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. Author manuscript; available in PMC: 2022 Oct 1.
Published in final edited form as: Hisp Health Care Int. 2013;11(2):72–77. doi: 10.1891/1540-4153.11.2.72

Effect of Emotionally Complex Roles on HIV-Related Simulated Patients

Ximena Triviño 1, Lilian Ferrer 2, Margarita Bernales 3, Rosina Cianelli 4, Philippa Moore 5, Nilda Peragallo 6
PMCID: PMC9526398  NIHMSID: NIHMS1831520  PMID: 24830729

Abstract

Simulated patients (SPs) have participated successfully in nursing and medical education. The SPs portraying stressful situations may have psychological or physiological effects for several days after their performance; however, long-term effects have not been well documented in the literature. The purpose of this study is to investigate the impact of interpreting roles related to HIV among SPs. A qualitative descriptive approach was used for this study. Questionnaires with open-ended questions were conducted immediately after the interpretation of HIV-related roles and a year later by 10 SPs. In addition, a focus group was run a year later using a preestablished interview guide. As a result of direct content analysis, 2 major themes emerged: effects of interpreting roles relating to HIV and complexity of the roles. The findings of this study stress that interpreting an HIV-related role produces emotional, behavioral, and physical effects in SPs, at any stage during the training or performance, and has a long-term impact on their perception of their personal health and risk.

Los pacientes simulados (PS) han participado exitosamente en la educación de enfermeras y médicos. Simular situaciones complejas puede producir efectos sicológicos o fisiológicos incluso varios días después de la interpretación, sin embargo, efectos a largo plazo no han sido bien documentados en la literatura. El propósito del estudio es investigar el impacto de la interpretación de roles relacionados con VIH en PS. La metodología usada fue cualitativa descriptiva. Los 10 PS respondieron a cuestionarios con preguntas abiertas inmediatamente y un año después de la interpretación de los roles en escenarios relacionados con VIH. Además se realizó un grupo focal usando un guión preestablecido. Como resultado del análisis de contenido emergieron dos grandes temas: efectos de la interpretación y complejidad de los roles. Los hallazgos de este estudio informan sobre los efectos emocionales, conductuales y físicos que se producen en los PS, durante el entrenamiento y la interpretación, y también a largo plazo sobre su percepción de salud y riesgo personal.

Keywords: simulated patient, Objective Structured Clinical Examination (OSCE), HIV, AIDS

Simulated patients (SPs) have been used successfully in health education for more than four decades. First introduced by Howard Barrows in the 1960s, the use of SPs has spread extensively; currently, more than 80% of the medical schools use SPs in teaching and evaluation in the United States (Adamo, 2003; Barrows, 1993). Their value as a useful teaching tool for nursing and medical students has been shown both in small group teaching sessions and assessment as well as communication skills (Ramsay, Keith, Ker, & Hogg, 2008). Over the last 10 years, SPs have been introduced in the high-stakes evaluations in Canada, United States, and United Kingdom (Barrows, 1993; Wettach, 2003; Whelan et al., 2005). They are acceptable to learners and can be effective, reliable, and valid as a method of instruction and evaluation (Fraser, McKinley, & Mulholland, 1994; Vu et al., 1992).

The SPs can be drawn from various sources: patient groups, interested laypersons, and professional actors (Barrows, 1993; Hanson et al., 2002; Sayer, Bowman, Evans, Wessier, & Wood, 2002) and can be so real that physicians and residents cannot distinguish between SPs and real patients (Kurtz, Silverman, & Draper, 2005). One of the advantages of SPs is that they can represent “difficult” clinical situations such as medical emergencies or highly charged emotional scenes in a more controlled setting. Communication related to sexual behaviors and HIV are known to be particularly difficult for health professionals who may feel discomfort in discussing HIV-related issues, and situations that cannot be repeated in real life can be replicated for teaching and evaluative purposes (Epstein et al., 2001; Harrison et al., 2000).

Little has been written about the effect on the person acting as an SP (Spencer & Dales, 2006). In general, the benefits—such as improvement of his or her own communication skills, greater tolerance to others, and educational in general—outweigh the adverse effects (Hanson et al., 2002; Wallach et al., 2001; Woodward & Gliva-McConvey, 1995). However, situations that are highly charged emotionally or where the SP portrays at risk behaviors have the potential to create more adverse effects (Bokken, van Dalen, & Rethans, 2004, 2006; McNaughton, Tiberius, & Hodges, 1999). Bokken et al. (2004) reported 73% of mild stress symptoms in SPs and in adult SPs portraying psychologically intense situations, some psychophysiological effects were observed for several days after the performance. Rubin and Philp (1998) found that the SPs’ perception of health care was significantly worse 1 year after performing in an Objective Structured Clinical Examination (OSCE). However, they argue that this may represent a change in their expectations and therefore be interpreted as a positive outcome. Blake, Gusella, Greaven, and Wakefield (2006), in a study with adolescent SPs, did not find any adverse outcomes.

