standardized patient acting class response paper

Clinical Simulation in Nursing (2016) 12, 539-545

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Featured Article

Acting With a Purpose: The Lived Experience of Actors in the Role of Standardized Patients Portraying Mental Illness

Judith M. Jarosinski, PhD, RN*, Debra A. Webster, EdD, RN, CNE Department of Nursing, Salisbury University, Salisbury, MD 21801, USA

KEYWORDS standardized patients; acting; simulation; Colaizzi; nursing education; phenomenology; qualitative; research

ng author: jmjarosinski@

e front matter � 2016 Int /10.1016/j.ecns.2016.08.

Abstract Background: Standardized patients (SPs) allow students to apply nursing skills in a safe/supportive environment. This study examined the experience of SPs in psychiatric/mental health simulations. Method: The day-to-day experiences of SPs portraying mental illness was explored in this qualitative study. Using interviews as the primary data source, a qualitative, phenomenological perspective) guided inquiry and analysis. Results: Four themes: Sparks something in me, Building on confidence, Stepping into the shoes of the educator, and Letting it get to me, investigated SPs’ initiation into and their growing confidence in the acting/teaching role. Letting it get to me, SPs discussed the difficulty SPs later had ‘‘shaking off’’ their roles. Conclusions: Research underscores the value of SPs in creating an accurate representation of a client with mental illness; however, this reality often stayed with them even after the portrayal was over. To provide the best experiences, nurse educators must train, follow up, and debrief to ensure that actors not only provide an accurate portrayal, but must also address any psychological harm.

Cite this article: Jarosinski, J. M., & Webster, D. A. (2016, December). Acting with a purpose: The lived experience of actors in the role of standardized patients portraying mental illness. Clinical Simulation in Nursing, 12(12), 539-545. http://dx.doi.org/10.1016/j.ecns.2016.08.005.

� 2016 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.

Creating relevant and interactive teaching strategies has become the primary goal for today’s educator. Crookes, Crookes, and Walsh (2013) described educators as ‘‘pressed to contextualize and make meaningful and engaging, the theoretical material that they cover so that students are able to explicitly map the connection between course content and its practical application ..’’ (p. 240).

salisbury.edu (J. M. Jarosinski).

ernational Nursing Association for Clinica

005

Becker et al. (2006) suggests that ‘‘educators hope that knowledge and skills learned in the classroom and practiced in the clinical settings are transferred into clinical reasoning skills required for direct clinical care of patients’’ (p. 103). This transference of knowledge and skills has made the incorporation of simulation in nursing education increasingly popular. Students can practice and make mistakes in a safe and supportive environment, and apply this learning to their own clinical practice through the use of simulation. ‘‘Thus, realism,

l Simulation and Learning. Published by Elsevier Inc. All rights reserved.

Acting with a Purpose 540

accompanying the use of standardized patients (SPs) in simulation learning, bridges the gap between theory and practice’’ (Dearmon et al., 2013, p. 30). In addition, the use of simulation as a teaching tool appreciably reduces anxiety in students.

Key Points � Standardized patients play a key role in the education of nursing students.

� Standardized patients take their roles seri- ously and attempt to portray clients with mental illness honestly.

� Some standardized patients find shedding the role difficult.

Competencies for psychi- atric/mental health nursing include complex relation- ship skills and responses. Communication skills, assessment proficiency, and adeptness in the use of explo- ration require an authentic representation of the patient and scenario. Dunnington (2013) examined the nature of reality in simulation and cautioned that mis- representation can become the reality, that is, ‘‘.misrepresentation of the real phenomenon may

become the actual phenomena understood and retained (p. 17).’’ Consequently, educators who incorporate simula- tion, especially high-fidelity simulation, require an authentic presentation that most closely represents the phenomenon; otherwise, the misrepresentation becomes the reality for the student. Therefore, authenticity requires SPs or actors to immerse themselves in their role to present an authentic picture of the patient at that moment. While the instructor provides guidance and feedback, the actor represents the patient experience. Thus, SPs can be used to teach therapeutic communication and management of care in mental health nursing (Jack, Gerolamo, Frederick, Szanjz, & Muccitelli, 2014). Nurse educators have also used SPs to address issues related to bias, stigma, and fear (Brown, 2015).

