Abstract
Reliable and valid methods to evaluate student competence are needed in social work education, and practice examinations with standardized clients may hold promise for social work. The authors conducted a critical appraisal of standardized client simulations used in social work education to assess their effectiveness for teaching and for evaluating social work students' competence. Following a comprehensive search, 18 studies, including 515 social work students, were examined. The authors extracted data from these studies and study methods and assessed the results. This review found that studies vary in methodological quality; however, using standardized client simulations is well-received by students. Consistent implementation methods and reliable, valid assessment measures are needed to advance this evaluation method for social work.
Education for the professions aims to prepare students in the professions' fundamental ways of thinking, performing, and acting with integrity (CitationShulman, 2005). In Educational Policy and Accreditation Standards, the CitationCouncil on Social Work Education (2008) adopted a competence framework with a focus on outcomes, similar to related health and human service professions such as medicine (CitationCarraccio, Wolfsthal, Englander, Ferentz, & Marin, 2002; CitationFrank, 2005), nursing (CitationWatson, Stimpson, Topping, & Porock, 2002), and psychology (CitationKaslow et al., 2004). Competence refers to the complex set of practice behaviors reflecting knowledge, skills, values, and attitudes that students should be able to demonstrate on completion of their educational program. Social work educators are now challenged to develop and test a range of methods to assess educational outcomes and to devise reliable and valid measures.
Schools of social work typically assess students' learning through written examinations, essays, student presentations, or portfolios (CitationCrisp & Lister, 2002; CitationLister, Dutton, & Crisp, 2005). The best measure of students' competence, however, is their ability to effectively perform the core functions of the profession in practice situations (CitationGambrill, 2001). Currently, evaluation of practice competence takes place primarily in the field practicum despite extensive research documenting conceptual, methodological, interpersonal, and structural problems (CitationAlperin, 1996; CitationBogo, Regehr, Hughes, Power, & Globerman, 2002; CitationBogo, Regehr, Power, & Regehr, 2007; CitationBogo et al., 2006; CitationKilpatrick, Turner, & Holland, 1994; CitationRegehr, Bogo, Regehr, & Power, 2007). A promising approach that may be able to supplement these traditional assessment methods is the objective structured clinical examination (OSCE). Originally developed for medical education (CitationHarden, Stevenson, Downie, & Wilson, 1975), it is now used to assess educational outcomes of health professionals such as nurses (CitationRoss et al., 1988), pharmacists (CitationAustin, O'Byrne, Pugsley, & Quero Munoz, 2003), physical therapists (CitationWessel, Williams, Finch, & Gemus, 2003), and dentists (CitationMossey, Newton, & Stirrups, 2001). In an OSCE, students interact with standardized patients (SPs) or clients (SCs) for a set period of time and perform a series of tasks. SP and SC are actors specially trained to enact a situation typical of that profession. Using standardized scales to measure competence, a faculty member or clinical instructor observes and evaluates student performance.
The use of simulations in social work education is not new; the literature reveals reports of simulations in the classroom through role plays with classmates (CitationDoelcker & Bedics, 1987; CitationKane, 2003; CitationMoss, 2000), scenarios depicted by drama students (CitationBerliner, 1982; CitationLevitov, Fall, & Jennings, 1999), and use of trained actors as standardized clients (CitationKoprowska, 2003; CitationMole, Scarlett, Campbell, & Themessl-Huber, 2006; CitationPetracchi, 1999; CitationPetracchi & Collins, 2006; CitationRobins et al., 2008). However, no critical appraisal of studies that use simulations with standardized clients in social work education exists. A careful evaluation of standardized client-simulation methods and results is timely to assess the effectiveness of this method and to guide future implementation in social work.
OBJECTIVES
The objective of this critical appraisal is to examine the use of standardized client simulations in social work education. Specifically, we aim (a) to provide a critical review of the literature examining the use of standardized client simulations in social work education, (b) to discuss methodological strengths and limitations of standardized client simulations in social work, and (c) to identify future directions for implementation and evaluation of standardized client simulations in social work education and research.
