Standardized Patient Encounters Improved Athletic Training Students' Confidence in Clinical Evaluations
Researchers have reported that interacting with standardized patients (SPs) is a worthwhile and realistic experience for athletic training (AT) students. These encounters enhance students' interviewing skills, confidence as a clinician, clinical skill development, and interpersonal communication. To determine how SP encounters impacted students' confidence in performing clinical evaluations. Pretest-posttest survey design. Athletic training simulation lab. Thirty-five students from the junior (n = 20) and senior (n = 15) AT cohorts from a public liberal arts institution in the Southeast. Athletic training students completed 2 SP encounters per semester throughout an academic year in the AT program, totaling 4 SP encounters. Each student completed a 17-item Likert scale (1 = strongly disagree, 5 = strongly agree) that rated confidence levels immediately before and after each SP encounter. The confidence rating assessed students' confidence regarding how the SP encounter affected their confidence in completing patient evaluations (eg, identifying history questions, interpreting results of special tests). We computed descriptive statistics for all items Wilcoxon signed rank tests determined differences in pre-encounter and should be postencounter confidence ratings. Overall, students from both cohorts reported that the SP encounter improved confidence in completing clinical evaluations. Specifically, students reported a significant increase from pre-encounter to postencounter confidence ratings after nutrition-based (Z = −2.991, P = .004), knee (Z = −3.261, P = 0.001), concussion (Z = −3.294, P = .001), psychosocial intervention (Z = −3.062, P = .002), and general medical (Z = −3.524, P > .001) SP encounters. The authenticity and fidelity of the SP encounter provided the AT students a real-time clinical evaluation in a nonthreatening environment. Students reported that their confidence improved after each encounter. By providing these experiences, AT students can become comfortable interacting with patients in clinical evaluations.Context
Objective
Design
Setting
Patients or Other Participants
Intervention(s)
Main Outcome Measure(s)
Results
Conclusions
INTRODUCTION
Clinical education, which enables students to integrate knowledge and skills into the context of patient care, is an important component of athletic training (AT) education.1 The importance of clinical education is emphasized in the latest edition of the Athletic Training Education Competencies.2 The clinical integration proficiencies represent the synthesis and integration of knowledge, skills, and clinical decision making into actual patient care. Unfortunately, AT students are not always able to complete all of the real-time patient encounters needed3,4 to prepare for initial practice as an athletic trainer.
As educators, we are challenged to provide meaningful and effective learning opportunities5 for our AT students. One way to provide a realistic patient encounter is the use of a standardized patient (SP). A SP is an individual who has been carefully trained to portray the pathology of an actual patient. The SP presents not just the history but also the gestalt of the patient.6 The SP encounter provides a lifelike experience for students to synthesize both interpersonal and clinical skills, which may help students diagnose and treat patients with conditions, illnesses, or injuries in real time3,4,7,8 when they are unable to complete real-time patient encounters during their clinical education. Providing a SP encounter is a more detailed process than simple role-playing or simulation. The case a SP portrays (eg, patient with medial knee pain) must be planned ahead of time to ensure that the educational goals of the encounter are met and that students demonstrate appropriate technical, assessment, interpersonal, and critical thinking skills. Additionally, the SP must be properly trained to portray the case consistently to all students.
Like all novice practitioners, AT students feel less confident performing skills they have not practiced within the context of patient care. Considerable research exists regarding the benefits of SP encounters in improving students' confidence in nursing,5,9–13 medicine,14,15 and physical therapy.16 When students have repeated exposures to a clinical experience, they have a greater potential for their confidence to improve.11 There is no research regarding whether SP encounters improve an AT student's confidence in clinical evaluations. Therefore, the purpose of this investigation was to determine how 4 SP encounters, implemented strategically throughout the AT curriculum (ie, junior and senior years), affected the AT student's confidence in clinical evaluations and patient encounters.
METHODS
Participants
A total of 35 AT students from a junior (n = 20) or senior (n = 15) cohort completed 2 SP encounters per semester (ie, 4 SP encounters total) that were relevant to their progression through the AT curriculum for the academic year. Participant demographics are presented in Table 1.
SP Case Development and SP Training
Each of the SP encounters was developed using a template adapted from the Southern Illinois University School of Medicine (used with permission17). The primary investigator for this study and select preceptors derived each of the cases used in the encounters by using information from the relevant literature and actual patient encounters from the high school and collegiate settings. Each case consisted of the following elements: summary of the case, instructions for the AT student, and training materials for the SP. After each case was developed, content experts from AT and nursing reviewed each case for accuracy. Each encounter included not only the current medical history of the patient but also the patient's past medical history and social history to increase the authenticity and fidelity of SP. Each of the SP encounters represented a pathology that AT students are likely to encounter during their clinical practice but may or may not see during clinical experiences.
