Significant improvements in student self-efficacy in the physiotherapy assessment and management of paediatric clients was found with SBE, demonstrating that students felt improved confidence in clinical skills, clinical decision-making, treatment preparation and planning, communication skills, evaluating and modifying interventions and interprofessional practice. These improvements mirror previous research conducted in an adult physiotherapy context.(36, 37, 42)
Students showed the largest improvements in Question 2, indicating that students perceived the greatest improvements to their clinical decision-making skills. Interestingly, this question had the lowest pre and post SBE scores in all scenarios, demonstrating that despite the improvement, students remained least confident in their clinical decision-making skills. Students have had limited opportunities to refine their clinical decision-making skills at this stage of their learning, which is a possible explanation for their lower initial levels of confidence. Given this lack of experience, it is reasonable that a small amount of experience (such as a single SBE session) would be sufficient to cause a significant increase in confidence.
Conversely, Questions 4 and 7 had the highest pre and post SBE scores, while having the smallest overall improvements in self-efficacy. Students were most confident in their communication and inter professional skills and perceived the least amount of improvements to these skills. Previous research has also shown students to have higher levels of confidence in their communication skills compared to their confidence in treatment and hazard awareness.(43) It is likely that students were more confident with their communication and interpersonal skills prior to SBE as they have had the more opportunities to develop these skills throughout the early years of their program of study. Furthermore, it is possible that additional learning experiences may be required to realise changes in these more well-developed skills. It is also possible that these smaller improvements to communication and interpersonal skills can be explained by a ceiling effect, given students’ higher initial levels of confidence.
A lack of confidence working with children has been reported to be a barrier to graduates seeking employment in paediatric physiotherapy, and evidence suggests confidence in graduate paediatric physiotherapists is directly related to competence in communication skills.(48) Therefore, confidence in communication is particularly important for graduates seeking employment as a paediatric physiotherapist. Although the questions relating to communication skills (4 and 7) had the smallest improvements in self-efficacy, they were still statistically significant and the majority of students (64.9%) reported scores of 3 or higher after SBE, indicating that they had at least “a lot” of confidence in their communication and inter professional skills. It seems that the SBE has provided a level of confidence in communication skills which may aid reduction of the barriers to working in a paediatric context.
Although self-efficacy improved from the start to the end of each SBE scenario, there was no improvement in pre self-efficacy scores over the course of the entire academic unit. At the start of each new SBE scenario, self-efficacy scores returned to baseline levels. As previously described by Wright et al (43), this suggests that students’ self-efficacy is linked to area-specific knowledge and skills and does not necessarily transfer between areas. It is not a function of simulation, but the specific clinical knowledge and skills gained during the process.
Student Satisfaction with SBE
The secondary aim of this research project was to determine student satisfaction with SBE as a learning strategy. The response was positive, with most students considering that SBE met their style of learning, promoted self-directed learning, delivered evidence-based principles of paediatric physiotherapy, assisted in retention of paediatric physiotherapy, provided an ideal learning environment, and provided incentive for further skill development in paediatric physiotherapy. Only one student (0.7%) thought that SBE provided no incentive at all for further skill development in paediatric physiotherapy. These findings are consistent with two systematic reviews, which concluded that SBE is generally well received by students and an experience valuable to learning.(2, 8) The positive findings observed in the quantitative results were reflected by students’ comments. The thematic analysis identified
that students found SBE to be a beneficial and enjoyable learning experience.
The mean rating for Question 2 (promotion of self-directed learning) of 2.76 was substantially lower than the other questions, and again may reflect the structure of the SBE scenarios and/or insufficient emphasis on self-directed learning activities.
Overall, the student response to SBE was positive, and if students respond well to this method of learning, it could suggest they are more likely to be engaged with the learning experience and be more motivated to learn.(41)
Translation to Performance
While the improvements to self-efficacy observed in this study are significant, these improvements may not translate to an improved level of workplace-based clinical performance. The self-efficacy questionnaires provide a measure of perceived confidence in students’ knowledge, skills and attitudes, demonstrating that they have achieved a degree of learning, according to the Kirkpatrick-Phillips’ model of training evaluation.(46) The questionnaires give no indication whether participants have applied what they’ve learned through changes in behaviour, the next tier in the Kirkpatrick-Phillips’ model.(46) There are well-established links between self-efficacy and work-related performance (45) so it is reasonable to suggest that students who demonstrated improvements in self-efficacy following SBE would have improved performance following SBE. Previously, SBE has led to significant improvements in student performance, (28, 43) improved patient care and better patient outcomes,(49) strengthening the suggestion that these improvements to self-efficacy may translate to improved performance with real patients. However, students who receive SBE also may be more likely to overestimate their ability (50) and are likely to be less realistic in their self-evaluation in a simulated environment.(32) Therefore translation to improved performance should not be assumed based on these self-reported measures alone.
To measure performance, student behaviour would need to be evaluated in a standardised or clinical environment. There are established instruments for measuring performance, such as the validated Assessment of Physiotherapy Performance (APP) (51) or the Physical Therapy Clinical Performance Instrument (PT CPI).(52) The APP is currently used by Australian universities to evaluate the performance of students on clinical placement and has been used in other studies examining the efficacy of SBE.(28, 29, 43, 50, 53) In two previous studies, students who participated in SBE achieved superior grades, measured through their performance in the APP.(28, 43) It would be beneficial to conduct a follow-up study to determine if there are similar differences in student performance for this student group.
Limitations
Although clear improvements to student self-efficacy following SBE were observed in this study, there is no comparison to standard educational methods. Without this comparison, it is not possible to determine whether the educational benefit gained from SBE differs from standard curriculum. This is especially important given the high cost of SBE, which is often a barrier to its implementation.(54)
Students completed their self-efficacy questionnaires immediately after the SBE scenarios ended, meaning that the results only reflect the short-term effect of SBE. Although some students commented that they felt SBE improved their retention of paediatric physiotherapy, without further investigation it is not possible to determine if SBE had any long-lasting effects. There is also no measure on actual student performance.
By comparing APP results of paediatric placements, we could investigate if there is any difference between the performance of students who participated in SBE and those who received standard curriculum, as well as gain information on the long-term effects of SBE, as clinical placements occur months after the SBE ends.
There is no information on whether SBE changed students desire to work in paediatric physiotherapy in the future. Results from learning reactionnaire Question 6 (incentive to develop skills further in paediatric physiotherapy) offers some support for this, with 82% responses recorded as “a lot” or “totally”, demonstrating that students had incentive to further develop paediatric physiotherapy skills following SBE. However, this does not mean students would pursue paediatric physiotherapy opportunities. To get a better indication of this, it would be beneficial to ask students if SBE has increased the likelihood of them pursuing a career in paediatric physiotherapy or requesting a paediatric placement in future research in this area.
Only undergraduate university students were included in this study, so results should not be extrapolated and applied to other populations such as junior, employed physiotherapists. Furthermore, participants were all from one campus of one Australian university and may not accurately represent students of other campuses or Australian universities.