The effect of simulation-based education on student self-efficacy in the physiotherapy assessment and management of paediatric patients: An observational study

The Australian Physiotherapy Council mandates that physiotherapy clinical education be sufficient to produce graduates who are competent to practice across the lifespan. Due to a lack of opportunities for paediatric clinical placements, there is a risk of graduates not having the opportunity to develop competency in paediatric physiotherapy. To address this risk, simulation-based education (SBE) has been proposed as an additional educational strategy, and despite encouraging evidence for its use in physiotherapy education, there is limited evidence supporting its use specifically in paediatric populations. The aims of this research were to investigate the effect of SBE on student self-efficacy in the physiotherapy assessment and management of paediatric clients, and to determine student satisfaction with SBE as a learning strategy. Three interactive SBE sessions were run during the undergraduate paediatric physiotherapy unit at the campus of one Australian university. Self-efficacy was surveyed before and after each session, to determine confidence in clinical skills, clinical decision-making, treatment preparation and planning, communication skills; evaluating and modifying interventions, and interprofessional practice. Student satisfaction with SBE as a learning strategy was surveyed after the final SBE session. For the 164 participants included in this study, self-efficacy survey response rate varied from 77-96% for each session. Significant increases in mean student self-efficacy were recorded for all questions (p<0.001). A total of 139 (85%) responded to the reactionnaire with 78.6% indicating they were very satisfied with SBE as a learning strategy. Written comments from 41 participants identified ‘experience’ as the primary theme. Conclusion: SBE had a significant positive effect on student self-efficacy in the

3 physiotherapy assessment and management of paediatric clients. Students also perceived SBE to be a valuable learning experience. Future research is needed to investigate whether SBE improves student performance and how SBE compares to standard educational methods.

Background
In physiotherapy undergraduate courses, clinical education constitutes approximately a third of the program, with students spending between 900-1000 hours in supervised clinical time with patients. This professional practice component is required for program accreditation by the Australian Physiotherapy Council (APC). (1) Clinical education relies on the availability of a diverse range of patients, however the scenarios students are exposed to vary depending on the patients present during the placement.(2) Individual learning experiences vary in this model, creating learning environments which may be opportunistic, unstructured and disparate.(3) Furthermore, students may get inadequate exposure to higher risk patients, resulting in additional missed learning opportunities. (4) In addition to these challenges, paediatric placements are limited due to a lack of suitably qualified paediatric physiotherapists to act as educators.(5) Students may therefore not have the opportunity to develop competency in paediatric physiotherapy practice prior to registration as a physiotherapist, despite the APC's requirement for development of competency across the lifespan. (1) To address the limitations of clinical education in general, and more specifically in paediatric physiotherapy education, simulation-based education (SBE) has been proposed as an additional educational strategy. SBE attempts to replicate real-life 4 experiences through simulated scenarios, environments or patients, creating a safe environment where clinical confidence and competence can be developed. (6,7) With SBE, learning experiences can be tailored to specific learning objectives and can be set up on demand, eliminating the dependence on patient availability. (2) If implemented successfully, SBE can guarantee provision of consistent and diverse learning experiences and include exposure to scenarios that are clinically uncommon, promoting a more equitable learning experience for all students.
SBE has been shown to be an effective method for learning a range of physiotherapy skills, including hands-on (2,(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19) and interdisciplinary skills (including teamwork and communication). (20)(21)(22)(23)(24)(25)(26)(27) Up to 25% of clinical placement experiences may be replaced by SBE without compromising student learning. (28,29) Changes to student attitudes have also been reported following SBE, (30)(31)(32)(33) including improved motivation to learn (30) and improved awareness of physiotherapy core values. (32,33) Students have generally viewed SBE as a positive learning experience (2,15,20,25,(34)(35)(36)(37)(38)(39)(40) and while this does not equate to an actual learning effect, it may influence motivation to learn. (41) Improved levels of student self-efficacy have also been demonstrated with SBE, (28, 29, 32, 36-40, 42, 43) where self-efficacy is defined as an individual's personal judgment in their own ability to successfully accomplish a task.(44) Self-efficacy is a key attribute in professional practice as there is a demonstrated relationship between self-efficacy and work-related performance, such as performance in clinical environments. (45) Despite this encouraging evidence for the use of SBE in physiotherapy education, there is insufficient evidence supporting the use of SBE specifically in paediatric populations. Considering the limited clinical learning opportunities available in paediatric physiotherapy, it is important for alternative methods of education to be considered. Therefore, the primary aim of this study was to investigate the effect of SBE on student self-efficacy in the physiotherapy assessment and management of paediatric clients. A secondary aim of this study was to determine student satisfaction with SBE as a learning strategy.

