Introduction

In healthcare education, simulation is used to enhance knowledge, psychomotor, interpersonal and professional skill development. With the added benefits of realism, active learning and challenge, ideally without associated harm to patients and participants, simulation-based education (SBE) is an effective way for learners to prepare for professional practice. Simulation can involve paid professional or semi-professional actors, volunteers or simulated patients (SPs).

Regardless of their title, they can be defined as ‘All human role players within simulation-based education (SBE) who have been trained for the consistent portrayal of a role’ [1]. Consistently playing a role they have been trained for enables them to effectively contribute to the development of skills that may not be achievable with the inclusion of manikins alone. SPs are widely recognized as a positive addition to educational initiatives, particularly those focused on the development of effective communication skills [2]. From the earliest days of SP inclusion documented by Barrows [3], SPs, particularly adults, now engage in a wide variety of SBE opportunities, with an ever-expanding depth and breadth of role requirements.

Although young people, those aged 16 or below, are less able to make the same autonomous healthcare decisions those aged above 16 years can, they are often capable of making thoughtful choices [4]. The capacity to make choices is obviously development-dependent, but for those young people who can make their own decisions (with or without parental support/guidance) and provide assent prior to undertaking an SP role, involvement in SBE is feasible. The involvement of young people in SBE occurred sometime after that of adults; however, the amount of published literature referencing young SPs does appear to be slowly increasing. It has also become apparent that young people can contribute valuable insights into role development and add realism in presentation and interactions that an adult playing a young person’s role, or a manikin cannot achieve. As with adult SP roles, those assumed by young SPs are also moving beyond traditional communication-focused interactions to include complex and multi-faceted scenarios.

ASPE standards

The safety of simulation participants, including SPs is often dependent on adherence to guidelines underpinning their involvement. Although there is no specific framework or standards of best practice supporting the engagement of young SPs, there is potential for the Association of Standardized Patient Educators (ASPE) standards to be adapted to simulation where young SPs are involved. The domains, principles and underlying values are as relevant to adult SPs as they could be to young people [1].

The ethics of including young SPs in health professions education draw on the experience of the author, who works with young people in simulation. During prior research, the author identified concerns about informed consent/assent, ensuring benefit outweighs harm and protecting young SPs from any potential unsafe situations. These ethical principles are paramount in determining whether young people should actually be involved in SP roles.

This paper reflects the experience of a young SP, told to the author by the SP and their parent. The findings discussed in this case can be easily extrapolated to any situation in which young people are engaged as SPs. This is the story of Sam, a paid SP employed to portray the role outlined below.

Sam is 11 years old and in the first year of secondary school. Sam wants to be an actor and is involved in community drama. Through Sam’s acting teacher, an opportunity arises for Sam to play a role in a simulation for medical students. Sam immediately says YES. Although Sam has acted in school plays and local community theatre productions, Sam has not been an SP before. Despite this, there is no offer of orientation to the environment, to being an SP or to the role.

Sam’s parents do not read the script before providing consent. They are happy to take Sam’s word that the role is within their capabilities, and they love seeing Sam so excited. Sam’s mum accompanies Sam to the simulation but does not plan to stay. Sam receives limited briefing – just a quick chat to ensure they know how to play the character. There are lots of stressed-out adults helping to direct the simulation. No other young people are involved and there is no space for Sam to rest between student groups – Sam will play the role four times in one day. No debriefing is offered but there is an expectation Sam will provide feedback to the learners. Sam is a bit nervous about this as they have never done this before.

What is wrong with this picture?

Answering this crucial question allows healthcare professionals to gain insight into the ethical challenges associated with engaging young people as SPs. The way it is answered and the ethical principles addressed can ultimately shape the experience for Sam and inevitably for other young SPs. Although complex and intertwining, ethical principles should be forefront in the decision-making process and ultimately usurp the desire and excitement Sam expresses about this acting opportunity.

