A comparison of the simulation and clinical environments in physiotherapy education

Abstract

Simulation-based education is being embedded increasingly in health professional curricula. In a climate of decreasing clinical exposure and concern regarding patient safety, simulation offers opportunities for repeated safe practice of clinical skills prior to clinical exposure with real patients and for extended training opportunities (Sabus & Macauley, 2016). Generally, there is a presumption that simulation is a replication of the clinical environment which allows, in preparation for clinical practice, authentic practice of skills and behaviours. However, there has been little research comparing aspects of these two environments to determine the extent to which they may be providing similar learning experiences to students. The growing use of simulation in physiotherapy education calls for an evidencebased approach (Sabus & Macauley, 2016). This is particularly critical considering that many Australian universities are embracing simulation as a substitute for a proportion of clinical placement training (Watson et al., 2012; Wright et al., 2015). Accordingly, the central purpose of this thesis was to compare simulated and clinical practice learning environments from several perspectives. The first aim of this thesis was to systematically review the literature on simulation-based assessment in physiotherapy to ascertain the merits of this assessment approach. Due to a significant lack of research in this area, the search was broadened to include all health professions. Using the Preferred Reporting Items for Systematic Reviews and MetaAnalyses guidelines and additional exclusion criteria based on methodological quality from a critical appraisal score, a final 21 articles were included in the systematic review. The results indicated that simulation was more robust when used as an assessment in combination with other assessment tools and when more than one simulation scenario was used. Small participant numbers, poor methodological quality, and predominance of studies from medicine were limitations to the review. There was evidence to suggest that simulationbased assessments can be used effectively; however, the effectiveness as a stand-alone assessment tool requires further research. Research also needs to expand further into physiotherapy, with only one study from physiotherapy eligible for inclusion in the review. The second aim of this thesis was to determine if an assessment tool measuring physiotherapy student professional competency was valid when used to assess student performance in simulation. A Rasch analysis was undertaken of 1220 Assessments of Physiotherapy Practice (APP), a nationally-supported assessment tool designed specifically for clinical practice settings only. The construct validity and suitability of the APP for use in simulation was examined. Four different assessment formats in which the APP was administered were considered in the analysis: longitudinal simulation assessments over one week; longitudinal simulation assessments over two weeks; short-form, single 25-minute assessments in simulation; and compared with longitudinal assessments undertaken in traditional clinical practice settings. Both longitudinal formats in simulation, as well as the longitudinal clinical placement assessments were a good fit to the Rasch model exhibiting uni-dimensional properties that could distinguish different levels of student performance, demonstrating comprehensive construct validity. The suitability of the APP for simulationbased short-form assessments was impeded by large amounts of ‘non-assessed’ items due to the inapplicability of scoring all APP items in the short-form style assessment format. Nine of the 20 items recorded greater than 25% of scores as ‘not-assessed’ by clinical educators, indicating that students did not have the opportunity to demonstrate all the skills and behaviours included in the APP in the short format. Although the validity of the APP for longitudinal simulations has now been established, a revised APP is recommended for single short assessments in simulation. The third aim of this thesis was to compare the acute psycho-physiological stress of physiotherapy students undertaking simulation and clinical placements. A combination of objective measures (salivary cortisol and continuous heart rate) and subjective visual analogue scales of stress and anxiety were used to quantify acute psycho-physiological stress of 36 participants (3rd year undergraduate physiotherapy students). The study design was a within-group comparison of stress levels of participants between simulation and clinical environments during matched patient encounters. Simulated patients portrayed the clinical cases in simulation. Self-reported stress (100mm visual analogue scale) was found to be higher in simulation (45mm [SD 22]) compared to clinical (31mm [SD 21], p=0.003). Heart rate during the simulation patient encounter averaged 90 beats.min-1 [SD 16] and was not significantly different compared to the clinical setting (87 beats.min-1 [SD 15], p=0.89). Changes in salivary cortisol before and after patient encounters were also not statistically different between the two settings (simulation: 1.5 nmol.L-1 [SD 2.4]; clinical: 2.5 nmol.L-1 [SD 2.9], p=0.70). Educators should consider that high-fidelity clinical simulation using simulated patients may evoke elevated self-reported stress in participants and may have implications on simulation curricula design. The fourth aim of this thesis was to determine if there was a relationship between clinical performances of physiotherapy students in simulation and clinical practice. A total of 296 APP reports were collected from 148 students, one APP from each student in both simulation and clinical practice. Pearson’s product moment coefficient showed a moderate, significant positive relationship between the performance of students in simulation and clinical practice (r= 0.40, p<0.001). Similarity in the performances of the same student across both settings adds to the evidence of the comparability of the two learningenvironments. The final aim of this thesis was to establish if there were domains of professional competency of physiotherapy student performance in simulation, as measured by the APP tool that could predict subsequent clinical performance. Multiple regression with backward elimination was used to explore potential predictors of clinical performance. Two of the APP’s seven domains of physiotherapy performance, ‘analysis and planning’ and ‘risk assessment’, were found to be modestly predictive of student performance in subsequent clinical practice accounting for 16% of the variability in clinical performance (β=0.26, p=0.002; β=0.25, p=0.003 respectively). Educators may consider implementing barriers in simulation relating to poor performance that require underperforming students to undergo further development prior to clinical practice exposure. In conclusion, this thesis makes a substantial contribution to the research into simulationbased education in physiotherapy. Through a systematic review and three linked, original research studies, the clinical practice and simulation-based learning environments for physiotherapy students were compared from multiple perspectives. Important differences between the two learning environments were revealed. An evaluation tool from clinical practice was found to be valid for longitudinal but not short-form assessments in simulation. Student psycho-physiological stress was elevated in simulation from subjective markers, but comparable to clinical practice on objective markers of stress. Two significant simulationbased predictors of clinical performance were observed, and a positive relationship between performances of students in the two settings was identified. These findings will inform current practice and guide future directions for physiotherapy simulation towards a tailored and optimal embedding of simulation-based education in physiotherapy curricula.