Hybrid simulation in health professions education

Kelly Macauley, PT, DPT, EdD, CHSE, CCS, GCS

Emily Gherghel, PT, DPT, CHSE

Introduction

Simulation-based education (SBE) is a teaching methodology that “replaces or amplifies real experiences with guided experiences” [1] and comprises simulation-based learning experiences (SBLE) [2]. Different simulation modalities can create an SBLE, including paper-, mannikin-, standardized patient-, and computer-based. A hybrid simulation combines two or more simulation modalities into one SBLE to maximize fidelity and learning outcomes. This paper describes existing hybrid simulation literature in health professions education and provides examples of how to use computer-based simulation as a component of hybrid simulation. To support these examples, authors offer a sample curriculum for a Cardiovascular and Pulmonary Physical Therapy course within a hybrid DPT program that embeds computer-based simulation.

Hybrid Simulation Examples in Health Professions Education

Only a few examples of hybrid simulations exist in the literature. The most common example of a hybrid simulation is using standardized patients attached to “invasive” monitoring equipment or a task trainer. Invasive monitoring may include ECG leads, IV, catheter, and central or arterial lines. A task trainer may include pads to auscultate lung sounds. The monitoring equipment can increase physical and environmental fidelity and the learner’s familiarity with the equipment, which results in improved self-efficacy and decreased anxiety when faced with the same equipment or situation in clinical practice. Using a standardized patient helps maximize emotional and psychological fidelity, incorporating a realistic communication experience for the learner. The monitoring equipment allows the simulation facilitator to manipulate vital signs or other information in real-time to drive the learner’s clinical reasoning throughout the simulation scenario. A task trainer permits the learner to practice a skill on the standardized patient without harming them, which maximizes the physical fidelity of the SBLE.

A variety of SBLEs reported using standardized patients coupled with monitoring equipment [3-7]. The addition of these elements yielded improved outcomes compared to comparison groups, including improvements in clinical decision-making [4-5] and interprofessional competencies [6-7]. Standardized patients were combined with mannikins or task trainers in labor and delivery simulations with positive learning outcomes [7]. Nursing students practiced intramuscular injections on a standardized patient wearing a foam model around the abdomen that allowed the students to inject the patient without potential injury to the patient [8]. This hybrid teaching method was compared with teaching the same skill via a computer-based simulation. Interestingly, the students had less anxiety and higher skill scores after participating in the computer-based simulation [8]. The results indicate that dedicated and repeated practice via a computer interface can translate to improved performance.

Computer-based Simulation in Health Professions Education

Computer-based simulation encompasses a wide array of SBLEs. It can include augmented reality, virtual reality, or a virtual case, which is an interaction with a patient via a computer interface. Augmented reality combines a virtual environment with a haptic interface. Nursing and medical education programs [9-17] have implemented augmented reality into SBLEs, but use in other health professions education programs [18-19] has been more limited. One of the largest constraints to using augmented reality is the expense of development, equipment, and maintenance.

Virtual reality allows the learner to become immersed in a virtual environment, navigating the environment as a patient or health care provider. Virtual reality has facilitated learning across broad domains, including but not limited to cultural empathy [20], interacting with patients with dementia [21], completing a home assessment [22], and assessing movement [23]. Learners enjoy participating in virtual reality activities, and there are positive learning outcomes after participating [20-23]. Similar to augmented reality, virtual reality can be expensive and time-consuming to implement, especially for large cohorts of students.

Other types of computer-based simulation incorporate a case study, with or without patient videos. The learner navigates through a patient's examination and/or intervention, receiving feedback on their decision-making. This type of computer-based simulation is more accessible to learners, as it is often delivered asynchronously and usually does not require special equipment or skills to work through the virtual case. Virtual cases have led to achieving interprofessional competencies [24-26], equivalent outcomes in clinical reasoning compared to usual instruction, and addressing learning needs around bias and racism [27].

Strategies to Incorporate Computer-based Virtual Cases into Hybrid Simulations

By combining two or more simulation modalities into a hybrid simulation, the educator can capitalize on different types of fidelity throughout an SBLE. While it is possible the perfect unimodality simulation can be created, it may not be practical. For example, it may not be feasible at times to convene large groups of students due to scheduling conflicts or large numbers. Time may also be a limiting factor, especially if the optimal SBLE requires allowing the learner extended periods of time to navigate through it. Using the same case across different simulation modalities can assist with reducing faculty load in developing simulation scenarios. The following list provides some examples where virtual cases can be combined with other simulation modalities to enhance student learning.

• A learner completes an assigned virtual case, navigating through all aspects of the case. They receive feedback on their clinical reasoning throughout. Soon after completing the virtual case, the learner performs all psychomotor aspects of the case on a standardized patient, which can be completed in a variety of ways. If time and space allow, the learners can complete the examination independently or in pairs in a simulated environment. If space or time are limited, then the learners can complete the examination in a classroom-based simulation [29]. Each learner or pair of learners can be responsible for 1-2 psychomotor components of the examination.

