Partial Substitution of Simulation-Based Learning Allows Equal Student Self-confidence in the Acute Care Setting: A Pilot Study : Journal of Acute Care Physical Therapy

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Partial Substitution of Simulation-Based Learning Allows Equal Student Self-confidence in the Acute Care Setting

A Pilot Study

Dale, Daniel C.; Perlow, Ellen R.; Lucado, Ann M.

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Journal of Acute Care Physical Therapy 14(1):p 10-17, January 2023. | DOI: 10.1097/JAT.0000000000000199
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Over the past decade, clinical site placement in physical therapist (PT) education has become increasingly difficult in the acute care and intensive care unit (ICU) environments.1–13 The growing acuity of patients with complex diagnoses and comorbidities in these environments may be a hindrance to student placement.9–11,14–16 The skills required and the risk involved with treating medically complex patients may prove impractical for student placement. Placement of students in acute care settings can be difficult in integrated clinical experiences (ICEs) and full-time clinical education experiences. The Commission on Accreditation in Physical Therapy Education (CAPTE) requires ICEs, defined as students participating in purposively organized experiences within the didactic curriculum and are generally of a shorter duration.17,18 Full-time clinical education experiences are at least 35 hours per week.17,18 Clinical sites may open these acute care opportunities to students in their terminal full-time clinical experiences. Terminal full-time clinical experiences are defined by the American Council of Academic Physical Therapy (ACAPT) as “a single, or set of, full-time clinical education experience(s) designated to achieve the minimum number of weeks set forth by the Commission on Accreditation in Physical Therapy Education (CAPTE) that occurs after the student has completed the didactic curriculum of a physical therapist professional education program.”18 In these experiences, the expected outcome is entry-level performance.17,18 However, earlier placement of students in varying health care disciplines can prove to be difficult for academic institutions.3,19 Productivity demands, high-stress environments, and clinician burnout may be reasons why clinical placement is becoming increasingly difficult in acute care and ICU environments.12 Moreover, increased mergers and acquisitions of large medical centers have resulted in fewer available sites.12,15 Therefore, health care simulation has been explored as a potential solution to provide students with early exposure to common acute care scenarios to better prepare them for later clinical education experiences in this environment.

Simulation, as it pertains to health care education, is defined as “a technique that creates a situation or environment to allow persons to experience a representation of a real event for the purpose of practice, learning, evaluation, testing, or to gain understanding of systems or human actions.”20 The Society for Simulation in Healthcare is a leader advocating for the use of simulation and identifies 4 main purposes: education, assessment, research, and health system integration.21 Each of the identified purposes facilitates patient safety. Teaching through the implementation of health care simulation provides hands-on learning experiences that allow the learner the freedom to make mistakes in an environment where no harm will come to the patient or health care team. Learning experiences can be developed with all ranges of expertise and talent in mind. Finally, simulation allows for detailed feedback and evaluation, provided through formal debriefing and assessment, as outlined in the International Nursing Association for Clinical Simulation and Learning (INACSL) Standards of Best Practice.22

Simulation in health care is an established education model in medical and nursing programs.15,23–25 For example, Hayden and colleagues15 found that nursing students exposed to varying levels of substitutions with simulation-based learning had comparable changes in knowledge, clinical competency, critical thinking, and self-efficacy. While all new graduates reported feeling prepared for clinical practice, the students who had the most exposure to simulation-based learning experience (SBLE) consistently reported higher levels of self-confidence.15 This teaching mechanism has only recently become more formalized in PT education over the past decade. Research has been conducted on simulation in PT education programs, focusing on outcomes including student self-confidence,2,3,5,7–11,25–32 clinical performan-ce,3,5,9,11,14,26,28,30 and clinical-reasoning skills.3,5,6,9,16,26,29,30,33

