Reflections on simulation patient methodology: A pillar of the healthcare simulation community

Opening Plenary – Debra Nestel, PhD, CHSE-A

Reflections on simulation patient methodology: A pillar of the healthcare simulation communityASPE_2014Nestel_Jun21-22 0113

By: Darlene Self, University of Texas Medical Branch, Galveston, Texas

Dr. Nestel began her presentation by reflecting on a career that spans many disciplines as well as numerous pathways that patients must negotiate as they navigate through the complex healthcare systems. Her career spans thirty years and consists of multiple milestones associated with her experiences in simulated patient methodology. During this time, she has seen the expansion of SPs from one-on-one interactions into team-based interprofessional simulations.

She set the scene by describing several key terms associated with this unique profession. Although “standardized patient” is the phrase many ASPE conference attendees commonly use, it is not universal. Instead, in some countries, the terminology has evolved to “simulated patient”. As she explained, a simulated patient (SP) is able to standardize his/her performance when he/she is required to perform a specific function. She defined “SP methodology” as the study of our practice (or method of working with SPs). And, she described “SP educator” as the role of those involved in supporting SPs.

As her lecture progressed, she described the role simulated patients play in creating authentic learning opportunities for healthcare students. SPs are able to replicate real world experiences because they possess a complex set of skills. SPs, for example, have the ability to realistically portray the role of a patient. When required during an encounter, they adjust the intensity of their emotions and/or standardize their performance. They respond appropriately to feedback about their performance as well as provide feedback based on a learner’s performance to both the student and faculty. And because SPs have an understanding of educational principles, they possess the expertise needed to fulfill the role of teacher.

The presentation took a fascinating direction as she illustrated how the “community of practice” concept relates to SP educators. “Communities of practice are groups of people who share a concern or passion for something they do and learn how to do it better as they interact regularly” (Wenger, 1998). She used this reconceptualization of apprenticeship learning to describe how newcomer and old timer SP educators can work together to build relationships and learn from each other. For instance, newcomers become familiar with the tasks, language and organizing principles of the community as they observe veteran SP educators. Collaborative efforts also enable new educators to transition from participating in basic, low risk tasks to ones that are central to the functioning of the community. As members of this community of practice, newcomer and old timers interact to develop a shared repertoire of resources, such as scenarios, scripts, roles, briefing materials, and rating boards. It is through these relevant activities that newcomers grow to become experienced members and eventually old timers of the communities of practice. With this in mind, she urged old timers to create conditions for new SP educators to join them.

There were several key messages in Dr. Nestel’s presentation.

  1. “SPs are potentially best placed to support the development of patient-centeredness.” SPs have far more to offer than other simulators due to their ability for “in and of the moment” human presence during a portrayal. Another unique contribution is their ability to offer feedback from the perspective of the patient. Unfortunately, the desire for standardization often compromises SPs’ spontaneity, and in these situations, their potential goes untapped.
  1. “If SPs are to be proxies for real patients then they (simulated and real patients) must be connected in some way.” It is a well-known fact that SPs must possess a working knowledge of SP methodology in order to effectively teach, deliver feedback and assess student performance. However, focusing solely on educational principles hinders the SPs’ ability to develop and maintain an authentic patient voice. Reconnecting SPs with real patients, who have a tremendous bank of experience and knowledge, enables SPs to evoke the patient’s perspective. This not only reduces the production of phony portrayals but it also ensures learners receive high-quality educational experiences. Real patients, therefore, should be used routinely in the delivery of training that is focused on communication skills and patient needs.
  1. “SP educators are actively shaping practice (for better or for worse).” For this reason, they must choose their language very carefully. Failure to do so results in SPs receiving information that contains clinician-focused rather than patient-centered language. Using improper terminology when naming roles is one area where this misunderstanding frequently occurs. Real patients do not describe themselves based on clinical conditions or differential diagnoses yet this is often the way SP educators designate roles they assign to SPs. This miscommunication has caused some SPs to develop an allegiance to faculty while failing to even consider patients. As this example reveals, the influence of SP educators might be “for worse” if they are not diligent to send messages to SPs which convey that they are proxies for patients.
  1. “Although SP methodology is a pillar of healthcare simulation education there are risks if it develops in isolation.” When used as a metaphor, the word pillar implies there is a foundation and the pillar is supporting something. SP educators and SPs form the pillars of SP methodology because they have a common goal – the delivery of high-quality, patient-centered care through the offering of effective education to healthcare students and professionals. They accomplish this goal through mutual engagements and evolving shared repertoire within their community of practice. But, as the image illustrates, this metaphor has a major limitation. The pillars of the practice are separated from patients, healthcare students and professionals as well as the broader community.

A more feasible concept is to create a structure that gives credit to the specialization of SP methodology, encourages the use of many simulation modalities, plus promotes interactions with patients, practitioners, clinical teachers, and supervisors. In this modified diagram, a single pillar of reflective SP educators sits within the broader palace of educators. SP methodology continues to develop in a highly specialized way because both SPs and patients are included. Also incorporated in the revised image are the various entities and methods needed to enhance healthcare education. This model encourages everyone to learn with and from each other. As a result of these collaborative efforts, simulation patient methodology will remain a pillar of the healthcare simulation community.

At the conclusion of her lecture, she was asked to share her thoughts about the relationship between authenticity and standardization. She contended that the desire to create consistency (via standardization) actually causes us to lose the value of what SPs bring to the table. She urged us to work towards creating adaptive experts rather than standardized ones. She recognized that her comments might be unsettling to a number of conference attendees. However, as she rationalized, this divergence is beneficial because we are exposing each other to different ways of doing things.

Dr. Nestel’s rich and provocative plenary certainly challenged many to consider her position. It also stimulated numerous discussions, which continued beyond the conclusion of the opening session. Thus, she achieved her goal – to provoke us to ponder our view of SP methodology in order to promote a greater connection.



Debra Nestel, PhD, CHSE-A, is Professor of Simulation Education in Healthcare, School of Rural Health, and HealthPEER, Faculty of Medicine, Nursing & Health Sciences, Monash University. For over 25 years, Dr. Nestel has used simulation as an educational method. She is an experienced qualitative researcher in medical and health professions education. She has worked at Imperial College London and the University of Hong Kong and is a Visiting Professor at Imperial College London and an Honorary Professorial Fellow in the Department of Surgery, University of Melbourne. In 2008, Dr. Nestel returned to Monash where she leads several healthcare simulation projects. Her research interests include the role of simulation in the development of clinical skills. She is especially interested in the role of simulated patients in supporting learning. Dr. Nestel is Course Director of the Masters of Surgical Education, a program designed for surgeons as teachers and co-badged by the University of Melbourne and the Royal Australasian College of Surgeons. She is Immediate Past Chair of the Australian Society for Simulation in Healthcare and is a Board Member of Simulation Australia, the national peak body for the simulation industry. With colleagues around Australia, she has developed two national programs for simulation educators: and She has also led the development of the Victorian Simulated Patient Network – a repository of resources on simulated patient methodology. Dr. Nestel has over 120 peer reviewed publications in the field of clinical communication and simulation-based education. In 2014, she will be publishing an edited book on simulated patient methodology.