Description of Studies
There were 15 included studies; Tables 3, 4, 5 outline overviews of content and quality. Of these studies, 5 were conducted in the USA [17–21] or Canada [22–26] while one study was a systematic review from multiple countries [12]. The remaining four studies originated in New Zealand [27], Africa [28] and The Netherlands [29, 30].
Eleven studies identified the health professional group to which the learner belonged. Nursing students [17] were involved in one study, while 10 studies focused on medical students or physicians. Participant numbers ranged from 34 paediatric residents [26] to 341 medical students [30]. Two randomised control trials were included, and in both cases, baseline data of participants was comparable [19, 23].
In relation to the central focus of the intervention, two studies focused on Objective Structured Clinical Examination (OSCE) or Clinical skills assessment (CSA), eleven related to simulation, while two studies addressed these in combination. Communication was the primary learning outcome for participants in ten studies and four studies related to a combination of communication and physical examination skills.
All studies discussed the experience of children or adolescents as SPs with varying degrees of focus on participant numbers, gender, ages and recruitment strategies. SP participant numbers ranged from four to twenty-four. Ten studies either did not specifically identify gender of the children or adolescent SPs or employed both males and females [12, 17–21, 24–26, 28], three studies focused solely on females [22, 23, 27] and two studies included a small number of males through convenience rather than planning [29, 30]. SPs were recruited from an existing database, following contact with a local community theatre or drama group or from faculty willing to involve their own children. Seven studies focused solely on adolescents whilst five expanded their CASP involvement to children aged 6–7 years [17, 18, 20, 21, 28].
For qualitative studies, the experience of children and adolescents was captured in post simulation interviews and focus groups. Perspectives of CASPs, biological parents and SP parents were sought at variable points after CASP involvement although Austin [17] chose to focus solely on evaluation data collected from parents. In contrast, a selection of studies used a multi-layered approach to analyse effects of participation on adolescent SPs. Tools employed to gather data included pre and post administration of behavioural type questionnaires and specific project surveys designed to assess the impact of role playing on CASP participants [23–26].
In two studies, CASP evaluated the performance of students. Feddock et al. [19] provided SPs with case-specific checklists designed to assess adolescent medicine knowledge and general interviewing/counselling skills. While not completing a specific checklist, Lindsey-Lane et al. [20] allowed children as young as 7Â years to give an overall satisfaction rating on the simulated encounter. Students were also involved in direct assessment of CASP performance. Bokken et al. [29] applied the Maastricht assessment of SP (MaSP) to evaluate role performance and quality of feedback provided by adolescent SPs.
The type of outcome measures and associated data collection tools varied widely. A variety of data was captured through the use of questionnaires, interviews, focus groups, assessment results and validated screening instruments. Of note was the repeated focus on the specific outcomes for the child and their ability to give feedback. However, even within these diverse data collection methods, the impetus for many studies appeared to be the identification of risk or adverse outcomes for the child or adolescent.
Whilst diversity in outcome is apparent, most studies chose to refine their focus to specific aspects of learning, most prominent being the choice between clinical skills or knowledge. Limited studies chose to evaluate both of these domains despite their obvious need to inter-link in clinical practice. When both domains were assessed in end of clerkship written and clinical exams, a higher score was attained by those learners receiving SP based education in comparison to those who did not.
In most cases, SP views were included in data collection in those situations where an adolescent rather than a child had fulfilled the SP role. Additionally, those studies that did involve younger children chose to focus more on the evaluation provided by either the child’s biological parent, or the adult role playing their parent within the simulation activity. Perhaps an opportunity exists in this situation for the incorporation of developmentally appropriate evaluation tools as a means to ensure the valuable feedback of children is not omitted.
Longitudinal application and retention of knowledge were not common outcome measures, despite the potential for these to reinforce the value of child and adolescent SPs to educational outcomes. Two studies included these measurements with variation in the result apparent. Although one study indicated the retention of knowledge for up to one year [22], a second paper provided contrast by identifying that even in the short term there was no appreciable positive impact on clinical performance [27].