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Martine Boerjan a, Frederik Boone b, Sibyl Anthierens b,
Evelyn van Weel-Baumgarten c, Myriam Deveugele b,*
a Radboud University Nijmegen, The Netherlands
b Department of General Practice and Primary Health Care, Ghent University, Belgium
c Department of General Practice and Primary Health Care, Radboud University Nijmegen, The Netherlands
ABSTRACT
Objective: To explore the effect of simulating medical conditions on simulated patients (SPs). Main points
of interest are influence on: perception of personal health and perception of their relation with the health
care provider (HCP), personal well being.
Methods: Semi-structured interviews were undertaken with eight experienced, well-selected SPs
involved in communication training at the medical faculty of Ghent University. Content of the data were
analysed qualitatively.
Results: SPs believe that their medical knowledge improved, which changes their health-seeking
behaviour. Simulating made SPs realize that being a doctor is difficult, making themmore critical towards
their own GP. SPs enjoy their work; they feel happy and content afterwards. Negative effects are stress,
anxiety, exhaustion, dissatisfaction and sleeping problems.
Discussion: The perceived ‘increased knowledge’ leads to a different way of dealing with symptoms. It is
positive that SPs are more critical towards their GP, this leads to a more equal relationship. The effects of
stress and anxiety probably contribute positively to the performance. Dissatisfaction, anxiety and sleeping problems could be work-related and consequently occur in practicing other occupations. Practice implications: Proper selection, preparation and guidance could minimize the problems encountered during simulation.
1. Introduction
Although simulated patients (SPs) have been used in medical education over the past 30 years, research has mainly focused on their feasibility, reliability and validity [1–3]. SPs are seen as a valuable and reliable teaching and assessment tool [1–3]. They provide an opportunity for medical students to interact with patients in a realistic and controlled setting. Nevertheless this ‘didactical tool’ is a human being and therefore it is not unlikely that simulation of medical conditions has consequences. For example: could it be possible that the SP gets fear of suffering from the disease he/she plays? Can it be that some SPs become anxious as a result of knowing severe aspects of the disease they play? Being concerned about possible side effects for the SPs was the start for this research.
Literature of studies on side effects reveals two main areas: influences of simulating on personal health and influences on the perception of and contact with their own health care provider (HCP) [4–9]. Bokken et al. conducted a quantitative study in 2004. 73% of the SPs reported that they experience stress symptoms due to
simulating [4]. The most frequent reported symptoms were tiredness, nervousness, dissatisfaction with their own performance and anxiety. Fortunately, the severity of the reported symptoms was moderate (2.2 on a 5-point scale). Two years later, the same researchers conducted a qualitative focus group study, SPs reported more negative effects: exhaustion, dissatisfaction, physical complaints and continuing to feel like or act like the person portrayed. These effects were influenced by the type of role, the number of performances, having to give feedback, experience in a role and the response of the students; the effects lasted for a short time during and/or after the performance [5]. In a qualitative study McNaughton et al. looked at the effects of portraying psychologically and emotionally complex standardized patient roles in objective structured clinical exams (OSCE’s) forstudents in their psychiatry clerkship. Anxiety, increased energy, psychological irritation, physical trauma, role adherence and sleeping problems were found. These effects were influenced by: repetition of performances, total performance time, transitions in and out of the role and long breaks between the performances [6].
Three studies, by Wallach [7], Rubin [8] (both quantitative) and Woodward (qualitative) [9], described the influence of simulation on the contact with the own HCP and the perception of this HCP. SPs, experienced in medical communication either with OSCEs or teaching for medical students were invited to reflect on the relationshipwith their usual HCP. The authors concluded that SPs felt more comfortable and communicated more effectively with their own HCP [7]. SPs reported a better understanding of medical history taking and physical examination [7] and perceived their ability to judge the quality of a health care interaction as improved [7,8]. The perception of the SP towards the HCP had changed: SPs developed a more balanced perspective regarding HCPs, renegotiated the relationship or even changed their personal physicians [7,9].
Our research questions focus on the following topics:
● What influence does simulation of a medical condition have onthe perception of own health and healthrelated behaviour?
