Standardized patients (SPs) are commonly used in health care education to teach and evaluate the skills of students. Although this has been a common practice among other health care programs, it is not currently a widespread practice among athletic training programs. Currently, limited information exists about the use of SPs as a teaching tool in athletic training education.
To explore athletic training educators' perceptions of using SPs as a mechanism of teaching and learning for students enrolled in a Commission on Accreditation of Athletic Training Education-accredited professional athletic training program.
Consensual qualitative research study.
Individual teleconference interviews.
Fifteen athletic training educators (11 women, 4 men) that teach in a Commission on Accreditation of Athletic Training Education-accredited professional athletic training program and use SPs as a teaching method.
We conducted 1 individual interview with each participant. After transcription, the data were analyzed and coded into common themes and categories. Triangulation of the data occurred via the use of multiple researchers and member checking to confirm the accuracy of the data.
Four themes related to athletic training educators' perceptions of SPs as a teaching method emerged from data analysis: (1) rationale, (2) benefits, (3) challenges, and (4) misconceptions. Regardless of the rationales and benefits identified, there is also an acknowledged need to inform educators about best practices for inclusion of SPs.
These findings highlighted the value of SPs as a teaching method. In addition, it also identified many challenges faced by athletic training educators to be able to implement such a practice. The need for additional and consensus education of best practices of SPs as a teaching method was also identified.
Athletic training educators' perceptions of using standardized patients as a teaching method are positive for student education.
Athletic training educators face challenges such as time and resources, both financial and personnel, when implementing standardized patients into the classroom.
An understanding of best practices needs to be established before an educator incorporated standardized patients into their teaching method.
Clinical education is a vital component of athletic training education because of the need to be competent to practice autonomously in the profession.1 Currently, students must demonstrate competence in a series of proficiencies which are a combination of clinical skills and decision-making abilities.2,3 Additionally, in both the current educational competencies and the future curricular content standards, there is an expectation that students demonstrate health care competence.4–6 Programs should ensure students are competent to practice these skills independently and should offer ample opportunities through authentic, real-time or simulated experiences.7 Students must gain practical knowledge through real-life situations where they have the opportunity to experience the cause and effect of their actions.6 The nature of clinical education experience presents an uncertainty about the frequency and uniqueness of exposure to patient encounters.8 To ensure the safety of actual patients, faculty can engage students in learning through high impact, evidence-based teaching methods that are similar to their application in real-life settings.9 Previously, the most commonly used method by educators was simulated patients.10 More recently, there has been evidence to support the transition from simulated patients to standardized patients (SPs) based on feedback provided from students that had exposure to both situations.11
Other health care professions, such as nursing and medicine, have been using SPs for over 30 years as a process of teaching and evaluating their students' level of competence on clinical care. However, SPs were not introduced into athletic training literature until 2006 when they were first mentioned in the fourth edition of Athletic Training Education Competencies as a recommendation for use in clinical proficiency evaluation when real patients were not available.10,12 In 2008, the first written research was available that mentioned the use of SPs specifically in athletic training related to their use with educational competencies.10 With this transition away from simulated patients and toward SPs in athletic training education, there is a need to evaluate how athletic training faculty will implement this practice as a standard part of the teaching method and the impact it will have on the students' competence.
A SP is an individual that is trained to repetitively portray a condition or scenario in a scripted manner for the purpose of instruction, practice, or evaluation.13 These techniques provide the opportunity for formative assessment where the faculty has the opportunity to focus on the students' progress toward a goal through a preset criteria and provide constructive feedback while facilitating the progression of the encounter.13 One technique, using a time-in/time-out period, allows the student to suspend the encounter and allows the facilitator to discuss the patient case in the moment.3 The ability to stop a patient interaction is not possible in an evaluative SP or in real patient encounters.3 It is also possible, in a teaching SP, the student can stop and begin the encounter again, incorporating feedback and the results of the previous encounter in their new attempt.3 The SP is prepared for the student to perform inadequately and is prepared to be used as a learning tool.3 The concern about students making inappropriate comments or performing skills inaccurately can be eliminated when using a SP for instruction and practice.3 The condition or scenario being presented can be manipulated as needed to meet the educational needs of the students.3
Standardized patients can also be used as a mechanism to evaluate student competence of clinical skills. These encounters are presented as a summative evaluation, meaning that they are at the end of a learning period or a specific point in time where the student is provided feedback about their achievements on a preset criteria.13 Standardized patients used for the purpose of evaluation are used to determine a students' competence of a specific skill.13 Generally, these evaluations are associated with a grade based on the preset criteria of the encounter.13 Even though an evaluative SP encounter is higher stakes for a student, it still presents the safe environment for the patient actor.3
Currently, there is more evidence available on the use of evaluative SPs and not about teaching SPs. Also, the evidence that is available is generally related to the students' perceptions of SPs. Therefore, the purpose of this study was to explore athletic training educators' perceptions of using SPs as an instructional tool for students enrolled in a Commission on Accreditation of Athletic Training Education-accredited professional athletic training program. The following research questions guided this investigation:
Why do athletic training faculty choose SPs as a teaching tool over other methods?
