Look Who’s Talking! When The Simulator Is The Child Simulated Patient

The use of the pediatric simulated patient is emerging as a new resource in the training of pediatric doctors. Used in realistic simulation scenarios, this approach helps develop fundamental communication skills, especially in managing complex situations with children. However, recruiting minors, preparing them adequately for the role, teaching them how to provide constructive feedback and supporting them in participating in repeated simulation sessions is a complex process and not without difficulties. The results collected during the Pediatric Simulation Experience of 2024 showed a strong appreciation for the effectiveness of the approach, demonstrating that the integration of simulated patients is a useful tool for refining the relational and clinical skills of future pediatricians.

What if one day children could give a doctor feedback on how they felt during the visit? Well, that moment has arrived! This short article aims to describe the experience of the SIMNOVA center where, perhaps for the first time in Italy, simulation scenarios with a child simulated patient have been introduced, specifically designed for doctors in specialist training in pediatrics. In fact, if the aspect of doctor-patient communication is rarely included in training programs, even less so is that with child patients, so often the ability to relate to young patients is left to innate qualities and not to skills learned during the training course.  In the field of simulation, training with simulated patients is now a well-established learning strategy for the development of cross-disciplinary skills for doctors and nurses. 

The use of simulated patients in pediatrics: between benefits and complexity

“A simulated patient is a person who is carefully trained to act the part and represent signs and symptoms, to the extent that they cannot be distinguished from a real patient even by an expert professional” [1]. Adult simulated patients are widely used today in the training of healthcare professionals, for the development of standards to support best practices and the safety of both the patient and the operator. In the pediatric field, communication aspects play a particularly important role: in this context, healthcare professionals are often called upon to deal with complex situations that require not only solid clinical skills, but also communication/relational abilities that take into account the cognitive development of children, their emotional state and the family context they are part of. The important contribution of child simulated patients in promoting the acquisition of communication skills is documented in the literature. [2,3] Gamble and colleagues (2016) analyzed 15 studies from various sources and involving different healthcare professions, and it clearly emerged that the involvement of children and adolescents is feasible as a strategy not only for learning but also for evaluation. The systematic review by Gamble et al. highlights how their use in realistic simulations improves participant engagement by increasing the realism of interactions thanks to their authenticity and ability to provide direct feedback. Furthermore, the feedback received from child simulated patients was particularly powerful, helping participants improve communication skills in pediatric-specific contexts.

In a 2020 study, also conducted by Gamble and other collaborators, adolescents who had experience as simulated patients shared intimate and unique reflections on their experiences. Among the motivating factors that emerged, an almost altruistic enthusiasm stood out: the desire to actively contribute to the training of future health professionals, an aspect that gave further value to their educational role. In addition, the adolescents emphasized the importance of being prepared through induction and training programs, which proved essential to increase their confidence and competence in effectively fulfilling the role and providing constructive feedback. It is also interesting to note that the adolescents who had observed adults in charge of interpreting adolescent roles as SPs, felt that this choice in some cases damaged both the satisfaction of the simulated patient and the achievement of the training objectives by the participants. Although mainly positive, the experience was not without its critical aspects: the younger ones reported fatigue due to the long days and discomfort in providing feedback, while some older adolescents experienced potentially negative consequences, even if they did not interpret them as such.

Recruiting minors, training them adequately for the role, helping them acquire the ability to give feedback constructively and guiding them to participate in repeated simulation sessions, therefore, turns out to be a complex process, not without its critical issues. [4,5] Specific recommendations have been produced in accordance with the standards of best practice published by the Association of Standardized Patient Educators (ASPE) in conjunction with the International Nursing Association of Clinical Simulation and Learning (INACSL) to ensure that children and adolescents are involved in the role of simulated patients in a safe manner. While the ASPE Standards of Best Practice provide a general framework for the safe and standardized use of child simulated patients, the guidelines developed by Budd et al. in 2017 propose specific strategies to ensure the safety, particularly psychological safety, of young children. Among these, the importance of obtaining informed consent from parents and assent from children, explaining their participation in an understandable way, as well as the need for sessions to take place in safe environments and include regular breaks, emotional support and feedback from the children themselves. This approach, which respects their cognitive and emotional abilities, seems capable of guaranteeing an ethical and protective educational context.

A direct experience with child simulated patients: the PSE 2024

In April 2024, the Pediatric Simulation Experience (PSE) was held at the SIMNOVA center, a training event aimed at doctors in specialist training in pediatrics, coming from various Italian schools, aimed at improving the care of infants and children through simulation-based training.

One of the stations proposed included a simulation scenario in an immersive environment, with a child simulated patient, and focused on communicating the diagnosis of celiac disease to the child and his or her caregiver. At the end of the simulation scenario, as part of the formal debriefing offered to the participants and led by expert SIMNOVA facilitators, “protected” feedback was provided by the child simulated patient and his/her caregiver/companion. To guarantee the psychological safety of the children involved, their impressions of the interaction with the young doctors were collected separately, through video recording, and then viewed by the various teams involved during the debriefing. For participation in the simulation scenario, the child simulated patients and their caregivers/companions were selected and appropriately trained, through dedicated sessions, both in role interpretation and in giving feedback. At the end of the event, the participants were given an anonymous online questionnaire, with the aim of evaluating the satisfaction and effectiveness of the simulation experience. The questionnaire included initial dichotomous yes/no questions, followed by 3 questions that could be scored from 1 to 5.

The results of the questionnaire, which 63% of the participants (22/35) completed, showed a considerable interest in the approach with pediatric simulated patients. Most of the participants (77.3%) were not familiar with this methodology, but 100% expressed amazement at meeting a pediatric simulated patient. The experience was particularly appreciated: 69.2% of respondents gave the highest score to their involvement in the scenario and 91% rated the training effectiveness with a score of 5. The feedback provided by the simulated patient was also considered useful, with 57.1% of respondents giving it the highest score.

Conclusions

We believe that the use of the child simulated patient in the celiac disease communication scenario is a useful tool for training the relational skills of doctors in specialist training.

More generally, this pioneering approach could represent an opportunity to refine the clinical and communication skills of current and future pediatricians, in a safe and realistic environment, with the unique opportunity to receive feedback on their performance from children.

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