Challenges facing standardised patients representing equity-deserving groups: Insights from health care educators

Abstract

Introduction

Health professions training programmes increasingly rely on standardised patient (SP) programmes to integrate equity-deserving groups into learning and assessment opportunities. However, little is known about the optimal approach, and many SP programmes struggle to meet these growing needs. This study explored insights from health care educators working with SP programmes to deliver curricular content around equity-deserving groups.

Methods

We interviewed 14 key informants in 2021 who were involved in creating or managing SP-based education. Verbatim transcripts were analysed in an iterative coding process, anchored by qualitative content analysis methodology and informed by two theoretical frameworks: sociologic translation and simulation design. Repeated cycles of data collection and analyses continued until themes could be constructed, aligned with existing theories and grounded in empirical data, with sufficient relevance and robustness to inform educators and curricular leads.

Results

Three themes were constructed: (i) creating safety for SPs paid to be vulnerable, (ii) fidelity as an issue broader than who plays the role and (iii) engaging equity-deserving groups. SP work involving traditionally marginalised groups risk re-traumatization, highlighting the importance of (i) informed consent in recruiting SPs, (ii) separating role portrayal from lived experiences, (iii) adequately preparing learners and facilitators, (iv) creating time-outs and escapes for SPs and (v) building opportunity for de-roling with community support.

Conclusions

SP programmes are well positioned to be allies and advocates to equity-deserving groups and to collaborate and share governance of the educational development process from its outset. SP programmes can support the delivery of curricular content around equity-deserving groups by advocating with curricular leadership, building relationships with community partners, facilitating co-creation and co-delivery of educational content and building safety into simulation.

1 INTRODUCTION

Our future health care providers must be trained to effectively deliver health care services that meet the needs of patients from equity-deserving groups. To meet this need, health professions training programmes have curricular mandates to integrate equity-deserving groups. This mandate is supported by advocacy from many sources, including the Sullivan Commission report ‘Missing Persons: Minorities in the Health Professions’,¹ and the Institute of Medicine report ‘Unequal Treatment: What Healthcare Providers Need to Know About Racial and Ethnic Disparities in Health Care’.² Health professions training programmes are increasingly relying on standardised patient (SP) programmes to integrate equity-deserving groups into learning and assessment opportunities. However, little is known about the optimal approach, and many SP programmes struggle to meet these growing needs.

1.1 Standardisation as it relates to equity, diversity and inclusion (EDI)

SP programmes focus on delivering consistent, carefully constructed on-demand experiences, allowing tailored content for learners. This consistency, or standardised approach, is a strength in assessment contexts. The ability to deliver consistent content to all examinees ensures fairness.³ In an education context, however, a standardised approach, while being consistent for learners, may create restricted experiences drawn from a limited set of well-developed scenarios. Although SP programmes offer a venue for integrating EDI issues for learners to tackle, the focus on standardisation can limit the application of EDI across scenarios. In theory, SPs can represent diverse traits, including gender, age, race, educational level, psychological state and marginalised social, ethnic or religious groups, and can be trained to reproduce health states and physical and psychological findings with reliability and accuracy.^{4, 5} When done correctly, SP encounters focus on unique health care issues of equity-deserving groups and can help learners develop skillsets around culturally safe communication, diverse cultural perspectives and avoidance of implicit bias.^6-8 However, a general mandate for standardisation may lead instead to ‘stereotyped’ or ‘typical’ scenario scripts.⁹

1.2 Existing literature

Many questions remain around operationalising SP-based equity-seeking educational opportunities. A recent review of the literature¹⁰ revealed multiple ways to work with SPs to meet curricular mandates around equity-deserving groups, including enriching the SP pool with diversity characteristics,^11-14 construction of cases focusing on equity-deserving populations,^{15, 16} physical examination sessions with SPs to develop cultural competence¹⁷ and use of diverse SPs as part of an OSCE.^{18, 19} Studies have shown a promising impact on learner awareness,^{8, 11, 13, 15} self-efficacy¹¹ and competence in trans-cultural care.^{7, 12-14} However, studies frequently focused on a single equity-deserving group or health care need and summarised lessons learned without providing overarching principles or frameworks to help guide SP programmes in translating these lessons to programmes more broadly. This study explored the insights of health care educators working with SP programmes to develop and deliver SP-based education related to equity-deserving groups.

