Field Educator: A Scholarly Journal from the Simmons University School of Social Work

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Abstract

Health science programs have engaged in simulation and have involved standardized patients (SPs) to create learning opportunities. This paper is centered on a class activity that involved social work clinicians/field instructors from the community as SPs to engage in simulated situations. The activity was incorporated in courses to create opportunities for students to apply knowledge gained in classrooms to enhance skills through simulated situations with an SP. Findings suggest that students agreed or strongly agreed that the activity helped them with active listening skills. This paper highlights the educational strengths of engaging field instructors as SPs to strengthen practice skills.

Keywords: standardized patient; field educator; simulation

Introduction

The use of standardized patients and simulated environments for student learning has a robust history within medical and nursing education. Physicians have relied on this teaching technique since the 1960’s, while nursing has gradually incorporated it into a standard approach in programs across the country. “Simulated patients” and “standardized patients” are acceptable, interchangeable terms in the medical literature highlighting that these individuals are often trained actors, professionals, or volunteers from the community and are trained to present an illness in a standardized manner in simulated scenarios to enhance learning outcomes (Abe, Roter, Erby, & Ban, 2011; Ha, 2018). This pedagogical approach offers students an opportunity to apply theories in their practice and strengthen skills/techniques in a way that prepares them for their chosen field of practice. Research suggests that engaging standardized patients improves students’ confidence and critical thinking (Arbuckle et al., 2013; Dodds, Heslop, & Meredith, 2018).

Simulation and the Standardized Patient in Educational Settings

Historically, measures of simulation in both medicine and nursing (including the use of technology, such as internet-based portals) were used to build the efficacy of role-playing to build motivational interviewing skills while furthering communication skills overall (Anttila, Koivunen, & Välimäki, 2008; Mounsey, Bovbjerg, White, & Gazewood, 2006). It is necessary to delineate the difference between studies that consider “simulation” as a learning exercise and those that focus on standardized patients to engage students. Simulation addresses the environment and context of hypothetical scenarios that students then learn to work through in their coursework. Simulations can include devices, trained persons, lifelike virtual environments (Avatars), and contrived social situations that mimic problems, events, or conditions that arise in professional encounters (Issenberg, Mcgaghie, Petrusa, Gordon, & Scalese, 2005). In nursing, to address the increasing demand of their role in mental health crisis scenarios, programs are using internet-based modules to measure students’ knowledge and skills (Anttila et al., 2008). More recently, Washburn, Bordnick, and Rizzo (2016) utilized virtual patient software with a cohort of social work students where students applied their knowledge to assess virtual patients. Both fields found that students reported an increased confidence in approaching complex mental/behavioral crisis scenarios, and such learning environments led to meaningful connections between students and clients (Anttila et al., 2008; Washburn et al., 2016). Simulation exercises have been established as a necessary component of students’ preparation for human services work.

Separate or complementary to simulations, educators have invited standardized patients to engage with students. Standardized patients are defined as individuals trained to portray a patient with a specific condition in a realistic, standardized and repeatable way (Hart & Chilcote, 2016). According to a nationwide survey by Abe et al. (2011), standardized patients are actors, teachers, health care and business professionals. In some of these activities, standardized patients have been students recruited from within a specific medical school (Bosse et al., 2012). Standardized patients are engaged to ensure students apply knowledge through structured, defined scenarios that incorporate specific learning objectives into the activity. Regardless of the standardized patients’ experience, students are evaluated on their communication skills, their applied knowledge, and the actions they take to resolve a simulated situation (Becker, Rose, Berg, Park, & Shatzer, 2006).

Health science programs have engaged in simulation to augment skills training when working with varied populations. Simulation could happen in labs with or without mannequins, with one profession or an interprofessional learning experience to facilitate collaborative practice. As indicated earlier, engaging standardized patients (SPs) in a structured setting to create learning opportunities has also been beneficial in learning outcomes. Engaging SPs has varied where some programs engage actors, some train graduate students, while others engage professionals from the community. Typically, simulation and use of SPs go hand in hand. However, it is not imperative to have both at the same time. Simulation and SP engagement in teaching can be done independent or in combination.

Since engaging standardized patients in Medicine, Nursing, and other health professions has been beneficial, it seems appropriate to utilize this method in the Social Work curriculum. Social workers are one of the major care providers in the area of behavioral health, and it would be beneficial to incorporate new pedagogical approaches to enhance their skills.

