‘It’s the ultimate observer role…you’re feeling and seeing what’s happening to you’: students’ experiences of peer simulation

Abstract

Introduction

Simulation-based education (SBE) benefits learners, but multiple barriers limit curriculum integration. Peer simulation, where students are formally educated to portray patient roles in simulated interactions with their peers, might maintain the educational benefits of SBE, be cost-effective, and enable additional learning. Our research question was: ‘What are the perspectives and experiences of physiotherapy students who participated in peer simulation?’.

Methods

Second-year physiotherapy students (n=16) participated in a blended peer simulation programme that included preparation for patient role portrayal and simulated clinical interactions with peers. Using an interpretivist approach, students’ experiences and perspectives were explored in two focus groups. Inductive thematic analysis was completed by two researchers.

Results

Three primary themes were identified that characterised the experiences and perspectives of physiotherapy students: peer simulation is a valuable learning experience, specific design features enable effective peer simulation, and portraying a patient provides unique insight. Peer simulation was unexpectedly realistic, revealed knowledge and skill deficits, and improved their clinical skills. Specific design features included consistent engagement, repetitive, individualised practice, multiple forms of feedback, and detailed role preparation. Being the patient in peer simulation gave students unique and valuable insight into patients’ experiences of and feelings about health issues and healthcare interactions.

Conclusion

Physiotherapy students acquire new insights during peer simulation that may enrich their capabilities for practice through understanding healthcare interactions from patients’ perspectives. Physiotherapy students’ learning in peer simulation appears to align with the powerful learning experiences of health professional students in other immersive simulation modalities.

INTRODUCTION

Simulation-based education (SBE) has become a standard teaching approach in many medical and surgical education programmes. ¹ Considerable evidence supports the use of SBE to improve students’ knowledge, skills and behaviours. ^2–4 However, the sustainable implementation of SBE in broader health professions education continues to be limited by high costs, and location and resource limitations. Nursing, ^{5 6} physiotherapy ⁷ and pharmacy ⁸ education programmes continue to be restricted despite abundant evidence of SBE effectiveness.

Peer simulation is becoming increasingly popular in such programmes in response to the barriers of limited resources and cost. ^{6 9 10} Peer simulation is an approach to human simulation where health professional students are formally trained to portray patients’ roles in simulated interactions with their peers. Inherently by design peer simulation is less costly, as students are not paid to portray patients’ roles in the same way that lay people typically are. In addition, the educational design features that enable learning for healthcare professionals during SBE, including deliberate practice, varied difficulty, individualised learning, and clinical environment representation, ^{1 11} remain possible. Quantitative studies exploring peer simulation across various health professions have suggested that students develop improved clinical skills, ^{10 12–15} confidence, ^{6 10} knowledge ⁹ and empathy. ^{16 17}

Like other modalities of human simulation, peer simulation involves a simulated clinical environment that has been intentionally designed to replicate features of real clinical interactions, and scenarios that are aligned to learning outcomes of the SBE experience. ¹² Students portray patients’ roles that have characters and health issues other than their own, and undertake preparatory activities that support the development of portrayal abilities. ^{6 11 12 18} While there are similarities to peer role-play, including the need to develop learning objectives, and the use of patient or practitioner notes, feedback, reflection and debriefing, ¹⁹ peer simulation is different because of the replication of simulated clinical environment (which is not a feature of peer role-play), and the detailed preparatory activities for role portrayal. In addition, in contrast to the guidance provided in peer simulation, preparation for peer role-play typically involves students conceptualising their own roles and improvising behaviours based on intellectual or scripted understandings. ^18–20

The Association of Standardised Patient Educators (ASPE) Standards of Best Practice (SOBP) is intended to provide a comprehensive conceptual framework for educators implementing SBE with human role-players. ²¹ However, while a broad definition of simulated participant (SP) is provided in the SOBP as ‘a person trained to portray a patient in realistic and repeatable ways’, the inclusion of students as human role-players for their peers is not explicitly addressed. Differences between student and lay-person portrayal of patients’ roles may include familiarity with peers who are interacting in the practitioner role, students being younger than typical SP cohorts, ²² and prior student knowledge of conditions and healthcare associated with health professional education. While the SOBP provide clear and practical guidelines that intend to enable safe and effective SBE design, this framework may require modification for SBE involving student portrayal of patient roles. Additional or modified practices may need to be considered to enable safe and effective peer simulation programme design.

