Simulation-based education within respiratory physiotherapy training: a scoping review

INTRODUCTION

In recent years there has been an increase in the adoption of simulation-based education (SBE) in healthcare disciplines across both pre-registration and postgraduate environments, including physiotherapy. There are numerous definitions available for simulation used as a pedagogical approach but there is no universally agreed definition. Hawker et al¹ has perhaps the most comprehensive and recent explanation:

"Simulation is a learning tool that supports development through experiential learning by creating or replicating a particular set of conditions which resemble real life situations. It should provide a safe environment where participants can learn from their mistakes without any danger to patients, allowing individuals to analyse and respond to these realistic situations, with the aim of developing or enhancing their knowledge, skills, behaviour, and attitudes.”

The Association of Chartered Physiotherapists in Respiratory Care (ACPRC) Editorial Board is comprised of respiratory physiotherapy clinicians and academics who lead scoping of latest evidence, commissioning, co-ordination and delivery of all new ACPRC guidance documents and resources. The aim of this work is to facilitate knowledge sharing and drive improvements in the quality of care for respiratory patients.

The Editorial Board discussed potential areas for investigation and agreed that the area of SBE should be prioritised. A member of the Editorial Board (SKM) was nominated to lead the topic group and other respiratory physiotherapists were approached to be part of the team. A scoping review was the most appropriate method for exploring new evidence or guidance in the simulation-based education field.

AIMS/OBJECTIVES

The aim of this scoping review is to provide respiratory physiotherapists with guidance on the effectiveness of SBE in respiratory physiotherapy.

REVIEW QUESTION

How effective is simulation-based education as a pedagogical approach in both pre-registration and postgraduate respiratory physiotherapy?

METHODS

This scoping review was conducted in accordance with Joanna Briggs Institute Guidance for Conducting Scoping reviews² and has been reported in accordance with the PRISMA extension for Scoping Reviews.³ The scoping review was registered on Open Source Framework (reg number: ps8a7).

INCLUSION CRITERIA

The following were included in the scoping review: 1) studies investigating the use of SBE within respiratory physiotherapy, both at pre-registration and postgraduate level 2) Meta-analyses, systematic reviews, scoping reviews, randomised controlled trials (RCT), prospective and retrospective observational studies including case-controlled studies, cohort studies and cross-sectional studies. The following exclusion criteria were applied: 1) studies that were narrative reviews, non-research letters, abstracts, case reports, conference proceedings, theses and books; 2) studies involving non-human subjects; 3) studies that did not include respiratory physiotherapists and 4) studies not reported in English as there was no funding for translation.

TYPES OF PARTICIPANTS

Studies were included that considered the application of SBE within respiratory physiotherapy, both at pre-registration and postgraduate level.

CONCEPT

For the purpose of this scoping review, we considered SBE to be a broad umbrella term and included studies that used all SBE techniques including high fidelity simulation using mannequins, in-situ simulation, part task trainers, actors and team based/interprofessional simulation.

CONTEXT

The authors identified that previous scoping review, systematic reviews and meta-analyses had limited their context to pre-registration education or included respiratory physiotherapists within a broader context. This scoping review therefore sought to limit the context to respiratory physiotherapists but to include both pre-registration and postgraduate education.

SEARCH STRATEGY

The literature search was developed and refined through piloting, during which the search criteria was used to test if known papers were identified with the search strategy. The search terms included: high fidelity simulation, physio*, resp*, physical therapy and simulation

Nine databases were searched between 01/01/2014 and 31/10/2022: AMED, BNI, CINAHL, EMBASE, HEALTH BUSINESS ELITE, HMIC, MEDLINE, PsycINFO and PubMED. These databases were chosen as they are the most commonly used in the physiotherapy field. The search strategy was limited to the dates given as previously reported work was published prior to 2014. Database searches were supplemented by screening reference lists and hand searching. ResearchRabbit (www.researchrabbit.ai) was used to identify additional references. ResearchRabbit is an innovative citation-based literature mapping tool available online which optimises time compared to hand searching.

SOURCE OF EVIDENCE SELECTION

References were imported into Rayyan.⁴ Duplicates were removed. Two authors (SKM and KG) independently screened the title and abstract for inclusion. Discrepancies were resolved through discussion. Full text sources were retrieved and assessed against the inclusion criteria.

DATA EXTRACTION AND SYNTHESIS

Data regarding study design, population, intervention, comparator and control were extracted into a data extraction table. Results were grouped by study design, intervention or context. Quality assessments were not undertaken as this was not the intention of this scoping review.

RESULTS

141 sources were retrieved from the searches. As per figure 1. 24 studies were included.

META-ANALYSIS AND SYSTEMATIC REVIEWS

Five meta-analyses and systematic reviews^5-9 were sourced.

PRE-REGISTRATION USE OF SBE

Ten studies^10-19 were sourced investigating SBE in pre-registration respiratory physiotherapy pedagogy.

INTERPROFESSIONAL LEARNING (PRE-REGISTRATION)

Five studies^20-24 were sourced investigating SBE in interprofessional learning.

PART TASK TRAINERS

One study²⁵ investigated the use of part task trainers.

POSTGRADUATE USE OF SBE

Three studies^26-28 were sourced that investigated SBE in postgraduate respiratory physiotherapy pedagogy.

DISCUSSION

This scoping review provides an overview of the current knowledge base for the use of SBE within pre-registration and postgraduate respiratory physiotherapy training. Kirkpatrick’s evaluation framework classifies training outcomes into 4 levels of reaction or satisfaction, learning or knowledge, behaviour or practice change and results or impacts.^29-31 There has been an increase in publication of SBE evidence within the last 10 years, however the evidence base continues to focus on learner experience (Kirkpatrick level 1 and 2) and does not consider translation into clinical practice (Kirkpatrick level 3), patient outcomes or patient safety (Kirkpatrick level 4). Therefore, it remains challenging for some to justify the need for SBE.