The ACAPT convened a Strategic Initiative Panel on Simulation (SIPS) to investigate simulation in PT education. The SIPS provided a preliminary report on the current utilization of simulation in PT education and the perceived benefits for students.25 Ninety-two percent of the responding institutions (81 of 136 participating programs) noted some form of simulation being used in their respective PT education programs. Eighty-six percent included at least 3 SBLEs during the course of the academic program. The majority of programs that responded to the SIPS survey reported a high prevalence of acute care simulation-based learning activities (94%). Finally, 69% have plans to expand the use of simulation in their respective PT programs.25

The SIPS report noted the following perceived benefits of SBLEs. First, physical therapy faculty recognized the benefit of helping students prepare for clinical experiences by increasing student self-confidence and self-efficacy. Second, faculty perceived value in providing experiential learning through an authentic learning environment. Third, faculty noted the ability to challenge and enhance student clinical decision-making through simulation. Finally, faculty noted how simulation allows for individualized learner assessment and feedback, including feedback in the affective domain.25

The SIPS report also explored how other health care professions use simulation to substitute for on-site clinical education experiences. In nursing, activities completed in a simulation environment can account for up to 50% of required clinical time, depending on state law.19,34 In the profession of pharmacy, simulation can meet up to 20% of the required interprofessional education activities, including clinical experiences, as set forth by the American Association of Colleges of Pharmacy.23,24 The Accreditation Council for Occupational Therapy Education (ACOTE) allows for “simulated environments” and “standardized patients” to meet the accrediting standard related to level 1 fieldwork experiences.35,36 In response to the COVID-19 pandemic, more leniency has been allowed by the ACOTE.35,36 Currently, the CAPTE has not approved the use of simulation to replace full-time clinical experiences.18

Research that examines the outcomes of substituting simulation for traditional clinical experiences exists in the nursing literature, as they have examined the effect of health care simulation as an alternative for on-site clinical education experiences. The National Council of State Boards of Nursing landmark study in 2015 involved students who received either traditional full-time clinical experiences or replacement of the experience with either 25% or 50% of health care simulation-based learning.15 No significant differences in students' self-confidence, National Council Licensure Examination pass rates, or perceived job readiness by employers were demonstrated between groups.15 With the projected shortage of acute care clinical education site placements in physical therapy due to factors previously mentioned, health care simulation needs to be investigated as a possible adjunct mode of teaching to better prepare students for these experiences in the physical therapy profession.15

To date, only 2 studies in the physical therapy literature have explored the idea of substituting simulation-based learning for on-site clinical education experiences, both based out of Australia.1,13 The 2 studies replaced traditional clinical placement with standardized patient interactions for 1 week of a 4-week clinical experience in the musculoskeletal and cardiopulmonary areas of practice. Participants were volunteer physical therapy students entering an acute care cardiorespiratory clinical placement1 or an outpatient musculoskeletal clinical placement13 at varying stages in their academic programs. This replacement of 25% of a clinical experience indicated no significant differences between groups in performance. Competency of performance was assessed by PT educators using the Assessment of Physiotherapy Practice, which is a validated measure of competence with high interrater reliability (intraclass correlation coefficient [ICC] = 0.92; 95% confidence interval, 0.84-0.96).1 Both studies used standardized patients for simulating patient care. However, the usage, procurement, and training of standardized or simulated patients, defined by the Healthcare Simulation Dictionary, can be time-consuming and costly and may not be feasible for academic programs with smaller budgets.37 More research is needed to determine whether SBLEs in PT education can be used as a possible substitution for traditional clinical experiences. This study examines whether a 20% substitution of an SBLE during a PT ICE produces differences in student confidence in the acute care setting.


Thirty-eight students from a single doctor of physical therapy (DPT) cohort participated in ICE as part of their coursework. The selected ICE occurs in semester 2 of the 8-semester DPT program. During this ICE, students participate in a total of 5 days in the clinic, dispersed over the course of the semester. Each day of the ICE consists of students participating at a physical therapy clinical site in an interdisciplinary setting (acute care, inpatient rehabilitation facility, ICU, skilled nursing facility, or hospital-based outpatient facility). Students perform hands-on skills as directed by the licensed PT, who acts as the clinical instructor. Normal tasks in which the student may participate include performing a chart review, taking a subjective and objective history, performing objective tests and measures, such as range of motion and muscle testing, and performing basic functional mobility tasks with a patient, such as bed mobility, transfers, or guarding during gait training. Students are introduced to lines and tubes, laboratory value interpretation, electronic medical record systems, safe patient handling equipment, and interprofessional communication.

