Abstract
Simulation is increasingly being used in health care education to address experiential learning and development of entry-level practice competencies. Simulation can be described as a technique for practice and learning that replaces and amplifies real experiences with guided ones, often immersive in nature, that evoke and replicate substantial aspects of the real world in an interactive fashion (Lateef, 2010). In the 21st century, health care providers are challenged to bridge the gap between what occurs in the classroom and what is required in the practice setting to deliver quality services and to address current health care needs (Galloway, 2009). Contributing factors that have fostered a shift in clinical education to increased use of simulation include growing workforce demands, limited staffing to provide trainees with oversight in certain practice settings, competition for clinical site placements among the growing number of academic programs, reimbursement guidelines that dictate productivity, student supervision guidelines, and patient safety regulations. Thus, the traditional model of clinical education has changed. Lateef (2010) attributed the increased use of simulation to two competing needs: the obligation to provide optimal treatment and the need to ensure patient safety and well-being. Moreover, at the forefront of an evolving health care system is the emphasis on competencies related to delivering patient-centered care, practicing evidence-based health care, using information technologies, decreasing safety errors, and improving communication with patients and other health care practitioners (Brindley, Suen, & Drummond, 2008; Galloway, 2009; Harder, 2010).
Outcomes of Use
Simulation has been described as a platform that develops health professionals’ knowledge, skills, and attitudes while protecting patients from unnecessary risks (Lateef, 2010). It is thought to enhance students’ competency and clinical practice through problem solving and clinical reasoning (Mieure, Vincent, Cox, & Jones, 2010), by teaching diagnostic procedures and comprehension of medical concepts (Qayumi, 2010), by enhancing decision making, and by addressing interpersonal communication and team-based competencies (Lateef, 2010).
Increasing evidence has shown that practices related to human patient simulation and standardized patient simulation enhance student learning outcomes and allow students to integrate their knowledge and clinical reasoning ability by making real-time decisions (Mieure et al., 2010). Considered ideal for interactive teaching and learning strategies because of its authentic nature, simulation is best used in a clinical environment “as a standard of performance of certain competencies” (Gantt & Webb-Corbett, 2010, p. 51). Reported outcomes of using simulation include building interdisciplinary skills (Bai & Fusco, 2011), assessing clinical skills (Stamper, Jones, & Thompson, 2008), giving immediate feedback on performance (Brooks, Moriarty, & Welyczko, 2010; Robinson, Bray, Willson, & Weeks, 2011), and promoting critical reflection (Elfrink, Kirkpatrick, Nininger, & Schubert, 2010). A controlled, simulated setting allows students to practice skills without the risk of harming real patients, provides a realistic environment, and promotes increased confidence (Grant & Davis, 2007).
Evidence has indicated that professions including nursing, pharmacy, and medicine have used simulation to augment student training for more than a decade (Mieure et al., 2010; Rosen, 2008; Thompson, 2011), whereas occupational therapy remains in the early stages of using simulation in the educational arena. The literature on simulation in occupational therapy and evidence supporting its use and its effectiveness in the classroom is limited to a few published articles (Castillo, 2011; Lindstrom-Hazel & West-Frasier, 2004; Shoemaker, Beasley, Cooper, Perkins, & Smith, 2011; Tomlin, 2005; Vegni, Mauri, D’Apice, & Moja, 2010). Collectively, these articles report specific instructional experiences with simulation in their respective setting. However, we found no study that has comprehensively examined the use of simulation as a method of instruction in occupational therapy education. How occupational therapy academic programs cumulatively view simulation, the range of simulation experiences, and how simulation is used for teaching and learning are issues in need of in-depth research. As the demands of health care increase, it is essential to provide students with the knowledge and educational experiences to develop skills that will equip them for entry-level practice. Some believe that “simulation can pave the path between formal education and professional practice for experiences that can be difficult to find, but are essential for progressing to the next level of competence and beyond” (Galloway, 2009, para. 30).
The purpose of this exploratory study was to provide evidence-based research that investigates simulation and its use as a method of instruction in the context of occupational therapy assistant (OTA) undergraduate and occupational therapy graduate entry-level academic programs including both master’s (MOT) and doctoral (OTD) entry-level degree programs. Occupational therapy educational institutions were recruited to address two research questions:
What methods of simulation are being used in occupational therapy and occupational therapy assistant education for student learning?
What are challenges, strengths, or learned lessons of programs and faculty that incorporate simulation into occupational therapy and occupational therapy assistant education?
Types of Simulation
For the purpose of this research, we identified categories of simulation on the basis of common perspectives found in the literature:
Standardized patient simulation involves people trained to play the roles of patients, family members, or others (Bradley, 2006; Rosen, 2008; Thompson, 2011).