The prioritized goal of healthcare education is to realistically prepare future health professions learners for practice. Including SPs, in the absence of adequate clinical placements, is a reasonable option to realize this goal. However, this cannot be achieved without due diligence to a range of considerations, not least of which is adherence to the key practices and principles related to ethics, safe practice and establishment of a learning environment devoid of potential harms.

Ethical principles

Although the precise number of ethical principles varies within the literature, those pertinent to this case study include assent, consent, autonomy, beneficence, non-maleficence and justice. A brief overview of these principles identifies the following (Table 1).

Table 1:

Ethical principles

Principle	Definition
Consent/Assent	Consent: (i) The person must be competent to understand and decide, (ii) receive a full disclosure, (iii) comprehends the disclosure, (iv) acts voluntarily and (v) consents to the proposed action [5]. Assent: Participation and engagement with a non-competent or partially competent individual, giving them the opportunity to participate in the decision-making process, rather than just getting them to agree or to cooperate [6,7].
Autonomy	All persons have intrinsic and unconditional worth, and therefore should have the power to make rational decisions and moral choices, and each should be allowed to exercise his or her capacity for self-determination [5].
Beneficence	The act of minimizing harms and risks and maximizing benefits. It involves acting with the intention of promoting the well-being, happiness or welfare of others [5,8].
Non-maleficence	The obligation to abstain from causing harm to others [9].
Justice	Equitable distribution of benefits and risks/harms [10].

Young people can participate and meaningfully contribute to research. Involving them in developing new knowledge, providing insights into particular illnesses or health challenges and collaboratively participating in the design of educational resources applicable to the young are all valuable ways the voices of young people can be heard [11]. The National Statement on Ethical Conduct in Human Research [12] identifies that research with young people requires special consideration of ethical principles, including their ability to understand the research requirements, and therefore their capacity to provide informed consent. The statement also suggests children and young people (CYP) should be protected from parental, peer or researcher coercion, including the possibility that the values and interests of CYP conflict with those of parents. In addition to these core ethical responsibilities, researchers must be responsive to the CYP’s individual developmental levels and realize ethical requirements may vary with each interaction as the nature and complexity of requirements change.

There is also a framework for engaging young people in entertainment such as television or film. The Mandatory Code of Practice for the Employment of Children in Entertainment [13] exists in Victoria, Australia, to govern the involvement of young people aged below 15 years who work in any form of entertainment. Employers are obligated by law to provide information to the young person and family about the role requirements and are mandated to ensure that:

the parent or guardian of the child has sufficient information about the intended role and duties that the child will perform and the intended employment hours and workplaces to make an informed decision;

the parent or guardian of the child has consented in writing to the proposed employment [9];

The child or young person has a valid employment permit.

Scrupulous documentation pertaining to every detail of young people’s employment in any form of entertainment is required. Personal demographic details through emergency contacts and authorised adults permitted to collect the young person are secured to ensure safety. Employers are also obligated to maintain detailed documentation focused on employment details such as hours required, duration of each individual period of involvement, location of work and engagement/content taught by a tutor should school be missed. Additionally, employers must ensure young people have access to adequate food and drink, toilets, washrooms and dressing room facilities, recreation options and protection from harmful weather. Employers must also ensure young people are protected from any form of punishment, social isolation or any other behaviour likely to frighten the young person.

Interestingly, and quite pertinent to Sam’s case is the mandate on employers to ensure young people are not exposed to inappropriate roles or situations. Employers must have regard for the young person’s age, maturity, emotional or psychological development and sensitivity [9]. Young people should also have dedicated supervision from a parent or guardian and be able to contact them or another responsible adult whenever they make such a request.

CYP are also protected under the auspices of the UN Convention of the Rights of the Child [14]. Amongst other guidelines, the convention stipulates that CYP have the right to say what they think should happen when adults are making decisions that affect them and to have their opinions considered (Article 12). This article also stipulates that CYP should be protected from any activities that could harm their development (Article 36). A final consideration is a statement at the heart of paediatrics – not about me without me. This communicates the idea that the full and direct participation of members of the group(s) affected should be involved in decisions affecting them [15].

