Preparing Physiotherapy Students for Clinical Placement

Student Perceptions of Low-Cost Peer Simulation. A Mixed-Methods Study

Abstract

Introduction 

Simulation is increasingly used in health care education, yet the organizational and financial costs can be prohibitive. This study aimed to investigate whether peer simulation is perceived by third-year undergraduate physiotherapy students as valuable for clinical placement preparation.

Methods 

Third-year undergraduate physiotherapy students participated in a 9-week peer simulation program, using each other as patients, and were invited to complete two surveys evaluating perceptions of the program. The program consisted of weekly patient interactions during which students were required to assess and treat a “patient” under strict simulation guidelines and in accordance with stated learning objectives. Items rated included self-perceived skills, confidence, time management, and clinical placement readiness and included collection of qualitative responses. Surveys were released at commencement and completion of the simulation program.

Results 

Of 79 third-year students, 63% completed survey 1 and 66% completed survey 2. Students had high expectations of the program and these were consistently met. Peer simulation rated highly for all items, including identifying knowledge and skill deficits, and improving confidence, clinical reasoning, time management, and communication. Simulation was considered safe, supportive, engaging, and valuable for clinical placement preparation. Students identified some lack of authenticity when working with peers.

Conclusions 

Peer simulation was perceived by students as valuable in preparing them for clinical placement, despite a perceived lack of realism. These findings support the use of peer simulation as an alternative to the use of more formalized standardized patients in an undergraduate physiotherapy program. Further investigation is required to establish a detailed cost analysis of the program and to determine the amount of realism required to optimize the benefits of this promising educational strategy.

Simulation is an educational technique that uses guided, interactive experiences to reflect real experiences.¹ Simulation is recognized as a legitimate educational tool in health disciplines to enhance student clinical skills,^2,3 optimize transfer of skills,⁴ and augment or partially replace clinical training.⁵ Simulation is used to educate, train, and provide students with practice opportunities for skills that they will be required to demonstrate in a clinical setting.¹ This encourages the transfer of theoretical knowledge to clinical practice.

A simulated patient is defined as “an individual who is trained to portray a real patient to simulate a set of symptoms or problems used for healthcare education, evaluation, and research.”⁶ The terms simulated patients and standardized patients are often used interchangeably in the literature and will be described as SPs in this article.^7,8 There is mounting evidence for the use of simulation to train physiotherapy students using SPs.^3,5 Recent systematic reviews conclude that simulation-based learning is valued by physiotherapy students with no detrimental outcomes reported when working with SPs.^9,10 However, inherent methodological weaknesses in available literature limit the conclusions that can be derived about the contributions of SPs to physiotherapy education.⁹ Health Workforce Australia recently trialed a national simulation project, using trained actors as SPs, with 1790 physiotherapy students across 16 schools of physiotherapy in Australia.¹¹ The simulation program was highly valued with students reporting improved clinical confidence and supervisors reporting more “clinic ready” students.¹¹ Students valued the opportunity to practice a clinical interaction without risk.¹¹ However, published barriers to high-fidelity simulation include financial costs,^12–14 availability, recruitment and training requirements of actors, and lack of availability of simulation equipment and facilities.^11,12 Consequently, educators continue to explore innovative methods of delivering low-cost, high-value simulation.

Of particular interest is the extent of realism or “fidelity” required during simulation for reported benefits to be achieved. The extent to which simulated tasks are a believable substitute for real tasks, their “psychological fidelity,” is important to achieve effective skill transfer and requires participants to interact and respond to the simulation scenarios as they would in reality.¹³ Health care simulation has traditionally used mannequins with physiological monitoring, used SPs who may be professional actors trained to accurately portray a patient presentation, and/or replicated a genuine healthcare setting. However, the cost and accessibility barriers to such simulation prompt the need to explore the educational benefits of more basic, accessible, and functionally realistic simulation learning activities.^13,15,16 Hamstra et al¹⁷ propose that the term “fidelity” is inherently flawed and that educators should instead focus on functional task alignment (aligning the simulator's functional properties with the requirements of the task) rather than physical resemblance when designing simulation-based educational activities.