How do faculty include SPs into their teaching plans?
What benefits do faculty perceive from teaching students when including SPs?
The design of this study was modeled after the consensual qualitative research (CQR) approach. The CQR tradition focuses on the use of multiple researchers, the process of reaching a consensus, and a methodologic approach to constantly and repetitively analyze multiple cases to reach a comprehensive representation of the results.14 We selected the CQR approach for this qualitative study to explore the perceptions of athletic training educators in using teaching SPs.
Given the consensual process of CQR, multiple researchers are essential to the construction of a solid research team. As complex issues arise within qualitative data, multiple perspectives, opinions, and levels of awareness are needed to increase the approximation of truth and simultaneously diminish researcher bias.14 The research team for this study consisted of 4 athletic trainers: (J.D., S.E.W., L.E.E., C.E.W.B.) with various levels of CQR experience. One member of the research team (C.E.W.B.) also served as the internal auditor. Auditors often participate within CQR to verify the interpretations made by the research team and to provide continual appraisal during each stage of data analysis.14 They must ensure the data were closely and appropriately analyzed and multiple perspectives were considered and discussed before consensus was reached.14
A purposeful sample of athletic training educators from Commission on Accreditation of Athletic Training Education-accredited professional athletic training programs that were currently using SPs as a teaching method were recruited. Potential participants were only excluded if they were not currently using SPs as a teaching tool during the time of data collection. A known list of athletic training educators believed to meet the inclusion criteria was developed by the research team. Fifteen individuals from the list were initially contacted via e-mail requesting voluntary participation in the study; 8 responded that they met the criteria for using SPs as a teaching method and would be willing to participate in the study. Snowball sampling was also used to identify potential participants for the study. At the end of each individual interview, the participant was asked if they were willing to provide any other educator's name that met the inclusion criteria so that he or she could be e-mailed as a potential participant. An additional 9 individuals were recruited to participate via snowball sampling, and of those individuals, 7 agreed to participate. Data saturation was achieved following individual interviews with 15 athletic training educators (11 women, 4 men).
Due to the lack of preexisting interview protocol to address the guiding research questions of this study, 2 of the researchers (J.D., C.E.W.B.) developed a semistructured interview protocol. The interview protocol consisted of 10 open-ended questions (Table 1). However, as part of the emergent design of this study, the interview protocol was flexible to allow for the questions to evolve throughout the study and within each interview.14,15 The semistructured nature permitted the principal investigator (J.D.) to ask each participant probing questions during the interview to explore their responses and clarify certain points. The interview protocol was developed based on existing literature related to SPs in athletic training, and the gap in literature between other health care professions and athletic training was taken into consideration.
After development, the interview protocol was reviewed by 2 athletic training educators experienced in CQR research methods and knowledgeable about best practices of SPs; minor revisions to the interview protocol were made based on the feedback provided. These individuals were later recruited to serve as members of the data analysis team.
Prior to data collection, the university institutional review board approved this study. The principal investigator contacted the potential participants via e-mail after individuals who met the inclusion criteria were identified. The e-mail included the purpose of the study, contact information, and a request for his or her voluntary participation. Given the various locations of the athletic trainers participating in this research, the primary mode of data collection was via teleconferencing. After an individual agreed to participate, an individual 30 to 45 minute interview was scheduled, and the participant completed a brief demographic questionnaire via e-mail. Participants did not receive the interview protocol in advance of their interview to limit any premeditated responses. All interviews were conducted by the principal investigator. All participants provided verbal consent to have their interview audio recorded.
Each individual interview was audio recorded via Zoom software (version 3.6; zoom.us, San Jose, CA). Once the interview was completed, an audio file of that interview was automatically saved to the principal investigator's computer. Each audio file was transcribed verbatim by the principal investigator. All personal identifying information (eg, name, place of employment) was deleted from each transcript to ensure participant anonymity. Once the de-identified transcript was completed, the audio file was permanently deleted from the principal investigator's computer. The transcript was sent to the participant via e-mail to ensure the information was accurate through a member check. During the member check, each participant was provided the opportunity to provide clarifications or additional information, but were instructed no alterations could be made to the original transcript. In total, 3 participants provided clarifications during the member checking process.
