The experiences and impact of nursing student acting as standardized patient: a qualitative study

This study utilized a qualitative exploratory research design grounded in the interpretivist paradigm. This paradigm prompted the use of semi-structured interview questions in the research design [14], enabling participants to elaborate on their personal interpretations rather than merely pursuing “objective” truths [15]. In the analysis process, emphasis was placed on the unique backgrounds of the participants, while avoiding the imposition of predefined categories [16]. Reporting adhered to the Standards for Reporting Qualitative Research (SRQR) framework [17].

The participants were nursing undergraduate students enrolled in higher education institutions in Macau. Inclusion criteria were as follows: (1) currently registered in the nursing program; (2) having at least one experience of acting as SPs; (3) aged 18 or above to ensure sufficient maturity; (4) possessing adequate language communication skills to clearly express their experiences and feelings in Chinese (Mandarin or Cantonese); and (5) voluntarily participating in the study and providing written informed consent. Participants were excluded if they: (1) had expressive disorders that would hinder their ability to recall and express personal experiences; (2) were unable to participate in the interview within the scheduled time of the study; or (3) showed severe emotional instability during the initial contact, which could compromise their well-being.

Recruitment strategies included: (1) posting recruitment notices on the bulletin boards of nursing education institutions and student groups; (2) utilizing social media and online platforms to broaden the recruitment scope; and (3) inviting students who had participated in the interviews to refer other eligible classmates. Purposeful sampling was employed to ensure that the sample included individuals from diverse backgrounds, with specific attention to variation in grade level, gender, and prior experience as SPs. Recruitment was managed by team members unaffiliated with the students’ current coursework.

The sample size was determined based on the concept of information power [18], which considers three key elements. First, the study’s narrowly defined objective—to explore how nursing students experience and are influenced by acting as SPs—combined with the high specificity of the cohort, as all participants had at least one prior SPs encounter and thus possessed concentrated experiential knowledge. Second, the anticipated quality of dialogue, facilitated by an interviewer with a PhD in Nursing and over a decade of experience in SPs-based nursing education and qualitative research. Third, the use of thematic analysis as the analytic strategy. Given these factors, a sample size ranging from six to ten participants was deemed adequate. Data saturation was reached by the tenth interview, when no further relevant new information was being contributed. These ten interviews were utilized for analysis. An additional two interviews were conducted to confirm the absence of additional emerging information, and they were excluded from the analysis. Exclusion was considered appropriate because the two supplementary interviews added no new codes or conceptual insights. Their removal served to maintain analytic focus and efficiency, and their omission did not compromise the study’s overall information power.

The research team developed an initial interview outline based on prior research experience and a literature review. This outline was refined through consultation with three experts: a nursing specialist, a simulation-based education expert, and a qualitative research methodologist. The revised outline was then employed for pilot interviews conducted with three nursing students who met the inclusion and exclusion criteria. The pilot interviews were not included in the analysis. The interview outline was finalized after the pilot interviews. The final interview outline is shown in Supplement 1.

All interviews were facilitated by a nurse educator with over 20 years of teaching experience and more than a decade of expertise in qualitative research. Recognizing the potential power dynamics due to the interviewer’s role as a course instructor for some participants, interviews were scheduled post-finals to encourage open responses. To accommodate the interviewees’ preferences, the interviews were conducted either face-to-face in a tutorial room at a school in Macau or via an online platform. Interviews were conducted in Cantonese or Mandarin to match participants’ language skills, ensuring clear communication and accurate expression. Each interview was recorded using a voice recorder, while the interviewer documented non-verbal cues exhibited by the participants. The interviews were conducted from June to July 2025. The average duration of the interviews was 28 min, with a range of 20 to 32 min.

The interview recordings were transcribed into verbatim transcripts by professional transcribers. The transcripts were then reviewed and revised for accuracy by a research assistant, who is currently pursuing an undergraduate in healthcare. The data analysis was based on Chinese transcripts, with relevant segments translated into English by the research team. Accuracy was ensured through cross-checking by a bilingual colleague not involved in the study.

