American Speech-Language-Hearing Association

The Use of Standardized Patients in Communication Sciences and Disorders

Richard I. Zraick, PhD, CCC-SLP
Professor
University of Arkansas at Little Rock

Educational programs in Communication Sciences and Disorders (CSD) have at their core a dual and complementary mission: (1) to teach fundamental knowledge about normal and disordered communication and (2) to teach and assess clinical skills. Clinical placements in 'real-world' settings such as schools, clinics, hospitals, and nursing homes traditionally have been used to provide CSD students with the opportunity to apply information learned in the classroom, and to develop interpersonal, clinical reasoning, and management skills that are required for professional practice. More recently, however, clinical education in CSD has expanded to include problem-based learning methods such as simulation.

Simulation, for purposes of health care education, is a method that replaces or amplifies real patient experiences with scenarios designed to replicate real health encounters (Passiment, Sacks, & Huang, 2011). Tools such as lifelike mannequins, physical models, case studies, computer avatars, or standardized patients can be used to teach and assess clinical skills. Simulation allows the student to build knowledge and experience through practice and rehearsal in a safe environment where, fortuitously, the inconvenience, discomfort, and potential harm to 'real' patients is minimized.

A well-accepted form of patient simulation is the standardized patient (Barrows, 1971). A standardized patient (SP) provides a controlled condition for the instruction, assessment, or practice of communication and/or examining skills of a health care provider. The SP may be an able-bodied individual trained to replicate a patient's illness, or a patient with who has been trained to present his/her disease. The 'standardization' refers to the consistent content of the SPs verbal and behavioral responses to the student. SPs often participate in a performance-based clinical assessment called the Objective Structured Clinical Examination (OSCE), a method of clinical skills assessment requiring students to perform specific tasks within a prescribed time period in a highly structured encounter (Harden, 1988). Particular benefits of using SPs include standardization of the clinical experience, safety of the clinical experience, and the provision of immediate real-time feedback. OSCE is a standard assessment tool in medical settings and is a critical component of SP methodology.

Use of SPs in Clinical Disciplines

SPs and OSCEs have been used worldwide to assess the clinical skills and competencies of students and professionals in medicine, nursing, pharmacy, dentistry and chiropractic care. SPs and OSCEs also have been used in allied-health disciplines such as nutrition and dietetics, dental hygiene, genetic counseling, community health education, radiological sciences, physical therapy, and occupational therapy. Their adoption for CSD education is very limited, but has been growing over the past decade or so. Two comprehensive review articles (Hill & colleagues, 2010; Zraick, 2012) describe how SPs have been implemented in clinical education programs in both Audiology and Speech-Language Pathology. These articles discuss the ways in which SPs have been utilized to portray adults with a variety of speech, language, and hearing disorders. They also describe a number of different pedagogical approaches that have been used, ranging from a single SP case being brought into a classroom, to a cadre of SPs being used for formal evaluation of clinical competency. In some instances, SP 'families' also have been utilized to teach case history interviewing and information-sharing skills.

I am fortunate to be at a medical sciences university which houses a state-of-the-art facility for case development consultations, SP recruitment, and teaching and assessment of clinical skills. Regardless of whether one has limited or unlimited resources, there are a number of key elements which must be considered in building a full-scale SP protocol. These include: case development, training of SPs, development of the OSCE, procedures for conducting the OSCE, recruitment and training of judges, and measurement and evaluation (Hill and colleagues, 2010; Zraick, 2012). This being said, all one really needs to begin utilizing SPs is one volunteer, one judge, one room, and one camera.

Fertile Area for Research

Our discipline's understanding of how to best utilize SPs for clinical education in CSD is still in its infancy, providing numerous directions for future research. Among the most important areas are: development of valid student clinical assessment tools, exploration of effective ways to implement SPs with CSD students and clinical educators, and designing SP cases for teaching in an inter-professional education model.

Personal Reflections and Vision for Future

I have developed SPs to portray the classic aphasia syndromes, acquired apraxia of speech, right hemisphere syndrome, traumatic brain injury, and Alzheimer's disease. I also have created standardized "family" members for use during counseling sessions. These SPs have been used both in the classroom and the clinic for teaching, and in our simulation center for performance-based OSCE assessment. My vision for training tomorrow's clinicians is that further research will support the infusion of SPs and OSCEs into all disorders classes across both graduate and undergraduate curricula, and support their integration into traditional clinical practicum. If this vision is realized, then use of SPs may provide an opportunity for expanding graduate admissions given that current clinical education/ placement needs are prohibitive to expanding capacity. The use of SPs also may prompt a re-examination of competency testing. For example, at the program level, SPs may be used for a 'capstone' OSCE experience. At the national level, OSCEs may be added to the Praxis® examination. Ultimately, the use of SPs can result in better trained clinicians to serve those individuals with communication impairments.

