An Inter-Professional Education Experience Between Physician Assistant and Physical Therapy Students Utilizing Standardized Patients: A Technical Report > The Society for Simulation in Healthcare

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An Inter-Professional Education Experience Between Physician Assistant and Physical Therapy Students Utilizing Standardized Patients: A Technical Report

Julie M Skrzat PT, DPT, PhD, CCS1, Jason Konzelmann BS, NR-P2, Melissa Carabba BS3,
Melissa Brown MSPAS, PA-C4, Melissa Gilroy DC, MSPAS, PA-C4, Kathleen Ehrhardt MMS, PA-C4, Stephen J Carp PT, PhD, GCS1

1 Physical Therapy Program, DeSales University, Center Valley, PA
2 Simulation in Healthcare Programs, DeSales University, Center Valley, PA
3 Simulation in Healthcare Programs, DeSales University, Center Valley, PA
4 Physician Assistant Program, DeSales University, Center Valley, PA

Work should be attributed to Physical Therapy, Physician Assistant, and Simulation in Healthcare Programs at DeSales University, Center Valley, PA.

Corresponding Author:
Julie M Skrzat PT, DPT, PhD, CCS, Physical Therapy Program, DeSales University, Center Valley, PA (Email: julie.skrzat@gmail.com)

Abstract

Introduction: Healthcare simulation is being used to promote inter-professional education (IPE). While literature discussing simulation experiences between physician assistant (PA) and physical therapy (PT) students is limited, it is of importance that each discipline learns the value of the other, as both are assuming a more critical role in acute-care discharge planning. The purpose of this paper is to describe an IPE methodology developed to provide PA and PT students an opportunity to collaborate on implementing a comprehensive plan of care, including discharge location, utilizing standardized patients.

Methods: The methods were divided into three parts: inter-departmental collaborations, standardized patient utilization, and use of an electronic management system (EMS).  Four clinical cases, as acted out by standardized patients, were developed.  Twenty-eight PT students and eighty PA students participated in the IPE as part of the respective curricula. 

Results: Faculty and staff from two professional healthcare programs and SIM Center successfully implemented the institution’s first simulation IPE experience. Objectives, schedules, and clinical cases were collectively developed. Twelve standardized patients participated in the entirety of the IPE. Lastly, the EMS housed all information and captured audio and visual data without difficulty. 

Conclusion: As a result of collaboration and communication between multiple programs, the IPE experience using standardized patients was successful.  It facilitated teamwork between students of two disciplines to develop a comprehensive plan of care and discharge plan, optimizing patient outcomes.

Introduction

Healthcare simulation (sim) is defined as “a technique to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner”1, allowing assessments of students in multiple domains.2 One mode of simulation is the use of standardized patients (SPs), who are trained to play the same diagnostic role, with or without specific behavioral characteristics, with the expectation of a predictable performance, increasing internal validity.3SPs are very accurate in their presentations of cases, both in providing detailed medical histories and physical examination findings.4Additionally, SPs’ roles can be tailored to accommodate the students’ level of skill and knowledge.3This is compared to an actual patient, where the students may need guidance from their clinical supervisor depending upon the students’ placement in the curriculum.SPs allow the students’ experiences clinical and administrative situations found in real life practice and which may not be encountered in shorter clinical internships.5 For these reasons, SPs in clinical healthcare simulations are described as a valuable and effective resource for teaching and assessing communication and physical examination skills in medical students. 6,7

Since the 1960s, simulation has served as an adjunct to medical education, being integrated into various medical specialties.8 Other healthcare disciplines, including physician assistant (PA) and physical therapy (PT) programs, more recently began following suit.

SPs were introduced into PA curricula in the late 1990s, with the addition of an objective structured clinical examination (OSCE) for formative evaluations as a part of a program’s physical examination course.9 Coerver, et al. reported that the use of SPs was the most common simulation modality used in PA curricula, with the primary aim to train students in medical knowledge through summative assessments.10,11

While a valuable teaching and learning tool6, the effects of the incorporation of SPs in to PT education are not clear.7 Historically, SPs have commonly been integrated into PT clinical scenarios that take place in the acute care setting.This is because PT students generally have the greatest challenge in adapting to the acute care environment, which is compounded in the intensive care unit (ICU).12 Therefore, simulation experiences allow the PT students to be immersed in the complex clinical scenarios to develop interpersonal skills, clinical decision-making, and physical therapy management without risk to an actual patient.12