2 METHODS

We conducted a theory-informed, exploratory study using semi-structured interviews of key informants around how SP simulations can be used for EDI curricular objectives (refer to Appendix A for the interview guide). The analytic process was guided by qualitative content analysis²⁰ in an iterative design to establish themes.

2.1 Data collection procedures

2.1.1 Participants, recruitment and sampling strategy for key informant interviews

Recruitment focused on those who had active roles in supporting EDI oriented curriculum involving SPs, including corresponding authors identified in a recent narrative review,¹⁰ speakers at international SP conferences on EDI-related issues in the last 5 years and leads involved in the delivery of EDI SP curricular from SP programmes identified through centre collaborations. We recruited using published email addresses in literature sources, conference materials and our internal lists for national SP programmes. We purposefully sampled different content domains, curricular approaches, institutional contexts and health care training environments. Our a priori review of the literature¹⁰ identified 17 key literature sources with corresponding author information, review of conference material revealed five key speakers, and internal lists included 10 SP programmes. Guided by our study aims, sampling specificity and analysis strategy, we anticipated requiring 15–20 interviews to reach saturation.²¹ Written informed consent was obtained from all participants. The study was approved by the Hamilton Integrated Ethics Review Board (#12614).

2.1.2 Interview process

Semi-structured 1-h interviews were conducted by an SP trainer (NL) with a background in qualitative interviewing, supported by a student (US). Interviews were audio recorded from an online platform (Zoom), transcribed verbatim and anonymized (AK, NL). Participants were asked about what led them to work with equity-deserving groups, experiences working with SPs and SP programmes to integrate equity-deserving groups, educational structures and processes used, community and sociological engagement processes, delivery and evaluation of learner satisfaction and achievement. The analytic team met with the interview team on a monthly basis to review two to four transcripts and evolve the interview guide, inform sampling and determine when saturation was reached.

2.1.3 Data analysis

Two theoretical perspectives informed the analysis: sociologic translation and simulation learning.

1. Sociologic translation—Callon's theory²² provides a framework for how groups or individuals come together to enact change. Four phases are described: surfacing a problem (‘problematization’), engaging around the change process (‘interessement’), defining roles (‘enrolment’) and aligning and coordinating to achieve a goal (‘mobilization’). Callon's theory sensitises us to the context of SP curricula development within academic training centres, health professions training programmes, health care systems and equity-deserving populations. Adopting this theoretical lens allows us to separate phases in the process: how individuals and groups within this network can convince each other of the need for curricular change, form interest groups, enrol community members and mobilise curricular change.
2. Simulation—Simulation with SPs is an established effective pedagogical approach to training health care professionals, allowing learners to develop their knowledge, skills and attitudes, while avoiding unnecessary harm to patients.^{23, 24} Consistent learning opportunities with patients from equity-deserving groups are not always accessible, allowing a valued role for simulation-based learning with SPs. However, simulation approaches must contend with how much the experience authentically represents the clinical task.²⁵ The fidelity, or elements of realism and authenticity, must be sufficient to engage learners, allow the transfer of acquired skills and enable learners to ‘suspend their disbelief’. The conditions under which SP programmes can achieve appropriate fidelity to build cultural humility in learners are vital to their success in supporting curriculum around equity-deserving groups. Simulation with SPs as a training modality informed the development of the interview guide in this study and the interpretation of the results.

The analytic team reviewed transcripts in a staged approach moving from qualitative description to qualitative content analysis. Initial readings relied predominantly on open coding to identify key themes using a shared online document, sensitised by the two theoretical perspectives in a manner consistent with direct content analysis.²⁶ The team discussed codes and linkages in recorded monthly meetings, enabling the subsequent transfer of the group's coding into qualitative analysis software (HyperRESEARCH 4.5.2) by two team members (NL and US). The recording allowed the group to reference prior discussions and ensure the diversity of perspectives from the analytic team was represented in the final coding; this allowed for an iterative transition to axial coding, identifying more in-depth linkages between material. This process continued until saturation was achieved, defined as coherence and empiric support for themes with meaningful implications for educators and the SP community.

