Simulated Patients’ Experience towards Simulated Patient- Based Simulation Session: A Qualitative Study

Background: Simulated Patient (SP) is defined as a layperson that simulates to portray the role of a patient with healthrelated conditions. International Medical University (IMU) has been utilizing SP for more than 10 years, however, the SP's experience toward the SP-based simulation session yet to be explored, the aim of the study was to explore the SP's experience toward the SP-based simulation session. Methods: Total of 6 participants recruited for a focused group interview, with the inclusive criteria of participated at least an SP-based simulation session. The interviewer used a list of guide question to explore both the positive and negative experience of the SP-based simulation session. A combination of manual and computer software Program was used for data management and analysis. Manual transcribing and coding technique was used for data analysis, while Qualitative Data Analysis (QDA) was used for data management and additional analysis. Results: Three main themes and eleven sub-themes have emerged. The first theme was Effective learning session, with the sub-themes of Student learning attitude, Treated as real patient, Standardization among lecturer, Appropriate respond to student and Focused learning outcome; second theme was Motivation, with the sub-themes of Respect, Feedback, and Caring; the third theme was Preparation prior to class, with the sub-themes of Clear instruction, Role-play, and Script. Conclusions: SPs perceived that lecturers should pay attention to the students’ learning outcome and fully utilize SPs for teaching. Besides that, SPs wished to be treated as a real patient due to the lecturer who treated the SPs as they are real patient gave students a mind-set that the learners were actually dealing with a patient with real conditions. SPs supposed that another role of the lecturer was well-prepared the SPs prior to the actual sessions. SPs expressed that students who took the session seriously, well-preparation before the classes, active participation during the sessions and proactive attitude encouraged realistic portrayal of the character. While SP role was memorizing a series of information needed for the scenario, prepare mentally for portrayal certain emotional as well as physical symptoms. Lecturer, SP as well as student influence a successful SP-based simulation session.


Introduction
Simulated patient (SP) is defined as a healthy trained individual [1] to portray role of a patient with various health associated conditions [2,3]. Combination of above, SP can be defined as a lay person that simulates to portray a role of patient with health-related conditions based on varying levels of training.
Many studies on the participants' experience involved in SP work. Russell et al. (2012), Gamble et al. (2016) and Burgess et al. (2013) reported that the positive impact by participating as an SP was including development of knowledge particularly referred to medical knowledge and satisfaction as giving opportunities to contribute to the training of future healthcare professionals [4][5][6].

Methods
This was a descriptive qualitative studies, using purposive sampling method. The participants were selected based on the inclusive criteria of the SP must be willing and voluntary as well as the SPs must have enrolled as SP for more than one year; have attended at least one SP training, one SP-based simulation session as well as one OSCE that conducted in Clinical Skill and Simulation Centre. A total five participants were involved for a focused group interview and one student was involved in one-to-one interview session. A list of guided questions used to assist the researcher to explore the experience of participants towards Simulated Patient-based simulation session (refer Appendix). The interview was audio-recorded and transcript manually, followed by a combination of manual coding and computer software Program (Qualitative Data Analysis Miner) was used for additional data management and analysis.

Results
Six SPs were participated in two interview sessions; one individual interview and one focused group with five SPs. There were five female SPs and a male SPs; age ranged from 30s to 50s; and year of experience as SP ranged from one year to eight years. Three themes revealed from the SPs group interviews, i.e. Effective learning session (coded the most), followed by Motivation and Preparation prior class.