Background

In our nursing program, actors have been trained as SPs and used to teach communication and assessment skills during the psychiatric/mental health nursing clinical experience. These actors have also participated in special activities in which they have interacted with the public while remaining in their roles. Backgrounds of SPs include retired nurses, actors, students who are theater and psychology majors, a former police officer, and stay-at home moms. Yearly, actors attend a 3-day training workshop that encompasses the mental illness symptomatology, client presentation, and clinical settings. These actors also view movies, video clips, and learn detailed scripts on schizophrenia, depression, suicidality, bipolar mania, anxiety, substance abuse, post-traumatic stress disorder, and dementia. In the training workshop, actors rehearse scripts with faculty,

pp 539-5

often repeating the role-play and reworking the dialogue. After the workshop, actors ‘‘graduate’’ to become SPs. They return annually for a refresher workshop.

In their psychiatric/mental health clinical course, students in their senior year of nursing completed two interactions with an SP. These interactions were videotaped, and, as part of the assignment, the student was required to view the videotape assessing their interaction with the patient. Small groups of other students viewed the interaction live and provided feedback. The student then received feedback from their instructor; all students were debriefed by faculty and a licensed professional counselor. The SPs were also invited to provide feedback to students related to how they felt as a patient and their reaction to students’ questions, strategies, and verbal/nonverbal demeanor. In this study, SPs conveyed personal experiences of their role as a patient portraying mental illness.

A preliminary literature review reveals the absence of studies aimed at exploring the lived experience of SPs portraying mental illness in nursing education. While not studied, it was noted that SPs who had not previously engaged in roles involving the depiction of mental illness were able to quickly adjust to the role and create an accurate portrayal of the client (Jack et al., 2014). These same authors also reported that the SPs found the mental health role to be demanding (p. 518). Likewise, others have written to describe the necessity of addressing psychological harm to students resulting from simulation (Janzen et al., 2016). While this does not address the issue of psychological harm to the SP, there remains a question as to any psychological harm that may occur for individuals realistically portraying mental illness scenarios in simulation. Spencer and Dales (2006) identified the importance of addressing issues related to de-rolling those involved in simulation. Likewise, Bokken, Van Dalen, and Rethans (2006) reported that simulation had a negative impact on actors. Using focus group interviews, the authors found that the role types, number of consecutive perfor- mances, feedback, and amount of experience played a part in this impact that was minimal and of short duration. However, it was our intent to discover the experience for actors to immerse themselves into the role of a mentally ill individual while interacting with students. To this end, the purpose of this study examined the lived experience of the SP through interviews, both in their role as an actor and in their interactions with students.

Method

A qualitative research design explored the day-to-day experience of SPs portraying clients with mental illness in the psychiatric/mental health clinical course of senior nursing students enrolled in a baccalaureate program. The

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Table 1 The Phenomenological Method by Colaizzi for Proto- col Analysis

Stage Interpretation Method by Colaizzi

1 Read all protocols to acquire a feeling for them. 2 Read each protocol and extract significant

statements. 3 Spell out the meaning of each significant statement,

that is, formulate meanings. 4 Organize the formulated meanings into clusters of

themes, refer back to original protocols to validate and note discrepancies.

5 Integrate results into an exhaustive description of the study.

6 Formulate an exhaustive description under study in as unequivocal identification as possible.

7 Ask participants to validate findings as a final step.

Table 2 Semistructured Interview Guide

Interview Question

Tell me about your experience as an standardized patient (SP) when engaging with nursing students?

How was this experience different from the first interaction to final interaction?

Tell me about your experience as an SP while engaging with faculty?

Tell me about your experience as an SP while engaging with staff?

Tell me about your experience as an SP when engaging with others (public)?