Students from the selected cohort were randomized into 2 groups prior to the start of the academic semester; 17 students did not complete the study. The control group (n = 10) received the normal allocation of ICE days (5), with no simulation experience during the semester. The experimental simulation group (n = 11) received 4 days of ICE and 1 day of SBLE (20% of the ICE). The SBLE was conducted at midterm for all students in the experimental simulation group, following their participation in 2 days of ICE. The SBLE involved the completion of one 5-hour laboratory (see Table 1). The first half-hour of the laboratory consisted of using a high-fidelity manikin to practice basic examination skills, such as taking vital signs, auscultating heart and lung sounds, and finding anatomical landmarks. During the remaining 4 hours, students played the role of student physical therapist (SPT) once and the role of the simulated patient once, portraying various acute care scenarios in 1:1 student-to-simulated patient encounters. Students playing the role of the patient were provided training from a faculty member regarding their role as the patient. Also, students were provided a standardized script to follow. Students conducted a chart review in a simulated electronic medical record before each patient encounter. Students had access to a simulated physician, played by a single faculty member, to help clarify any orders, if needed.

TABLE 1. - Simulation Day Schedule
Total Time Activity
30 min Basic assessment skills (vital signs, lung sounds) on high-fidelity manikin
30 min Chart review and interprofessional interactions
60 min Patient treatment
60 min Formal debrief
60 min Patient treatment
60 min Formal debrief

The simulation followed INACSL Standards of Best Practice for simulation, including prebriefing and debriefing, to promote optimal learning.22 The Promoting Excellence and Reflective Learning in Simulation, or PEARLS approach, was used during debriefing.38 The PEARLS approach was chosen for its comprehensive approach to student reflection and learning.22,39 The simulation had clearly defined objectives related to patient examination, mobility, and safety, similar to the objectives for ICEs. The goals of the SBLE focused on psychomotor skills being used in the traditional ICE, such as bed mobility, transfers, gait training, and patient education. Students also exercised skills in the affective domain, working on communication and building rapport with patients and the interdisciplinary team.

Student confidence was measured at 3 unique points throughout the semester using the Acute Care Confidence Survey (ACCS).4,40 Students from both the experimental and control groups completed the ACCS prior to the semester, at midterm, and the conclusion of the 16-week semester. When the survey was administered at midterm, all students had completed 60% of the course. The experimental group had completed the SBLE along with 2 days of ICE, and the control group had completed 3-days of ICE.

The ACCS measures PT student self-confidence in preparation for acute care clinical education.4,40 The measure consists of 15 items ranked on a visual analog scale scored from 0 to 100 and measures the student's perceived confidence in performing tasks related to acute care. Higher scores from a participant on an item on the ACCS indicate higher perceived confidence. Examples of items include hearing the first sound when taking blood pressure in acute care and performing a transfer from a hospital bed to a wheelchair with a patient who requires maximum assistance. The ACCS has previously been found to have excellent test-retest reliability (ICC = 0.915) and content validity, as confirmed by a panel of expert practitioners.40 The ACCS has also demonstrated a low to moderate ability to predict clinical performance as measured by the Physical Therapist Clinical Performance Instrument41 through 4 specific ACCS items, including judgment regarding appropriate instruction in bed mobility, judgment regarding the frequency of treatments, judgment regarding assistance with transfers, and ability to justify physical therapy to a physician.4,40 These skills are consistent with the American Physical Therapy Association's Academy of Acute Care Core Competencies for Entry-Level Practice.14

