Five over-arching themes were identified from the data analysis; 1) Feedback processes, 2) Challenges in providing feedback, 3) Cumulative experiences, 4) Web of interpersonal relationships and dynamics and 5) Portraying the character and patient representations.
Feedback processes
The findings highlighted the complexity of the feedback process in how effective feedback was understood, the language used to convey it, the ways of giving feedback (e.g. ‘in-role’ or ‘out-of role), the order in which feedback is given in the teaching context and the cumulative experiences SPs utilise to develop their knowledge and vocabulary on how to provide feedback.
Participants regularly made reference to describing “how they felt” when defining effective feedback. They expressed the necessity of prioritising emotions and feelings in their feedback, stating,
“It’s always about how they made me feel as a human being … it’s all about me and it’s very personal.” (Focus group 3)
Whilst participants did refer to the importance of retaining specific details of the communication process such as the language used or non-verbal aspects, greater emphasis was placed on the interpersonal emotional connection between them and the students. Participants varied in their use of language to give feedback, either describing in first person, “I felt”, third person, “the character felt” or alternating between the two. Some participants described the benefit of using the third person to detach themselves from the character that was portrayed. Conversely, others argued the feedback was more personal and authentic when given using the first person.
The majority of participants generally expressed a strong preference for ‘out-of-role’ feedback, where they were able to return to being themselves, rather than giving feedback whilst portraying the character. They described that this better enabled the delivery of constructive feedback that was filtered to account for the students and the facilitator’s receptivity to the feedback. ‘In-role-feedback’ was considered as “raw unfiltered emotions and reactions” that characterised the feelings and temperament of the ‘patient’, with little regard for how they might affect others. Participants also reported the significance of using a lay person’s words in providing feedback, rather than technical communication jargon that was employed by the facilitator and the students, as this was more representative of the patient.
Participants frequently preferred the ‘sandwich style’ method for delivering feedback, comprising of first giving positive, followed by negative and then again positive feedback. Their insistence on this method stemmed from the notion that providing feedback as a SP can potentially be construed as an act which threatens students’ self-esteem, particularly in the context of communication teaching where students’ performance is observed by their peers. Feedback conversations and evaluative narratives were continually influenced by a persistent rhetoric among the SP community of “always being positive” in their feedback. This tendency to protect the self-esteem and self-efficacy of the student was often made at the expense of providing ‘fully honest’ feedback. By contrast, some participants began with their feedback by facilitating the students to self-assess their performance, reporting that “rather than you take on the mantle of deconstructing their performance, I think it is collaborative. ‘How was it for you? How was it for me?’” (Focus group 4).
After the role play is enacted, the facilitator conducts feedback with student self-appraisal, SP, observing students and facilitator. Participants described how this order of feedback varied depending on the facilitator’s preference, which in turn affected how feedback was given and received. Participants reported differing personal opinions on order of feedback, although many expressed a preference for going last to enable them to gauge the student’s level of insight and readiness to receive feedback and the facilitator’s preference for how feedback should be given. Participants described how they actively built upon their cumulative experiences of being an SP to develop their understanding and vocabulary to frame feedback.
Challenges of providing feedback
The findings highlighted an array of variables influencing the delivery and content of SP feedback. Participants stressed a distinction between the SP and the student participating in the role play, with the students and facilitator observing the role play. The former pair characterised an ‘active’ interpersonal experience, whereas the students and facilitator observing the interaction were “spectators” to that experience.
“There is a difference between the observational aspect of watching the role play, which the facilitator is doing along with the rest of the students, and someone who is actually engaged in the emotional interaction of the role play. I think that is where we can give real benefit. We have a very different perspective and we will all have a very different perspective. They might cover all the correct ground, but even a tutor can’t tell you how you feel and you know exactly as an actor how you feel in that moment. I think there needs to be more of an understanding that there are two slightly different experiences from spectating and being involved directly in the conversation.” (Focus group 4)
These distinct standpoints gave different vantage perspectives on the communication process and assessment of the student’s performance, which often resulted in contradictions, as illustrated below.
