Current Uses of Simulation and Standardized Patients in Athletic Training Education: Uses for Teaching and Assessment and Barriers to Use

Participants

All program directors of the CAATE-accredited graduate professional athletic training programs were invited to participate. The invitation email asked the program director to complete the survey or forward it to the individual affiliated with the program who has the most knowledge about using SPs and simulations. As of September 2022, 245 program directors had been contacted (with bachelor’s level programs excluded). Seventy-two individuals accessed the survey (29.4% access rate), and 43 completed at least half of the survey items (59.7% completion rate).

Respondent demographics are presented in Table 1.

Table 1. Participant Demographics

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Procedures

Institutional review board approval was obtained before data collection. The email addresses of all program directors from all CAATE-accredited graduate professional athletic training programs as of September 2022 were obtained. Each program director received an email invitation for participation in the investigation, which contained the overall purpose and importance of the research study, the estimated time to complete the survey, and a link to the survey instrument. Two reminder emails were sent to nonrespondents to solicit participation at 2-week intervals.

Instrumentation

This study represents a follow-up of previous research. The validity and reliability of the original instrument, The Methods of Clinical Proficiency Evaluation in Athletic Training (MCPEAT) survey, and the updated MCPEAT had been previously established.^8,9 The MCPEAT survey was updated for the current investigation to examine how athletic training programs use simulations and SPEs to teach and assess clinical skills and the barriers preventing their use. The instrument was also updated to align with the uses of simulations and SPEs within current CAATE curricular content standards.²⁴

The survey consisted of a total of 19 items. Three questions examined the uses of simulations and SPs for teaching and evaluation, including frequency of use per semester and uses within specific curricular content areas. Two open-ended questions allowed respondents to explain additional uses of simulations and SPs. Two questions used a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree) regarding barriers to simulations and SP use within athletic training education and an additional item examining whom faculty collaborate with to implement simulations and SPEs. Two additional open-ended questions allowed respondents to explain additional barriers preventing use. Eight items captured demographic characteristics or respondents (eg, gender, Carnegie classification of institution, number of simulations/SPs mapped to curricular content).

Within the survey, the following definitions were used to operationalize terminology for respondents. Simulations were defined as encounters in which athletic training students provide patient care to a mock patient (which could include using a mock patient, task trainer, hybrid simulation, and/or patient simulator), applying patient care skills in a manner that mimics actual patient care. We defined an SPE as a specific type of simulation in which athletic training students provide patient care to a SP. An SP is an individual intentionally trained to portray a patient consistently.

Face and content validity of the updated MCPEAT survey were established by 3 educators who were considered content experts in using simulations and SPs (2 athletic training educators and 1 nursing educator). Each item was assessed for content and clarity, and items were clarified or additional items were added as needed. Cronbach α was used to determine the internal consistency of survey items, with an α coefficient of 0.891 to 0.911.

Data Analysis

Descriptive statistics were computed for all survey items. A Kruskal-Wallis test determined differences between the use of simulations and SPs for teaching and evaluation with regard to selected demographic variables (eg, Carnegie classification, number of students enrolled in the program, simulations/SPs mapped to curricular content). A Mann-Whitney U test or Kruskal-Wallis test also determined differences between barriers to using simulations and SPs with regard to select demographic variables. The α level was set at .05 a priori, and Bonferroni corrections were used for multiple comparisons. Data analysis was performed using IBM SPSS (version 28; IBM SPSS Inc).