2.1.4 Approach to methodologic rigour

A systematic approach to rigour was adopted through data collection and analysis. We used an online system to keep track and add to this list of potential participant recruits, seeking meaningful variation and deviant cases for sampling of interview participants.²⁷ Interviewers used a structured pre-briefing to establish expectations around confidentiality and psychological safety for the interview process. Transcripts were verified for accuracy and anonymity prior to analysis. The analytic team was constructed to include varying perspectives and included academics of varying degrees, health care practitioners, SP trainers, students, those who have experience in developing standardised patient educational experiences and those who identify with traditionally underrepresented groups. Before beginning this work, as a method of reflexivity, the analytic team discussed and shared with each other individual perspectives, philosophical and epistemological stances and beliefs related to this research. The analytic team recognises the role of the qualitative researcher as part of the research process; the team made an effort to remain sensitive to the ways in which we shaped the research process by constantly reflecting on our decisions, acknowledging our own and others' prior assumptions and biases and being attentive to the perspectives and voices of the research participants. In addition, analysis involved triangulating data across interviews, examining multiple theoretical perspectives, reflexive journaling by researchers to identify emergent insights and revisiting codes and themes throughout the analytic process.²⁸

3 RESULTS

We interviewed 14 participants from Australia (Queensland and Victoria), Canada (Manitoba, Nova Scotia, Ontario and Saskatchewan) and the United States (Connecticut, Nevada, Ohio and Pennsylvania). Ten participants identified as female, and four out of the nine participants who disclosed identity-related information identified with a marginalised group (disclosed groups were lesbian, gay, bisexual and/or transgender). Six participants worked in an SP Programme capacity as either an SP educator (n = 3) or programme coordinator (n = 3). Five participants were in a faculty role as either a professor/lecturer (n = 3) or dean/assistant dean (n = 2). Three participants were health care professional learners involved in the development of SP educational experiences. Years in SP worked ranged from less than one to 27. Three key themes were constructed from the participant data: (i) creating safety for SPs paid to be vulnerable, (ii) fidelity as an issue broader than who plays the role and (iii) engaging equity-deserving groups.

1. Paid to be vulnerable. How do we reduce risks to SPs involved in role portrayals of equity-deserving groups? SPs recruited for roles involving health inequities risked re-traumatization, particularly if past experiences were similar to the case. Participants highlighted the importance of informed consent in the recruitment process, including access to the case before accepting the role and the ability to back out of the booking. Dissociating lived experience from the scripted role was thought important for safety, ‘It eliminated the vulnerability of feeling that maybe you have to divulge something about self. … The script protected them’ (Participant 13, Faculty). This was emphasised in training, ‘I made it a rule that you don't talk about your personal history in cases, in training’ (Participant 8, SP Program Director), and signalled explicitly:

   It's very hard sometimes for some people to separate when you're acting and when you're being yourself. So we wanted to make it very clear. We used the word like, ‘This is acting a part.’ And so we didn't want it to bleed into their own story – blend too much with their own story, so they felt vulnerable. (Participant 13, Faculty)

Learners and facilitators should be prepared for the role content to avoid repetitive exposure of the SP to triggering behaviours by learners. Time-outs and safe spaces were mechanisms of support for SPs to step out of the role:

Say to the students and to the faculty lead and to the SP, ‘There can be a timeout. Or you can flag me as the trainer that something is going off course, and we can have a conversation around it.’ Being able to stop and say, ‘Do you know what, let's stop and chat about this for a minute before we go any further.’ Or saying, ‘I need to pull myself out of this.’ (Participant 9, SP Trainer/Educator)

Trainers often supplemented the support of faculty for SPs:

We'll keep … an SP room … open that people can jump back into and have a conversation with us if they want to, and we'll say, ‘Okay, we'll hang out there afterwards. You don't have to come, but if you wanna come and chat with us about something, we'll be there. If you wanna take this conversation offline, we can do it.’ (Participant 9, SP Trainer/Educator)

Finally, SP debriefing after a session with trainers or faculty provides another opportunity for support and connection with community resources to address triggering and re-traumatization induced by role portrayal: ‘We had an extensive debrief and de-role after both of those sessions. And I think that's very important … and we're doing that with the transgender patients as well, a debrief and de-role’ (Participant 6, SP Program Director).

2. Fidelity is not just who plays the role. Who plays a role raised issues around to what extent individuals playing a role should associate with the equity-deserving group or have lived experience around the health care disparity it addresses. What was acceptable or not seemed best left to the group in question: ‘My sense is that it's more about the sensitivity of the group than the ability to play the role’ (Participant 12, Faculty), though this leaves open the challenge of achieving consensus among people who associate with an equity-deserving group.