Data Analysis and Management
The data analysis process occurred in 4 progressive stages: (a) identifying initial code domains, (b) extracting core ideas from each domain, (c) cross-analysis of multiple participant interviews via development of categories, and (d) establishing the frequency of data presented in the determined categories. Once 3 participants' interviews were transcribed, the research team determined initial code domains. The domains were used to group data about similar topics.14,15 Once the initial domains were deployed and agreed upon, each research team member individually coded the first transcript and placed the data in a domain as they saw fit. From there, the research team reconvened to discuss their coding decisions until a consensus was reached about the placement of the transcribed information. A consensus version of the domains was used to recode the initial transcript as well as the transcripts that followed.14,15 Generally, with the CQR process, it is beneficial to code the data into domains for several transcripts before progressing to the next step of the data analysis process. Coding multiple transcripts will allow the research team to get a clearer sense of the content that will represent each domain.14,15
The next stage of data analysis involved constructing core ideas from the data in each domain. This process is called abstracting16 and essentially involves summarizing what the participant has said in each domain in a more concise manner.14,15 Each team member extracted core ideas independently, and then the research team gathered to discuss the abstracting process until a consensus was reached.
The third stage of data analysis involved constructing cross-analyses of multiple participant interviews. The research team must look for relationships, similarities, and differences that emerge from the interviews when they are examined together. Cross-analysis allows the research team to distinguish categories in which the core ideas can be placed.14,15 Categories can be developed in 2 manners: (a) each team member independently creates categories to cluster the core ideas, and then the research team reaches a consensus on the various categories, or (b) the research team brainstorms potential categories together.14,15 The research team in this study developed categories by independently creating categories and then meeting to reach a consensus of the identified categories. It is imperative for the research team to understand that these categories are discovered based on the data provided and are not established from the literature or preconceived ideas.14,15 Additionally, it is important to understand that core ideas can be placed in several categories if necessary, and categories can be modified as the research team becomes more familiar with the data.14,15
The final stage of data analysis consists of frequency counting. More specifically, frequency counting allows the research team to determine how often each category is applied across the whole sample, which will therefore provide a sense of representativeness of the entire sample.14,15 Frequency of the categories is most often broken into components: (a) general, (b) typical, (c) variant. A category is considered general if it applies to all cases, typical if it applies to as least half of the cases, and variant if it applies to less than half the cases.14,15 For this study, a category was deemed general if 14 or more cases were included, typical if 8 or more cases were included, and variant if 7 or less cases were included.
Four main themes emerged during data analysis regarding athletic training educators' perceptions of using SPs (Figure). The frequency of participant cases per category is displayed in Table 2, and additional participant cases to support the categories of each theme are available in Tables 3–6. In addition to the 4 themes, demographic information pertaining to participants' mechanisms and implementation of SPs as a teaching tool was recorded (Tables 7 and 8).
Rationale was identified as a theme to comprise reasons that educators chose to include SPs as a part of their teaching methods. Within this theme, 6 categories were identified including: safe environment, confidence, decision making, exposure to patient encounters, exposure to unique cases, and fidelity.
Participants discussed the opportunity for students to perform skills in a safe and controlled environment that has been created to simulate many of the same cues as in clinical practice as a reason for choosing to implement teaching SPs. Amanda commented:
It is a risk-free encounter for them where they are not going to injure anyone, and they have the ability to make mistakes and have immediate feedback when they are making the mistake and not feel like they are getting called out.
Paige echoed the value of a safe environment explaining, “I think the benefit is that I can create a safe environment that can be risky, and students can take responsible risks in it. I think I can really help them identify.”
Participants noted that a specific reason for using SPs in their classroom was the ability to see the students' confidence improve as they were exposed to multiple encounters. Some participants even valued confidence so much so that they would have the students complete presurveys and postsurveys focusing solely on their confidence before and after a given encounter. Brandon discussed his observations of student confidence levels as related to SP encounters by stating:
What we really didn't expect is when we actually looked at [confidence levels] from semester 1, 2, 3, to 4. When we set them all side by side, we saw that not only did they increase from pre to post in encounter 1, but then the pre of encounter 2 was higher than the post in encounter 1. There appeared to be an a cumulative effect meaning that the more experience the student got with the [SP], the more their confidence grew, which you see it and think that absolutely makes sense. The more experience students get with different patient populations or multiple patients of the same type of injury, the more confident they are going to be in their skills.
Katie described the sense of autonomy of a SP encounter and its ability to improve a student's confidence when they do not have a preceptor to turn to for the answers:
Sometimes I think they gain even more confidence than when they are with an athlete or patient because they are independent. They are doing everything on their own, whereas in the clinic, they always want to look over, and a lot of preceptors are really good at saying, “No, you do it. I am not going to help you at this point.” I think it does build their confidence tremendously when they can go through the whole scenario and realize that they can know how to handle that situation.
