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Development and evaluation of pilot simulated patient centre: Learning from the experience

Objectives: To compare the performance of paid actor-simulated patients: 1) before and after a simulated patient training programme aiming for programme enhancement; 2) to postgraduate/staff-simulated patients. Methods : Fifty-six student participants watched a series of video recordings of student pharmacist-paid actor-simulated patients role-playing and blindly assessed the performance of paid actor-simulated patients pre- and post-training using the Maastricht Assessment of Simulated Patients (MaSP). Seventy-three student participants compared the paid actor- simulated patients’ performance to postgraduate/staff -simulated patients. Data collected were analysed using paired t-tests and independent t-tests, respectively. Results : There was a statistically significant improvement in the collated MaSP scores for paid actor- simulated patients’ performance post -training in the authenticity of role-playing (mean score ± standard deviation (SD): 2.61 ± 0.30 (Pre-training); 2.70 ± 0.31 (Post-training), p < 0.05) but not the quality of feedback. Similarly, paid actor-simulated patients performed better (in the authenticity of role-playing but not the quality of feedback) when compared to postgraduate/staff-simulated patients. Conclusions: Paid actor-simulated patients require improvement in providing quality feedback to students to enhance students’ learning.


Introduction
A simulated patient is an individual who is coached to portray a patient in a simulated environment (Smithson et al., 2015). The simulation can be scripted (actor performs the work as directed) or improvisational (actor improvises the character around the key elements given) (Churchouse & McCafferty, 2012). The teaching strategy of using simulated patients in pharmacy education has been viewed as valuable and beneficial (Raney, 2007;Rickles et al., 2009;Chin et al., 2014;Cravens et al., 2016), preferred by the learners (Grice et al., 2013), and can improve learners' confidence during their patient encounters and patient care (Branch, 2013;Maxwell et al., 2016;Zamami et al., 2016;Ong et al., 2018).
Role-playing is useful in developing pharmacy students' patient care skills, including communication skills, information gathering, and professionalism (Rao, 2011;Adrian et al., 2015;Fejzic & Barker, 2015). The authenticity of role-playing and high-quality feedback are more important than uniformity and consistency of role-playing during educational sessions involving simulated patients (Wind et al., 2004). Therefore, simulated patients should be trained to be able to act authentically during roleplaying and be capable of providing high-quality feedback to students (Perera et al., 2009).
The three types of simulated patients most described in the pharmaceutical literature are community volunteers or paid actors, academic staff, and peers. Table I presents some of the benefits and limitations of each type of simulated patient (Gallimore et al., 2008;Smithson et al., 2015). The technique of role-playing with peers or staff members can provide a variety of active learning experiences for students (Barrows, 1993). The disadvantages of this approach include the lack of useful or critical feedback from other students (who are often peers or non-experts), inconsistent learning experiences Pharmacy Education 21(1) 771 -780 772 resulting from wide variations in acting skills among participants, and difficulty pretending a known peer or faculty member is a "patient" (Rickles et al., 2009). Simulated patients are widely used in the performancebased teaching sessions of the medical and health sciences students. They are expected to provide feedback and have a positive impact on students' learning. However, the authenticity of role-playing and the quality of feedback provided by the simulated patients to students are rarely evaluated. Very little or no research to date has centred around an evaluation of the performance of the simulated patients from the learners' perspective. The present study aims to compare the paid actor-simulated patients' performance from the learners' perspective in the context of the authenticity of roleplaying and the quality of feedback 1) before and after a simulated patient training programme aiming for programme enhancement, and 2) to postgraduate/staffsimulated patients.

Study design
In this study, a half-day simulated patient training programme was designed to illustrate the key roles, skills, and techniques required for simulating a patient successfully. Table II

9-10
How to maintain privacy and confidentiality and health and safety

11-12
Aims and objectives of the University's Simulated Patient Training Programme

13-16
The use of simulated patients at the University is detailed

17,18
Types of roleplaying scenarios at the University

19-23
Details the scenarios that the simulated patients will be performing

24-27
How to give feedback to students Four paid actor-simulated patients were recruited into the University's Simulated Patient Training Programme. They were filmed in role-playing scenarios with four second-year pharmacy students, both before and after training. The four role-playing scenarios were responding to symptoms, medication history taking, prescription counselling, and device counselling. The four paid actor-simulated patients rotated around four different role-playing scenarios; however, only the video from the last scenario the paid actor-simulated patient enacted was chosen to be evaluated in this study, as detailed in Table III. There were eight video recordings in total, i.e. the pre-and post-training videos for each of the four paid actor-simulated patients in a role-playing scenario. Student participants then watched these series of video recordings of student pharmacist-paid actorsimulated patient role-playing and blindly assessed the performance of paid actor-simulated patients pre-and post-training in the context of the authenticity of the role-playing and the quality of feedback provided by paid actor-simulated patients using the Maastricht Assessment of Simulated Patients (MaSP) instrument (Wind et al., 2004). The patient had been prescribed Tiotropium Handihaler for his/her asthma and had never used it before and needed counselling on how to use it.