● How does being a simulated patient affect the perspective and/orthe contact with the own general practitioner?
● What are the effects of being a SP within a medical encounterwith students, on the perceived well being of the person?
2. Methods
2.1. Training and using SPs in the medical curriculum in GhentUniversity
Ghent University reformed its medical curriculum in 1998. Special attention was given to communication training, described elsewhere [10]. Students get communication training in every year of medical school. This training is given in small groups often in combination with the performance of one or more SPs. Apart from this; weak students get the opportunity to work and to exercise with the SPs as remedial teaching. Students are assessed in objective structured clinical exams (OSCE) with SPs.
As a result SPs gain lot of experience in diverse teaching settings. All the SPs (N = 20) are eligible for OSCEs and remedial teaching. During the OSCEs they are expected to do repeated simulation of the same role.
Ten SPs have experience with training situation in small groups. They simulate a given patient role in front of a group of 12–14 students.
Eight SPsworkwithin the project ‘theWaiting room’. This project is constructed as a learning tool for GP-registrars in order to deal with continuity of care. Each SP plays a common patient condition according to age and gender. He/she plays the same patient in 7–9 performances, spread over thewhole academic year. The SP consults with different complaints, asks for follow-up or presents a chronic disease. The students do the consultation, manage the patient files, give prescriptions, do referral if necessary and conduct successive
consultations.Due to thenumber of students, each SP has to perform his/her role 6–7 times during every training day.
Prior to workingwith the students, SPs are selected and the roles are prepared. Special attention is given to the ownmedical history of the SP. None of them is asked to simulate amedical condition which is a reality for themor for close relatives. This choice was made from the very beginning trying to prevent possible adverse effects of the simulation (e.g. following a, sometimeswrong, advice of the student,hearing students making different diagnoses for the same problem,increased anxiety by new information. . .).
SPs always play roles according to their age and gender. Training occurs group wise or individually according to the role and the situation.
Since all the simulations described in this paper are used in communication training, the students do not conduct physical examination of the SP. Nevertheless all kind of medical conditions can be simulated. Some of them are very emotional (e.g. breaking bad news, dealing with chronic disease. . .).
2.2. Sample
For this project, the most experienced SPs of the Ghent-SP programme were selected. The participants have experience with repeated simulation during OSCEs, with remedial teaching, with training situations in small groups and with repeated simulation during ‘the Waiting-room’. SPs with this amount of experience were expected to express detailed opinions about simulating.
2.3. Interviews
Data were collected using semi-structured interviews which consisted of predetermined, open-ended questions. These interviews, which took 60–90 min, were composed by an expert-panel of communication skills trainers and consisted of the following themes: ‘previous experiences in health care’ ‘first experiences as a
SP’, ‘experiences with roles and performances’, ‘relation between teacher and SP’, ‘influence on physical and psychological functioning’, ‘influence on medical knowledge’, ‘influence on the attitude towards medicine and physicians’.
If new topics emerged during questioning, the interviewer – a trained psychologist (FB) – pursued these in more detail. The interviewer made notes and the interviews were audio-taped and transcribed. After collection, data were analysed.
2.4. Analysis
The content of the interviews was analysed qualitatively [11]. The raw data were imported in the software program N5 [12]. One researcher (MB) started the open coding process. During the analysis the process of constant comparison was applied [11]; previously coded text from different interviews was checked to see if the new codes were relevant. After two interviews, a second researcher (LM) coded the first two interviews. The differences between codes and interpretations were compared and modified until a consensus was reached. The next six interviews were coded by one researcher (MB).
The codes were summarized using the One Sheet Of Paper (‘OSOP’) method [13]. The summarization of the codes and the axial coding process [11] were performed simultaneously. During both processes interpretative memos were written. The most relevant codes and correlations were selected from the summarized codes to answer the research questions. One researcher (MB) presented these to an expert panel consisting of
seven experienced researchers; three of them were involved in the project. Based on this discussion, new correlations were made and the main findings were formulated.