Often athletic training educators see students turn to a preceptor for the answer during their clinical experiences. Participants have experienced that in their programs and therefore explain that SPs put students in situations where they have to make a clinical decision and educate and share that plan with the patient within a low-stakes environment. Dianne explains her program's rationale by stating:
I think, with the way that we have it set up, the experience for the student is trying to give them something authentic in diagnosing the situation and making decisions that they need to be able to make right then and there after making their diagnosis and taking their patient through again that they are not familiar with or haven't worked with previously, I think really just giving them more of an authentic experience that they are going to see out in the clinical setting.
I actually did not tell the freshman what that injury was, so not only did the students have to evaluate them, they also had to educate the patient about what was going on and how they were going to treat and manage this.
Exposure to Patient Encounters
Participants discussed how SPs as a teaching method gave them the opportunity to provide their students increased exposure to conditions that they may encounter in future clinical practice. Amanda highlighted this concept by stating:
[T]he more exposures they have to any type of patient, simulated/standardized/actual patient, I think that, I mean, it has been said in the literature that multiple exposures increases their confidence and competence with the evaluation.
Furthermore, Grant summarized his rationale for multiple patient encounters by commenting, “[R]epetition is key. They have to be able to go in and repeatedly do these tasks.”
Exposure to Unique Cases
There are many conditions and situations that athletic trainers may encounter as a part of their clinical practice after graduation that they are not exposed to as a part of their clinical education. Therefore, participants reported using SPs to provide students with opportunities to encounter unique conditions in which they may not be exposed to during their typical clinical education experiences. Brandon discussed a specific encounter that he has created for their program and stated:
[T]he one that I have developed is an athletic director at a high school who is not wanting to do or permitting you to do rectal thermometry. You have requested a meeting with them to present information to this person on why rectal thermometers should be used.
He goes on to further discuss this topic and another specific encounter that he provided his students by commenting:
I partnered them up, and they had to actually perform rectal thermometry on a real person. It was a really eye-opening experience for them, and I think, they all said, “I would absolutely recommend doing it now before I had never done it on a real patient.”
Amanda summarizes it best by saying:
I think it is a really easy way to give them exposure to the things that you aren't sure they are going to get in their clinical experiences because of either the obscureness of some of the conditions that you may want them to be aware of that they may never actually get exposure to.
Participants described a desire to make the experience lifelike for the students and used different strategies to do so. For instance, Katie explains how fidelity can be increased with SPs by explaining:
I think it's something that I see more success with it when the students don't know the patient. You know, a lot of time in education, we are like, “I am going to have your peer come in and be the patient.” Then they know or use terms like inversion and eversion, and the patient goes along with it, whereas if it were a layperson or a SP, they wouldn't know what they were talking about. So I think the use of SPs is much more effective and more realistic than it is if you are using fellow athletic trainers or your athletic training staff or your graduate assistants, things like that.
Katie also provides commentary to an opportunity for increased fidelity by stating:
I think it is way better than getting peers and other athletic training students to be their model. I just think it is more realistic and practical of what they are going to have to deal in the, quote, real world. You know, we do all of this clinical education, and you are dealing with regular patients and go, and they work in a sports medicine clinic, or they go to a high school, and those are real patients, but they always have someone there. So I think, as a controlled environment, it is much more successful that grabbing an athletic training student.
However, other participants discuss their approaches which yielded lower environmental and psychological fidelity. Landon explains their methods by commenting:
What I have started doing is getting some students from other classes, and I will give them some brief information about an injury, and they will basically come in and play that part. So then my ortho students will get in groups of about 3–5, and there is usually 3, 4, and even 5 SPs in there, so they get to rotate around the classroom and get the opportunity to evaluate several different conditions.
Participants described skills that resulted from the use of teaching SPs including interpersonal communication, history taking, systematic evaluation/examination, and self-reflective practice. These skills represent where educators believed students were able to improve the most in terms of educational outcomes when they were exposed to teaching SPs.
Participants described the value of using SPs to educate their students about interpersonal communication. Many participants highlight this as the greatest benefit to their students, as communication plays a role in every component of evidence-based clinical practice. Charlie commented about the importance of interpersonal communication by explaining:
The first and most important skill that we always include is communication, patient communication, because the ability to draw out an appropriate, open-answered questioning, being able to communicate in a patient-centered manner, being able to articulate with both the patient and also the parent. We also do standardized dyads where we have a patient and a parent or a patient and a coach. So the patient communication is one of the first and most important skills we always incorporate. The secondly is utilizing the patient for physical exam skills, modality application, emergency care and response. In some cases, it is the psychosocial with a patient referral. It is about how to have those conversations with the patient, and it helps address their anxieties as well.
Paige echoed Charlie with:
I think, to get the student the real-life experience, and to get them to not only work on taking the knowledge and skills that they learned in the class and refined in the clinical setting, but to also get them to communicate effectively, show professionalism, articulate themselves.
