Simulation within physiotherapy education, is effective in developing many essential clinical and professional skills [1]. Standardised patients (SPs) help create high fidelity scenarios reflecting real-world environments, enabling students to practice person-centred care, communication skills and empathy, alongside hands-on clinical techniques [1]. The cost of hiring external actors, however, is one of the biggest barriers faced by Higher Education faculty staff [2]. While peer-peer simulation has been shown to be effective [1], our own experiences demonstrated a reluctance for many students to take on a performance role. Collaborative discussions with the university Acting programme highlighted several mutual benefits if the non-medically trained acting students were able to portray realistic patients and the physiotherapy students could ‘buy into’ character age differences. Maintaining psychological safety was also a priority.
This phenomenological study aimed to explore students’ perceptions of simulated learning, and the impact acting student SPs had on the learning experience. As qualitative methodologies are poorly represented in physiotherapy education simulation literature, a second aim was to add depth to our current knowledge.
70 physiotherapy students undertook a day of simulated learning in the University simulation wards. In groups of 6, students either led or observed 2 scenarios. 4 SPs of varying ages and medical presentations were portrayed by student actors, none of whom had previously been involved in simulation. A short training seminar helped the actors with clinical presentations. Following the simulation, all students were invited to participate in online focus groups. Thematic analysis was used to analyse data [3].
13 students participated in 3 focus groups. Physiotherapy participants reported the simulation supported the development of many skills including clinical reasoning, independent thinking, problem solving and teamworking. Although stressful, the simulation felt safe. It was an enjoyable and valuable learning experience. The acting students’ realistic portrayal of patients enhanced the session, and the physiotherapy students reported quickly ‘buying into’ patient characters, irrespective of the acting students’ age. Patient perspective feedback was particularly helpful, even though acting participants reported they found this aspect challenging. Acting participants also felt the simulation experience enabled them to create different, emotional characters and use improvisation skills to challenge the physiotherapy students as the scenarios developed (Table 1).
Results of this study add depth to the literature on simulation in physiotherapy education. It supports the use of acting students as SPs, offering an effective and cost-effective alternative to professional actors.
As the submitting author, I can confirm that all relevant ethical standards of research and dissemination have been met. Additionally, I can confirm that the necessary ethical approval has been obtained, where applicable.
1. Lowe CM, Heneghan N, Herbland A, Atkinson K, Beeton K. KNOWBEST: The KNOWledge, BEhaviours and Skills required of the modern physiotherapy graduate including the future role of practice based learning. Chartered Society of Physiotherapy; 2022.
2. O’Shea O, Mulhall C, Condron C, McDonough S, Larkin J, Eppich W. A qualitative study of physiotherapy educators’ views and experience of practice education and simulation-based learning. 2023. International Journal of Healthcare Simulation. https://ijohs.com/article/doi/10.54531/HKOI8650
3. Braun V, Clarke V. Thematic Analysis: A Practical Guide. 7 ed. Los Angeles: Sage Publications; 2022.
| Physiotherapy students’ perceptions of the simulated learning experience | |
|---|---|
| Themes | Participant quotes |
| Simulation helped develop professional skills | “I had to really actively think on my feet” (P4)“It was great to collaborate with other people” (P1)“We had to problem solve” (P7) |
| Emotional aspects of sim | “It was amazing” (P4)“I was a bit more scared actually because it was more real” (P5)“A real confidence booster” (P7) |
| Environmental fidelity increased learning | “It was a fantastically safe space” (P1)“As close to a real clinical setting as it could be” (P2)“My first real experience of a hospital ward” (P3) |
| Simulation as an educational/ learning experience | “So many things were learnt” (P8)“The point was to learn and that was clear” (P6)“I did get valuable learning from watching” (P1) |
| Physiotherapy students’ perceptions of acting students portraying SPs | |
| Skills of acting students in portraying patients | “The acting was absolutely incredible and far exceeded what I was expecting” (P2)“The acting students were taking their roles really seriously” (P9)“I found very easily that I slipped into looking at him as though he was an 82-year-old” (P11) |
| Enhanced learning experience | “Actors made it feel real” (P4)“It immediately put you in that professional frame of mind” (P2)“Looking at patient care, patient-centred care and how we’re actually treating the patient” (P5) |
| Comparisons with peer-on-peer scenarios | “If you do like mess up and you’re working with a friend, it’s like, yeah, OK we’ll give you a little bit of help” (P4)“There was a sense of realism from the acting patients that maybe we wouldn’t have got from like our peers” (P10) |
| Acting student opinions of the simulation experience. | |
| Simulation as a learning experience for actors | “I found it harder to criticise them” (P12“It was certainly different to things I’ve done in the past” (P13)“I couldn’t overdo it, but I couldn’t underplay it either” (P12)“I found being that vulnerable quite difficult, even though it was fake” (P12) |
| Professionalism of physiotherapy students | “There was a lot of trust involved, but there wasn’t any point where I felt I wasn’t safe with it” (P12)“I didn’t feel like I needed that safety net of the lecture” (P13)“They all did brilliantly” (P12) |
| Actors reacting to changing situations | “Ohh, this is too easy for them. And so I made it more difficult” (P13)“I made it harder in the afternoon” (P12) |
While simulated participant (SP) methodology has been documented since 1964 [1], it has evolved into a specialized practice. The growth is evidenced by SP methodology embedded in most health professions curricula, expansion of SP programs and development of practice standards [2] and professional networks [3]. What is less clear are pathways for simulation practitioners seeking to expand their expertise in SP methodology.
