International Journal of Healthcare Simulation

Research team

The authors have significant experience in healthcare simulation practice, with diverse roles as educators, healthcare providers and researchers. Our backgrounds include emergency medicine with a special interest in the care of older persons (NA), medical speech-language pathology (LS), education (DN) and performance (CS). We all have extensive experience working with SPs and with older adult SPs in several countries, including Australia, Canada, Hong Kong and the United Kingdom. We came together to undertake this scoping review due to a shared curiosity around this topic. Individual experiences informed discussion at each stage of the scoping review process, which proved valuable, especially in checking assumptions.

Scoping review methodology framework

This review was guided by the five-stage approach described by Arksey and O’Malley [10]. We chose to follow this framework as the seminal method in scoping review methods.

Stage 2: Identifying relevant articles

To answer the research question, specific criteria were set regarding which articles to include in the review. The search focused on articles that addressed simulation activities involving older adult SPs. Only articles written in English and published between 2011 and 2021 were included. We chose 2011 as the start date as we wanted to capture articles that were relevant to more current practices. We excluded articles written in languages other than English as we did not have the resources (time, money) to have them translated in a reliable manner. We developed and refined an iterative search strategy in consultation with academic librarians experienced with healthcare databases (see Table 1 for a list of these search terms). In keeping with the open-ended research question, we sought to include a broad range of perspectives, including research, commentaries, essays and simulation scenarios. In keeping with this type of scoping review, we did not assess the quality of the research [10]. Our search had three phases. First, we accessed the MEDLINE database (December 2021), and then two additional databases: PsychINFO and EBSCO (February 2022). To capture any additional articles, we hand-searched the reference lists of articles selected for inclusion as well as MedEdPORTAL. We also searched Google Scholar (June 2022) with a modified list of search terms (see Table 1 for the list of these search terms). Additional articles were generated through this search. Citations were imported to Covidence Systematic Review Software (Melbourne, Australia).

Table 1:

Databases searched, and search terms used

Database searched	Search terms used
MEDLINE PsychINFO EBSCO	Group 1 Patient simulation OR Simulated patient OR Standardized patient OR Simulated participant OR Programmed patient OR Actor OR Role-player OR Confederate AND Group 2 Aged OR Geriatric OR Older OR Senior OR Elderly AND Group 3 Simulation AND Group 4 Dementia OR Stroke OR Falls OR Elder abuse OR End of life
Google Scholar	‘Simulated patient’ OR ‘Standardized patient’ OR ‘Simulated participant’ OR ‘Actor’ AND ‘Older adult’ OR ‘Senior’ OR ‘Elderly adult’ AND ‘Simulation’ OR ‘Geriatric simulation’ or ‘gerontological simulation’ or ‘simulation for the care of older adults’.

Stage 3: Article selection

All abstracts were screened by the four researchers in teams of two (variously configured). Full-text reviews were similarly undertaken. Inclusion criteria were refined through this process. Articles had to mention involvement of older adult SPs, although various terms could be used to refer to them other than SP (e.g. actor, volunteer). In line with the UN and WHO definition of an older adult, we required specific reference in the article to SPs being at least 60 years old. Articles where the SP age was described as ‘older’, ‘elderly’ or as having an age similar to that of the older adult being portrayed in a scenario were also included. The exclusion criteria were set by consensus of all authors (Table 2). Articles describing the involvement of SPs under the age of 60 portraying older adults (e.g. a younger person portraying the role of an older adult) were excluded as we were focusing on the practices of older SPs. During this process, conflicts were discussed, and consensus was achieved during regularly scheduled meetings between authors.

Table 2:

Exclusion criteria

Article written outside of timeline for search

Simulation is focused on older adults, but the age of the SP is not clear

Simulation is not focused on older adults or SPs

Not clear if older SPs were involved

Minimal description of involvement of older SPs

Simulation involved a younger person (e.g. student) portraying a person 60 years or older

Simulation used a mannikin rather than human SP

Simulation has a person (e.g. family member, health professional) who is younger than 60 and no human role player 60 or older

Simulation involves a person 60 or older with actual findings who is recruited to work with students and is not trained in SP methodology

General characteristics

More articles were published in the latter half of the decade, 2017–2021 [11–15,18,20,22] than between 2011–2016 [16,17,19,21]. Based on the first author’s place of work, all articles were from the Global North. The majority of articles were generated from the United States [11,12,14,15,17,19,21], with two from Australia [13,16], and one each from Canada [20], Switzerland [18] and the United Kingdom [22]. Journals had an education [12,14,16,17,19,21], simulation [15,18,20,22] or profession-specific focus [11]; one journal focused on both education and profession [13].

Ten articles described older adult SP involvement in simulation scenarios [11–17,19,21,22]. Learners included specific student groups [12–14,16,21,22], including an interprofessional group [14], and single healthcare professions [15,17,19,21]. One article did not mention the learner group [11]. The remaining two articles focused on SPs rather than learners [18,20].