Participants explained the value of teaching students the process of taking a thorough and complete history. They highlighted the importance of asking appropriate questions to obtain as much detail as possible to help them progress through the evaluation. Amanda stated their focus on the process, “I think it is just going to help them hone in some on how they ask their questions and how they guide their history.” Natalie described the value that taking a thorough history presents to the student because they were able to recognize the need for the history to guide further evaluation. Specifically, she remarked:
I also think that their ability to ask questions increased because they knew that the answers really mattered. Previous to some other assessments that we would do, they would ask history questions, but they knew in the next section that they would be told to perform a Lachman's [test] or perform lung oscillations, whereas with this, they had to listen to what the patient was saying and make that decision. So, definitely clinical decision making increased, and their ability to take and process the information from the student and apply it to what they were going to do next was a pretty big aspect.
Participants described the importance of students being able to perform an evaluation/examination in a systematic manner. Students need the opportunity to create a specific process that they follow during each patient encounter whether it is with an actual patient/simulation/SP. Emily discussed the need for a systematic process by stating, “I think that is part of it in the teaching, remind them to do a systematic evaluation and not get hung up on trying to find that exact diagnosis.” She goes on the state:
So it makes them think about the injury differently, and it gives the student that is doing the evaluation a chance to work through a full evaluation instead of just measuring range of motion and performing special tests. They can start to see how these would group together, and they do have some time limitations. So they learn to be more selective in the special tests that they will use or to be more efficient in how they measure motion.
Participants discussed the importance of not only having the students go through an encounter but then reflecting on the situation to learn from what they did or did not do. Participants also highlighted various ways they encouraged their students to participate in this process. Amanda discussed the benefit of a student learning through self-reflection by explaining:
There are just so many positives that are drawn out. From a student engagement standpoint, the realism, the deep learning, the reflective learning, the opportunity to engage in metacognition. There is just a dynamic about having [SPs] that is different from what I consider to be a very passive learning style.
Paige states the opportunity that SPs give a student to learn about their personal clinical skills by stating:
I think it helps to link theory to practice. It gives them an opportunity to do and recognize for themselves what their gaps are and where their deficits are in knowledge or skill. I think it really provides an open door to say, “XYZ is what you are really good at, but ABC is what you are struggling with. So, let's find some time to deliberately practice these skills.”
Participants indicated that they do not look for the students to make an accurate diagnosis, but that they wanted to see the students work through the patient care and make informed decisions. Brandon discussed the goals of their patient encounters to include:
We want to see that they can provide patient-centered care, and our focus is more on their ability to ask the right history questions, perform the appropriate physical exam, and differentiate them to make some clinical decisions.
He went on to explain,
I mean, again, it is providing students opportunities to teach. From a teaching perspective, from a learning perspective, engage in a patient scenario that is going to help prepare them to make decisions and interact with a patient just like they would in real patient care so that when they actually have to perform an evaluation or perform a therapeutic modality or have a difficult conversation with a coach or a patient, they feel much more comfortable and prepared.
Landon summarized the experience by stating, “It is just another way to see the students working through that process and coming up with a clinical decision.”
As participants explained their experiences with SPs, they identified barriers that prevented them from using them to their fullest potential. These categories included time, personnel resources, and physical resources.
Participants described how the inclusion of SPs increased their workload because of the time required to create encounters and train the patients. Francis discussed the time barrier in her position by stating:
[A]bsolutely because it takes a lot of time. It takes a lot of time to develop these and train the people and everything like that. Really, in looking at it, for me, I just used it in 1 day, so it was a lot of prep time for 1 day experience.
Jennifer is in a dual role where she serves as both a clinical athletic trainer and educator which presents even greater time restraints to her schedule for being able to include SPs. She describes her experience by stating:
So, especially in my role where it is dual. I am not only trying to prep for courses, but I am also treating patients and covering practices and traveling to games. Finding that extra 3 hours to meet with and train these SPs is pretty challenging. So that is why a lot of the times, I train the same person or utilize a population that sort of already knows what they are doing, and I just have to guide them into what I want. So, in utilizing athletic trainers from the area and senior athletic training students that may not have a relationship with the younger students, they need less training, whereas ideally, I would like to get students or actors that the students have never seen. You know, pulling from the theater department, or we have a local theater company, pulling from them I think would be better, but I just don't have the time.
However, other participants, even though they recognized the increased time required to implement SPs as a teaching method, they felt it was worth the added time commitment to class preparation. Also, many discussed the benefits as outweighing the inconvenience of time. Dianne summarized this viewpoint by commenting:
I think, in an already busy workload, yes, but I just view it as part of the class prep. So, I think it is worth the extra effort to put some time into it on the front end knowing that you can use some of those cases over again. So, I don't think it adds that much. I think there is time invested to prepare your patients, but again, it is minimal in my mind for the experience they get.
