Context

Standardized patient (SP) encounters are an assessment technique in health and medical education that can improve participants' communication and clinical skills.

Objective

The purpose of this study was to explore experiences of postprofessional athletic trainers before, during, and after a SP encounter.

Design

Qualitative research.

Setting

Before and after participants engaged in the same SP encounter.

Patients or Other Participants

Athletic trainers enrolled in a postprofessional doctor of athletic training program (age = 24 ± 2, years of experience = 3 ± 3).

Main Outcome Measure(s)

Individual, semistructured interviews were completed before and after the SP encounter via teleconferencing software. Interviews were transcribed, and data were analyzed via the consensual qualitative research tradition using a 3-person coding team. Using a multistage process, the team identified common domains and categories to confirm a consensus codebook. Trustworthiness was established using member checking and external auditing.

Results

Four domains emerged during analysis: (1) emotional state, (2) design of encounter, (3) realism, and (4) conscious consideration. Participants identified an emotional state related to self-judgment and feeling overwhelmed by time constraints. The postprofessional learners felt the SP encounter created a safe environment for integrating newly learned skills. Contrastingly, they also expressed uncertainty, as the SP encounter was perceived as an unknown situation. Before the SP encounter, participants doubted their ability to suspend reality but were surprised by the authenticity. They mentioned using self-management strategies for their feelings. After the SP encounter, participants expressed a growth mindset related to improving clinical skills, while others lacked ownership through blaming.

Conclusions

Despite disbelief before the SP encounter, the design of the encounter provided an authentic learning environment for practicing athletic trainers to integrate and rehearse their clinical skills in a safe setting. However, participants expressed anxiety related to the SP encounter that altered their preparation and experience.

KEY POINTS

  • Participants demonstrated alterations in their emotional state before and after engaging in a standardized patient encounter.

  • Standardized patient encounters allow for participants to practice both health care delivery and stress-management skills in a nonthreatening environment.

  • A standardized patient encounter provides participants with the opportunity to engage in reflective learning that can help identify areas to improve and apply to practice.

  • Even though standardized patient encounters pose logistical challenges, continuing education should consider the use of standardized patient encounters to maintain and advance health care provider competence, as they provide active and reflective learning.

INTRODUCTION

To effectively maintain competence, practicing clinicians and postprofessional learners should engage in continuous quality improvement. This should include things like a root cause analysis1  of practice to identify areas of weakness and then the use of valid, reliable, and affective assessments that mimic regular clinical practice. In nursing practice, we have seen the effective use of root cause analysis to improve the delivery of patient care. However, methods of assessing competence are often indirect; simulation, including standardized patient (SP) encounters serve as the best measure, besides direct observation, to assess clinical competence.2  Competence encompasses knowledge, skills, abilities, and traits that demonstrate a good working background from which the provider is able to work independently, although they may lack refinement.3  Medical educators should assess their learners using valid and reliable measures. Inaccurate and invalid measures of health care competence, both in the professional learner and practicing clinician, can lead to future medical errors.4 

Formative assessments provide feedback throughout the learning process5  and are inherent within quality improvement, in that quality improvement is continuous, and the assessments serve as periodic updates on progress. However, in more structured educational settings, summative assessments provide culminating data to determine progression, matriculation, and qualification for completion.5  Standardized patient (SP) encounters can be used as both formative and summative assessments, in a variety of educational settings, to provide an accurate assessment of clinical care. A SP encounter is a simulated situation that allows the learner the opportunity to demonstrate their knowledge and skills related to clinical practice taught in medical education.6  During a SP encounter, an individual, the SP, is formally trained to portray the symptoms of an injury or illness as well as certain affects (ie, frame of mind, reaction to pain) of a condition in a consistent and repeatable fashion.7  Standardized patient encounters have been used throughout medical education, both as formative and summative assessments.79 

Oftentimes, participants perceive assessments, regardless of whether they are formative or summative, as high stakes and can elicit a negative emotional, physical, and cognitive reactions.10  The same feelings of academic anxiety have also been identified in newly graduated athletic trainers attempting to pass their Board of Certification (BOC) examination.11  Specifically, participants experienced increased academic worry, which was correlated to increased emotional focus and decreased locus of control.11  This suggests that athletic training students who felt more anxiety and worry associated with the BOC exam were more likely to use emotions to cope with the situation and perceived a lessened degree of control over their ability to perform on the assessment.11  No additional literature describes academic stress in athletic training beyond that felt during the BOC examination. Other assessment methods such as the Objective Structured Clinical Examination (OSCE) have created a similar negative emotional response.12  Students enrolled in a dental education program indicated that, when exposed to an OSCE, a written examination and a preclinical preparation test, they found the OSCE was the most anxiety-provoking assessment method for participants.12  However, little evidence characterizes the academic anxiety of postprofessional learners, regardless of health care profession.

Like the OSCE described above, a SP encounter is designed to provide a simulated learning environment for participants to demonstrate competence in clinical practice. As such, a SP encounter is an assessment tool designed to mirror clinical practice but may inadvertently predispose learners to stress and anxiety before, during, and after the experience. Currently, the medical literature lacks the exploration of how learners, specifically in postprofessional education and continuing education in athletic training, prepare for and engage in a SP encounter. Therefore, the purpose of this study was to explore the experiences of athletic trainers before and after a SP encounter relative to academic anxiety.

METHODS

Design

We used a qualitative research design to explore the experiences of athletic trainers enrolled in a postprofessional doctoral degree program before, during, and after a SP encounter. The study was designed to collect pre-SP and post-SP interviews with postprofessional athletic trainers regarding their thoughts and perceptions of the upcoming or recently completed experience.

Participants

Participants consisted of athletic trainers (n = 15) enrolled in a postprofessional doctoral program at a Midwestern institution. Contact information was collected using an e-mail roster developed by the primary investigators of the study. Inclusion criteria consisted of (1) being a certified athletic trainer, (2) being currently enrolled and matriculating in the postprofessional degree program, and (3) having completed the SP encounter. In total, 15 participants volunteered for the study. Demographic data, including age, gender, years of experiences, and presence of a stress or anxiety disorder, are provided in Table 1.