Although HIV-related clinical encounters may be highly charged emotionally, no reports of the effects in SPs who perform them were found in the literature. The purpose of this study is to investigate the impact of interpreting roles relating to HIV/AIDS among SPs because no previous study has been conducted in Chile related to this topic.

Method

Design

A qualitative descriptive approach was used to gather information about perceptions and experiences of a group of SPs who performed an HIV-related role. Focus groups and interviews with open-ended questions were used to collect the information.

Participants

Ten SPs participated in this study. Six were women and four were men, ages ranged between 21 and 32 years old. Seven were professional actors and three had other university degrees but were formally trained for this particular role.

Previously, they had been selected according to the age and gender required to perform the roles as SPs in an OSCE on HIV/AIDS clinical situations and received training to standardize the role at an individual level and also with the other SPs performing the same case. All of the SPs were working at the OSCE.

The OSCE was the evaluation instrument used to assess nursing and medical students attending an HIV training program. The OSCE had five 10-min stations, three of which were run with SPs portraying clinical encounters with patients in the context of HIV-related care, and each SP had to perform his or her role 12–24 times.

The stations were (a) “informed consent”: to obtain consent for HIV testing from an SP acting as a young woman needing an elective surgery, with no HIV risk factor; (b) “pretest counseling”: to assess HIV risk factors and offer a test to an SP performing the role of a pregnant woman on her first prenatal visit; she was worried about HIV because her partner had a history of infidelity and a neighbor was recently diagnosed as HIV positive; and (c) “posttest counseling”: to inform an SP acting as a truck driver about his HIV test result. He was single and bisexual with multiple partners. When the student informs him that the test is positive, he reacts with aggressive denial.

Data Collection

A focus group was conducted 1 year after the simulation with 10 participants led by the principal investigator and coinvestigator of this study, both with experience with this methodology. Before the focus group, refreshments were provided allowing time for the participants to speak informally with the facilitators. At the beginning of the focus group, the facilitator read the consent form to participants, asked them to follow along with the reading, and informed them to ask any questions they may have prior to the commencement of the focus group. Ethical approval for this study was granted by the Ethics Committee, School of Nursing at the Pontificia Universidad Católica de Chile. Once participants agreed to participate, the facilitator asked them to sign the consent form. The facilitator conducted the focus group using a discussion guide. Examples of the questions used to guide the discussion are the following: “How did you feel when you performed these roles?”; “Did you have any effect in your life after this performance?”; and “Did you change any of your behaviors?” Probes were used to stimulate discussion among the group participants. The focus group lasted 90 min and was recorded using digital technology to assure clarity of responses and to facilitate accuracy of transcriptions.

Also, immediately after the OSCE and 1 year later, SPs answered a questionnaire with open-ended questions about the emotional, physical, and behavioral effects of interpreting roles related to HIV at any stage during the training, performance, or postacting until 1 year.

Data Analysis

Qualitative content analysis was used to identify and define the major themes that emerged from the data. Data provided by open-ended questions were analyzed and triangulated with data obtained from the focus group. Content analysis was a method used to recognize, code, and categorize patterns from text data (Patton, 2002; Sandelowski, 2000).

To transcribe the data, three coders worked through the transcripts and coded each of them line by line. Each of the three coders would code every line independent of input from the others. At the point of completion, the results were compared and a 90% agreement of transcription was obtained. The final two themes—effects of interpreting roles related to HIV and complexity of the roles—were decided through consensus among the research team.

Results

Two major themes related to the impact of interpreting roles relating to HIV among SPs were included in the qualitative analysis: (a) effects of interpreting roles related to HIV and (b) complexity of the roles.

Effects of Interpreting Roles Related to HIV

Physical and Emotional Effects.

This theme considered both physical and emotional effects. Regarding physical effects, participants reported having physical tension, nausea, and exhaustion. In addition, the SPs described weariness and headache as well as “losing physical energy, empty stomach, and loss of appetite.”

During the training period for the OSCE, the SPs reported reflecting on issues of discrimination and feeling effects such as fear, compassion, and emotional tension.

