In Australia, the number of physiotherapy students requiring clinical education placements is fast exceeding the number of opportunities available. This shortage is reaching crisis point.
Education in simulated learning environments (SLE) is being considered as an alternative educational model to address clinical capacity issues. A literature review was undertaken to understand the growing trend of SLE use and its potential to replace some of the traditional clinical immersion with patients. It was found that SLEs were being used primarily to train communication or other clinical skills as an adjunct to traditional clinical learning rather than being used to replace clinical time. While there is potential for SLEs to replace clinical time and address clinical education shortages, there was little research exploring this possibility.
If clinical education in a SLE is to replace part of traditional clinical immersion, it is essential that there is evidence that it would not adversely affect students’ competency to practice and is acceptable to stakeholders. Thus the overall aim of this research was to develop and test, in randomised controlled trials (RCTs), a SLE program that replaced one week of a four week clinical placement in musculoskeletal physiotherapy. The primary hypothesis was that there would be no significant difference in the clinical competency of students educated in the new SLE model compared to those students educated in the traditional clinical immersion model.
Methods: The research involved a collaboration of six universities around Australia to ensure adequate participant numbers. The multicentre nature of the research ensured wider extrapolation of results. The collaboration required detailed preparation and administration to ensure consistency of operations across trial sites.
A 1-week clinical education program was developed for the SLE. It aimed to address course objectives and incorporate the reported advantages of SLEs including use of a variety of cases; integrating professional challenges into scenarios; use of SLE teaching techniques and realistic environments. Both actors (simulated patients) and educators received training. As little is known about the best construction of SLE models, two models for the 1-week program were configured and trialed. Model 1 (25:75) was one week in a SLE followed by three weeks in the traditional clinical practice; Model 2 (interspersed) was the equivalent one week SLE, offered in parallel and interspersed with clinical immersion over the first two weeks of the 4-week placement.
A single blind, non-inferiority design was used to conduct the two parallel but independent, multicentre single blind randomised controlled trials (RCTs). Participants were physiotherapy students entering their musculoskeletal clinical placements from the six participating universities. Participants were allocated to one of the two RCTs. Within each RCT, students were randomised to the SLE or Traditional immersion group within units of 8 students after stratification for academic score. The primary outcome was student clinical competency, judged in two clinical vivas undertaken by blinded examiners using the Assessment of Physiotherapy Practice (APP Tool) during the final week of the clinical placement. Purposefully designed questionnaires were developed to gain students’ and clinical educators’ opinions of the SLE program both immediately after the SLE and at conclusion of the placement. Patients were also surveyed at the end of the placement.
Results: The RCTs included 370 physiotherapy students (n=192 RCT 1; n=178 RCT 2). A non-inferiority test for difference in means was conducted for each trial. The results revealed that student clinical competencies in the SLE groups were no worse than the Traditional groups in either RCT (Margin (Δ) = >0.4 difference on APP score; RCT 1: 95% CI -0.07 to 0.17; RCT 2:95% CI -0.11 to 0.16).
Students rated the overall usefulness of the SLEs highly after the SLE (RCT 1; Median 8 (IQR 8,9); RCT 2; Median 8 (IQR 7,9)). On their reflection at the end of the placement, there was a relevant decline (difference = 1.0) in the overall rating of the experience in RCT 1 (Model 1) but no change in rating in RCT 2 (Model 2). In the main students in both RCTs were positive about all aspects of the experience in the SLE elements but where neutral in their opinion to have greater than 25% in simulation. Clinical educators rated SLE student performance as comparable on entry into clinic as well as in overall performance (week 4). Patients rated highly the care of both SLE and control students.
Conclusions: The importance of students experiencing contact with real patients is not disputed but this research has provided evidence that 25% of a traditional clinical immersion placement could be replaced by SLE without compromising students’ competency to practice. SLEs therefore have the potential to increase clinical capacity. SLEs were accepted by all key stakeholders, giving institutions confidence for future implementation.
This work opens further avenues for research including for example, the maximum clinical hours that can replaced with a SLE while maintaining student competency standards and acceptability; the optimal timing of SLEs in coursework; its effectiveness in other fields of physiotherapy and indeed other health disciplines. SLEs offer an exciting adjunct model of clinical education, with its own advantages as well as its capacity to increase clinical capacity.