Table 1

Participant Characteristics

Participant Characteristics
Participant Characteristics

Interview Protocols

We created 2 interview protocols for this study, 1 for before the SP encounter and 1 for after. After initial development, we engaged in several rounds of revision within the research team, including an external review. Once the interview protocols were approved by external review, 2 pre-SP and 2 post-SP encounter interview practice trials were recorded and reviewed by the research team in order to determine the appropriateness of the interview questions and approximate duration for each interview. Each of the practice trials were completed with volunteers who were not associated with the study but had previous SP encounter experience. Neither of the interview protocols were adjusted based on practicing the interviews. The pre-SP encounter interview included 13 questions, and the post-SP encounter interview protocol included 10 questions (Table 2).

Table 2

Interview Scripts

Interview Scripts
Interview Scripts

SP Encounter

The intervention used in this research study was a SP encounter at the end of the first semester of the curriculum after the completion of 3 courses (9 credits) foundational to the delivery of health care that integrates the National Academy of Medicine core competencies. The objectives of the SP encounter included the ability to (1) integrate best research with clinical expertise and patient values for optimum care; (2) demonstrate performance on a comprehensive and systematic injury evaluation while maintaining a whole-body approach to health care; (3) integrate skills of prevention, recognition, and treatment into comprehensive whole-body health care; and (4) search, retrieve, and use information derived from online databases, internal databases, or both for clinical decision support. A SP is an actor who portrays an injury, illness, or condition consistently to multiple leaners.13  These persons have been trained to accurately portray a medical case in a standardized fashion, providing a lifelike encounter for participants to practice interpersonal and clinical skills.6  The research team used best practice for developing the SP encounter by having the case reviewed by multiple clinicians and educators with experience creating and implementing SP cases.13  Additionally, the actors went through training and practice to ensure that the case was acted out according to the script and the same for all of the learners.12  Each participant interacted with 1 of 4 SPs portraying a common orthopaedic condition. The case consisted of a patient who suffered a lateral ankle sprain while participating in an intramural recreational activity 24 hours before presenting to the health care facility. The SP presented with typical signs and symptoms but had self-administered narcotic medication to manage pain symptoms and resisted referral due to potential costs and time-loss relative to work-related responsibilities and a desire to continue participation. Participants had 30 minutes to complete the SP encounter, and their performance was graded. The SP encounter was followed by a debriefing session in which participants had the opportunity to discuss and reflect upon their experiences.14  The course instructor facilitated a 90-minute diamond debriefing session with all learners present. No data were collected until after the entire SP encounter and debriefing session.

Procedures

The host institution's institutional review board approved the research project before initiating the investigation. At the beginning of the semester, the course instructor provided assignment descriptions and scoring criteria for the SP encounter. As an initial SP encounter in the curriculum, it served as a baseline evaluative benchmark for the host institution. Participants were recruited from 1 postprofessional athletic training degree program during their first semester enrolled in the program. The principal investigator (B.B. sent an e-mail to all who met the inclusion criteria (n = 23). The e-mail included the purpose of the study and B.B.'s contact information to schedule interviews. The rationale for having only B.B. involved in recruitment was to avoid dual role conflict as both teacher and researcher.

Upon the participants' interest in the study, a follow-up e-mail was sent to each participant via a Web-based survey link (Qualtrics, Inc, Provo, UT) including the informed consent and demographic information. The informed consent described the purpose of the study, expected durations of each phase of the study, and risks and benefits associated with the study. Also placed within the e-mail was a link to a synchronous, video conference with B.B. The video conference conducted using teleconferencing software (Zoom, San Jose, CA), was used to explain what to expect during the SP encounter and answer questions regarding their role in the study. The course instructor provided videos explaining how a SP encounter occurs and an example of a student completing a SP encounter to help all learners conceptualize the learning activity.

After the synchronous session, an e-mail was sent to schedule a time for an individual interview with B.B. All pre-SP encounter interviews were completed at least 1 week but no more than 2 weeks before the SP encounter. Participants then completed the SP encounter with faculty evaluators observing from a control room with livestreaming video. All members of the research team, except B.B. and S.E.W. were involved to some degree with the delivery of the SP encounter, specifically as evaluators, but blinded to whether the learners had chosen to participate or not. After the SP encounter, B.B. contacted participants via e-mail to schedule the post-SP encounter, which occurred within 1 week but no more than 2 weeks after the SP encounter. The time allotment was designed to allow the participant an opportunity to explore his or her perceptions of the event as well as to reflect on his or her performance during the SP encounter. Interviews for both pre-SP and post-SP encounter interviews for the participants lasted approximately 30 minutes each. Each of the interviews was conducted one on one with B.B and were audio recorded via Zoom.

Data Coding and Analysis

The consensual qualitative research approach, as described by Hill et al, was used to analyze the data.15  Each member of the data analysis team independently segmented the data into domains and came together to work toward consensus on necessary cases. The data analysis process consisted of 5 progressive stages: (1) identifying initial code domains, (2) extracting core ideas from each domain, (3) cross-analysis of multiple participant interviews via development of categories, (4) establishing the frequency of data presented in the determined categories, and (5) establishing a running list of quotes representative of the data presented in the determined categories.

The research team (Table 3) consisted of 5 members with varying levels of experience. The data analysis team (B.B., E.R.N., S.E.W.) engaged in a multiphased process. In the first phase, each member of the data analysis team reviewed 4 transcripts independently using an inductive approach. The team met and developed an initial codebook. In the next phase of analysis, the data analysis team applied the initial codebook to 2 of the original transcripts and 2 new transcripts. This phase of analysis was used to ensure that the codebook was reflective of the data.16  Then team met to modify the initial codebook and came to consensus on the final codebook. Independently, the members of the data analysis team coded all transcripts with the consensus codebook and then exchanged for multi-analyst triangulation. At the conclusion of the data analysis process, the interview scripts (pre-SP and post-SP), consensus codebook, and 30 coded transcripts (pre-SP and post-SP per participant) were shared with an auditor (Z.K.W.) in order to ensure the codebook reflected the data and no research bias was present. Triangulation of the data was ensured, and trustworthiness was established using multiple researchers, member checking, and auditing.16  The auditor confirmed the domains and categories but made suggestions for codebook organization. All data were reorganized using the codebook verified and organized through the auditing process.