• A learner completes the virtual case, and instead of completing the components of the examination on a standardized patient, they complete the intervention plan. Multiple learners can demonstrate their intervention to plan, or a component of it, to the entire class.

• In this example, it is important that the selected case requires family teaching as part of the intervention plan. To begin, a learner or group of learners complete a virtual case on the same patient. They complete all aspects receiving feedback on their care. The additional component to the virtual case is completing the family training on a standardized patient (playing the patient) and embedded participant (playing the family member or caregiver). For example, a case where a patient had a stroke may require family teaching in car transfers, guarding on stairs, assisting during ADLs or cues for communication during training. The activity can be completed by one profession, or it can be completed as an interprofessional learning experience (i.e. physical therapy students focus on the mechanics of a car transfer while the speech-language pathology students assist with maximizing communication for a patient with aphasia).

• Each discipline (SLP, OT, PT) starts by completing an examination of the same virtual case but engages in their discipline-specific examination and evaluation process within the virtual case. The learner creates their patient management plan/plan of care and receives feedback on their choices to allow reflection and improvement. Then, outside of the virtual case platform, the trio of professionals engages in an interprofessional team meeting to discuss their plan and coordinate discharge. The interprofessional team meeting can be conducted in person or via a teleconferencing platform to facilitate ease of scheduling [28]. Debriefing of the entire activity occurs after the interprofessional team meeting.

While not an exhaustive list of opportunities, these examples provide options to maximize the use of computer-based simulations combined with other simulation modalities.

Hybrid Simulation Application: Hybrid DPT Program

An increasing number of hybrid Doctor of Physical Therapy (DPT) programs are being developed in the United States. Like a hybrid simulation, a hybrid DPT program combines two elements: online learning and in-person labs within a 2- to 3-year program. Similar to traditional DPT programs, a range of variability exists in the design of hybrid DPT programs. Some programs are constructed like traditional, systems-based programs where students learn about the anatomy, cardiovascular and pulmonary, integumentary, musculoskeletal, and neurologic systems in separate courses. Other programs follow a more integrated approach and lack traditional course silos. Typically, each semester contains a mixture of asynchronous and synchronous online learning opportunities. Onsite labs are interspersed in the middle and/or at the end of the semester, and they usually range from 1 to 2 weeks long. While most programs incorporate opportunities for learners to demonstrate skills during the online portion of the curriculum, the onsite labs are a chance for learners to engage in deliberate practice and receive targeted faculty feedback, especially on their psychomotor performance. The main benefits of a hybrid program are decreased cost and increased learner flexibility as it can be completed anywhere, anytime. This allows students, especially nontraditional learners, the flexibility to balance work and family obligations while pursuing a DPT degree.

Incorporating hybrid simulations into hybrid DPT curricula is a natural fit. Learners can work through computer-based cases during the online portion of the semester at their own pace while receiving meaningful feedback from the program and the faculty. Learners can repeat the case to improve their online-learning time, which has been shown to improve learning outcomes [30]. During the onsite labs, students can demonstrate components of the case or proceed through the case in its entirety. Integrating an example outlined above, a learner can complete the examination of one of the patients within a computer-based simulation system. They can hone their critical thinking skills and repeat the process until mastery occurs. When onsite, they can demonstrate their examination skills on a patient in a lab or classroom-based simulation, on a standardized patient, or using lower-fidelity, peer role-play. Repeating the same case streamlines the learning process for both students and faculty. It takes a lot of bandwidth for students to learn a new case, and developing a comprehensive case is time-intensive for faculty. In addition, it is difficult to expose all learners within a hybrid program to the same patient diagnoses. Using a computer-based simulation allows each learner to evaluate and treat the same patient, providing equitable learning experiences. It is important to pick exemplar cases that are representative of cases seen in clinical practice such as those available in Simucase®. Simucase is a computer-based simulation platform that provides students with experiences designed to teach complete processes using video-recordings of client scenarios [31].

Appendix 1 includes a sample curriculum for a full Cardiovascular and Pulmonary Physical Therapy course within a hybrid DPT program that combines Simucase computer-based simulations and video content with other SBLE. The curriculum describes course track, learning objectives, and scaffolded examples for practical application. Figure 1 provides an example of the sample hybrid curriculum for course topics: vital signs, auscultation, and breathing patterns.

Figure 1. Hybrid curriculum assignment ideas that incorporate Simucase computer-based simulations and videos

Summary

Simulation-based learning experiences help lessen gaps in access, opportunity, and experience for learners. By including computer-based simulation as part of a hybrid simulation curriculum, learners bridge from theoretical knowledge to clinical understanding. Learners participating in hybrid simulation have less anxiety, [8] facilitating their ability to focus on the clinical encounter, which allows them to recognize potential errors and ameliorate them. Maximizing use of computer-based simulations as part of SBLEs is a critical step for improving clinical decision-making by augmenting opportunity for both practice and reflection. Infusing hybrid simulations into hybrid curricula allows opportunities to target and focus learning at different times in a semester, thereby maximizing learning potential.

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