Four
Responding to symptoms* The patient had symptoms of heartburn and have had it before. The patient needed to explain his/her symptoms to the student pharmacist, for the student pharmacist to recommend a suitable course of action.
The patient had heartburn symptoms which followed from eating a large meal.
The patient needed to tell the student pharmacist this information for the student pharmacist to recommend a suitable course of action.
*Note each paid actor-simulated patient performed all the role-playing scenarios; however they were only evaluated performing the one indicated above After paid actor-simulated patients went through the University's Simulated Patient Training Programme, their performance was compared to the postgraduate/staff-simulated patients (simulated patients type commonly used in the timetabled teaching and learning sessions requiring patient's interaction at the University) during the timetabled teaching and learning sessions. Pharmacy students were divided into two groups to have allocated either a paid actor-simulated patient or a postgraduate/staffsimulated patient during the timetabled teaching and learning sessions requiring simulated patients at the University. It should be noted that postgraduate/staffsimulated patients were provided with training (in terms of safety and giving feedback) before helping with the timetabled teaching and learning sessions, but their training was not as extensive or recent as the training given to the paid actor-simulated patients.

Maastricht Assessment of Simulated Patients (MaSP)
The Maastricht Assessment of Simulated Patients (MaSP) consisted of 20 statements: items 1-10 relating to 'authenticity of role-play' and items 11-20 relating to 'quality of feedback'. The instrument utilised a 4-point Likert scale for assessors to respond to each statement regarding the simulated patient's performance (4=complete agreement and 1=complete disagreement) except for items 10 and 11 (both of which are dichotomous questions) (Wind et al., 2004). Item 10 and 11 of the MaSP were not included in the calculation of mean scores for the 'authenticity of roleplay' and 'quality of feedback' in this study. The benefit of a 4-point Likert scale is that there is no option for a 'neutral' answer, allowing for more specific conclusions to be made. Item 21 on the MaSP instrument enables assessors to provide a general mark out of 10 for the simulated patient's performance.

Study population
The student participants of this study were first-and second-year pharmacy students at the University. No other exclusion criteria were set. Student participants were recruited from a mixture of notifications during timetabled teaching and learning sessions and emails (sent from the investigator to the MPharm Year 1 and Year 2 cohorts). Two methods of recruitment were employed in the hope of maximising participation. Student participants were not paid; however, they received a small token of appreciation, such as a mug or keychain, for taking part. All student participants were given full details of the study both verbally and in written form before taking part. Each student participant received a participant information sheet and a research privacy notice to read before signing a consent form agreeing to take part. Each student participant was free to withdraw from the study at any time and was not disadvantaged for not participating. The Science & Engineering Research Ethics Committee (SEREC) at the University granted the ethical application and approval.

Data analysis
Student participants' responses were compiled and a second independent individual checked all data entered. Any disagreement in the data entry was reconciled and resolved. A paired t-test was calculated for each of the four paid actor-simulated patients and the collated MaSP scores for paid actor-simulated patients' performance in the context of the authenticity of role-playing and quality of feedback. An independent sample t-test was used to compare the performance of the paid actor-simulated patients and the simulated patient type commonly used at the University, namely the postgraduate/staff-simulated patients. The alpha value was set at 0.05 and a confidence interval of 95%. All data were analysed using the Statistical Package for Social Sciences (SPSS) version 26.

