Patient Education and Counseling 67 (2007) 13–20 www.elsevier.com/locate/pateducou

Review

The use of simulated patients and role-play in communication skills training: A review of the literature to August 2005 Claire Lane a,*, Stephen Rollnick b a

Nursing, Health and Social Care Research Centre, Cardiff University, School of Nursing and Midwifery Studies, Fourth Floor, EastGate House, 35-42 Newport Road, Cardiff CF24 0AB, UK b Department of General Practice, Cardiff University, UK Received 10 November 2006; received in revised form 27 February 2007; accepted 28 February 2007

Abstract Objective: To assess whether the practice and rehearsal of communication skills is likely to lead to better outcomes following training, and whether the use of simulated patients in training is likely to be superior to role-play in terms of communication skill acquisition. Methods: The databases Medline, Amed, Cinahl, BNI, Embase, Psychinfo and HMIC were searched for articles which compared the use of simulated patients and/or role-play in training healthcare practitioners in acquiring communication skills. Results: Most studies appear to indicate that outcomes are better in communication skills training programs where skills practice has taken place. However, a number of methodological weaknesses make concrete conclusions difficult to draw. There was just one study that directly compared the use of role-play with simulated patients. This found no significant difference in outcomes between the two methods. Conclusion: There is a need for more well-designed studies that assess skill acquisition following the use of simulated patients and/or role-play in a number of different settings. Practice implications: Simulated patients and role-play are frequently used in teaching communication skills worldwide. Given the expense of using simulated patients, educators should be made aware of cheaper alternatives that may be equally effective in facilitating the acquisition of communication skills. # 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Simulated patients; Role-play; Communication skills; Practice; Rehearsal

1. Introduction One question raised in regard to teaching communication skills is which methods are most successful in helping those individuals to learn the skills that they are being trained in? Reviews in the medical education field have provided evidence that those programs that incorporate interactive methods of teaching are often more successful in helping individuals to acquire communication skills in comparison to more didactic methods of teaching [1,2]. However, the question as to which methods of interactive learning produce the most potent effects on clinical behavior is one that remains unanswered. One approach is to use ‘simulated patients’ (professional actors or patients who have been briefed to play a patient role). This has proved popular with medical undergraduates world-

* Corresponding author. Tel.: +44 29 2091 7813; fax: +44 29 2091 7803. E-mail address: [email protected] (C. Lane). 0738-3991/$ – see front matter # 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2007.02.011

wide [3–5]. Student reception to the use of simulated patients in teaching communication skills has been mostly positive, and in some cases preferable to the use of real patients for learning [6–8]. The use of simulated patients in teaching communication skills is also gaining increasing popularity in other professions allied to medicine, such as nursing [9], dentistry [10,11] and dietetics [12]. There are a number of advantages to the use of simulated patients in communication skills training [13]. They enable trainees to try out and experiment with the new skills learned. Scenarios can be tweaked and re-played as necessary within the session, with the opportunity for the standardization and customization of cases, and an opportunity for difficult issues to be dealt with. Simulated patients can also be trained to provide feedback to trainees, and can assist with the teaching and facilitation of a teaching session. The main drawback of using simulated patients is the expense. Prices do vary, but in the authors’ experience, paying for experienced, reliable actors for a training workshop can cost around £200 per day per actor.

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In addition to this, other disadvantages include the time consuming nature of the training and selection of actors, and the organization process. There is also the possibility that no matter how well they are briefed and trained, simulated patients may choose to play the case differently to how they were asked to do so. The use of role-play with fellow trainees is a similar way in which communication skills can be practiced. Its use within studies that evaluate training is rarely discussed in detail with regard to acceptability to trainees in comparison with studies that use simulated patients. However, trainee resistance to taking part in role-plays with colleagues is a problem that faces many trainers [14–18]. A common complaint is that role-play with colleagues or peers feels artificial, although this may be more a reflection of trainee anxiety [13]. The fact that some trainees may be more ‘theatrical’ and more willing/able to adopt a role than others, can often prove challenging. Despite the fact that some practitioners may feel uncomfortable conducting role-plays with fellow trainees, role-play provides an opportunity to practice and rehearse communication skills in the same way that practice with simulated patients does, without having to spend large amounts of time and money on the training and selection of patients. There is also the added bonus that trainees can gain additional knowledge by experiencing the role of the patient. Other interactive methods that can facilitate communication skills learning can include descriptive feedback on performance, reviewing own practice via video and/or audio recording, and observing others practice [13]. In descriptive feedback, the educator observes the trainee and provides guidance, highlighting the trainee’s strengths and weaknesses in a supportive manner. By reviewing recordings of one’s own practice, either individually or in a small group, the trainee is encouraged to actively reflect on their own strengths and weaknesses. Similarly, the learner can enhance their own learning of communication skills by critically evaluating the performance of others. Encouraging the learner to play an active role in their learning like this can assist them in skill acquisition. However, trainee worries about being observed, and facilitator anxieties about taking on a more passive role in the teaching process can also present challenges in using interactive methods to teach communication skills [13]. It should also be noted that although interactive methods have been shown to be effective in helping trainees to use communication skills, didactic methods have been shown to be useful in increasing knowledge about different communication skills, and their use in different contexts [13]. The use of simulated patients has a lot to offer practitioners in terms of helping them to acquire skills, but is the use of simulated patients superior in assisting practitioners to incorporate communication skills into their everyday practice in comparison to other teaching methods? It has been argued that the more relevant the learning is to real life, the more quickly and effectively skills should be learned [19]. This suggests that practicing skills with a simulated patient may lead to better skill acquisition, as this may be more like ‘real life’ than consulting with a fellow