The qualitative data analysis was performed using codebook thematic analysis [19], with NVivo 12.0 employed to facilitate data management and analysis Data analysis proceeded as follows: 1) Familiarization and initial coding: Two members of the research team independently reviewed all transcripts multiple times to ensure familiarity with the data. Inductive coding was applied to capture key concepts, phrases, and recurring patterns directly from the transcripts. Each code was defined and supported with illustrative examples to maintain traceability. This process yielded 87 initial codes, which were compiled into a preliminary code list. 2) Codebook construction and refinement: The research team conducted three iterative meetings to refine the codebook. Initial codes were grouped into overarching themes and subthemes through semantic analysis. For example, codes such as “Exam-readiness intention,” “Exam-anxiety reduction motive,” “Examiner-insight seeking,” and “Peer-learning aspiration” were consolidated under the subtheme “Academic and exam preparation,” which was categorized within the theme “Motivations for participating as SPs.” Redundant codes were merged (e.g., “Familiarize with clinical evaluation standards " and “Preview exam scenario perspectives” combined into “Exam-Readiness Intention”). The final codebook included three overarching themes, 15 subthemes, and 57 definitive codes, each with clear definitions and supporting data excerpts. A copy of the final codebook is provided in Supplement 2. 3) Independent coding and consensus building: Two trained coders independently applied the final codebook to all transcripts using NVivo 12.0. Inter-coder reliability was assessed with Cohen’s kappa (k = 0.86) indicating strong agreement. Discrepancies were resolved through discussion to align coding with codebook definitions and original data context; when consensus was not reached, a senior researcher mediated to achieve final agreement. 4) Theme boundary definition: Theme boundaries were defined based on three criteria: (1) distinctiveness, ensuring each theme’s core meaning did not overlap with others; (2) internal coherence, where subthemes within a theme shared a common conceptual focus; and (3) relevance, confirming that each theme directly addressed the study’s research objectives. For example, the theme “Motivations for participating as SPs " was distinguished from " Impact on academic and professional development " by defining the former as pre-existing drivers for participation, whereas the latter captured post-hoc changes attributed to the SPs experience. Boundary checks were conducted throughout independent coding, and ambiguities were resolved through team discussion.

To ensure the validity and reliability of the findings, the results were shared via email with all members of the research team, a selection of interviewees, and an external nursing educator who has over 10 years of qualitative research experience and holds a doctoral degree. The feedback received from these individuals was carefully considered, and the findings were revised accordingly to reflect their insights and suggestions. The coding matrix is provided in Supplement 2.

A critical aspect of qualitative research is recognizing how researchers’ positionality may influence data collection and interpretation. The research team comprised five members with complementary expertise. Three members with nursing backgrounds contributed clinical and practical insights, ensuring alignment with actual nursing contexts. One member specialized in educational theory, focusing on learning outcomes, the educational significance of the SPs role, and its effect on student learning. Additionally, a management specialist integrated consideration of organizational aspects, including resource allocation and program management.

Notably, two members had prior experience training students as SPs, introducing a potential bias toward portraying the role as educationally valuable.

To minimize potential researcher bias, a structured reflexivity protocol was adopted. Before engaging with the data, each team member prepared a positionality statement outlining prior experience with SPs methodology, assumptions regarding its educational value, professional or career interests related to the study’s outcomes, and anticipated blind spots. These statements were revisited at four predetermined checkpoints: after pilot coding, initial theme generation, preliminary thematic mapping, and final analytic review.

A total of ten nursing students participated in this study, comprising five males and five females. The participants included four second-year students, four third-year students, and two fourth-year students; no first-year students were included. The number of times they had acted as SPs ranged from one to four (Table 1).

The diverse motivations identified in this study resonate with prior research on student engagement in simulation-based roles. The findings of this study are consistent with existing literature reporting that participants emphasized altruism as a key motivation for engaging in SPs roles. Both nursing students and non-professionals often cited the opportunity to contribute to the education and training of future healthcare professionals as a significant driving force [20]. Furthermore, the results of this study are similar to those of prior studies involving nursing students, which demonstrate that they serve as SPs to develop skills and gain patient perspectives [8, 21]. These findings are in line with our results, further emphasizing the importance of these factors in driving student engagement in such roles.