Results
The recruitment process managed to engage fifty-six pharmacy students to participate in the video recordings viewing study comparing the performance of the paid actor-simulated patients pre-and posttraining of the University's Simulated Patient Training Programme. Seventy-three pharmacy students were recruited to participate in the comparison study between paid actor-simulated patients and postgraduate/staff-simulated patients.
Fifty-six pharmacy student participants reviewed the eight role-playing scenarios, four for each pre-and post-training using the MaSP instrument. The results of this study revealed that there was a statistically significant improvement in the collated MaSP scores for paid actor-simulated patients with regards to the authenticity of the role-playing post-training (mean score ± standard deviation (SD): 2.61 ± 0.30 Pretraining; 2.70 ± 0.31 Post-training, p<0.05). However, there was no statistically significant difference in the performance of the collated MaSP scores for paid actor-simulated patients with regards to the quality of the feedback pre-and post-training (mean score ± SD: 2.83 ± 0.32 Pre-training; 2.82 ± 0.34 Post-training, p>0.05). When considering individual paid actorsimulated patients, there was a statistically significant improvement for paid actor-simulated patient one (p=0.001) and paid actor-simulated patient three (p=0.008) for the authenticity of role-playing. The mean scores for the authenticity of role-playing for paid actor-simulated patient two and paid actor-simulated patient four increased post-training, but these were not statistically significant (p>0.05). In terms of the quality of feedback, paid actor-simulated patients one, three, and four all showed an increase in the mean scores attained for the quality of feedback, but these were not of statistical significance. The mean scores for the quality of feedback for paid actor-simulated patient two showed a statistically significant decrease posttraining (p=0.001). This result was in the opposite direction as the mean scores dropped from 2.77 ± 0.30 pre-training to 2.57 ± 0.32 post-training, indicating the student participants judged the feedback provided to be of lower quality post-training.  Table VI shows the mean scores received by each paid actor-simulated patient for each question on the MaSP instrument (omitting items 10 and 11), pre-and post-training.
When the performance of the paid actor-simulated patients was compared to the postgraduate/staffsimulated patients in the timetabled teaching and learning sessions, paid actor-simulated patients performed significantly better than postgraduate/staffsimulated patients concerning the authenticity of roleplaying (p<0.05) but not the quality of the feedback (p>0.05). Seventy-three pharmacy students participated in this study, comparing the performance of paid actor-simulated patients against the postgraduate/staff-simulated patients.

Paid actor-simulated patients' performance before and after University's Simulated Patient Training Programme
The results obtained in this study can be interpreted in two challenging ways. The University's Simulated Patient Training Programme was successful as there was a statistically significant improvement in the collated paid actor-simulated patients' performance post-training in the context of the authenticity of roleplaying, although not in the context of quality of feedback. On the other hand, the results obtained indicated that it might not be a true reflection of the University's Simulated Patient Training Programme but When evaluating the video recordings of the student pharmacist-paid actor-simulated patient role-playing, only the last scenario enacted by the paid actorsimulated patient was chosen to be evaluated by student participants. The objective was to ensure the performance of both the student pharmacists and the paid actor-simulated patients were not affected by the anxiety of participation which could potentially affect their role-playing and, subsequently, their performance.

Lessons learned from the student participants' evaluation of student pharmacist-paid actorsimulated patients' role-playing scenarios
Paid actor-simulated patients require improvement in providing quality feedback to students to enhance students' learning. However, there is limited information on how to train simulated patients to provide high-quality feedback. One method reported by Perera and colleagues (2009) was to use 'experienced simulated patients' to train new simulated patients. However, since paid actorsimulated patients were a new introduction to the University, implementing this would have involved the recruitment of simulated patients from other pharmacy and medical schools in the country, making it less feasible. Therefore, the areas where paid actorsimulated patients performed poorly were studied and highlighted to enhance the quality of feedback of the paid actor-simulated patients to the students.
The areas where paid actor-simulated patients performed poorly and required improvement to ensure quality feedback provided to students were 1) stimulating students to ask questions; 2) providing feedback from the patient's perspective; 3) providing constructive criticism. Peer-reviewed findings stated that students benefit from the exercise if they are actively engaged with the simulated patient (Lloyd et al., 2018). Austin and colleagues (2006) had incorporated the simulated patients' feedback from the patient's perspective into building the teaching and assessment cases for students. Students valued the use of this approach, which improved their pharmaceutical care skills and helped them to better understand the psychosocial needs of patients in practice. Therefore, paid actor-simulated patients should provide feedback from the patient's perspective, so the students gain a deeper understanding of how they have made patients feel during the consultation. This type of feedback also identified areas of weakness regarding the students' consultation skills, allowing them to reflect and improve. Feedback provided to students should be constructive and not overly critical or demoralising (Melluish et al., 2007;Bouter et al., 2013). Students' weaknesses were not just highlighted but delivered in a way the student feels supported, allowing them to reflect and improve their performance in the future. One method of doing this was educating simulated patients on feedback frameworks such as the "Pendleton rules of feedback", as reported by James and co-workers (2001). Chowdhury and Kalu (2004) stated that the focus of this type of feedback was to ensure they were constructive, and they added that the positives should be delivered first, followed by the areas students could improve.
The other areas where paid actor-simulated patients performed poorly were 1) not comparing between students; 2) not giving examples from the consultation; 3) not giving feedback about medical issues. It could be argued that giving students examples of good consultation techniques demonstrated by their peers may be beneficial; however, the other school of thought felt that feedback should be tailored to the individual involved in the scenario and comparisons between students served a limited purpose. Further investigation is needed on how the comparison is made as it is likely to be vital, and the opinions of the students should be considered. The paid actor-simulated patients are lay individuals with limited pharmacy knowledge, and it is not expected that they give feedback relating to specific case details since this is the role of the academic observing the scenario. As such, this should be communicated to the students before the teaching and learning sessions.
On the other hand, the results from the study described herein were encouraging in the aspect that paid actorsimulated patients actively listened to the student during the role-playing and were friendly to the students. These reassuring experiences are expected to positively impact students' learning.