META-ANALYSES AND SYSTEMATIC REVIEWS

There was heterogeneity within the studies included in the meta-analyses and systematic reviews in the populations included, the modality of SBE and the outcome measures utilised. It is clear that a range of SBE modalities have been deployed in educating respiratory physiotherapists. The optimal duration and frequency of SBE is unclear. There was a trend in all meta-analyses towards an improvement in confidence and self-efficacy as a result of SBE.

PRE-REGISTRATION

It is recognised that there is a shortage of clinical placements to meet the current demands of pre-registration physiotherapy education, and this is especially apparent in acute respiratory settings.³² The evidence base presented in this scoping review suggests it might be possible to replace up to 25% of traditional clinical time with SBE without a detrimental impact on student attainment.¹¹ However, SBE is resource intense in terms of equipment, time to prepare and faculty to deliver the training. Cost-effectiveness of SBE in this model of education has not been considered and may be one of the limitations to implementing this pedagogical approach successfully.

INTERPROFESSIONAL LEARNING

Studies sourced for this scoping review revealed that the current evidence specifically for interprofessional learning SBE is limited to pre-registration in the respiratory physiotherapy field. There was a suggestion that interprofessional learning SBE improved aspects of teamwork. Uni-professional SBE may be considered appropriate when introducing SBE to a profession, or when developing specific skills.

However, current educational theories encourage SBE to be delivered in multi-professional ways, which more closely represent the clinical environment.^33-35 Anecdotally, the deployment of multi-professional SBE is being incentivised, for example via funding routes.

PART TASK TRAINERS

Part task trainers are physical replicas of a body part used to help train specific skills. Part task trainers in SBE have been most widely used as a surgical pedagogical intervention. Studies included within this scoping review have indicated that part task trainers are used within respiratory physiotherapy education. They are most commonly deployed to allow the repetition of a specific skill and are most useful to allow the learner to increase proficiency and confidence in specific tasks that are invasive.³⁶ Part task trainers allow the learner to make mistakes in a safe environment.³⁷ The impact of part task trainers is limited to one study, which demonstrated improved competence. Measuring the impact on patient safety and outcomes could prove an ethically challenging methodology for many of the invasive interventions conducted by respiratory physiotherapists. Part task trainers can be costly to establish and maintain, perhaps one way to increase access would be for collaboration across organisations and geographical locations.

POSTGRADUATE

Whilst there has been an increase in research outputs in the respiratory physiotherapy arena, these are disproportionately in pre-registration contexts. This suggests there are still barriers to respiratory physiotherapists accessing SBE in the workplace. Barriers might include a lack of trained faculty (educators trained specifically in SBE to deliver it safely and effectively), access to facilities and equipment and perceived cost.²⁶ As SBE pedagogical approaches adapt to suit the needs of the workforce, innovations such as insituation scenarios, virtual/augmented reality and 360 degree videos may help to increase access to SBE. Application of these innovations has progressed rapidly in response to the COVID-19 pandemic, however they are still in their infancy. Whilst increased access to equipment is potentially on the horizon, without faculty adequately trained to deliver SBE access will remain poor. The sources presented in this scoping review have demonstrated SBE increases confidence and self-efficacy. There is a known association between confidence, self -efficacy, stress and competence but not attainment.^13,38-41 Where staff are more stressed there is a perceived need for more support, it is feasible therefore that SBE could result in reduced need for support, thus reducing pressure on senior staff.

LIMITATIONS

It was outside of the aims of this scoping review to undertake a quality assessment of the included studies. There is heterogeneity within the included studies with regards to the populations recruited, the design of the simulation based education and the outcome measures used, thus making it challenging to synthesize the results and draw conclusions. This scoping review provides an overview of the current literature and has not included the depth of analysis that a meta-analysis would provide.

FUTURE RESEARCH

None of the studies included in this scoping review have considered evolving modalities of SBE such as virtual reality, 360 degree video or gamification. The studies conducted continue to focus outcomes on learner experience. There continues to be paucity of evidence demonstrating translation of knowledge or skills learnt in SBE into clinical practice. Similarly, the impact on patient outcomes and safety specifically within the respiratory physiotherapy field has not been examined or reported. Regardless the benefits of SBE on patient safety is well documented in other fields, and whilst research in this area is encouraged this should not be considered a limitation or barrier to the further development and deployment of SBE for respiratory physiotherapists. The optimal modality and frequency of SBE remains unclear. There is increased emphasis on interprofessional education and there have been no studies considering this in a post graduate setting.

CONCLUSION

There is an increasing research output in the SBE field for respiratory physiotherapy. The evidence continues to focus on learner experience with paucity of evidence exploring impact on translation into clinical practice or patient safety. There is an increasing focus on Inter professional learning and the benefits this pedagogical approach has on teamwork. More resources and support are required to increase access to SBE for respiratory physiotherapists.

Key points

• There is an increasing research output in the simulation-based education field for respiratory physiotherapy
• The evidence continues to focus on learner experience with paucity of evidence exploring impact on translation into clinical practice or patient safety
• There is an increasing focus on inter-professional learning and the benefits this pedagogical approach has on teamwork
• There are very few research outputs considering simulation-based education in postgraduate respiratory physiotherapy training.

DECLARATION OF INTEREST

Nil to declare.

FUNDING

This work was unfunded.

ACKNOWLEDGEMENTS

Association of Chartered Physiotherapists in Respiratory Care Editorial Board.

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