Statistical Analysis

Descriptive statistics were used to summarize participant information. Baseline characteristics between groups were compared using the Mann-Whitney test for continuous data and the χ2 test for categorical data. A repeated-measures general linear model was used to examine within- and between-group differences in confidence as measured by the ACCS over the 3 time points (initial, midterm, and end of the semester). Post hoc pairwise comparisons were performed using independent t tests. Missing data for either the midterm or final ACCS scores for 4 students in the simulation group and 8 in the control group were imputed by carrying the last observation forward. Statistical analysis was completed using SPSS Version 24 (SPSS Inc, Chicago, Illinois). An a priori α level of 0.05 was used for all data analysis.


Groups of first-year DPT students were similar at baseline. No statistically significant difference was found between groups for age, gender, ethnicity, or ACCS score at baseline (see Table 2). Repeated-measures testing demonstrated a time effect for acute care confidence, which improved significantly within both groups over time with total scores (see Table 3) and individual items (see Table 4) on the scale. A between-group interaction effect was demonstrated on 4 specific items on the ACCS; post hoc analysis revealed significant differences between group changes in scores in favor of the simulation group at midterm on these items and on the ACCS total score (see Table 5). However, no statistically significant difference was found between group scores at the end of the semester (see Table 5). The experimental group, who received SBLE, demonstrated a greater change in total score and scores on items 7, 8, 12, and 13 on the ACCS at midterm. These items include confidence in ambulating a patient with an intravenous (IV) pole in the acute care setting (item 7), instructing a person to get out of bed after a total hip replacement in the acute care setting (item 8), safely assisting a patient with supine to sitting positions who has a chest tube in the acute care setting (item 12), and educating a nurse on how to properly transfer a patient who is touch-down weight-bearing in the acute care setting (item 13).

TABLE 2. - Demographic Data
Variable Group 1 (Simulation, n = 11) Group 2 (Clinical, n = 10) P Value
Age, mean (SD), y 23.6 (0.81) 24.7 (1.2) .31
Female gender, n (%) 9 (82%) 7 (70%) .53
White ethnicity, n (%) 10 (91%) 9 (90%) .94
ACCS at baseline: mean (95% CI) 494.1 (314.7-673.5) 640.1 (466.0-814.2) .60
ACCS, Acute Care Confidence Survey; CI, confidence interval; SD, standard deviation.

TABLE 3. - Acute Care Confidence Survey Score Total Repeated-Measures Time Effect
Group 1 (Simulation, n = 11) P Value Group 2 (Clinical, n = 10) P Value Mean (95% CI)
Initial Mean (95% CI) Midterm Mean (95% CI) Final Mean (95% CI) Initial Mean (95% CI) Midterm Mean (95% CI) Final Mean (95% CI)
Total ACCS scorea 494.1
<.001 640.1
ACCS, Acute Care Confidence Survey; CI, confidence interval.
aTotal ACCS score is ranked from 0 to 1500.

TABLE 4. - Student Confidence by Item on the Acute Care Confidence Surveya
Questions Group 1 (Simulation, n = 11) Group 2 (Clinical, n = 10)
Initial Mean (95% CI) Midterm Mean (95% CI) Final Mean (95% CI) Initial Mean (95% CI) Midterm Mean (95% CI) Final Mean (95% CI)
(1) How certain are you that you can put a blood pressure cuff on a patient correctly in the acute care setting? 84.5
(2) How certain are you that you can determine if a patient is safe to go home from the acute care setting? 18.1
(3) How certain are you that you can decide if a person needs subacute rehab? 14.7
(4) How certain are you that you can safely perform a max assist transfer from a hospital bed to a wheel chair in the acute care setting? 15.8
(5) How certain are you that you can hear the first sound when taking a blood pressure in the acute care setting? 75.5
(6) How certain are you that you can accurately measure a person's knee flexion in the acute care setting? 81.8
(7) How certain are you that you can ambulate with a patient who has an IV in the acute care setting? 35.4
(8) How certain are you that you can instruct a person to get out of bed after a total hip replacement in the acute care setting? 25.4
(9) How certain are you that you can educate a physician that a patient does not need physical therapy in the acute care setting? 17.0
(10) How certain are you that you can determine an appropriate frequency of physical therapy for a patient in the acute care setting? 16.8
(11) How certain are you that you can interpret your patients' hematocrit results to determine the appropriateness of PT intervention in the acute care setting 37.4
(12) How certain are you that you can safely assist a patient with supine to sitting positions who has a chest tube in the acute care setting? 15.2
(13) How certain are you that you can educate a nurse on how to properly transfer a patient who is touch-down weight-bearing in the acute care setting 13.5
(14) How certain are you that you can identify when you need a second assistant with transferring a patient in the acute care setting? 29.3
(15) How certain are you that you can properly position a patient in bed with hemiplegia in the acute care setting? 13.7
CI, confidence interval; IV, intravenous; PT, physical therapist.
aEach ACCS item is ranked from 0 to 100.
bIndicates statistically significant group interaction effect.