To portray the SPs, theater students were recruited and trained specifically for each case. In total, each SP completed approximately 4 hours of training per case. Training included a 60-minute training session that presented information of the case to the SP. The training also included assessment methods on how to evaluate each AT student at the conclusion of the encounter and methods regarding how to provide feedback to students during the encounter. We completed review sessions on 2 different occasions: a few days before the SP encounter with AT students and again 30 minutes before the encounter.
To evaluate the AT student, we developed a checklist of pertinent history and physical examination components specifically for each SP case, and we wrote the objectives and critical components of the case (eg, emphasis on previous medication history, selecting a special test with high sensitivity/specificity). Although we did not use these encounter-specific checklists for data collection in the current study, we did use the checklists to guide the SP in giving feedback to each AT student. We verified each checklist item through the professional literature. As an additional measure, we had 5 educators (2 from AT, 3 from nursing) who are considered content experts in the use of SPs review and establish each SP encounter checklist for face and content validity.
Procedures
We obtained institutional review board approval before beginning the study. Students completed each of the SP encounters as a component of their respective clinical experience AT course after consenting to participate in the research study. Students from the junior and senior cohorts completed 2 SP encounters per semester, with each student completing a total of 4 SP encounters throughout an academic year. In the fall semester, junior-level students completed the nutrition-based and cervical spine emergency SP encounters, whereas senior-level students completed the shoulder and concussion SP encounters. In the spring semester, junior-level students completed the knee and low back SP encounters, and the senior-level students completed the psychosocial intervention and general medical SP encounters. Each of the SP encounters were completed during week 5 and week 10 of each academic semester.
Immediately before and after each SP encounter, each AT student completed the pre-encounter and postencounter confidence ratings, respectively. To make data collection easier, all responses were captured electronically via SurveyMonkey (http://www.surveymonkey.com, Palo Alto, CA).
Instrumentation
We developed a confidence rating scale to assess how each SP encounter affected a participant's confidence in completing patient evaluations. We derived all of the items from the professional literature.5,9,11–13,15,16,18–19 The instrument consisted of 17 items (eg, identifying history questions, selecting appropriate special tests, interpreting results of special testing, formulating a treatment plan) that assessed confidence in completing a clinical evaluation (Table 2). Participants scored each item on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree) to rate how they perceived their confidence in completing the clinical evaluations.
We had 5 educators (2 from AT, 3 from nursing) who are considered content experts in the use of SPs establish face validity and content validity for the confidence rating scale. Each item was assessed for content and clarity, and we clarified or added items as needed. We measured reliability using Cronbach α to determine internal consistency of survey items. The α coefficient was 0.971.
Data Analysis
We computed descriptive statistics on all survey items. We used the Wilcoxon signed rank test to analyze differences between pre-encounter and postencounter confidence ratings for each of the 17 items after each SP encounter. We set the α level for all of our analyses at .05, and we used a Bonferroni correction for multiple comparisons to reduce the risk of type I error. The corrected α level was .002 for comparing confidence rating scale items and .013 for comparing first with fourth encounter mean confidence ratings. We performed our data analyses using IBM SPSS (version 21.0; SPSS Inc, New York, NY).
Although this was not a qualitative study, we had a sufficient number of comments to warrant qualitative analysis of the following survey question: “Specific comments explaining how this SP encounter improved my confidence.”
We used interpretative coding to analyze the qualitative data.20 This process involved taking individual comments and categorizing them into concepts. We then organized the concepts into themes using pattern analysis20 and assigned labels to capture their meaning. Three different analysts who were highly skilled in qualitative research independently evaluated the data, and a consensus of themes was reached among analysts to ensure trustworthiness and accurate interpretation.
RESULTS
Overall, students reported an increase from pre-encounter to postencounter confidence ratings for many of the 17 items after each SP encounter. Of most importance, when we examined the mean confidence ratings of all 17 items from encounters 1 to 4 within 1 year, our findings indicated a significant increase in confidence. A Wilcoxon signed rank analysis indicated a significant increase in mean confidence ratings from the first to fourth encounter for junior-level students (Z = −3.527, P < .001) and senior level (Z = −3.196, P = .001) students. This trend highlights that there is an increase not only within pre-encounter to postencounter ratings but also a cumulative effect from one SP encounter to the next.
Perceived Confidence of Junior AT Students
Overall, the mean pre-encounter to postencounter confidence ratings increased after the completion of each of the 4 SP encounters. Specifically, a Wilcoxon signed rank test revealed a significant increase from mean pre-encounter to postencounter confidence ratings after the nutrition-based (Z = −2.991, P = .004) and knee (Z = −3.261, P = .001) encounters. A complete summary of the Wilcoxon signed rank test results comparing mean pre-encounter and postencounter ratings for each SP encounter is presented in Table 3.