The consideration of ethical principles begins at the planning phase of simulation. Guillemin and Gillam [16] refer to this as procedural ethics as it involves the process of gaining approval. Although this is a crucial aspect of preparing young people to engage in simulation roles, ethical principles are paramount considerations right throughout the activity. Guillemin and Gillam [16] go beyond the initial approval phase to identify ethics as situational, and therefore capable of exerting an impact at any moment during an activity; this is known as process ethics.

Creating a safe practice environment

Understanding how to effectively create a safe working environment for young SPs is crucial. Even in an established simulation programme with trained healthcare professionals preparing SPs and facilitating scenarios, if there is a lack of knowledge about catering to young SPs such as Sam, there is potential for harm. Creating a safe environment for Sam, as the only young SP involved in the scenario, involves thinking about, but also beyond, the traditional aspects of simulation, such as pre-briefing, preparation for role portrayal, provision of feedback and debriefing. Working with young SPs requires the application of a developmental lens to all elements of simulation, from recruitment through to debriefing.

Ideally, there should be one person, preferably with knowledge of development principles, whose dedicated role is to support and guide the young SP throughout their simulation experience. Their involvement extends from ensuring orientation and preparation are pitched at an appropriate level and the young person is given opportunity to practice their role and ask questions. Young people should also be given the opportunity to offer their own suggestions for role portrayal if this enhances realism for the learner, enables a degree of autonomy and promotes effective SP engagement. In the absence of a dedicated support person, the SP coordinator should ensure informed consent has been provided. Although in Sam’s situation, neither was there a dedicated person nor sufficient oversight to ensure all pre-involvement requirements were met.

Returning to Sam…

There is a myriad of potential challenges ahead for Sam, their parent/caregiver and healthcare professionals as they traverse the complexity and possibly opposing perspectives surrounding Sam’s involvement. Although central to the argument is the well-being of Sam, at a young age and with acting aspirations, concepts such as informed consent, beneficence and non-maleficence are not likely to be foremost in Sam’s mind. Sam’s parents, busy with other commitments and perhaps comfortable in delegating decisions such as SP roles to Sam, may have offered limited guidance or potentially even reviewed the role prior to acceptance. This potential lack of involvement in the consent process is concerning given the legal requirement to provide informed consent for a minor – either by reading the role, talking to Sam or comprehensively discussing the requirements with simulation educators.

One could also argue that devoid of a ‘real person’ to play the role, healthcare professionals with realistic learner preparation and a dearth of quality clinical placements in mind may also pay limited attention or indeed be unaware of any potential negative outcomes.

Sam

Being an SP is an activity Sam enjoys and one that aligns with their overall career goals. Although this enthusiasm positively impacts Sam’s investment in preparation and role portrayal, it should not usurp due diligence by healthcare professionals in adhering to ethical principles. It is assumed that Sam’s parents/caregivers will be involved in providing informed consent. It is imperative this is a discussion that occurs very early in the recruitment process and is revisited before every SP opportunity. In addition to this being a legal requirement, it also serves as a safety net to ensure parents/caregivers are aware of the role requirements. This discussion can also allow for identification of any potential challenges that may result in an increased need for post-role support.

Regardless of age, Sam should be given a developmentally appropriate opportunity to learn about the requirements and expectations of SP work and provide informed assent in a manner that reflects their cognitive development level [17]. Assessing Sam’s ability to give informed assent requires an assessment of competence. Because adult consent already exists, a formal assessment of competence is not necessary. However, it remains essential before confirming Sam’s involvement, that they understand the situation, expectations and potential consequences of their decision [7].

Literature suggests that the benefits of SP work for young SPs outweigh the risks [18]. However, playing roles that are emotionally challenging can still have an adverse effect [19]. It is not only prudent to be aware of risks but also to mitigate these if possible. Encouraging an SP to critically consider their involvement is important, but equally so is informing them that they can withdraw, or be withdrawn, prior to or during the scenario. SPs such as Sam should be asked to think about whether the role is suitable for them; an exercise that should include parents/caregivers in Sam’s case.

