Working with actors and non-actors as simulated patients: An advantage?

Background: Actors as well as non-actors are currently hired as simulated patients (SPs) in medical education, and it is not clear whether one group performs better than the other. Aim: This study explores two facets of working with actor and non-actor SPs: their performance as perceived by students and tutors and how the two groups feel about being trained together. Method: A convergent parallel mixed-method approach was used, with a survey and focus groups. The survey was administered to tutors and third-year medical students after an SP encounter. They were asked to rate the SPs’ performance, without information about whether the SP was a professional actor or not. Two focus groups with SPs were held, one with actors and one with non-actors, to explore the disadvantages and benefits of mixed training sessions. Results: The survey showed that actors and non-actors perform equally well from the viewpoint of the students and tutors and that the SPs valued being trained in mixed groups. Conclusion: When trained together for the same role, actors and non-actors exhibit the same quality of performance. Moreover, common training helps them improve their performance and standardize the play, and also contributes to fostering team spirit.


Introduction
Simulated patients (SPs) have been employed in medical education for decades (Barrow et al 1964; Barrows & Abrahamson 1993;Cleland et al. 2009). At some institutions, only actors are hired to play SPs, while at others only lay people are enrolled. Moreover, at some institutions, both actors and non-actors are hired (Adamo 2003, Tierney et al. 2015. There is no published evidence that demonstrates the superiority of actors over non-actors or vice versa (Cleland et al. 2009), and the question of who the most desirable SPs are remains unanswered (Adamo 2003). However, there is some concern about having a mix of actors and non-actors, especially in cases with a strong emotional element: "We dishonour the actors we have hired if we have to spend too much time during training working to bring a non-actor to the same level of performance" (Wallace 2006, p. 155).
We have been working with mixed groups of SPs (actors and non-actors), but we have not noticed any significant difference between both groups with regard to the accuracy and standardization of the role play. We also found that both the actors and non-actors enjoyed working together.
In this investigation, we tried to examine whether there was a difference in the performance of the actors and nonactors. We also tried to find out more about how actors and non-actors feel about being trained together.

Context
The Medical Education Unit of the University of Lausanne has been working with SPs since 2006. They are enrolled for teaching and assessment purposes in the undergraduate curriculum, postgraduate training and for professional development courses (for the faculty and for inter-professional collaboration). Actors and non-actors are recruited and trained together, regardless of their professional status. Our pool of SPs comprises 150 persons (60 actors and 90 non-actors).
To play a role, both actors and non-actors are cast based on criteria related to the need of the role play (age, sex, condition of the patient, etc.). All SPs recruited to play a role are trained together to accurately portray a specific patient, so that they express the symptoms and emotions in an authentic and standardized way.
To carry out this study, we chose a formative SP encounter in the third-year undergraduate medical curriculum (part of a six-year curriculum) at the University of Lausanne. The students were given 18 min to perform a history and physical examination of a patient with acute chest pain. After the encounter, the SP took a 2-min break and then provided 5-10 min of feedback to the student.
The role was moderately difficult to portray at the emotional and physical level: the patient consulted the private practice because of sudden chest pain. The SPs were required to portray the physical symptoms as well as express some anxiety triggered by a history of a father who had died of a heart attack.
Based on the requirements of the existing curriculum, for the duration of the study, half of the class had a tutor present in the room and the other half did not. Each tutor was involved in several sessions.

SP training
We trained 15 SPs: 9 actors (6 women and 3 men) and 6 non-actors (all women). At the beginning of the training, most of the SPs were not aware of each other's background. In the group of actors, one had been hired the year Viret F, Vadot S, Morend L, Christen A, Bonvin R MedEdPublish https://doi.org/10.15694/mep.2016.000061 Page | 3 before and all the others had between 2 and 5 years of experience. In the non-actor group, two were very experienced (more than 5 years), one had begun the year before, and the two others had 1 to 3 years of experience. Each SP was required to attend two training sessions of 3 h each. During one of the sessions, a physician fine-tuned the SPs' role play and answered their questions about the case.

Method
A convergent parallel mixed-method design (Creswell 2014) was adopted: quantitative data collection (Part 1) was performed using a survey, and qualitative data collection (Part 2) was performed with focus groups. The analyses in both parts were carried out separately, and the findings are combined for the final discussion.
The use of both quantitative and qualitative methods enabled us to understand different views on the advantage of mixing actors and non-actors, involved all the people in the process, and provided us with a more complete picture.