After students completed the nutrition-based encounter, their confidence rating trends showed an increase in nearly all items pre-encounter to postencounter; however, no significant increase existed among the 17 items.
Similarly, student confidence rating trends showed an increase in many items from pre-encounter to postencounter after the cervical spine emergency encounter. The results of Wilcoxon signed rank tests indicated that students reported a significant increase in confidence regarding their ability to obtain adequate information during a patient history and use nonverbal communication. A complete summary of pre-encounter and postencounter confidence ratings for the nutrition-based and cervical spine emergency SP encounters is presented in Table 4.
After students completed the knee encounter, their confidence rating trends showed an increase in nearly all items from pre-encounter to postencounter. The results of Wilcoxon signed rank tests suggested that students reported a significant increase in confidence related to their ability to generate follow-up questions, select special tests, interpret results of special tests, and use professional language.
Similarly, student confidence rating trends showed an increase in nearly all items from pre-encounter to postencounter after the low back encounter, with a significant increase in confidence related to their ability to obtain adequate information during a patient history, use nonverbal communication, and use professional language. A complete summary of pre-encounter and postencounter confidence ratings for the knee and low back SP encounters is presented in Table 5.
Perceived Confidence of Senior AT Students
Similar to the junior-level students, the senior-level students reported an increase in mean pre-encounter to postencounter confidence ratings after each of the four SP encounters. The results of Wilcoxon signed rank tests demonstrated a significant increase in mean confidence scores from pre-encounters to postencounters for the concussion (Z = −3.294, P = .001), psychosocial intervention (Z = −3.062, P = .002), and general medical (Z = −3.524, P < .001) SP encounters. A complete summary of the results for the Wilcoxon signed rank tests is presented in Table 3.
After completing the shoulder encounter, student confidence rating trends showed an increase in several items pre-encounter to postencounter; however, there were no significant increases among any of the 17 items.
Similarly, student confidence rating trends showed an increase in nearly all items pre-encounter to postencounter after the concussion encounter. Results of the Wilcoxon signed rank tests revealed that students reported a significant increase in confidence related to their ability to identify appropriate questions during a patient history, formulate a treatment plan, provide adequate patient education, and evaluate the patient holistically. A complete summary of pre-encounter and postencounter confidence ratings for the shoulder and concussion SP encounters is presented in Table 6.
After completing the psychosocial intervention encounter, student confidence rating trends showed an increase in most items pre-encounter to postencounter. Results of the Wilcoxon signed rank tests revealed that students reported a significant increase in confidence related to their ability to select appropriate special tests and interpret the results of special tests.
Similarly, student confidence rating trends showed an increase in all items pre- to postencounter after the general medical encounter. Results of the Wilcoxon signed rank tests indicated that students reported a significant increase in confidence related to their ability to generate appropriate follow-up questions and their overall abilities as an athletic trainer. A complete summary of the pre-encounter and postencounter confidence ratings for the psychosocial intervention and general medical SP encounters is presented in Table 7.
Three themes and two subthemes emerged from the representative comments regarding how the SP encounter improved the students' confidence (Figure). Theme 1, improved clinical decision making, describes how students believed the SP encounter improved their ability to think critically through clinical decisions. Theme 2, transfer to clinical practice, describes how students were able to connect what was completed during the SP encounter directly to patient care. Theme 3, improved communication, describes how students believed their communication skills improved as a result of the SP encounter. The first subtheme, connecting with patients, describes how students were able to make a better connection and develop good rapport with the SP during the encounter. The second subtheme, depth of patient history, describes how students were able to appropriately determine how in-depth they needed to probe while obtaining a patient history from the SP. Whether intentional or not, several students also reported that the SP encounter stimulated reflection on what they know and do not know and, more important, where and how they can improve with subsequent patient encounters.
Citation: Athletic Training Education Journal 10, 2; 10.4085/1002113
DISCUSSION
A considerable number of researchers3,4,9,10,14,19,21,22 across AT and various health care disciplines have examined clinical evaluation methods, including specific means to improve a student's confidence in patient care encounters. The current study provides an understanding of how SPs have been used in the professional education of AT students to affect their confidence when performing clinical evaluations.