Table 3

The Roles and Experience of the Research Team

The Roles and Experience of the Research Team
The Roles and Experience of the Research Team

To explain the data, the qualitative categories that emerged were assigned a frequency classification count as either general, meaning the category was identified in all 15 of the participants, or typical, meaning the category was identified in at least 8 but less than 15 of the participants. Less common categories were identified as either variant, meaning the category was present in 4 to 7 of the participants, or rare, meaning the category was identified in 3 or fewer the participants.16 

RESULTS

Four main domains emerged during the data analysis regarding the perceptions and expectations of participants after a SP encounter: (1) emotional state, (2) design of encounter, (3) realism, and (4) conscious considerations. Categories supported the domain to describe the thoughts leading up to and after the SP encounter. Table 4 provides the frequency of each category. Specifically, we calculated overall frequencies and then frequencies in each of the pre-SP and post-SP interviews. This helped to contextualize pre-SP expectations and experiences during and after the SP encounter. The Figure depicts the categories that emerged from each of the domains.

Table 4

Frequency Counts of Categories

Frequency Counts of Categories
Frequency Counts of Categories
Figure

Domains and categories.

Figure

Domains and categories.

Emotional State

Emotional state was identified as a domain to comprise reasons that a participant experienced adverse feeling or thoughts while engaging in the SP encounter. The 4 categories that comprised this domain were fear of judgment, uncertainty, overwhelmed, and self-management. In general, a majority of participants experienced some form of altered emotional state leading up to or after the SP encounter. Participants in our study noted feeling alterations in their emotional state as they thought about and were preparing for the upcoming SP encounter. In the collection of demographic information during the pre-SP encounter interview, we asked if any of the participants suffered from a stress or anxiety-related disorder. A total of 4 participants (4/15, 26.6%) disclosed that they had a diagnosed anxiety-related disorder. The following categories were identified as factors effecting changes in the emotional state of participants.

Fear of Judgment

Fourteen out of the 15 participants expressed a fear of judgment. Before the encounter, participants discussed preparing for the sensation of being watched and judged by the SP, faculty evaluator, or themselves during the SP encounter. Participants were notified that they were being graded, and this domain was associated with participants' anxiety as they went through the process of the SP encounter. Nina described her anticipated feelings of judgment by stating:

I do anticipate that feeling of being under the microscope a little bit, just knowing that there are going to be people watching and observing as I am going through this interaction with this patient. I think I am just mentally preparing to be as confident as possible because there is a bunch of people literally picking apart what you are doing, so that's adding a different type of stress to it.

After the SP encounter, the participants described noticing the camera on the ceiling that displayed the recorded session in the simulation center to a faculty member assessing from a control room. The participants remarked that they felt stressed knowing that someone was in another room observing and that the patient might judge their performance. Common among new professionals with fears about their ability to provide autonomous patient care, Jerry reflected:

I think it goes back to like that preconceived, perfectionist mentality. I did not want the patient to know that I did not know what I was doing, and I did not want to let the evaluator to know that I did not know what I was doing. I guess that was kind of the reason why I felt so stressed out.

Overwhelmed

Participants felt overwhelmed before, during, and after the SP encounter. Participants typically shared this sensation when they identified issues with time (waiting time before the SP) or the 30-minute limit for the SP encounter and trying to fit in as much information as they could think of during the patient interaction. When asked to describe how he handled multiple tasks at the same, Jeff described his feelings by sharing:

I mean, it was definitely tough. I am handling all these different things whilst still trying to have some sort of normal interaction with the patient. I feel that my interactions with the patient probably suffered because I was so focused on all these different things that I was trying to do at the same time.

The participants also identified instances in which the encounter did not go as smoothly as they were anticipating. Pam reflected on phenomenon by mentioning:

I feel like I got jumbled at points. I did have some usual flow and some order to my question and my encounter overall, but you do get a little jumbled. I thought, “Oh, I want to focus on this, but I also have to focus on this,” and then I focused on that. It is overwhelming at times because you have so much going on in your head.

Uncertainty

Despite participants being provided the previously mentioned materials for the SP encounter, a stressor that affected all participants' emotional state before the SP encounter was uncertainty of the upcoming experience. Participants noted having a lack of expectations for how the SP encounter would be organized, no previous experience completing a SP encounter, and a lack of knowledge with particular conditions as driving factors that influenced this emotional state. The perceived lack of direction and expectation with these factors made participants feel nervous about the encounter. Despite the provided resources, Jake mentioned feeling unsure about what to expect. He stated:

It is stressful because I do not know. The only information that we have been given to my knowledge so far is that we will be working with a [SP], and then an [evaluator] in the room, and I believe it said we will have 30 minutes to interact with and evaluate the [SP]. That does not give me a lot of information, and I do you prefer a lot of information. I am not really certain what my [evaluator] is going to be looking for. I am not really sure what the expectation is other than do your best.

The participants in this SP encounter were not provided details of the presenting situation other than that the focus would be on completing a thorough history and clinical evaluation including communicating a plan of care. The ambiguity left Sandy feeling unsure of how to prepare for the SP encounter during the pre-interview. She expressed:

I have no idea what type of patient it is going to be. Could it be general medical? Could it be just strictly orthopaedic? Could it be they just all of a sudden drop into cardiac arrest? I do not know. I guess, with that in mind, I can only prepare so much.

Self-Management

The category of self-management refers to how learners coped with the stress and anxiety from the SP encounter. Jerry identified his unique coping mechanism that he previously learned as a self-management strategy before the SP encounter by explaining:

Most of the times when I feel anxious, I try to suppress it or just use some deep breathing concepts to really focus on the task at hand. My mentality has always been, if you are anxious, use it to better yourself rather than cripple you into inaction.