The authors have varied backgrounds and bring many years of collective experience working with SP methodology in diverse global contexts. In response to almost weekly requests from individuals interested in developing their SP practice, we wanted to provide high-quality resources to an international audience and to meet this need efficiently. The development of an online network was an obvious response.
This report documents a decade-long history of surfacing issues with feasibility in the provision of online resources for professional development.
In 2012, we launched the Victorian Simulated Patient Network – renamed in 2016 to the Simulated Patient Network (SPN) (www.simulatedpatientnetwork.org) – a web-based resource that includes online learning materials for SP educators and SPs. In development, we brainstormed topics that we believed were important and reflected the nature of the varied requests we received, as well as consulting widely with colleagues.
Table 1 lists the module topics that sit in a Moodle-based learning management system (LMS). Each module was designed to take about 3 hours and structured according to a template framework that promoted effective educational design. Authors were guided to include learning objectives (LOs); text, audio and visual content; practical resources such as scenarios and worksheets; reflective exercises; and evaluations. Using this framework, modules were developed by nine scholars and practitioners, and underwent an initial peer review. Modules were offered for asynchronous learning and were complimentary until 2021. While the development of resources was funded, there was no additional funding for long-term maintenance.
| Module | Title |
|---|---|
| M1 | Introduction to SP methodology* [Foundation program in SP methodology] |
| M2 | SP program management* |
| M3 | Creating roles for SPs* |
| M4 | Training methods for SPs – role portrayal* |
| M5 | Training methods for SPs – feedback* |
| M6 | The art and science of teaching and learning with SPs using audio-visual review |
| M7 | SPs in assessments |
| M8 | Developing hybrid simulations |
| M9 | SPs and moulage |
| M10 | Debriefing SPs after simulation events |
| M11 | SPs in action |
| M12 | Interprofessional SP-based education |
| M13 | Children as SPs |
* Indicates the revised course title in [] and now available on https://learn.healthysimulation.com/
Our evaluation strategy focused on reach, engagement and quality improvement. The country of origin of participants and completion rates were considered. In the module evaluation, 6-point rating scales (1 = Not at all met/helpful/satisfied to 6 = Completely met/helpful/satisfied) were presented to the participants to rate the meeting of LOs: the helpfulness of the content in meeting LOs and their satisfaction on the overall learning materials and LMS. Open-ended questions (What worked well? and What can be improved?) were also included.
By 2021, there were 1,322 enrolments from 71 countries, with major sources of enrolments from Australia (695), the United States (326) and Canada (71).
The highest completion rate achieved was 11.8% (Module 1). Low completion rates are typical of massive open online courses (MOOCs) [4,5]. Furthermore, given our limited resources, we were unable to undertake activities such as increasing social interaction, running webinars and providing feedback and CE credits, which might have assisted in boosting completion rates.
Participants’ evaluations of LOs across the 13 modules had mean ratings of 4.9 to 5.7; the helpfulness of the exercises was 4.8 to 5.5; the satisfaction with the module content was 4.9 to 5.4; and satisfaction with the LMS was 4.8 to 5.4. These ratings indicate that the course materials were well received.