METHOD
Inclusion Criteria
Inclusion criteria for this critical overview consisted of original research studies reporting intervention and observational data. Studies must have used standardized clients or actors, including trained actors, faculty, or drama students, within simulations for any level of social work education. There were no geographical, language, or time restrictions on studies included in this review. Participants in the studies were undergraduate and graduate social work students. Types of educational interventions included individual-, group-, or classroom-level interactions with an SC. Role plays were excluded unless trained actors, faculty, or drama students participated in conducting them.
Search Strategy
The comprehensive search strategy involved searching multiple electronic databases to locate relevant articles, using no geographical, time, or language restrictions. The following databases were searched from Scholars Portal: ASSIA (Applied Social Sciences Index and Abstracts), Digital Dissertations, E-Journals, Education Abstracts, ERIC, Expanded Academic ASAP, Family Studies Abstracts, LGBT Life, MEDLINE, PILOTS database, Proquest Education Journals, PsycARTICLES, PsycINFO, Social Sciences Abstracts, Social Sciences Citation Index. ProQuest was used to access Dissertation Abstracts International. The following databases were searched from CSA: Social Services Abstracts and Sociological Abstracts. Key search terms were social work*, social work educat*, student*, standard* client*, standard* patient*, OSCE, structured exam, role play*, simulat*, practice simulat*, standard* client* case*, and simulated session*. The following is an example of a search strategy using keywords (KW) conducted in Scholars Portal databases on May 15, 2011: KW=(social work* or social work educat* or social work student*) AND KW=(standard* client* or standard* patient* or OSCE or role play* or practice simulat* or simulated session*). We hand-searched references cited in peer-reviewed articles.
Data Collection and Analysis
We screened all titles and abstracts highlighted in the search strategy for inclusion. The full article was obtained when the first reviewer determined the article may meet inclusion criteria based on the review objectives. Two reviewers (CL, MB) assessed each of these short-listed articles for inclusion. A data extraction form, developed using Microsoft Excel, contained (a) article information, (b) methods and study design, (c) poststandardized client-simulation debriefings or activities, (d) descriptive data, and (e) results.
This critical review consists of 17 studies from peer-reviewed journals (CitationBadger & MacNeil, 1998, 2002; CitationBaez, 2005; CitationBogo et al., 2011; CitationEmlet, 2010; CitationLinsk & Tunney, 1997; CitationLu et al., 2011; CitationMellor, Hyer, & Howe, 2002; CitationMiller, 2002, 2004; CitationMole et al., 2006; CitationMooradian, 2007, 2008; CitationPetracchi, 1999; CitationPetracchi & Collins, 2006; CitationRobins et al., 2008; CitationRogers & Welch, 2009) and a dissertation (CitationRawlings, 2008), involving a total of 515 social work students. The studies are detailed in . The majority of these studies (n = 10) used mixed methodology and collected both quantitative and qualitative data; the remaining studies (n = 8) collected quantitative data.
TABLE 1 Overview of Social Work Standardized Client-Simulation Articles (N = 18)
What Educational and Design Approaches Were Used in Standardized Client Simulations?
The studies adopted a wide range of approaches with respect to duration, purpose, methods, and types of SC cases used for implementing standardized client simulations. Simulations ranged in duration from 10 to 90 minutes. Studies used standardized client simulations primarily for education (n = 9), evaluation (n = 6), and pilot testing of their effectiveness or acceptability (n = 3).
Educational methods differed. The studies used three approaches, sometimes in combination: (1) team-based, in which a group of students conducted an assessment of the SC; (2) individual, in which an individual student interacted with the SC; and (3) classroom, in which students observed a team or individual student interacting with the SC. All but one study (CitationBadger & MacNeil, 2002) described a poststandardized client-simulation activity that invited self-reflections and/or that obtained feedback and evaluations from fellow students, the SC, and instructors.
Standardized client-simulation cases varied greatly across studies. Studies used different types of standardized clients: theater students (n = 5), trained actors (n = 7), trained volunteers (n = 3), and faculty (n = 3). The number of cases ranged from 1 to 18, with the majority (n = 11) using between 1 to 3 cases. Sample sizes ranged from 3 to 101 participants with a mean of 36.8 (SD: 31.0; median: 28.5). Studies included MSW students only (n = 10), BSW students only (n = 3), or both BSW and MSW students (n = 3). Social work specializations included generalist practice (n = 5), family (n = 4), mental health (n = 3), gerontology (n = 2), and school social work (n = 2).