Eight articles were research-based: five of these were qualitative [13,15,18,20,22], and three were mixed methods [11,14,16]. Two research articles focused on learner outcomes [14,16], four explored SP methodology related to a specific simulation activity and/or the lived experiences of SPs [15,18,20,22], one focused on the believability of the SP in their role [11] and one explored both the SP experience and the impact on learners [13]. One paper stated that the older SPs were part of the research team and that the authors followed published reporting guidelines related to SP methodology [11]. All research reported human research ethics approval. All research articles had some component of qualitative research and for most, it was the primary focus. Research methods included observation in real time [13,21] or of recorded videos [11,21], written field notes [13], interviews [13,18], focus groups [20,22] and survey and other measurement instruments (e.g. evaluation forms, empathy scales) [14,16,21]. Four articles were educational guides involving SPs with a focus on learner outcomes [12,17,19,21] (Table 4).

Table 4:

General characteristics of included sources (n = 12)

Year of publication	2011–2016 [16,17,19,21]	2017–2021 [11–15,18,20,22]
Country of origin	USA [11,12,14,15,17,19, 21]	Australia [13,16]	Canada [20]	Switzerland [18]	United Kingdom [22]
Focus of Journal	Educational focus [12,14,16,17,19,21]	Simulation focus [15,18,20,22]	Profession- specific focus [11]	Education and profession- specific focus [13]
Learner group	Specific student groups [12,13,14,16,21,22]	Healthcare professional groups [15,17,19,21]	Not mentioned [11]	Not applicable [18,20]
Article type	Research – Qualitative [13,15,18,20,22]	Research – Mixed methods [11,14,16]	Educational guide [12,17,19,21]

Describing SPs

SPs were described with language that included ‘standardized patient’ [11,12,14,19,22], ‘simulated patient’ [13,18] or ‘simulated participant’ [15,20]. Certain articles described the SP as both a ‘standardized patient’ and ‘actor’ [16], a ‘simulated patient’ and ‘actor’ [21] or a ‘simulated’ and ‘standardized patient’ [17].

Eight articles noted the specific age of the SPs, with an age range of 50–92 years old [11,13–15,18,20–22]. In one of these articles, the SPs’ age ranges were described as being between 50–70, so it was included [11]. Where a specific age was not noted, the SPs were described as being older adults [12], elderly [16], within ±5 years of the stated age of character (over 60) [17] or having an age that reflected the age of the person they were portraying (over 60) [19].

Conceptualizing SP roles and scenarios

SP roles – that is, the information provided to the SP about the character to be portrayed – were all described as being some type of written document except for one study which indicated that role details were communicated to the SP through an oral briefing [14]. Where described, SP roles were called a blueprint [11], script [12,15,17] or scenario [19]. The articles that were educational guides provided the complete roles [12,17,19,21].

Information in the SP roles included identifying that the character, the person the SP was portraying, was a patient [11–17,19,22], the spouse of a patient [19] or a grandparent [21]. In five studies, the specific age of the character was reported, with the range of 60–92 years old [11,12,17,19,21]. In two studies, the characters were described as being elderly [14,16]. Other information included name [17,19], gender (either male or female) [11,12,15,17,19,21], current health status/disease state [11,12,14,15,17,19], social history [11,12,17,19], past medical history [12,17], mental state [19], medications [12,19], description of affect and/or behaviour [11,12], physical appearance [12,19], marital status [12,17,19], place of residence [12,16,17,19], degree of independence [12] and relationships with others [12,17,19,21]. Two articles specifically noted no restrictions on ‘race’ or ‘ethnicity’ [11,17]. Two articles described characters as having a specific religious background [17,19]. Two articles provided in-depth disease-specific characteristics (e.g. related to aphasia post-stroke or Parkinson’s disease [11] or hearing loss [21]).

Some roles also reported the inclusion of prompts or scripted lines/guidelines for the SP [12,15,16,19,21], detailed information about the medical condition, including symptoms and behavioural markers with specific examples [11,12,19,21], instructions for SPs about how to respond to different communication strategies used by learners [11,19] and a list of questions for SPs to ask and/or possible learner responses [13,19,21].

Within the scenarios – that is, the more encompassing documentation of a simulation session within which the SP role is located – information provided included the objectives of the simulation activity (e.g. stated aims and objectives, descriptions of desired outcomes or scenario overviews [12–17,19,21,22]). Settings were provided for all scenarios and related directly to the context and objectives, including medical/hospital areas (e.g. outpatient clinics or acute care) [11–15,21]; clients’/patients’ homes; nursing homes [16,19] or multiple settings across sectors [17,22].

Additional scenario information included: behaviours students were expected to demonstrate [11], an outline of the expected flow of the scenario [12,17,19], debriefing questions [12,17,19], patient charts, tests, forms, medication lists and/or assessment tools the learners were expected to use [14,17,19,21], different versions of the scenario (e.g. for students, faculty, SPs) [17,19,21], roles for other role players in the scenario [12,19] and evaluation forms [17,21]. Complete scenarios were provided in two articles, both descriptions of educational activities in MedEdPORTAL [17,21].