Also known as “role-play” and “peer role-play,” peer simulation is the process of engaging fellow students to portray patient scenarios.^18–21 For the purposes of this investigation, the term “peer simulation” will be used. Peer simulation does not require paid actors and may be useful in teaching and training scenarios where accuracy and standardization of portrayal are not imperative. Extensive training of “patients” is thus unnecessary for authenticity because the scenarios are somewhat familiar, particularly to senior students who have sufficient theoretical background. As such, the functional task alignment and accessibility of peer simulation are high.¹⁷

The literature to date provides mixed results on the value of peer simulation (or role-play) compared with SPs in health sciences education. Most promisingly, peer simulation compares favorably with SPs for the training of communication skills in medical students and qualified health professionals.^19,21–24 Peer simulation and SPs were both well accepted and perceived as highly realistic and useful for training communication skills by prefinal year medical students.²¹ However, SPs were found superior to peer simulation for enhancing clinical skills in musculoskeletal assessment and rehabilitation.²⁵ Of note, nursing students found peer simulation provided the opportunity to apply previously learned observation, reflection, evaluation, and communication skills and provided insight into the patient experience.²⁶ Peer simulation is considered most effective if executed with clearly defined learning objectives and challenging cases.²⁷ Peer simulation (having senior students as patients for junior students) has been used in physiotherapy education with junior students self-reporting improved communication, confidence in practical skills, and preparedness for clinic.²⁸ However, there is relatively little information regarding the efficacy of peer simulation in the physiotherapy education literature. The use of fellow classmates for peer simulation in undergraduate physiotherapy education, the most readily available resource, is largely unexplored.

This study aimed to investigate whether peer simulation, using fellow classmates, was perceived by preclinical undergraduate physiotherapy students as valuable in preparing them for subsequent clinical placements.

METHODS

Participants

All third-year students enrolled within the four-year undergraduate physiotherapy program at Monash University (Melbourne, Australia) were invited to participate in the study. Student recruitment was performed by an administrative staff member who had no educational responsibilities for the cohort. No students had previous experience with any formal simulation program. This study was approved by the Monash University Ethics Committee.

Study Design

Peer simulation was conducted weekly for 9 weeks as part of the standard curriculum of the third-year undergraduate program. Simulation scenarios covered a mix of pathologies including musculoskeletal, falls, vestibular, and stroke. Scenarios were developed to reflect a variety of clinical settings, including inpatient, outpatient, rehabilitation, and community environments. Scenarios were tailored to meet unit learning objectives and aligned with additional theoretical curriculum delivered each week. Case scenarios were developed as a full patient interaction, including preparatory note reading, interview, physical examination, development of goals and treatment plan, and treatment implementation (Table 1). This allowed for students to practice all aspects of the case, encouraging basic skills to be integrated into layers of clinical practice.¹ Students were also expected to interact with tutors who were acting as “clinical supervisors.” Tutors were briefed in their role of supervising the students as they would in a clinical setting—providing direction, asking questions, ensuring safety, modifying handling, and providing feedback. Tutors interacted with the “patient” and student as they would in a clinical setting. They did not provide advice on patient portrayal.

TABLE 1: Example of a Case Scenario and Key Student Activities

Students were allocated a partner each week, participated in two 1-hour cases each session, and switched roles between cases. Thus, each student had the opportunity to role-play both the physiotherapist and the patient for each of the 9 weeks. In a 1-hour briefing session, the “physiotherapists” were provided with mock patient notes. The patients were provided with written instructions on patient presentation and objectives of the interaction. All relevant theoretical information regarding pathology of the case was provided via lecture and tutorial format before the simulation activity. Students were expected to have sufficient theoretical background developed from the first 2 years of the course to ensure some accuracy of patient portrayal. The students were not provided with acting training. All students were provided with the opportunity to ask questions of staff about the patient portrayal or the planned physiotherapy interaction. Scripts were not standardized, thus allowing all participants some freedom with interpretation of the case within the stated parameters of the interaction. Role-playing was expected to elicit a variety of performances; hence, physiotherapists were instructed to “treat what they see.” Students were corrected if their patient portrayal was significantly inaccurate or misleading to the scenario, but otherwise, minor differences in individual patient portrayal were tolerated.

