Simulated Learning Environments
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Does the simulated learning environment provide the occupational therapy (OT) student with an increase in self-efficacy, as compared to traditional hands-on peer practice, in preparation for the fieldwork experience?
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Simulated Learning Environments
- 1. Simulated Learning Environments • Searching for Self-Efficacy Prepared By: Carol Zaricor, OTR, CNDT 12/12/2016
- 3. Objectives – Identify barriers encountered in fieldwork placement – Summarize the literature including common themes and findings to support using simulation for training students prior to fieldwork. – Describe the significance simulation has on fieldwork. – Present a change model.
- 4. Objectives continued • Objectives Continued – Illustrate the process for the planned change. – Identify options for evaluating the change including data analysis – Outline the dissemination proposal – Summarize the presentation
- 5. Significance of Practice Problem • Fieldwork is anxiety provoking • High-Hazard industry • Patient Safety • Reimbursement • Productivity • Student Autonomy • Reduction in Clinical Sites • Student competency The safety of the patient and provision of quality healthcare require a change in the traditional learning experiences of the student (Bethea et al., 2014)
- 6. PICO QUESTION • Does the simulated learning environment provide the occupational therapy (OT) student with an increase in self-efficacy, as compared to traditional hands-on peer practice, in preparation for the fieldwork experience?
- 7. Definition • simulation ‘…an educational technique that allows interactive, and at times immersive, activity by recreating all or part of a clinical experience without exposing patients to the associated risks’ (Maran & Glavin, 2003, p. 22).
- 8. Definition • Self-efficacy is a “a cognitive mechanism based on expectations or beliefs about one’s ability to perform actions necessary to produce a given effect” (Nishisaki et al., 2007, p. 225). • The student’s degree of confidence and/or instructor’s degree of confidence in the student, in providing the simulated task in the actual environment (Nishiasaki et al., 2007, p. 225).
- 9. Barriers To Fieldwork Readiness Regulatory Requirements Clinical Instructors Student Clinical Assignments
- 10. Regulatory Barriers Regulatory Requirements Curriculum Changes Reimbursement Supervision Guidelines
- 11. Supervision Barriers Clinical Supervisors Lack of Fieldwork Sites Refusals to Supervise Lack of Time for Training Safety and Quality Risks Productivity
- 13. Search Strategy • 137 articles • 12 articles retained after extracting duplicates, not applicable and not available articles • 2 Systematic Reviews were included • Cohort and pilot studies were reviewed
- 14. CINAHL Complete 1999-2015 21 citations EBSCO 1999-2016 65 citations AJOT 2005-2016 5 citations GALE Powersearch 2008-2016 1 citation MEDLINE 2006-2016 11 citations ProQuest 2006-2016 14 citations PubMed 2005-2016 12 citations Cochran 2015-2016 1 citation Google Scholar 2003-2016 7 citations 137 Non-Duplicated Citations Screened Inclusion/Exclusion Criteria Applied 115 excluded after title/abstract screened 22 Articles Retrieved Inclusion/Exclusion Criteria Applied 19 excluded after Full- Text screened Articles Excluded After Data Extraction 13 Articles Included 1 Article Excluded After Further Review 12 Articles Included PRISMA DESIGN
- 15. LITERATURE REVIEW COMMON THEMES • SIMULATION TYPE • TIME INVOLVED • ASSESSMENT TOOLS USED • COST OF SIMULATION • SELF-EFFICACY TOPIC OF ASSESSMENT • SUSTAINABILITY OF OUTCOMES • RESULTS
- 17. Time Involved Ranged from 1 session to a full semester
- 18. SELF-EFFICACY STUDIES • COMMUNICATION • PERFORMANCE • FIELDWORK READINESS
- 19. Assessment Tools found in Literature – Student Evaluation of Teaching (SET) – Satisfaction with Simulation experience scale(SSES); – Nursing Student Self-Efficacy Scale (NSSES) – General Perceived Self Efficacy Scale (GSES); – The Educational Practices in Simulation Scale (EPSS) – The Conditions of Work Effectiveness Questionnaire- II-Education: Vaccination Clinic Simulated Learning experience (CWEQ-II-ED-SL); – The Conditions of Work Effectiveness Questionnaire- II-Education: Actual Practice experience (CWEQ-II-ED-AP); Self-efficacy for Public Health Nursing: Vaccination Clinic (SEPHNVC);