TABLE 5. - Mean Difference in Change of Scores Between-Groups Pairwise Comparisons
Significance (2-Tailed) Mean Difference Between Groups 95% Confidence Interval of the Difference
Lower Upper
ACCS total score Baseline to midterm .01a −366.54 −631.00 −102.08
Midterm to final .29 131.25 −128.58 391.09
Baseline to final .14 −235.28 −551.96 81.40
(7) How certain are you that you can ambulate with a patient who has an IV in the acute care setting? Baseline to midterm .01a −35.35 −62.63 −8.08
Midterm to final .12 14.39 −4.35 33.13
Baseline to final .17 −20.96 −51.34 9.42
(8) How certain are you that you can instruct a person to get out of bed following a total hip replacement in the acute care setting? Baseline to midterm .00a −39.78 −63.47 −16.10
Midterm to final .07 29.32 −2.97 61.61
Baseline to final .53 −10.46 −44.76 23.83
(12) How certain are you that you can safely assist a patient with supine to sitting positions who has a chest tube in the acute care setting? Baseline to midterm .02a −30.64 −54.79 −6.49
Midterm to final .81 2.59 −20.73 25.91
Baseline to final .06 −25.57 −52.29 1.14
(13) How certain are you that you can educate a nurse on how to properly transfer a patient that is touch-down weight-bearing in the acute care setting? Baseline to midterm .02a −39.26 −71.34 −7.18
Midterm to final .50 7.58 −16.60 31.75
Baseline to final .07 −28.51 −59.16 2.14
ACCS: Acute Care Confidence Survey; IV, intravenous.
aStatistically significant at P < .05.


When assessing confidence through the ACCS, students demonstrated statistically significant improvements from initial to final assessment, regardless of group. Whether a student participated in the simulation group or the control group did not negatively affect student confidence. Students in the simulation group who completed the SBLE demonstrated a greater shift in feeling more confident than the control group at midterm in 4 acute care-specific psychomotor skills (see Table 4). These include student confidence when: ambulating a patient who has an IV (item 7), instructing a patient how to get out of bed after a total hip replacement (item 8), assisting a patient with a chest tube from supine to sitting positions (item 12), and educating a nurse on how to properly transfer a patient who is touch-down weight-bearing (item 13). However, by the end of the semester, confidence scores for both groups were comparable for all 15 items of the ACCS. One possibility for the difference at mid-term is that students in the control group may not have had the opportunity to perform certain psychomotor tasks in the acute care setting. Due to the nature of acute care and the acuity of the patients, it is possible that certain clinical instructors did not provide students the opportunity to perform these skills, perhaps leading to lower early shifts in confidence scores in the ICE group. Students in the experimental simulation group did have the opportunity to work with simulated patients on these skills, perhaps increasing their self-confidence.