While Bob used a self-management strategy, he expressed that the positive self-talk was not successful in his post-SP reflection:

I was asked to go back to my specified room for my SP. The whole way there, I focused on my breathing and my direction. To be a 100% honest with you, the positive self-talk did not do a whole lot for me. I still felt like a bumbling idiot going through the entire thing.

Design of Encounter

The second domain that emerged from the participants' interviews was the design of the encounter. The design of the encounter should be considered as a contributing factor when creating and implementing medical assessments such as a SP encounter. The elements of the SP encounter were both physical and theoretical, consisting of the patient setting and the objectives in which the SP actor was portraying. Within this domain, 2 categories emerged: safe learning environment and integration of the learning outcomes.

Safe Learning Environment

Only 9 of the 15 participants discussed a safe learning environment during their pre-SP interviews, which increased post-SP to 12 of 15 participants. A majority of participants felt that the environment of the SP encounter was a place that was safe to fail, meaning that, despite it being watched and graded, they understood the nature of the experience in the curriculum. Participants often described the SP encounter as a time for them to practice newly learned concepts of patient-centered care, an opportunity to try something new in a patient interaction, and an encounter to improve their clinical skills. Bill shared: “[The SP encounter] is a learning opportunity, and instead of taking a lot of time preparing for it, I am just [going to] let it happen.” Jane, who did not have previous SP experience, expressed her gratitude for the opportunity to practice her clinical skills in a new environment by mentioning:

I am glad to have the opportunity because I am in a very safe environment to do it. I think, ultimately, like the fact that I am in such a safe environment to develop it now will make me a better clinician in the long run. I mean, obviously, I wish I had those experiences in the past and been able to develop them then rather than like 2 years into being a professional and just now being able to develop that.

Integration of Learning Outcomes

Participants typically described that the SP encounter allowed them to integrate the learning outcomes during the encounter. The participants shared that the design of the encounter allowed for them an opportunity to practice newly learned skills and techniques that they had learned during the semester. Participants identified using previous assignment feedback (ie, formative assignment feedback from previous assignments) to potentially improve their performance for the upcoming SP encounter. Before the SP encounter, Jane noted preparing by focusing on key themes learned in her coursework by sharing: “just remembering like the key concepts of the program is patient-centered care and trying to just reassure myself that nobody is going to have the perfect evaluation.” Pam also talked about preparing materials that she had learned about previously leading up the SP encounter by adding:

The moments leading up to [the SP encounter], I knew I wanted to implement patient-rated outcomes into my practice, so I did pull those up previously on my computer, and then I just had a note section that I could take notes during the encounter if I needed to.

Realism

One of the primary goals of the SP encounter is to develop an experience that demonstrates high fidelity that imitates a real-life encounter. The realism of the encounter comprised the categories authenticity, disbelief, and previous experiences.

Authenticity

Authenticity represented the perception that the SP encounter produced a lifelike encounter for the participants. Jill noted how the SP encounter felt familiar to a real patient encounter. The SP actor had moulage with ecchymosis around her lateral malleolus and was wearing an elastic wrap around her foot as she presented into the encounter. The fidelity of the presenting patient put Jill in the right mindset as she shared her internal reflection:

I think, once I was getting through history questions and going more into the observation and I took off the ace bandage and there was bruising and she was pretty good at acting, when I palpated certain structure, she acted as a normal patient would. Then I think that is when I was like, “Okay, this is not a ‘mock' evaluation. This is an evaluation. This is what I will be doing every day, so I need to treat it as that.”

Participants also talked about being surprised by the ability for the SP encounter to be so authentic. The SP actors were all trained for an extensive amount of time after best practices leading up to the encounter to depict not only an injury but also a persona, including work, life, and other contextual factors. Tami talked about her surprise in the SP encounter by stating:

I thought it was just someone random [person] that [the faculty] were just going to tell: “Fake this injury.” [The SP] had sheets to fill out for different [patient-reported outcomes] they had. She had obviously memorized so many different things. I thought about just how well the SP was as the patient they were portraying. Honestly, I do not know who this girl was, but I believe she could have been an intramural player, working, and all those other things. I thought the portraying of the person that we were using actually was very, very good.

As part of the case, the SP actress was trained to state that she had taken hydrocodone, a prescription pain medication, from a previous surgery for her current orthopaedic condition. Sandy mentioned how a common topic in her previous clinical experience provided realism for her during the SP encounter. Sandy went on to explain how she approached the situation after the group debriefing session by stating:

I know a big topic of conversation was that the fact that the patient had utilized some illicit drugs. It did not take me aback during my evaluation because I think that's something that happens more frequently than then everybody would think. That part didn't take me aback. After we starting talking about how that all kind of played in, I started to kind of put the dots together. I should have because [that was] not the first time that drugs or something should not be utilized. If anything, I would say that, but it didn't take me aback during the SP. It only made me reflect once we started talking about it a little bit differently.

Disbelief

Disbelief was mentioned by participants in both pre-SP and post-SP interviews, more so in the post-SP interview. The disbelief feeling centered on the apprehension and skepticism regarding the SP experience. Jake expressed feeling that the experience was not real, so he was allowing himself space to make mistakes saying:

My understanding was that it's uncomfortable, but they know that it wasn't necessarily real. There's this weird kind of thing in the back of your mind that says, “Well, this isn't real, so I can kind of mess around with it a little bit. I'm allowed to make a few mistakes.”

Additionally, participants stated that it was challenging to step into a new environment and treat it was their own. Steve talked about his struggles not being in his own space by stating:

I mean, just really the unfamiliarity of it, that is really it. I just, I did not know what was available to me. Even though I have been told to treat it like my clinic, I cannot treat it like my client because it is not my clinic. It was hard for me to do that, to be in the mindset of like, “Hey, like just act like this is your workplace,” when I know it is not because I do not like typically—like if I am looking for a specific instrument, I know what drawer to go to. Here is the instrument, make the measurement, do the evaluation, and go from there.