The impacts of portraying patients’ roles on students themselves are not currently known. SPs who have a lay background are impacted by role portrayal in both positive and negative ways. ^{23 24} Increased confidence, empowerment, improved health literacy, in addition to physical discomfort, psychological distress, shame and anxiety are reported. ^{23 25 26} Prior knowledge of health conditions, and familiarity of fellow students may amplify or reduce these impacts. Of particular interest is whether student portrayal of patients’ roles leads to greater learning related to empathy for patients’ perspectives. ^{12 16 27} This outcome has been proposed as a unique benefit of peer simulation above other SBE approaches. ²⁸ It is also unclear whether the familiarity that exists between the simulated patient and simulated practitioner in peer simulation is a barrier, an enabler, or irrelevant with respect to the value of the exercise.

No study appears to be available that has directly explored in depth students’ experiences and perspectives on engaging in peer simulation. Such data could inform best practice guides for peer simulation programmes that are safe and effective. In addition, if evidence is found in support of this approach from the student perspective, then larger evaluative studies exploring long-term student and patient outcomes compared with costs might be justified. Given that previous literature has not focused on students’ perspectives on peer simulation, we posed the following research question: ‘What are the experiences and perspectives of physiotherapy students who participated in peer simulation?’

METHODS

Research paradigm and study design

We adopted an interpretivist research approach for this study. ²⁹ Interpretivism maintains that multiple, diverse interpretations of reality (ontology) and knowledge (epistemology) related to the phenomenon of interest (peer simulation) may exist among participants (physiotherapy students) and researchers. ²⁹ Therefore, meaning (knowledge) is co-constructed by the researchers (who have beliefs and assumptions about the phenomenon of interest) with the participants (who have personal experience of the phenomenon of interest). ²⁹ Subsequently, an inductive qualitative design with focus groups was chosen to align with the interpretivist paradigm, and encourage rich exploration of students’ experiences and perspectives of a peer simulation programme that could be co-constructed by the research team. ^{30 31}

Researcher characteristics and reflexivity

Given it is imperative for qualitative researchers to engage in reflexivity across all stages of the research, ³² we adopted personal, ³² epistemological ³² and team-based ³³ reflexive strategies to enhance the integrity of this study. For ease of reading, the strategies we used are described in the relevant sub-sections of the methods. ³⁴

Our research team comprised five health professional educators with experience in simulation methodology, as physiotherapists (SAP, ND, FB, JLK, MT) and a social scientist (DN). SAP conducted the study as part of the final stages of his PhD. ND has more than 20 years of experience in health professional education, and at time of writing had recently enrolled in a PhD investigating models of peer simulation curriculum design. FB has more than 15 years of experience in health professions education and research. JK has more than 30 years of experience in health professions education and research. MT has 4 years of experience in health professional education and at time of writing was in the final stages of her PhD in health professional education. DN has more than 30 years of experience in health professions education and research, and considerable experience in qualitative research methods.

Context

The study setting was an Australian university (Western Sydney University (WSU) Campbelltown campus) delivering a 4-year pre-registration physiotherapy bachelor’s degree to undergraduate students.

Sampling strategy

A purposive homogenous sampling approach informed the recruitment of participants for this study. ³⁵ We sought expressions of interest from WSU physiotherapy students (n=57) who were enrolled in a 2nd year subject that included participation in peer simulation interactions as part of their curriculum.

Invitations to participate were shared via periodic email and lecture announcement from a colleague who was not a member of the research team. Study rationale, information about the researcher team, a participant information statement and consent form, and a link to an online survey that captured participation interest was provided. It was explicitly outlined in the email and announcement that although the coordinator of the subject (FB) was a co-investigator of the research, she would not be involved in data collection or analysis, that the investigator conducting the focus groups (SAP) would not have involvement in future academic processes, that participation/non-participation would not influence future academic progress, and that participants with affirming and contradictory perspectives were welcomed. ³² These strategies were implemented for ethical and reflexive purposes. Students were offered a free-catered lunch during the focus group. Interested students provided their name, contact email, and preference of focus group timing from three options. Recruitment continued over a 3-month period from the time students initially participated in peer simulation interactions until the day of data collection to enable the largest possible sample size from the subgroup of interest.

Peer simulation programme

Students had completed a peer simulation programme that comprised 8 hours of online learning activities across SBE activities. Guidelines for successful SP programmes ^{11 26 36} were used to inform programme design, which occurred across 2016–2017.

