Effectiveness of high fidelity simulation versus low fidelity simulation on practical/clinical skill development in pre-registration physiotherapy students: a systematic review.

OBJECTIVE: The objective of this review is to evaluate the effectiveness of high fidelity simulation (HFS) versus low fidelity simulation (LFS) on practical/clinical skill development in pre-registration physiotherapy students.
INTRODUCTION: Evidence suggests that improved skill development in university can reduce anxiety in practice, improving performance of skills and overall learning at clinical placement for health professions students. However, evidence indicates that the clinical environment is most effective for learning. As a result, there has been increased interest in the use of HFS where students can test knowledge and skills in an increasingly self-directed way. No previous reviews on the effectiveness of HFS on skill development in physiotherapy students were identified. INCLUSION CRITERIA: Experimental and quasi-experimental studies comparing HFS (simulated person, manikin, virtual simulation, video case-studies) to LFS (peer role-play, paper-based case-studies) in pre-registration physiotherapy education were included. Primary outcomes were objective measures of skills performance; secondary outcomes were students' perceptions of the impact of simulation on learning measured using quantitative outcomes.
METHODS: A three-step search strategy was employed. Following an initial search of MEDLINE and CINAHL and analysis of text words, MEDLINE, CINAHL, ERIC, AMED, EThOS and Google Scholar were searched in November 2017. Reference lists of studies included at critical appraisal stage were hand-searched. Studies published in English from 1978 onwards were included. Title/abstract screening, critical appraisal and data extraction were conducted by two independent reviewers; conflicts were resolved by discussion.
RESULTS: Meta-analysis was not possible due to heterogeneity; therefore, results were presented in narrative form. Three randomized controlled trials (RCT) and three quasi-experimental studies (310 participants) were included. They were conducted in the USA and Australia, and evaluated standardized patients (people who take on the role of a real patient), near-peers, computerized manikins and virtual simulation in pre-registration Bachelor of Science (Honors), Master of Science and Doctor of Physiotherapy students. One RCT was considered high quality, with the remainder moderate quality. The findings related to five main areas: i) In terms of motor skills performance, an increased number of safety fails were found with HFS (HFS = 13.5% safety fails, HFS plus video feedback = 15.4% safety fails, control [LFS] = 8.1% safety fails); ii) In terms of clinical performance, the Assessment of Physiotherapy Practice (APP) tool indicated no significant improvement in mean APP scores at week 6 of clinical placement (HFS mean APP score = 60.7 [9.1], control mean APP score = 58.7 [8.4]; P = 0.35); iii) In terms of self-efficacy, only one of two studies showed a statistically significant difference with HFS, as measured by the Acute Care Confidence Survey (P = 0.001); however, became non-significant once students were on clinical placement (P = 0.328); iv) Students did not perceive a significant difference in their communication skills with HFS, as measured on a visual analogue scale (simulation = 9.05 [1.27]; control 8.75 [1.2]; P = 0.482); and v) In terms of general perceptions, students were significantly more positive about HFS for increasing awareness of safety issues (P = 0.002), patients' emotional status (P = 0.002), handling skills (P < 0.0001) and ability to provide instructions to patients (P < 0.0001).
CONCLUSIONS: Currently, there is no high quality evidence that HFS improves motor skill performance in pre-registration physiotherapy students. There is a small amount of moderate-quality evidence it may improve students' perception of their self-efficacy but no evidence that it improves communication skills. However, a lack of studies and variation in outcome measures meant that meta-analysis was not possible. At present, no recommendations can be made regarding the use of HFS to improve skill performance in this population.