Previous Experiences

While not all participants had previous experiences with SP encounters, the previous clinical experiences or educational assessment experiences influenced the realism of the encounter for the participants. Although this category was more common in the pre-SP interviews than in the post-SP interviews, many were able to better articulate and reflect how the previous experience compared to the SP encounter. In her follow-up interview, Tami talked about how the current SP encounter mirrored similar experiences by stating:

I would say there's some similarities in the fact that it's someone who's trying to mock an injury or an illness, but I think the differences is more of the standardized part of it. That's 1 person who's trained to do this, as opposed to its 1 injury that someone is told right before doing it that, “Okay, this is the injury you have to do. Try to make it seem realistic.”

Some participants also discussed their previous clinical experiences as a strength toward the upcoming SP encounter. Steve remarked: “I think I have seen a wide range of injuries and illnesses within the past 3 years of my practice that I think that I will be able to manage what I see when I come through the door.” Participants talked about using their experiences in current practice or previous educational settings to use as a reference for the upcoming SP encounter.

Conscious Consideration

The domain of conscious considerations comprised participant reflections after the SP encounter and what the participants thought they could use in their practice moving forward. The domain also included participant perceptions related to feeling that their previous educational experiences had not prepared them well after engaging in the SP encounter. Within this domain, 2 categories were identified including lack of ownership and growth mindset.

Lack of Ownership

A lack of ownership was identified in only 1 participant before the SP encounter. After the SP encounter, 4 participants described their previous educational experiences had not prepared them well, they themselves had not prepared well, or they blamed other factors for lack of execution in the SP encounter. Mary articulated her reactions by stating:

I have never personally dealt with medication. I've always suggested taking a pain medication just naturally, but I've yet to have experienced a patient where they told me about a medication that they were taking and that it was a medication they should not have been taking. I have never really had that experience in dealing with that and in what I should say and how to go about it without insulting the patient or making the situation too uncomfortable. That is why [I] glazed over [it] because I just did not know what to do, and that's what brought on that moment of where I hesitated.

The unfamiliar experience was not something that Mary was accustomed to experiencing with patients, and it led her to avoid further investigating that question to maintain a comfortable feeling between her and the patient. However, not asking more questions may have prevented Mary from being able to collect important information regarding the patient's situation.

Growth Mindset

Participants who described characteristics of a growth mindset believed the SP encounter enlightened them about areas in their clinical practice that could be further developed. After the SP encounter, the participants recognized areas in which they could improve their clinical skills, what went well for them, and how they intended to implement what they had learned in future clinical practice. For example, Sandy expressed that she felt her ability to use communication skills were reinforced during her post-SP interview:

I left [the SP encounter], and I felt kind of like I was out of breath, which tells me I did not do a great job listening. I did a great job talking, but I did not necessarily listen very well. That is definitely an area I want to improve on is using my 2 ears rather than my 1 mouth.

Jill identified areas of her evaluation that she could improve upon moving forward by adding:

I definitely could have asked more questions or palpated a little bit better. I did not come necessarily to the right diagnosis, and then once I had what my diagnosis was, I stopped and was said, “Okay, well, this is what I think it is.” I think that is something that I need to challenge myself to do better, just in every day in the clinic, not jumping to a diagnosis and assuming that is what it is, making a more thorough evaluation. Obviously, I knew that she was an intramural softball player that wanted to get back to play [in the] championships, but I did not necessarily know a ton. For instance, she lived on the third floor and had to take steps and stuff like that, so definitely gathering more information about the patient life outside of sport.

Jerry appraised the SP encounter for boosting the confidence in himself as a clinician by stating:

I thought that the overall learning experience was very conducive towards improving my education. I thought I would be really anxious going into it, like I mentioned in my previous interview, but once I actually went into the experience, I was more confident than I thought it would be. After completing the encounter, I definitely felt a lot more confident in my abilities. I think it kind of validated by confidence in my own abilities as a clinician.

DISCUSSION

Standardized patient encounters have been used for some time in other health care professions, like nursing and medicine, to measure and develop quality care of practicing clinicians.17,18  Despite participants' disbelief before the SP encounter, the design of the encounter provided an authentic learning opportunity for athletic trainers to integrate and practice their clinical skills, including whole-person evaluation, in a safe environment. The SP encounter also allowed most participants to engage in critical self-reflection and identify areas of improvement to work on in future practice. However, the learners expressed anxiety and fear related to the SP encounter that altered their preparation and experience.

Preparing for the SP Encounter

For learners with stress and anxiety disorders, it is common to have intensified feelings and to become exasperated when preparing for and engaging in an assessment that challenges them to demonstrate their proficiency.19  It is important to note that, although most of our participants described negative sentiments about their academic stress relative to the SP encounter, stress can be either eustress or distress. Eustress can have a positive influence on actions, while distress can induce anticipatory anxiety,20  which among our participants likely modified their actions and experience. This perceived pressure for learners to demonstrate their proficiency of clinical skills can also heighten feelings of anxiousness when they are aware of receiving a grade.19  Because participants were preparing to experience their first graded SP encounter in the program, it is possible this anticipation enhanced feelings of anxiety.

