The Use of Simulation in Self-Perception of Learning in Occupational Therapy Students

1 Introduction

Simulation-based education, rooted in collaborative and constructivist learning theories, emphasizes active and collaborative learning within a group setting known as a “constructive group.” This approach allows students to build and transform ideas based on their current and prior knowledge, promoting enduring learning experiences (Shapira-Lishchinsky, 2015). Simulation has been used for some years to train healthcare professionals (Moreno, Hor, Valencia, & Iacopino, 2020), especially physicians (Figueiredo, Mafalda, & Kamensky, 2021), to maintain the safety of the patients involved (Sá-Couto, Patrão, Maio-Matos, & Pêgo, 2016). Simulation is defined, according to Gaba (2004), as “…a technique (…) to replace (…) real experiences with guided experiences (…) that evoke or replicate substantial aspects of the real world…” (p. i2) and can be used in education to demonstrate procedures and improve decision-making and critical thinking (Jeffries, 2005) and training the application of theory to practice, in a safe and structured environment (Zigmont, Kappus, & Sudikoff, 2011), which can be considered as always interactive and student centred (Jeffries, Rodgers, & Adamson, 2015).

Several studies have shown that there is an improvement in student performance (Tuttle & Horan, 2019) with optimization in attitude and professional skills (Cerra et al., 2019; Hassanein, Tantawi, Sadek, Hendy, & Awad, 2021). Considering these studies, it can be assumed that the use of simulation shows to have a significant impact on students’ learning.

In occupational therapy (OT), several programs use simulation to improve the quality of teaching and learning and to contribute towards the development of the knowledge, skills, and attitudes required for clinical practice (Gustafsson, Brown, McKinstry, & Caine, 2017; Rodger, Bennett, Fiztgerald, & Neads, 2010; Turesson & Lindh Falk, 2021). Studies show improvements in knowledge (Shea, 2015), confidence (Shea, 2015; Springfield, Honnery, & Bennett, 2018), decreased anxiety during job performance (Springfield et al., 2018), and increased professional/technical and non-technical skills (Imms et al., 2018). These studies focused on the various areas of practice, such as paediatrics or geriatrics, and, in paediatrics, simulation was used not only for intervention training (Springfield et al., 2018) but also in training communication skills required during parent interviews (Shea, 2015). The advantages of simulation for developing communication skills are also mentioned by OT students, who consider that, for achieving this goal, simulation is superior to other methods (Grant, Thomas, Gossman, & Berragan, 2021).

Despite the widespread use of simulation in health professional education, there is a notable lack of research comparing the effectiveness of active participation versus observation in enhancing learning outcomes for OT students. A 2016 systematic review concluded that learning outcomes and satisfaction for observers in simulation-based education are improved through active learner engagement, effective use of observer tools, and the inclusion of observers’ perspectives in the debriefing process (O’Regan, Molloy, Watterson, & Nestel, 2016). Also, findings based on a meta-analysis comparing observation versus active participation in simulation-based education in healthcare state that while there is no significant difference in participants’ reactions, active participants outperform observers in terms of learning outcomes (Delisle et al., 2019).

Thus, to confirm, within the Portuguese reality, the efficacy of simulation in the training of OT students, a study was developed. Its main objective was to evaluate the self-perception of the development of communication skills, through simulation, among second-year students of the degree in OT of the School of Health of the Polytechnic of Porto. Students assumed the role of participants or observers and both were assessed.

2 Methods

We designed an exploratory case study focused on evaluating students’ self-perception of the use of simulation as a teaching tool to develop communication skills.

3 Results

The sample was composed of 33 students, divided into participants and observers, most of whom (87%) were females, with an average age of 20.33 years and more than 75% lived in Porto (Table 1). Participants were older (21.5 years compared to 19.83 years in the observers’ group).

Table 2 shows the results of the participants’ self-perception. All of them were quite satisfied with their learning, considered the simulation motivating and that it allowed them to put into practice the knowledge and communication skills acquired in class. However, only 10% felt confident in mastering the communication skills, with 80% feeling only partially confident. Also, 70% of them considered that the simulation allowed them to develop skills and knowledge for a real context but 30% considered that in the absence of feedback, they would not know how to evaluate their performance. The feedback was considered enlightening by 100% of the participants.

Table 3 shows the results of the observers’ self-perception, where it was found that all students enjoyed the simulation and reported that it was an effective learning method. More than 80% considered that they acquired communication skills similar to those of the participants, but their self-confidence was lower. Most of the observers (73.91%) considered that they mastered only partially the communication skills, but developed skills and knowledge for a real context, and it can be assumed that the observers are satisfied with the learning, even though not so confident with the acquired skills.

