Combining medical, physiotherapy and nursing undergraduates in high-fidelity simulation: determining students’ perceptions

Abstract

High-fidelity simulation (Hi-Fi SIM) is increasingly used to provide undergraduate interprofessional education (IPE). Although research has reported positive student feedback, studies have predominantly involved medical and nursing specialties. The present study sought to further explore this area by determining the perceptions of medical, physiotherapy and nursing students participating in the same simulation session. A total of 145 medical, physiotherapy and nursing undergraduate students jointly participated in a novel Hi-Fi SIM IPE programme. Immediately before and after their session, students completed the KidSIM ATTITUDES questionnaire where statements were rated regarding simulation, IPE and human factors. A high score indicated a more positive attitude. Physiotherapy students reported the lowest level of previous Hi-Fi SIM experience. Students from each specialty had more positive attitudes related to simulation, IPE and human factors following their simulation. Physiotherapy students had predominantly less positive attitudes compared with nursing and medical students. Participation in an IPE Hi-Fi SIM session positively impacted on the perceptions of medical, physiotherapy and nursing students regarding the relevance of simulation, IPE and the importance of human factors. Such findings support the use of this learning modality for the provision of IPE in a range of specialties.

Introduction

Interprofessional education (IPE) is increasingly acknowledged to be an important component of undergraduate healthcare training as a means of ensuring students become adept at working in the multidisciplinary clinical environment, the ability of which had been linked with clinical competence.¹ Despite a lack of consensus in the literature regarding the most effective way of providing IPE, research has advocated the use of clinical experience.² The current climate of financial strain, time constraints and busy clinical areas has meant that providing the growing number of healthcare students with worthwhile and similar clinical experiences is a challenge. By allowing students to practise and develop their clinical and human factor skills together in a safe and controlled environment, high-fidelity simulation (Hi-Fi SIM) is increasingly being used to provide IPE to undergraduate students.

The positive perceptions and increased understanding of the roles of other healthcare team members following IPE Hi-Fi SIM supports its use in the undergraduate setting.^{3 4} However, research to date has predominantly focused on IPE sessions involving medical and nursing students only.³ In contrast, few studies have explored the addition of wider members of the multidisciplinary team such as physiotherapists. The use of low to medium fidelity mannequins is well established in the physiotherapy curriculum⁵ whereas, in comparison to medicine and nursing, Hi-Fi SIM is not widely utilised either alone or as an IPE component.^{5 6} The limited number of studies involving physiotherapy students in an interprofessional simulation session have predominantly reported a positive outcome.^{7 8} However, such research has often entailed small numbers and has not explored the perceptions of each specialty with regard to the IPE element of the experience and the importance of human factors.

The School of Medical Education’s clinical skills team at King’s College London (KCL) has recently expanded their IPE programme to include physiotherapy students alongside those from medicine and nursing. Using this combination of disciplines, we sought to further explore the role of Hi-Fi SIM in IPE from the student’s perspective by determining the attitudes of undergraduate students from each specialty towards simulation, IPE and human factors both before and after an IPE Hi-Fi SIM session.

Methods

Sample

A total of 145 final year undergraduate KCL medical (n=54), physiotherapy (n=26) and nursing (n=65) students voluntarily participated. Students were recruited though an e-mail advertisement sent by the KCL clinical skills team.

Study design

Groups consisting of 2–4 students from each specialty attended a half-day simulation session at the KCL Chantler SaIL centre between November 2016 and February 2017. Following an introduction to the mannequin, a maximum of two physiotherapy/nursing students and two medical students participated in one of three clinical scenarios. Each 10 min scenario consisted of the management of an acute clinical case focused on the skill set appropriate for a final year student from the relevant specialties. Remaining group members viewed the scenario via a live video link. A group debrief facilitated by two clinically qualified tutors using the ‘Debrief Diamond’ structure⁹ followed each scenario. All participants consented to complete the previously validated KidSIM ATTITUDES questionnaire¹⁰ immediately before and after their simulation.

Data analysis

The KidSIM ATTITUDES questionnaire¹⁰ comprises a five-point Likert scale for 30 items divided into five domains: ‘relevance of simulation’; ‘opportunities for IPE’ and the team work aspects of ‘roles and responsibilities’; ‘communication’ and ‘situation awareness’. A high score indicates a more positive perception and attitude towards the domain being measured. Data is also collected regarding previous team-based experiences. Reliability testing of the questionnaire indicated a good internal reliability (Cronbach’s alpha=0.92). Each student was given a unique identifier code. Questionnaire responses were analysed using SPSS V.22.0. For Likert scale analysis, item scores for all statements contained under each of the five domain headings were grouped for each participant. To compare pre-scores and post-scores both within and between specialties, a mixed analysis of variance for each set of grouped results was conducted. Bonferroni tests were used for post hoc testing of scores between specialties.

Results

In response to questions relating to previous learning experiences, fewer physiotherapy (n=3, 12%) compared with medical (n=17, 32%) and nursing (n=31, 49%) students reported prior simulation experience. Students from each specialty had similar levels of workshop and seminar team-based learning, whereas more physiotherapy (n=16, 62%) compared with medical (n=10, 20%) and nursing students (n=22, 36%) reported team-based work experience. The majority of medical (n=45, 85%) and nursing (n=58, 91%) students had prior critical care experience compared with physiotherapy (n=12, 47%) students.

For each Likert scale domain, there was a significant difference between pre-simulation and post-simulation scores for all specialties (table 1). Specifically, following an IPE Hi-Fi SIM session, students more strongly agreed with each set of domain items (each domain; P<0.001).

Table 1.