trainee. Another argument in favor of simulated patients is one of emotion, or ‘affective learning’. Induction of positive affect has been shown to directly affect clinical behavior [20]. Learners may be more likely to draw meaning from new learning experiences if the encounter is an enjoyable one, and less likely to engage in learning if they experience discomfort during an activity [21]. Following this rationale, it could also be argued that the skills practiced in situations where the trainee experiences negative feelings (such as anxiety during role-play with colleagues) could possibly be less likely to be retained, but this not a greatly researched area. Although many evaluation studies ask how the students felt about the teaching methods, this is seldom related to behavioral outcomes. However, if adults generally learn best through ‘doing’ [19], there is potentially a real benefit from experiencing the role of the patient, as this experience could result in personal reflection, in turn affecting clinical practice. The practice and rehearsal of skills with simulated patients is, however, not without its problems. In practice, they can also provoke resistance from trainees, who remark that rehearsing communication skills with them is ‘nothing like’ their clinical world, and some have found empathizing with them difficult [22]. The aim of this review was to assess:  If the use of simulated patients and/or role-play in teaching communication skills is likely to lead to better outcomes than other methods of training.  If the use of simulated patients is likely to lead to better outcomes in communication skills in comparison to conducting role-play. 2. Method The Ovid electronic databases Medline, Amed, Cinahl, BNI, Embase, Psychinfo and HMIC were searched for articles which compared the use of simulated patients and/or role-play with other methods of training in communication skills teaching. The search terms can be viewed in Table 1. Following the reading of all abstracts, only those studies that compared the use of simulated patients/role-play with another method of communication skills teaching were selected Table 1 Search terms used in the review Search 1a ‘‘Simulate$ patient$’’ or (role play or roleplay) or actor$ or (spi.mp. not (Plants, Medicinal/ or Trans-Activators/ or Plants, Toxic/ or Antineoplastic Agents/ or Proto-Oncogene Proteins/ or Podophyllum/ or Transcription Factors/ or Coronary Disease/ or DNA-Binding Proteins/or Nuclear Proteins/)) or instruct$ or standard$ patient$ Search 2a Educate$ or teach$ or trainer$ or counsel$ or mentor or coach or lesson$ or workshop$ or work shop$ or lecture$ or facilitat$ or demonstrator or tutor or supervisor a Databases searched: Medline, Amed, Cinahl, BNI, Embase, Psychinfo and HMIC.