The first online module (approx. 6 hours) involved reviewing recommendations for peer simulation, and written and video activities that aimed to develop skills for preparing and portraying patient roles in a simulated learning environment. This module is presented online as Open Access (www.peerpatient.com.au). The second online module (approx. 2 hours) involved observing videos, guided by structured learning activities, of real patients with a particular injury or condition. This module is password protected online to protect patient confidentiality, through the same website described above. Videos included interviews with patients about their experiences and demonstrations of the physical features to be portrayed. Students were also required to learn a patient role overview, including reviewing example questions and answers. Students completed the online component of the programme across September and October 2017.

SBE activities involved student allocation to a group of three, and random assignment such that they were allocated to one of the three roles on each of three consecutive weeks: peer-therapist, peer-observer, or peer-patient. The first hour of the session comprised different educator-guided preparatory activities for peer-patients (discussion of role features that were presented in online module, rehearsal and feedback on portrayal from an educator) and preparatory activities for peer-observers and peer-therapists (review of medical notes and development of an assessment and management plan). The second hour involved the simulation interaction, where peer-patients were asked to portray patient roles in a simulated clinical environment. Classrooms were set up to look as much like the real clinical environment as possible using equipment, props and costumes. Peer-therapists were asked to engage in the interaction as if it were a real patient–therapist interaction, ³⁷ with peer-observers completing structured observation activities relating to identifying learning opportunities and assessment of competency of peer-therapists, to inform later debriefing activities. ³⁸ The third hour of the session involved all students completing out-of-role group debriefing activities that were informed by the SHARP approach ³⁹ and guided by an educator. SHARP ³⁶ is an acronym that represents five prompts for learners to consider when conducting a time-limited debrief after a simulated learning experience: Set learning objectives; How did it go; Address concerns; Review learning points; Plan ahead. An overview of the programme is presented in table 1.

Table 1.

Peer simulation curriculum overview

Curriculum component	Structure and content
Module 1: How to…	Guidelines for Your Peer Simulation Experience. Video with captions (approx. 6 min providing overview of guidelines to make the most of simulation experience. Prepare for the Simulated Patient Role. 10 videos (approx. 1 min each) introducing SP concepts, spoken by an experienced SP. The Craft of Acting for Patient Simulation. Article presenting acting skills and techniques, including the Method acting technique (interspersed with pictures). Observe and Portray Movement Patterns. Three activities including review of videos, activities to identify physical characteristics seen on video, and guided activities for practicing physicality. Observe and Portray Emotions. Four activities targeting identification of emotions and embodiment in physicality.
Module 2: Patient cases	Watch the patient video (physiotherapy assessment) and take notes. Complete observational notes activity. Read the script, presented in the template of character, health issue, simulation environment. Watch the patient video (impact of health condition). Complete question/response activity.
Face-to-face hour 1 (preparation)	Peer patients:  10 min review of patient role details 5 min discussion led by tutor about case details 5 min rotating role play led by tutor 10 min physical examination practice in pairs 20 min environment set up (costume, props) Peer therapists:  Review clinical paperwork provided by tutor Plan interview and physical examination Peer therapists:  Familiarise with observational activities (assessment tool) Review clinical paperwork Support peer therapists to formulate plan
Face-to-face hour 2 (simulation)	60 min simulated clinical interaction Students working in groups of three, supervised by a tutor Utilisation of time-in/time-out process to allow students deliberate practice
Face-to-face hour 3 (debrief)	5 min independent reflection time and de-role-ing. 25 min guided debriefing (SHARP approach) in small groups of three. 25 min of guided debriefing (SHARP approach) in the whole group (approx. 18 students).

Prior to this study, students had completed physiotherapy theory and practical skills subjects as per the course structure (http://handbook.westernsydney.edu.au/hbook/course.aspx?course=4706.2), and had not completed any SBE or work-integrated learning activities such as clinical placements.

Data collection

Focus groups were chosen to enable an open environment in which participants could talk in-depth, and in their own vocabulary, about their experiences and perspectives of peer simulation. Focus groups were also a logistically feasible method of bringing together study participants. ³⁴ Scheduling of focus groups occurred at times when students were on-campus and not assigned to other classes. Each focus group was conducted in a room that was familiar to the students to align with an interpretivist approach. ²⁹ A topic guide containing focused prompts and unstructured open questions was developed by the research team to encourage discussion related to the research aim ⁴⁰ (online appendix I).