3. Results
3.1. Sample
The participants were SPs performing in communication skillstraining, OSCE’s, remedial teaching and ‘the Waiting-room’. These SPs were recruited by co-workers in the department and were carefully selected; they were healthy adults without severe psychosocial and/or medical conditions. None of them are professional
actors. Their experience ranged from 9 months to 5 years. The overall mean frequency of performances was 12 times a year. The maximum performance time was 4 h (mean 3 h). At the maximum SPs play 4–7 times the same role consecutively. They played maximum 2–3 different roles during the same performance. The eight selected participants agreed to co-operate; they signed for informed consent. Ages ranged from 25 to 62 years old. The male/female-ratio was 1/1. Five SPs had paid employment, one was retired, one was unfit for work and one was unemployed (Table 1).
3.2. Simulation and the influence on the perception of their own health
One of the pre-determined topics from the interviews was how simulating influences their medical knowledge. Most SPs believe that their knowledge increases.
WV3 I am more aware of the variety in medical complaints. . .about what is possible
WV5 I know more about the causes of different complaints
This increase changes their feelings about symptoms theyexperience.
WV2 Simulating makes me worry less about my symptoms,knowing how many symptoms and diseases exist, improved myability to put my symptoms into perspective
Knowing more about diseases makes SPs realize that life itself isvulnerable.
WV5 I feel more vulnerable . . .By this I mean that simulating has made me realize that life is precious, and that you can get ill, in stead of thinking that it cannot happen to you
It makes them think more about symptoms.
WV4 I have given it a moment’s thought that for example anormal head ache can be a symptom for a very severe disease, like a brain tumour.
Knowing more about diseases changes the way they deal with their symptoms.
SPs are more conscious of certain symptoms and recognize them sooner. They feel more able to judge their symptoms and they look for information. They use this information to make a distinction between harmless and harmful symptoms. As a result some SPs reduce their visits to the GP.
WV3 My awareness on the difference between harmless and harmful symptoms grew over the years. . .therefore I don’t go as often to the GP as I did before The symptoms I worry about, look up. . .Sometimes I ask other people about my symptoms. Then I decide whether it’s necessary to go to the GP
Others depend on recommendations given by students.
WV2 I have taken a recommendation that a student gave me during the simulation
3.3. Simulation and the influence on the relation with their own caregiver
All SPs still have the fullest confidence in their GP. However, by being an SP, they are more aware of clinical and communicational skills of doctors. This gives them more insight in the complexity of the occupation of a physician.
WV5 It is really difficult for a physician to integrate communication and knowledge into one consultation. . .doctors can make mistakes. . . all this isn’t self-evident.
It also enables them to judge their physicians.
WV3 Now I understand better which things the physician does are correct and which things are not
Both the ability to judge the physician and the insight in the complexity of the physician’s occupation makes them more assertive towards their GP.
WV5 Knowing that being a doctor isn’t self-evident has made me more assertive. . .if a physician acts as though he is superior, I’ll say something about it
The different therapies and recommendations by the students make the SPs realize that not every doctor prescribes the same treatment for the same symptoms. This, the perceived increase in medical knowledge and the ability to judge the GP, changes their perceptionofphysicians tobe less authority-basedandmore critical.
WV3 I am more aware of the doctor–patient relation, because I understand better which things the physician does are correct and which are not. . . there are as many opinions as there are doctors, you should not always believe what they say and remain critical and look for information through other channels as well. . . I see the doctor less as an authority now WV3 the fact that students give contradictory recommendations strengthens my opinion: you should be critical during the consultation and think about it yourself instead of passively obeying the doctors
Being more critical can have an effect on their compliance.
WV3 Contradictory advice from students during simulation have strengthened my opinion that you should be critical. . .if the physician isn’t sure about his own advice, I’ll only follow it partially
WV4 I follow recommendations by the doctor easily if he is 100% sure, if not, I don’t follow the recommendation or only partially
Finally simulating has an influence on their consultation behaviour; they think carefully about the things they want to ask their GP.
WV6 I am a little more alert, I make lists before I go to the doctor, especially when I go to the specialist
3.4. Simulation and influence on well being
3.4. Simulation and influence on well being
SPs enjoy simulated work and feel good, happy and content after the performance. Some SPs even find simulating therapeutic; it helps them to forget their personal problems and to overcome certain fears.