Though this was not a qualitative study, several responses were provided for the open-ended questions. We used an interpretive coding analysis method to determine themes and subthemes for the open-ended questions. Codes were created to group data into common themes. The qualitative data were read by 2 individuals independently, and then they met to discuss the codes. After creating a system of codes, the reviewers then recoded the responses. If there was disagreement on the assigned code, a third reviewer was used to determine the outcome. Once coding was completed, an experienced qualitative researcher audited the data and codes to determine accuracy.³²

Uses of Simulations and SPEs

Programmatically, only 51.2% of respondents (n = 21) reported tracking the number of simulations and SPEs students interacted with throughout their professional program. Nearly all respondents reported using simulations for both teaching and evaluation purposes within their program (n = 41, 97.6%, and n = 38, 95.0%, respectively). The use of SPEs for teaching and evaluation was also high, with most respondents using SPEs for teaching and evaluation (n = 32, 76.2%; n = 34, 81.0%, respectively). Descriptive statistics regarding the use and frequency of use for simulations and SPEs are presented in Table 2. A Kruskal-Wallis test revealed that respondents from institutions with a Carnegie classification of Doctoral (R2) or Doctoral/Professional reported significantly more uses of SPEs for evaluation purposes (H = 11.205, P = .024).

Table 2. Frequency per Semester for Use of Simulations and Standardized Patients

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When examining the frequency of use, 1 to 3 simulations per semester for teaching (n = 17, 40.5%) and 4 to 6 simulations per semester for evaluation (n = 16, 40.0%) were reported the most. Similarly, 1 to 3 SPEs for teaching (n = 25, 59.5%) and evaluation (n = 24, 60.0%) were reported the most. See Table 2 for complete frequency of use data for simulations and SPEs. A Kruskal-Wallis test revealed that respondents who received administrative release time to oversee simulations and SPEs used teaching SPs significantly more frequently (H = 10.255, P = .006).

A sufficient number of comments were captured regarding additional uses of simulations and SPs for teaching and evaluation. Two themes emerged: uses for teaching (including 2 subcategories) and uses for evaluation (including 2 subcategories). Refer to Figure 2 for the additional uses of simulations and SPs for teaching and evaluations.

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Frequency of Simulation Use Within Curricular Content Areas

Descriptive statistics regarding the frequency of use of simulations for teaching or evaluation by curricular content area are presented in Table 3. Respondents reported using simulations for teaching or evaluation most within the curricular content areas of nonorthopaedic evaluation (n = 40, 97.6%), emergency care and life-threatening injuries (n = 38, 95.0%), and orthopaedic evaluation (n = 36, 87.8%). The frequency of use most common for simulation was 4 to 6 encounters, reported within the curricular content areas of nonorthopaedic evaluation (n = 26, 63.4%), emergency care and life-threatening injuries (n = 25, 62.5%), and orthopaedic evaluation (n = 18, 43.9%). Simulations were not used frequently within the curricular content areas of foundational knowledge and health literacy and health informatics (n = 28, 68.3%) for teaching or evaluation. A Kruskal-Wallis test revealed that respondents from institutions with a Carnegie classification of Doctoral (R1) or Doctoral/Professional reported significantly more uses of simulations for teaching or evaluation within the curricular content areas of ethical practice (H = 10.891, P = .028) and prevention (H = 9.677, P = .046). Additionally, respondents who received administrative release time to oversee simulations and SPs used simulations significantly more frequently in the curricular content areas of collaborative practice (H = 6.673, P = .036).

Table 3. Frequency of Simulation Use in Curricular Content Areas for Teaching or Evaluation

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Frequency of Standardized Patient Use Within Curricular Content Areas

Descriptive statistics regarding the frequency of use of SPEs for teaching or evaluation within curricular content areas are presented in Table 4. Respondents reported using SPs for teaching or evaluation most within the curricular content areas of orthopaedic evaluation (n = 32, 76.2%), nonorthopaedic evaluation (n = 32, 76.2%), and emergency care and life-threatening injuries (n = 28, 66.7%). The frequency of use most common for SPEs included 4 to 6 encounters within the orthopaedic and nonorthopaedic evaluation curricular content areas (n = 14, 33.3%, and n = 17, 40.5%, respectively) and 1 to 3 encounters used within emergency care and life-threatening injuries (n = 15, 35.7%). Standardized patient encounters were not used within the curricular content area of health care administration most of the time (n = 38, 90.5%) for teaching or evaluation. A Kruskal-Wallis test revealed that respondents from institutions with a Carnegie classification of Doctoral (R1) or Doctoral/Professional reported significantly more uses of SPEs for teaching or evaluation within the curricular content areas of health literacy and health informatics (H = 11.842, P = .019) and cultural competency (H = 12.234, P = .016).