However, this study identified two novel and previously underexplored motivational drivers that diverge from existing literature: academic/exam preparation and the importance of tangible incentives. Unlike prior research, which framed nursing students’ participation as SPs as motivated by skill development, our study found participants explicitly emphasized OSCE preparation. This indicates that for nursing students, SPs roles serve not only as a learning tool but also as a strategic exam-preparation tactic. Their proactive effort to reduce exam anxiety by familiarizing themselves with assessment processes likely arises from the pressure to perform well in structured evaluations like the OSCE [22]. This aligns with existing findings that exposure to exam environments enhances performance and mitigates stress, as students gain clarity on expectations and procedures [23].

Similarly, the emphasis on tangible benefits (e.g., course credits, volunteer hours) as a motivator adds nuance to existing literature, which has often framed student SPs participation as primarily intrinsic (e.g., driven by professional growth). Our participants noted that SPs activities were appealing because they aligned with academic requirements, highlighting that practical incentives—particularly those integrated with curriculum demands—play a significant role in nursing students’ decision to participate. This suggests that nursing students, balancing heavy academic loads, may weigh the instrumental value of activities alongside intrinsic motivations [24]. The findings suggest that aligning SPs activities with academic requirements enhances participation, offering practical insights for educators designing such programs.

Macau’s unique cultural blend—rooted in Confucian ethics, collective-oriented social norms, and a fusion of Eastern care traditions with Western medical education—exerts distinct impacts on students’ motivations for SPs participation. motivations for SP participation are shaped by collective rather than purely individual goals. Macau students frequently framed their participation as “contributing to peers’ learning” and “supporting the program’s training objectives”—a reflection of Confucian values of group harmony and interpersonal reciprocity. This collective motivation enhanced role investment but implies transferability limits: in individualistic regions, explicit individual incentives may be needed to replicate similar engagement.

While the positive impacts of SPs participation on nursing students’ academic growth and professional development observed in this study align with existing literature, this research more importantly uncovers understudied mechanisms underlying these benefits and supplements the cognitive framework of current simulation-based education through a role-reversal perspective—rather than merely reiterating known conclusions. A systematic review has confirmed that nursing students acting as SPs enhance their theoretical knowledge and clinical skills [25], with most existing studies attributing this improvement to passive reinforcement via repeated script review and symptom simulation [26]. However, this study revealed that knowledge deepening essentially stems from a transition to active construction of disease cognition: when serving as SPs, students shift from passively receiving disease knowledge from instructors to proactively integrating symptom manifestations, patient experiences, and clinical judgments to construct clinically logical patient roles. This active knowledge reconstruction deepens theoretical understanding far beyond rote memorization, aligning more precisely with the core mechanisms of active recall and simulation in enhancing theoretical cognition [27, 28]. It corrects the oversimplified perception in existing research that the SPs role is merely a tool for skill practice, highlighting its active value in knowledge internalization.

Moreover, the experiences of acting as SPs refine clinical skills through observational learning, which aligns with the principles of social learning theory [29]. This study found that the core value of this observational learning lies not in imitating best practices but in reconstructing skill evaluation criteria through the patient perspective. When students experience peers’ operations as SPs, their observation focus shifts from whether procedures are standardized to the actual impact of operations on patients. This expanded evaluation dimension transforms clinical skills from technical tasks back to patient-centered comprehensive behaviors, complementing the conclusion in existing research that observational learning emphasizes technical replication [30]. More crucially, this perspective shift directly challenges the traditional simulation-based education paradigm where instructors are the sole evaluators, integrating the patient perspective as a core dimension into the skill evaluation system [31].