- 20. Assessment Tools Found in Literature – Acute Care Confidence Survey (ACCS); – Clinical Practice Exam (CPE); – Assessment of physiotherapy practice; Likert scales; non-validated – Reflective thinking instrument; – Scenario checklists – video reflection – Visual Analog Scale – Objective Structured Clinical Exam – General Perceived Self- Efficacy and Competency Scale (GPSEC)
- 23. SELF-EFFICACY OUTCOMES Communication Standardized Patients = Role Play Performance > sim group vs control group no correlation between performance and self- efficacy (Stayt et al., 2015) General Self-Efficacy improved with all types of simulation Fieldwork Readiness 3 studies with positive results
- 26. Change Process • Rogers’ (2005) Diffusion of Innovation Model
- 28. Rogers’ Diffusion of Innovation Model Redefining RoutinizingClarifying Outcomes Measurement Relative Advantages Safety Concerns Ongoing Support Information Sharing Process Evaluation Updating Information Program Evaluation Research
- 29. Evaluation Tools SimulationIQ program Pre-Post Surveys Self-efficacy Questionaires Fieldwork Evaluation focusing on intervention skills Routinizing
- 30. Assessment Tools found in Literature – Student Evaluation of Teaching (SET) – Satisfaction with Simulation experience scale(SSES); – Nursing Student Self-Efficacy Scale (NSSES) – General Perceived Self Efficacy Scale (GSES); – The Educational Practices in Simulation Scale (EPSS) – The Conditions of Work Effectiveness Questionnaire- II-Education: Vaccination Clinic Simulated Learning experience (CWEQ-II-ED-SL); – The Conditions of Work Effectiveness Questionnaire- II-Education: Actual Practice experience (CWEQ-II-ED-AP); Self-efficacy for Public Health Nursing: Vaccination Clinic (SEPHNVC);
- 31. Assessment Tools Found in Literature – Acute Care Confidence Survey (ACCS); – Clinical Practice Exam (CPE); – Assessment of physiotherapy practice; Likert scales; non-validated – Reflective thinking instrument; – Scenario checklists – video reflection – Visual Analog Scale – Objective Structured Clinical Exam – General Perceived Self- Efficacy and Competency Scale (GPSEC)
- 32. Data Analysis • Compare individually pre- post • Compare between pre-post • Compare setting types within pre-post • Compare between settings pre-post • Additional qualitative survey regarding learning experience. CONFIRMATION
- 33. Dissemination • Within the department • Simulation lab staff • Allied Health programs • Nursing • Administration • Family Practice • Conference Presentations • Great Teachers Seminar CONFIRMATION
- 34. Conclusion • Self-Efficacy improves with simulation experiences • Students express satisfaction with simulation experiences • Student performance improves with simulation experiences • More research is needed for evidence of longevity and patient outcomes
- 35. QUESTIONS
- 36. References • Babenko-Mould, Y., Ferguson, K., Riddell, T., Hancock, M., & Atthill, S. (2015). Influence of simulated and actual community vaccination clinics on student empowerment and self-efficacy for public health nursing competencies. Public Health Nursing, 32(3), 277–283. doi.org/10.1111/phn.12151 • Baird, J. M., Raina, K. D., Rogers, J. C., O’Donnell, J., & Holm, M. B. (2015). Wheelchair transfer simulations to enhance procedural skills and clinical reasoning. American Journal of Occupational Therapy, 69, 1–8. doi.org/10.5014/ajot.2015.018697 • Baird, J. M., Raina, K. D., Rogers, J. C., O’Donnell, J., Terhorst, L., & Holm, M. B. (2015). Simulation strategies to teach patient transfers: Self-efficacy by strategy. American Journal of Occupational Therapy, 69, 1–7. doi.org/10.5014/ajot.2015.018705 • Bethea, D. P., Castillo, D. C., & Harvison, N. (2014). Use of simulation in occupational therapy education: Way of the future? American Journal of Occupational Therapy, 68, S32-9. doi.org/10.5014/ajot.2014.012716 • Bosse, H. M., Schultz, J.