In January 2018, the primary investigator (SAP), who is trained in focus group methodology, led two focus groups with eight participants each, informed by the guidelines of Hansen. ⁴⁰ SAP was not directly involved in the educational activities of the students, and did not have a previous relationship with them, thereby minimising the potential influence of power or hierarchy on the sharing of perspectives.

Memo-writing was completed by SAP immediately after each focus group to capture initial thoughts and reactions. Focus groups were audio recorded using a digital voice recorder, then transcribed verbatim and de-identified by an external agency. SAP confirmed transcript accuracy before forwarding to the other members of the research team for analysis.

Data analysis

Braun and Clarke’s method of inductive thematic analysis (TA) was chosen for this study. ⁴¹ Inductive TA is a flexible qualitative data analysis approach, meaning our analysis could align with an interpretivist approach whereby meaning and knowledge is constructed ‘bottom-up’ without sensitising theory or concepts needing to be defined a priori. ³⁴ Additionally, the clearly articulated guidelines associated with TA meant that although one researcher (ND) had limited experience in qualitative methods, it was an accessible approach through which we could conduct data analysis.

Prior to starting analysis, the two researchers (SAP, ND) completed a reflexivity exercise using discussion and memos to reflect and articulate pre-conceived ideas and assumptions. ³² Both SAP and ND had worked as educators in SBE in a different university physiotherapy programme to the programme within which this study was conducted. It was identified in these reflexive discussions that SAP and ND had previously received feedback from students (in a different university programme to this study) that peer simulation can be enjoyable, engaging, and helpful for learning, that structure and guidance enables greater insight, and that replicating the clinical environment is appreciated.

Both researchers independently read both transcripts multiple times to become familiar with the data, recording initial ideas for coding by taking notes (phase 1). SAP and ND then independently produced initial codes from the entire data set (phase 2), which were phrases of transcript that appeared interesting that were then extracted into a separate document with a summarised statement. Participants’ words were used as much as possible when coding to align with an inductive approach. Complementary and divergent opinions were sought in the data. ³²

Both researchers independently created thematic maps by collating codes into candidate themes and subthemes using tables and mind-maps (phase 3). SAP and ND then met to discuss and seek agreement on an initial thematic map. Discussion, note-taking, and reference to the memos facilitated reflection and articulation of underlying assumptions and their impact on theme construction.

SAP and ND then refined the thematic map by reviewing the coded data extracts, and reading the transcripts to consider the validity of theme in relation to the data set (phase 4), before meeting a second time to seek agreement on the working thematic map, including themes, subthemes, discussion points, and supportive quotes.

An investigator who was not involved in delivering teaching activities or data collection (MT) was then consulted for higher-level discussion of the thematic map, to check for negative and alternative cases, and for opinion on validity of illustrative quotes.

SAP then produced the first draft of the narrative of each theme (phase 5), with refinement occurring via iterative email and face-to-face discussion with ND and MT in preparation for report writing (phase 6). Microsoft Word software was used to manage the data in all stages.

Ethical approval

Institutional ethical approval was granted for the study (Western Sydney University Human Research Ethics Committee project number H10388).

RESULTS

Demographic information

Two focus groups each with eight participants were conducted on consecutive days in January 2018, lasting 79 min and 94 min, respectively. Of the 16 participants, 9 were female and 7 were male.

Thematic analysis

Three primary themes were identified that represented the experiences and perspectives of physiotherapy students who participated in peer simulation. Students considered that peer simulation is a valuable learning experience, specific design features enable effective peer simulation, and portraying a patient provides unique insight. These themes are discussed below with supporting sub-themes. Quotes are included to illuminate the essence of each theme.

Theme 1: Peer simulation is a valuable learning experience

Unexpectedly realistic

Students perceived peer simulation to be unexpectedly realistic and serious, and felt this was helpful for engagement and learning. The design of the simulated clinical environment, use of clinical equipment, detail and inclusion of real patients in the patient role scenarios, and formality with which their peers engaged in the simulation and represented the patients’ stories contributed to the sense of realism. This created a point of difference to standard practical classes.