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(including studies that involved teaching other clinical skills with a communication skills component). Studies that used simulated patients or role-play as a method of assessment, but did not use either method during the actual training process were also excluded, because it was the use of these approaches during the training process that was of interest within the scope of this review. The full articles were retrieved for all studies that appeared to be eligible for inclusion in the review and for any studies where it was not possible to draw firm conclusions regarding eligibility from the abstract. 3. Results Exactly 5305 references were generated. Twenty-three studies that compared the use of simulated patients and/or role-play with other methods of training were included in the final review. 3.1. The use of simulated patients and/or role-play versus no intervention Most studies of this kind have been conducted with simulated patients in undergraduate settings. Colletti et al. [23] trained medical students in breaking bad news, and compared those who were given the opportunity to practice to break bad news with a simulated patient with those who did not undertake this experience. Those students who had practiced breaking bad news with a simulated patient scored significantly better on a 27-item measure of communications skills than those who did not. Similarly, Haist et al. [24] compared medical students who participated in a workshop about domestic violence (which involved consulting with simulated patients) with students who did not participate. The workshop participants scored significantly higher on items about domestic violence on a clinical performance examination checklist following training (in comparison to non-participants), but they did not score significantly better on interpersonal skills. In a later study, Haist et al. found that medical students who attended a workshop (that involved the use of simulated patients) demonstrated significantly more sexual health and HIV counseling behaviors in comparison to those who did not [25]. Johnson and Kopp [26] compared first year dental students with second year dental students on an examination, using a simulated patient (who scored the consultation using a checklist). The first year students were taught record keeping, examination and communication skills using simulated patients who gave feedback. The second year students only had experience of consulting with real patients. The first years scored higher on all three areas in comparison to the second years, but the differences in communication skills were not statistically significant. Koerber et al. [11] randomized 22 dental student volunteers to an experimental group who undertook a training course in brief motivational interviewing for smoking cessation (which incorporated the use of simulated patients), and a control group who did not take the course. Those participants who took the

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course displayed more brief motivational interviewing techniques in their practice, and patients were more actively involved. Stillman et al. [5] developed a program where simulated patients were used to assist in the development of clinical skills (including interviewing skills and history taking skills) in three medical schools in China. Third year medical students, who undertook this program of learning in 1993 were compared to third, fourth and fifth year students in 1992 who followed the previous program (which did not incorporate the use of simulated patients). The students who followed the new curriculum performed significantly better on adult and pediatric interviewing skills than those who followed the old curriculum. Other undergraduate studies include Littlefield et al. [27], who randomized students to either an experimental group (who performed a role-play exercise with a faculty member playing the role of a parent), or a control group who did not undertake the role-play activity. The students in the experimental group scored significantly higher in an assessment of their history taking skills than the controls. Sasson et al. [28] trained 28 out of 154 fourth year medical students to role-play patients for first and second year medical students. The fourth-year medical students were later assessed by a professional simulated patient using checklists that measured five different aspects of communication skills (four of which were identical to those measured by the students who acted as patients for the first and second year medical students). Students who had acted as patients scored significantly higher on these four areas than students who were not, although there were no significant differences between students who had been simulated patients and those students who had not on the fifth area of communication skills. Mukohara et al. [29] compared the communication skills of undergraduate medical students who had received a workshop on medical interviewing with those who had not. Out of a possible sixteen communication skills to be acquired, students who had attended the workshop performed significantly better on just two of the skills measured. There were no significant differences between groups in any of the other communication skills. Few studies have investigated the effects of training experienced healthcare practitioners in communication skills using either role-play or simulated patients. Carney et al. [30] compared physicians who had undertaken a continuing medical education course, which included the use of role-play, in reducing cancer risk factors, with physicians who had not. Physicians who had taken the course showed significantly better practice in breast cancer risk assessment, and smoking cessation counseling with an unannounced simulated patient in their clinical practice. Cornuz et al. [31] randomly allocated medical residents to either a training workshop in smoking cessation counseling (that involved the use of both simulated patients and role-play), or a didactic lecture on the management of dyslipedemia. At one-year follow-up, patients reported that the residents who received the smoking cessation training provided significantly better smoking cessation counseling than those who did not. Krijver et al. [9] studied differences between trained and untrained cancer nurses in patient centered communication

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skills. The training included the practice and rehearsal of communication skills with simulated patients. Trained nurses asked significantly more open-ended, psychosocial questions than untrained nurses, and facilitated more affective talk in simulated patients. In a randomized controlled trial of communication skills training in Spain, Moral et al. [32] showed that trainee family practice physicians who attended a communication skills training program did not demonstrate better skills in comparison to those who did not attend. 3.1.1. Discussion and conclusion The majority of studies (with the exception of Haist et al. [24], Johnson and Kopp [26] and Moral et al. [32]) that compared the use of simulated patients and/or role-play with no intervention appear to indicate that the use of simulated patients and/or role-play in training leads to a significant improvement in the use of communication skills. However, there are a number of methodological weaknesses associated with the studies which make concrete conclusions difficult to draw. Several studies are unclear as to whether the simulated patients used to assess trainees were blinded to the trainees’ experimental condition [11,23–26,28]. Many did not appear to randomize participants into groups [24,25,28–30], and several did not measure skills prior to training making it impossible to assess whether each group had demonstrated similar amounts of change in their communication skills following training [23–30]. The students in the Sasson et al. [28] study were self selecting, in turn questioning whether these students may have been more motivated to enhance their clinical performance than if the students were chosen at random. Whether the differences observed were down to students having learned the skills through teaching the skills themselves or familiarity with the examination format is unclear. It is also interesting to note from the Moral et al. [32] study that those who were ‘unwilling’ or ‘unable’ to attend were excluded, which implies that those who were included in the study (both control and intervention subjects) may have been more keen to improve their communication skills. 3.2. The use of simulated patients and/or role-play versus didactic methods of learning Two randomized controlled trials have compared the provision of written information with the use of simulated patients or role-play. Abraham et al. [33] investigated whether an interactive training program (which involved the use of roleplay) significantly improved the violence screening skills of second year residents and third year medical students, in comparison to controls who received the standard ambulatory clinic manual with articles on violence prevention. Subjects who attended the training program demonstrated significantly better interpersonal skills in comparison to controls. Rabin et al. [34] produced similar findings while comparing the effects of three experimental conditions (mailed educational materials only, mailed educational materials plus an office visit by a simulated patient instructor, or no educational intervention) on general practitioners’ HIV risk assessment and counseling