There was a shared belief among participants that including marginalisation as an added case detail is problematic: ‘This needs to be based upon reality of real patients’ (Participant 8, SP Program Director), and risked devaluing the engagement of the diversity group if it did not align with a meaningful purpose: ‘A lot of the Indigenous or even ethnic diversity cases that I've come across, ethnicity was thrown in as an added detail or a feature. It didn't have anything to do with the learning objective of the case’ (Participant 4, SP Trainer/Educator). Some participants felt that simply recruiting individuals who identified with the groups being represented for role portrayal was insufficient and highlighted a need to engage these groups systematically throughout the entire educational process.

Collaborative engagement throughout the entire educational process included customised approaches required to co-create, co-train and co-debrief.

Specific to co-creation was the need to create spaces to listen to the narratives of equity-deserving groups and prioritising those narratives in the educational process:

Tell us about your healthcare experiences. And then from their own medical narrative. … we took something that was a little bit of their story, something that they could relate to, that they could portray, and then co-created the script. (Participant 13, Faculty)

Co-training was a strategy to provide perspective from the equity-deserving group to the role portrayal beyond who plays the role: ‘If there's somebody in the room who is contributing to the training and is able to speak from that lens … and the input and the content development has been there … maybe that's ok’ (Participant 9, SP Trainer/Educator). Co-debriefing was also highlighted as a strategy to enhance the equity-deserving group's perspective when the SP was not within the group: ‘If there's feedback and the person is supposed to be giving feedback from a particular lens, I think that somebody representing that community should probably be in the room’ (Participant 9, SP Trainer/Educator).

Fidelity to the equity-deserving group's perspective can also be enhanced with a pre-recorded recounting of lived experience: ‘That would hit the ball out of the park for the students. … When people come in and share their experience. … it can really open their eyes to something maybe they hadn't seen before’ (Participant 11, Faculty). This strategy allows the material to be reused across groups and sessions, mitigating the minority tax on a select number of individuals and allowing student attention to be sensitised and focused before the session:

We ended up doing an interview with two trans folks, one who identifies as non-binary and one who identifies as a trans man … we showed that [video] instead to students beforehand, so that it was really much more pointed as to what we wanted to focus on. (Participant 10, Faculty)

3. Engaging equity-deserving groups. Equity-deserving groups often have inequities in their social determinants of health, including access to email, convenient transportation and childcare. These same barriers limited their abilities to participate in SP programmes:

You expect people to have access to email. You expect them to have access to a computer system that works really well, particularly now, when everything is virtual. You expect people to be able to get themselves here at a certain time, and if you don't have a car, then you have to rely on the bus. You expect people to arrive and not to be late. (Participant 7, SP Program Coordinator)

In some contexts, these barriers proved too great to overcome:

It became extraordinarily difficult because people just wouldn't show up. You had these things scheduled with groups of dozens of people and multiple facilitators in large complex structures, and you'd have about 30% to 40% just not arrive for the day. Eventually they pretty much just stopped … because it just was logistically not possible. (Participant 12, Faculty)

Prior health care experiences themselves were often deterrents to participation: ‘They may have a very traumatic experience with the healthcare system in their history or in their family's history … why would they want to participate in this program?’ (Participant 7, SP Program Coordinator). Overcoming these obstacles requires relationship building: ‘You have to build trust, which in and of itself takes a very long time’ (Participant 7, SP Program Coordinator). Theatre groups of traditionally underrepresented or marginalised groups were helpful communities of practice accustomed to acting roles aligned with their identities: ‘The first people we chose already were performers. … and we already knew that they could do the job. Like they wouldn't be daunted by it’ (Participant 13, Faculty).

Similarly, health professionals who identify with a traditionally underrepresented or marginalised group had unique perspectives and ability to engage and enrol their community to support SP education: ‘I guess it's my own identity as a member of a sexual minority. … when my own community was being decimated, that's when I felt that I needed to be contributing to that effort’ (Participant 14, Faculty).

4 DISCUSSION

This work identified three key themes related to the work of educators in promoting and developing SP-based education involving equity-seeking groups. First, it is essential to consider the safety risks involved in these role portrayals and efforts made to mitigate them. Second, fidelity requires careful balancing of the need for in-group representation without overburdening an equity-seeking group in providing education to address health care disparities. Finally, engaging equity-deserving groups requires an appreciation of the barriers within the education system as well as the health care system.