I definitely didn’t think it would be as realistic as it was, like when you walked in and people were lying in beds with drips and stuff coming out of them. (FG1)

My patient was the pneumonia case, and…I’d never experienced knowing someone that’s had pneumonia. I thought the acting ability was at a level where I could imagine this person as having pneumonia. (FG2)

Revealed knowledge and skill deficits

Value was also associated with the identification of knowledge gaps, making mistakes, and building confidence through practice. Peer simulation provided context and examples of how previous knowledge, skills and theory were relevant for practice. This motivated students to improve their learning behaviours. Students appreciated the timing of peer simulation in their education pathway and considered it especially valuable prior to interacting with real patients. The formality of the environment, the need to conduct a complete physiotherapy interaction independently (including aspects of assessment and treatment), and being required to integrate multiple skills and apply considerable knowledge simultaneously, was challenging and helped learning.

If you went in really confident, you still made a ton of mistakes, and I really liked that because if I had a real patient, it would’ve been a lot more intimidating, so I thought it was really good practice before we do actually go out. (FG1)

I didn’t do many of the readings before, but then after seeing Peer Patient and the amount of stuff you need to know, it was like, “Actually, like this year, you’ve got to know your stuff, inside out, back to front”. Now, in preparation for the tutes I’m like okay, do I know how to do this? (FG1)

Improved clinical skills

Students described experiences of improving their clinical reasoning, physical examination, and communication skills in peer simulation. Critical thinking, decision-making, and justification skills were perceived to have been challenged and developed. Positive communication experiences that influenced learning included feeling comfortable in flowing conversation and receiving clear information in response to questioning. Negative experiences included awkward silences, unintended jargon use, misunderstandings, and confusion. Peer simulation afforded students practice in effective listening, prioritising their assessment and management, modifying their practice based on patient preference and time-pressures, and consideration of unexpected new information.

I saw a lot of jargon. I mean, we would throw that around in class all the time because we’re all physio students…because it’s not a real situation, like the simulation more was. (FG2)

Planning an overall assessment…you get the case, meet your patient, and you think you know everything, but then when you’re talking to your patient and new stuff comes up, and being able to think on your feet and quickly apply that into what you’ve already come up with. (FG2)

Students also described an increased awareness of clinician and patient safety after engaging in peer simulation. This notion primarily arose from experiencing or observing unsafe practices that put the patient and/or the therapist at risk of injury. Discomfort experienced as a peer-patient from poor manual handling and inappropriate placement of leads and tubes, difficulty as a peer-therapist arranging equipment in a small space, and identification as a peer-observer of suboptimal environment set up, were examples of powerful learning experiences.

The oxygen mask we had on, she was moving me, but almost choking me at the same time because she wasn’t moving it. It’s really important…when you’re the therapist, you need to make sure that you have safety under control. In a real-life situation, if you are moving a patient, you need to make sure that IV drips and everything get out of the way. (FG1)

I had to learn to manage it, the small space, which I’m sure is similar to when you go to placement, right…how to move the bed and handle your environment… that was good stuff. (FG2)

Theme 2: Specific design features enable peer simulation

Consistent engagement

Students shared that consistent engagement, and an absence of interruptions, was preferable for learning in peer simulation because it reflected real life. Timeouts, where students or educators could pause the simulation for reflection, were considered unhelpful because engagement was lost. Students also shared experiences where peer-patients broke character to assist the peer-therapist if they were momentarily challenged. On reflection, this was also felt to be unhelpful. Student preference was for student commitment to the patient role portrayal.

When the tutor came up and was listening in on my interaction, it put me off a little bit. And then whilst they were there, I’d take an opportunity to timeout and ask them a question, and then I would go back in and lose my train of thought. (FG1)

As a therapist, looking back, I probably would have preferred no timeouts and the patient in character the whole time…as soon as your patient lost character, you were kind of just—oh, this is casual. (FG2)

Repetitive, individualised practice

More frequent peer simulation sessions to enable opportunities to repeat previous scenarios were identified as a likely helpful experience. Students also shared that a wider range of topics that progressively increased in complexity would be preferable. Earlier completion of peer simulation in their training might enable further refinement of skills. Students also expressed a desire for more opportunities for independent rather than group practice, to greater align the experience with future clinical practice.

I feel like it would be better to initiate more of these, so we can see, maybe the next time we do Peer Patient, “Oh, awesome, we didn’t make that mistake” or, “Okay, we’ve made a new mistake”. (FG2)

I would have liked it…if we didn’t do it in such a big group, because I feel like absolutely everyone did exactly the same testing…whereas if we’d done it by ourselves …you’d have to think more for yourself, which is what you have to do when you’re actually out there on placement. (FG2)

Multiple forms of feedback

Students described preferences for peer assessment and feedback, in addition to educator feedback. Peer feedback helped identify mistakes and gaps in learning in a non-confronting manner. Educator feedback was valuable due to the expertise that could inform learning. Feedback was generally preferred at the end of a scenario, rather than during an interaction, when it felt more like an interruption than helpful.