While each discipline has used simulation independently, simulation is now being used to promote inter-professional education (IPE).IPE “occurs when two or more professions learn with, about, and from each other to enable effective collaboration and improve health outcomes”13, which is enforced by The Institute of Medicine’s Health Professions Education Summit.14 PA students most commonly participate in IPE with medical students and nurses, with the primary competency being interpersonal communication skills.10PT students have participated in simulation with nursing students to examine student attitudes toward inter-professional collaboration and inter-professional learning15, and social work and nursing students to explore the ability to communicate and use clinical thinking to make a safe and appropriate inter-professional discharge recommendation.16Lastly, Wise, et al. conducted a survey to understand data on current and projected IPE initiatives within PT education.17 The results showed that 58.5% of the 106 respondents reported that IPE was a focus of their physical therapist education curriculum; 46.2% identified IPE as a focus of their institution and supported by the institution’s strategic plan, mission, or vision. 17

Literature discussing simulation experiences between PA and PT students is limited to assessment of cross-cultural experiences via IPE modules18 and use of a computer-based virtual patient to collaborate and develop an appropriate treatment plan.12 It is imperative that PAs and PTs learn the value of each other’s discipline, as each discipline is assuming a more critical role in acute-care discharge planning. PAs have greater content knowledge related to pathology, diagnostics, clinical interventions, and medications while PTs have unique content knowledge related to function, functional prognosis, functional needs, and site-specific disposition requirements.The purpose of this paper is to describe our simulation inter-professional education (Sim-IPE) methodology, which was developed to permit PA and PT students an opportunity to independently assess SPs and collaborate on findings to come up with a comprehensive, interdisciplinary care and discharge plan.

Methods

The DeSales University’s Institutional Review Board approved this study.  The methods are divided into three parts: 1) inter-departmental collaborations, 2) standardized patient utilization, and 3) use of an electronic management system.

1. Inter-departmental Collaborations

Three PA faculty, two PT faculty and two simulation center staff met biweekly for eight months prior to implementation of the encounter to develop a) Sim-IPE objectives and corresponding clinical cases, b) encounter design (summative vs. formative) and c) schedules for 80 first year PA students and 28 second year PT students. The overarching goal was to provide an authentic experience with a simulation modality that would meet the learning objectives assigned to the encounter by both departments.

1a. Objectives and Case Development

The aims of this Sim-IPE were to assess if there is a difference in 1) discharge location between PA and PT students, 2) priorities when making discharge location recommendations between PA and PT students, and 3) culture, perception, and appreciation of the other discipline after an inter-professional interaction. These aims were developed based on where the students were in the didactic portion of the curriculum and feedback from clinical rotations.

The objectives were to be met by twelve SPs acting out one of four clinical complex cases, with admitting diagnoses of normal pressure hydrocephalus, septic joint leading to endocarditis, cerebrovascular accident, and pneumonia superimposed on chronic obstructive pulmonary disease. The diagnoses were chosen because of the medical complexity and necessity to consult PAs and PTs. Inpatient medical charts were developed by PA and PT faculty, with one faculty member being the primary author for one chart. Charts were then cross referenced by a minimum of one faculty member from within and between the other department for accuracy and face validity. Medical charts included an admission note, daily notes from a minimum of four disciplines appropriate for the case (including PA and PT), diagnostic testing and imaging results, daily lab values, vital signs, and medical orders that followed that patient’s progress for at least 3 days after admission.  Paper charts were placed in binders for PT students. Electronic charts were placed in SIMULATIONiQÒ for PA students. This difference was to accommodate scheduling logistics.

1b&c. Encounter Design & Scheduling

The encounter was divided into three phases: individual discipline’s assessments, Sim-IPE experience, and debrief.  The only summative component was the individual PT assessment, which was counted as the students’ final lab practical in their course.  Otherwise, it was a formative experience.

Individual Discipline’s Assessments

Encounters occurred on 2 days per week over 4 consecutive weeks. This was done to accommodate intra-departmental didactic schedules, as each cohort of students had limited availability. On Day 1, 8 PT students completed an individual treatment session with the SP.  Each PT student had one hour to read the case and develop a plan of care, followed by a one-hour SP encounter, and 30 minutes to document a daily SOAP note.

On Day 2, 20 PA students completed their SP assessment. In contrast to the PT students, each PA students saw three patients.  PA students were granted access to their patients’ charts 24 hours in advance, and were allotted 12 minutes per patient encounter to examine and assess the patient’s current status. The PA students did not document their findings. This was designed to parallel clinical practice, with the idea that the PA students were evaluating their assigned patients ahead of morning rounds.

All encounters were 1 student to 1 SP.  The PT students’ schedule and the PA students’ schedule for individual encounters with the SP can be found in Table 1 and Table 2, respectively. After individual encounters, all students completed a survey indicating their recommended discharge location and ranked factors contributing to their decision.  Additional outcome measures were also completed.