WV5 If I start playing a role, I am that person. . .It is therapeutic for me. . .I don’t have to think about my concerns
WV6 I was always frightened to perform for a bigger audience. . .Simulating made me overcome this fear, therefore it is therapeutic
These positive feelings are enhanced when teachers express their appreciation.
WV1 When I had to play a difficult role, the teacher said to me that she really appreciated it. . .this gave me a good feeling
3.4.2. Performance anxiety
SPs take their job seriously. Despite proper preparation and training, they still report being nervous preceding their very first performance. Most of them believe this has to do with stage fright.
WV2 I was afraid I wouldn’t perform well and that everyone would look at me
WV5 I was nervous. . .will I play well enough?
Despite of their level of experience some SPs still feel nervous.
WV7 Every time before simulating I feel a little stressed
3.4.3. The use of life experiences during the performance
SPs play roles that sometimes show much resemblance to their personal lives, both the medical condition as well as the context of the role. Some SPs use these experiences to enhance their performance.
WV5 I have suffered from some medical conditions I play. . .I used this experience to enter into the role. . .it improved my performance. . .I was able to separate this from my life. . .once the role was finished, it was also finished for me
performance. . .I was able to separate this from my life. . .once the role was finished, it was also finished for me
Further SPs use personal emotions in role-playing. For some this has proven to be beneficial, as it provides an outlet to deal with these emotions.
WV2 During an emotional role, I use my own emotions of that time to act emotional. . .at that moment the simulation is an outlet for me
Other SPs need a clear boundary between their role and their own life, in order to separate the two properly. For them, playing roles that resemble their personal circumstances would worsen the performance and the pleasure of simulating.
WV2 If certain symptoms of the character would resemble my own, I wouldn’t be able to play my role well. . .my reaction would be personal in stead of out of the character. . .this doesn’tfeel right for me
However, these SPs do not refuse a role, even though they dislike similarities between the role and their personal situation. To the general question if SPs could refuse a role, they all answer they feel they could. The main reason to refuse would be the distance between the role and their experiences.
WV4 I once had to play a homosexual male person. . .I did not like to play this role
It seems that personal experiences can help a SP to play a role well, as long as the role does not come too close to personal circumstances. Despite the fact that they say they would refuse a role they dislike, in reality they seldom do.
WV3 As an actor, I believe I should be able to play everything
WV4 If I don’t do it, somebody else has to. . .further I believe these are all credible situations. . .that is why I can’t see why I would refuse a role
3.4.4. Emotions elicited by the student
All SPs agree that the student defines how the SPs feel about their performance. If the student has proper communication and medical skills, the SP will have a better feeling about the role-play.
WV2 How I play my role depends on how the student performs
WV4 Sometimes they give me a good feeling afterwards; they were good and I was good
If the students lack certain skills, the SP feels sorry.
WV1 I felt sorry for a student who couldn’t speak Dutch properly. . . because I noticed she was feeling uncomfortable-. . .her performance worsened during the simulation
The student can also summon other emotions, for example when the student does not show enough empathy.
The student can also summon other emotions, for example when the student does not show enough empathy.
Finally someSPs report that students canelicit anger, for example when they strongly disagree with recommendations or therapies.SomeSPs commentuponthis to the studentduringthe performance, so the simulation backfires. An important element contributing to this anger is the personal well being of the SP at that moment.
WV8 I have been really angry with a student whom, in my perception, didn’t give the correct recommendation. . .at that moment I told him he failed his exam during my performance; while we weren’t allowed to give feedback. . .it had to do with the fact that that week was distressing for me personally
Therapies and/or recommendations for the same medical condition can vary or even contradict each other. This gives some SPs a feeling of indignation.
WV1 This shouldn’t be possible. . .it should be clear for the students what they should recommend or which therapy they should administer
Others put these differences in perspective and realize that the students still have to learn a lot.
WV2 Doctors are also different, so it isn’t strange that therapies by students do not always correspond
WV7 They’re students, they’re still learning
3.4.5. Negative influences on well being
SPs are exposed to many emotions within a short period: nervous students, emotions within different roles, emotions towards the students etc. This causes them to feel tired and sometimes they sleep restless after a day of simulating.