I liked getting the feedback from my peers, having someone observe and really critique what you’re doing, because it really showed where your pitfalls are. (FG2)

In those five minutes when [academic staff member] came over, she sat down with me. She’s like, “What do you think the patient’s doing well?” and we had a little chat. I found that really, really valuable and I like that feedback from someone who knows what they’re doing. (FG1)

Detailed role preparation

Portraying roles was challenging, experienced from both perspectives of peer-therapists and peer-patients. Staying in character, consistent role portrayal, and remembering role details was challenging. Specific preparation for portraying a patient role was considered very important. Role-specific content, rather than material on patient portrayal and peer feedback skills, was valued. Students preferred videos of real patients, with supplementary written material for later recall. Activities to supplement videos were considered helpful for memory and learning. Group-based rehearsal activities enabled embodiment and confidence. Props were helpful for getting into character.

I thought the videos, out of everything, were the best because you really got to see facial characteristics, and understand how the person moves and talks, their demeanor and I found that a lot more personal instead of just reading a script. It was actually a person who had this condition and is actually willing to talk to you about it. (FG2)

I feel like that [rehearsal] hour we had before was plenty. Yeah, I think we all really got into the patient role and we were fine. We kind of learned off each other as well, as we were practicing. (FG1)

Theme 3: Portraying a patient provides unique insight

Unique perspective to healthcare

Students shared that the interaction in which they portrayed the patient role was the most valuable of the three interactions. This was due to the different perspective and new insights they obtained, and the experiential nature of observing their peers through active participation in the interaction. Portraying patient roles was also considered valuable because it enabled students to quickly identify how their own future practice could be improved.

I think I observed more as a patient than I did as the observer. Yeah, I feel like it puts you in the ultimate observer role because you’re feeling what’s happening to you as well as just seeing everything. (FG1)

As a patient, you can see, “Okay, so that’s something I need to consider when I become a therapist”. (FG2)

Patients’ experiences of health conditions

Students described learning about the experiences of people living with health conditions. As the peer-patient, students felt they gained empathy and insight into the impact of a health condition, hospital admission, and prolonged recovery on a person’s life. Students also experienced insight into what it feels like to experience specific symptoms related to a condition, such as shortness of breath and movement restriction. These experiences were described as influential for learning, and had not been considered before they portrayed the patient role in peer simulation.

When I was the patient, something that I really started thinking about is…how it impacts your life, how you’re going to get from A to B, how you’re going to get into your car…I should be asking these things, I should be finding out what this person is doing in their daily life and how this disorder or injury is really impacting them. (FG1)

It was quite interesting…being so out of breath. That changed my view as a therapist, realizing that. We hear in class, “Okay, they can walk five, ten meters and they’re out of breath,” but then being a patient, literally walking one meter and portraying how out of breath you are…as a therapist it’s like “wow, they’re really out of breath”. (FG2)

Patients’ experiences of healthcare

Students described new insights into what participating in healthcare might feel like from a patient’s perspective. This was primarily associated with portraying the patient role. Peer-patients discussed experiences of unclear explanations, and the potential negative impact of sub-optimal peer-therapist verbal and non-verbal communication. Peer-patients described having opinions about their condition and goals that were either ignored, not sought or not well understood by peer-therapists. Peer-patients emphasised the confusion felt when they could not see a clear link between their goals and the therapist’s plan for the interaction. Additionally, when peer-patients did not understand peer-therapist questions and advice or the purpose of the interaction, they experienced confusion and anxiety. Students also reported experiences of peer-therapists ‘missing information’ and the impact of these omissions on the patient. For example, as the peer-patient they had learnt the patient’s history and current problems, and believed these to be important to the patient, but were not asked to share this information by the peer-therapist.