Simulation/Standardized Patient Evaluation

Mcgaghie, Issenberg, Petrusa, and Scalese (2006) reported that simulated scenarios for students were received positively, but questions concerning student evaluations were often raised. While evaluation is different in simulation scenarios from regular classroom competency assessments, common themes emerge when measuring students’ knowledge and skills (Mcgaghie et al., 2006). Standardized patients often struggle with providing appropriate feedback to students if they are unfamiliar with the field the student is enrolled in (i.e., if they are trained actors or volunteer community members) (Abe et al., 2011). As Washburn and Zhou (2018) assert, turning to technology has provided answers for consistent evaluation, yet sometimes is cited as lacking the fidelity of standardized patient activities from participants. Through self-reported surveys from students and SPs, participants have elicited that students have the opportunity to apply knowledge learned to handle situations with appropriate skills.

Despite simulation and SPs’ presence across disciplines, standardized methods of evaluation require further study and need to be strengthened as there is currently no common approach. Not only is it important to study students’ progress in mastering competencies, it is crucial that clear evaluation methods are used. Bogo et al. (2011) adapted Objective Structured Clinical Examinations (OSCE), an existing examination traditionally used for health care professionals, but can also be used for masters-level social work students to measure student competencies following exercises with standardized patients. These examinations support competencies that align with the Council on Social Work Education’s (CSWE) Educational Policy and Accreditation Standards (EPAS), particularly in the aspects of internal processing and critical thinking reported by students. Engaging standardized clients and providing simulations offers students the opportunity to assess various situations like crises, suicidal ideation, etc., that could arise in the day-to-day human service delivery work. Further, providing a platform for thorough feedback of student performance empowers students in exercising their knowledge, as well as practitioners in the field (Abe et al., 2011). In cases of simulation through technological aids, Washburn et al. (2016) argue that through consistent and controlled environments, and with a trained clinician observing the assessment, students are afforded clear, comprehensive evaluation. Conversely, studies that use experiential models of standardized patients address evaluation through careful training of participating standardized patients (Gellis & Kim, 2017). Such a creative, educational opportunity becomes invaluable as it prepares students well into their advanced year of graduate studies for real life scenarios that they may face early in their careers.

Field education has remained ubiquitous amongst social work programs. Working with field instructors in field placement agencies (internships), students gain knowledge through the application of learned techniques in real world settings. As part of the CSWE (2015) EPAS, field education is the intersection of “performance…knowledge, values, critical thinking, affective reactions [and] judgment.” Proficiency achieved by students can be measured multi-dimensionally, and should demonstrate a duality of “competencies” and “internal processing” in a holistic manner (CSWE, 2015). Current research suggests that despite its prevalence, field education lacks consistency in evaluation and does not always provide opportunities for students to gain the necessary skills for crisis intervention (Bogo, 2015). Depending on the placement, students may miss opportunities to learn how to handle a crisis situation or how to engage, assess, and intervene in complex mental/behavioral situations. A crisis situation, for example, could happen in a mental health clinic or in a community because of natural disaster in a community or region. To ensure students are able to demonstrate competencies in crisis management, it is vital for all students to engage in the application of appropriate assessments and intervention plans for their clients regardless of the micro-macro placement continuum, as the skill training opportunity may not be available in their respective field agencies. Moreover, new accreditation standards are inviting instructors to examine new approaches to competency demonstration (Wayne, Bogo, & Raskin, 2010).

SPs in education provide many of the missing pieces to social work pedagogy, offering students and instructors alike new ways to evaluate and learn. With this as the background, it is prudent that social workers and other social service providers are trained using simulated scenarios to translate the knowledge gained in classes and apply it in internship settings (Arbuckle et al., 2013). The use of SPs in social work programs can bridge this gap between the classroom and the field.

Current Project

This paper is centered on a class activity that was conceptualized and implemented to engage social work clinicians/field instructors from the community as standardized patients to engage in simulated situations.

The activity was incorporated to help facilitate the learning process and to create opportunities for students to demonstrate the application of knowledge gained in classrooms to a pragmatic situation with a client. Students had an opportunity to evaluate their own learning through the simulated situation and for the SPs to provide feedback right after the simulated session. This paper highlights the educational benefits for students when the standardized patients are field instructors whose experience in direct practice provided added value (beyond what trained actors may be able to provide). The authors provide some preliminary data on the positive satisfaction of students who participate in such training. Institutional Review Board approval was sought from the host university.