-H., Nickel, M., Lutz, T., Möltner, A., Jünger, J., … Nikendei, C. (2012). The effect of using standardized patients or peer role play on ratings of undergraduate communication training: A randomized controlled trial. Patient Education & Counseling, 87(3), 300–306. • Bradley, G., Whittington, S., & Mottram, P. (2013). Enhancing occupational therapy education through simulation. British Journal of Occupational Therapy, 76(1), 43– 46. doi.org/10.4276/030802213X13576469254775 SIMULATED LEARNING ENVIRONMENTS: 12 • Dunn, K. E., Osborne, C., & Link, H. J. (2014). High-fidelity simulation and nursing student self-efficacy: Does training help the little engines know they can? Nursing Education Perspectives, 35(6), 403–404. • Ebell, M. H., Siwek, J., Weiss, B. D., Woolf, S. H., Susman, J., Ewigman, B., & Bowman, M. (2004). Strength of recommendation taxonomy (SORT): A patient-centered approach to grading evidence in the medical literature. The Journal of the American Board of Family Practice, 17(1), 59–67. • Franklin, A. E., & Lee, C. S. (2014). Effectiveness of Simulation for Improvement in Self-Efficacy Among Novice Nurses: A Meta-Analysis. Journal of Nursing Education, 53(11), 607–14. doi.org/10.3928/01484834-20141023-03 • Giles, A. K., Carson, N. E., Breland, H. L., Coker-Bolt, P., & Bowman, P. J. (2014). Use of simulated patients and reflective video analysis to assess occupational therapy students’ preparedness for fieldwork. American Journal of Occupational Therapy, 68, S57-66. doi.org/10.5014/ajot.2014.685S03
- 37. References • Hooper, B., King, R., Wood, W., Bilics, A., & Gupta, J. (2013). An international systematic mapping review of educational approaches and teaching methods in occupational therapy. British Journal of Occupational Therapy, 76(1), 9–22. doi.org/10.4276/030802213X13576469254612 • Maran, N. J., & Glavin, R. (2003). Low-to high-fidelity simulation–a continuum of medical education? Medical Education, 37(s1), 22–28. • McGee, C., & Sopeth, L. (2015). Occupational therapy student learning in acute care contexts: Blending online, classroom, simulation, and fieldwork education. American Journal of Occupational Therapy, 69(Supplement_1), p. 1. doi.org/10.5014/ajot.2015.69S1-RP401 SIMULATED LEARNING ENVIRONMENTS: 13 • Nishisaki, A., Keren, R., & Nadkarni, V. (2007). Does simulation improve patient safety?: Self-efficacy, competence, operational performance, and patient safety. Anesthesiology Clinics, 25(2), 225–236. doi.org/10.1016/j.anclin.2007.03 • Pritchard, S. A., Blackstock, F. C., Nestel, D., & Keating, J. L. (2016). Simulated patients in physical therapy education: Systematic review and meta-analysis. Physical Therapy, 96(9), 1342–1353. doi.org/10.2522/ptj.20150500 • Silberman, Nicki J, PT,D.P.T., PhD., Litwin, Bini, PT,D.P.T., PhD., Panzarella, Karen J, PT,PhD., C.H.S.E., & Fernandez- Fernandez, A. (2016). High fidelity human simulation improves physical therapist student self-efficacy for acute care clinical practice. Journal of Physical Therapy Education, 30(1), 14-24. Retrieved from http://search.proquest.com.prx-usa.lirn.net/docview/1777919449?accountid=158603 • Stayt, L. C., Merriman, C., Ricketts, B., Morton, S., & Simpson, T. (2015). Recognizing and managing a deteriorating patient: a randomized controlled trial investigating the effectiveness of clinical simulation in improving clinical performance in undergraduate nursing students. Journal of Advanced Nursing, 71(11), 2563–2574. • Tutticci, N., Lewis, P. A., & Coyer, F. (2016). Measuring third year undergraduate nursing students’ reflective thinking skills and critical reflection self-efficacy following high fidelity simulation: A pilot study. Nurse Education in Practice, 18, 52–59. doi.org/10.1016/j.nepr.2016.03.001
Editor's Notes
- Hello, my name is Carol Zaricor and I am the Academic Fieldwork Coordinator and teach the 2nd year students for the occupational Therapy Assistant program at McLennan Community College. As Fieldwork coordinator I am challenged with ensuring students are prepared for clinical placements. Being new to academia I was unsure how to gauge fieldwork readiness. My first year I used traditional lecture and case studies with return demonstration to teach specific skills. My program director and administration have encouraged the use of the campus simulation lab. I tried a few scenarios with role playing and the students really seemed to enjoy it. There is a lot of work to prepare for simulation lab (role playing). I wanted to be sure the work was worth it. Were the students gaining knowledge and confidence necessary in preparation for fieldwork. My presentation today will walk you through the process I used to find my answer. The objectives are………………….