References

Barrows, H.S. (1971). Simulated patients (programmed patients): The development and use of a new technique in medical education. Springfield, IL: Charles C. Thomas.

Harden, R.M. (1988). What is an OSCE? Med Teach, 10, 19-22.

Hill, A.E., Davidson, B.J., & Theodoros, D. (2010). A review of standardized patients in clinical education: Implications for speech-language pathology programs. International Journal of Speech-Language Pathology, 12(3), 259–270.

Passiment, M., Sacks, H., & Huang, G. (2011). Medical simulation in medical education: Results of an AAMC survey. Association of American Medical Colleges. Washington DC, 1–48.

Zraick, R.I. (2012). A review of the use of standardized patients in speech pathology clinical education. International Journal of Therapy and Rehabilitation, 19(2), 112–118.

Additional Readings

Bressmann, T., & Eriks-Brophy, A. (2012). Use of simulated patients for a student learning experience on managing difficult patient behaviour in speech-language pathology contexts. International Journal of Speech-Language Pathology, 14(2), 165–173.

Dinsmore, B. F., Bohnert, C., & Preminger, J. E. (2013). Standardized patients in audiology: A proposal for a new method of evaluating clinical competence. Journal of the American Academy of Audiology, 24(5), 372–392.

Edwards, H., Franke, M., & McGuiness, B. (1995). Using simulated patients to teach clinical reasoning. In J. Higgs, & M. Jones (Eds.), Clinical reasoning in the health professions (pp. 269–278). Oxford: Butterworth-Heinemann.

Edwards, H., McGuiness, B., & Rose, M. (2000). Using simulated patients to teach clinical reasoning. In J. Higgs, & M. Jones (Eds.), Clinical reasoning in the health professions (2nd ed.) (pp. 262–269). Oxford: Butterworth-Heinemann.

Edwards, H., & Rose, M. (2008). Using simulated patients to teach clinical reasoning. In J. Higgs, M. A. Jones, S. Loftus, & N. Christensen (Eds.), Clinical reasoning in the health professions (3rd ed.) (pp. 423–431). Edinburgh: Elsevier, Churchill Livingstone.

Harten, A.C. (2012). Role-playing and its carryover to practice in speech-language pathology. American Speech-Language Hearing Association Perspectives on Issues in Higher Education, 15(1), 29–37.

Hill, A.E., Davidson, B.J., McAllister, S., Wright, J. & Theodores, D.G. (2013). Assessment of student competency in a simulated speech-language pathology clinical placement. International Journal of Speech-Language Pathology, Early Online (August 30), 1–12.

Syder, D. (1996). The use of simulated clients to develop the clinical skills of speech and language therapy students. European Journal of Disorders of Communication, 31, 181–192.

Tharpe, A.M. & Rokuson, J.M. (2010, August 31). Simulated patients enhance clinical education: Vanderbilt offers unique program for audiology students. The ASHA Leader.

Wilson, W.J., Hill, A., Hughes, J., Sher, A., & Laplante-Levesque, A. (2010). Student audiologists' impressions of a simulation training program. The Australian and New Zealand Journal of Audiology, 32(1), 19–30.

Zraick, R.I. (2002). The use of standardized patients in Speech-Language Pathology. American Speech-Language Hearing Association Perspectives on Issues in Higher Education, 5(1), 14–16.

Zraick, R.I. (2004, May 25). Playacting with a purpose: Using standardized patients to assess clinical skills. The ASHA Leader.

Zraick, R.I. & Allen, R.M. (2002). Using standardized patients to train and test Speech-Language Pathology students. The Innovative Professor in Communication Disorders: The American Speech-Language Hearing Association Perspectives on Issues in Higher Education, 1, 17–19.

Zraick, R., Allen, R., & Johnson, S. (2003). The use of standardized patients to teach and test interpersonal and communication skills with students in speech-language pathology. Advances in Health Science Education, 8, 237–248.

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