Context

The simulated sessions took place in the simulation lab on the university’s main campus. Students used single rooms in the simulation lab that mimic a doctor’s examination room. By removing students from a traditional classroom setting, simulation labs offered both students and standardized patients a high fidelity experience to enact practice scenarios.

The first author was the lead instructor in two courses, one related to Multidimensional Assessment and the other related to an Advanced Social Work Interventions course to implement this teaching technique. Both courses were at the 2nd year Specialized Practice level of the MSW program. At this stage in the curriculum, students are prepared to demonstrate competencies in engagement, assessment, interventions, and evaluations. All students enrolled in the courses were required to participate in the exercises, which were planned throughout the semester.

Prior to engaging in the exercise, students had previous experience working with clients either in a workplace or internship setting. Students in the concentration-level completed a field placement either in their Bachelor’s program (BSW) or in the foundation-year of their MSW program. Knowing that students had prior exposure and that they had the opportunity to work with clients, the instructor prepared for the assignment with course objectives in mind. When students were introduced to the course the first week of the semester, they were told they would be engaging in simulated activities with SPs. Further, the instructor explained the purpose of doing simulated sessions, engaging standardized patients, and the role that students would play in the learning experience.

Logistics

Given the class schedule requirements (the class met for three hours once a week with a class size of over twenty students), the simulation exercises/activities were spread over the course of the semester. Students self-selected to participate in a simulated session to role-play as a clinician to enact the simulated case scenario that was provided.

To assess students’ performance and to provide realistic client situations, social work clinicians from the community were enlisted to participate in the activity as standardized patients. By engaging clinicians, the activity could focus on skill building and knowledge application. Further, by inviting these individuals to engage in the activity, the university engaged in community collaboration that could lead to future collaborations and engagement in new teaching methods across the program. Individuals who agreed to participate were excited and enthusiastic to try out new teaching techniques and to contribute to the education of future social workers. SPs were compensated on an hourly basis for their time commitment to prepare for the simulated session and to engage in teaching. Some of the SPs received the remuneration while others declined and committed time pro-bono. SPs were enthusiastic about engaging in a new teaching/learning experience.

On the day of the simulation, both students and standardized patients were expected to arrive at the simulation lab thirty minutes prior to the scheduled meeting time of the class. At that time, students were given an overview of the activity, case scenario, and their roles. Students were given the case situation to familiarize themselves. They were given enough information to understand the identified problem and to consider possible assessment and/or intervention plans. The rationale for providing an overview of the case to students prior to the simulation exercise was to assist students with the context and nature of the presenting problems. Additionally, during this time, students were given the opportunity to ask questions regarding logistics or clarifications about case scenarios prior to engaging in the activity.

On arrival, the SPs received the same case scenario that the students received. However, there were certain statements included in the case scenario as standardized statements. The SPs were briefed on the version that students had and that they had to incorporate the standardized statements during the session with the student clinician. They were also briefed that response/reaction to the statements was key to the exercise. Finally, SPs had time for open discussion where the standardized patients and the students could ask questions to clarify questions and logistics to help alleviate any possible ambiguity in the experience.

Evaluation

Once the teaching exercise and the process was explained, the students and the SPs were introduced to the checklist that was developed for the purpose of this exercise. The SPs were given the checklist (standardized patient evaluation of student clinician) intended to measure the knowledge, values, and skills demonstrated by the students during the session. The knowledge, values, and skills were mapped to the competencies assigned to the course to ensure student learning outcomes were appropriately measured. Instructions directed standardized patients to mark the checklist at the end of the session and also review it with the students to give immediate feedback regarding their performance during the session. Students, on the other hand, were given instructions to review the checklist (student learning with the standardized patient) developed for them, and were asked to complete it by the end of the session.

Findings/Results

Student Learning with Standardized Patients

In examining the feedback received from students on their knowledge, values, and skills, Table 1 illustrates that almost 96% of students strongly agreed or agreed that they had an opportunity to engage in a new learning environment or situation. An overwhelming 94% strongly agreed or agreed that they were able to apply knowledge gained in class to the simulated session. Based on knowledge gained in the classroom, 94% of students strongly agreed or agreed that they were able to attend to interpersonal dynamics between therapist and client. To the question whether they were able to apply knowledge to the situation, 87% strongly agreed or agreed. Hence, from the students’ perspective, this learning opportunity provided avenues to apply knowledge gained in class to very specific clinical opportunities.