- Patient is safety is paramount in healthcare. By providing the student with a safe environment to learn from mistakes we could be protecting a patient from harm. Clinical sites are dwindling and clinicians are having less time for 1:1 teaching. The student must begin fieldwork with competence in basic skills. The simulated environment provides the student a safe place for learning.
- What exactly is simulation
- How do we know simulation works? One way is to ask the students. Self-efficacy is “a cognitive mechanism based on expectations or beliefs about one’s ability to perform actions necessary to produce a given effect” (Nishisaki et al., 2007, p. 225). Self-efficacy, as assessed in the academic simulated environment, is the students’ degree of confidence and/or instructors’ degree of confidence in the student, in providing the simulated task/procedure/activity, etc., in the actual healthcare environment (Nishisaki et al., 2007).
- REIMBURSEMENT= REDUCED NUMBER OF CLINICAL SITES REDUCED CURRICULUM HOURS=STUDENT SKILL AQUISITION
- AVAILABLE SUPERVISION =PATIENT SAFETY RISK PRODUCTIVITY =LACK OF TIME FOR SUPERVISION
- STUDENT’S LACK OF CLINICAL= EXPERIENCE STUDENT ANXIETY INSURANCE SUPERVSION REQUIREMENTS=LOSS OF STUDENT AUTONOMY
- The final twelve articles included in the review were dated from 2012 to present. Meta-analyses, random control trials (RCT), cohort studies and pilot studies were included. The subjects of the studies were allied health students from occupational therapy, nursing, physical therapy and medicine. The Strength of Recommendation Taxonomy (SORT) approach was used to grade the evidence included in the review (Ebell et al., 2004).
- Many various types of simulation exist. High fidelity simulation, also known as high fidelity human simulation was the focus in eight of the twelve studies. Role play was utilized in three of the 10 primary studies and one of the two systematic reviews. Standardized patients were used in three out of the ten primary studies and both systematic reviews. There were only two primary studies which used a control group to compare simulation to the classroom lecture and didactic learning environment. Role play and standardized patients were compared in two studies. Role play against actual patient intervention was measured in one study. Video reflection was common among the studies and typically combined with high fidelity simulation. Both systematic reviews included data with control group studies. Traditional learning methods are defined as lectures with discussion and didactic presentations, as well as peer practice of the material from the lecture. Classroom laboratory training of specific techniques such as body mechanics, transfers skills, hand washing and manual muscle testing to name a few. Skills assessments such as check-off sheets and test questions would be included in the comparison (Baird et al., 2015). High-fidelity simulation, such as interactive technology, including mannequins, standardized patient participants, such as students, teachers or even those involved in theatre, and video analysis are all examples of simulation styles. Simulation can take place in a home, clinic or staged sites such as the classroom or designated simulation laboratory located on the school campus. Video footage can be used, as well as, scripted scenarios. Interaction with mannequins from two-way mirrors have also been utilized. Simple problem based scenarios to multi-disciplinary team simulation activity has been performed. (Bradley, Whittington & Mottram, 2013)
- The literature compared cohorts of allied health students throughout their undergraduate and pre-entry level education. The years ranged from two to four. There were several studies that were completed in one to two days, while others followed the students through their undergraduate experience. The actual length and amount of simulation sessions varied throughout the studies and ranged from fifteen minutes to one hour. For the purpose of the search time can be considered at any point in the student’s academic career.