Tell me how these experiences were the same or different based on the mental illness diagnosis you were portraying or with whom you were interacting with?

How did your training prepare you for these roles? Is there anything that you feel would have better prepared you?

Please share with us a description of your creative art project as it relates to your role as an SP.

Is there anything else you would like to share?

Acting with a Purpose 541

researchers chose a phenomenological method most closely aligned with the project’s aim. The method by Colaizzi (1978) underscored allegiance to the participants’ experience and adherence to the text (Table 1).

Recruitment of Participants

Approval for the study was obtained by the university IRB. Sampling was purposive. SPs working in our psychiatric mental health course were asked if they would be interested in participating in the study. No compensation was offered for participation. Five of eight SPs agreed to participate in the study. There were no dropouts. All completed the interviews. Participant experience as an SP ranged from one to six years. All study participants provided written informed consent to be interviewed and videotaped. Videotaping was used to include nonverbal communication as data, to be included as field notes. Participants could choose to complete, or not complete, any or part of the entire interview, and drop out at any time. The IRB consent form included assurances that agreement to participate or not participate in the study, as well as the nature of their participation, would not affect participants’ job status. Only the two researchers have password-protected access to audio and videotapes.

Data Collection

Interviews were the primary means of inquiry. Assessment of nonverbal communication and field notes were also used as part of data gathering. SPs met with one of two educators in the psychiatric mental health course. Interviews lasting 30-45 minutes were held off campus in the simulation laboratory outside of normal usage hours. The initial question was: Tell me about your experience as an SP when engaging with nursing students? Questions and probes followed were guided by the progression of the interview in a semistructured format (Table 2). Tapes were transcribed verbatim.

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Data Analysis

The interpretive phenomenological perspective of Colaizzi (1978) was used to guide data analysis. Phenomenology is the study of the human condition, the lived experience. The perspective of Colaizzi (1978) more closely aligns with descriptive emphasis of Husserlian tradition; however, Colaizzi agrees with the Heideggerian perspective that in research, it is impossible to bracket, or separate oneself from presuppositions (Heidegger, 1962/1927). Consequently, the method by Colaizzi (1978) informed the direction and analysis of our research. Interviews, nonverbal communication observations, and field notes were data sources. In this study, the research team consisted of two psychiatric nursing educators with expertise in SP educational models and qualitative methodology. Independently, both researchers read transcribed texts multiple times to gain a better understanding of the experience. Individually, meaningful statements were extracted and organized into thematic clusters (Table 3). In back-and-forth conversations, the two researchers’ interpretations were reread and discussed; preliminary themes were identified. A delineation of final themes was derived from preliminary themes and compared with the transcribed texts. Credibility and confirmability were augmented by extensive field notes, verbatim audio taping of interviews, and researcher collaboration. Saturation occurred when the two researchers agreed that content was repetitive.

Data collection was ongoing until the two researchers agreed that content was redundant, or saturation had occurred. While the sample was small (five) participants, Morse (2010) reminds us that saturation is not wholly

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Table 3 Thematic Analysis

Preliminary Thematic Reduction (n ¼ 11)

Final Thematic Reduction (n ¼ 4)

Sparks something in me Sparks something in me Building on confidence Building on confidence What we do is important Stepping into the shoes of

the educator Letting it Get to Me Letting it Get to Me Acting with a purpose Responding to stigma The emotions you’re expressing, you take it on

When students don’t take it seriously

Rescuing the student The responsibility of providing an accurate depiction

Faculty is approachable and helpful

Acting with a Purpose 542

dependent on the number of participants. Rather, saturation depends on factors such as ‘‘scope of the study, the nature of the topic, the amount of useful information obtained from each participant, the number of interviews per participant, the use of shadowed data and the qualitative method and study design used’’ (p. 4). Fewer participants are required when the scope of study is small, the topic is clearly understood, and there is inclusion of shadowed data (information from another source) and quality of data with depth of information (Morse, 2010; p. 4). While our sample was small, the clarity of the topic, and depth and richness of data allowed for a smaller number of participants than the recommended 6-10 participants. The amount of useable and repetitive data obtained from each participant also informed our decision that saturation had occurred.