Balancing the potential benefits of Sam’s involvement with the possible risks aligns with the ethical principles of beneficence and non-maleficence. Arming Sam with enough information to enable the provision of informed assent does not mean Sam has a good understanding of benefits and risk. There are a multitude of reasons why young SPs become involved in health professions simulation. Altruistic goals of improving healthcare for all young people through their role portrayal and feedback are cited as a primary rationale for their involvement. Along with altruism, an interest in drama/acting, improving their own communication skills and developing self-confidence are important. Financial remuneration in whatever form it comes (money, vouchers) is important, although not the most important reason for their engagement in SP work [20]. It might not be a mandatory requirement to identify their reason for involvement, but it can provide useful information that can help align the SP experience with the goals of the simulation and those of the young SP.

The issue of drawing on an SP’s lived experience is a debated topic. Authenticity of the role is important to a meaningful learning episode [21]. However, even in the presence of a pre-determined role outline, an SP drawing on their own experience, beliefs and values may deflect from the intended learning outcomes [22]. An SPs lived experiences can help shape a role, and make it more realistic for the learner. However, this can cause distress should the young person have an experience that resurfaces negative emotions. Young SPs such as Sam do have the ability to decline a role but often do not. Hearing their voice during scenario preparation and confirming their comfort level with the role, unfortunately, not an option for Sam can help protect their psychological well-being [23].

The simulation in which Sam is involved requires one SP. Sam is therefore the only young person on campus amongst a plethora of adults in educator, technology and SP roles. Although this is not an unrealistic or infrequent situation, it does raise some red flags around the suitability of the environment and the availability of support. Sam is younger than the role they are portraying, a point that should be identified to all involved educators. Additional considerations surrounding the engagement of a young person are perhaps not often considered when engaging adult SPs or actors. Sam is a sponge for all things associated with acting, including what happens in the environment. The use of inappropriate language, poor nutritional offerings and lack of developmentally congruent activities are important as they can negatively impact the experience. At such a young age, Sam still requires parental guidance, supervision and support. Without these crucial elements, the risk to Sam’s psychological well-being is very real.

Parents/family/caregivers

SPs, be they adults or young people, cannot prepare for something they have never experienced. Educating parents/caregivers about SP work, potential scenarios and associated expectations allows them to appropriately educate and support their child. This process should commence during the initial recruitment and orientation phase and be revisited at intermittent points during the young person’s period of involvement. Parents/caregivers should be informed about each distinct role and required preparation, duration of engagement and expectations of the young person and their parents during the scenario.

Sam may be 11 years old but presents as mature beyond their years. Sam’s parents delegate acceptance of SP roles to Sam, and in this case, they accepted the role on Sam’s behalf without actually reading the script. They were not actively involved in preparing Sam for participation or staying with Sam during the scenario. This is a situation where the risks potentially outweigh the benefit but the risks have not been fully recognized and thus put Sam in a very challenging environment that can and did have long-term consequences.

Sam’s parents are both employed in arts/drama-associated roles but did not recognize the situation as being potentially fraught with danger. Their involvement in role preparation, debriefing and provision of ongoing support should the adverse impacts of the role follow Sam into their ‘normal life’ should be an expectation. This can be challenging as their availability and possibly their interest may be limited. However, Sam needed someone dedicated to their well-being during the simulation, rather than being dropped off at the door. Unfortunately, a lesson learned by Sam’s parents after the scenario where the adverse effects became evident.

Sam’s initial response aligns with the literature suggesting the potential for short-term fatigue and anxiety immediately following simulation involvement [18]. If the role is psychologically intense or involves content that causes unease or embarrassment, young SPs may also experience transient discomfort [24]. Sam played such a role, and this is where their responses differed from the experiences documented in the literature. Sam was quiet, withdrawn and unusually, not eager to share their acting experience. This response generated parental concern, and it is this that triggered them to seek details about the role. Quite sometime after the simulation, Sam continued to withdraw from a conversation about the role, a worrying sign given their normally extroverted personality and willingness to excitedly share acting experiences with others.