WV6 Before every performance I energize myself . . . after this I feel like I have given everything. . .after one day of simulating I’m exhausted
WV4 Sometimes the night after simulating I sleep very restless, this is due to many emotions during a brief period. . . these emotions include the different reactions from the students and the emotional diversity of the roles within one day
Playing one role repeatedly has different effects. Some find this positive, because repetition gives them more routine, while others become bored. They even mention a feeling of dissatisfaction during the performance.
WV3 Playing the same role frequently does not satisfy me, it makes simulating not interesting enough for me
3.4.6. Physical complaints
Simulating the same physical complaint repeatedly can cause SPs to experience physical symptoms afterwards.
WV5 I had to put much effort into playing a person who suffers from hyperventilation, at the end of the day I felt light-headed and faint
WV8For one role I constantly had to cough, at the end of the day my throat actually hurt
4. Discussion and conclusion
4.1. Discussion
The most important finding is that SPs believe their medical knowledge increase due to simulation. As a result they cope differently with their own symptoms.
The relation towards their own caregiver changes, SPs are more critical, assertive and alert.
Simulating can elicit positive effects, although stress and tiredness cannot be denied.
A new finding in this study is that SPs believe their medical knowledge has improved which leads to a change in the way they deal with their symptoms. In our study SPs are more aware of the difference between harmless and harmful symptoms. Hanson also asserts a higher degree of awareness but on harmful symptoms [14].
The perceived increased knowledge leads to a change in health related behaviour: the SPs are more prepared when they see a doctor, there is a reported decrease in the frequency of consulting the GP and recommendations given by students are used. The last two consequences may be precarious. Information taken from the role-play is not always correct and often incomplete, due to the nature of the training situation. One possible solution could be to provide the SP with evidence of good medical practice in relation to the performed symptoms. Nevertheless, it is important to warn them that similar symptoms could have different causes and that this ‘knowledge’ should not keep them from going to their GP.
The perception of their own caregiver changed. SPs mention that they are aware that being a physician is a difficult and not selfevident job and they know better what the skills of a physician ought to be. Instead of leading to comprehension and sympathy towards their own GP, they become more critical, assertive and
alert. This was contradictory to other studies. In one study adolescent SPs had more appreciation for clinicians with different viewpoints and doubts in various situations [15]. In another research project SPs reported a more balanced perspective on physicians [7]. It could be that adolescents are more open-minded to these differences.
SPs also believe that they are more able to judge the actions taken by a physician. This improved ability was also found in a study conducted by Wallach [7]. In fact, being more critical leads to more questioning and being more prepared before entering the medical office. This is a positive finding, which can lead to improved shared-decision making. Research reveals that most patients do not question their physicians and sometimes leave the
consultation without being able to express their full spectrum of concerns [16]. Being an SP can give the person tools to communicate more effectively with the own caregiver.
Although they tend to be more critical and assertive, roleplaying did not affect the relationship negatively, contradictory to other studies where SPs changed their personal physician due to simulating [7,9]. A possible explanation for this difference could be the quality or familiarity of the relationship before simulating. If the relationship with the GP would have been poor or if they had to change GP due to situational components, working as an SP would probably influence this relation more than it does now.
Apart from the above-mentioned conclusions the data of this study confirm most positive and negative effects experienced by SPs found in other studies; however, this study describes effects elicited by students and the use of life-experiences during the performance more extensively.
The following positive effects on well being were mentioned: SPs enjoy it, feel good and appreciated, and some find simulating therapeutic. Simulating can give more self-confidence and awareness. These positive effects were also found in at least one other study [5]. So at first sight, the fear that it is harmful to use human beings as ‘didactical tool’, can be rejected.
However, even well selected and trained SPs experience stress and anxiety before the performance; as found in other studies [4–6]. Both emotions probably contribute positively to the performance; it is acknowledged that some stress in relation to performance is necessary and useful.