Cases examined issues such as mental health (n = 8), physical health (n = 6), geriatrics (n = 5), family/relationship conflict (n = 1), grief and loss (n = 2), sexual orientation (n = 2), addictions (n = 1), child welfare (n = 1), and immigration (n = 1). Four studies (CitationBaez, 2005; CitationBogo et al., 2011; CitationLu et al., 2011; CitationRogers & Welch, 2009) reported including diversity issues in the SC encounter (e.g., religious, cultural, sexual orientation). CitationBogo et al. (2011) reported that participants' performances across stations differed significantly, suggesting that social work skills are context specific: A student who demonstrates competence with sexual orientation issues may not demonstrate competence with immigration issues. CitationLu et al. (2011), having found that racial and ethnic matching between students and the SC was not associated with higher rapport or more cultural empathy, highlighted that clinical skills were not synonymous with cultural empathy. The other studies did not comment on diversity in relation to findings.
What Was Evaluated?
Studies measured student performance (n = 14), student satisfaction (n = 12), and both student performance and satisfaction (n = 8). Evaluations of student performance included (a) assessing the ability of SC simulations to differentiate between skill levels of students in different years of undergraduate and graduate social work education and (b) examining performance results and correlates of performance. Four studies indicated the SC simulation was able to differentiate skills between students at some levels of education. CitationBadger and MacNeil (2002) found that SC simulations increased MSW students' performance scores in comparison with students exposed to role plays but noted no significant difference in students' performance in SC simulations between educational levels. CitationBogo et al. (2011) reported significantly higher scores on SC simulations among experienced practitioners compared with MSW students but detected no meaningful differences between second-year MSW students and recent MSW graduates. CitationMiller (2004) found higher overall scores on checklists of completed tasks for MSW foundation students in comparison with BSW students, but statistical significance of the differences in scores was not reported. CitationRawlings (2008) found that BSW education predicted notably higher levels of practice skills and practice self-efficacy.
Other studies reported student performance results or correlates with the results. Undergraduate students demonstrated effective interviewing and listening skills (CitationRogers & Welch, 2009). The majority of undergraduate and graduate students met the SC learning objectives (CitationMiller, 2004), and most graduate students demonstrated the ability to develop clinical care plans (CitationEmlet, 2010). CitationRawlings (2008) found previous work experience was correlated with direct practice skills. CitationBaez (2005) indicated that the SC simulation was associated with increased knowledge of substance use among BSW and MSW students. CitationLu et al. (2011) reported that students' self-ratings for cultural empathy and metacognition were generally higher than ratings by the SC and instructors. CitationBogo et al. (2011) reported that performance and reflection scores were associated but that they reflected different aspects of competence. Most studies used disparate measures, student populations, or outcomes—precluding meaningful comparison of results.
Student satisfaction was measured qualitatively or quantitatively or was observed and reported in the majority of studies (n = 12). In general, students rated the SC encounters as realistic, beneficial to skill development, and helpful with application of social work knowledge, and they recommended future use in social work education. However, studies used different measures of student satisfaction, preventing meaningful comparison of results.
What Were the Methodological Limitations?
Methodological limitations included incomplete reporting of participant characteristics and methods or results. For example, several studies did not report educational level (e.g., undergraduate, graduate) of participants or study sample size. Most studies did not report participant demographics: Age was listed in six studies (3 reported mean; 3 reported range), gender in five studies (mean female rate of participation: 89.6%; SD 6.9), and ethnicity in four studies (mean Caucasian rate of participants: 87.25%; SD 9.9). Most studies that evaluated SC encounter performances did not report scores or results. Scale reliability analyses were only listed in four studies. The studies reported insufficient quantitative data on either performance or satisfaction to conduct meta-analyses or to ascertain the effectiveness of interventions.
DISCUSSION
This review has identified several methodological and conceptual issues in researching and implementing standardized client simulations in social work. The majority of studies did not report participant demographics, and for studies that stated this information, most participants were female and Caucasian. The generalizability of findings to other student populations (i.e., non-Caucasian, male) was not explored. This area is an important one to examine, as previous research has found significantly lower performance in OSCEs in the United Kingdom among ethnic minority male medical students in comparison with Caucasian students (CitationWass, Roberts, Hoogenboom, Jones, & Van der Vleuten, 2003).