Methods
This study was a prospective, observational study using self-efficacy questionnaires and a reactionnaire to survey student satisfaction with SBE as a learning strategy.

Participants
Students studying physiotherapy at an Australian university campus were eligible for admission to the study if there were enrolled in the Paediatric Physiotherapy Practice unit of study in 2014 or 2018 and consented to participate. Students who have previously attended any classes in the Paediatric Physiotherapy Practice unit (or equivalent) were excluded from the study.
Written consent was obtained prior to commencement of the first scenario. Human Research Ethics clearance was obtained through the institute HREC committee (2018-56E).

Outcome Measures
The primary outcome measured in this research project was student self-efficacy in the physiotherapy assessment and management of paediatric patients. Student selfefficacy was measured using a self-efficacy questionnaire currently used throughout Self-efficacy questionnaires were completed by participants in the first 5 minutes of 7 each session and were collected prior to commencement of the scenario. A second, identical questionnaire was given to each participant at the completion of the SBE scenario. At the completion of the final SBE session the reactionnaire was also given to participants and collected as students left the session. All questionnaires were given in paper format.

Statistical Analysis
To analyse the pre-post differences in self-efficacy for each of the three scenarios, a Wilcoxon Signed Ranks Test and a descriptive statistics report was undertaken using IBM SPSS Version 25 (IBM Corp, Armonk, NY, USA). A p-value of 0.05 was considered significant.
To report student satisfaction with SBE, descriptive statistics were used to report on quantitative data and a thematic analysis with Leximancer software Leximancer (Leximancer Pty Ltd, Brisbane, Australia) was used to report qualitative data.

Results
From the cohort of ninety-two (92) students enrolled in the Paediatric Physiotherapy Practice unit in 2018, 1 student was excluded due to previous enrolment and 1 student declined to participate, 86/90 students (96%) completed both pre and post SBE questionnaires for SBE scenario 1, 82/90 students (91%) completed both pre and post SBE questionnaires for scenario 2, 77/90 students (86%) completed both pre and post SBE questionnaires for scenario 3, and 77/90 students (86%) completed the learning reactionnaire. scenarios (cardiorespiratory and neurological). Question 4 also had the highest number of total negative ranks (10) and ties (147) recorded across all scenarios (Table 4).

Student Satisfaction with SBE as a Learning Strategy
There was a total of 139 responses to the reactionnaire, 62 (83.8%) in 2014 and 77 (85.6%) in 2018 (Table 5) were more confident with their communication and interpersonal skills prior to SBE as they have had the opportunity to develop these skills throughout the early years of their program of study. Furthermore, it is possible that additional learning experiences may be required to realise changes in these more well-developed skills.
It is also possible that these smaller improvements to communication and interpersonal skills can be explained by a ceiling effect, given students' higher initial levels of confidence.
A lack of confidence working with children has been reported to be a barrier to graduates seeking employment in paediatric physiotherapy, and evidence suggests 11 confidence in graduate paediatric physiotherapists is directly related to competence in communication skills.(48) Therefore, confidence in communication is particularly important for graduates seeking employment as a paediatric physiotherapist.
Although the questions relating to communication skills (4 and 7) had the smallest improvements in self-efficacy, they were still statistically significant and the majority of students (64.9%) reported scores of 3 or higher after SBE, indicating that they had at least "a lot" of confidence in their communication and inter professional skills. It seems that the SBE has provided a level of confidence in communication skills which may aid reduction of the barriers to working in a paediatric context.