4 Discussion

This study assessed the self-perception of students’ learning through simulation in the second year of the OT program at the E2S, Polytechnic of Porto. The results showed a high level of satisfaction with the method, classifying it as an effective learning method, as in studies carried out in OT (Hung, Ho, & Lin, 2021) and other health areas (Karlsen, Gabrielsen, Falch, & Stubberud, 2017).

Both groups, observers and participants, considered that the simulation allowed them to acquire communication skills and knowledge applicable to a real-life setting, reflecting previous studies conducted with paediatric OT students (Shea, 2015; Springfield et al., 2018). There were no differences between the two groups in the perception of the learning acquired. This is in line with that reported in Bong et al.’s (2017) study of anaesthesia trainees, which concluded that observers achieved an equivalent level of non-technical performance, while experiencing lower stress than participants. The authors concluded that the role of observer could be a practical alternative to the traditional “hot-seat” role, potentially rendering training through simulation accessible to a wider audience. Another study states clearly that simulation observers learn the same as participants (Johnson, 2019). Nevertheless, educators often undervalue learning in observer roles compared to hands-on roles despite the critical skill of focused observation in clinical practice (Tutticci, Theobald, Ramsbotham, & Johnston, 2022). To elevate the appreciation of observer roles, scenario design should explicitly include objectives for observers, integrating them throughout all simulation phases and highlighting the distinct value of learning through observation (O’Regan, Molloy, Watterson, & Nestel, 2021).

Regarding perceived confidence in acquired learning, and although Springfield et al. (2018) state that, when exposed to simulation, students improve their confidence in their communication skills, and the participants in the present study only felt partially confident. However, they consider that the feedback helped them improve these skills, rating it as an enlightening and useful process, corroborating what has been found in other studies (Dreifuerst, 2009; Springfield et al., 2018; Tärning, 2018; Verkuyl et al., 2018).

In this study, feedback was given face to face, and it was chosen to inform students during feedback which areas in their performance had met expectations and which needed improvement. This may explain the positive reaction students showed towards the feedback they received. Verkuyl et al. (2018) state that in-person feedback seems to be the most effective method for learning and improvement, and Tärning (2018) asserts that verification feedback – being informed of correct or incorrect performance – is less effective compared to explanatory feedback – providing students with explanations of why their performance is lacking (Tärning, 2018), thus confirming the effectiveness of the type of feedback used. In addition, scaffolding, defined as providing timely support for learners, is crucial in simulation-based learning. Structured activities, like clinical decision-making models, serve as effective scaffolds, optimizing cognitive engagement. The clinical reasoning model by Levett-Jones et al. (2010) offers a cycle of assessment, planning, implementation, and evaluation, acting as a scaffold for developing clinical reasoning during simulation. Thus, it is possible to perceive feedback as a tool for a formative evaluation, which in addition will promote the scaffolding of specific ability-related clinical practice.

This study possesses some limitations that warrant acknowledgement. First, the self-perception assessment instrument used was adapted from a tool originally designed for nursing students, focusing solely on assessing participants in the simulation. Although content validation involves an expert panel, there is a need for a more rigorous process to ensure comprehensive coverage of various dimensions of learning perception in OT. In addition, the study’s characteristics and sample size, as well as the non-standardized nature of the assessment questionnaire, pose challenges in comparing results with previous studies or advancing knowledge in the field. The research design, while common in simulation-based training studies, could be improved by considering aspects beyond participants’ reactions/satisfaction and randomly assigning subjects to participant vs observer conditions. Emphasizing the importance of comparing effects at different levels of evaluation (satisfaction/learning/transfer) and learning outcomes remains essential despite commonalities in simulation research methodologies.

5 Conclusions

In this study, it was shown that, through the simulation of an interview with the mother of a child, the students were motivated and satisfied with the process, classifying it as an effective learning method for acquiring knowledge and communication skills applicable to a real context. This method allowed them to put into practice the skills and knowledge previously learned in the classroom. Moreover, these gains were verified in both groups, observers and active participants, so that it can be considered that participation in simulations, regardless of the role assumed, is positive and contributes to learning. Furthermore, the subsequent feedback proved to be an important simulation process. Despite the learning benefits that the simulation seems to have achieved, exposure to further simulations would be necessary to conclude not only learning but also generalization of what was learned in real-life situations.