- Throughout this literature search, assessing self-efficacy has been the theme. The focus for the self-efficacy assessment has varied. Student’s self-efficacy regarding patient communication was common with several studies including Bosse et al. (2012), and Dunn, Osborn and Link (2014). Self- efficacy regarding performance skills was included in seven of the remaining eight primary sources. Self-satisfaction regarding simulation was measured in the remaining primary source. Self-efficacy related specifically to fieldwork readiness was measured in three of the studies. One could correlate the self-efficacy testing results with fieldwork readiness as communication, confidence, empowerment and skill performance are all expectations for the clinical experience.
- Multiple evaluation tools were used throughout the research. The common tool was the visual analog survey (VAS). The VAS was adapted for each study relative to the self-efficacy topic being assessed. Pritchard et al (2016) recommended further research be performed to validate self-efficacy evaluation tools. In the systematic review, Pritchard indicates few evaluation tools were validated which leaves room for bias in the findings. Tutticci et al. (2016) performed a study to validate the VAS and the reflective thinking survey. Tutticci’s et al. (2016) research proved the instruments reliable and recommending further assessment on a larger scale. Franklin and Lee (2014) also encourage the use of valid instruments rather than the researcher developing their own tools. Franklin and Lee (2014) report developing a non-standardized, non-validated assessment tool makes it difficult to synthesize the comparison of simulation to self-efficacy.
- of Simulation Little is known about the economic impact of simulation on learning outcomes (Pritchard et al., 2016). Pritchard recommends further research regarding the cost for high fidelity simulation use in physical therapy education. Concerns with the financial impact on the program was mentioned in four of the twelve studies. Students responded to a survey, regarding satisfaction with the simulation exercise, with concern of the college using simulation to gain increased revenue (Tutticci., 2016). With cost being a limiting factor for simulation, alternatives need to be developed. Babenko, Ferguson, Riddell, Hancock and Atthill (2015) are affiliated with a public health center where they assist with vaccinations and the public health nurses from the clinic assist with role playing and clinical supervision.
- A common question throughout the studies was: Does simulation transfer into clinical performance and patient outcomes? Stayt, Merriman, Ricketts, Morton and Simpson (2015) recommended a continuation or longitudinal study to determine transference of skills into practice. Tutticci et al. (2016) questioned transferability from educational to clinical setting. Silberman, Litwin, Panzarella, Fernandez and Fernandez (2016) recommended to measure students’ self-efficacy over multiple semesters. Dunn, Osborn and Link (2014) conclude that confidence leads to better patient care; thereby, gaining transference into clinical practice. The literature provides consensus that further research is necessary to determine if simulation has an impact on performance carry over into clinical practice.
