Abstract
BackgroundWorking with standardised or simulated patients (SPs) is now commonplace in Simulated Learning Environments. Embracing the fact that they are not a homogenous group, some literature suggests expansion of learning with SPs in health professional education by foregrounding their personal experiences. Intimate examination teaching, whether with or without the help of SPs, is protected by a particular degree of ceremony given the degree of potential vulnerability. However, other examinations may be equally intrusive for example the close proximity of an eye examination or a chest examination in a female patient. In this study, we looked at SPs’ experiences of boundary crossing in any examinations, sensitised by Foucault’s concept of the clinical gaze. We wished to problematise power relations that construct and subject SPs as clinical tools within simulation-based education.MethodsWe collected data from 22 SPs, through five focus groups. Analysis was an iterative process, using thematic analysis. Data collection and reflexive analysis continued iteratively until concepts were fully developed and all theoretical directions explored.ResultsStudents and SPs construct simulated teaching consultations by negotiating the unequal distribution of power between them. The SPs themselves discussed how they, perhaps unknowingly, acted in accordance with the discourse of the clinical gaze. However, SPs became disempowered when students deviated from the negotiated terms of consent and they used their agency to resist this. The SPs used strong sexual metaphors to express the subjugation they experienced, as discourses of sexuality and gender played out in the Simulated Learning Environment.ConclusionWe demonstrate that power dynamics and the clinical gaze can have important consequences within the Simulated Learning Environment. Every physical examination can be potentially ‘intimate’ and can therefore be underpinned by discourses of sexuality and gendered undertones. In partnership with SPs, simulation-based education should create a teaching space that no longer fosters the discourse of the clinical gaze but facilitates students to learn to reflectively navigate, in the moment, the fine line between touching patients versus touching loved ones, and the blurred boundaries that exist in the gulf between sexual contact and benevolent touch.
Highlights
Working with standardised or simulated patients (SPs) is commonplace in Simulated Learning Environments
SPs described instances where they subjected themselves as teaching tools in order to facilitate students’ learning; in essence, the SPs themselves were acting in accordance with the discourse of the clinical gaze
Evidence has shown that many SPs strive to be considered active teachers, rather than passive technology, [7, 8] so why do SPs at times still appear to subject themselves, under the clinical gaze, to subordination? What are the unspoken power dynamics promoted in simulation based education which enables this to happen?
Summary
Working with standardised or simulated patients (SPs) is commonplace in Simulated Learning Environments. Wallace et al stated that ‘they are not a homogeneous group’ [4] and it is recognised that the terminology used to define them, in addition to their demographics, motivating factors and degree of adoption of professional status vary throughout the world’s health profession schools and according to cultural context It has previously been discussed how SPs working within a typical UK institution may sometimes feel dehumanised because some do not see their role as simulated at all, experiencing some or all of the physical and much of the emotional responses that would be expected in a genuine consultation [5]. Other literature shows different motivating factors for SPs; for example, they may feel they benefit from the health knowledge that they gain and from insights that they acquire into the practice of medicine [6], seeing themselves very much as unreal patients [7], prioritising the learning needs of the student Understanding such differing SP views of their work and identity (as ‘faculty proxy’ vs ‘patient proxy’) is a conversation that is continually shifting
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