Participants discussed other individuals that were available to assist them in the implementation of SPs. Some individuals were the only people using SPs on their campus, while others were fortunate enough to have additional personnel resources to assist them with the encounters. Grant explained the desire for additional staff assistance, but it was not present, by saying, “I would love help, but we don't have it. I am in charge of the whole shebang right now. It is time intensive.” Others, like Brandon, explained how their situation did not present any challenges because of the resources available at his institution. He stated:
I know that we are going to be out of the norm here, but we have a simulation center. I tell them what encounter we are going to be running at the time, and they actually have a pool of SPs that they pull from.
Participants described facilities and financial resources as the greatest challenge to the implementation of SPs at their institution. Some participants described their physical resource challenges and offered methods they have used to overcome those barriers. Grant explained the minimal budget available to him and how he was looking to potentially overcome that challenge by commenting:
My budget in total for all supplies is $1750, and when we buy tape for practicing, our budget gets pretty slim in a hurry, so not much of a budget. I am currently working with our Dean to share resources that the School of Nursing has right now. So, we are looking at having some collaborative efforts next year.
Katie echoed the financial challenge present to her in their program's budget for being able to use resources her campus for SPs:
We train the patients. Now I am working with our PA [physician's assistant] program because they have someone that trains their patient, and I am working with them to see if we can collaborate. It is a financial thing. I mean, to be honest with you, they pay for it out of their budget, and we have to figure out where that comes into play and all of that. Right now, I currently train all of our patients, but I would love to hook up with another department that has a pool of them. Our nursing program has someone who trains, who is actually the coordinator. She doesn't actually train them, but she coordinates them. I am in the process of connecting with her as well.
As participants elaborated on their process of implementing SPs, there were many inconsistencies identified among educators that did not provide them the greatest benefits from using teaching SPs. Other educators discussed their concern that individuals were attempting to implement SPs but not using the best techniques. Emily described her process by stating:
I am not the one in charge. The students are working with their peers and are not looking at me for the answers. I think that is a really valuable thing. They start to ask each other instead of asking me or another instructor.
Jennifer explained her technique for including a SP encounter by commenting:
We generally tend to do it in the traditional athletic training sense where you know who your patient is, and they know you. You don't have to introduce yourself and do all that stuff. So the students walk in right off bat with a little bit of background, and then the students are told to go into the evaluation.
Natalie expressed her concern for others' limited knowledge of SPs by explaining:
I think the other challenge is knowledge and trying to be a resource for that. People think that they know what a [SP] is, and they are like, “Oh, yeah, I am using [SPs] tomorrow in class,” and I am like, “Oh, tell me about the case,” and they are like, “Oh, I haven't developed the case yet. I am going to do it tonight.” Then I am like, “You are not actually utilizing a [SP] if you haven't yet developed the case.” I would say that is a challenge, trying to work with others that think they are doing it. They are not.
As athletic training programs continue to adopt the 2020 Standards for Accreditation of Professional Athletic Training Programs,4 educators must ensure that students gain hands-on experience and provide opportunities to demonstrate decision making and competence. If clinical experiences do not give students the opportunity to be exposed to real patients, simulation or SPs should be implemented to measure a student's competence.4 Previous researchers have demonstrated that over 50% of clinical proficiencies are being evaluated using some other method besides real patient encounters as a part of their clinical experience.2,9,17 While simulated patients are often the choice to meet this requirement, those types of encounters are not generally created in a consistent manner for all students within an athletic training program.2 Standardized patients on the other hand, present an opportunity for all students to demonstrate their skills within the same scenario that is focused on using patient-oriented evidence as a guide for clinical decision making which is often excluded during simulated patients.2
Standardized patients have been used effectively in both the teaching and evaluation of competence.2 During these teaching encounters, students learn a task through a classroom introduction of knowledge and the skill.2 Next, they gain hands-on experience in a laboratory setting or similar method.2 Finally, before being evaluated on a skill, students participate in a teaching SP in a group setting.2 A benefit to use of a teaching SP is the opportunity the educator has to direct the student's thinking during the encounter rather than performing a completely reflective discussion once the encounter is complete.2,3
Athletic training educators in our study described several reasons for including SPs as a part of their teaching methods and discussed many skills they believe students learned through the encounters they participated in. Participants also explained the resources that were available to them to assist or were unavailable and presented a hindrance to the implementation of teaching SPs. However, there were also many inconsistencies identified in the mechanics of how cases were developed, patients were trained, and students/faculty interacted during the encounter that did not follow best practices.