When examining responses related to values, it was found that 95% of the students strongly agreed or agreed that the learning activity strengthened insight into social work values. Another area that reflected some interesting learning opportunities was that which allowed students to reflect on their own biases based on their own worldview and upbringing. About 71% of students strongly agreed or agreed that the exercise created opportunities for them to reflect on their biases. Students also believed that it gave them the opportunity to reflect on power and privilege in the client/clinician roles; 71% reported that they were able (strongly agreed or agreed) to reflect on power and privilege during the exercise.

The intent of the exercise to utilize simulated situations, simulated case scenarios, and standardized patients was to strengthen the skills of students during their educational experience. When analyzing the data collected from the exercise, four specific statements that address active listening, verbal communication skills, non-verbal communication skills, and direct practice examined the impact of the experience on communication skills with individuals. Students’ responses indicate that the activity created a very strong opportunity to demonstrate these skills. More specifically, 100% of students strongly agreed or agreed that the exercise helped them use their active listening skills and strengthen their verbal communication skills. Further, an overwhelming 93% of students strongly agreed or agreed that the exercise created opportunities for practicing non-verbal communication skills. Finally, 100% of students strongly agreed or agreed that the exercise created an opportunity to gain a better understanding of working with individuals. In summary, on examining the four statements related to skills, students either agreed or strongly agreed that the exercise of simulated situations and working with SPs helped them to demonstrate or to strengthen their verbal and non-verbal communication skills.

Standardized Patient Evaluation of Student Clinician

On examining information gathered from standardized patients on the knowledge, values, and skills that students demonstrated during the simulated session, Table 2 indicates the range of responses to each of the statements. About 98% of the social workers (or SPs) agreed or strongly agreed that students were able to adjust well or demonstrate knowledge required for the situation. Around 98% of SPs agreed or strongly agreed that students applied knowledge gained in class. Nearly 98% of the SPs agreed or strongly agreed that students paid attention to interpersonal dynamics. Almost 83% of the SPs agreed or strongly agreed that students were able to apply theory during their simulated session.

On examining the values that students expressed during the simulated session, the standardized patients expressed that students demonstrated insight into social work values to better work with clients. Nearly 96% of SPs agreed or strongly agreed that students developed insight into social work values during the learning exercise. Almost 81% of SPs agreed or strongly agreed that the students were both aware of their belief systems and able to incorporate that into the simulated session. Further, they observed that students were able to perceive and address power and privilege differentials in clinician/client roles (82% agreed or strongly agreed). About 54% of the standardized patients agreed or strongly agreed that students addressed ethical issues that emerged during the therapeutic relationship and about 41% reported that there was no opportunity to address ethics in such situations. It is possible that the simulated exercise did not have enough time to measure ethical decision-making.

On examining data related to skills students demonstrated during the simulated session, the SPs agreed or strongly agreed that about 98% of students clearly demonstrated active listening skills. Nearly 97% of the SPs agreed or strongly agreed that students demonstrated verbal and non-verbal communication skills that were appropriate to the session. Approximately 98% of standardized patients agreed or strongly agreed that students were professional in their working relationships one-on-one with clients.

Discussion

As the practice of engaging standardized patients has been exponentially maturing, Standards of Best Practice (SOBP) in the field has also evolved under the auspices of the Association of Standardized Patient Educators (ASPE). Lewis et al.’s (2017) holistic approach to ensure safety and effectiveness in the (planned or simulated) sessions falls into 5 major domains: 1) Safe Work Environment, 2) Case Development, 3) SP Training, 4) Program Management, and 5) Professional Development. Table 3 provides a summary of the Best Practice Principles that were adopted in this teaching exercise.

