of older age to advantage to provide authentic learning experiences for students. For these participants, growing older, and indeed looking older, came to mean they were afforded the opportunity to be involved in this new endeavour. SPS engagement also supported participants to reflect on, and make sense of, their life course, in that it provided links to their past lives yet also helped them to look forward to the future. For example, some participants perceived SPS as a means of getting back to work/employment or regaining lost social roles. Others viewed the activity as a chance to fulfil aspirations and dreams that they thought had passed them by. For these participants, the activity offered a link with the past and a sense of continuity.

However, in some cases, ageing and disability meant that participants were no longer able to carry on with activities they had enjoyed in the past. In these instances, teaching provided new interests and achievable activities. For these participants, involvement in SPS signified ability and achievement and focused on what they could do, rather than what they could not do. Involvement in simulation required the participants to undertake preparatory work. For some, this sparked new interests in health-related topics and a desire for learning and research—activities that provided these participants with a sense of purpose.

Involvement in SPS assisted the participants to position themselves in the world, in that it gave them a sense of belonging to, and being part of, a team. Being appreciated by staff and students was integral to fostering these feelings of belonging. The appreciation of others also served to confirm to the participants that their ‘good work’ was valuable. This was particularly significant for some participants who strived to continue to contribute to, as well as appropriate from, society. For these participants, feeling ‘involved’ and being able to ‘give’ were important aspects of life, which they felt they had lost due to retirement or disability. Their responses indicated that, to some extent, being involved in SPS helped them to regain these aspects. Some participants also viewed being appreciated as a sign that others acknowledged and valued them as individuals.

Limitations

This study’s findings are based on the responses of a small number of participants located in one university in England. Although other education providers may use SPS programmes involving older people, differences in how programmes are organised and utilised may influence older SPs’ experiences. The insights and new perspectives offered by this study should therefore be considered by further studies in other contexts.

Conclusion

If older people are to be involved in SPS, it is essential to understand how they perceive and experience the activity. This study suggests that while engaging in the activity can be fatiguing, a number of benefits ensue. Findings support the need for nurse educators to consider developing SPS programmes that involve older people as a learning strategy for students and as a means of promoting the well-being of the older SPs. However, further research in this area is warranted.