Simulation in health care allows the learner to train in a realistic, life-like environment while allowing them to think and practice freely. Students have the freedom to make mistakes that cause no harm to a patient in an environment that encourages reflection. Previous literature has shown that health care simulation better prepares learners for real-time decisions related to patient care.5,6,9,15,16,26,32,42 Additionally, higher student self-confidence has been associated with improved performance in the acute care setting.5,7,9,11 This is especially important in situations that involve medically complex patients. Anecdotally, students in our DPT program have previously reported that hands-on time during ICEs can be limited. Clinical instructors commonly manage situations in ICE that could be overly complicated or pose a risk to the patient. The student is often only observing in these scenarios and does not get to participate in the clinical reasoning or management of the situation. In these cases, the clinical instructor should limit the risk of harm to the patient.

Health care simulation and SBLE aim to provide the same fidelity of clinical experiences in a simulated manner, allowing the learner to have a realistic learning opportunity in these high-stress environments. This current study may lead to future research that explores the usage of SBLE to augment ICE in PT education. Increasing the use of SBLE could potentially reduce onboarding times for students in acute care experiences.15 Furthermore, SBLE may ease the burden of both academic and clinical sites by producing equally confident and prepared students. Academic programs must best prepare students to succeed in these environments, despite the perceived shortages in acute care clinical experiences. Substitution of SBLE in other areas of health care education has shown to produce similar outcomes to standard experiential learning.15,19,23,24

It should be noted that these researchers do not believe that SBLE should ever completely replace the clinical education experience. Even when simulation is created using best standard design methods, it still cannot fully replicate the authenticity, fluidity, and fast-moving environment that is the clinical education experience. Current CAPTE standards state that PT education programs in the United States must contain at least 30 weeks, or 1050 hours, of clinical education.18 According to the CAPTE, “integrated experiences cannot be satisfied with patient simulations or the use of real patients in class; these types of experiences are too limited and do not provide the full range of experiences a student would encounter in an actual clinical setting.”18 However, the CAPTE endorses simulation as a teaching opportunity, as long as programs meet the full 30-week clinical education requirement. Additionally, programs must meet their own requirement for clinical education hours, as described in their curricular documents.

Physical therapy as a profession has started to focus on best practices for simulation in PT education. However, as of yet, no physical therapy discipline-specific document guiding the delivery of simulation has been created. In 2020, ACAPT's Simulation in Physical Therapy Education Consortium (SIPTEC) was formed to address this need. SIPTEC “represents ACAPT institutional members with a strong interest in simulation as a pedagogical approach to the education and professional development of PT students, residents/fellows and clinical educators.”43 Creation of SIPTEC is a foundational step in exploring and promoting health care simulation in PT education.

Further research is needed on simulation usage in PT education. Our study provides one successful model of SBLE that partially substitutes for ICE without negatively impacting student confidence. We believe that increasing student confidence may also impact student readiness for clinical education in the acute care environment. We infer that increases in student confidence and readiness may potentially make these students more attractive for placement in these complex environments for clinical education programs. This study examined one model of SBLE at a single site, which is a limitation of this study. Additionally, the results of this study should be interpreted with caution because the sample size was small, and not all students fully completed the surveys. Moreover, students played the role of the simulated patient, which may not reflect a high level of fidelity related to how actual patients may respond or present. Therefore, a limitation of this study is that increases in student confidence may not carry over to the clinical environment due to the limited training of the student actors.

Future studies should aim to be collaborative between institutions to improve statistical power and generalizability of study findings to other settings. Research should examine the timing of the SBLE in the curriculum and how that affects student learning and confidence. Future research could also explore the differences in outcomes when using students versus standardized patients. Finally, further research should examine beyond confidence scores of the student by including faculty and clinical instructor assessment of the student's competency following SBLEs. This would allow for investigating whether student readiness and confidence are associated with increased competence in the acute care environment.


This pilot study found that 20% substitution of SBLE during a PT ICE produced equal improvements in student self-confidence compared with traditional ICE in the acute care setting. Therefore, augmenting ICE with SBLE may provide relief related to student placement in acute care settings.


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