Simulations and Standardized Patients in Athletic Training: Part 1 Athletic Training Educators' Use and Perceptions

Methodological Design

A phenomenological qualitative approach was used to gain a thick description and understanding of the participants' use and perceptions of simulations and SPs. Phenomenology uses discovery and description by participants of their lived experiences or knowledge to capture the essence and meaning of the phenomenon of interest.²⁴ Understanding the depth of lived experiences of a phenomenon through data collection and analysis is the premise behind selecting the phenomenological research approach.²⁵ Additionally, a social constructivist paradigm was used to examine the research purpose. Social constructivism was selected because it directly relates to the multiple contextual perspectives and subjective voices that exist to explain a phenomenon. Seeking knowledge through social interactions and understanding how individuals construct that knowledge is critical to social constructivism.²⁴

Given the process of inquiry involved in general inductive analysis, the construction of a solid research team was necessary. The multiple perspectives and opinions that arise in qualitative data inquiry necessitated the development of a research team trained in qualitative inquiry and analysis to reduce researcher bias. The research team for this study consisted of 4 athletic trainers: 3 researchers (J.W.C., S.E.W., B.V.L.) composed the research team, and 1 individual who was trained in qualitative inquiry (not an author) reviewed the data. Peer review is often used in a research team to provide objective bias to ensure the data are being closely and appropriately analyzed and the multiple perspectives of the participants are readily seen.

Participants

Twenty-one athletic training faculty (6 males, 15 females) participated in 1 of three 45- to 50-minute focus groups. The focus groups ranged from 4 to 9 participants. The average age of the participants was 39.4 ± 7.96 years, with 1 participant not disclosing their age. Eleven of the participants were program directors, 8 were clinical education coordinators, and 2 were athletic training faculty. Participants were faculty/staff within professional athletic training programs at the undergraduate level (n = 20) and professional master's level (n = 1), with 1 participant teaching in both an athletic training program at the undergraduate level and within an accredited postprofessional athletic training program. Participants were from District 9 (n = 12), 3 (n = 4), 1 (n = 2), 8 (n = 2), and 4 (n = 1) of the National Athletic Trainers' Association. Demographic information was obtained from each participant through a demographic questionnaire (Table 1). All participant demographic information is summarized in Table 2 along with additional information in reference to their simulation and SP use in Table 3. One participant chose not to complete some demographic information on the questionnaire and was therefore omitted from Tables 2 and 3.

Table 1 Demographic Questionnaire

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Table 2 Participant Information

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Table 3 Participant Simulation and SP Use

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Participant Recruitment

Institutional review board approval was obtained before this study. Participants were recruited via e-mail and onsite at the Southeastern Athletic Trainers' Association (SEATA) Educators' Conference and the SEATA Athletic Training Student Symposium. Conference registrants and/or assisting faculty for the student symposium were contacted via e-mail from a SEATA representative 5 days before the focus groups. The e-mail contained a description of the study and a link to a survey on the online platform Qualtrics (Qualtrics International Inc, Provo, UT). The survey asked participants if they were attending the SEATA Athletic Training Educators' Conference or the SEATA Athletic Training Student Symposium, if they used SPs and/or simulations in their program, and if they would be interested in participating in 1 of 3 focus groups. Inclusion criteria consisted of using SPs and/or simulations to teach and/or evaluate their athletic training students. If a respondent indicated they did not use SPs or simulations, they were taken to a screen thanking them for completing the survey. Participants who indicated they used SPs or simulations were asked to indicate the time and date of the focus group they preferred to attend and provide their contact information (phone number, e-mail address). A few participants were also recruited by personal contacts onsite. Participants were contacted 1 day before the session and provided with the time and location of their assigned focus group.

Data Collection Procedures

Upon arriving, participants signed consent forms and completed the demographic questionnaire. An interview guide (Table 4) was developed based on the purpose of the study. The interview guide was sent to 2 athletic training faculty members for clarity and content validity. The interview guide was piloted with 1 athletic training faculty member, and only minor modifications were made. The pilot interview was not used in the data analysis portion of the study. The focus groups began by having the research team members (J.W.C., S.E.W., B.V.L.) and participants introduce themselves, and then the questions from the interview guide were asked. Each participant responded one at a time to the first question, and then discussion ensued. This was repeated for all questions. All focus groups were facilitated by a member of the research team (S.E.W.), audio recorded, and lasted 45 to 60 minutes in length.