Strategies for increasing trustworthiness included researchereresearcher examination, recoding proced- ures, and member checking. Member checking was valuable in that participants not only validated the themes, but felt supported in the researchers’ articulation of them. All participants reviewed the final thematic analysis. Comments included the following: ‘‘you really captured this,’’ and ‘‘I couldn’t agree more.’’ All the participants agreed with the themesdthere were no suggestions for revisions.

Emergent Themes

The following four themes emerged from participant interviews: (a) Sparks something in me, (b) Building on confidence, (c) Stepping into the shoes of the educator, and (d) Letting it get to me.

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Sparks Something in Me

For most participants, their original interest working as SPs emanated from a long-held interest they may or may not have explored. The chance to act and go outside of themselves presented itself as an opportunity to do something close to who they were or wanted to be: ‘‘I think that in a way it sort of suited parts of my personality which is why I picked the roles.the two roles that I picked. One role was the paranoid schizophrenic and the other was post-traumatic stress disorder. So it kind of fit me in a small way.’’ For other participants, the opportunity to teach fulfilled one of their personal goals, ‘‘.helping the student to understand what it feels like for the patient. These are important things to do.’’ One of the older participants described a personal yearning to be an actress. She told us of her childhood, with strict parents and a father who felt that acting was ‘‘not an appropriate occupation for a lady.’’ This became her opportunity to fulfill a personal desire.

In addition, the importance of the nursing role resonated with participants. It was as if they wanted to remind students of the importance of their own work. As one noted, ‘‘If you have a broken bone, you’re going to the doctor to fix that.but if you have pain inside; what you guys are doing here is really important.’’ One SP mentioned, ‘‘The experience. I usually feel really good. I feel like I’ve accomplished something. I enjoy acting and I feel this is ‘acting with a purpose’.’’ Not only did participants value their work but they also felt they provided an authentic picture of the client presentation. ‘‘I think I tried to draw them into the character. I tried to keep everything into reality and not go too far out of the box.’’

Building on Confidence

As SPs developed, they also grew in confidence. ‘‘When I first began I was very nervous. I think I was just as, if not more, nervous for the student. I took it very seriously. I didn’t want to mess it up for the student. So now I have the confidence, I know the role enough-I feel more confident.’’ Still, other participants described this evolution as moving towards authenticity. ‘‘Once you have the script you are responding to their words, and it became second nature.’’ Other participants were able to gauge student groups and noted trends: timidity, lack of strategic assessment, lackluster communication skills, adherence to checklists, and use of automatic responses, but they also noted progression, curiosity, critical assessment strategies, and responding to the individual in the moment. This was noted more in those SPs who had worked the longest as SPs. One SP commented that she believed the SP experiences played a significant role in training students to work with individuals with mental illness. This in turn, enhanced the SP’s own confidence in the acting role.

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Acting with a Purpose 543

.In the earlier years I noticed a huge difference from the first time to the last time. I think they’re (students) better prepared. This time I notice less of a difference; they’ve had more classroom time, they had more clinical, probably reading more on their own-so, this time, I’ve noticed less of a difference. I’ve had some students who’ve told me, which makes me feel good (say I’m schizophrenic) that, the first time they thought we were over the top-they’d see me later (after clinical) and say ‘‘Whoa you’re not so far off’’ I’ve never met a schizophrenic and never had to deal with a schizophrenic (person with schizo- phrenia) so for me, I would probably have thought, oh, that’s something you’d see in Law and Order. There’s no doubt. the growth is so obvious and so prevalent.

SPs discovered this evolution with initial faithfulness to the script, proceeding to a clearer understanding of the role itself. Inhabiting the role of the SP drew from their identification and ability to respond to students as the patient would. The communication and demeanor of the SP more closely resembled a real encounter and thus were more beneficial to the student. This focus on teaching/ learning was more fully realized in the theme, Stepping into the shoes of the educator.

