Simulation Experience Enhances Physical Therapist Student Confidence in Managing a Patient in the Critical Care Environment

Discussion

This is the first study to demonstrate that physical therapist student confidence in technical, behavioral, and cognitive performance measures increased following participation in a simulated critical care patient treatment session. Initially, more than half of the students expressed low confidence levels in the technical, behavioral, and cognitive performance measures examined. Following the simulation experience, confidence in all of these performance measures increased, with the largest improvements being made in the cognitive performance measures, as shown by the large and very large effect sizes for the confidence level change. Students viewed high-fidelity simulation as a positive learning experience and a desirable educational tool for the physical therapy curriculum, agreeing it reinforced course content and facilitated integration of classroom knowledge and clinical performance.

The results of this investigation contribute to the literature regarding the use of high-fidelity simulation to prepare physical therapist students for acute and critical care practice. The aim of physical therapy education is to ensure students attain the skills, knowledge, attitudes, and behaviors to enable solid clinical decision making, resulting in safe, effective practice in all settings. Currently, physical therapist student clinical education occurs in both academic and clinical environments. The objective of the simulation experience in this study was to provide physical therapist students with an opportunity to manage a simulated patient in a simulated critical care setting, an experience otherwise impossible to obtain in the academic setting and inconsistently available during acute care clinical affiliations. Simulation may have an important role in providing learning opportunities for managing patients in the critical care environment, especially considering the relatively limited opportunities for exposure to this practice area during physical therapist student clinical affiliations. A recent study of nursing students showed that the substitution of simulation experiences for time spent in clinical settings did not negatively affect performance on examinations or students' perceptions of their competence.³⁷ This finding suggests that judicious substitution of scenario-based simulation for traditional clinical experiences may be a useful strategy when specific clinical experiences are limited.

Although there are limitations to the realism of high-fidelity simulators, most students considered simulation an authentic learning experience. Simulation provides an environment where mistakes can be made and learned from without risk of patient harm. Opportunities to integrate content knowledge, clinical skills, and critical thinking in a realistic but nonthreatening environment abound with simulation. Furthermore, simulation presents rich opportunities for the development of the important nontechnical skills of communication and teamwork in a real-life situation.³⁸ In this scenario, safe mobilization of the simulated patient from a supine to a sitting position required interactions with the patient and attending nurse, teamwork among the students, and clinical decision making.

Our findings are consistent with those of other investigations of high-fidelity simulation use in health care education. In the only other report of high-fidelity simulation use with physical therapist students, informal feedback from the students (no quantitative or qualitative measurements were performed) suggested that participation in an ICU case scenario positively affected their confidence prior to entering an acute care clinical experience.²⁶ Similar effects have been found for pharmacy students³⁹ and nursing students.⁴⁰ The increase in confidence in this study of 219 nursing students⁴⁰ was similar in magnitude to that seen in the present study, and they demonstrated a very large effect size for this response (Cohen d=1.7) compared with the moderate to very large effect sizes observed in the present study with a smaller sample. Thus, exposure to managing a patient in a critical care environment using high-fidelity simulation appears to increase practitioner confidence.

In this study, we examined confidence levels in technical, behavioral, and cognitive skills and found increased confidence in all performance measures following the simulation experience, demonstrating a possible role for high-fidelity simulation to improve confidence in both technical and nontechnical performance measures. Simulation has been used for the acquisition of technical skills in health care professions for many years⁴¹ as a low-risk means to ensure patient safety. Although technical performance is important, the significance of nontechnical skills as major determinants of successful patient management, especially in a crisis, is emerging.²⁸ Nontechnical skills encompass behavioral or interpersonal skills, such as exchanging information and assertiveness, as well as cognitive skills, including clinical decision making and situation awareness.²⁸ Consistent with this observation, behavioral, interpersonal, and cognitive skills, rather than technical skills and knowledge, are considered hallmarks of a good clinician.²⁹ However, behavioral and cognitive skills are not necessarily acquired through routine clinical experiences and may need to be specifically taught,⁴² and simulation appears to be one method to develop these nontechnical skills.⁴³

In studies where performance has been evaluated, high-fidelity simulation experiences have improved clinical knowledge acquisition of both participants and observers,⁴⁴ and it recently has been proposed that high-fidelity simulation may be an effective substitute for traditional clinical experience, as shown in a study of undergraduate nursing students comparing participation in high-fidelity simulation scenarios with traditional clinical experience.⁴⁵ On the other hand, there is substantial evidence that simulation-based medical education complements, but does not duplicate, education involving real patients in genuine settings.^46,47 Thus, appropriate use of simulation is important. Finally, it is not yet clear the extent to which technical, behavioral, and cognitive performance learned through participation in simulation experiences carries over into clinical practice.^47,48

Satisfaction is an important component of engaged and meaningful learning experiences and facilitates active and purposeful participation in simulation experiences.⁴⁹ Student enthusiasm and confidence with simulation as an instructional tool enhances student understanding of material through increased motivation and effort.⁴⁷ Given the very high level of satisfaction with the simulation experience expressed by this group of physical therapist students, it is very likely this simulation experience provided an environment conducive to learning.

Recently, the Satisfaction With Simulation Experience (SSE) Scale was published along with its reliability and validity.²⁴ Although this instrument was not available at the time of the present study, many components of the SSE Scale were captured in our survey of student satisfaction. Specifically, student satisfaction with the debriefing session in the present study was consistent with that assessed with the SSE Scale in a group of Australian nursing students. In the area of cognitive skills, the satisfaction level of students in the present study was similar to values reported for the SSE Scale subsection of clinical reasoning.²⁴ These findings indicate that the high level of student satisfaction with simulation found in the present study is consistent with findings in other health care disciplines and in other countries.