skills. Physicians who received the educational materials and a visit from a simulated patient asked significantly more about condom use and risky sex practices in comparison to those who received written materials only and those who received no information. Other studies have compared training using simulated patients with didactic lectures in a range of clinical areas, including breast examination [35], HIV risk assessment skills [36] and speech/language pathology [37]. Two studies [35,36] have found that students who underwent training involving simulated patients performed significantly better in their communication skills than those who received lectures. Conversely, one study by Zraick et al. [37] did not favor the use of simulated patients in the acquisition of communication skills. Participants in this study performed two Objective Structured Clinical Examinations (OSCEs)—one in the middle of term and one at the end of term. There were no significant differences between the students who consulted with simulated patients and those who received lectures on communication skills at OSCE one. In fact, both groups scored less than competently in their interpersonal and communication skills. All participants received more class lectures that addressed interpersonal skills. Following this, both groups scored significantly better in OSCE two. The authors argued that the instrument used to assess the OSCEs may not have been sensitive enough to detect between group differences, as the level of skill achieved by students was relatively low. It was felt that students may have performed better on OSCE two as a result of the lectures, and because many students had already mastered the technical skills in OSCE one, which gave them the space to focus on their communication skills in OSCE two. The didactic lectures between OSCE one and OSCE two did appear to improve communication skills, but it is interesting to note that neither group showed an improvement in skill at OSCE one, showing that communication skills were not acquired following either method of teaching at that point. Additionally, Seim and Verhoye [38] compared the use of a smoking cessation algorithm by fourth year medical students who either attended a 2-h workshop on smoking cessation techniques (which included the use of role-play), or received 5 min of instruction on how to incorporate a patient centered approach while using the algorithm. Those who attended the workshop performed significantly better in providing information to a simulated patient, eliciting and responding to patients’ feelings and past experiences of stopping smoking, advising on resources available for change, and negotiating a plan. No significant differences were found between groups in eliciting information, identifying the patient’s motivation to quit smoking, and identifying barriers to change. Students’ skills in smoking cessation techniques remained quite low, despite the improvement shown by those who attended the workshop. 3.2.1. Discussion and conclusion Most studies appear to indicate that training programs that incorporate practice with simulated patients or peers may be more successful in improving communication skills than those that use purely didactic methods. However, methodological

