The contribution of simulated patients to meaningful student learning

Health professionals’ strong communication skills have been linked to effective patient interviewing, enhanced patient and professional satisfaction and improved patient outcomes [1‐3]. Simulated patients (SPs) play an instrumental role in teaching communication skills. SPs are lay people or actors trained to portray a patient with a specific condition in a realistic way [4, 5]. Most medical schools include SP programs in their curriculum to create an effective learning environment[6].

Teaching communication skills with SPs in a simulated setting can optimize students’ approaches toward meaningful learning. During communication training, the student’s interaction with the SP facilitates the learning experience. SPs provide specific advantages over working with peers or real patients. For example, there are opportunities to experiment with different approaches, to standardize patient cases across student encounters, and to customize students’ learning needs [4‐7]. However, what exactly makes the interaction with SPs a meaningful learning experience to students remains unclear.

There are multiple perspectives on meaningful learning [10, 11]. According to the Experiential Learning Theory, experience is the core element in a learning process [8, 9]. This experience can stimulate more or less meaningful learning for students. Ausubel described meaningful learning as learning that is well anchored and integrated in the cognitive structure of learners, in contrast to rote learning such as reproduction-oriented learning [11]. Meaning-oriented learning can be seen as deep learning that stimulates reflection [10]. In educational programs, this reflection is often facilitated retrospectively to support meaningful learning. However, according to the Performance-Relevant Information (PRI) theory, there can already be information that is deemed relevant to the learner in the interaction itself, so during an event [12]. PRI theory focuses on how learners interpret their performance in terms of what is relevant for their learning. It includes all types of information, from explicit feedback to the more implicit interpretations [12]. The study by Van der Leeuw et al. about workplace-based learning in clinical context described an implicit form of feedback such as interruptions and questions that served as a potential motivator for changing future behavior [12]. Also, SP responses during SP interactions can provide students with information about their performance during the interaction, which can facilitate deep learning by stimulating reflection. We propose that this reflection likely occurs not only after, but during the activity. Schön called this reflection-in-action, meaning that we can think about what we are doing, while we are doing it [13]. In line with Ausubel and Schön, we defined meaningful learning as deep learning that is anchored and integrated in the cognitive structures of a student and is stimulated by reflection [11, 13].

Given that the SP-student interaction provides a learning experience, we propose that this experience might stimulate meaningful learning. For example, different SPs can have different reactions during a medical interview where the student tries to empathize with the patient, which could lead to different learning experiences. If a student were to say: “I understand how you feel about it” in one instance the SP (1) might respond incredulously “Do you?!” whereas a second SP (2) might say “Yes, I am really sad about it”. These reactions can result in two different subsequent interactions and learning experiences for a student. From SP1, the student might learn to avoid responding to emotions in this way, while with SP2 the student might be encouraged to explore the emotional response of the SP in-depth. However, whether both situations lead to meaningful learning experience from a student perspective remains unclear. Therefore, our research question is: How does the SP contribute to meaningful learning of the student during a specific SP-student encounter, from a student perspective? By better understanding the contribution of SPs during the SP-student interaction, SP-mediated learning can be enhanced. Based on meaningful learning [11], Experiential Learning Theory [8, 9] and Performance-Relevant Information [12, 13], we expect SP-student encounters to potentially facilitate meaningful learning experiences by simultaneously providing relevant information for the learner during the encounter.

We identified three main themes derived from 17 code groups. Meaningful learning experiences reported by the students were characterized by implicit feedback-in-action and reflection-in-action, at times contributing to identity development. Implicit feedback-in-action and reflection-in-action are closely related processes during the SP-student encounter, as they take place in the flow of the interaction. In the following sections, we describe the three themes separately and provide context by presenting quotes from a variety of student participants as indicated by S#.

In this study, we examined the contribution of the SP to students’ meaningful learning during SP-student encounters, from their own perspective. We were interested in what aspects during the SP-student interaction make the learning experience meaningful to a student. Meaningful learning experiences reported by the students were characterized by implicit feedback-in-action and reflection-in-action, at times contributing to identity development. Implicit feedback-in-action and reflection-in-action in this study are described as two different, but closely related processes during the SP-student encounter, as becomes clear in Fig. 1 about SP-student interaction.