Part 1: Survey
We adapted the MaSP questionnaire (Wind et al. 2004) to our specific needs: some items were not applicable (Q6 and Q10), one item was modified (Q3a and Q3b), and two items were aggregated (Q1 and Q2). A pilot run of this adapted questionnaire was conducted in the first semester of the academic year 2012-13 with 154 students and 16 tutors. Based on the responses, the questions were modified as required and a new version of the questionnaire was created that contained eight close-ended questions for assessing the SPs' performances on a 4-point Likert scale (strongly agree to strongly disagree, with a not applicable choice), one global rating of the entire performance (scaled from 1, worst to 10, best), and three open-ended questions (what was the most appreciated feature, what could be improved, and free suggestions or commentaries).
In the autumn of 2013, the questionnaire was administered anonymously to tutors and students after their encounter with the SP.
Both students and tutors were blinded to the SPs' backgrounds.
We compared the two groups (actors vs. non-actors): the Mann-Whitney U-test was used to analyze the findings of the eight closed-ended questions (a nonparametric statistics test), and an independent samples t-test was used to analyze the global rating. A narrative analysis was performed on the responses to the open-ended questions.

Part 2: Focus groups
After all the student-SP encounters, we conducted two focus groups, one with the actors and one with the nonactors. The semi-structured interviews explored their experience of being trained together. All the SPs who had taken part in the encounters were invited to participate in these focus groups. Participation was on a voluntary basis, and SPs were assured of their anonymity. They also received a small financial compensation for their participation.
The same persons performed all the interviews (SV conducted the interviews, and LM recorded and observed them). A thematic analysis was performed on the findings from the interviews. Based on the results, the first author performed a conceptual analysis, and the results were merged with the results of the quantitative analysis.

Part 1: Questionnaire
In total, 219 questionnaires were answered: 155 by students (out of 198 third-year medical students who attended the course), 31 by tutors and 33 with no status indication.
In general, all the students and tutors had a very good opinion of the SPs' performances (Table 1). The satisfaction rating for all eight questions was more than 93% (strongly agree + somewhat agree). The mean global rating was 9.34 ± 0.73 (N = 214, min = 7, max = 10) (five ratings were missing).
The responses were significantly different between the actors and non-actors with regard to only one question (3b): SP provides adequate information, he/she does not give out information too easily (U = 4400.50; p < 0.05; mean rank of the actors, 95.79; mean rank of the non-actors, 112.69). The difference between the responses to all the other questions was not significant. The global rating of the overall performance demonstrated a comparable average score between both groups (F = 3.193, p = 0.075): 9.45 ± 0.69 for the actors and 9.26 ± 0.76 for the non-actors.

Comments of the students and tutors
The respondents commented on the performance of seven actors and six non-actors. Both tutors and students used the same words to describe the performance: authenticity, credibility, realism, natural, perfect, good, sincere, and believable. One actress was observed to be a very good actress, and the words outstanding acting were used to describe the performance of one non-actress. On many occasions, students and tutors stated that the SP could be a real patient. Students claimed to have the feeling of being with a real patient. Another student stated that we really believe it. Students and tutors found that both actors and non-actors were equally credible and could be mistaken for real patients.

Part 2: Focus groups
Seven actors (4 women and 3 men) and five non-actors (all women) participated in the focus groups. All SPs were eager to talk about their experience.

Actors talking about being trained with non-actors
According to some actors, mixing actors and non-actors is fantastic, the non-actors do incredible things in playing. They are less technique, they are astonishing with regards to the role play. Further, one actor stated that the non-actors played their roles in a naturalistic way and seemed to genuinely express the plight of a patient and not roleplaying it.
The actors were of the opinion that interacting with a trainee is not comparable with playing on stage, so they tried to play like non-actors. When playing a patient, one of them didn't feel like an actress: "I could be a hairdresser, a salesgirl, a teacher or anyone else, I feel that I would act the same way (…)". She added, though, that her background did also matter: "Besides, things happen during the encounter in spite of myself, that come from my professional experience." With regard to the management of emotions, some of the actors thought they were more comfortable keeping an emotional distance: in this way, they could more easily come out of role every 20 min to provide feedback and start over again. They saw themselves as "sponges" that were constantly filled up with emotions and emptied. The others were not sure of the advantage of having acting skills.

Non-actors talking about being trained with actors
Some non-actors did not realize that some SPs were in fact actors. For one of them, it was obvious. One of the nonactors emphasized on the stimulation that they receive when training with actors: "They are more eager to explore the limits of the character, and the way to play it", in a way, she said, made the training sessions more enjoyable. Interestingly, the discussion quickly shifted to more difficult roles such as breaking bad news, and one of the nonactors expressed her admiration for how easily some actors could cry. Another noted that in any specific role, each person played their role according to his/her own personality, regardless of their personal background.
None of them had a problem with the common training, even when asked directly if they felt dishonoured or disesteemed. On the contrary, training and role playing with the other group was appreciated: "It is stimulating, the exchange is very interesting."