Setting

The simulation sessions were conducted in the practical rooms of the university with standard equipment that would typically be found in the clinical setting. No costumes were provided for patients, and all students wore their clinical uniform. Each session lasted 4 hours, including group briefing and debriefing facilitated by tutors. The duration of each patient interaction was 1 hour, including note writing, discharge planning, and exercise prescription (Table 2). “Patients” were encouraged to provide feedback about their patient experience to their “physiotherapist” at the completion of the case. All participants were expected to stay within role for the entirety of the interaction, except when a “time-out” was employed. A time-out could be called by either a student participant or a tutor. This allowed the participants to break from their character and revert to their status of student or tutor, respectively. At the completion of the 2-hour simulation session, a 1-hour whole-group debriefing session was held, based on the SHARP model of debriefing.²⁹ This provided an opportunity for staff to provide general feedback on cohort performance and students to provide feedback from both the patient and therapist perspective. All participants discussed what went well, what did not go well, and why and reviewed if session learning objectives were achieved. Students were encouraged to reflect on their clinical, technical, and teamwork skills and discuss how best to improve their future practice.²⁹

TABLE 2: Schedule of Simulation Sessions

Data Sources/Measurement

This was a mixed-methods study using anonymous online surveys preintervention and postintervention (weeks 0 and 9). These time points aligned with commencement of semester (week 0) and at the conclusion of the peer simulation program toward the end of the semester (week 9). The surveys included both quantitative responses to questions and additional qualitative comments to evaluate perceptions of the simulation program. Statements explored student self-perceived skills, confidence, time management, clinical placement readiness, and attributes of the program itself. Survey statements (Table 3) were scored using a five-point Likert scale, “strongly disagree” (1) to “strongly agree” (5). Free-text options were included at the end of the survey.

TABLE 3: Survey 1 (Pre) and 2 (Post) Results

Statistical Analysis

Quantitative

Quantitative data from the survey were entered into the SPSS statistical software, Version 22.0 (SPSS Inc, Chicago, IL). Descriptive statistics were used to report completion rates for each survey and sex distribution. As the data were not normally distributed, medians and interquartile ranges (IQRs) were reported for responses.

Qualitative

Free-text comments were extracted from the survey and entered into a spread sheet. Analysis of the free-text comments was conducted using thematic analysis, with data initially examined in a first round of analysis to allow themes to emerge. The emergent themes were then used to provide coding categories for a more in-depth analysis. Coding of all comments into themes was undertaken independently by two researchers (N.D. and P.M.), and any discrepancies in key themes were resolved by discussion. The final analysis revealed three consistent themes that augmented and illuminated the quantitative results.

RESULTS

Of the 79 enrolled third-year students (age range = 20–34), 50 students (63%; female n = 35, male n = 15) completed the first survey. Fifty-two students (66%; female n = 35, male n = 17) completed the second survey. Each respondent answered all survey questions. The sex spread reflects the overall sex distribution of the cohort.

Most statements were rated highly both before and after the simulation program (Table 3). All but one statement were rated 4/5 or above for both before and after simulation program surveys. The statements rated most highly at the conclusion of the program were “peer simulation did improve my clinical reasoning skills” [median (IQR) = 5.0 (4.0–5.0)], “peer simulation did improve my communication skills” [median (IQR) = 5.0 (4.0–5.0)], and “peer simulation did help me identify deficits in knowledge and skills” [median (IQR) = 5.0 (4.0–5.0)]. The median score for realism of peer simulation remained unchanged between the two surveys but realism was rated lower on both surveys than other aspects of the program by some students [median (IQR) = 4.0 (3.0–4.0)]. Three statements were rated less highly at the conclusion of the program. These were “peer simulation will (did) improve my confidence for Objective Structured Clinical Examinations (OSCEs)”³⁰ [survey 1 median (IQR) = 5.0 (4.0–5.0); survey 2 median (IQR) = 4.0 (4.0–5.0)], “peer simulation will (did) improve my confidence for clinical placements” [survey 1 median (IQR) = 4.5 (4.0–5.0); survey 2 median (IQR) = 4.0 (4.0–5.0)], and “peer simulation will (did) provide a challenging and engaging learning environment” [survey 1 median (IQR) = 5.0 (4.0–5.0); survey 2 median (IQR) = 4.0 (4.0–5.0)].