Table 4 Focus Group Interview Guide

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Data Analysis

All focus groups were transcribed verbatim. Names, academic institutions, and other identifiable characteristics were removed to protect the identity of those involved, and pseudonyms were assigned. Inductive content analysis was used to analyze the data.²⁴ Two members of the research team (J.W.C., S.E.W.) individually read through the transcripts, coding the data with labels to capture meaning. Those codes were then organized into themes. Upon further analysis, lower-order themes were identified.²⁴ The 2 researchers then shared their themes, and consensus coding was established for each code's meaning.²⁴ After this process, the themes and subthemes and transcripts were sent to an individual with qualitative research experience (peer debriefer) to validate the findings. Figure 2 displays the themes with subthemes.

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Strategies for Trustworthiness

Several strategies were used throughout the study to ensure trustworthiness. All participants were assigned a pseudonym. Vital to phenomenological studies is the process of member checking.²⁴ Member checking allowed the researcher to return the transcript back to each participant for clarification and checks for accuracy. By allowing the participant to review the transcript before the completion of the study, the researchers were able to gain authenticity, sampling adequacy, and substantive validation before the study's end.²⁴ Each participant was e-mailed his or her focus group transcript and pseudonym for their review. A total of 5 participants responded to the member checking e-mail, 3 to inform the researchers that all data presented in the transcripts were accurate for their portions, 1 to inform the researchers that an identifiable name was not omitted, and 1 also to clarify a concept that was discussed in the focus group session. Two participants were from focus group session 1, 2 were from focus group session 2, and 1 was from the third focus group session.

The use of peer debriefing builds credibility, coherence, and validation of the researchers and research design for the study. The peer was trained in qualitative inquiry and was used to review the transcripts and codebooks to ensure that the voice of the participants was readily seen in the theme development for the study and provided a voice of reason when discrepancies in the consensus coding existed.²⁴

Using multiple data sources, such as focus group interview transcripts and demographic questionnaires, helped the researchers build credibility, transferability, and authenticity by giving the researchers data sources for triangulation. These techniques also gave the researchers valuable data for collection and analysis, which helped in the write up of the study through the use of thick description of the focus group interviews and contacts with participants.²⁴

Standardized Patient Encounters

Only 6 participants used SPs. Of those 6, all reported using them 2 to 3 times per semester, often for a practical examination (eg, midterm, final practical exam), some other graded component (eg, in class case portrayals requiring class participation) of a course, or for teaching purposes. The students were described as interacting with the SP individually or in groups. Three faculty described using SPs in the classroom as a nongraded component, where the SPs were used to expose the students to SPs so they were comfortable with the environment of an SP encounter and eventually real patient care. Julia described how they use SPs, “We have them at midterm and final. We have our juniors and seniors go through. They are tested on what they have been taught the previous semester.” Their students interact with 2 different SPs at the middle and end of each semester. When asked if she used SPs, Meredith responded, “Typically, it is about 2 or 3 times a semester.” She further described using students from the neighboring physical therapy program or theater department to serve as the SP. Leah described the use of SP encounters for interprofessional education (IPE) by having her athletic training students and medical students come together to evaluate an SP with an orthopaedic condition. Julia stated, “We generally use [SPs] for the [IPE] with medical students, kind of help teach the medical students orthopaedic evaluation.” In Aaron's description of his use of SPs during an evaluation course, he stated:

One of the things I've wanted to do is evaluate the students culminating at the end of the year with a lab practical, and 1 of the things I wanted to do was have a very [SP] encounter for all students. So, I trained 1 SP to do that evaluation.

Most of the participants who used SPs were doing so for the purpose of middle or end-of-semester evaluation of skills. These were usually associated with the lab portion of a class or the clinical practicum classes and often were either a comprehensive practical examination from the entire current semester or from the previous semester's content.

Simulations

Participants often used simulations to provide learning opportunities where students interacted in groups and were then provided feedback. Some of the simulations occurred in a simulation laboratory and included a simulator (computerized human patient simulator), while others occurred in the classroom with a partial task trainer (noncomputerized mannequin) or simulated patient (mock; non-SP) with faculty, other athletic training students, premajors, or students from other majors serving as a simulated patient. A simulated patient is an individual who has been given a basic background of what they need to portray (eg, basketball player who just sustained an ankle sprain) but has not undergone formalized training as is done with SPs. Simulated patients are often used in the classroom setting to prepare students for actual patient encounters as well as graded encounters. The process of standardization that occurs in the use of SPs is much more in depth and requires the person playing the role of the patient to be very intimate with the details of the case and characteristics of the patient being portrayed. Simulations, as described by the participants, could occur in group (2–6 students) or individual encounters.