Human patient simulation is use of a computerized full-body low-, mid-, or high-fidelity mannequin that is capable of providing real-time physiological and pharmacological responses to various health conditions and interventions (Johnson, Flagg, & Dremsa, 2008; Rosen, 2008).
Computerized software simulation is use of computer-based programs to practice decision making and skills such as part-task training, advanced cardiac life support, and trauma management training (Bradley, 2006; Rosen, 2008; Thompson, 2011).
Virtual immersive-reality simulation uses advanced computerized technology to allow learning by projecting or immersing the person into the computerized environment or setting. The person’s movement becomes the actual motion of the game (Bradley, 2006; Rosen, 2008).
Simulated training equipment may encompass skillful interaction with equipment in a realistic environment, primarily to teach skills and focus on an isolated task correlated with the equipment. We added this category to encompass approaches used in occupational therapy such as driver simulation.
Method
Research Design
This descriptive survey research study was approved by the Winston-Salem State University Institutional Review Board for Human Subjects. Participants were informed at the initial introduction to the survey instrument that they gave consent by agreeing to complete the online survey.
Participants
Study participants consisted of program directors and faculty representatives assigned to teach simulation in occupational therapy assistant undergraduate and occupational therapy graduate entry-level academic programs. Participants were recruited and contacted though the national program director educator’s database through the American Occupational Therapy Association.
Instrument
We developed a 23-item online survey questionnaire with multiple-choice and open-ended questions to collect descriptive data. Six questions related to program demographics such as type of academic program, regional location of program, type of institution, and number of faculty trained in and teaching various forms of simulation; 13 questions solicited information describing the type of simulation used and academic program practices and use of simulation in the curriculum; and 4 questions addressed faculty members’ perceptions about the challenges and benefits of the simulated learning experiences.
Data Collection
The study was conducted during the 2012–2013 academic school year. To maximize responses, notification of the upcoming study was announced at a biennial program directors’ meeting and via email. While the study was in progress, multiple email reminders were sent encouraging participation. Data were collected over a 4-mo period.
Data Analysis
Once collected, demographic data were analyzed using descriptive statistics. We used IBM SPSS Statistics (Version 19; IBM Corporation, Armonk, NY) to tabulate quantitative data about the type and use of simulation in the curriculum on the basis of frequency and percentage of responses. Qualitative data were analyzed using the three-step process of open, axial, and selective coding to categorize participants’ responses and opinions into meaningful and relevant themes or context.
Results
Program Demographics
Of 310 occupational therapy assistant and occupational therapy entry-level programs, 245 responded, yielding a response rate of 79%. Of those who responded, 175 (71%) reported using some form of simulation in their education programs. Respondents’ distribution reflected occupational therapy education in the United States, based on regional location, program level (OTA vs. MOT vs. OTD), and public versus private institution. Programs reported that the average number of faculty formally trained in using simulations was 2.9 and the average number of faculty implementing some type of simulation experience in programs was 3.3.
Types of Simulation Used
Simulation strategies most frequently used in all programs were human simulation using actors or students (75%, n = 132) and video cases (69%, n = 121; Table 1). The least frequently used strategy was simulation through virtual immersive games with avatar or self-projections (13%, n = 22). Overall, the simulation strategies most used were consistent across all program levels. Graduate-level programs were more likely to use human patient simulation (26%, n = 46) than the undergraduate programs (16%, n = 28).
Types of Simulation (N = 175)
Note. OT = occupational therapy.
Academic Program Practices and Use of Simulation in the Curriculum
The majority of the programs (69%, n = 121) had been using simulation for ≥3 yr. Overall, the programs reported that the majority of students participated in simulated experiences at least 4 times a year (60%, n = 105) for ≤2 hr duration (65%, n = 113). The programs reported that simulation was used in one to six courses (87%, n = 152), with three to four courses (44%, n = 77) being the most common (Table 2).
Academic Program Practices and Use of Simulation in the Curriculum (N = 175)
Note. MMT = manual muscle testing; OT = occupational therapy; ROM = range of motion.
The most frequently reported goals for use of simulation included development of clinical reasoning, problem solving and decision making, intervention and treatment planning, client assessment, communication, client interaction, and therapeutic use of self (Table 2). Other goals identified by 4% (n = 7) of respondents included fieldwork preparation, competency testing, documentation, and the effort to incorporate alternative teaching methods. In most cases, simulation was used in intervention courses.
Respondents were asked what setting or venue the simulated experience attempted to replicate or enhance. The majority of programs indicated the acute care setting, followed by the outpatient setting, the home setting, the community setting, the school-based setting, and emergency care (Table 2).
