Clinical competence is a fundamental quality of healthcare professionals. As such, a substantial focus has been placed over the years on ways to facilitate healthcare students in developing optimal level of clinical competence, with SPs becoming increasingly used as an educational tool. This scoping review examined 33 articles that assessed the effectiveness of working with SPs in this regard, under the three main domains of clinical competence. These will now be discussed.
Technical skills
Traditionally, technical aspects of clinical competence such as physical examination skills have been taught using a didactic approach, often involving textbooks and lecture notes limiting student’s opportunities to perform and practise the necessary skills [3, 32]. In order to overcome these limitations and move towards a more self-directed and interactive learning, SPs have been introduced over the past 50 years [33] in the field of healthcare education.
Within the included articles that examined the impact of SPs on students’ technical skill development, the majority (8 out of 11 studies) supported the view that SPs are effective in improving students’ examination skills. SPs were effective at reinforcing knowledge attained from the traditional didactic learning through actual performing of manoeuvres on a real person. SPs could also provide direct feedback, which allowed students to reflect on their performance and improve on areas of weakness.
For example, in a study by Safeieh [34] involving medical students, a single training session with SPs on breast and abdominal examination techniques in addition to a standard textbook teaching resulted in a significantly higher performance scores than standard textbook teaching only (p = 0.002 and <0.001 on breast and abdominal examinations respectively). Moreover, calculation of pre- and post-test scores showed a greater improvement of scores in students who received a training session with SPs as compared to those who did not (p = 0.036 and <0.001 on breast and abdominal examinations respectively).
This positive impact of working with SPs is further shown in a study by [35] which found that an additional training session with a SP resulted in a significantly higher performance in clinical breast examination among third-year medical students, with a p = 0.04.
However, there has been some concern that these positive effects of SP training sessions on medical students’ clinical competence may only be short-term, as most published data examined outcomes that were measured soon after the intervention [36, 37]. Safdieh et al. [34] attempted to address this concern by analysing student performance 2 years after the intervention. The trial showed that medical students who received neurological examination session by SPs as part of their second-year curriculum performed better than those who did not receive the session by SPs, as measured in an objective-structured clinical exercise at the end of their fourth-year, with a p < 0.001.
These studies confirm the important role of SPs in providing students with opportunities to develop and enhance their technical skills such as examination skills, which can best be done through practice. SPs also seem to have a long-term benefit in technical skills acquisition for medical students.
Non-technical skills
Effective communication skills play an integral part of successful interaction between healthcare professionals and patients [38]. SPs provide an opportunity to practise such skills where students are able to interact and communicate with patients, while learning and developing their interpersonal skills.
Analysis of the included articles reflected an emphasis on this domain of clinical competence in particular, with a majority of them focusing on the effectiveness of SPs in students’ development of non-technical skills, such as communication or interpersonal skills. Overall, 16 out of 22 concluded that programs or training sessions by SPs result in better performance of communication skills in students than without SP involvement.
The above referred pilot study by Bachmann et al. [38] showed that undergraduate medical students who underwent a brief two-hour communication skills training performed better in a primary care communication examination than students who had no training (p = 0.02). The study also commented on its feasibility of such intervention for other healthcare professions.
The benefit of working with SPs in improving students’ communication competence seem to be further enhanced by ‘hybrid simulation’, which is essentially an integration of SPs and mannequins [39]. It allows students to verbally interact with the SP while performing practical manoeuvres on a part of the mannequin attached to the patient, thereby developing their communication competence while practising technical skills at the same time.
The same study [39] found that training fourth-year medical students with hybrid simulation resulted in higher communication scores than training in small-group tutorials, with a p = 0.01, supporting the potential of SPs as an effective additional tool in communication skill development.
However, a minority (6 out of 22 studies) failed to show effectiveness of SPs in facilitating non-technical skill development. For instance, a randomised controlled study by [40] involving 129 nursing students compared the effect of adding SPs to didactic lectures-only on students’ communication skills. Analysis of post-encounter SP checklist scores, which objectively measured students’ performance on communication and interpersonal skills, showed no significant difference between the two groups (p = 0.238).
Despite variability in the results, the majority of studies (16 out of 22) supported working with SPs in helping students develop communication and interpersonal skills. This was evidenced by favourable outcomes of student performances in majority of the cases, indicating the advisability of working with SPs in healthcare education for students’ non-technical skills development.
Cognitive skills
The cognitive aspect of clinical competence may include skills such as decision-making and clinical reasoning [30]. History-taking is also one of the important skills under this domain, as obtaining sufficient information from effective history-taking allows healthcare professionals to make correct diagnosis and take appropriate management actions [41].
The effectiveness of SPs in assisting students’ development of such skills was highlighted in 8 out of 11 studies.
For example, Haist et al. [42] reviewed the impact of a four-hour workshop working with SPs on third year medical students in improving their clinical diagnosis skills, specifically on the topic of domestic violence. Students’ performance on checklist examinations was measured at four and 27 weeks after the workshop, and was compared to those who did not participate in the workshop. Results showed significant difference in the scores between the two groups, both at four and 27 weeks, with p = 0.002 and p = 0.01 at respective times, favouring the students who had participated in the workshop working with SPs.
Overall, SPs were assessed to be effective in facilitating students’ cognitive skills. Both short-term and long-term benefits of SPs were seen, demonstrating their potential to be used as an effective means of education.
Limitations and future research
While scoping reviews offer a number of advantages over other methodological approaches in literature reviews, including a relatively shorter research process and a broader range of data that can be examined, there are certain limitations to be addressed, which are discussed below [28].
Firstly in this scoping review, the quality of evidence in the research articles was not assessed or appraised, as opposed to in systematic reviews. This hinders the measurement of validity and generalisability of such findings from these studies. Secondly, as a considerable amount of data was extracted in the preliminary research, specific and focused inclusion and exclusion criteria had to be applied, in order to obtain articles that met the objective of this scoping review. For example, only the terms ‘simulated patient’ and ‘standardized patient’ were used for the search, while literature describes other terms that can be used as alternatives such as ‘trained patient’ or ‘actor patient’ [14]. This may have missed some literature that could have been relevant in this review. Furthermore, only the studies published in English were included, limiting the scope of literature to be considered.
Nevertheless, this scoping review provides a valuable overview of the current literature regarding the effectiveness of SPs in healthcare education. Although most of the data identified in this review (24 out of 33 studies) seems to favour working with SPs in facilitating students’ clinical competence, there was some variability of findings as indicated by 9 studies that failed to show effectiveness of SPs. One should consider variable factors that may have contributed to such findings, such as small sample size, and carefully review the methodology used in the studies and the implications of statistical significance.
With the nature of scoping reviews which incorporates a wide ranging research data, a more rigorous search using systematic approach will help yield a more definitive conclusion on the topic. It may also be interesting to focus on quantitatively comparing the effectiveness of SPs with other methods of teaching clinical skills in order to aid in future development of education for healthcare students. Furthermore, inclusion of SPs’ associated costs may be of a practical benefit, essentially when universities must decide on working with SPs at a time when resources are scarce, thereby providing useful information for future directions in healthcare education.