Valued Educational Experiences

Valued educational experiences encompassed the next theme and involved components of how simulation and SP experiences were viewed as valuable experiences for the students. This theme was subdivided into acute care and nonorthopaedic evaluation, orthopaedic evaluation, and communication. Participants felt these experiences offered learning opportunities for students that either rarely occurred (eg, spine boarding) or occurred so often they wanted to prepare the students properly (eg, ankle sprain). The subtheme of acute care and nonorthopaedic evaluation describes simulations that were used to prepare students in the skills necessary for an emergency medical situation or general medical evaluation. The subtheme of orthopaedic evaluation describes how simulations were used to prepare students to evaluate patients with orthopaedic injuries. Many of the participants identified the need to expose students to a variety of encounters that they would likely see in their clinical education. The final subtheme was communication and included interactions with coaches, parents, emergency medical services, and other health care providers. Simulations provided the opportunity to practice the interpersonal and communication skills necessary to perform a successful clinical patient evaluation and communicate the findings to others.

Standardized Patient Encounters

Our data indicate that SPs are often used to teach as well as evaluate students at the middle and end of the semester. This is consistent with medical school practices, where SP encounters are used for end-of-year evaluations to determine progression to the next year of medical training and for medical licensure exams.²⁶ Standardized patients are also used to teach various communication and clinical skills.^27,28 Engaging students in IPE has been an initiative supported by many health professions and the World Health Organization that fosters improved collaboration for effective communication and team-building skills.^28,29 Participants described how they engaged in IPE by having athletic training students provide a teaching role in orthopaedic evaluation for other professional students. The use of SPs in health care education is often for the purpose of teaching and refining communication skills as well as evaluating the clinical skills necessary for proper and effective patient care.^8,29 Both nursing and physical therapy programs use SPs for the teaching and evaluation of communication and clinical skills as well as to supplement clinical education experiences.^12,17 Incorporating SPs in both formative learning experiences and summative evaluation of skills acquisition is consistent with literature of most health professions.^12,17,27,28 It was interesting to see that some participants only used SPs to evaluate knowledge and skill, but they were not used to teach these skills. This is possibly due to lack of faculty time and program funding for multiple encounters throughout the semester. The use of SPs for both teaching and evaluation is widely seen in medicine.^7,9–11 If a student is not exposed to SP encounters before an evaluation, it is uncertain how well he or she will perform.^29,30 Students could spend a great deal of cognitive energy trying to understand the logistics and how to interact with the SP and may not focus on the actual skill/evaluation.²⁹ Current literature in cognitive load theory suggests that, in order to be successful in the use of simulation, educators must expose learners to simple tasks and move into more complex tasks.^29,30 Incorporating SP encounters into the classroom environment after an academic unit or learning objective will allow students to practice their clinical skills and ability to interact with a patient while also familiarizing them with the process involved in an effective SP encounter. Providing students with familiarity may ease the cognitive burden during an evaluative encounter. We recommend those who do use SPs for evaluative purposes also incorporate them into the formative aspects of their program.

Simulations

The next overarching theme described by our participants was simulations, which was further divided into the subthemes of group encounters, individual encounters, and feedback. All participants reported placing students in groups for simulations on acute care or nonorthopaedic conditions. Group encounters provided faculty an opportunity to efficiently use their time in the classroom and/or laboratory while also preparing the students to work together. Group simulations are used to prepare students to act as a team in nursing and medicine.^6,28,31,32 Having students work together during group encounters on skills such as spine boarding helped develop effective communication and team-building skills. Almost all participants described these 2 qualities of group encounters, which has also been supported by literature involving multiple health care professions working as a cohesive unit.²⁸ Other critical situations, such as cardiac life support, warrant effective teamwork and communication skills. The use of simulations in the teaching of cardiopulmonary resuscitation has been shown to assist in communication skills necessary for effective teamwork and leadership in emergency situations.³³ Group encounters offer a formative environment for students that facilitate interpersonal and professional skill development.

All of our participants reported using simulations for individual encounters with learners. Our participants felt that individual encounters were a more effective way to evaluate specific clinical skills while also providing added practice for students, which is consistent with the literature.^3,34–36 In a study examining second year internal medicine residents' effective use of advanced cardiac life support protocols, participants who engaged in repetitive practice using a simulator performed significantly better as compared with those students who just continued with their normal clinical duties.³⁶ The simulator was used for individual recognition of common cardiac abnormalities or conditions and the proper use of current advanced life support techniques for the condition.³⁶ Butter et al³⁵ evaluated medical students' performance and effectiveness of the core clinical skill of cardiac auscultations. Deliberate practice with a computer-based tutorial and cardiac patient simulator resulted in significantly higher cardiac auscultation accuracy by the third year students compared to the untrained fourth year students.³⁵ Participants of our study described the use of partial task trainers, simulators, and SPs to provide a realistic patient encounter when vital signs and other skills such as cardiac, lung, and abdominal auscultations need to be mastered by an individual student. The use of partial task trainers were often described when there were more invasive clinical skills being taught or assessed in which an SP or simulated patient may not be effective for the carrying out the encounter. Each learner must show mastery in the individual skills necessary for general medical and emergency medical conditions and evaluation such as blood pressure, cardiac, or abdominal auscultation and cardiopulmonary resuscitation, which can be adequately replicated with a partial task trainer. The literature on simulation use in procedural skills development in medical education supports the use of partial task trainers and simulators for such skills.^34–36 Blum et al³⁴ examined the effectiveness of teaching procedural skills with a simulator to first year surgical residents and found that, through the use of the simulator, trained surgical residents individually performed a more thorough exam and required fewer verbal and physical directions during the exam as compared with the nontrained residents.³⁴