Faculty Members’ Perceptions of the Challenges and Benefits
The respondents overwhelmingly indicated that their program planned to continue use of simulated learning (98%, n = 171; Table 3). In addition, thematic analysis of the respondents’ comments identified several themes regarding the benefits and challenges of using simulation as a learning tool. Simulated experiences both assess student performance and teach skills. Respondents noted that the simulated experience seemed real to students and provided them an opportunity to develop safety with clients, practice clinical skills, use clinical reasoning and critical thinking, prepare for fieldwork, and facilitate concept integration.
Program Goal for Using Simulation and Future Use (N = 175)
Note. OT = occupational therapy.
One respondent summarized the benefits to faculty by stating, “Simulation allows for the application of knowledge and skills in a safe environment. We believe it’s one of the best methods available to evaluate student performance.” Challenges to faculty included the time required to prepare simulation experiences for students, the cost of establishing a simulation laboratory, and the scheduling issues surrounding simulations. Another respondent stated that “developing simulation is a time-consuming process; faculty must also learn to use the technology; scheduling the lab time and coordinating with other disciplines can be challenging.” Most respondents (83%, n = 145) viewed simulation as a valuable learning experience and reported more positive comments about the benefits of simulated experiences than about the challenges.
Discussion
At least 71% (n = 175) of occupational therapy assistant and occupational therapy entry-level programs in the United States use simulation in various formats and to varying degrees to assist students in acquiring experience with patients in real scenarios, to practice clinical skills in a safe environment, to facilitate clinical reasoning and critical thinking, as preparation for fieldwork, and to integrate concepts. The primary goals reported by more than 90% (n = 160) of programs were clinical reasoning and problem solving or decision making. The use of simulation was consistent at all program levels.
In several respects, our findings regarding simulation in occupational therapy education, including the benefits and challenges, are similar to what has been reported in the literature by other disciplines. First, this study affirms clinical reasoning and problem solving (Elfrink et al., 2010; Galloway, 2009; Lindstrom-Hazel et al., 2004; Mieure et al., 2010) as the primary aim for academic programs’ use of this mode of teaching to help skills and concept integration. Second, the authentic realistic environment (Gantt & Webb-Corbett, 2010; Grant & Davis, 2007) in which students engage in real-time decision making (Grant & Davis, 2007; Lindstrom-Hazel & West-Frazier, 2004; Mieure et al., 2010), along with opportunities for immediate feedback (Bai & Fusco, 2011; Brooks et al., 2010; Robinson et al., 2011), was seen as inherent in simulated learning. Third, attention to safe practice and reducing errors (Galloway, 2009; Gantt & Webb-Corbett, 2010; Grant & Davis, 2007; Lateef, 2010) were also confirmed as important. Fourth, other professions have described time, scheduling, and expense as the primary challenges to its implementation (Rhodes & Curran, 2005; Taekman & Shelley, 2010).
Limitations and Future Research
This survey research focused on simulation and its uses in occupational therapy assistant and occupational therapy education from a program perspective. Definitive effects on program and student learning outcomes, examination of the topic from the student perspective, and investigation of best-practice teaching scenarios need further research. Although the survey instrument was scrutinized for formatting and construction of questions by a biostatistician in the university’s Office of Institutional Effectiveness whose role is instrumentation development, data collection, and assessment, it was not formally field tested. The disadvantage is that participants may misinterpret the questions; therefore, any future use of the survey would need greater rigor. Surveys used for cross-sectional analysis are a good way to determine prevalence as explored in this study; however, identification of associations or causality should be pursued in the future.
Implications for Occupational Therapy Education
The fact that such a large number of occupational therapy programs reported using some form of simulation indicates its growing popularity as a teaching strategy. Occupational therapy academic programs are only beginning to scratch the surface in terms of reporting research on using simulation. With supportive evidence-based research on simulation, academic programs may gain a more grounded understanding of the implications and benefits of incorporating this method of instruction into occupational therapy curricula. The following are some research considerations:
Because of the array of methods to deliver simulation that programs identified (e.g., use of actors, video cases, high- or low-fidelity mannequins, and other computerized equipment), it is important to determine the effectiveness of each approach to identify best-practice scenarios.
It is important that occupational therapy practitioners continue to research and disseminate results of using simulation relative to student learning outcomes and pedagogy. This will allow us to define and broadly identify parameters for continued use in the profession.
Moreover, it is essential to determine to what extent the use of simulation builds and enhances the foundational and clinical skills and competencies required of students to meet the demands for entry-level practice and current health care trends. In other words, where in the educational arena might simulation experiences be of most value? Some have questioned whether simulated learning has a place as a component of fieldwork.
On the basis of these findings, simulation appears to be used to some extent in more than half of occupational therapy educational programs. Therefore, with future research, does a need exist for the profession to consider adopting a position on simulation in terms of parameters for its uses in educating future practitioners?
Footnotes
Acknowledgment
We acknowledge the American Occupational Therapy Association for making it possible for us to access occupational therapy academic programs in the United States through its email group and for disseminating the electronic survey.