Summary of the focus groups
During the first training session, the SPs could not identify who was an actor and who was not. They discovered each other's background during the course of the training, when they began to get to know each other. During the common training sessions, they all enjoyed working together, as it was mutually stimulating. They all agreed on the necessity of training actors and non-actors together and could not figure why they should be trained separately.

Discussion
Our results show that students and tutors do not see any difference in the performance of an actor or non-actor who plays the role of an SP of mid-level difficulty (except for item 3b). There are two main reasons why these findings contradict Wallace's (2006) opinion about mixing actors and non-actors. First, playing a patient role, improvising and adjusting to different trainee behaviours is different from playing on stage, memorizing and delivering the same lines to the same partners. So actors are exposed to new challenges, as the non-actors are. Moreover, SP roles are close to familiar situations experienced by anyone, and it is quite easy to project oneself into this type of role, even for non-actors. Second, for the selected role in this study, the SP was required to express some anxiety about his/her condition. There was no deep emotional issue or complex symptoms at stake, and the character was not challenging. Thus, the role was easy for non-actors to play too.
With regard to item 3b ("SP does not give out information too easily"), both students and tutors reported that the actors seemed to give away information more easily than non-actors. This item explores how easily SPs tend to talk when they need to retain information. It seems that actors do talk more easily in this situation than non-actors. Further investigations are needed to better understand this difference and to determine if the information delivered is of clinical relevance (i.e. information they should have retained) or not.
With regard to the training conditions, both actors and non-actors enjoyed being trained together, and they reported that they learned from each other. The actors seemed very pleased to be trained with non-actors, who they found inspiring, and the non-actors appreciated the creativity of the actors as they tried to explore different ways of playing the role. Thus, both groups found that training together was stimulating. It seems that training together allows actors and non-actors to learn from each other and share their experience. The training method was appreciated by every participant in the focus groups.
The participants described the work atmosphere as "benevolent and relaxed," which surely helped them appreciate others and find them inspiring. They found no disadvantages of common training, and none of the SPs in the study Viret F, Vadot S, Morend L, Christen A, Bonvin R MedEdPublish https://doi.org/10.15694/mep.2016.000061 Page | 6 could imagine having separate training for actors and non-actors. SP trainers certainly play an important role in establishing this culture of equally welcoming actors and non-actors. SP trainers are actors or persons who have worked for years with actors outside of the SP program. All of them have been SPs in this mixed environment before enrolling as SP trainers. Another aspect to consider is that our SPs are paid for their training time, which may explain why none of them felt dishonoured or that it was a waste of their time. However, the discussions never alluded to such feelings in the actors, even when they were directly asked about it. SPs are selected for a specific role based on their previous performance. Therefore, the findings may reflect a good selection process. This means that non-actors can perform as well as actors in these cases.
From our SP trainers' point of view, training actors and non-actors together for the same role adds more consistency and richness, as actors like to explore all the aspects of the patient, and non-actors do not employ any form of theatrics. With their combined perspective, the SPs can form a common vision and gain a better understanding of the character and his/her condition. It allows for better standardization and authenticity for the play. Moreover, common training also fosters team spirit.
There are some limitations to this study, which have been described here. As the findings are preliminary, further studies are required to confirm our findings. Further, our research was conducted from the perspective of only one SP role: a teaching scenario offering a mid-level challenge in portraying physical and emotional elements and no standardization requirement. The SPs were required to play the role four times in a row, which is quite different from an Objective Structured Clinical Exam (OSCE) situation where they have to play the same role again and again at the same level of standardization. A more challenging situation (portrayal, number of repetitions, standardization) could reveal some differences between actors and non-actors.
Even though 219 observations were performed by students and tutors, the small number of SPs in each group (9 actors and 6 non-actors) makes it difficult to generalize the results. This is true with regard to the focus groups, too, as only two groups were used.
Our exploratory study confirmed our empirical observations that actors and non-actors at our institution benefit from being trained together and appreciate the mutual enrichment. With regard to the mid-level challenging role studied here, students and tutors did not notice any differences in performance between actors and non-actors. However, further studies need to be conducted to determine whether these findings apply to other situations, such as more difficult cases (e.g., a "breaking bad news" role) and whether the findings are true even with a larger group of SPs and at other institutions.