Simulated client role plays using trained actors in the teaching and assessment of clinical skills w

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Simulated client role plays using trained
actors in the teaching and assessment of clinical
skills within a Clinical Psychology training
programme An evaluation

• Steve Melluish
• Jon Crossley
• Alison Tweed
• University of Leicester

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Introduction and Background

• Clinical skills assessment (CSA) project devised
  to broaden trainee development and tie in with
  BPS Core Competencies
• Competencies skills in assessment, formulation,
  communication and reflection.
• 2 elements teaching programme and formative
  assessment in Year 1 using simulated clients.

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Two Elements

• Teaching 2 full-days covering basic assessment
  and boundary issues. Role play observed by peers
  and group facilitator. Feedback provided by
  group.
• Formative 30 minute assessment, observed and
  rated by panel. Feedback provided based on
  specific criteria. Written summary provided as
  part of developmental process.

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(No Transcript)
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Literature

• Simulated patients (SPs) have been used to teach
• Communication skills to doctors (Cegala
  Lenzmeier Broz, 2002) .
• Clinical decision making to midwives (Clioffi,
  1997)
• SPs have been used in introductory psychotherapy
  course for psychiatrists (Klamen and Yudowsky,
  2002)
• No literature on the use of SPs in clinical
  psychology training.

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Evaluation

• Aim- to explore the experience and acceptability
  of CSA project, impact on trainees learning and
  future developments.
• Focus groups undertaken with Year 2 trainees
  (15), Year 3 trainees (15), staff (4) and
  supervisors (3).

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Data Analysis

• Focus groups material transcribed verbatim and
  analysed using Template Analysis (TA) (King,
  1998).
• TA is a flexible phenomenological approach that
  is particularly suited to examine the
  perspectives of different groups within
  organisational contexts.
• Template developed, initially from a priori
  codes. Based on analysis, codes were refined, and
  categorised hierarchically. Model developed to
  illustrate main themes and processes in the data.

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ROLE PLAY
Actor

• Staff
• Peers
• Self

Observation
Response Learning Change
Impact / Anxiety
Trainee
Authenticity
Impact/ Anxiety
Practice
Client
CLINICAL PRACTICE
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Main themes - Authenticity

• The core theme concerned the capacity of the CSA
  project to authentically recreate a clinical
  environment and capture the trainees clinical
  practice.
• Obstacles to authentic clinical practice were
• 1) medium (actors, cameras, video)
• I think for me, it was the idea that its not an
  accurate portrayal of how I am clinically.
  Because of the fact that it was quite anxiety
  provoking and it was not a real situation with a
  real client. (Pippa)
• 2) task (e.g. first assessment session)
• I wonder if theres a danger about feeling that
  you have to do things in a particular way as well
  because its an opening assessment that you had
  to kind of do X, Y and Z maybe for some people,
  and I think that could be quite constraining of
  somebodys individual style (Sara)

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Main themes - Authenticity

• Advantages of the CSA project being an
  inauthentic clinical environment were the
  possibilities for observation, feedback and
  experimentation.
• I think it maybe gave us the chance to try
  something that we may not do with a client. So
  theres somebody in my group did something very
  out of the ordinary and different which he said
  he probably wouldnt have done with a client but
  it was interesting to see how the actor responded
  to it. That was useful.(Alice)
• Relates to broader discourses within the
  profession about the difficulty of accurately
  portraying clinical practice, and the way
  observation changes the observed.

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Main themes - Observation

• Staff observation
• The CSA project was perceived as acting as a
  formative and a summative assessment. Some
  advantages for the latter were acknowledged, but
  consensus from trainees of their preference for
  the former, and the value of the former also
  recognised by staff.
• I think it was more towards the kind of
  developmental side but my fear would be that in
  the future it could shift towards an assessment
  and youve got to pass this and I think it
  would become less useful, I think it would be a
  less useful training tool. (Tom)
• in a very formative way it was a good way of
  assessing the trainees reflective capacity to
  actually look at their work and to come up with
  plans for how in the future they might try it
  differently, and I thought that worked really,
  really well as a kind of general formative
  process. (Alan, staff)

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Main themes - Observation

• Peer observation
• The opportunity to observe and thereby learn from
  peers was seen as valuable.
• Observation allowed trainees to move from more
  normative positions about correct practice to
  accepting and valuing different approaches.
• Limitations of peer involvement included an
  absence of critical feedback.
• Its certainly good watching other people as
  well. Not only doing it yourself. Watching
  everybody else doing it, talking about that. I
  found it really useful. Seeing how you know we
  all do it differently. Knowing that thats kind
  of OK, but also knowing that thats a good thing
  to do. Knowing also thats one of my peers whos
  done that, you know I might be able to do that as
  well. (Rob)

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Main themes - Observation

• Self observation
• The opportunity to observe oneself on video was
  valued for providing space to reflect upon both
  the trainees own presentation and the
  interaction itself.
• Something that I found useful was like on the
  last one watching the video back I was able
  to sort of focus more on me as the therapist
  whereas I think in sessions its always about the
  client and you are trying to follow their story.
  I thought it was really useful watching the video
  back and picking up all my why did I ask that
  question and I missed so much there (Jane)

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Main themes - Response

• Response to exercise
• The trainees response to the exercise were
  feelings of anxiety, fuelled by uncertainty about
  the project and fear of evaluation, and a sense
  of achievement.
• And also doing something that sounds really
  horrific, but actually that it is anxiety
  provoking, but its OK and maybe a bit of an
  achievement. (Kath)

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Main themes - Response

• Clinical response
• Trainees described cognitive changes as a result
  of the CSA project, including increased
  confidence about being observed.
• if you can work with an actor in a false
  situation with a group of your peers watching you
  live on a TV in another room then you can sit in
  a room on your own and see how it goes with a
  client when you can always see them again next
  week and fill in the gaps. that gave me a bit
  more confidence, I think. (Kath)
• Trainees and supervisors also described changed
  clinical practice, as well as shifting approaches
  to supervision.
• people I supervise seem to be much braver about
  supervision once that exercise has happened and
  people seem more open to bringing clients, they
  are a bit more vulnerable in the context of a
  very competitive process. (Rory, supervisor)

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Recommendations

• CSA is generally well-regarded so continue as
  formative, with regular reviews. Possible
  extension into Year 2
• Quality checking simulated clients, consistency
  of feedback, membership of panel
• Integrate into Programme and enhance
  self-reflective element
• Share experience and promote on other Programmes

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Conclusions

• Concept of authenticity seen as main theme
  relates to CSA and wider profession. Some
  difference in emphasis between trainees and
  qualified staff.
• Despite anxiety, trainees found the opportunity
  to observe each other and themselves valuable.
  Elements were carried forward into supervision
  and clinical practice.
• CSA requires further integration but has a place
  in clinical training.