One similarity between all participants was the feeling of uncertainty as they prepared for their engagement in the SP encounter. Participants' feelings of uncertainty could be explained by a lack of experience with SP encounters. Some participants also had a limited amount of clinical experience, which could have led participants toward their perceived feelings of uncertainty. While some participants had practiced clinically for 2 to 7 years, other participants were newly certified in their first year of autonomous practice. By virtue of having more patient encounters, we may assume seasoned participants are likely to experience less uncertainty than newly credentialed participants.21  It may also be safe to assume that, regardless of the clinician's level of experience, an inherent degree of uncertainty is present within all patient encounters. Just as clinicians would likely not know what to expect from a real-time patient encounter, they would not know what to expect from a SP encounter. This component of environmental fidelity is critical to providing participants with exposure to encounters that mirror clinical practice. High-fidelity environments have been shown to encourage active participation in the learning process, allowing individuals to construct knowledge, explore assumptions, and develop psychomotor skills in a safe environment.22 

As faculty members prepare SP encounters and other forms of simulation-based learning, they should consider how to design a SP encounter that follows current best practice guidelines.14  First and foremost, the SP encounter must allow the participants to integrate the course's learning outcomes.13  Then there is a responsibility to create a psychologically safe learning environment, coordinate robust case based off of the literature or real patient cases or both, train SP actors to fully understand their role portrayal, and provide constructive feedback to the participants.23  Psychological safety is created through 3 key characteristics: (1) the ability to make mistakes without consequences, (2) the qualities of the facilitator, and (3) foundational activities such as orientation, preparation, and clearly defined learning objectives.24  It is still important to note that stress in simulation may actually be helpful in preparing learners to manage stress in real-time situations,25  and as such, total elimination is neither warranted or beneficial to the learners. Although best practices were incorporated into the planning of the SP encounter, participants still expressed feelings of uncertainty about the upcoming SP encounter.

To cope with the anticipated feelings of anxiety, the participants discussed planning to use self-management strategies: positive self-talk, deep breathing, and looking at the SP encounter as a baseline of their skills. These tactics were thought to help reduce their anxious thoughts as they prepared for the SP encounter. Similar self-management strategies have been used in other forms of simulation-based learning to cope with feelings of anxiety.6,10,26,27  Some participants noted that using self-management strategies helped them organize their thoughts before the SP encounter and focus on the objectives of the encounter. Participants who intended to use coping strategies to reinforce belief in their own clinical abilities seemed to approach the SP encounter with less apprehension. These participants also looked at the SP encounter as the baseline benchmark for improvement, for which it was intended.

During the SP Encounter

When engaging in the SP encounter, a similarity between participants was a fear of judgment. Other health care professions using simulation-based learning have identified emotional reactions such as apprehension and fear of judgment on behalf of the learners.69,12,26,28,29  For the participants in our study, fear of judgment took multiple forms including evaluation by faculty members, apprehensions of being watched on the simulation center camera, and judgment by the SP actors (patient) and of themselves. Interestingly, a literature review in nursing education found that the most widespread theme which appeared to increase anxiety during simulation was being observed or video recored.9  Current research suggests that video recording commonly elicits thoughts of judgment and results in increased anxiety6,7,24,26 ; however, video recording is also used to help facilitate debrief and critical self-reflection in simulation.17  In addition, concerns about being judged by faculty evaluators during a simulation has also been addressed, noting feeling distracted by a nonparticipating observer.29  Being observed and responding differently than typical is called the Hawthorne effect.30  It is clear that participants in our study and in previous research experienced increased stress and anxiety when recognizing their actions were being captured by video camera and observed.

A SP encounter should be a realistic and authentic learning experience,31  and literature has confirmed that SP encounters provide realistic experiences for learners.28,3133  All but 1 participant in our study indicated the SP encounter provided an authentic clinical atmosphere. The ability for participants to suspend reality and recognize the authenticity of the SP encounter allowed them to engage in decision making as they would in clinical practice, consistent with previous research.6  These findings mirror a previous study, indicating that athletic training participants feel SP encounters provided worthwhile and realistic patient-centered experiences.31  For SP encounters to be perceived as beneficial, participants must feel the experience is applicable to their clinical practice. Based on our findings, encouraging participants to suspend reality during the SP encounter can yield benefits to learning and self-improvement.

After the SP Encounter

Previous research found that different aspects of simulation-based learning, such as intimacy of the case, realistic presentation by the SP actors, and awareness of being observed and evaluated, influenced the expressed levels of stress and anxiety by participants after they engaged in SP encounters.10,11,27,34,35  After the SP encounter, participants expressed sensations of being overwhelmed, which is not uncommon during assessments.36  Standardized patients are a form of clinical assessment that require an individual to use preexisting information about a clinical scenario while engaging with newly obtained information during task completion.37  This is derived from the cognitive load theory. The cognitive load theory states that the working memory has a limited capacity when dealing with novel information, and when requirements surpass this capacity, learning is impaired.38  Emotional state, mood, or motivation serve as mediators to the relationship between the physical learning environment and lead to perceptions of diminished performance. That said, health care environments continue to pose overwhelming work environments, and SP encounters can help prepare clinicians to cope with stress and cognitive overload to improve their ability to provide health care when similar situations arise.25 

Participants also discussed the perception of the SP encounter being a safe learning environment. Participants were able to take what they had learned during the SP encounter and develop ideas for improving skills in the future. As mentioned previously, we identified this type of reflective thinking as a growth mindset. This phenomenon has also been recognized in other health care professions preparing trainees for mitigating medical error.39  Those with a growth mindset view their ability as acquired through effort, practice, and learning from setbacks, and thus, failure represents an opportunity for development and improvement.39  Most participants experienced this feeling through critical self-reflection, that allowed them to identify errors and plan for improvements. This growth mindset is directly related to the desired outcomes of continuing professional development, in which the learning activity is simply not enough. Metacognition, the ability for a participant to actively think about their thought processes,40  may aid learners to apply the concepts from continuing education learning experiences into clinical practice. The ability for a participant to reflect on how he or she thinks and his or her decision-making process would allow him or her to recognize areas for future improvement after a SP encounter. Therefore, it is critical for educators to consider teaching participants about the importance of metacognition and how to integrate self-reflection, specifically when using high stakes assessment procedures such as a SP encounter, OSCE, or laboratory practical examination. Standardized patient encounters are constructive experiences that introduce participants to self-reflective behaviors designed to encourage personal growth across the span of their clinical practice.