- The primary literature included in the review is conclusive that generalized self-efficacy is improved with the use of simulation as a learning tool. The systematic reviews indicate simulation does in fact increase self-efficacy. Pritchard et al. (2016) report self-efficacy is shown to increase with simulation however the studies have bias and without valid assessment tools results could be skewed. When comparing standardized patients to role play, the findings are mixed. Stayt et al. (2015) found student satisfaction and self-efficacy to increase with both the patient simulation and control group. The performance scores in the patient simulation group were significantly higher than the control group with no correlation to self-efficacy. Dunn et al. (2014) found an increase in self-efficacy and patient care regarding communication skills. Consistently students were satisfied with the simulation experiences and requested additional simulation opportunities throughout the curriculum. Franklin and Lee (2014) recommend that the nursing research community move past assessing self-efficacy as a general topic and look forward to comparison with performance and learning outcomes. There is solid evidence to prove self-efficacy regarding confidence, empowerment and performance skills improves through simulated learning environments. Recommendations to move on from self efficacy studies Developing confidence and ability to handle lines were greater in the Campus 1 simulation group. Clinical supervisors agreed with the findings. (McGee & Sopeth, 2015) (Giles, Carson, Breland, Coker-Bolt, & Bowman, 2014) OT fieldwork readiness using FWPE
- Using simulation as a teaching tool in combination with didactic education is recommended. This is an (A) recommendation using the SORT tool (Ebell et al., 2004). Learning framework. Role Play versus Standardized patient was evaluated with mixed results. Recommendation (B) for role play during training and standardized patient during examination is being made based on cost effectiveness and feedback responses from qualitative studies (Bosse et al., 2012; Stayt et al., 2015).
- The actual implementation will require additional training for the instructor. The testing and analysis of data will be performed by a single instructor. Simulation equipment and assessment procedures will need to be addressed. There will be a very little cost if any required for the change process as the simulation activities will be incorporated into the curriculum without additional course time required. Students will receive an orientation to the simulation process. Consistency and compliance will be maintained through regularly scheduled simulation experiences including pre-post testing and video reflection. Facilitators of the process include faculty support and instructor interest in the process. Past student experience and feedback provided valuable information to facilitate this process. Barriers to the change might include the time required for the learning curve of both instructor and students as well as the simulation facility staff. A careful review of the data will be necessary comparing the initial attempts for consistency. There is potential for equipment failures which could inhibit accuracy of data.
- Self-efficacy re-assessment during the student’s fieldwork experience is recommended as a follow-up to the simulation learning experience is given a (B) rating as it was deemed beneficial by several researchers (Babenko et al., 2015; Dunn et al., 2014; Giles et al., 2014; Pritchard et al., 2016; Silberman et al., 2016)
- The VAS has been validated for assessing self-efficacy during simulation learning activities. Larger reliability studies were recommended (Tutticci et al., 2016). Reflective thinking and video reflection are given a (B) recommendation as they were positive aspects of the simulation experience by the students and the instructors (Baird et al., 2015; Giles et al. 2014; McGee et al., 2015).
- Measuring data will include testing self-efficacy before simulation and after simulation for each student. Data analysis may include paired t-test, McNemar's test, or Wilcoxon signed-rank test. When assessing the self-efficacy difference between beginning of semester and end of the semester, repeated-measures analysis of variance, Cochrane Q+, or Friedman statistic, may be used. Another area of interest for me is the skill performance compared to the self-efficacy scores. Sources of data could include self-efficacy surveys, clinical observations, test scores, standardized simulation assessment tools, Fieldwork Performance Evaluation results, and video reflection.
- Following the successful implementation of the change process, a plan for sustaining the change will be put in place. Gawlinski, A. (2007) recommends communicating results to staff, adding the change to policies and procedures, incorporating change into orientation programs, disseminating results at meetings and forums, and reporting results during council or committee meetings. Once deemed successful, these recommendations will be easy to implement at my college by placing the requirements in the course instructional plan and student orientation. Results can be disseminated at advisory meetings and departmental committee meetings.
- This project initially focused on student self-efficacy and the effect a simulated learning environment had on fieldwork readiness. The literature has provided that and so much more. The evidence for a simulated learning environment is plentiful in both improving students self-efficacy toward fieldwork readiness and improving learning outcomes. The practice change described is only the beginning of the plethora of opportunities using simulation can bring to both the self efficacy and learning outcomes of the occupational therapy student. Consideration for further research regarding learning outcomes and transference to practice should be made. Using the proposed dissemination plan, I would like to see this change spark interest in the development of a college wide inter-professional education committee that can add research to the use of simulation in the allied health community.