Descriptions of the actual standardized client-simulation case were also vague: The majority of studies did not describe in what social work setting the SC simulations took place, and many did not report what challenges the SC was facing in the simulation. The absence of this information is indeed unfortunate, as this review highlights that SC simulations have been reported in social work for the last 14 years (1997–2011). If SC simulations are potentially effective in measuring student practice competence and are well accepted by students, an impetus for replication across different schools of social work may be evident. However, without standardized, reliable, and valid tools, progress is hampered.
Despite the small number of studies conducted on the use of SC simulations in social work education and the methodological problems identified, interest in using SC in teaching and assessment of student learning appears to be growing. The diversity of methods, outcomes, and measures used in SC simulations may present difficulties in synthesizing results, yet it also indicates creativity and a commitment of educators to test the relevance of this tool across content areas, student level, and social work specializations. This creativity can be viewed as a methodological strength: Social work educators are taking initiative to develop context-specific SC encounters to meet their program learning objectives.
Adoption of a competency-based framework for social work education and the associated expectations of educational outcomes assessment provide incentive for the development of reliable and valid measures of student performance (CitationCouncil on Social Work Education, 2008). Use of standardized client simulations in a variety of ways, following systematic descriptions and well-researched methods, may provide a feasible and useful approach for social work educators.
One limitation to this review is the relatively small number of studies examined; another is that we did not search or include gray literature. The incomplete data reported for the intervention studies in this review precluded meta-analyses or assessing studies for risk of bias using Cochrane guidelines (CitationHiggins & Green, 2011). However, this review critically appraised the methods and reporting of each study in an effort to emphasize methodological and conceptual issues.
IMPLICATIONS FOR SOCIAL WORK EDUCATION
This review highlights three important points to advance education and assessment research and practices for use of standardized client simulations. First, the studies reviewed were unique and did not suggest that educators and researchers were building on each other's contributions. We found considerable difference along a number of dimensions (e.g., duration, number and content of case studies, performance and satisfaction measurement tools). This variance precludes comparing the experiences and results of standardized client simulations. Systematic and well-described protocols for using standardized client simulations and for studying educational outcomes are needed to advance social work pedagogy and research.
Second, reports of using standardized client simulations have focused on educational, rather than evaluative, purposes. In the outcomes reported, we discerned an overemphasis on student satisfaction and an underemphasis on student performance. Even when data on performance outcomes were collected in some studies, they were not reported. Reporting satisfaction is valuable, but we cannot assess effectiveness of standardized client simulations in evaluating student competency without reported (and comparable) performance measures.
Finally, social work education has moved to integrate cultural competence and diversity throughout the curriculum. Most SC simulations included in this review, however, were not developed to prepare students for competently addressing issues of diversity—ethnicity, culture, sexual orientation, language barriers, and immigration status were not assessed in most SC cases. Studies that examined issues of diversity highlighted that clinical skill does not equate with cultural empathy (CitationLu et al., 2011) and that competency in one area of diversity (e.g., sexual orientation) does not necessarily translate into competency in other areas of diversity (CitationBogo et al., 2011). Thus, assessing clinical skill and cultural empathy or competence in the SC interview necessitates complexity. SC simulations have the potential to provide insight into education and assessment of students' ability to practice competently and empathetically across multiple areas of diversity. Future research can explore effective ways to teach and to assess cultural competency and empathy.
Given widespread confidence in using standardized client simulations in teaching and in assessing learning in related health professions education, social work educators may want to consider adapting and studying this methodology. The next step is to develop and to report fully on approaches to teaching and learning that involve standardized clients, while simultaneously studying the reliability and validity of such methods in improving student learning and in assessing student competence.
Acknowledgments
This research was funded by the Social Sciences and Humanities Research Council of Canada (SSHRC) and a Royal Bank Fellowship. Carmen Logie was also funded by an SSHRC Doctoral Fellowship and a Canadian Institutes of Health Research Post-Doctoral Fellowship.
Related Research Data
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