Avenues of adult and continuing education, such as postprofessional athletic training programs, allow practicing clinicians to engage in robust learning experiences that offer opportunities to reflect on clinical practice. By facilitating postprofessional education through SP encounters, participants were able to develop advanced thinking about their own practice. Often, adult learners' immediate focus is on practical, short-term objectives, but instead, they must recognize both short-term objectives and long-term learning goals.41  The participants in our study were able to recognize the concepts of short-term and long-term goals within their own clinical philosophy to work on after reflecting on their SP encounter. Therefore, SP encounters should be used across athletic training education, professional, postprofessional, and continuing education, to create robust learning experiences for students and practicing clinicians alike.

LIMITATIONS AND FUTURE RESEARCH

Continuing education encompasses formal postprofessional education programs, residencies, fellowships, and both formal and informal continuing professional development experiences. Some may suggest that educational experiences within a postprofessional education program, specifically doctoral programs, may challenge the generalizability of this study. The larger scope and definition of continuing education is to promote continued competence; increase knowledge, skills, and abilities; and enhance professional judgment. Future research should consider whether planned educational experiences, like SP encounters, with objective measures in an academic environment are experienced similarly to other continuing education opportunities.

Participants recognized a variety of factors that led to their stress and anxiety before engaging in the SP encounter. However, the feedback collected from participants in this study was descriptive in nature. As with all qualitative research, the findings must be explored using cross-sectional methods in other continuing professional development environments to ensure the generalizability of the conclusions. Furthermore, within our study, no measure was used to objectively determine whether participants experienced increased levels of cognitive load or perceived mental workload from the SP encounter, which would have helped to quantify a change in stress, anxiety, or cognitive load in conjunction with the SP encounter.

Future investigations should consider objective assessment tools designed to analyze stress, anxiety, and cognitive load, such as the Depression, Anxiety and Stress Scale42  and the Paas Scale43  for cognitive load. The greatest challenge in considering the pedagogical planning for stressful educational environments is the reality that athletic training and health care in general are stressful, and often, the results of our actions are consequential for our patients. Although the participants experienced stress and anxiety, they also clearly expressed the ability to learn from the SP encounter, despite their stress.

CONCLUSIONS

Despite disbelief before the SP, the design of the encounter provided an authentic learning environment for practicing athletic trainers to integrate and rehearse their clinical skills in a safe setting. Although participants expressed anxiety related to the SP encounter, it offers a realistic learning opportunity to assess the participants' knowledge, skills, and clinical decision-making behavior. Specifically, critical self-reflection that allows learners to consider how to identify errors and plan for improvements in care is the greatest benefit. This benefit can occur across a continuum of learning in health care.