Table 2 presents free-text comments from participants. The feedback reinforced that, overall, the participants found the course materials to be of high quality and valuable. The data also suggest opportunities for improvement, which were limited by our lack of resources.
| Theme | Example |
|---|---|
| What worked well? | |
| Structure of learning materials | ‘I thought the module was very well laid out. It gave an overview of the chapter and expectations. I also felt it flowed very well and logically from one chapter to the next. I found the examples of feedback from learners useful’. |
| Provided resources | ‘The resources were all very informative and helpful in expanding my understanding of this topic. I appreciated the insight into different sites and how they are challenged and coping with a variety of situations’. |
| Quality content that suits both novices and experts in SP methodology | ‘This module is very well developed. The information is relevant and detailed. Even though I had been working in this field for 18 years, this module reminded me of aspects I had not thought of for a long time. It enabled me to take a much-needed objective approach to SPs and SP methodology again. And yet, the module would be great for someone beginning in this field as well. I also liked the fact that this module opened my eyes to areas that could still be explored that I might have lost sight of amidst the admin and having gotten used to how things are done. If I had to substantiate the use of SPs now, I could do it with enthusiasm and conviction’. |
| Exercises provided | ‘I really enjoyed being able to come up with a scenario. This was fun yet challenging. It was also useful to have an example that we could follow. It was also informative to learn the different ways that one could come up with roles’. |
| Inclusion of audio-visual material | ‘I liked the 2 short videos, firstly showing the SP ‘in role’ during the scenario and then secondly showing the SP ‘out of her role’ giving the learner pertinent feedback. I learnt what to appreciate and value and look for whilst ‘in role’ and then to honestly feed that back’ |
| What could be improved? | |
| LMS navigation | ‘The content management system is a bit clunky. I found it hard to know where I was up to (when I returned in subsequent days). Sometimes the pages contained only a little text, so there was quite a bit of clicking to move through it’. |
| More engagement via interaction with other participants and feedback from instructors | ‘Interaction with other students would be good and some feedback from the assessor’ |
| More visual images to be used to complement the text | ‘Images would brighten the Moodle books’ |
| Maintenance, including technical issues (such as broken links, video not loading fast enough) | ‘Some of the links did not work...not sure of this is related to the web browser that I was using (IE)’ |
| Opportunity to cater to non-English-speaking participants | ‘I wish there were videos that contain subtitles so we can understand in a better way’ |
By 2021, several events converged to facilitate directional change. We had long depleted funding for maintenance and had limited capacity for administration and other activities. The advent of Covid-19 with almost universal uptake of online learning increased the acceptability of the format of our modules. We needed to consider a new approach that stayed with our vision of the provision of high-quality resources to a global audience.
We were approached by a provider of online resources for the international simulation community (https://learn.healthysimulation.com/) with a more sophisticated LMS that supports deeper engagement with learners (e.g. webinars with amplification of ideas; Q&A) and the embedding of exercises directly into the module, providing smoother navigation for users. CE credits are also provided.
Five courses have been revised, and others are slowly transitioning to the new platform. We have switched from the use of the term ‘module’ to ‘course’ to accommodate Healthy Simulation and better align with the Continuing Professional Development format. A new course – Working with SPs online – has also been developed in response to contemporary needs. Participants are given three months of access with their fee. While we retain asynchronous learning, synchronous aspects (e.g. webinars) have enabled the opportunity for engagement with us and networking between participants. The platform also has the potential for hosting different languages. Currently, evaluations are standardized across all resources on the LMS, enabling comparisons between them that target user experiences and preferences.
We believe that these strategies will assist in achieving increased engagement while offering long-term sustainability. We hope that sharing this experience highlights considerations related to sustainability and feasibility for anyone planning online learning materials.
DN drafted the initial version of the manuscript. All authors met to review. CS led all further revisions. JH collected and organized data in Tables. All authors contributed equally to draft revisions and approved the final version of the manuscript.
A small selection of SPN courses were funded initially by the Department of Health, SLE Program, Health Workforce Australia, Australia.
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None declared.
None declared.
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A21 A Qualitative Exploration of Physiotherapy Students’ Opinions of Simulation and the Impact of Acting Students as Standardised Patients
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