The feelings of dissatisfaction, tiredness and restless sleep correspond with effects from other studies. SPs from studies in several settings experience the same effects [4–6]. It could be argued that effects of tiredness, stress and dissatisfaction are common in a work-setting and that people practicing other occupations experience the same. To confirm this assertion, data of a similar group who do not undertake simulated work, is needed.
Still it is important to be aware that simulating can instigate these consequences; to minimize them, debriefing as suggested by Stafford [17], can be useful.
The SPs in our study did not develop the symptoms they perform; an effect that Hanson described [14]. Contradictory to our study, the SPs in the Hanson study were adolescents and therefore may be more susceptible to these effects. The few physical complaints the participants in our study developed were due to overburdening; this effect was also found by Bokken [5].
In practice, it is often forgotten that the student can elicit emotions. The finding that students mainly determine the way SPs feel after a performance was also reported by Bokken [5]. It is important that SPs get instructions on how to deal with these emotions to diminish possible lasting residual effects.
4.1.1. Limitations of the study
Our sample of eight participants was small. Probably more different viewpoints can be explored if we could have interviewed more SPs. The participants were selected from our setting in Ghent only. Although this study gains insight into new perspectives on this topic, the results may not be transferable to other situations.
In some cases the SPs were recruited by their own GP, a coworker in the department. This might cause SPs to give socially desirable answers. However, the interviewer was an independent party and he guaranteed their privacy.
4.2. Conclusion
Simulation of medical conditions has positive as well as negative effects on the well being of simulated patients. SPs cope differently with their symptoms and they develop a more equalrelationship with their caregiver.
To prevent the negative effects, selection, guidance and especially debriefing are of great significance.
4.3. Practice implications
As a result of our finding that life-events influence the performance and the occurrence of negative feelings (e.g. towards students) and stress during or after the performance, we would recommend to be attentive in selecting, preparing and guiding the SPs.
4.3.1. Selection
Much attention ought to be paid to selection. It is important to be cautious with applicants who have history of problematic lifeevents or severe medical conditions. They may need more support, debriefing and may even be unsuitable to work as an SP.
It is important to take individual medical histories of SPs into account before the roles are distributed; not every SP wants their medical experiences resembling those of the role. SPs should be told they can refuse a role they dislike, for example when it is too far away from their own perspectives.
The relation towards their own caregiver changes, SPs are more critical, assertive and alert.
Simulating can elicit positive effects, although stress and tiredness cannot be denied.
A new finding in this study is that SPs believe their medical knowledge has improved which leads to a change in the way they deal with their symptoms. In our study SPs are more aware of the difference between harmless and harmful symptoms. Hanson also asserts a higher degree of awareness but on harmful symptoms [14].
The perceived increased knowledge leads to a change in health related behaviour: the SPs are more prepared when they see a doctor, there is a reported decrease in the frequency of consulting the GP and recommendations given by students are used. The last two consequences may be precarious. Information taken from the role-play is not always correct and often incomplete, due to the nature of the training situation. One possible solution could be to provide the SP with evidence of good medical practice in relation to the performed symptoms. Nevertheless, it is important to warn them that similar symptoms could have different causes and that this ‘knowledge’ should not keep them from going to their GP.
The perceived increased knowledge leads to a change in health related behaviour: the SPs are more prepared when they see a doctor, there is a reported decrease in the frequency of consulting the GP and recommendations given by students are used. The last two consequences may be precarious. Information taken from the role-play is not always correct and often incomplete, due to the nature of the training situation. One possible solution could be to provide the SP with evidence of good medical practice in relation to the performed symptoms. Nevertheless, it is important to warn them that similar symptoms could have different causes and that this ‘knowledge’ should not keep them from going to their GP.
SPs also believe that they are more able to judge the actions taken by a physician. This improved ability was also found in a study conducted by Wallach [7]. In fact, being more critical leads to more questioning and being more prepared before entering the medical office. This is a positive finding, which can lead to improved shared-decision making. Research reveals that most patients do not question their physicians and sometimes leave the
consultation without being able to express their full spectrum of concerns [16]. Being an SP can give the person tools to communicate more effectively with the own caregiver.