Study participants reported providing feedback in various ways, from the faculty, preceptors, other students, or even in some cases the SP. Students also reflected on their performance through journaling or SOAP note writing. Most participants described some form of debriefing that would occur either immediately after an encounter or within the first few days after an encounter. Debriefing is a planned conversation after a learning encounter or critical event where participants analyze their actions, thought processes, emotional states, and any other information to improve future performance.^31,37 The process assists students in recognizing strengths and weaknesses in communication and clinical skills necessary for proper patient care.³⁸ The debriefing process is essential to the learning process because it not only identifies performance gaps, but gives the student learners ways to provide better patient care.^31,32,37,38 All faculty found that feedback sessions after simulation encounters provided additional opportunities for learning by the student and provided an open atmosphere in which the faculty could address concerns about the skills observed while also providing feedback to student learners about the clinical skills they were performing. The debriefing also provided the students the opportunity to justify actions and work out the reasoning process without the fear of harm to an actual patient. Conducting a simulation is only half of the process. Another important process is the debriefing and reflection that students are involved in after the experience has ended.^31,37,38 Regardless of the type of encounter being offered, faculty should offer feedback to students, whether it be through formal debriefing with an entire class within the days after an encounter or more individualized feedback directly after an interaction.

Valued Educational Experiences

The next theme described is valued educational experiences, which was further divided into subthemes of acute care and nonorthopaedic evaluation, orthopaedic evaluation, and communication. Our participants agree that both simulations and SPs provide students with realistic patient encounters to better prepare their students for clinical practice. Our participants reported using simulation encounters for spine boarding, cardiac care, and advanced emergency medical conditions which are not commonly seen in the course of every student's clinical experience.^6,20 The educational training of multiple health professions to include less common conditions is supported in the literature.^{6,7,9–20,29} Providing students the opportunity to engage in emergency simulations that were not seen as often in everyday patient care exposed the learner to realistic stressful encounters and were valued educational experiences noted by the participants.

The ability to accurately and effectively perform a clinical evaluation of an orthopaedic condition was described by several faculty as a valued educational experience. These faculty found it valuable to use simulations to provide repetition in the commonly seen clinical conditions such as an ankle sprain in order to expose the student learner to experiences he or she will likely encounter regularly during clinical education. This is consistent with the literature on use of simulations and SPs in clinical skill acquisition for various health professions.^9,14,17

Communication skills are enhanced by having students interact with a patient, coach, parent, or other health care professional as part of the interprofessional team. Becker et al¹² described the teaching of therapeutic communication to nursing students through the use of SPs in a pilot intervention study. Their findings supported the use of SPs in the teaching of communication skills and showed that SP use increased the students' ability to use different interviewing techniques, and overall, students thought it increased their critical thinking skills.¹² Many of our participants described interprofessional collaborations to evaluate effective communication. Wamsely et al²⁸ described an interprofessional SP exercise involving dentistry, medicine, nursing, pharmacy, and physical therapy students. The students involved in the experience reported an increase in perceived knowledge of professional roles and were provided the opportunity to teach others about their role.²⁸ Students' confidence in interacting with other health care professionals increased along with improvement in team value and team efficiency.²⁸

Implications, Limitations, and Future Research

The results from our study add to the literature and describe the context in which simulations and SPs are being used in athletic training education. Our initial purpose was to explore the use of SPs, but some of the educational techniques included simulations. While our focus groups did yield rich data on the use of simulations and SPs, the interview guide was developed specific to SPs. Our findings illustrate that simulations are currently being used in a variety of ways. While we did reach data saturation, our results cannot be generalized to all professional athletic training programs. Further investigation needs to be conducted on the feasibility of simulation use, including SPs, within athletic training professional programs as well as their effects on program outcomes and patient care. Individual programs should consider using simulations and SPs based on their individual resources. Although we examined the perceptions of faculty within athletic training programs, we did not examine students' perceptions of the use and utility of simulations and SPs within their program to learn which aspects they feel are of value and benefit to their learning process. Future research could investigate students' perceptions of simulations and SP experiences.