As a patient I just felt like a physio was doing things to me. She wasn’t really talking to me or telling me what was going on. And I would have done completely the same thing. I didn’t think about it until I was the patient. (FG1)

As the patient you have all the details of their background story, and you realized how much information you can potentially miss as a physio. So, being the patient, when the physio is asking you questions, you’re going, tick, tick, tick, but they missed this vital thing. As a patient, you can see, “Okay, so that’s something I need to consider when I become a therapist”. (FG2)

DISCUSSION

This study explored physiotherapy students’ experiences and perspectives of peer simulation, to enable deeper insight into the potential impacts of this approach and to investigate whether modified practices are required to enable safe and effective programme design. Analysis revealed that students think peer simulation is a valuable learning experience, as it was unexpectedly realistic, revealed knowledge and skill deficits, and improved their clinical skills. Students shared that specific design features appeared to enable effective peer simulation, including consistent engagement, repetitive and individualised practice, multiple forms of feedback, and detailed role preparation. Being the patient in peer simulation gave students unique and valuable insight to patients’ experiences and feelings of health conditions and healthcare interactions.

Empathy, defined as “understanding ‘the experiences, concerns, and perspectives of the patient, including the capacity to communicate this understanding”, ²⁸ appears to be a unique benefit to peer simulation that was experienced by students in this study. Specifically, an increased awareness of patient-related safety (attachments, manual handling, and environment set up), insight into patient experiences of a health condition and healthcare interactions, and feelings and preferences for healthcare can be gained by students in peer simulation. These insights relating to the patient perspective largely originated from portraying the patient role. It is beyond the scope of this study to determine changes to students’ empathy as a result of portraying the patient role. However, health professional learners have described elsewhere that “being in the patient’s shoes” is profoundly meaningful and valuable for learning. ^{9 12 42} Portraying patients’ roles in SBE has been specifically associated with development of greater empathy. ²⁸ Additionally, medical students have recently advocated for increased emphasis on the student-as-patient role in simulated interactions. ²⁷ This shift is thought to be beneficial for the development of skills providing holistic patient care and empathy. ²⁷ As Rasasingam et al ²⁷ alluded to in their commentary, most SBE in medical education involves the learner as the practitioner, and not as the patient. Achieving similar learning about patient experiences is unlikely to be possible with SBE that involves the learner predominantly simulating a practitioner role. Therefore, considering these findings in addition to previous work, ^{28 42} it is not unreasonable to contend that peer simulation ought to be included as part of core training in pre-registration health professional programmes that require learners to demonstrate empathy prior to graduation.

Students in this study described various impacts of portraying patient roles. Experiences of physical discomfort while portraying a patient role (see subthemes 1.3 and 3.3) appear similar to those reported in the wider SP literature. ^{23 26} However, instances of psychological disturbance from portraying a patient role were less prevalent in this study compared with those reported by professional SPs. ^{25 26} The most challenging components of peer simulation for students appeared to be related to acting as the peer-therapist. This may have been because the patient roles were not psychologically or emotionally complex. ²⁵ Unlike SPs who are lay people, students portrayed both therapist and patient roles, and this may influence the experience of being the ‘patient’. The formal debriefing with peers involved in the simulation may have also softened possible negative effects of portraying the patient role. ²⁶ Peer debriefing might be a potential strategy to support SPs who are lay people and this is worthy of further investigation. In summary, we observed few negative impacts to role portrayal in peer simulation, and considerable positive impacts related to learning.

Students’ engagement in peer simulation in this study appeared to be encouraged by the unexpected realism of the simulation environment and patient portrayal, the inclusion of real patients in scenario development, and the challenge and emotion associated with making mistakes. In a narrative analysis of learners’ experiences of SBE across various modalities, Bearman et al ⁴² concluded that learning through verisimilitude (learning taking place through enacting something that felt real), social learning through feedback and debriefing, observation, repetition, and being the patient, were key mechanisms to learning in simulation. These features appear to be present in the experiences and perspectives shared by students in this study. Further, students’ experiences and perspectives relating to the authenticity and realism of the peer simulation environment suggest that portraying patient roles is possible with preparation. Engaging as a practitioner with your peer portraying a patient role does not appear to detract from the power of the simulation experience. ⁴² In addition, despite reservations in published literature regarding the credibility of peers as patients, ^{9 11} students’ age, prior knowledge of health conditions, and the familiarity that exists between students in peer simulation, did not appear to negatively influence the value or perceived realism of students’ experiences. However, specific investigation of the impacts of these factors on students’ attainment of learning outcomes, or perceptions of the experience in other contexts (locations, disciplines), is warranted.