“Only we as the role player know how it feels. I have also been in a situation where the facilitator has said, ‘I thought that there was terrific empathy there,’ and I have thought, no. I really didn’t feel that because it was me. As an observer that facilitator thought that there was, but I didn’t feel it at all.” (Focus group 4)
Dissonance sometimes arose between the facilitator and the SP. Many participants felt a prevailing expectation from facilitators that SPs were to provide largely positive feedback, even if it contradicted their assessment of the interaction. They attributed this to the facilitators’ anxiety in having to protect the students from experiencing adverse emotions and reactions to negative feedback. They also referred to a culture in medical education of constant summative assessments with negative feedback viewed as failing. One participant described their experience below:
“The tutor sort of intervened. I thought I was being positive, but intervened to get me to say something which was just flat-out, ‘but it was good,’ or something … I think the tutor wanted everything prefaced with, ‘it was great,’ and then go into it, and it wasn’t, that particular one. That was my disagreement with the tutor. It felt like I was having to dilute it or manufacture generic positive feedback for the sake of self-esteem or protection.” (Focus group 2)
Some participants conveyed that these contradictions were sometimes exhibited by facilitators through implicitly disregarding the validity of the SP’s feedback, for example:
“What I dislike and what is not effective is when I am giving a feedback and then it is disagreed by the facilitator. That has happened before within this room and that doesn’t set us up. ‘He is only an actor. What does he know about?” (Focus group 6)
A recurring theme was the challenge in providing feedback to those students struggling with their communication skills. The careful balancing act of providing the right level of positive and negative feedback was continually reported and appeared to be modulated by a host of factors. These ranged from the student’s level of insight, their receptiveness to receiving negative feedback, the openness of their peers to giving honest feedback and the facilitator’s preference for how feedback should be given. Being ‘fully honest’ when providing feedback was a debated practice among SPs, with some reporting an absolute need for honesty to foster improvement. Others were hindered by what they perceived as the institutional culture of medicine in not wanting to acknowledge and experience failure and the hierarchical educational culture which impeded bidirectional feedback between the SP and the student.
“They are quite fragile’ the tutors say. ‘Yes, but they have to learn’. You are not going to go in there and destroy them, sometimes these are really personal things. If you are told anything to do with, ‘I didn’t connect with you,’ it hurts a bit. but if you can somehow pull up a point of something that they could do to improve … ‘No, that is up to me. We just want positive stuff’ is the response I sometimes I get from the tutor.” (Focus group 3)
The artificial nature of a simulated environment and the vulnerability of the students in being observed by their peers was thought to create a barrier to full engagement in the process. Participants repeatedly noted that if the consultation had not gone well, students would be quick to blame the inauthenticity of the situation and begin to question whether ‘real patients’ would behave as depicted by the SP:
“They say that it is not real. The inauthenticity of the situation is often used as a defence. ‘In reality it wouldn’t happen like this so then I wouldn’t do that.’ They will then say ‘this is unrealistic, this would never happen.’ What I find really difficult about giving feedback? Resistance. If they are super resistant to what I am saying, they are almost cynical about the process? ‘This is not real...it wouldn’t really be like that.’” (Focus group 3)
Cumulative experiences
The findings illustrated the multifaceted role of a SP when involved in communication skills teaching. These different experiences were cumulative, concurrent and were susceptible to a range of contextual and socio-cultural influences. The findings highlighted a set of core experiences outlined in Table 3.
Participants frequently noted the distinctive experiences of the SP in their roles and the differing perspectives they bring compared to those of the facilitator and students, which presents both inherent benefits but also considerable challenges. As described by one participant.
“There is a difference between the observational aspect of watching the role play, which the facilitator is doing along with the rest of the students, and someone who is actually engaged in the emotional interaction of the role play. I think that is where we can give real benefit. We have a very different perspective and we will all have a very different perspective. They might cover all the correct ground, but even a tutor can’t tell you how you feel and you know exactly as an actor how you feel in that moment. I think there needs to be more of an understanding that there are two slightly different experiences from spectating and being involved directly in the conversation.” (Focus group 4)
Over the years SPs had been working in a variety of programmes, in the same or different roles and in formative or summative contexts. They described how they evolved expertise and insights from previous interactions, sometimes repeating the same role in different sessions, honing their ‘third eye’ whereby they mentally retain points to recall in feedback, giving ‘in-role’ and ‘out-of role’ feedback, sometimes drawing upon their own experiences as a patient, interpreting the patient scripts, linking their prompts and cues to the learning objectives for ‘teachable moments, and standardising their delivery and assessment.
These different experiences were cumulative, concurrent and susceptible to a range of contextual and socio-cultural influences. They highlight the many facets of fulfilling the role of an SP in communication skills learning.
All SPs in this study had more than 5 years’ experience of medical role-play (Table 2). This can inform their knowledge about clinical features of patient scenarios and the nuances of teaching communication skills, whilst building their vocabulary for feedback delivery. They described the duality of their role in being both a participant and an observer during the simulation, and its importance in providing effective feedback.
Furthermore, participants described utilising their real-life experiences as patients in playing roles when these roles resonated personally. As one participant remarks “as simulated patients sometimes we have the disease that we’re pretending to have, sometimes we’ve actually been through it.” Drawing upon real life experiences was deemed essential in fostering effective feedback.
Web of interpersonal relationships
Participants described how their experiences and provision of feedback was modulated and influenced by a web of relationships; namely the relationship between the SP and facilitator, the SP and the students and the facilitator and the students. The relationship between SP and facilitator was deemed most influential to the quality of the other two relationships. Participants described this relationship variously. They often referred to the hierarchical difference and the importance of “tip-toeing” or “not stepping on each-other” roles.