Although they tend to be more critical and assertive, roleplaying did not affect the relationship negatively, contradictory to other studies where SPs changed their personal physician due to simulating [7,9]. A possible explanation for this difference could be the quality or familiarity of the relationship before simulating. If the relationship with the GP would have been poor or if they had to change GP due to situational components, working as an SP would probably influence this relation more than it does now.
Apart from the above-mentioned conclusions the data of this study confirm most positive and negative effects experienced by SPs found in other studies; however, this study describes effects elicited by students and the use of life-experiences during the performance more extensively.
The following positive effects on well being were mentioned: SPs enjoy it, feel good and appreciated, and some find simulating therapeutic. Simulating can give more self-confidence and awareness. These positive effects were also found in at least one other study [5]. So at first sight, the fear that it is harmful to use human beings as ‘didactical tool’, can be rejected.
However, even well selected and trained SPs experience stress and anxiety before the performance; as found in other studies [4–6]. Both emotions probably contribute positively to the performance; it is acknowledged that some stress in relation to performance is necessary and useful.
The feelings of dissatisfaction, tiredness and restless sleep correspond with effects from other studies. SPs from studies in several settings experience the same effects [4–6]. It could be argued that effects of tiredness, stress and dissatisfaction are common in a work-setting and that people practicing other occupations experience the same. To confirm this assertion, data of a similar group who do not undertake simulated work, is needed.
Still it is important to be aware that simulating can instigate these consequences; to minimize them, debriefing as suggested by Stafford [17], can be useful.
The SPs in our study did not develop the symptoms they perform; an effect that Hanson described [14]. Contradictory to our study, the SPs in the Hanson study were adolescents and therefore may be more susceptible to these effects. The few physical complaints the participants in our study developed were due to overburdening; this effect was also found by Bokken [5].
In practice, it is often forgotten that the student can elicit emotions. The finding that students mainly determine the way SPs feel after a performance was also reported by Bokken [5]. It is important that SPs get instructions on how to deal with these emotions to diminish possible lasting residual effects.
4.1.1. Limitations of the study
Our sample of eight participants was small. Probably more different viewpoints can be explored if we could have interviewed more SPs. The participants were selected from our setting in Ghent only. Although this study gains insight into new perspectives on this topic, the results may not be transferable to other situations.
In some cases the SPs were recruited by their own GP, a coworker in the department. This might cause SPs to give socially desirable answers. However, the interviewer was an independent party and he guaranteed their privacy.
4.2. Conclusion
Simulation of medical conditions has positive as well as negative effects on the well being of simulated patients. SPs cope differently with their symptoms and they develop a more equal relationship with their caregiver.
To prevent the negative effects, selection, guidance and especially debriefing are of great significance.
4.3. Practice implications
As a result of our finding that life-events influence the performance and the occurrence of negative feelings (e.g. towards students) and stress during or after the performance, we would recommend to be attentive in selecting, preparing and guiding the SPs.
4.3.1. Selection
Much attention ought to be paid to selection. It is important to be cautious with applicants who have history of problematic lifeevents or severe medical conditions. They may need more support, debriefing and may even be unsuitable to work as an SP.
It is important to take individual medical histories of SPs into account before the roles are distributed; not every SP wants their medical experiences resembling those of the role. SPs should be told they can refuse a role they dislike, for example when it is too far away from their own perspectives.
4.3.2. Preparation
Before every simulation session, it is important to emphasize that SPs can experience problems or negative feelings. If this occurs, they can tell the teacher, who can help them to deal with these feelings or problems in the concerning situation, or they can share this at the debriefing sessions with other SPs. Further, teachers should prepare them for the fact that students can give contradictory recommendations or therapies.
4.3.3. Guidance
Throughout the first day of simulating it is important to ask SPs how they are doing and to pay attention to experienced stress or nervousness.
A debriefing session can facilitate sharing emotional effects with the instructor and the other SPs. If the role causes too much emotional stress teachers should emphasize on the possibility to refuse. SPs should be careful with applying knowledge obtained during simulating to their personal lives.
Acknowledgements
We thank the simulated patients, who participated in this study. Further we thank L Maas for coding the first two interviews and discussing the codes.
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