Enhancing occupational therapy education with clinical simulation

Simucase Education Division

Posted March 16, 2019

Maura Lavelle, MS, OTR/L, Clint Johnson, MA, CCC-SLP, CHSE, Katie Ondo, MA, CCC-SLP, CHSE

What is Clinical Simulation?

Clinical simulation is a teaching approach that aims to represent a real-world process in order to achieve educational goals, (Abdulmohsen, 2010) and its use is growing in medical and allied health programs. Clinical simulation offers enhanced experiential learning opportunities to meet competencies for entry-level practice by presenting scenarios that are guided, immersive, and interactive (Lateef, 2010).

The healthcare climate has been changing rapidly for the past decade. Practitioners are faced with increased client acuity, reduced length of stay, changes in reimbursement and healthcare costs, and a greater reliance on community-based care. Occupational therapy practitioners must have adequate experiential learning opportunities (Coker, 2010) and possess strong clinical reasoning skills to navigate the dynamic healthcare environment (Mitchell & Xu, 2011).

Clinical simulation has been used in various health and medical professions to improve comfort with different client populations, hone skills necessary for therapeutic relationship-building (Lateef, 2010), and build physical skills required for optimal patient care. A primary goal of faculty who incorporate simulation into their curriculum is to foster clinical reasoning skills (Bethea, 2014). The importance of building clinical reasoning into occupational therapy case studies for students has been demonstrated and been shown to yield better treatment planning (Neistadt, 1998). Occupational therapy students who engage in video simulation exhibit strong decisionmaking skills, such as being able to make appropriate decisions more quickly (Tomlin, 2005). Simulation learning also offers students the opportunity to safely practice skills in the controlled environment of a classroom (Hope, 2017). Within the controlled environment, faculty can provide support as needed and work to improve problem solving and critical reasoning skills.

Interprofessional Practice and Simulation

In addition to acquisition of the aforementioned skill sets, occupational therapy educators are charged with providing opportunities to their students for interprofessional education, defined by the World Health Organization as “when students from two or more professions learn about, from, and with each other to enable effective collaboration and improve health outcomes” (WHO). The AOTA also stresses that entry-level occupational therapy curricula should include opportunities for interprofessional collaborative practice (AOTA position paper on IPE). Occupational therapy practitioners must be able to effectively collaborate with other professionals in order to meet the rising complexity of clinical practice, to support optimal outcomes for their clients, and to assist with reducing healthcare costs (Earnest & Brandt, 2014). The opportunity to obtain this practice, however, is affected by a number of different variables, including the cost of clinic-based fieldwork assignment and the availability of experienced practitioners working in a multidisciplinary setting. Allied health students who have used interprofessional simulation in an educational setting have reported increased confidence in the ability to communicate across professions and a heightened awareness of the importance of teamwork to produce quality care (Buckley et al., 2012; Titzer, 2012). High-quality, computerbased simulations such as those provided by Simucase support interprofessional education by featuring frequent and required opportunities to collaborate with other professionals in a variety of settings within each interactive simulation.

Fieldwork Experiences and Simulation

Clinical simulation in occupational therapy had traditionally been used to augment the curriculum and aid in preparation for experiential fieldwork experiences, an essential component of occupational therapy curricula. As student enrollment in OT programs grows and workload pressures on practitioners increase, many are finding that it is increasingly difficult to locate sufficient placement sites. The Accreditation Council for Occupational Therapy Education (ACOTE®) has released standards, effective 2020, that recognize simulated environments as an instructional method to meet initial fieldwork competencies (ACOTE, 2018). The professional accrediting body for occupational therapy in some countries outside of the United States also allows a percentage of the initial experiential learning requirements to be replaced by simulated and standardized patient experiences (Imms et al., 2017; Van Vuuren, 2016). This shift is supported by the research, as no statistical difference in outcomes for student learners has been found in several healthcare fields when simulation was used to replace a portion of in-clinic training hours (AOTA Board of Directors, 2017).

Simulation Modalities

Clinical simulation can take many forms, including standardized patients, high-fidelity manikins, computer-based simulations, and virtual reality (Gaba, 2004). A review of the literature documents a variety of simulation modalities that have been used in occupational therapy curricula.

Bradley (2013) reported that simulation using live actors in occupational therapy curriculum can strengthen learning when realistic scenarios are used. Live scenarios with actors can improve learning by allowing reflection and support from peers as well as faculty (Velde, 2009). Simulated scenarios with live actors in a multidisciplinary context have been used in occupational therapy curriculum to provide exposure to clinical situations and interprofessional communication skills (Chown & Horn, 2017).Simulated patients and reflective video analysis have been used in occupational therapy programs to evaluate readiness for clinic-based fieldwork experiences (Giles, 2014).