“I think as an overall learning experience it is like as an actor in a production. You can’t really be better than the director. You can be very slightly better than the director because you are always attuned to the play. You can’t be better than the facilitator because if you are, you undermine the facilitator.” (Focus group 1)
The relationships between the SP and the facilitator that worked the best was described as a “negotiated, equal partnership”. This involved an active acknowledgment of the value SPs bring, discussing feedback processes and clarifying information in the patient script in a briefing beforehand, and establishing mutual respect. One participant expressed it as:
“You are making a journey together and you are collaborating. Basically what we do is we are codifying things that most people take for granted in everyday life, then we build up a bank of vocabulary and ways to describe these very natural interactions.” (Focus group 5).
The relationship between the facilitator and the students was described as the pre-requisite that influenced the quality of SPs’ relationship with the students in creating a safe learning environment in which to practice. Participants argued that facilitators were key in adequately preparing students for participation, creating an atmosphere of safety where the patient’s perspective is valued, and encouraging students to try, be allowed to make mistakes and repeat practice.
This web of interpersonal relationships, in particular the relationship between the SP and the facilitator, was also influenced by the unique context of communication skills teaching. Typically, communication teaching in medical schools involves a number of small group sessions running simultaneously and SPs may be required to rotate between the groups. Whilst SPs play the same role, the learning environments they enter in quick succession differ, affecting how the role plays out and resulting in different feedback. One participant describes.
“It is very difficult if you go into a room and you get used to … , going from room to room to room, you cannot help in your head almost compare the preparation that has been done to facilitate the group before you get there and then sometimes it is quite difficult because you go into a room and the tutor is running it differently, asking for different types of feedback or the student may be nervous.” (Focus group 2)
These rotations and the unique context of teaching communication skills necessitated adaptability from SPs in having to adjust to different facilitator styles, feedback preferences and the dynamics of student groups. Participants emphasised the significance in not under-estimating the importance of contextual factors in their influence on the quality of these different relationships. These hidden social rules and implicit expectations which are different to each tutor require SPs to have the ability to identify and navigate these subtle dynamics within a short space of time. From the participants accounts, it appears they need to rapidly adapt to a different set of rules and expectations when they move across the hallway to a different tutor, which can create considerable potential for misunderstanding and uncertainty.
Portraying the character and patient representations
Participants talked of their experiences in portrayal of the patient character. They commonly shared and exchanged perspectives on interpreting patient scripts with each other. Whilst clinical facts were a given, the personal aspects lacked detail and SPs improvised the patient’s characteristics such as their personality, demeanour, temperament and social situation. The findings also suggested many patient scripts were devoid of information on the learning objectives of the teaching session.
“Sometimes when you get the brief it’s written in medicalised way … most patients sometimes blurt everything out. We don’t know that knee infection is connected to a sexually transmitted disease. Sometimes character briefs are quite good because they tell you roughly how you might react in different situations, but we have to do a lot of filling in the gaps.” (Focus group 2)
Participants were generally assigned roles based on their personal characteristics such as gender, age, race and weight. This often resulted in identification between the character being portrayed and the SP, making it simpler to draw on real-life experiences. The subtleties in how SPs’ personal characteristics affected the interaction and the feedback provided was raised by participants with some reporting that they would become more sensitive, attuned and reactive. Below is an account from a participant playing roles associated with motivational interviewing.
“I am considerably overweight and often play the lifestyle/motivational interviewing roles. How people handle talking about being overweight must go to me at some level because I am overweight. I am assuming there must be some reaction to that. I don’t think anybody has ever dealt with it insensitively, but if they did I would probably notice. That is just because in that particular situation there is a parity between me and the patient.” (Focus group 4)
Participants raised the issue that the way certain characters were asked to be portrayed inadvertently stereotyped patients, “Asian and type II diabetes, Black patients usually seen as aggressive.” Some participants reported that facilitators would describe SPs as “difficult patients”, giving a negative representation of patients. One participant recalls:
“‘This is a difficult patient.’ You think, I am representing a patient that is very real. They are not thinking they are difficult. They might just be ill. They might be crying out for something. That should come from the facilitator as well.” (Focus group 5)
These negative remarks made participants approach their feedback with apprehension as they wanted to avoid contributing to preconceived ideas and biases about particular patients. Participants noted that they “symbolise the outside world” of patients and disparaging comments were harmful in shaping students’ perceptions of patients. Rather than depicting a patient as “difficult”, they thought students could be encouraged to acknowledge that “this is a patient with difficulties.”
The socio-cultural influences on SPs feedback derived from the findings are summarised in Fig. 2 which draws together the interplay of personal, structural and perceptions of institutional factors to illustrate a landscape of feedback moderators.