Student Learning Attitude
Four SPs observed that student did not take the SP-based learning sessions seriously. SPs were expecting students take the learning sessions seriously. Students who failed to do such can cause dissatisfaction for SPs.
"I feel the role of being 19, 25 or sometimes, I free hair, I look, some people say I looked younger, so they don't really take it seriously." -IT "They don't take it seriously." -NR "I do feel irritated if the students do not take me seriously, yes, I do feel, to be honest, is very irritating." -TPY "Ya, I want to say the same thing, take it seriously like sometimes we doing the role." -MG While, four SPs observed that lack of active participation during SP-based simulation sessions. In another word, students proactive to take part in the learning session. One SP observed that only small quantity of students was proactive to learn.
"They very quiet, so I think once like that ya, I think the class will be very boring, will be very dull, if they do not take the initiative to say: Yes, I come to do, you know?" -TPY "They always hang around at the back; you know? They avoid eye contact, maybe one or two would always will be the first." -LTC "They look uninterested. I not want to be here, I forced to be here. Just keep quiet, sometimes they just look at me and smile and like I don't know what to ask you." -IT Not so responsive, you know they are like responsive, they are like waiting for each other. Quite quiet, like they are scared of being the first one to sit on the seat to ask the simulated patient." -SZ Two SPs mentioned about students' preparation prior to the session. Well-prepared student able to achieved learning outcome, while students who not well-prepared prior to classes may reduce SPs' confidence.
"Let's say they are supposed to do certain cardio, you know? CVS, you know? They really know, they do, they don't go side incident or go off point, you see? Ya, and do something else totally not relevant, you know?" -LTC "They are maybe asking like out of, maybe not directly asking directly to what is supposed to I am to portray out, you know, I don't know whether did I really not do well or they did not prepare the day before." -SZ

Treated as Real Patient
Three out of six SPs expressed that lecturers influenced on the SPs' role as a real patient. One SP wanted the facilitators treat SP as a real patient, while lecturers who neglected the SP role and arguing with SP about accuracy of script may devastated the realism of character.
"Once I come in, they really, totally not the felt like I know you before, I seen you before many times, this is your patient, I have been encounter a lots and that was the best experience, because I already in character, I already a patient and the lecturer is being another support system that this is a real patient." -IT "There is one time, is ok, she just an SP, so I was like, ok, so I not need to act, so I just forget my dialog, forget my script, I think this, you know? I am a normal person, I should have broken legs but because I am just SP, so I can just sit like that loh." -IT "When we were interview with the student, and it wasn't me, you know forgetting about the script, but I think is the lecturer, and she try to correct me during the interview itself, and then when I told her that, you know, is in the script is like this, and then after that she realize she the one who make the mistake, and then ya, it didn't turn up that well." -NR "When the student was asking me question, and then I remember their lecturer said: Aiya, not need to tell lah, SP condition already, I mean if you would tell the student, the SP is been in condition in so many things, there nothing, there is no participation between two parties." -TPY On the other hand, one SP emphasized in several conversations that students also influence SP' role as a real patient. Students' verbal and non-verbal communication can increase the realistic of character portrayal.
"Their tone of voice, the way they greeted me, the way they look at me, and then the way they looking at me, so comforting, I was supposed to have some pain and the way they comfort me, the way they do is their tone and their expression, their facial expression and the tone of voice they used, I was very impressed with the tone. They stand up quickly and help you up all that." -MG "They really treat us as real patient, like a few… when I did the depression one, when I did the stroke one, they really took me as a real… I mean they really treated me as a real patient, the way they talk to me, the way they look at me although they know me, ya, but they really make me feel like I am the real." -MG "They don't treat us like a real patient. They know from the start that this is simulated patient, so you know? They ask for the sake of asking." -NR

Standardization Among Lecturer
Majority (five out of six) SPs did not satisfied with the standardization among lecturers for both teaching and learning sessions and OSCE. The lecturers should standardize the teaching content and release or holding information to student during OSCE, instead of instructed SPs according to own preference.
"There are sometimes their approaches differed lah, I noticed from class to class lah. Let's say they talk about spine, they will go beyond that, what are the causes, so many causes, so many other things you know, can magnify, you know or amplify other areas and all, but some like quite superficial lah, that border me also lah. Some group they are quite superficial also. I feel more for the student than anything, you see. I feel certain group may, they in ah, the students get more out of the lecturer than with certain other group. Yet, they paid the same fee." -LTC "For one lecturer is not prompting, for another lecturer, it can be prompting, I don't know. Some, got too strict too on standard or what?" -LTC "We come prepare as what as we are being briefed, ya, been told, but sometimes, the examiner you know expect us to do, like you said, they think we are prompting, we are not giving out enough information to the student." -NR "When the student actually asked, we supposed to, you know, during briefing they said, student ask something like this, you can actually volunteer the answer, but the examiner they were like, no, you don't have, you no need to say it, I want their direct question." -IT "I was doing in the first room, I was doing there, the lecturer was very happy with me, she said very good lah, and I had a break, you know? Reserve, you know? Then I went into another room, so there I said the same thing lah, I had fever and the student left the, then the lecturer said: that the problem, you all SP all give so much." -MG "Some lecturers are sterner than the other and some are not." -SZ