With clinical decision making, confidence is often associated with knowledge; however, other factors can affect a student's level of confidence (eg, amount of training and expertise, time allocated to decision making, levels of self-confidence).14 What seems most evident in terms of student confidence is that when students have repeated exposure to a clinical experience, they have a greater potential for their confidence to improve.11 We used eight different SP encounters to provide additional opportunities for AT students to have repeated exposures to real-time patient care situations. The results of this study highlighted that repeated exposures to real-time clinical evaluations may help to increase the student's confidence in his or her abilities to complete a clinical evaluation. The results also indicated that the cumulative effect of these SP encounters significantly increased a student's confidence in his or her abilities to complete clinical evaluations. Even though many of the SP encounters had small increases (or at times a decrease) in confidence ratings from pre-encounter to postencounter, the comments from students showed the overall positive impact these encounters had on improving confidence.
The SP encounter provides a lifelike experience for students to synthesize interpersonal and clinical skills when diagnosing and treating patients with conditions, illnesses, or injuries during their clinical education.3,4,7,8 Our study revealed that a planned sequencing of SP encounters increased the AT students' confidence in completing clinical evaluations. These encounters support the notion that SP authenticity and fidelity can provide a real-time clinical evaluation in a nonthreatening (eg, no harm to patient) environment18 that allows students to build confidence regarding their clinical skills, interpersonal skills, and AT knowledge. Other researchers in AT,19 medicine,14 nursing,5,9,10,12 and physical therapy16 have also reported that SPs are beneficial for increasing students' confidence toward clinical practice.
Students may enhance their confidence and clinical expertise if they learn information in a way that parallels how the information will be used in real-time practice.13 The results of our study identified that students reported increased confidence regarding some components of obtaining a patient history and completing a physical examination, while also reporting decreased confidence in other components of the examination. We observed that a student's confidence with a particular skill often paralleled the goals of each SP encounter (eg, the nutrition-based encounter emphasized obtaining a patient history and interpersonal communication, the knee encounter emphasized completing a physical examination). The SP encounter provides the necessary repetition and reinforcement for AT students to build not only new skills but also confidence.9 In our study, we found that students reported an increase in their confidence related to obtaining a patient history, which includes interpersonal communication. Previous researchers also reported an increase in student confidence related to obtaining a patient history16 and interpersonal communication5,9,16 after a SP encounter. Specifically, increased confidence has been reported in interviewing patients,16 verbal communication skills,16 and educating and interacting with patients9 after engaging in an SP encounter. In addition, Wagner et al9 reported that because SPs provide repetition and reinforcement, these encounters help students build competence and confidence in their acquired skills.
Limitations and Future Research
The current study had some limitations, namely the number of real-time patient encounters students were exposed to during their clinical experiences between SP encounters. As educators we cannot control what patient encounters an AT student will complete during clinical experiences; however, the SP encounter does provide an opportunity to assess the AT student's skill and application of knowledge in real-time.
In addition, the small cohorts of students we examined were from a single institution. Due to the small cohort sizes, the possibility existed that students from different cohorts would discuss the specifics of each SP encounter because the same ones are used for each AT cohort. As a means to prevent communication with other individuals, each student signed a confidentiality form before completing each SP encounter. This form indicated that students would not discuss the contents of a SP encounter (neither specific nor general information) with anyone, including their preceptor.
The findings of this study provide initial data that can be compared across years to better understand trends in the confidence of AT students after each SP encounter. Although a variety of other factors exist that may relate to an AT student's confidence (eg, semester in the program, clinical experience placements, characteristics of preceptor, skill practice, maturity), this research provides a baseline of educational outcomes to support using SPs to improve the confidence of AT students. These results also suggest that further exploration into why AT students' confidence improved in only some areas of the SP encounter is needed. Future research should also include larger groups of AT students, and it should compare larger cohorts of students from multiple institutions.
CONCLUSIONS
Standardized patients provide educators the ability to provide real-time patient encounters to students in a nonthreatening environment that allows the direct application of knowledge and skill within the context of patient care. We found that the authenticity and fidelity of the SP encounters allowed students to interact with the SP in a manner similar to how they would interact with a patient during clinical experiences. Overall, students reported that the SP encounters improved their confidence in completing clinical evaluations. In addition, we saw a significant increase in student confidence from the first to fourth encounter within an academic year, indicating that there may be a cumulative effect of having multiple encounters within 1 year. These encounters provide positive educational outcomes that reflect the strength of the SP encounters on AT students' confidence. Athletic training educators should continue to explore the use of SPs as an innovative, evidence-based educational practice that can enhance the students' progression toward professional practice.
Conceptual framework of qualitative data: how standardized patients (SP) encounter improved confidence.
Contributor Notes
Dr Armstrong is currently an Associate Professor and Athletic Training Program Director in the School of Health and Human Performance at Georgia College & State University. Please address all correspondence to Kirk J. Armstrong, EdD, LAT, ATC, School of Health and Human Performance, Georgia College & State University, Campus Box 112, Milledgeville, GA 31061. kirk.armstrong@gcsu.edu.