High-fidelity simulation is being used to enhance student education across the UK, CSP education adviser Nina Paterson explains


Physiotherapy has always used creative techniques to teach students safely and effectively. You only have to look back through the CSP’s Wellcome archive to see the patterns for knitted wombs for teaching women’s health for evidence of this. With technology advancing over the years since those knitting patterns were utilised, educators have continued to make use of the opportunities technological advances bring.

High-fidelity (hi-fi) simulation that involves the use of sophisticated life-like manikins is one such example. What was unusual maybe 10 to 15 years ago is now a mainstay within most programmes. 

The question we’re asking in 2021 is…Can it replace placements? Other professions have already taken that leap. Physiotherapy, normally first, is coming later to these discussions but we will be addressing it as part of the forthcoming pre-registration review. We want you to be part of that debate.  

It’s worth saying that the ground work has already been laid in terms of evidence and efficacy. We already know that it: 

  • gives students the chance to apply underlying theoretical concepts within context
  • provides opportunities to practice complex patient communication, professional and clinical skills safely
  • enhances placement performance
  • improves patient safety 
  • is an authentic way to introduce students to patients, service users and members of the multi-disciplinary team.

The review will therefore be considering how best to embed simulation into the mosaic of placement experiences in a way that the whole profession can get behind. To start the debate, we’d like to present four case studies to inspire and challenge our individual and collective thinking…

What is simulation?

Simulation is a technique (not a tool or technology) to replace, augment or amplify reality with guided experiences, often immersive in nature, that evoke or replicate substantial aspects of the real world in an interactive fashion.

Oxford Brookes University: Preparation for practice module. Case study supplied by Robyn Stiger 

The educational philosophy at Brookes is based on Enquiry Based Learning. The BSc programme structure utilises a ‘front loading’ approach, where the students complete a year and a half of study at the university and then go out on a year consisting of five placement experiences.

The ‘front loading’ approach is seen as a strength, however, anxiety prior to the first placement is always prevalent. 

To help reduce anxiety, a six-week module, Integrated Physiotherapy Practice, runs immediately before the students go out on their placement year. First year concepts are revisited and developed by adding complexity and clinical reasoning.  

By using immersive environments and trained actors, students experience what it feels like when the emergency buzzer goes off, or when a patient feels dizzy, or how to deal with an angry or upset relative. It affords the students the ability to make mistakes, and learn from, without compromising patient safety, as well as experience a variety of approaches for the same scenario through peer observation and feedback. Within the scenario, the facilitators can add ‘noise’ in the form of distractions, to add complexity to the scenario, depending on the skill set of the learners.  

Faculty team members are trained to ensure they understand the underlying principles of simulation as well as effective and thorough debriefing methods. Debriefing complements standard feedback, allowing students to pause, unpick and consider more perspectives than would be possible in a real clinical environment. ‘Pausing’, for example, maximises the teachable moments.  

By using actors, trained in debriefing, alongside the teaching faculty students feel as if they are receiving patient feedback.  

Southampton University: Virtual on-call teaching and assessment – preparing for on-call module. Case study supplied by Dr Debbie Thackray, principal teaching fellow 

This level 5 BSc Physiotherapy module is deliberately planned to run before students go out on their final placements. It synthesises all the previous respiratory knowledge within the programme, enabling students to synthesise their knowledge, clinically reason and rehearse the on-call situation using simulated scenarios. Due to the pandemic, the team realised they’d need to deliver this already-simulated learning experience in a different way.

Instead of in-person, four days of simulation were delivered via Microsoft Teams. Alongside this a virtual communication teaching session was run for the whole cohort, using actor role players to portray different members of the multidisciplinary team. 

The simulations were organised so that four students took part and four observed. Students were briefed at the beginning of each session about the patient scenario and about the role of the nurse and practice educator.

A trained nurse facilitator supported the scenario, giving appropriate information about the patient over the phone and during the scenario to the students. A physio practice educator was also present to support students with their A-E assessment, facilitate the discussion about patient management, and facilitate the debrief.

Actor role players (simulated patients) joined the ‘Teams call’ from their bedside at home (with blurred backgrounds). They had been provided with appropriate props such as hospital gowns, nasal specs, venturi oxygen masks, nebulisers, BP cuff and saturation probes. The actors were trained in how to portray the respiratory deterioration of the scenario and how to respond when they heard certain ‘prompt words’ from the students and/or nurse. 

Manchester Metropolitan University: Birley Place, a virtual community to enhance practice-based learning, funded by Health Education England. Case study supplied by Dr Kirsten Jack, professor of nursing education

During the pandemic we needed to provide a one-week observational placement for current first year BSc and MSc (pre-reg) students and retrieve this week of learning for students who had missed out. 

This provided an opportunity to develop an existing faculty educational resource, Birley Place. 

What students say

  • ‘It allowed us to piece together everything we have learnt over the last three years and relate it to a clinical scenario. It also allowed me to easily identify strengths and areas which needed improvements. This made me feel more comfortable when thinking about treating patients alone in the future.’
  • ‘I was able to safely practise and perfect my on-call skills. I developed the ability to keep calm, communicate well and to make well informed, clinical decisions. Feedback was always brilliant and I felt safe to make mistakes and to ask questions.’
  • ‘It was useful to reflect on and highlight areas that need improvement.’
  • ‘The simulation aspect of this module has been great. Do more of this!’

Birley Place is a virtual online community which enables learners to interact in their own time, wherever they are, and for as often as they like. The site is updated regularly to ensure it reflects changes in contemporary practice.

To address the above needs, the team (academics, e-learning experts, clinical colleagues), created a simulated placement, enabling students to practise communication, collaboration, and professional values. The resources were co-produced using student feedback to inform ongoing development and related to three settings – primary, acute and intermediate care. 

For the student each day of the simulated placement was different depending on the setting. For example, when the simulated student arrived at the health centre on day two, they witnessed a confidentiality breach and was required to think about how to deal with it using effective communication skills. 

Interactivity was enhanced using quizzes, video and reflective activities. Students valued this interactivity enabling them to feel like they were on a ‘real placement’.

The simulation enabled students to experience situations they might not be able to engage within a physical placement, such as dealing with conflict, meaning students were able to rehearse responses to difficult issues in a safe environment.

University of Winchester: The WinchSim project, funded by HEE Clinical Placement Expansion Programme. Case study supplied by Louise Stanley and Sophie Gay

This project saw 15 first year students undertake a four-week fully simulated placement. It created a learning environment across cardiorespiratory and musculoskeletal physiotherapy.  

Sequential simulation was utilised to replicate clinical practice, following simulated patients from pre-admission/injury, through to admission, deterioration, rehabilitation and long-term management, enabling experience of a full patient journey, unachievable through standard placement timelines. 

Students developed clinical records, simulated clinical handovers, MDT meetings, discharge planning and specific peer-assisted clinical skill scenarios. Students worked in groups of three or four, setting daily/simulation objectives, recording learning logs, reflections and peer assessments. 

The simulations used actors, high fidelity manikins and peer enhanced learning.

Two hospital bay simulation spaces were equipped to replicate a clinical environment as well as outpatient and community settings. Students were supervised by the teaching team.

Members of the physiotherapy and wider faculty teaching team undertook training to develop a consistent approach to facilitation and debriefing, and the development of scenarios.

Placement handbooks for each area were created to introduce students to the key scenarios they would encounter across the placement, as well as tasks and resources to support their learning.

On completion of the placement students submitted a final placement portfolio evidencing their learning throughout the four weeks.

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