Stepping Into the Shoes of the Educator

When SPs became more comfortable in their roles, they identified a new role, one of educator, not merely actor. As the SPs gained in experience, they were able to discern student gaps in learning and become part of the teaching team. They aimed to provide a realistic representation the student could respond to. One SP described it this way: ‘‘You want it for the student. You can tell they’re nervous and they’re so caught up in the simulation and they miss something totally. I say to myself-oh man you’re nearly there-so I really feel for the role and feel for the student.’’ One of the SPs, a retired nurse, recalled when she was a student. She realized the importance for students to understand how to best establish a therapeutic relationship with a mentally ill patient and wanted them to be successful. This reflection underscored a cautious and caring approach. She described it this way:

Some of the students looked very intimidated. For some of them it was a natural thing. You want them to learn, you don’t want them flunking out left and right. You want good learning to take place. I think we should all remember what it was like, especially my generation, what it was like to be a nursing student. It was different then, but now I think .you’re treated more like an adult. We were so afraid of the nursing instructors. I don’t see any point in scaring someone.

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Ongoing communication was made available by instructors to enable SPs to ask questions about problems, targeted scenarios, or student capability. SPs were cognizant of the issue of attempting to ‘‘rescue’’ the student, but, as one SP mentioned, ‘‘you want it for the student, but you can’t hand-hold.’’ They also realized their role was to ‘‘stay in role’’ and be authentic. This led to another identified theme, Letting it get to me.

Letting It Get to Me

SPs recalled days when they felt immersed in the experience, not only in that moment, but days afterward. They describe the ‘‘difficulty of shaking if off.’’

Participants voiced disappointment with students who were not invested and empathetic; who did not seem to understand the seriousness or relevancy of the interaction:

I don’t want to scare you-I’m not taking it home or anything, but that’s what shocked me more than anything. The real sense, like for example, our patient L.G., (in one scenario). I’ve never been divorced, kids aren’t talking to her, who circumstan- tially has had some scary things happened to her. When I share those things with the student nurse for the lack of a better term, who is blowing me off-not really hearing what I’m trying to say-I get in touch with that vulnerable side of that character. I guess, even though it’s not happening to me personally, even though it’s a specific illness, there is still the universal theme of being human. I don’t know anyone who has schizophrenia, I’ve never been schizophrenic, but when I am playing that character, I still feel very protective of that character and understand it well enough to know that if I have someone who pushes me too hard to make me think that what I’m hearing is false. It’s my reality. It’s kind of like that term-dissonance.

Other SPs felt the interaction stayed with them: ‘‘After I left here, I was still thinking about those roles so I can understand how actors, real actors, will have trouble getting rid of that feeling.’’ In some cases, the roles reminded them of their own personal experiences or SPs described their roles as evocative of their own lives. One SP remembered a personal experience with depression after a divorce. Her SP experience reminded her of this time in her life.

Still others, without personal experiences, viewed the SP experience as difficult to shed, especially when they were playing the role of depression. ‘‘I feel it and that makes me feel bad. Not days later-but in that moment.’’ Another participant noted: ‘‘Depression is so heavy. The main stressor is to get into the role. I think about the script. What if I had no money-or my wife had left me?’’ One

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individual identified this experience more closely: ‘‘The emotions you’re expressing, you take it on.’’

Limitations

With phenomenological research, we are able to look at the unique experience of individuals. While this study explored the lived experience of a small sample of SPs, the findings provided a glance at how this experience impacted each individual SP. Limitations of this study include the small sample size and variance in the amount of time that each actor had worked as an SP portraying an individual with mental illness. Also, having only one medical simulation laboratory precluded us from using multiple sites.

Discussion

The following four themes emerged from participant interviews: (a) Sparks something in me, (b) Building on confidence, (c) Stepping into the shoes of the educator, and (d) Letting it get to me.