SPs reported emotional effects such as anguish, fear of acquiring HIV, feeling worried, and sad.

I had never interpreted a character with such emotional weight; it was the first time I had to confront and deal with such rapid emotions and then I had to repeat it quickly as well, in order to maintain, as we say, the standardization required so that it is the same each time.

The SPs described the challenge of taking on the character “how to think and act like a sex maniac” produced anxiety. Also, all SPs described being worried about their physical or emotional health. One SP stated, “As the character, I felt the stress, but suddenly, I don’t know, considering the AIDS situation in general … everything made me feel scared and stressed.”

During the interpretation of the OSCE, similar, intense effects emerged:

I felt scared, sad, and vulnerable. I started to feel that I shared this hard and silent reality. On the other hand, I felt fragile, as though I was wearing my emotions on my sleeve. I had to protect myself in order to not be so affected.

One female SP described having another reaction after the OSCE during the first year. This included denial and a need not to focus on HIV:

For me, it, it was like when I felt the paranoia, eh, eh, eh, it was like the reverse, I didn’t want to know, like watching a movie and someone comes on, with I don’t know, AIDS, and I changed the channel, like it was too much anxiety for me, like I said I don’t want this, I want to change the topic so I wouldn’t feel so much anxiety.

Feelings of discrimination and personal vulnerability emerged after the OSCE, “I thought about what it would feel like to receive this type of news. I felt anger and sadness for a society, which marginalized people and forces them to live with such little honesty.”

One year later, one SP stated that the experience had a positive impact on reducing her prejudices.

Behavioral Changes.

Within this subtheme, we could identify behaviors mainly related to knowing the HIV serostatus. One of the SPs requested an HIV test from her health care provider immediately after the OSCE as a result of her feelings of vulnerability.

During the year after participating in the OSCE, all of the SPs asked their partners about getting tested and had used prophylactic methods more than before. Some SPs took a more active role in prevention with their friends or acquaintances. For instance, one SP stated, “Maybe I did it before, but I have been even more insistent with the people I know, you know, like, to take care of yourselves, and be careful, like an old lady.”

Four SPs talked about HIV with their partners and described a reflective process regarding the illness, which resulted in concrete actions such as taking the enzyme-linked immunosorbent assay (ELISA) test for HIV: “I questioned myself, I became paranoid, rea-a-a-a-ally paranoid and I began to look for ways in which I might have become infected. For example, I don’t know, an example, I asked an ex-partner to have an HIV test.”

During the first year after the performance, neither of the SPs in Station 1 had an HIV test nor consulted a health care professional regarding HIV nor expressed the need to have a group support as a consequence of this experience.

Strategies to Reduce the Effects.

They described strategies for reducing these emotional effects using acting techniques such as breathing, staying in character, and “staying true to what the patient feels.” “Concentrate on the emotions that my character is feeling once he has learned about his situation, without inserting my own emotions. Organize my emotions so that they do not interfere with the role.”

Physical effects were counteracted with similar acting techniques, although the SPs commented that they were not always effective. These effects were counteracted with breathing and concentration exercises; however, by the end of the OSCE, the SPs were exhausted and wanted to “escape” from the simulated situation: “I need to take off this shirt [the character]; I can’t take having this man near me.”

Complexity of the Roles

In the focus group, Station 3, associated with HIV posttest counseling, was perceived as being the most complex and “emotionally demanding and physically exhausting.” The role performed in Station 1, informed consent, was perceived as less complex and no references were made by the SPs about emotional or physical effects during the training period, performance, or after 1 year of the OSCEs. Station 2, pretest counseling, was perceived as having medium complexity.

Of the six SPs who had previous experience with OSCEs, five of them believed that they needed more preparation for this HIV-related OSCE, and seven SPs felt the need to get more information after the performance to improve their simulation. During the focus group, SPs referred to the need to have more information because clearly, this was different from other roles they had played. The need arose not only because of the nature of the role but also because of a unique personal interest in the topic.

Six SPs reported intentionally talking with a person living with HIV, and this activity was considered by them as crucial to perform the role effectively. Others sought out a person associated with the health professions: “I was given newspapers and magazines with articles related to this for me to read. So I just asked a little bit more.”