Athletic Training Educators' Rationale and Skills Learned
Participants identified several rationales regarding their use of SPs as a teaching tool, including a safe environment, student confidence, clinical decision making, and exposure to common and unique pathologies. Educators must be able to simulate a safe environment that mimics that of an actual clinical experience. The International Nursing Association for Clinical Simulation and Learning defines an environment as the emotional climate that is created through the interaction among all participants, including the facilitator.13 In a safe environment, all participants feel comfortable taking risks, making mistakes, or extending themselves beyond their usual comfort zone.13 Awareness of the psychological aspects of learning, effects of unintentional bias, cultural differences, and attentiveness to one's own state of mind is essential in successfully creating a safe environment.13 As students perform SP encounters in a safe environment, the potential for their confidence to increase is present because of the low stakes with decreased pressure on the student to always be correct.
Previous research that has evaluated students' perceptions of SPs has highlighted increased confidence as a primary outcome from the encounter exposure.18,19 Educators in our study indicated they aspire for students' abilities to make clinical decisions to improve as they work through patient encounters. The focus is not necessarily on a correct diagnosis, but the ability to process the scenario and formulate a plan of management for the patient. Since the educator is in control in a teaching environment and has the ability to manipulate the scenario to meet the needs of the student, they are able to expose them to the practice of common skills and unique conditions that they may not encounter in their clinical education experiences.
In addition to identifying the reasons for using SPs as a teaching tool, educators highlighted several clinical skills in which they taught through the use of a teaching SP. These skills included interpersonal communication, history taking, systematic evaluation/examination, clinical decisions, and self-reflective practice. Interpersonal communication in particular was recognized by the participants as one of the main benefits seen from a SP encounter. The skills that are often viewed as components of interpersonal communication includes the student introducing themselves to the patient, touching the patient or shaking hands with the patient, dressing appropriately for the encounter, maintaining eye contact with the patient, student “telling before doing,” and treating the patient with respect.20 Other common interpersonal communication items that may be included in an encounter are basic communication with the patient, interviewing skills, counseling and delivering information, and personal manner and rapport.8 Communication played a key role in all other skills that educators perceived as teachable skills.
Standardized patients provide students with the opportunity to obtain a detailed patient history during the encounter.21 Being able to communicate effectively with the patient and ask the right questions is essential to taking a thorough history. The use of a teaching SP encounter allows the educator to facilitate the systematic flow of a patient evaluation while allowing students to practice their skills in a safe environment where no harm will be done to the patient.9 Educators want to be able to observe their students working through the process of the evaluation and ask questions when needed to ultimately reach a clinical decision that they can then communicate to the patient and with any other health care professionals that may be necessary. Finally, reflection is at the center of any educational learning experience.19 Previous research has found that students use their past experiences to plan for future patient care.19 Reflection on previous patient encounters not only informs future decision making, but it also is a component needed to developing clinical reasoning skills.19 Athletic training educators should develop educational activities that encourage students to self-reflect on their clinical experiences.19 Since educators are in control of the SP scenarios and have the opportunity to create any learning experience that the student needs to encounter, unique SP scenarios can be developed to focus on particular areas of weakness as students continue to develop and refine their clinical skills.
Barriers Toward Standardized Patient Implementation
There were some educators that had SP resources available to them through their institution, and they did not view time as a barrier. However, most of our participants discussed time as a challenge to their ability to include SPs within their teaching methods. Actual time requirements varied per participant, but all reported a strain on their workload because of the extensive amount of time needed for case development, recruiting a patient, training the patient, implementing the case, and debriefing following the encounter. Athletic training educators have reported available time and the resultant role strain as a barrier to not only implementing SPs but also the inclusion of any time-intensive educational techniques.22
Along with time, physical and personnel resources available to the participants were also identified as a barrier toward successful implementation of SPs as a teaching tool. The most commonly reported physical resource was appropriate budgetary funds to support the inclusion of SPs. While some participants reported they had funds to pay their SPs, others described the need to seek volunteers with no compensation. Furthermore, several participants discussed that, in additional to budgetary constraints, they were the only individuals responsible for the entire process of implementing the practice of SPs. This linked back to the time constraints because they did not have help in any phase of the process.
The resources needed to successfully develop a SP program and have the data to support the need for the program within health care education includes 3 components: personnel, space, and operation.23 The personnel that are needed for a SP program include faculty, trainer for the SP, educator/psychometrician, support staff, and SP.23 Often 1 person may serve in several of these roles much like our participants discussed. However, if 1 person is expected to do the tasks of all personnel except for serve as the SP, time can become a challenge for that individual. Teaching SP encounters can be implemented within a basic classroom setting, but space is also a component of cost to develop an all-inclusive SP program. For a teaching encounter, spaces that are often needed include a clinical exam room, conference room, classroom, lecture hall, office, and/or learning lab.23 Finally, the resources needed for the operations of a SP encounter include audiovisual equipment supplies, clinical evaluation equipment, clinical evaluation consumables, and educational material.23
Fidelity and Misconceptions in Standardized Patients
Fidelity is defined as the degree of realism displayed.24 The closer the SP case is developed to reality of a real-time patient encounter, the higher the fidelity.12 The level of fidelity is determined by the environment, tools and resources included, and participant factors.12 Fidelity involves a variety of dimensions including conceptual, physical/environmental, and psychological.12 Conceptual fidelity ensures that all elements of the case relate to each other in a realistic way so that the student can understand the case.12 Physical/environmental fidelity includes the realism of elements such as the actual encounter environment, manikins, room, moulage, equipment, noise, and/or props.12 Psychological fidelity addressed the extent to which the encounter evokes the underlying psychological process (emotions, beliefs, and self-awareness) that would be necessary in a real-time encounter for the student.12 As misconceptions were revealed when the participants described their methods for implementing SPs, it was clear that many of the cases had diminished fidelity.