Specialty pre-KidSIM ATTITUDES questionnaire and post-KidSIM ATTITUDES questionnaire mean scores (SD) for each domain

Domain	Student group (n)	Pre-SIM mean score (SD)	Post-SIM mean score (SD)	Effect size (d)	P value for scores between specialties
Relevance of simulation	Medical (54)	26.39 (2.7)*	28.39 (2.5)	0.77	<0.001† 1.00‡
	Physiotherapy (26)	23.62 (3.3)*	26.23 (3.3)	0.79	<0.001§ 0.002‡
	Nursing (65)	25.34 (4.3)*	28.74 (2.0)	1.01	1.00§ 0.002†
Opportunities for IPE	Medical (54)	27.91 (4.5)*	31.98 (4.0)	0.96	1.00† 0.056‡
	Physiotherapy (26)	27.73 (3.7)*	30.77 (3.4)	0.86	1.00§ 0.018‡
	Nursing (65)	29.57 (4.9)*	33.32 (2.2)	0.99	0.056§ 0.018†
Communication	Medical (54)	36.00 (3.2)*	38.35 (2.6)	0.81	0.005† 0.538‡
	Physiotherapy (26)	33.85 (3.6)*	36.58 (2.9)	0.84	0.005§ <0.001‡
	Nursing (65)	36.74 (4.3)*	38.89 (1.9)	0.65	0.538§ <0.001†
Roles and responsibilities	Medical (54)	25.22 (3.0)*	27.83 (2.6)	0.93	0.171† 0.125‡
	Physiotherapy (26)	23.96 (2.9)*	27.04 (2.6)	1.12	0.171§ 0.001‡
	Nursing (65)	26.14 (3.2)*	28.61 (1.9)	0.92	0.125§ 0.001†
Situation awareness	Medical (54)	13.09 (1.4)*	14.28 (1.3)	0.88	0.558† 0.045‡
	Physiotherapy (26)	12.77 (1.7)*	13.92 (1.4)	0.74	0.558§ 0.003‡
	Nursing (65)	13.62 (1.7)*	14.72 (0.7)	0.85	0.045§ 0.003†

*P<0.001 for pre-KidSIM questionnaire scores compared with post-KidSIM questionnaire scores.

†Compared with physiotherapy student scores.

‡Compared with nursing student scores.

§Compared with medical student scores.

Independent of questionnaire timing, physiotherapy students gave significantly lower scores for each of the five domains compared with nursing students and for the ‘relevance of simulation’ and ‘communication’ domains when compared with medical students (table 1). Medical students scored statements relating to aspects of ‘situation awareness’ significantly lower than nursing students (table 1).

Discussion

This study sought to determine medical, physiotherapy and nursing students’ perceptions and attitudes regarding simulation as a learning tool, IPE and human factors both before and after an IPE Hi-Fi SIM session. The demonstration that simulation resulted in a more positive response to domain statements by each specialty highlights the ability of a single simulation to impact on the attitudes of its participants, a finding previously reported in the literature for non-IPE simulation sessions.^{8 11 12}

The significantly less positive attitude expressed by physiotherapy students in relation to the relevance of simulation may be a consequence of their lower levels of Hi-Fi SIM experience and debriefing sessions and/or unfamiliarity with the design of the scenarios used. Physiotherapy students also gave significantly lower scores for the remaining four domains compared with nursing students and for the communication domain compared with medical students. The negative attitude expressed by physiotherapy students for IPE and human factors compared with nursing and to a lesser degree medical students, appears counterintuitive given that all specialties reported analogous levels of team-based seminar and workshop opportunities, with physiotherapy students reporting the highest levels of work experience team learning. This finding may reflect differences in the content of team-based experiences encountered by the three specialties or indicate a difference in the interpretation of the questionnaire term ‘team-based learning’ by the student groups resulting in an overestimation or underestimation of their previous exposure. Alternatively, a lack of prior simulation experience for many physiotherapy students may have impacted on their questionnaire responses for all the domains measured. Specifically, an individual’s first Hi-Fi SIM experience is often accompanied by feelings of anxiety and apprehension^{13 14} which, in the current situation, could have influenced the questionnaire responses by any affected students. In the absence of data assessing the students’ emotional response, the accuracy of this proposition cannot be ascertained.

The significantly lower scoring by medical students on issues regarding situational awareness compared with nurses may be a consequence of a greater level of clinical exposure for nursing compared with medical students throughout their course, as suggested by the increased level of team-based work experience in the nursing group. However, the current finding that physiotherapy students reported the lowest levels of situational awareness despite high levels of prior team-based work experience disputes this suggestion.

There are a number of limitations to this study. The small number of physiotherapy compared with medical and nursing students and the confinement to one medical school reduces generalisation of the results. Participation was voluntary and consequently opinions may only reflect a subset of each specialty. Finally, using a purely quantitative methodology prevented a deeper understanding of the views of the students.

Conclusion

The present study has demonstrated the ability of IPE Hi-Fi SIM to positively impact on the perceptions of medical, physiotherapy and nursing students with regard to the relevance of Hi-Fi SIM, IPE and the importance of human factors in team working. The discrepancy in attitudes between physiotherapy students and their nursing and medical counterparts may partly reflect the lower levels of simulation currently used in physiotherapy curriculums although qualitative studies are required to explore this further. Nevertheless, in a time when opportunities and resources in clinical practice are limited with regard to providing adequate levels of IPE, results from this study advocate that IPE Hi-Fi SIM undergraduate programmes should incorporate students from a range of healthcare specialties, such as physiotherapy, to ensure a broad and educationally valuable interdisciplinary experience.