Table 4. Frequency of Standardized Patient Use in Curricular Content Areas for Teaching or Evaluation

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Barriers to Use

To effectively provide students with simulations and SPEs, athletic training educators often collaborated with others (both within and beyond athletic training) to assist in implementation. Respondents reported their most frequent collaborators as other athletic training faculty (n = 37, 90.2%) and medical faculty (n = 16, 38.1%). Participants reported collaborating less frequently with simulation center staff from other institutions (n = 5, 11.9%) or a neighboring hospital/medical center (n = 2, 4.8%). See Table 5 for a complete list of collaborators when implementing simulations and SPEs.

Table 5. Collaborators With Athletic Training Faculty to Implement Simulations or Standardized Patients

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Programmatic Barriers

Descriptive statistics regarding barriers preventing the use of simulations and SPEs in athletic training education are presented in Table 6. When considering simulation and SP use, respondents identified a lack of faculty knowledge to implement simulations/SPEs (4.40 ± 0.989), a lack of faculty time to implement simulations/SPEs (4.36 ± 0.727), and a lack of faculty knowledge to develop simulations/SPEs (4.33 ± 0.979) as the most prominent barriers prohibiting use. The respondents reported a lack of student buy-in for simulation-based evaluation (3.33 ± 1.493) as the barrier least prohibiting simulation/SPE use.

Table 6. Programmatic Barriers Preventing Athletic Training Programs From Using Simulations or Standardized Patients

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A Mann-Whitney U test revealed significant differences in respondents identifying as a man compared with those identifying as a woman regarding programmatic barriers. Respondents identifying as a man perceived a lack of student buy-in for simulation-based teaching (Z = −3.088, P = .002) and a lack of student buy-in for simulation-based evaluation (Z = −2.662, P = .008). No differences were found related to Carnegie classification of the institution, the number of students enrolled in the professional programs, nor faculty release time regarding programmatic barriers prohibiting the use of simulations/SPs.

Institutional Barriers

Descriptive statistics regarding barriers preventing the use of simulations and SPEs in athletic training education are presented in Table 7. When considering simulation and SPE use, respondents identified a lack of available trainees to serve as patients (4.38 ± 0.909), lack of financial resources to implement simulations/SPEs (4.24 ± 1.100), and lack of simulation equipment (4.24 ± 1.100) as the most prominent institutional barriers prohibiting use. Additionally, respondents reported a lack of administrative support for simulation-based learning (3.83 ± 1.360) as the barrier least prohibiting use.

Table 7. Institutional Barriers Preventing Athletic Training Programs From Using Simulations or Standardized Patients

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A Kruskal-Wallis test revealed that respondents from institutions with a Carnegie classification as a baccalaureate or master’s college/university reported a lack of simulation technology (H₅ = 11.930, P = .036) and a lack of technology equipment for recording simulations/SPs (H₅ = 12.816, P = .025) significantly more as a barrier to use. No differences were found related to gender identity of respondents, number of students enrolled in the professional programs, or faculty release time regarding programmatic barriers prohibiting the use of simulations and SPs.

Though not qualitative in nature, a sufficient number of comments were recorded regarding additional barriers prohibiting use of simulations and SPs. Two themes emerged from the qualitative data: institutional barriers and logistical barriers. Institutional barriers included comments regarding how the unique institutional structure presented barriers to use, including a lack of administrative support staff members, administrative understanding of simulation-based learning, or understanding of the scope of athletic training practice. Logistical barriers included comments regarding how logistical constraints, such as time, financial resources, access to simulation spaces, or number of athletic training faculty prevented use. The conceptual framework for the qualitative data is presented in Figure 3.