In the theme ‘‘Sparks something in me,’’ participants discovered their initiation into the acting role emanated from their personal life. They described their original interest working as SPs proceeded from a long-held interest. This initial investment in their role progressed to the second theme, Building on confidence. This theme became the platform for their roles as educators, or Stepping into the shoes of the educator. While their entry into the simulation role came from an initial interest in acting, their growth and authenticity in their role changed how they saw themselves; they began to see themselves as part of the ‘‘teaching team.’’ The SPs viewed their participation and excellence in their role as integral to students’ growth. The first three themes, Sparks something in me, Building on confidence, and Stepping into the shoes of the educator, involved a complex change in attitudes from one of ‘‘I’m not sure of these patients’’ and ‘‘I’m scared of this diagnosis,’’ to empathy and identification with the patient. However, this identification with the patient is not without its pitfalls. One of the most challenging scenarios for the SP is the student who is not invested or empathetic. In a clinical or naturalistic setting, the student nurse would have difficulty garnering information from the patient or establishing rapport. One way the SP can help the student is to replicate that same situation. When the student is distant or disengaged the interaction fails to unfold naturally, and the SP responds similarly distantly. If a student fails to convey interest and is focused on a checklist of symptoms, the SP may continue to demonstrate symptomatology and the student has difficulty proceeding. In essence, in integrating a

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‘‘real-world’’ interaction, SPs provide an opportunity for students to make mistakes and prepare for their inpatient and community experiences.

We conducted this study to determine the lived experience of the SP. We were led to an additional question: ‘‘How do we address these issues and feelings with our SPs so that we create the best learning experience for our students?’’ While the literature suggests the importance of debriefing for students, there are no recommendations for helping actors to deal with the resulting feelings associated with providing a ‘‘real experience’’ for nursing students. Taking on the role of mental illness may invoke feelings that need to be addressed; each SP may have past experiences that unexpectedly surface, as they portray sensitive and personal roles as they de-role (Blake, Gusella, Greaven, and Wakefield, 2005; Spencer & Dales, 2006). In Blake et al. (2005), simulated patients in their study identified similar experiences, particularly in terms of stigma, ‘‘when I was seen on the street I felt the med student saw me as the bad SP person’’ (p. 32, Table 1). Our training focused on the portrayal of symptoms and has not addressed issues related to the themes identified as a result of this study. Future training will, however, be designed to address these issues. We now recognize the need to also address the issues related to the theme of letting it get to me. The initial step must begin with recruitment. It is not only important to hire the most capable SPs to engage in these interactions; it is also necessary to identify those who may need extra coaching to perform and de-role in addition to debriefing.

Recommendations

Nursing recommendations include the use of strategies such as (a) targeted recruitment procedures, (b) training protocols, (c) debriefing, and (d) progress meetings. From our experience, we have noticed that sometimes younger actors have more difficulty portraying the illness presentation, and separating themselves from the role. As SPs engage with students in these roles, the nurse educator must consider the impact these demanding roles have on the actor. Training should include a mechanism to address issues related not only to stepping into the role, but also to de-rolling once the scenario is over. Pairing experienced actors with inexperienced actors would be one way of doing this. In a one-day immersion training program, other researchers have suggested that increasing the number of practice sessions enhances actor confidence (Kasab et al., 2010; p. 258). Debriefing of actors should include a strategy to address this issue. Finally, progress meetings would afford an opportunity for SPs to discuss issues, note trends, and highlight future trainings. Project meetings have the added benefit of keeping SPs engaged in the teaching/learning process.

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Acting with a Purpose 545

Conclusion

Ultimately, this phenomenological research highlighted the motivations of actors in SP roles, the impact of role immersion, and the importance of acknowledging their experiential perspective. Desirous to both protect SPs and provide the best clinical learning experiences, nurse educators need to work closely with SPs to provide training that promotes an authentic presentation without harming the SP. This should include proper recruiting, training including de-rolling, debriefing, and ongoing support. In the future, our plan is to develop a collaborative, multisite study at simulation centers in Maryland universities.

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