Three articles addressed development of the SP role and/or scenario [17,19,22]. Roles were based on actual cases/practices and either described an intervention [11], an educational process [19] or were an educational guide [17]. No articles directly noted SP co-development of the role or scenario, although some articles indicated that the SPs were encouraged to use personal details about themselves or their experiences in healthcare to enhance authenticity [13,21,22].

SP preparation

Scenario implementation

Sessions were formative and described as being one-time events [14] or recurring sessions [12,13,15,16,19,21,22]. There was also a six-station formative Objective Structured Clinical Examination (OSCE) [17]. Two studies described hybrid simulations: one with SPs and task trainers [13] and another with an SP and a manikin [21]. One article featured a videotaped interview between an SP and a simulated doctor that was used for research [11]. Six articles indicated the number of SPs who participated in the activity [11,13,15,16,21,22]. Two articles did not explicitly state the number of SPs, but the number might be inferred based on context and the number of scenarios run at the same time [14,19]. Eight sessions were delivered to pairs or small groups of learners, some with faculty present [12–16,19,21,22]. The length of the SP interactions per encounter, when reported, ranged from a ‘few minutes’ to 75 minutes [11,13,14,17,19,21,22]. Two studies indicated that SPs portrayed their roles five [14] or six [17] times in a row; otherwise, this detail was not provided. One study described debriefing SPs separately after the simulation [13].

Reporting details of articles involving older adult SPs

The limited reporting of details when working with older adult SPs could delay the intended application of such knowledge to the care of older people. This was emphasized in previous research about SP work [23] and simulation in general [24], along with suggested frameworks for reporting. From the research reporting guidelines developed by Cheng et al. [25], we recommend the minimum requirement for reporting on simulations involving older adults for the sub-element labelled Actors/confederates/standardized/simulated patients should include the age of SPs who played the role, the age of character/role, recruitment criteria and specific information related to training for role portrayal and for feedback. By improving the reporting details, we would also gain insight to the importance of aligning the age of the older adult SP with the role to be portrayed.

As expected, educational guides offered more detail about older adult SPs than the research articles. The latter were not necessarily focused on educational interventions. Templates for writing SP-based scenarios exist [26]. Some are evidence-based, and some are not. Based on a scoping review, Davies et al. [27] make recommendations for reporting in SP role templates. While their template is comprehensive, it is intentionally confined to information about SP role portrayal. Our review has identified that without broader contextual information (e.g. recruitment, training approaches for role portrayal and for feedback), of the educational activity, the template information alone is limited. We recommend guidelines offered for Educational Summary Reports at MedEdPORTAL when reporting on older adult SP educational activities [28].

Diversity and inclusion in older adult SP practices

From the details provided, there appeared to be little diversity in the characters and situations contained in the articles, including ethnicity, culture and other social determinants of health; all derived from first authors in the Global North. Only two articles mentioned ethnicity: one noted that although SPs of any background could be recruited, the SPs recruited were ‘white’ [11]; the other mentioned that in the future, families from various ‘ethnic groups’ could be recruited [19]. The characters portrayed in the simulations appeared to be middle class. This lack of detail related to diversity in the role/scenario and recruitment instructions for the SPs is reflective of reports in broader simulation practices [31–33]. In response, simulation educators are increasingly focused on ideas and recommendations for supporting the creation of scenarios that feature inclusion of SPs across the simulation design process and the recruitment of more diverse SPs to portray those represented [34,35].

Words matter

Words matter and in working with older adult SPs, it starts with the way adults over the age of 60 years old are described. We have adopted the age of 60 and the term older adult from globally acknowledged organizations [1,2]. The American Medical Association [36] notes that the word ‘older’ is a respectful and neutral way of referring to adults in this age group rather than using terms such as ‘elderly’, ‘senior’ or ‘the aged’ which can ‘… connote discrimination and certain negative stereotypes that may undercut research-based recommendations for better serving our needs as we age’ ([36] p1386). We also recommend critical reflection of other terms used to describe the living spaces of older adults while also recognizing that terms will vary across countries. The American Gerontological Society offers recommendations for various terms [36]. It was also surprising to see that the term ‘standardized patient’ was the most prevalent one used to describe the acronym SP, despite international advocacy for ‘simulated participant’ [6,37], a more inclusive phrase that reflects the person-centred presentation of older peoples’ journeys in healthcare, one that can include patients, carers, family members and others. Some articles also referred to ‘using’ SPs, or ‘utilizing’ SPs, which signals that SPs may be seen as tools rather than as agentic members of an educational team. There has long been critique of this objectification of SPs with recommendations for ‘working with’ or ‘engaging with’ SPs as a more productive way to position their valuable contributions [38,39].

Conclusion

SBE related to the care of older adults is increasingly important as our population ages. Older adult SPs may contribute to healthcare providers training in authentic, engaging, safe and effective ways. This scoping review provides a foundation on which to further develop older adult SP practices by highlighting their well-being and safety (both physical and psychological), promoting ways to increase diversity and inclusion, and emphasizing that the words we use matter. Improved reporting details of articles involving older adult SPs will facilitate the identification of effective practices. Research to support both learner-centred and older SP-focused approaches is important to promote meaningful simulation-based learning in the care of older people.