The use of manikins has been shown to assist physical therapy students with understanding of clinical contexts while bridging didactic learning with realistic scenarios (Silberman, 2013). Simulation laboratories with programmable manikins have been used to expose occupational therapy students to elements of the ICU in a risk-free environment (Wu, 2009). Similar environments have demonstrated improvements in occupational therapy students’ self-efficacy with performing patient-handling skills (Baird et al., 2015).

Interactive computer-based simulations have been used since 2003 to improve students’ clinical reasoning and decision-making. August-Dalfen & Snider (2003) reported using a case-based CDROM software called ErgoRom to teach office ergonomics. Participants indicated that the use of this software to present clinical problems was second only to worksite visits. Additionally, Tomlin (2005) created a software program that required students to view video clips of clients and then make specific decisions before advancing to a new clip. He found that students who performed well on the program received higher ratings from their fieldwork supervisors. Additionally, in 2015, the National Board for Certification in Occupational Therapy (NBCOT®) created the NBCOT Navigator® Competency Assessment Platform, an online platform that includes computer-based simulations designed to assess the competency of practicing professionals (NBCOT, 2015).

Virtual reality platforms have been used in occupational therapy curricula to simulate the home environment and to practice home assessment and intervention. Sabus (2011) found that when using this platform, students met learning objectives, found support in the experience, and demonstrated strong decision-making skills. Virtual reality environments have been used as a tool to prepare occupational therapy students for interprofessional practice by allowing them to interact and experience collaboration in real time (Seefeldt et al., 2012). Virtual simulations have been used to augment hands-on training of wheelchair skills for occupational therapy students, and have resulted in improved discussion about technique (Chard, 1997).

Simulation Use in OT Programs and Associated Challenges

In a 2014 survey of occupational therapy assistant and occupational therapy entry-level programs in the US, Bethea et al. reported that 71% of respondents recognized the value of simulated learning and were using simulations to “practice clinical skills in a safe environment, to facilitate clinical reasoning and critical thinking, as preparation for fieldwork, and to integrate concepts.” A majority of programs were using standardized patients or high-fidelity manikins. More than 90% of programs reported that the primary goals for simulations were clinical reasoning and problem-solving or decision-making.

Although they recognize the value, faculty also pointed out that providing these experiences were challenging for a number of reasons, including:

  • Lengthy time to prepare the scenarios and create methods for evaluating outcomes

  • Cost of establishing a simulation lab

  • Scheduling lab time and coordination with other disciplines

  • Lack of time to learn new technology

Benefits of Computer-Based Simulations

Computer-based simulations address a number of these challenges. Simucase is a web-based collection of virtual patients designed to exhibit deficits necessitating screening, assessment, and/or intervention. These simulations are repeatable and can be accessed online at any time. The scenarios are already created and new simulations are added regularly. Feedback and scoring are built into the system. The online simulations can be used to teach complete processes (e.g., evaluation and treatment protocols) and/or teach specific skills (e.g., use of adaptive devices, administration of a standardized test, documenting plan of care). Additionally, computer-based simulations may be supervised asynchronously by providing a pre-brief prior to the experience and debrief at the conclusion. Finally, in-depth reporting provides an analysis of students’ strengths and weaknesses. Such computer-based simulations “provide users with a sophisticated, controlled, learner-centered experience that allows for repeated practice of clinical decision-making skills in a risk-free environment” (Simucase position paper 2014, Jansen et al.). This use of simulation learning provides a unique avenue to enhance didactic learning opportunities for skill acquisition and critical reasoning skills.

Implementing Simulation into OT Curricula

The primary goal upon completion of occupational therapy degree requirements is readiness for entry-level practice. Multiple studies have shown no difference in outcomes for students when simulation was used to replace a portion of clinical training hours. A randomized-control trial in physiotherapy looked at using simulation as a component of cardiopulmonary education and compared clinical immersion with a simulated learning experience. There was no statistical difference found between the groups on self-reported competency or competency to practice as assessed through clinical exam. It was also found that the students who practiced more in the simulated learning environment had higher scores than the clinical immersion group on practice standards, as assessed by clinical exams (Blackstock et al, 2013).

Conclusion

Clinical simulations have the potential to improve the clinical skills of students in occupational therapy; however, in order for clinical simulation to be an effective method for training students, well-designed classroom instruction that includes a pre-simulation experience, clinical simulation experience with feedback, and debriefing after participation for reflective learning is critical (Simucase White Paper, 2014; Shea, 2015). Successful implementation depends on curriculum planning that includes consideration of the ways that clinical simulations can enhance learning goals and objectives. When designed and implemented effectively, clinical simulation provides students with an opportunity to integrate their clinical knowledge with experiential practice.

References

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