Conclusion

This study shows that interpreting an HIV-related role can produce emotional, behavioral, and physical effects in SPs at any stage during the training and up to 1 year later. Not surprisingly, the more complex the role, the more effects the SPs had. In addition, interpreting a role associated with HIV has a long-term impact on the SP’s perception of his or her personal health and health risk. Feelings of vulnerability, anxiety, and paranoia emerged in SPs who identify potential HIV risk. They even had some changes in their sexual behaviors and in their relationship with their partners. This poses a challenge for health professional educators, especially because the use of SPs has been shown to be one of the best strategies in the assessment of HIV-/AIDS-related work for students in the health care professions (Epstein et al., 2001).

Several variables could limit or favor the impact of emotional challenges to SPs. A role that is performed only in a teaching setting may have less impact than a role used for assessment where the role has to be repeated several times. Likewise, the training of professional actors could have a greater capacity to “clean” themselves of the role compared to a layperson performing as SP. Professional actors were used to perform the more complex roles in this study, perhaps reducing the impact that might be expected when using someone with no professional acting experience.

McNaughton et al. (1999) suggests that one of the variables that may be important in alleviating or aggravating the effects on SPs of emotionally challenging roles is the acting style. From theatrical literature, we can define two different approaches to training and acting style; according to Stanislavski (1999), in “committed acting,” the actor takes the character using his or her own personal experiences and memories to enrich the experience. Other directors propose a more distant position: the actor does not try to create the illusion that he or she is the character (Ubersfeld, 1997). Our SPs were trained to perform their roles using “committed acting,” enriching the material created by faculty with information from their own experiences. This type of training may result in a greater impact in the actor when performing such complex and sensitive roles. However, no information was found in the literature on roles interpreted by SPs using the second approach.

Screening potential SPs prior to training and obtaining the candidates’ personal, medical, and psychological history may help to reduce the impact of complex roles. SPs who have negative attitudes to the health profession or unresolved issues related to the case should be excluded (Kurtz et al., 2005). SP training needs to alert the SP to the possibility of emotional demands that can emerge as part of the performance and to train the SP to respond to these emotions. Certainly, as Hanson et al. (2002) have emphasized, there is an ethical imperative to explain the risks and benefits of performing the role to the selected candidates before they accept the role.

Spencer and Dales (2006) have suggested that SP training should include training in coping mechanisms for the specific roles. But little has been written about which SP cases should be debriefed or how to do it with an SP. Although a greater long-term impact in those performing our complex roles was found, they did not mention the need for support. Perhaps, the fact that the SPs used in this study work from within a close group of actors and educators who have a sense of “belonging” to a mission to enrich health professional education using SPs contributed to lack of need for more support. The group meets regularly to reflect on the role of SPs in education and organizes meetings with faculty to promote communication between the actors and the faculty.

Finally, sensitive topics such as HIV may be difficult to represent without involving the SP’s own personal life. The challenge for educators is how to minimize negative effects in the SPs without compromising the quality of the simulation and standardization (Blake & Gusella, 2007; Boerjan, Boone, Anthierens, van Weel-Baumgarten, & Deveugele, 2008; Bokken, van Dalen, & Rethans, 2010; Taylor, 2011); hence, debriefing may be a good strategy for reducing negative effects on SPs.

We conclude that SPs who interpret complex roles should be professional actors who have been trained in acting techniques that can alleviate performance effects. Ideally, these SPs should work in an interdisciplinary collaboration team where their need for support can be detected early.

However, more research is needed to reduce the impact of the SPs’ simulation, particularly in complex roles that deal with sensitive issues such as HIV. What sort of debriefing, when, how, and to whom are all important questions that still need more answers. Health science schools should ensure that they have adequate systems in place for guiding staff and protecting patients involved in any aspects of the education of health professionals, and SPs are no exception. It is important to remember that although being excellent teaching tools, SPs are also human beings who respond to stimulus from the environment and who may need care from the educators who use them.

Acknowledgments.

Support for this study was provided by Direccion de Investigacion Pontificia Universidad Catolica de Chile (DIPUC) 2005/27Ce and National Institutes of Health (NIH) grants R03TW006980, R01TW006977, and D43TW01419. Support for this research was received from the Center of Excellence for Health Disparities Research: El Centro, National Center on Minority Health and Health Disparities grant P60MD00266.

Contributor Information

Ximena Triviño, Pontificia Universidad Católica de Chile, Escuela de Enfermería.

Lilian Ferrer, Pontificia Universidad Católica de Chile, Escuela de Enfermería.

Margarita Bernales, University of Auckland, School of Population Health, New Zealand.

Rosina Cianelli, University of Miami, School of Nursing and Health Studies.

Philippa Moore, Pontificia Universidad Católica de Chile, Escuela de Medicina.

Nilda Peragallo, University of Miami, School of Nursing and Health Studies.

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