Debriefing, defined as facilitated or guided reflection in the cycle of experiential learning,⁵⁰ serves a critical role in simulation-based education.⁴⁶ In this regard, feedback is the single most important feature of simulation-based medical education toward the goal of effective learning.⁴⁶ Debriefing facilitators serve to help learners identify and close gaps in knowledge and skills through active reflection and discussion; thus, active participation of learners is essential for meaningful learning during a debriefing session.⁵¹ In the present study, students engaged in a facilitated debriefing session the day following the simulation. Typically, debriefing occurs immediately following the simulation experience,⁵² allowing for immediate reflection, which can enhance learning. Although 98% of the students were satisfied with the debriefing session, the opportunity for learning may have been diminished due to the time delay. Indeed, several of the students felt a debriefing session immediately following their simulation experience would have been more meaningful.

Several students expressed interest in repeating the simulation experience to practice their newly acquired knowledge, consistent with the recognized importance of repetition for clinical skill acquisition and maintenance.⁵³ Repeating a simulation following debriefing was associated with improvements in behavioral and cognitive skills.⁴³ Interestingly, the same study demonstrated that performing the same simulation experience 1 month later did not result in further improvements in nontechnical skill performance, despite participants scoring below the highest performance levels on these measures.⁴³ This finding suggests repeating a simulation experience again at a later date may have minimal impact on nontechnical skills.

One of the current questions in the field of simulation is whether learner outcomes obtained through simulation experiences justify the substantial cost. Conducting a simulation experience requires mannequins (the cost of the mannequin used in this study is approximately $35,000); substantial audio, video, and computer technology and technical support; experienced, highly trained support personnel; and a dedicated facility. Many simulation centers have a cost associated with facility use, and how this cost is managed must be a factor when deciding to implement simulation into a curriculum.

Given the substantial financial and human investment associated with simulation, it is important to consider the objectives of the learning experience and critically evaluate whether high-fidelity simulation is the most appropriate educational tool to meet those objectives. It is conceivable lower-cost alternatives may be just as effective as high-fidelity simulation. A recent study examining the impact of low-fidelity simulators compared with high-fidelity simulators for neonatal resuscitation training showed that the simulator made no difference in technical and nontechnical skill performance between the groups.⁵⁴ A recent study compared the impact on clinical reasoning, knowledge acquisition, and student satisfaction using medium- and high-fidelity human patient simulators for a 20-minute simulation experience followed by a 20-minute debriefing session.²⁵ No differences were observed in knowledge acquisition or satisfaction. However, clinical reasoning scores were twice as high for high-fidelity (mean±SD score=42±16) mannequin use compared with medium-fidelity (mean±SD score=19±11) mannequin use.²⁵ A cost-utility analysis showed that high-fidelity simulator use was 5 times that of medium-fidelity simulator use ($291 compared with $46), suggesting that depending on the learning objectives and actual scenario, acceptable outcomes may be more economically achieved with medium-fidelity simulators.²⁵

One of the limitations of high-fidelity mannequin use in physical therapist education is the inability for realistic motion simulation. Despite state-of-the-art technology permitting moment-to-moment physiologic responses of the mannequin to interventions, mannequins are, in essence, a dead weight. Therefore, when the learning objectives require the student to engage in mobility assessment and intervention, standardized patient use may be more relevant than using high-fidelity simulators.

With the increased recognition of the importance of rehabilitation of patients in the ICU,¹⁰ there is a growing demand for physical therapists to practice in the critical care environment.^4,12,13 Critical care simulation experiences may serve to increase student interest in practicing in this clinical environment. This phenomenon has been observed with medical students who expressed an increased interest in vascular surgery following participation in an endovascular training course using simulation.⁵⁵ Similarly, participation in moderated simulation sessions improved attitudes toward cardiothoracic surgery as a career choice and correlated with a greater interest in selecting thoracic surgery as a third-year clerkship rotation.⁵⁶ Thus, exposing physical therapist students to this practice area in a low-stress, safe manner through the use of simulation may result in an increased interest in pursuing acute and critical care practice.

Although the findings of this study contribute to the literature on the use of high-fidelity simulation in physical therapist education, limitations are present. This study had a small sample size, data were collected from one class of physical therapist students at one higher education institution, and the data were self-reported perceptions and attitudes. Despite these limitations, the majority of the effect sizes for confidence were moderate to very large, suggesting the increases in physical therapist student confidence following participation in this simulation experience may be of practical significance.

Additionally, because participation in the simulation experience was a required component of a clinical course, no control group was used. The lack of a control group poses threats to the internal validity of the study; therefore, these results should be interpreted with this caution in mind.

The use of surveys with unknown reliability and validity is another drawback of this study. However, our findings of confidence and satisfaction were consistent with those reported for other health professional students when using similar survey instruments that are reliable and valid. However, the preliminary nature of these findings requires they be considered cautiously.

It is possible that having the facilitators observe the students from the control room during the simulation experience and conduct the debriefing may have influenced the students' comments on the postsimulation survey. However, we believe this influence is unlikely. It is common practice that the facilitator observes the learner's performance from the control room so the facilitator can adequately debrief the learner with specific information about the learner's performance following the simulation experience. Our procedures were consistent with this usual practice.

Finally, there were no objective assessments of participant performance. Subsequent studies are needed to determine objectively whether high-fidelity simulation experience improves technical, behavioral, and cognitive performance of physical therapist students when managing a patient in the critical care environment and whether improvements in performance translate into improved clinical practice.