REFERENCES

REFERENCES
1. 
Connelly
LM
.
Root cause analysis
.
Medsurg Nursing
.
2012
;
21
(5)
:
316
,
313.
2. 
Kak
N
,
Burkhalter
B
,
Cooper
M-A
.
Measuring the competence of healthcare providers
.
Operations Research Issue Paper
.
2001
;
2
(1)
:
1
28
.
3. 
Dreyfus
SE
.
The five-stage model of adult skill acquisition
.
Bull Sci Technol Soc
.
2004
;
24
(3)
:
177
181
.
4. 
Ouslander
JG
,
Naharci
I
,
Engstrom
G
, et al.
Root cause analyses of transfers of skilled nursing facility patients to acute hospitals: lessons learned for reducing unnecessary hospitalizations
.
J Am Med Dir Assoc
.
2016
;
17
(3)
:
256
262
.
5. 
Garrison
C
,
Ehringhaus
M.
Formative and summative assessments in the classroom
.
2007
.
Association for Middle Level Education Web site
.
6. 
Armstrong
KJ
,
Jarriel
AJ
.
Standardized patient encounters improved athletic training students' confidence in clinical evaluations
.
Athl Train Educ J
.
2015
;
10
(2)
:
113
121
.
7. 
Walker
S
,
Weidner
T
,
Armstrong
KJ
.
Standardized patient encounters and individual case-based simulations improve students' confidence and promote reflection: a preliminary study
.
Athl Train Educ J
.
2015
;
10
(2)
:
130
137
.
8. 
Kameg
KM
,
Szpak
JL
,
Cline
TW
,
Mcdermott
DS
.
Utilization of standardized patients to decrease nursing student anxiety
.
Clin Simul Nurs
.
2014
;
10
(11)
:
567
573
.
9. 
Nielsen
B
,
Harder
N.
Causes of student anxiety during simulation: what the literature says
.
Clin Simul Nurs
.
2013
;
9
(11)
:
e507
e512
.
10. 
Encandela
J
,
Gibson
C
,
Angoff
N
,
Leydon
G
,
Green
M.
Characteristics of test anxiety among medical students and congruence of strategies to address it
.
Med Educ Online
.
2014
;
19
(1)
:
25211
.
11. 
Breitbach
AP
,
Downey
DL
,
Frager
AJ
.
The relationship between candidate psychological factors and first-attempt pass rate on the Board of Certification examination
.
Athl Train Educ J
.
2013
;
8
(1)
:
10
16
.
12. 
Brand
H
,
Schoonheim-Klein
M.
Is the OSCE more stressful? Examination anxiety and its consequences in different assessment methods in dental education
.
Eur J Dent Educ
.
2009
;
13
(3)
:
147
153
.
13. 
Walker
S
,
Armstrong
KJ
,
Jarriel
AJ
.
Standardized patients, part 4: training
.
Int J Athl Ther Train
.
2011
;
16
(5)
:
29
33
.
14. 
INACSL Standards Committee
.
INACSL standards of best practice: SimulationSM debriefing
.
Clin Simul Nurs
.
2016
;
12
:
S21
S25
.
15. 
Hill
CE
,
Knox
S
,
Thompson
BJ
,
Williams
EN
,
Hess
SA
,
Ladany
N.
Consensual qualitative research: an update
.
J Couns Psychol
.
2005
;
52
(2)
:
196
.
16. 
Hill
CE
.
Consensual qualitative research (CQR): methods for conducting psychotherapy research
.
In:
Psychotherapy Research
.
Vienna
:
Springer;
2015
:
485
499
.
17. 
Ha
EH
.
Attitudes toward video-assisted debriefing after simulation in undergraduate nursing students: an application of Q methodology
.
Nurse Educ Today
.
2014
;
34
(6)
:
978
984
.
18. 
Vessey
JA
,
Huss
K.
Using standardized patients in advanced practice nursing education
.
J Prof Nurs
.
2002
;
18
(1)
:
29
35
.
19. 
Beiter
R
,
Nash
R
,
McCrady
M
, et al.
The prevalence and correlates of depression, anxiety, and stress in a sample of college students
.
J Affect Disord
.
2015
;
173
:
90
96
.
20. 
Gibbons
C
,
Dempster
M
,
Moutray
M.
Stress and eustress in nursing students
.
J Adv Nurs
.
2008
;
61
(3)
:
282
290
.
21. 
Walker
SE
,
Thrasher
AB
,
Mazerolle
SM
.
Exploring the perceptions of newly credentialed athletic trainers as they transition to practice
.
J Athl Train
.
2016
;
51
(8)
:
601
612
.
22. 
Yuan
HB
,
Williams
BA
,
Fang
JB
.
The contribution of high-fidelity simulation to nursing students' confidence and competence: a systematic review
.
Int Nurs Rev
.
2012
;
59
(1)
:
26
33
.
23. 
Lewis
KL
,
Bohnert
CA
,
Gammon
WL
, et al.
The association of standardized patient educators (ASPE) standards of best practice (SOBP)
.
Adv Simul (London)
.
2017
;
2
:
10
.
24. 
Turner
S
,
Harder
N.
Psychological safe environment: a concept analysis
.
Clin Simul Nurs
.
2018
;
18
:
47
55
.
25. 
Ignacio
J
,
Dolmans
D
,
Scherpbier
A
,
Rethans
JJ
,
Chan
S
,
Liaw
SY
.
Comparison of standardized patients with high-fidelity simulators for managing stress and improving performance in clinical deterioration: a mixed methods study
.
Nurse Educ Today
.
2015
;
35
(12)
:
1161
1168
.
26. 
Walker
SE
,
Weidner
TG
,
Thrasher
AB
.
Small-group standardized patient encounter improves athletic training students' psychosocial intervention and referral skills
.
Athl Train Educ J
.
2016
;
11
(1)
:
38
44
.
27. 
Szpak
JL
,
Kameg
KM
.
Simulation decreases nursing student anxiety prior to communication with mentally ill patients
.
Clin Simul Nurs
.
2013
;
9
(1)
:
e13
e19
.
28. 
Ndiwane
A
,
Koul
O
,
Theroux
R.
Implementing standardized patients to teach cultural competency to graduate nursing students
.
Clin Simul Nurs
.
2014
;
10
(2)
:
e87
e94
.
29. 
Henneman
EA
,
Cunningham
H.
Using clinical simulation to teach patient safety in an acute/critical care nursing course
.
Nurse Educ
.
2005
;
30
(4)
:
172
177
.
30. 
McCambridge
J
,
Witton
J
,
Elbourne
DR
.
Systematic review of the Hawthorne effect: new concepts are needed to study research participation effects
.
J Clin Epidemiol
.
2014
;
67
(3)
:
267
277
.
31. 
Walker
SE
,
Weidner
TG
.
Standardized patients provide realistic and worthwhile experiences for athletic training students
.
Athl Train Educ J
.
2010
;
5
(2)
:
77
86
.
32. 
Gormley
G
,
Sterling
M
,
Menary
A
,
McKeown
G.
Keeping it real! Enhancing realism in standardised patient OSCE stations
.
Clin Teach
.
2012
;
9
(6)
:
382
386
.
33. 
Epstein
RM
.
Assessment in medical education
.
N Engl J Med
.
2007
;
356
(4)
:
387
396
.
34. 
Townsend
AH
,
McLlvenny
S
,
Miller
CJ
,
Dunn
EV
.
The use of an Objective Structured Clinical Examination (OSCE) for formative and summative assessment in a general practice clinical attachment and its relationship to final medical school examination performance
.
Med Educ
.
2001
;
35
(9)
:
841
846
.
35. 
Dearmon
V
,
Graves
RJ
,
Hayden
S
, et al.
Effectiveness of simulation-based orientation of baccalaureate nursing students preparing for their first clinical experience
.
J Nurs Educ
.
2013
;
52
(1)
:
29
38
.
36. 
Lyndon
MP
,
Strom
JM
,
Alyami
HM
, et al.
The relationship between academic assessment and psychological distress among medical students: a systematic review
.
Perspect Med Educ
.
2014
;
3
(6)
:
405
418
.
37. 
Glassman
PA
,
Luck
J
,
O'Gara
EM
,
Peabody
JW
.
Using standardized patients to measure quality: evidence from the literature and a prospective study
.
Jt Comm J Qual Improv
.
2000
;
26
(11)
:
644
653
.
38. 
Sweller
J.
Cognitive load theory
.
Psychol Learn Motiv
.
2011
;
55
:
37
76
.
39. 
Klein
J
,
Delany
C
,
Fischer
MD
,
Smallwood
D
,
Trumble
S.
A growth mindset approach to preparing trainees for medical error
.
BMJ Qual Saf
.
2017
;
26
(9)
:
771
774
.
40. 
Veenman
MVJ
,
Van Hout-Wolters
BH
,
Afflerbach
P.
Metacognition and learning: conceptual and methodological considerations
.
Metacogn Learn
.
2006
;
1
(1)
:
3
14
.
41. 
Peer
KS
.
Perspective transformation: a mechanism to assist in the acceptance of contemporary education reform in athletic training
.
Athl Train Educ J
.
2017
;
12
(2)
:
73
80
.
42. 
Norton
PJ
.
Depression Anxiety and Stress Scales (DASS-21): psychometric analysis across four racial groups
.
Anxiety Stress Coping
2007
;
20
(3)
:
253
265
.
43. 
Naismith
LM
,
Cavalcanti
RB
.
Validity of cognitive load measures in simulation-based training: a systematic review
.
Acad Med
.
2015
;
90
(11 Suppl)
:
S24
S35
.