Appropriate Respond to Student
Four SPs believed that they appropriately respond to students, including justified students' direct and indirect questions, give calculated respond to students who were off track as well as following lecturers' instruction.
"When the student was asking, even though not a very direct question, it can be indirect, but I feel that, ok, I still can answer." -TPY "Students sometimes can ask an open ended question, related but is open like do you have any other problem, thing like that, similar problem with this, and then you give a reply. A lots of time, students come out with way off answer, questions like that, you know? We need to response as well. Sometimes like student will come with off, give all off questions, then of course, you have to give a (respond), like you say, keep quite also not good, ya, so we have to give some kind of reply lah, or a calculated reply." -LTC "I been briefed like that, if you are told give one answer, that will be the only one answer that will come out from our (mouth)." -NR "How much we volunteer or we are not volunteer, it depends very much how the student take the history, it depends so much." -TPY Three SPs considered consistency as one of the appropriateness respond to students.
"Consistent and withhold information at the correct time." -TPY "We are consistent." -MG "We have to be consistent to all students." -NR

Focused Learning Outcome
Four out of six SPs observed the learning sessions were not focused on the students' learning outcome, such as discussed issue out of the teaching content and inappropriate teaching style.
"Lecturer was very draggy, ya, he was very draggy, telling all the story about the friend, family, some other world issue, ya, so half of the class had become, not focusing on what they actually need to do, is actually 50% is about something else." -IT "The lecturers go off track and sometimes, we don't know we are finished or not? They keep on talking so much, ah, we are just sitting there." -MG "The lecturer was not really into the topic, so he was talking all the time, and sometimes not into the topic at all, so the SP and the students will be all the time listening to whatever he wanted to say, so that mean like even as a SP who come for the class, is like my time is not been utilized in a very professional way, because the whole class would be like not a class at all, is something like is sharing session." -TPY "Over content sometimes, misinterpretation of content." LTC

Respect
Four SPs expressed disrespect experience with both students and lecturers. SPs experienced scolding from lecturer and validate patients' privacy as well as students take the session lightly.
"I was scolded for giving the answer, then he said: you should not give that student that answer! Because this one I was not prepared. And I was being treated like that, and especially you did it in front of the students, so make me look like I don't know my stuff, like this SP come, don't know anything." -TPY "The lecturer like to be touchy touchy, ya, touching without asking permission and all that. He didn't ask my permission; he was just suddenly put up my pants." -IT "I think also show respect during the OSCE lah, you know? Like whatever SP is doing during that time, whatever is not right, or we missing out something, probably you know is after the student have left the room or cubicles." -NR "So when we are doing the kind of role ah, they tend to giggle, and that is not easy to do that kind of role, you know? To be teary, to be sick, and depressed that all, and then when they giggle." -MG There were three SPs observed experience respect from CSSC. The SP coordinator showed concerned, communicated politely and committed to the agreement.
"Take note of us, we are there." -NR "They are very polite." -SZ "When you all give a class, you all never cancelled, you always stick to that class." -MG

Feedback
Four out of six SPs mentioned their perception regarding feedback from the faculty. SPs appreciated lecturer's compliment on their SP performance, however they were upset when lecturer gave inappropriate feedback. Some SPs perceived that no feedback from lecturers mean they were doing good and doing right during sessions.
"If they tell you, you are not doing well, then you will get worried. When there is no comment, you didn't have anything to talk to us, I think is safe, you are safe for the day. This the first time that I had a very good feedback for my exam, I mean the first time, so I felt that, ok, that mean I am doing a good job as a SP, ya, that was the first feedback." -TPY "Sometimes they will tell you lah. Sometimes, even the external examiner also, when they come in, and they sit down, they watch you, when they go out, they will look at you, and say like that ah (thumb up) you will very happy." -MG

"If you don't give us the feedback, I considered I doing fine mah, so I continue what I doing mah, even though is wrong, nobody tells me, so I keep doing the wrong thing." -LTC
"Every single student, she wasn't satisfied with me, my performance. Comment each and every student, I make the mistake, I not telling enough, I am not withholding information too much." -NR