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Uses of Simulations and Standardized Patients

Simulations and SPs provide opportunities for teaching and evaluating athletic training students’ clinical skills in real time. This exposure provides a safe environment to increase confidence in clinical decision-making, unique patient cases, interpersonal communication, and self-reflective practice.⁷ Within the current investigation, we found that most participants used both simulations and SPs for teaching and evaluation purposes. This reported use represents a marked increase from previous years, with previously reported use at 79.9% for simulations and 24.6% for SPs within athletic training education.⁸ This increase is likely due to CAATE standards allowing simulations and/or SPEs to supplement clinical education experiences.²⁴

Overall use of simulations and SPEs per semester has increased.^8–10 Our current findings showed that most respondents used 1 to 3 or 4 to 6 encounters per semester. Comparatively, previous researchers reported lower use, with 30.0% using 1 to 3 encounters and 26.7% using 4 to 6 encounters per semester.⁸ Strong evidence supports that increased exposure to simulation-based learning (through both teaching and assessment) has resulted in improved patient outcomes and fewer errors in practice.³³ The unique learning presented through simulations and SPEs documents the importance of their frequency of use.³⁴

Frequency of Simulation Use Within Curricular Content Areas

In this investigation, we found that curricular content areas of nonorthopaedic evaluation emergency care and life-threatening injuries and orthopaedic evaluation reported the highest use of simulations for teaching or assessment. It is not surprising that these content areas were reported as most frequently instructed or assessed via simulations, as these content areas are commonly seen in patient care yet do not always provide opportunities for real-time patient encounters.^8,9 This finding is consistent with other health care education programs using simulation-based learning to provide students exposure to clinical skills necessary for clinical practice but not viewed regularly in patient care.³⁵

Simulations may not be suitable to teach or assess every clinical skill. Within this investigation, we found that the content areas of fundamental knowledge and understanding health care literacy and health informatics were not instructed or assessed via simulations nor SPEs. These findings show similarities to other literature in athletic training and other disciplines, where the nature of the content and accessibility of developing a simulation or SP present challenges for these content areas.³⁰

Frequency of Standardized Patient Use Within Curricular Content Areas

Within the current investigation, we found the curricular content areas of orthopaedic evaluation, nonorthopaedic evaluation, and emergency care and life-threatening injuries were most commonly instructed and assessed via SPs. These areas were most frequently used again due as these curricular content areas are widely seen in patient care yet may only sometimes provide opportunities for real-time patient encounters.^8,9 Additionally, these content areas require patient encounters that are straightforward, accessible, and accurate portrayals of patient signs, symptoms, or pathologies. Similarly, professional nursing programs report high levels of use of SPEs in areas widely seen in patient care, such as emergency and ambulatory care scenarios.³⁶ These encounters provide high levels of functional task alignment and fidelity, and students need to be better prepared for these types of patients in clinical practice.³⁶

Because SPEs require appropriate training to ensure the accuracy of patient portrayal,³⁰ not all curricular content areas are conducive to using SPEs. Our findings indicated that the curricular content areas of health care administration (which includes budgeting, insurance, and medical recordkeeping) were challenging to teach and assess via an SPE. Health care administration and other curricular content areas may better be instructed and evaluated using alternative methods.³⁶ Effective use of SPEs requires a clinical situation with adequate backstory to provide a realistic starting point for a patient’s clinical case to progress.³⁷ Some curricular content areas (including health care administration) make standardization and repeatability across multiple students challenging.³⁷ Thus, other methods for teaching and assessment are better aligned.