Comparison between paid actor-simulated patients and postgraduate/staff-simulated patients
The findings from this study and the literature agreed that, overall, paid actor-simulated patients were superior concerning the authenticity of role-playing. Although there was not a statistically significant difference in the quality of feedback, analysing the mean scores has shown that paid actor-simulated patients performed marginally better. Therefore, it can be concluded from the results of this study that the paid actor-simulated patients were the better performing type of simulated patients and may contribute more to pharmacy student professional development. However, further research is needed to confirm this finding and examine the types of simulated patients that specifically impact student skill development. Smithson and colleagues (2015) reported that unfamiliarity of the simulated patients to the students contributed to increasing the authenticity of the roleplaying. This finding was supported by a study undertaken by Gallimore and coworkers (2008), who found that students felt more prepared for real-patient encounters when simulated patients were used due to the highfidelity role-playing. The results from this study were in agreement with the above findings to a certain extent. The second-year pharmacy students had encountered the postgraduate/staff-simulated patients before, and perhaps, as a consequence of this, they deemed the paid actor-simulated patients significantly more authentic than the postgraduate/staff-simulated patients (p<0.05). Nevertheless, first-year pharmacy students had not been exposed to either type of simulated patients (before this study) and yet perceived paid actor-simulated patients to be more authentic than the postgraduate/staff-simulated patients (p<0.05), suggesting that paid actor-simulated patients were superior to postgraduate/staff-simulated patients as results of the University's Simulated Patient Training Programme, although an exclusive correlation cannot be made. Despite this result, it is worth noting that even for first-year pharmacy students, factors such as the perceived age of the simulated patient or whether the individual was perceived as being a postgraduate student/staff or not may have influenced these findings.
The comparison of the paid actor-simulated patients and postgraduate/staff-simulated patients revealed no statistically significant difference between the two types of simulated patients in terms of the quality of feedback, indicating that the University's Simulated Patient Training Programme should be enhanced with elements of quality feedback to students to ensure the use of simulated patients benefits students learning.

Limitations
Items 10 and 11 of the MaSP instrument were presented as scaled-response questions in this study. These should have been presented as dichotomous questions, as in the original MaSP instrument. However, the responses from items 10 and 11 of the MaSP instrument were excluded in the data analysis, similar to the original MaSP instrument.
The negative statements on the MaSP instrument were not re-coded, which could limit the comparability of the authenticity and feedback mean scores. However, previous studies have analysed the results without recoding, indicating these results can still be discussed in the context of other current literature.

Ways forward
The simulated patients can self-assess and peer-assess the recorded videos of their performance. The positives and negatives of the performances can be discussed, facilitated by a staff member. Perera and colleagues (2009) showed this approach has proven to be beneficial in terms of improving the simulated patients' performance, and it should be incorporated into any future simulated patients' training.
A qualitative approach should be undertaken to gain a deeper understanding of the views of the pharmacy students. It will also allow students to elaborate on the responses they provided in the questionnaire and have their say in what they value in terms of simulated patients' performance.
More data is needed for a conclusion to be made on the type of simulated patient most beneficial for improving students' skills development. One method of doing this is to conduct a study utilising various types of simulated patients for the student pharmacist-simulated patient's encounters and measuring students' performance or the accomplishment of specific professional competency skills after the consultation and feedback. This process takes off the onus of student perception and would allow for a skill or performance-based comparison with a certain type of simulated patient.

Conclusions
The use of simulated patients is useful in developing the professional skills of pharmacy students, providing that the portrayal of simulated patients is authentic, and simulated patients provide quality feedback to the students. It is therefore essential for the simulated patients' performance to be assessed to assure quality education is delivered, which contributes positively to students' development.
Analysis of the results of this study has highlighted areas the simulated patients' performance could be improved, particularly concerning the quality of feedback the simulated patients provide. The improved performance of the simulated patients regarding the authenticity of roleplaying and, in particular, the quality of feedback provided to the students will eventually positively impact the skills development of the pharmacy students.

Declaration of interest statement
This work was carried out in the School of Pharmacy, University of Nottingham Malaysia, Malaysia. Ms. Emily Farrow was a third-year pharmacy exchange student at

Funding
This study was funded by the University of Nottingham Malaysia Teaching and Learning Funding Scheme 2019.