International Journal of Healthcare Simulation

A decade ago I discovered a job called ‘simulated patient’ or ‘SP’. I thought it looked like an interesting use of my acting and improvisation skills. I attended an information session and I was sold. The idea of contributing in a meaningful way to the education of healthcare professionals was compelling. I took every job I was offered, quickly building a positive reputation. I also trained as a facilitator and found the sweet spot of being an educator from a creative place in the world of simulation – a place where science and art meet.

At the beginning, I knew nothing about the theories that underpin simulation practice. Luckily. The churn and burn of university medical school OSCEs, where the impossible was asked of both the SP and the student being assessed, was disillusioning. The work was boring (talk in detail about a mild cough for 8 minutes and repeat 30 times), traumatic (be told your father has died and react accordingly over the course of 9 hours, resetting every 10 minutes). Sometimes it was unintentionally funny to the point where a sign had to be posted on the door of the exam room: ‘The role of the dead father is played by a live actor, so please go through the steps of confirming there are no signs of life’. I didn’t know then that a mannequin could have been used to represent the dead father and be programmed to have no signs of life. My acting skills would have allowed me to shed tears for the expensive lump of plastic.

I was surprised at how varied the approaches to working with me as an SP were. Some places were so structured, they wanted specific sentences to be said in a particular order, even if the topic had already been covered within an unfolding conversation. I was told that I was not in a position to judge whether something had been covered. Others relied on my creativity and imagination to portray a patient with schizophrenia after a scant briefing. Some of them wanted me to give feedback; others didn’t. No one trained me in how to give feedback. Luckily, this was something I had been teaching in other contexts for years.

The thing that was common though was the sense that I was an outsider; a necessary encumbrance and nuisance to be indulged briefly before being sent on my way to chase payment for my work. What was the point of even having an SP involved if you weren’t going to include our perspectives and engage us as part of the faculty?

I became educated and assertive about simulation as a practice, including the role of SPs in both education and assessment settings. Sometimes the people running the simulations were open to conversation and willing to experiment. Sometimes it cost me work. As time passed and my experience deepened, I came to realize that it was better to be discerning about the work I said yes to. Over time I have noticed that some organizations do make changes in the way they work with SPs. It’s clear that they have been exposed to education and apply their new knowledge. Some organizations seem stuck in a mindset that SPs are a procedural task, rather than skilled humans who can enhance learning and have valid input into relevant parts of assessments. I notice this has an element of ‘class’ underpinning the approach – you’re not medically trained, so what would you know? I don’t choose to work with them if they stay stuck.

As an actor and writer, I see myself primarily as an artist of the storytelling kind. I think this is true even in healthcare education. People who interact with any element of the healthcare system come with a story. They have people who love them, people and pets who rely on them. They have faith or none. Sometimes they are lonely, often they are scared. They all come with various levels of education and capacity to deal with the clever and busy people working within healthcare.

As an educator, I see education and assessment that is often conducted in a way that is counter to all the aspirations of empathy and compassion that are stated, but often fall by the wayside as the demands of The System compel attention.

As an SP, in the crossover space of actor and educator, I see an unconscious dehumanization. For example, at muster for big university medical and nursing exams, it’s common to be summoned by condition or body part rather than name: ‘Persistent coughs to the library!’ ‘Arthritic hips to the boardroom!’ Actors are often not pre-screened regarding triggers and safety to play roles and are usually just sent home at the end of the day without a debrief or even check-in. To me, this says something about mindset.

When I had the opportunity to lead a mental health simulation project for a private healthcare provider, I decided to do things differently and learn from what I had experienced.

Here are some of the things I tried:

1. SPs were referred to by name, not condition.

2. Actors were given a verbal overview of the SP role and the topics included and asked directly whether they felt safe to play the role. They were invited to let me know privately and it was made clear that refusal of a role would not jeopardize future work.

3. Actors were given a private space in which to prepare prior to the simulation and were debriefed and de-rolled privately (after the whole of simulation debrief). Actors were phoned the following day to check in.

4. Actors were trained to provide feedback and always came out of character to give it. They were always included in simulation debriefs.

5. Actors’ invoices were paid on time without them having to chase or follow up.

Initially there was some scepticism amongst staff about simulation in the mental health space and whether it would be realistic. Working with trained actors who were treated as professional faculty members ensured realism and quality was never a problem. The program had a positive reputation amongst actors. Actors told me that the recruitment practices and overall approach were ‘markedly different’ from what they experienced in other places. They appreciated being case in suitable roles where they were believable. They were paid fairly and appreciated not having to chase payment. One SP summed up the impact of my approach: ‘All of this made a huge difference to the work I did as an SP. I felt respected and valued at all stages of the process, and the work was enjoyable and rewarding’.

Working as an SP has made me a good advocate for loved ones and for myself. It’s some of the most rewarding and interesting work I do and it makes a real difference if the people involved in simulations understand and appreciate the value trained and skilled SPs contribute.