Student Satisfaction with SBE
The secondary aim of this research project was to determine student satisfaction with SBE as a learning strategy. The response was positive, with most students considering that SBE met their style of learning, promoted self-directed learning, delivered evidence-based principles of paediatric physiotherapy, assisted in retention of paediatric physiotherapy, provided an ideal learning environment, and provided incentive for further skill development in paediatric physiotherapy. Only one student thought that SBE provided no incentive at all for further skill development in paediatric physiotherapy. These findings are consistent with two systematic reviews, which concluded that SBE is generally well received by students and an experience valuable to learning. (2,8) The positive findings observed in the quantitative results were reflected by students' comments. The thematic analysis identified that students found SBE to be a beneficial and enjoyable learning experience.
Overall, the student response to SBE was positive, and if students respond well to this method of learning, it could suggest they are more likely to be engaged with the learning experience and be more motivated to learn. (41) Translation to Performance While the improvements to self-efficacy observed in this study are significant, these improvements may not translate to an improved level of clinical performance. The self-efficacy questionnaires provide a measure of perceived confidence in students' knowledge, skills and attitudes, demonstrating that they have achieved a degree of model. (46) There are well-established links between self-efficacy and work-related performance (45) so it is reasonable to suggest that students who demonstrated improvements in self-efficacy following SBE would have improved performance following SBE. Previously, SBE has led to significant improvements in student performance, (28,43) improved patient care and better patient outcomes, (49) strengthening the suggestion that these improvements to self-efficacy may translate to improved performance with real patients. However, students who receive SBE also may be more likely to overestimate their ability (50) and are likely to be less realistic in their self-evaluation in a simulated environment.(32) Therefore translation to improved performance should not be assumed based on these selfreported measures alone.
To measure performance, student behaviour would need to be evaluated in a standardised or clinical environment. There are established instruments for measuring performance, such as the validated Assessment of Physiotherapy Performance (APP) (51) or the Physical Therapy Clinical Performance Instrument (PT 13 CPI). (52) The APP is currently used by Australian universities to evaluate the performance of students on clinical placement and has been used in other studies examining the efficacy of SBE. (28,29,43,50,53) In two previous studies, students who participated in SBE achieved superior grades, measured through their performance in the APP. (28,43) It would be beneficial to conduct a follow-up study to determine if there are similar differences in student performance for this student group.

Limitations
Although clear improvements to student self-efficacy following SBE were observed in this study, there is no comparison to standard educational methods. Without this comparison, it is not possible to determine whether the educational benefit gained from SBE differs from standard curriculum. This is especially important given the high cost of SBE, which is often a barrier to its implementation. (54) Students completed their self-efficacy questionnaires immediately after the SBE scenarios ended, meaning that the results only reflect the short-term effect of SBE.
Although some students commented that they felt SBE improved their retention of paediatric physiotherapy, without further investigation it is not possible to determine if SBE had any long-lasting effects. There is also no measure on actual student performance.
By comparing APP results of paediatric placements, we could investigate if there is any difference between the performance of students who participated in SBE and those who received standard curriculum, as well as gain information on the longterm effects of SBE, as clinical placements occur months after the SBE ends.
There is no information on whether SBE changed students desire to work in paediatric physiotherapy in the future. Results from reactionnaire Question 6 14 (incentive to develop skills further in paediatric physiotherapy) offers some support for this, with 82% responses recorded as "a lot" or "totally", demonstrating that students had incentive to further develop paediatric physiotherapy skills following SBE. However, this does not mean students would pursue paediatric physiotherapy opportunities. To get a better indication of this, it would be beneficial to ask students if SBE has increased the likelihood of them pursuing a career in paediatric physiotherapy or requesting a paediatric placement in future research in this area.
Only undergraduate university students were included in this study, so results should not be extrapolated and applied to other populations such as junior, employed physiotherapists. Furthermore, participants were all from one campus of one Australian university and may not accurately represent students of other campuses or Australian universities.

Conclusion
The results of the self-efficacy questionnaire were clearly positive, with significant improvements to student self-efficacy post SBE recorded for every question, indicating that SBE has a positive effect on student self-efficacy in the physiotherapy assessment and management of paediatric clients. Students also reported that they found SBE to be a valuable learning experience.

Consent for publication
All participants of this study provided written consent through the abovementioned form to the possible publication of their data.

Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.