SP educators

The involvement of young SPs increases the psychomotor, affective and cognitive learning of students [25]. Despite the positive impacts on learning and preparation for professional practice, the literature indicates that challenges and barriers still exist to the employment of children and/or young people in SP roles [22,26–27]. Simulation educators have a duty of care to ensure Sam’s well-being is monitored throughout the entire scenario from pre-brief through to post-simulation support. It is not enough to simply contact a young person, ask them to undertake a role, gain assent along with parental consent, observe their role portrayal and offer remuneration. At every step of this process, at least one simulation educator should be dedicated to the young person. Ensuring they truly understand the role and associated expectations, have access to developmentally appropriate activities and support when it is needed and a dedicated avenue for feedback and follow-up are all ethically responsible actions. Sam’s experience did not reflect these important aspects of safe SP practice.

Although Sam did not receive orientation to the environment or the role undertaken in this discussion, Sam was able to reflect on a general programme orientation and training session attended when they first became an SP. Sam indicated that the information, and style of delivery, was tailored to adult SPs. Had Sam’s parent(s) been present, the level of understanding may have been higher than that achieved by Sam attending independently. Sam voiced the need for orientation to be at least partially separate for young SPs so the content and delivery style can be developmentally congruent. This speaks to a need for further delineation of orientation/training/role-specific preparation into specific age/developmentally specific groups.

The fact that Sam is the only young SP involved in the scenario amplifies the onus of responsibility on SP educators. Research suggests that working with another SP, young person or adult has positive benefits [28]. A second person can offer support, a learning opportunity should the second SP be experienced, and a person to ‘bounce off ideas’ and keep the scenario on track. Sam’s experience may have been more positive had a second person been involved. Sam’s involvement was of limited duration, and they were expected to play the role only once. This reflects current guidelines suggesting young SPs should not be involved for an extended time period or repeat the role multiple times [29].

Additional considerations should focus on the environment for preparation and the actual scenario, along with detailing the need and the format for the SP to provide learner feedback. As previously mentioned, the environment in which Sam worked was concerning – perhaps not so for adult SPs, but definitely for Sam. Ensuring there is a safe and friendly working environment for young SPs is important to psychological safety and well-being. Despite being advised that the SP role involved giving learner feedback, Sam was not directly involved and neither was the question about their input raised. Although some young SPs prefer not to give feedback directly to learners, there are some who are comfortable in this role. The power of SP feedback is well documented, but simulation educators must consider alternatives to direct SP-learner feedback as this can be quite intimidating and curtail the free expression of their views [26].

Sam’s story elucidates the importance of key factors from multiple perspectives: Sam, their parents/caregivers and SP educators. Sam is 11 years old, but the character they were asked to portray had a backstory and faced consequences far beyond an 11-year-old’s level of understanding. Sam’s story reflects the Swiss cheese model, where a lack of due diligence or awareness causes errors in different areas that eventually line up and increase the potential for harm to occur [30].

Conclusion

Patient-centredness places the young person at the centre of their own experiences, and for this reason alone it is essential their voices are heard. Despite the potential young SPs can offer to SBE, there remains a plethora of barriers and challenges to their involvement. Not least of these are the ethical principles, safeguarding psychological safety, ensuring understanding of information, expectations and actual informed consent/assent through the use of developmentally appropriate language, content and delivery methods.

Preparing a young SP requires a different perspective that reflects their developmental understanding and recognizes their needs are different from those of adult SPs. Sam’s experience tells us that the potential for harm is real and can be long-lasting. It is therefore the responsibility of everyone involved in planning, implementing and evaluating simulation to ensure all strategies to safeguard well-being are implemented. One way to achieve consistent and safe practice is to ensure any future revisions of the ASPE standards incorporate domains and principles specific to the needs of young SPs.