Qualitative Results

Three key themes emerged from the open responses, which augment and provide greater insight into the quantitative results: (1) value of peer simulation as a learning resource, (2) value of peer simulation for clinical preparation, and (3) clinical realism of peer simulation. Direct quotes are provided hereinafter to illustrate themes with attribution to individual participants.

Value as a Learning Resource

Students were overwhelmingly positive in their assessment of peer simulation as a learning tool. There were no negative comments about the use of simulation as an educational method. Students reported that peer simulation enhanced their communication and clinical reasoning skills:

“It helped me develop my ability to talk to patients, explain pathologies, and maintain professionalism” (Student 6)

“…extremely useful in developing my clinical reasoning and practical skills but also in improving my performance and increasing my confidence in my abilities” (Student 32)

Feedback from tutors (who were portraying the role of clinical supervisors) was highly valued:

“The feedback from tutors, is really great, and definitely taken on board” (Student 1)

Students reported improving confidence, applying and consolidating knowledge, linking concepts, and practicing clinical skills and professionalism as highlights of the program.

Preparation for Clinics

One of the key educational objectives of the peer simulation program was to enhance clinical preparation. Many students identified this preparation as a key benefit of the program:

“It provides a great opportunity to practice before clinics - especially clinical reasoning, note writing and getting confused during a patient interaction, great to practice all that in safe environment first” (Student 25)

“I think it is an excellent addition to the course and the most helpful tool for clinical preparation” (Student 36)

Improved confidence for placements was also reported:

“I feel a lot better about going into placement after doing it” (Student 43)

Clinical Realism

This theme was explored from the perspective of authenticity of patient portrayal and realism of the task itself. Students welcomed the challenges of simulation, particularly working with peers that they were less familiar with:

“I think it was a good idea (when) partners (were assigned) as it allowed us to work with people from different friendship groups to make it more challenging and like a real life clinical scenario” (Student 17)

Students also valued the opportunity to portray a patient and the insights that the experience provided:

“Acting the part of the patient is also a valuable experience to truly understand how a condition would present. This then transfers as a good learning tool when acting as the therapist” (Student 33)

A number of students identified the importance of staying in character for the success of the program:

“Having to get into character and stay in character really helped make the scenarios more realistic” (Student 31)

“Sometimes it is hard for the patient [student] to create a realistic portrayal of the patient” (Student 1)

One student commented on perceived limitations of the physiotherapy practical room environment:

“Doing the simulation in the nursing laboratories (would be) a good way of making it more realistic” (Student 20)

Some students felt their time management was not challenged, and others felt that there should be more emphasis on note taking:

“The time allowed (1 hour) doesn't reflect on treatment time with patients in clinical situations” (Student 52)

“I would have liked more practice on note taking and presentation” (Student 49)

Students valued the use of mock patient notes to enhance the realism of the experience.

DISCUSSION

This study demonstrated that peer simulation, using student peers as patients, was perceived by third-year undergraduate physiotherapy students as valuable for developing clinical reasoning skills, improving communication, and identifying deficits in knowledge and skills. Peer simulation was considered safe, supportive, and valuable for clinical preparation. Students had high expectations of the simulation program before it commenced and these expectations were consistently met.

Interestingly, students' self-perceived confidence for OSCEs and clinical placements and their perceptions of the challenge of the peer simulation program decreased slightly at the end of the program. However, students reported feeling more prepared for clinical placements having completed peer simulation training. Confidence may have been impacted by the impending high-stakes assessment and clinical placements. As OSCEs and clinics approached at the conclusion of the program, some students may have increased awareness of a potential gap between the expected level of student performance and their perceptions of their own individual performance. The reported level of engagement and challenge in the program, although rated highly, also decreased slightly at the program's conclusion. This could potentially be explained by the length of the program. After 9 weeks, students perhaps felt less challenged and engaged than at the program's commencement, and this requires consideration when designing simulation-based activities.