Table 3: Domains of Best Practice When Engaging Standardized/Simulated Patients

SOBP Domains	Application of Domains
Safe Work Environment	Social work practitioners from the community; social work field/internship instructors; Simulation lab in the University; trust established with students in class
Case Development	Case scenarios developed based on student learning outcomes pertinent to courses
SP Training for role portrayal, feedback, and completion of assessment instruments	SPs trained by instructor before the simulated session. SPs trained on their role in the case scenario, the standardized statement that they had to state during the simulated session, pertinent feedback that they could provide to students  (based on the student learning outcomes of the courses) and orientation to complete assessment at the end of the simulated session.
Professional Development	Instructor  provided SPs’ overview of the pedagogy used in the course to train MSW students
Completion of Assessment	SPs were trained and expected to complete checklist to assess student’s mastery of knowledge and skills to engage, assess and intervene with “clients”

As literature and the findings of this exercise suggest, simulation with standardized patients is how social work students could bridge classroom learning to field, translating knowledge gained to real world practice. Evaluation data suggests that both students and SPs reported positively on the experience, the value in engaging SPs to ensure knowledge, values, and skills are applied. Based on the findings, the learning opportunity created a fertile ground for application of knowledge to strengthen skills. However, the exercise was not as much of a valuable experience to demonstrate values. This exercise clearly augments the notion to support and create simulated opportunities to facilitate learning opportunities that students may not be able to encounter in their respective field agencies.
The activity garnered overwhelmingly positive responses from students regarding skills. This indicates that it is important to engage in creative activities to strengthen learning outcomes. Students were able to demonstrate and hone their skills, including nonverbal communication, to prepare for work in the real world with real clients. The SPs/field instructors did see value in how students translated theories and knowledge gained in class while engaging in assessment and intervention and clearly identified strengths and skills demonstrated by students.

When processing with students their experience with the exercise in class, students reported initial anxiety before engaging in the activity. However, students then expressed excitement and valuing of the exercise after they completed the session. This reported confidence suggests an awareness of the application of their skills and knowledge. Their anxiety was assuaged by how they behaved during the situation, an affirmation of their ability to practice necessary components of the generalist model of social work practice. Utilizing the simulation labs, the presence of the SPs, and the specific scenario contributed greatly to the robust experience. Additionally, the exercise created an opportunity for students to get immediate feedback from the SPs and take corrective measures to strengthen areas of development and plan for an actual interaction with a client. Such controlled situations and high fidelity situations lead to overall advancement and avoid possible errors if one were to engage with clients directly.

Enlisting clinicians from the community was essential to gathering and offering quality feedback to students. Additionally, SPs gave students feedback right after the simulated session. Clinicians from the community were able to draw from their own knowledge and experience to give quality evaluations. All of the SPs also served as Field Instructors for students in the program and were familiar with the curriculum and expectations.

Future Directions and Conclusion

Using simulations with standardized patients for advanced-level social work classes is a creative way of educating social work students by measuring competencies in the required cognitive and affective domains (along with the competencies in the attainment of knowledge, values, and skills) of the holistic competence mandate of EPAS 2015. Also, with the accreditation standards specifying that students need to be evaluated on their practice skills with real and/or simulated clients, the use of standardized patients in simulation education will become more robust and meaningful in the education process. It is also possible to reduce a set number of hours from the field setting to incorporate simulated activities in practice classes within the curriculum. This will reduce some burden on non-traditional students who may find it difficult to pursue graduate education due to work, family, and education commitments.

While this method lends itself to traditional classrooms, the larger question becomes how these learning activities can be engaged and infused into online social work programs. How can educators prepare for the different aspects that a social work program needs to consider when using simulation to engage masters-level students? How can faculty members create an opportunity to infuse creative pedagogy into the curriculum with pragmatic, content-rich activities to better prepare students to work in an ever-changing health care system?

Health care is at a crossroads with changing roles for social workers and ever-increasing demands on various aspects of health care. In higher education, there is a trend towards accelerating online education to reach more students. The reach could be to increase enrollment and/or to address the workforce shortage that exists across the nation. A marriage between the vision, hopes, and dreams of higher education blended with the needs of the community and the ever-changing health care situations requires innovative approaches to teaching methods and further discussions on how to prepare social work students for the field. Hence, it is important as educators to examine how to bridge the higher education institutions’ expectations with the changing landscape of health care; and, in the process, universities can prepare new masters-level social workers to appropriately serve the clients in need.

Findings from evaluating engagement of SPs in a MSW program suggest ways one could incorporate SPs in face-to-face programs. It also creates opportunities to extend siloed learning towards an interprofessional learning experience by partnering with nursing, public health, or allied fields. While the focus of this exercise was on social work education, by using the simulation lab and engaging standardized patients, there are several opportunities for interprofessional education and cross-disciplinary trainings for collaborative practice in health care settings.

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