Caring
Five SPs mentioned that they appreciated the treatment given, such as outing, showed concerned, fulfilled physical need and solved their problem when raised.
"We had an outing recently and I am very happy with it." -SZ "They do show concern for us. If let's say if will to bring out some issue, you all will take note, you all show concern about thing, and then as she was saying, you do rectify in a short time. That why I said, that the best experience. Because that mean the concern for us, you really take care of us." -TPY "They show you know, they pay attention to us, show concern and you know, ok, you know, must be tired, come, have something, even during fasting month." -NR "They say: oi, you been doing this for… really ah? Really ah? How you? Ok ah? And then they will take the bottle and give to you, ah, this little gesture make you feel very nice." -MG "Some of the examiner really pay attention to us because we be sitting there, sometimes we need to stand, so it been a long hour, eight hours, six hours, so the fact that they actually pay attention to us." -IT

Clear Instruction
Four SPs mentioned regarding the accuracy of information received prior to the SP-based simulation sessions. SPs identified that the instructions were including prepared SP for various questions might raise from students, involvement of physical examination, amount of information to release as well as the accurate briefing date and time given.
"The lecturer will always tell us what to do, basically tell us our role lah, which is very good, so we don't just ah read the script, but the lecturer will also tell us and give us cues, if they ask you this question, then you answer this way, any script, the lecturer always prepare us ahead just in case, if they ask you like this, then you answer this, which is good. They always ask also; you know? If

Role play
Two out of six SPs mentioned that role play was part of preparation prior of class. Role play regarded as part of preparation prior to sessions.
"Nowadays the briefing, when we briefing before the OSCE, we do role play, you know? So, we already standardize already among ourselves." -MG "We have, we have the role play with them." TPY

Script
Two SPs believed that well prepared with the SP script given by studying and memorizing the scripts.
"We know the script; we really study the script." -IT "We knew our script very well." -TPY

Discussion
The group of SPs expressed that lecturers, SPs as well as students influence a successful SP-based simulation session.

Lecturer Role
SPs perceived that the lecturers should pay attention to the students' learning outcome and should fully utilize SPs for teaching based on students' learning outcome. A few participants from the SP group expressed that they felt wasted of the learning session when the lecturer did not focus on the students' learning outcome. Besides that, SPs expressed that they wished to be treated as a real patient during the session, such as referred them as a real patient during simulation session, respect their own flow with students, avoid interruption SPs' role play when they are inrole, and confidence in SP justification of student respond. According to the SPs, lecturer who treated the SPs as they are real patient gave students a mind-set that the learners were actually dealing with a patient with real conditions, therefore optimised the students learning as well as promotes the realistic portrayal of the character. On the other hand, SPs supposed that another role of the lecturers was to well-prepared the SPs prior to the actual sessions. They appreciated clear instruction from the lecturer, role play session, and discussion on the expected respond toward various situations or questions that possible posed by the students.

Student Role
SPs conveyed a strong message that the student's learning attitude decided the successfulness of a SP-based simulation session. SPs expressed that students who took the session seriously, well-preparation done before the classes, active participation during the sessions and proactive attitude encouraged realistic portrayal of the character.
Conversely, students who showed no interested, disrespect, insufficient knowledge-based prior to the session, lack of proactive participation, playful attitude can demotivate the SPs.

SP Role
SPs' preparation prior to the sessions play a crucial role to ensure the successfulness of a SP-based simulation session as well. SPs should make effort in memorizing a series of information needed for the scenario, prepare mentally for portrayal certain emotional as well as physical symptoms. SPs perceived that by well-equipped themselves with the script and emotional and clinical signs portrayal able to contribute in students' learning journey, and hopefully students able to pick up essential social intelligence skills, such as empathy, verbal and non-verbal communication skills.

Conclusion
Lecturer, SP as well as student influence a successful SP-based simulation session. SP was not the only part of the key element for the achievement of the SP program. It should include the lecturer as well as the learner. All party had a role to play and influence each other and within the simulation session. Within the SP-based simulation session, lecturer, student and SP were tied together for the achievement of the session; simultaneously each party influenced the achievement within the session itself. In another word, if one did not play their role well within the session, it will have affected the outcome as a whole. For example, one SP perform inconsistently during the clinical examination sabotaged the standardization of the SP performance and impacted negatively on the quality of session. Another scenario was absent of one party, can be either lecturer, SP or student would have supped the simulation session. Thus, achievement of an individual party determined the achievement of the SP-based simulation session as well as achievement of the SP program.