SPs’ reactions provide students with feedback on their behavior and attitude. This gives students the opportunity to reflect on their actions and can be seen as a feedback loop during the SP-student encounter, facilitated by SPs. Eppich et al. [16] described a similar process during the interaction between supervisors and doctors-in-training, where the trainee perceived feedback that was not explicit but ‘disguised’ to be an implicit form of feedback serving as a potential motivator to changing future behavior. As described in the introduction, this is called PRI [12]. Our results show that students described implicit feedback-in-action, a form of PRI, provided by the SPs as highly relevant for the learning and reflection process. This implicit feedback-in-action triggers a process of reflection-in-action: students are thinking about what they are doing while they are doing it [13]. Students indicated that they were sometimes even able to change their behavior right away or gained confidence that they were on the right track. In communication education, great emphasis is placed on feedback after a SP-student encounter. Our findings have potential to encourage teachers and students to also focus on the meaningful learning of the student on the spot, during the flow of the interaction. Thus, providing students the opportunity to learn during an encounter in which SPs provide feedback-in-action will be valuable. We therefore need to identify approaches to support SPs in giving feedback-in-action.

Meaningful learning experiences are not only important for refining students’ communication skills, but also contribute to students’ identity development. Students learn not only to communicate with patients, but also who they are as healthcare professionals. This also aligns with McLean et al.’s study in which SPs were interviewed about the students’ professional identity development. They found that SPs contributed to students’ professional identities by creating a supportive environment for honing skills, which they did through realistic role playing, making their bodies available, and by providing feedback as a patient [17]. Additionally, participants indicated that their identity development occurred on both a professional and personal level. Feedback during the event, therefore, has the potential for greater personal growth and learning [18].

A central characteristic of simulation-based (technical) medical education is its unique approach to making and learning from mistakes [19]. We noticed that moments of corrective feedback were fresher in students’ memories when asked about meaningful learning experiences. This suggests that, when looking back at the example in the introduction to this article, the reaction of SP1 has more potential to be a meaningful learning experience for the student, as corrective feedback is more likely to grab the student’s attention, leading to a moment of reflection-in-action. It might confront the student more in comparison with the reaction of SP2, which is affirmative. However, the interviews also revealed that it is not just a single sentence that makes an experience contribute to meaningful learning. It is the flow of the interaction that can facilitate a meaningful learning experience. In addition, it might be important to create a balance between emotional load associated with the experience and the professional lessons that can be learned [19].

Participants frequently mentioned SP authenticity. Timing and real emotions seem to play a role in the degree to which a student experienced the SP’s authenticity. It is not only the authenticity of the role play, but also the personal authenticity of the SP: the authentic, non-scripted, reaction of the SP that is integrated in the role play during implicit feedback-in-action. It is the SP, as an authentic person with an authentic response but still in the role play, who provides the student with feedback. Students described that they felt the SP’s real personal emotion, which evoked real emotions in them. As authenticity plays such an important role in SP-student interaction and meaningful learning experiences, it is important to recruit SPs able to maintain their authenticity during role play. Additionally, SPs should be stimulated to be authentic during role play while at the same time maintaining the right degree of standardization, even if this seems paradoxical. There might be a fragile balance between standardized role play and authentic responses during role play, which can create the learning experience for a student. In communication education great emphasis is placed on SP training and selection to achieve high standards of standardization. However, by doing so we may be losing the important aspect of authenticity, whereas authentic responses of the SPs can be of great impact for the learning experiences of the student. It is possible that with ‘overtraining’ and standardization of our SPs, we unknowingly and with the best intentions withhold meaningful learning experiences from our students.

This study is based on a single data source and a sample from one technical medical school. However, by describing the findings and the context in detail, explaining our sampling strategy and discussing our findings with existing literature from different settings, we promote transferability. Credibility could be enhanced by exploring this topic from different perspectives, including the perspectives of SPs. However, we used investigator triangulation and theory triangulation to promote trustworthiness. Furthermore, the interviews took place a few months after students had their last SP-student encounter. Interviewees therefore had to report from memory, which might have resulted in slightly different reports on their experiences compared with shortly after their last SP-student encounter. However, students now had more experience with multiple SPs, were better able to look back on the whole SP program and their response depended less on single experiences. In addition, the fact that students remembered learning moments after a time had passed could be an indication of meaningful learning anchored in their cognitive structures. Lastly, we did not observe the actual behavior during SP-student interactions. It would be worthwhile to observe the behavior during SP-student interaction and to analyze the thoughts and behaviors of the SPs and students with stimulated recall directly after an SP-student encounter.

During SP-student encounters students learn more than just communication skills; the interaction with SPs contributes to their professional and personal identity development. It is the implicit feedback-in-action as an authentic response of the SP during the interaction that gives students an understanding of how well they communicate. By balancing authenticity and standardization in SP role play, students learn most from SP encounters. This study raises issues about the impact of too much standardization on this balance, which should addressed in SP training and selection.