Our finding that SPs participation strengthens professional identity represents the most significant expansion of existing literature—its core contribution lies in revealing a new pathway for professional value internalization and triggering critical reflections on power dynamics in OSCE and simulation-based education. Existing research notes that learning from the patient perspective enhances professional identity [32], but fails to clarify how this learning transcends the theoretical limitations of classroom ethics discussions. This study found that the SPs role converts abstract concepts such as patient-centered care and behavioral impact on patients into personalized, sensory experiences through embodied experience of patient vulnerability [8]. For example, simulating postoperative pain allows students to intuitively perceive the harm of neglecting position adjustment during nursing operations. Such experiences internalize professional responsibility from cognitive awareness to emotional recognition, enabling an essential shift from knowing patients come first to truly recognizing one’s responsibility to patients [33]. This transformation not only deepens understanding of professional identity formation mechanisms but also directly impacts the power structure in traditional simulation-based education and OSCE.

Traditional OSCE and simulation-based education feature a clear power hierarchy: instructors/examiners hold absolute authority in knowledge transmission and skill evaluation; SPs passively execute preset scripts as standardized tools; and students occupy a subordinate position as evaluated objects. This power imbalance disconnects simulated scenarios from the power dynamics of real clinical settings—where nurses must establish equal collaborative relationships with patients, rather than one-way service-provider/service-recipient or evaluator/evaluated relationships. In contrast, the role-reversal practice of students acting as SPs in this study essentially reconstructs this power structure. First, in simulation-based education, students transition from passive evaluands to active participants in scenario construction. Their portrayal of patient roles directly influences peers’ learning outcomes, and they can even provide critical feedback on peers’ skills based on personal experiences, forming a flattened power relationship of peer mutual evaluation and learning. Second, in OSCE, students who have served as SPs no longer view examiners as authoritative judges but form independent judgments on skill rationality based on the patient perspective. This cognitive shift makes students focus more on the clinical significance of operations than meeting examiners’ evaluation criteria, transforming OSCE from standardized assessment tools back to simulated arenas for real clinical decision-making.

This adjustment of power dynamics may reshape the core objectives of simulation-based education. Traditional simulation emphasizes instructors transmitting standardized knowledge and skills to students—centralized power ensures consistency in knowledge transmission but suppresses students’ critical thinking. In contrast, the decentralized power brought by SPs role-reversal enables students to gradually develop patient needs-centered independent decision-making awareness through experiencing patient power and exercising peer evaluation power. This awareness embodies the core of nursing’s moral responsibility: the transition from executing nursing tasks taught by instructors to independently adjusting nursing behaviors based on patient experiences. This shift represents the most groundbreaking value of SPs participation in professional development, providing a critical correction to the skill-focused, value-neglected tendency in current simulation-based education [33].

A notable finding is that lower-grade nursing students struggled with SPs roles involving clinical content beyond their curriculum. However, non-healthcare professionals, despite weaker healthcare knowledge, rarely cite knowledge limits as a barrier to effective SPs performance [34, 35]. This difference likely stems from varying role expectations. Nursing students, with their professional training, may hold themselves to stricter standards for clinical accuracy. Non-professionals, however, often prioritize following scripts, which reduces their focus on knowledge gaps. This dynamic underscore the need for targeted strategies to boost the self-efficacy of junior nursing students in SPs roles, transforming their professional learning background into an asset rather than a constraint.

This study found that nursing students acting as SPs often experience a distinct form of role conflict. They feel a natural inclination to guide their peers when they observe procedural errors but are required to remain neutral, especially during assessments. This tension is unique to nursing students, as non-healthcare SPs, who lack extensive healthcare knowledge and focus less on clinical accuracy, rarely encounter such conflict [7]. However, this challenge presents a valuable opportunity for nursing educators. By integrating student SPs into teaching rather than assessment contexts, educators can transform this conflict into a teaching tool. During post-teaching debriefings, student SPs can share their observations of their peers’ performance, turning internal tension into a productive discussion that enhances teaching effectiveness. Conversely, when student SPs are used for assessment purposes, the conflict makes them better suited to formative rather than summative evaluation. In summative settings the demand for strict neutrality is likely to intensify role conflict, potentially compromising both the validity of the assessment and the learning experience of the student SPs themselves.