Peer simulation has been found to be similar or superior to the use of SPs for the training of students in other health disciplines.^19,23,24 Peer simulation is similarly effective to the use of SPs for teaching medical students interviewing skills for the cessation of smoking^19,24 and in teaching communication skills to health care practitioners.²³ The findings of this current study support those of Mandrusiak et al²⁸ who investigated the use of senior physiotherapy students as patients for junior students across a range of courses and activities in an undergraduate program. In this study, junior students reported improved confidence, client communication, and practical skills after completing the simulation program. There is a paucity of literature in the use of peer simulation to teach more complex skills and little evidence of its use in physiotherapy education thus far.

Nestel et al²⁰ discussed the potential for resistance and anxiety in medical students participating in peer simulation. This was not evident in the current study where students had high expectations of the simulation program and these expectations were consistently met. Data were not collected on the origin of the students' expectations of the program. The positive anticipation may reflect discussions with students from the previous cohort who had experienced an abridged version of the peer simulation program the year before. Students may also have been enthusiastic about a change in curriculum delivery and optimistic about the opportunity to practice patient interactions in their entirety before embarking on clinical placement the following semester.

One of the objectives of peer simulation was to approximate clinical reality as closely as possible to achieve the learning outcomes of the preclinical curriculum.¹³ All participants had to suspend disbelief and were encouraged to behave and participate in the scenario as they would in the real situation to enhance skill acquisition.^1,13 Recent literature suggests that authenticity may be achieved by accurate representation through the appropriate use of cues and stimuli.³¹ Participants also need to understand the simulator's limitations to engage authentically with the scenario.³¹ Students in this current study described positive benefits of peer simulation despite some lack of realism. This finding supports evidence that more basic simulation models can have similar effectiveness to “high-fidelity” or more authentic counterparts and may be more appropriate for novice learners participating in relatively straightforward patient scenarios.^14,16,32,33 Simulation may not require an exact reproduction of reality and lack of fidelity may not predict ability to produce learning outcomes.^31,33 In the current study, attempts were made to reflect clinical reality within budgetary, resource, staffing, and geographical constraints, and students were made aware of the simulation's limitations to promote suspension of disbelief.³¹

There were inherent benefits and challenges in the simulated clinical scenarios. Students worked in pairs, thus being able to complete an interaction with a patient individually, rather than in groups, reflecting the reality of student/patient ratios in clinical placements in physiotherapy. It was expected that students were familiar with patient depiction and physiotherapists' roles; however, some students may have portrayed the patient role more consistently and accurately than others.¹⁸ Some students may have unwittingly compensated for their colleague's incorrect performance in handling or instruction, and perhaps assisted their partner at times of therapist uncertainty. Others may have disengaged from the simulation and broke from the character they were meant to role-play. However, as students swapped roles, they may have been more invested in an accurate patient portrayal, anticipating the same degree of realism from their partner when taking on the role of the physiotherapist. Educators attempted to control for potential lack of realism by producing strict guidelines to participating in simulation. Tutors circulating the room as clinical supervisors would also help mitigate these inaccuracies to some extent. The environment also provided a potential challenge to authenticity. Simulation sessions were conducted in the practical rooms of the university and geographical constraints dictated that up to 10 pairs of students worked together in each room. Scenarios were set in a variety of facilities such as an outpatient clinic, an emergency department, or a rehabilitation gymnasium. Attempts were made to replicate these settings with appropriate equipment and materials but limitations to authenticity of location were unavoidable. However, despite the challenges of limited realism associated with patient appearance and the environment, students reported many benefits from the peer simulation model.

An understanding of the patient perspective was a challenge to consistently achieve in this peer simulation program. It was anticipated that students may gain additional knowledge by playing the patient's role, thus providing them with a unique perspective of the patient's situation.¹⁸ Values of understanding and empathy might be fostered by taking on the role of the one being “treated,” and it may encourage personal reflection.¹⁸ Bosse et al²² in a study of communication training with medical students also reported lower scores for the domain of “understanding of the patient's perspective.” Senior physiotherapy students reported a significant difference in “insight into what it is like to be a physiotherapy patient,” after portraying patient roles in a simulation program.²⁸ In the current study, patient portrayal may have been hindered by the students being direct peers. No attempt was made to change the patients' identity or appearance. This lack of visual authenticity may have made it difficult to put oneself “in the patient's shoes” and to interact authentically. Students may also have been cognizant of the potential complexities of a patient's situation and may not have wanted to assume that they could empathize with a patient's circumstance when they were merely acting a role.