Barriers to Use

Overall, nearly all respondents reported collaborating with another faculty member (within the athletic training program or beyond) to assist in developing and implementing simulations and SPEs. This collaboration was necessary due to a lack of knowledge and resources to develop and implement simulations and SPEs. In order to facilitate simulations and SPEs effectively, a facilitator needs to be skilled and knowledgeable in simulation pedagogy.³⁸ Because many athletic training faculty are not equipped with the necessary knowledge and skills to facilitate simulation-based learning, faculty reported restructuring their curriculum and seeking resources (through self-directed learning and independent research) to effectively develop and implement simulation-based learning.³⁹

Although some respondents reported having a simulation center available (either within their institution or at a local hospital/medical center), few reported using these facilities. This low use is likely because these simulation centers are housed outside of the athletic training program’s unit and/or require significant financial resources to use. Different facilities have varying costs, many with a high cost necessitating athletic training faculty to seek out other opportunities for collaboration to implement simulations and SPEs.

Limitations and Future Research

This second follow-up investigation contributes to the body of literature on athletic training as it provides updated insights into how professional athletic training programs use simulations and SPs for teaching and evaluation and examine barriers to use. One limitation of the current investigation is the response rate. Though our current response rate (17.5%) was lower than that in previous iterations (54%, 59%, and 24.2%), the results are representative of athletic training professional education.^8–10 The results of this investigation provide a snapshot of how professional athletic training programs use simulations and SPEs, while also guiding future research on the use of simulation and SPs. Similar to previous iterations, the current study emphasizes the importance of using simulations and SPs for teaching and evaluating.

Compared with previous studies, the current investigation did not focus on real-time patient encounters, whereas now, our emphasis has shifted to examining the frequency of use and curricular content areas in which simulations and SPs are used for teaching and evaluation.^8–10 Simulations are a valuable tool for teaching and assessing clinical skills.^{6,8,10,23,45,47} Authors of future research concerning the use of simulations and SPs should more carefully examine how use and implementation for teaching and evaluation change over time within professional athletic training programs. Specifically, how are simulations and SPs used, what curricular content areas are used, and what is their frequency?²⁴ Administrative release time should also be explored further: specifically, what expectations exist regarding administrative release time for developing and implementing simulations and SPEs, and a more thorough investigation of that release time. Additionally, the impact of integrating simulations and SPEs with professional education from the perspective of athletic training students would be valuable regarding how these techniques have impacted their patient-centered care skills.

Additionally, the current investigation evolved to include research questions examining the barriers prohibiting using simulations and SPs. With the full implementation of the CAATE standards as of July 1, 2020, in the current investigation we sought to understand what factors (both programmatically and institutionally) prevent faculty from using simulations and SPs.²⁴ As noted in the CAATE standards, when clinical practice opportunities with real patients are not possible, the program may use simulation to meet portions of this standard.²⁴ Future research should examine how these barriers change over time, but also whom athletic training faculty collaborate with to develop and implement simulation-based teaching and assessment.

CONCLUSIONS

Over the last 18 years, the use of simulations and SPs within athletic training professional education has increased, and now nearly all respondents report using these techniques for teaching and evaluation. Alarmingly, many athletic training educators still perceive a lack of evidence to support the use of simulations and SPEs for teaching and assessment. Simulations and SPEs provide opportunities for athletic training students to engage in real-time patient encounters in a safe learning environment. It is imperative that athletic training educators continue to use these techniques to facilitate the development of students’ clinical skills, communication skills, and confidence.

Though few encounters are currently facilitated per semester (eg, 1–3 encounters), it is important for athletic training educators to seek out mechanisms to increase use and exposure. Barriers preventing use, including a lack of knowledge to develop and implement simulations and SPEs, combined with a lack of time and financial resources, need to be considered. Thus, professional development is essential to enable educators to fill gaps in knowledge and skill. Simultaneously, administrative release time is needed to allow educators more time and opportunities to develop and implement simulations and SPEs. Professional programs cannot ignore that simulations and SPEs positively impact student learning. As athletic training education continues to evolve, it will be important to increase use of simulations and SPEs to allow students to enhance and integrate knowledge and clinical skills.