Traditional educational structures often silo SP case development within an educational programme, using structured curricular development processes that may unintentionally contribute to the marginalisation of equity-deserving groups.²⁹ SP programmes can advocate with curricular leadership to empower traditionally underrepresented groups to share ownership in the curricular development process, starting from defining the needs for education through to co-creation and co-delivery of the content. This inclusive approach to SP case design allows issues around standardisation, risks of tokenization, risks of re-traumatization and difficulties recruiting to be tackled early in the instructional design process rather than letting them unfold in the delivery process where the SP programme risks being unable to meet the goals set out by the educational programme.

All four moments for sociologic translation highlighted by Callon²² are relevant to the process: (i) recognising the need for education through problematization, (ii) building interest among community partners to participate, (iii) enrolling members in case design, training, or SP role portrayal and (iv) mobilising to provide the educational experience. SP programmes are uniquely positioned to assist in facilitating this process and build relationships with diverse community partners. SP programmes can also empower individuals within their networks who identify with an equity-deserving group and work as either health professions educators and/or clinicians. Although all three of these skill sets may rarely exist in the same person, several informants in this study had this combination of perspectives and described notable success in fulfilling curricular mandates related to their communities through SP education. Despite these successes, we note the downside of singular perspectives driving curriculum, which may not always resonate with the group suffering from health inequities.

Finally, safety for SP work related to equity-deserving groups requires a unique focus, as the educational process can itself be oppressive,²⁹ especially if SPs are paid to draw on their lived experiences for role portrayal. For this group, mitigating safety risks entirely may not be feasible; rather, educators may need to create room for ‘brave spaces’ to acknowledge and support SPs in drawing on lived experiences, despite the inherent discomfort and safety risks they pose. We recommend SP programmes invest time and energy into systematically incorporating ‘safe’ and ‘brave’ spaces into simulation processes.^{30, 31}

Several limitations of this work are worth mentioning. First, participants had unique contexts and roles within the communities and educational systems in which they worked. Although we strived to develop a nuanced understanding of the context in which they worked, our understanding of these situational factors may be incomplete and may limit the generalisation of these findings to other contexts. Second, although some had worked as SPs before their educator or training roles, we did not specifically recruit those who were active at portraying roles related to equity-deserving groups. This perspective may be underemphasized and is worth future research. Third, we did not require participants to have formal diversity training nor associate with an equity-deserving group; although this facilitated broad recruitment, it also incorporated varying degrees of understanding of diversity issues into our data. Finally, although there was considerable diversity among our analytic team, we are all situated within an academic health care training setting and may miss some of the assumptions deeply embedded within this perspective.

4.1 Implications of our work

We suggest SP programmes encourage educational programmes to think beyond the identity of who is hired to play a scripted role involving an equity-deserving group and consider the health care inequity that SP education is trying to address. Robust, inclusive processes to build relationships with and engage equity-deserving groups in the entire educational process, from needs assessment through case design, training, recruitment and delivery, are best positioned to fulfil the curricular goals. SP programmes should also consider how to guard against the unique threats to safety for those individuals identifying with equity-deserving groups engaging in SP education to avoid perpetuating oppression and marginalisation through educational structures and processes.

We recommend educational programmes build an understanding from the SP and patient perspective to understand better the impact simulation experiences have on learners and to incorporate inclusive processes in day-to-day education systematically.^{32, 33}

Future work should explore how SP and educational programmes can work together to expose health care learners to equity-deserving groups early on and throughout their education while providing a learning environment where all participants feel psychologically safe.

AUTHOR CONTRIBUTIONS

Matt Sibbald: Conceptualization; funding acquisition; investigation; methodology; supervision; writing–original draft; writing–review and editing. Nicole Last: Data curation; formal analysis; writing–original draft; writing–review and editing. Amy Keuhl: Formal analysis; project administration; writing–review and editing. Arden Azim: Formal analysis; writing–review and editing. Urmi Sheth: Data curation; formal analysis; writing–review and editing. Faran Muhammad Khalid: Formal analysis; writing–review and editing. Farhan Bhanji: Formal analysis; writing–review and editing. Aaron Geekie-Sousa: Formal analysis; writing–review and editing. Derya Uzelli Yilmaz: Formal analysis; writing–review and editing. Sandra D Monteiro: Formal analysis; writing–review and editing.

ACKNOWLEDGEMENTS

We would like to thank participants for sharing their experiences and perspectives with us, making this work possible. This project was funded by a Medical Education Research Grant from the Royal College of Physicians and Surgeons of Canada.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

ETHICS STATEMENT

The study was approved by the Hamilton Integrated Ethics Review Board (#12614).