One of the barriers to implementing a simulation program is financial cost.^13,14,18 Costs may vary widely, and if those associated with the implementation of simulation are prohibitive, it may not be a viable educational tool.^1,34 Low cost is important for the early stages of task learning where availability and repeated practice are imperative, and educators should be aware of more cost-effective alternatives to SPs, such as role-play.^1,18 Simulation can be labor intensive and thus costly, and the use of SPs was recognized as “the single biggest ongoing cost in simulation” for training physiotherapy students in the recent national Health Workforce Australia project.¹¹ The cost, logistics, and organizational commitments of employing and training SPs for large student cohorts would be considerable. Many universities are exploring alternative strategies to continue the use of simulation in their programs within budgetary and staffing constraints, such as implementing it for targeted activities (communication/teamwork) or across disciplines.¹¹ Although a cost analysis was not part of this current study, peer simulation may be a cost-effective method of simulation training that is relatively easy to establish in a curriculum.²² Zendejas et al¹⁴ provide a list of essential cost ingredients in simulation-based education, including personnel, equipment and materials, and facilities. In the current study, trained actors were not required as students portrayed the patient role. Organizational commitment was moderate once scenarios had been generated as educators staffed the simulation program. Typical hospital ward and gymnasium equipment were routinely available, and existing university facilities were used. Given the low cost of the peer simulation program, it was able to be integrated into the curriculum and repeated for 9 weeks with clearly defined learning objectives each week.²⁷ This allowed for repeated skill rehearsal,^1,13,16 practice in suspending reality,⁴ gradual increase in difficulty level towards challenging cases,²⁷ clinical variation,¹³ individual interactions, and gradual development of skills over time in a safe and supportive environment. As students progress through their training, they are likely to require greater authenticity and sophistication of approach, perhaps requiring the expertise of an SP in more complex simulated scenarios. However, in the preclinical stages of health care training, peer simulation seems to offer a number of potential benefits. This perhaps demonstrates that in educating health care students, “high fidelity is neither necessary nor sufficient to ensure effective training.”³³

There are limits to this study that could be addressed in future research. Because this was a study of student perceptions of simulation, no attempt was made to objectify change in student performance. Student perceptions are subjective in nature, and demonstrable benefit in learning outcomes is an important area for future research.

The extent of any previous clinical experience undertaken by the students outside of their current studies was not measured. All students had participated in 9 hours of observational clinics in the previous semester. However, some students may have had previous clinical exposure in a prior degree, working as an allied health assistant or in a volunteer or carer's role. Previous clinical exposure may positively or negatively influence a participant's ability to interact with the scenario realistically, in either the patient or physiotherapist role.

This study presents a basic simulation model with emphasis on the design and functional alignment of the learning activity.¹⁷ The patient's appearance remained unchanged. This lack of visual authenticity (or structural fidelity) may affect the ability of the learner to interact with the scenario in a way that reflects clinical reality and thus limits the transfer of learning of the method. Concealing identity and providing costumes may allow the patient to assume a character more easily and provide more authentic visual cues to the physiotherapist.

Possible extensions to this research may include measuring change in student performance, conducting a cost-effectiveness analysis of peer simulation versus the use of paid SPs, and determining the amount of realism required to optimize the benefits of this promising educational strategy.

This study demonstrated that peer simulation, using fellow students as patients, was perceived by students as valuable in preparing them for clinical placement, despite some feeling less confident as clinics approached. Students reported that peer simulation provided a safe, supportive, and engaging learning environment. This program allowed students to improve their clinical reasoning, enhance their communication, and assisted with identification of knowledge and skills deficits. These benefits were achieved despite an apparent lack of realism. These findings provide provisional support for the use of peer simulation as an alternative to the use of SPs in an undergraduate physiotherapy program.