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weaknesses make conclusions from these studies difficult to draw. The Abraham et al. study [33] provided no objective assessment of skill at baseline. It is not clear whether the simulated patients who conducted the assessments were blinded to the students’ experimental conditions in the Blue et al. [35] study. Seim and Verhoye [38] clearly stated that the simulated patient was a researcher involved in the study, and was therefore not blinded to the students’ experimental condition. However, attempts were made to remedy this by the addition of independent raters, who assessed the consistency of the simulated patient’s behavior across consultations. It was also acknowledged in some studies that the level of skill attained by trainees was often low [37,38], despite trainees being given the opportunity to practice their skills. 3.3. The use of simulated patients and/or role-play versus other interactive training methods Fallowfield et al. [39] evaluated the efficacy of three different models of training in communication skills for oncologists. Participants were randomly assigned to four groups, which were ‘course with written feedback after’, ‘course alone’, ‘written feedback alone’ and ‘control’ (or ‘no intervention’). Doctors’ consultations with real patients before and after training were assessed by two blinded, independent raters using a validated outcome measure. The course included feedback, videotape reviews of consultations, consultations with simulated patients, interactive group demonstrations and group discussion with a trained facilitator. Course attendance significantly improved the use of several communication skills. There was however, little evidence for feedback alone in changing practitioner behavior. Kleinman et al. [40] compared medical students undertaking an obstetrics and gynecology placement taught by laywomen serving as both simulated patients and teachers at one medical school, with students taught by teachers attending a pelvic examination of a simulated patient at another medical school. Students were assessed at the end of their placement by a simulated patient, and although there were no significant differences between the two groups of students in technical skill, those students who were taught by the simulated patient demonstrated better interpersonal skills. Conversely however, a number of studies have shown no difference in communication skill acquisition when comparing the use of simulated patients and/or role-play with other interactive methods of teaching. Peters et al. [41] compared four methods of teaching ‘microcounseling’ to counseling students by using written and video models of practice, modeling plus role-play, modeling plus role-play plus feedback, and modeling plus role-play plus feedback plus second role-play. Although all students demonstrated improvement in microcounseling skills, no significant differences were observed between groups. It should be noted however, that this experiment involved just forty participants. Roche et al. [42] conducted a randomized controlled trial which compared four different ways to teach smoking cessation skills to fifth

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year medical students: traditional didactic lecture, audiotaped role-play with feedback, role-plays with peer feedback, and videotaped role-play with feedback. All students showed significantly improved smoking cessation skills following training by all methods, except for the didactic lecture, with no significant differences between the groups that showed improvement. Despite this improvement, interactional skills remained at a low level, as noted by some other studies [37,38]. Similarly, Steinemann et al. [43] found that surgical residents who were randomized to either an evidence based medicine study group or a role-play group (following a didactic lecture on smoking cessation) demonstrated significantly increased skill in smoking cessation counseling skills. There were no significant differences between groups in the amount of improvement made, although it should be noted that only 25 residents participated. 3.3.1. Discussion and conclusion These studies show positive improvements in the use of communication skills after conducting role-plays or consulting with a simulated patient, although these improvements may be small. Some studies [39,40] have shown better outcomes when simulated patients have been used in comparison to other interactive methods of training, although the findings of Kleinman et al. [40] are however called into question, as it is possible that students were assessed by the same simulated patients used in training. Simulated patients were also not blinded to the students’ experimental conditions. Another possible confounding factor reported was the stage of study of the two groups of students (one medical school taught pelvic examination in the second year, and the other in the third year)—the third years were trained by the laywoman, but their communication skills may have been more advanced because they have more experience of using communication skills in practice. Other studies [41–43] have shown that the use of simulated patients and/or role-play produced improvements no greater than other interactive methods of training, although two studies [41,43] may not have been statistically powerful enough to detect between group differences. It should also be noted that the students in the Peters et al. [41] study were told to practice the nine steps of microcounseling that had been taught before the assessment. 3.4. The use of simulated patients in training versus the use of role-play with student colleagues There is one study that directly compares the two methods of simulated patients and role-play in the acquisition of communication skills. Papadakis et al. [44] compared the use of role-play with the use of simulated patients in teaching smoking cessation skills to first year medical students. All students received lectures and written information on the effects of smoking and how patients can be helped to stop. Students were then randomly assigned to practice counseling skills, either by consulting with a simulated patient, or roleplaying with fellow students. Simulated patients provided a rating of student performance and feedback using a

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standardized form. Those in the role-play group did the same for their role-play partners using the same form. Students also provided an evaluation of their respective exercises. All students were then assessed two weeks later using a simulated patient (blinded to whether the student was in the simulated patient or role-play group), who scored them on cognitive and communication skills using a rating form. There was no significant difference between groups in terms of consultations skills, but those who consulted with a simulated patient rated the experience higher than those who conducted role-plays. However, not all students assigned to the assessment exercise participated, and the sensitivity of the instrument used to assess student is questioned by the authors. 3.4.1. Discussion and conclusion This study implies that the use of simulated patients produces the same level of outcome as the use of role-play in terms of behavioral outcome. However, students who consulted with simulated patients rated their practice session more positively than those who conducted role-play. The authors did not investigate whether these ratings were related to the final outcome. 4. Discussion and conclusion 4.1. Discussion There are methodological weaknesses that appear to be common to several of the studies reviewed. Firstly, it is difficult to generalize from many of the studies reviewed. Many studies use simulated patients and/or role-play in combination with a number of other teaching methods, such as feedback and group discussion, making it difficult to deduce whether it is the actual use of simulated patients/role-play that have contributed to the greatest improvements in specific communication skills, or whether it is a combination of the practice and rehearsal of skills with other methods of training. Some of the studies reviewed used small sample sizes [36,37,41,43] with one study containing only six participants in each group for comparison [36], and another randomizing just eighteen students [37]. Only two of the studies reviewed conducted a statistical power calculation [9,31]. Although it is unlikely that significant differences would have been produced had the study been underpowered, questions are raised regarding how representative the findings from these small samples are. The vast majority of studies appear to have been conducted with medical students rather than experienced practitioners from a range of disciplines, and raises questions as to whether studies that report findings from teaching undergraduates communication skills are generalizable to experienced healthcare practitioners. Bias is a major factor that could have made the practice and rehearsal of communication skills appear to produce more favorable outcomes in terms of skill acquisition within the studies reviewed. Most investigations relied on ‘convenience samples’ of medical students. This may in turn have resulted in an imbalance between the groups in terms of their skills and