The design features that were identified to support effective peer simulation in this study provide insight as to how activities might be best designed to meet student learning needs. Similarities are noted between the perspectives shared by students in this study, and practice points of the ASPE SOBP, ²¹ including detailed and well-informed patient role description, high-quality preparation activities, briefing and debriefing. Broadly, the directives of the SOBP relating to safe work environment, case development, training, and programme management, also appear relevant for peer simulation activities. Students preferred end of scenario feedback and discussion (instead of mid-simulation ‘timeouts’). This preference has been shared by medical students elsewhere, where ‘pauses’ to receive input from observers has resulted in a reduction in educational value, rather than an enhancement in value. ⁴³ Students in this study felt that role preparation should be focused on learning the details of the patient role to be portrayed, rather than on development of role portrayal and SP feedback skills. Best practice guides in SP methodology suggest the opposite, that the development of SP skills is important prior to learning a specific role. ^{21 36} The education provided to students in this programme may have been inadequately aligned to their learning needs related to SP skills. Alternatively, it may have been presented in a way that was less engaging compared with the patient-specific material, or students may not have completed the independent education as they were instructed to. An option might be to teach SP skills in the context of learning specific patient roles. It is also not clear whether training approaches would need to be adapted for patient roles of more complexity or that require greater emotional affect. Further investigation into the optimal approaches for preparing students to portray patient roles in peer simulation appears to be warranted.

Peer simulation might be an attractive alternative for health professional education programmes involving direct clinical immersion or SBE activities with SPs that are constrained for extraneous reasons, such as those impacted by COVID-19 restrictions. Further research is required to investigate the impacts of engaging in peer simulation activities (compared with other learning activities) on student attainment of learning outcomes. From an economic perspective, although monetary cost data were not considered a primary outcome in this research, the design of this peer simulation experience would likely be cheaper to operationalise within a pre-existing simulation curriculum than if SPs were recruited. Cost-benefit analyses are required to capture and evaluate all costs associated with the design and delivery of peer simulation compared with alternative educational approaches, before budgetary decisions can be made.

Strengths and limitations

Manuscript writing was informed by standards of reporting a qualitative research report, ⁴⁴ the consolidated criteria for reporting qualitative research (COREQ), ⁴⁵ and reporting guidelines for healthcare simulation research ⁴⁶ in efforts to enhance quality and integrity. The topic guide structure and limited sample of students who voluntarily participated in this research may have influenced what was shared. We have no way of knowing if the students who did not participate in the focus groups had similar experiences and perceptions to those who did. Akin to much qualitative research, while outcomes were drawn from a specific context, the empirical data provided insight into the topics of interest and support from related research adds weight to transferability of findings. Researcher reflexivity strategies were effective in identifying occasions when researcher characteristics were inappropriately influencing the co-construction of meaning from data. The inclusion of a third researcher in analysis, and consideration of results in the context of relevant research provides confidence in the trustworthiness of findings.

CONCLUSION

Peer simulation, that embeds best practice guidelines for SP programme design and delivery appears to enable physiotherapy students to have learning experiences with the potential to enrich their capabilities related to communication, empathy, and knowledge of conditions. Students were strongly impacted by learning and portraying patient and therapist roles. New insights were obtained relating to patients’ experiences of and feelings about conditions, and of healthcare interactions. Peer simulation appears to facilitate similar learning to other SBE approaches and may be an appropriate substitute for more expensive designs. Further evaluation of this approach in cost-comparison studies that consider student attainment of learning outcomes, costs required to achieve these outcomes, and also patient outcomes, appears warranted.

What is already known on this subject.

• Peer simulation is an approach to human simulation where health professional students are formally trained to portray patients’ roles in simulated interactions with their peers.

• Peer simulation is becoming increasingly popular in such programmes in response to the barriers of cost and limited resources.

• Quantitative studies exploring peer simulation across various health professions have suggested that students develop improved perceived clinical skills, confidence, knowledge, and empathy.

What this study adds.

• Student portrayal of patient roles in formal simulation-based education activities (peer simulation) appears to maintain the educational benefits of SBE, and enable additional learning.

• Students think peer simulation is a valuable learning experience, as it is unexpectedly realistic, reveals knowledge and skill deficits, and improves perceived clinical skills, and gives students unique and valuable insight to patients’ experiences and feelings of health conditions and healthcare interactions.

• Students prefer specific design features to enable effective peer simulation, including consistent engagement, repetitive, individualised practice, multiple forms of feedback, and detailed role preparation.