An area that presented both high and low levels of fidelity among participants was that of who served as the SP. When faculty are used as the SPs, the advantages are that they are knowledgeable, are able to provide a more thorough assessment of the student, do not incur an outward cost, and minimal training is required.25 On the other hand, the disadvantages are that they may rescue the student, student bias may be present, it becomes time consuming, and the student is comfortable with the faculty.25 Several of our participants discussed using peers as the patient. When a classmate is used, the advantages are that they are an abundant resource, inexpensive, both parties may learn, and they may be less stressful for the students.25 However, this also presents several disadvantages which includes student bias, less enhanced feedback, increased likelihood of losing focus and breaking character, and may be less stressful for the student.25 Best practice for SPs would be to use someone that the student is unfamiliar with such as a community member.25 The advantages to using a community member are that they are unfamiliar to the student, similar to real patients, have variable health literacy, cultural awareness, and improvisation.25 Disadvantages to using a community member as a SP is highlighted by the challenges participants reported within the study. These include training is required, they are expensive, there are feedback limitations, more preparation is required, and improvisation.25 Therefore, a SP that the student is unfamiliar with should be used to provide the student the most realistic learning experience that mimics actual clinical practice.
Another component of the SP implementation that was identified as a misconception was the faculty's level of facilitation of the encounter. Many participants discussed being hands-off during the encounter and not intervening to help facilitate the encounter. This more describes an evaluative SP where the encounter is being graded.12 The facilitator's role should be to help the students develop their skills and explore their thought process throughout an encounter.26 By definition of a teaching SP, this is when the time-in/time-out method should be implemented to allow immediate feedback and discussion of the scenario and desired actions during the encounter while the patient goes unto a suspended mode.3 The approach should be one that meets the competence level of the student.26 Students should be prepared by the facilitator before the encounter for what they will experience.26 During the encounter, the facilitator should provide cues (predetermined and/or unplanned) to assist the students in achieving the expected outcomes.26 Finally, the facilitation should go beyond the encounter to assist the students in debriefing to discuss the encounter and the expected outcomes.26 Generally, the educator serves in the role of facilitator and should be in control during the situation to ensure the experience is conducted in a safe constructive environment where the student has the optimal opportunity to learn.
Limitations and Future Directions
Although we were able to achieve saturation, the number of potential participants that currently implement SPs as a teaching method in professional athletic training education is minimal. More importantly, the number of educators that use SPs and follow best practices are even smaller. Because this is a new technique that is slowly growing within athletic training education, the knowledge base lacks depth, and individuals are still learning the appropriate process for inclusion. Therefore, due to the small community of athletic training educators currently using SPs as a teaching tool, the use of snowball sampling to recruit additional participants may have created a potential for bias among the participant group.
Future research should examine athletic training educators' knowledge of how to best incorporate and apply the best practices for using teaching SPs. Additionally, more educational courses should be developed to assist in the education of those educators that wish to implement SPs into the classrooms. Many participants in the study also discussed the value of developing a repository for those educators' using SPs to submit their cases in an exchange mechanism. As the educational platform for athletic training changes, it provides an opportunity for the inclusion of additional teaching methods to be incorporated into program curricula.
Athletic training educators use SPs in their teaching methods to provide their students opportunities to practice patient care in an environment that simulates clinical practice. We found that the primary reasons educators included SPs within the classroom were the safe environment they offered, the ability to increase students' confidence, repetition of patient encounters presenting both common and unique pathologies, and the ability for the students to make a clinical decision. Additionally, educators saw an opportunity to teach interpersonal communication, history taking, systematic evaluation/examination, decision making, and self-reflective practice in the classroom through a SP encounter. The challenge to the educator's workload created by developing cases, recruiting and training patient actors, and conducting cases was noted, but it was also accepted by many because of the outweighing benefits. Financial and personnel support were also identified as barriers to the ability to include SP at a desired level and frequency. Athletic training educators should continue to learn about the practice of SPs as a teaching tool.