characteristics. Several studies did not conduct baseline assessments [23–28,30,34,35,37,40], making assessments of skill level before training and amounts of change following training impossible. Only one study analyzed their nonrandomized groups for equivalence in demographic characteristics at baseline and controlled for this in the analysis [24]. One study [38] was particularly notable, in that the simulated patient used to assess between group differences was not blinded to the participants’ conditions, although the consistency of the simulated patient across consultations in the assessment exercise and student competence was independently rated by two scorers, who were blinded to the students’ experimental conditions. Several other studies gave no indication as to whether the simulated patient assessors/other assessors were blinded to the students’ experimental conditions [23,24,28,35,37,40]. The measurement of outcomes was another area of weakness within these studies. Most studies gave little or no indication regarding the validity, reliability, internal consistency and responsiveness of the instruments used to this end (with the exception of five studies [9,23,31,33,39]), a common problem in the evaluation of healthcare professionals’ communication skills as identified in other reviews [45,46]. One systematic review [2] has indicated that the use of interactive training rather than didactic methods produced better skill acquisition outcomes than didactic methods, although the effect sizes were much smaller when the behavior taught was complex (such as communication skill), and has been reflected by two studies included in this review [24,26], suggesting that these skills are either more difficult to measure or more difficult to acquire. Another question that is raised is to what extent were actual communication skills assessed? Some studies seemed to imply that instruments scored whether the trainee had completed verbal tasks dichotomously, rather than giving an indication of how well specific behaviors had been performed [25,26,37]. It appears that a trainee could be considered by some measures of practitioner–patient communication [47] to be communicating to a low standard, despite scoring highly on the measures used in some studies. Most studies do not include trainee perceptions of the use of simulated patients and/or role-play, and none have related this to any of the skill outcomes measured. Given that factors such as applicability to clinical practice and emotion have been argued to possibly have an effect on the learning and retention of skills [19,21], this in turn offers to be an interesting angle of research. In spite of the methodological weaknesses discussed above, some studies are better designed than others [9,31,39], and appear to indicate that outcomes are better in communication skills training programs where skills practice (using simulated patients and/or role-play) has taken place. It should also be acknowledged that the actual content of the communication skills training, rather than the method of teaching used, may have had an effect on how well skills were acquired. This review examined studies where communication skills were taught for a number of different

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contexts, including sexual health [25,34,36], breaking bad news [23], behavior change [30,31,38,42–44], cancer [9,39] and domestic violence [24,33]. Trainees may, for whatever reason, have found it easier to implement communication skills in some contexts rather than others, and this warrants further investigation. Finally, this review has also highlighted a lack of studies comparing the use of simulated patients with the use of roleplay in learning communication skills (most have used simulated patients). This is surprising given the expense of using simulated patients, and the convenience of using readily available trainees/students, and should be investigated further. 4.2. Conclusion There is a need for more well-designed studies that assess skill acquisition following the use of simulated patients and/or role-play in a number of different settings, both at undergraduate level and with experienced clinicians. Further investigation is also needed to explore the similarities and differences between the use of simulated patients and the use of role-play in learning communication skills, and to establish which method is the most beneficial to use in what circumstances with what learners.

[10] [11]

[12]

[13] [14]

[15] [16] [17] [18] [19] [20]

[21]

[22]

4.3. Practice implications Simulated patients and role-play are frequently used in teaching communication skills worldwide. Given the expense of using simulated patients, educators should be made aware of cheaper alternatives that may be equally effective in facilitating the acquisition of communication skills.

[23] [24]

[25]

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