Sim-IPE Experience

Upon completion of all individual encounters, a PT student was paired with 2-3 PA students to discuss their individual findings and develop a unified discharge disposition. These “healthcare teams” were assigned by faculty based on the common case between participants. Healthcare teams representing each case then participated in clinical rounds with their “attendings” (PA and PT faculty) and SPs.  During the rounds, each healthcare team presented their findings, explained the rationale for the disposition recommendation, and answered case specific questions.  Additionally, respective SPs participated in an abbreviated bedside assessment and discussion, and were asked hospital discharge related questions designed to replicate the type of teaching seen in morning rounding on a clinical floor.  

Debrief

After completion of clinical rounds, all students and faculty gathered for a group debriefing on the SIM-IPE experience.  A standard group of 6 questions, as developed by the faculty, were posed to the group inquiring about learning and collaborative opportunities. A sample schedule for the IPE experience is found in Table 3.

2. Standardized Patient Utilization

Once the cases were developed, the simulation staff hired SPs to fulfill the roles.  Due to the volume of work and intricacy of four distinct cases over multiple weeks, 12 SPs, with 3 assigned to each case, were contracted.  SPs were men and women and were between 32 and 88 years of age with an average age of 66 years, and had tenure of 5.6 years of experience as SPs.  SPs received a copy of the assigned case and participated in approximately 12 hours of training with PA and PT faculty and simulation staff.  The first training (~ 8 hours) was a reading of the case and round table discussion with the primary authoring faculty member to familiarize themselves with the case and answer questions related to the medical and social history.  The second training (~ 4 hours) was a dress rehearsal in the acute care environment, with hospital gown, moulage, and applied lines / tubes / drains.  During this time, PT faculty met with the SPs from each case to discuss psychomotor and affective presentations. Overall, the total number of hours, including training and encounter, committed by all SPs for this experience was 352 hours.

3. Use of an Electronic Management System

SIMULATIONiQÒ (Education Management Solutions, Exton, PA), was the software used for a) scheduling the students, b) recording SP and student encounters, and c) electronic documentation.

3a. Scheduling the students

SIMULATIONiQÒ randomly scheduled all students into time slots, which also randomly assigned them to clinical cases. Specific to the PT encounters, they were summative so strict scheduling was mandatory. Since the timing was different for the PA and PT encounters, two different cases needed to be created in the software for each of the disciplines.

3b. Recording

SIMULATIONiQÒ has a built-in, ready-to-use recording feature, which timed and recorded all individual patient encounters for the PA and PT students. Recordings allowed the faculty members to watch student performance in real time, and review afterwards if necessary.  Additionally, the software allowed the students to self-evaluate their performance post-encounter, permitting inquiry and reflective thinking for students’ learning.19

Other recordings included the clinical rounds and debriefing.  The rounding experience was recorded onto SD cards using a standard handheld camcorder. One case per week was recorded, largely for qualitative reflection and analysis. The debriefing was video and audio recorded using Panopto (Seattle, WA) because the space in which the debriefing was held was not covered within the SIMULATIONiQÒ system. The only portion of the Sim-IPE that was not recorded was the collaboration period between PA and PT students, as was not recorded anywhere because we wanted to students to work, think, and discuss without fear of being watched.

3c. Electronic Document Access

Upon completion of the patient medical charts, they were uploaded to SIMULATIONiQÒ, where PA students accessed them prior to their individual encounter. By using a centralized system, faculty and staff were able to maintain integrity of the cases, as well as track when or if students accessed their respective cases. Additionally, PT students wrote a treatment note, which were part of their summative encounter, in SIMULATIONiQÒ. Afterwards, notes were printed and graded by faculty. Lastly, SIMULATIONiQÒ provided a stable and reliable platform to compile, store, and evaluate data related to additional outcome measures.

Results

Faculty from two professional healthcare departments and SIM staff successfully implemented the institution’s first Sim-IPE experience.  Together, mutual and discipline-specific encounter objectives, schedules to accommodate an uneven distribution of students, and clinical cases were developed.  All twelve SPs participated in the entirety of the Sim-IPE.  They were successfully trained in their respective cases, underwent multiple training sessions with faculty and staff, and portrayed the character accurately.  The electronic medical system housed all information (including electronic medical records, questionnaires, student documentation) and captured and archived audio and visual data without difficulty. Lastly, and most importantly, students found the experience to be beneficial to their learning. In the debriefs, the students unanimously commented that they learned from and with each other in an authentic clinical experience. By having a one-on-one simulation encounter, they were able to take ownership of the patient’s care and, therefore, have active meaningful dialogue with their counterpart. Further results can be found in Carp, et al. Journal of Interprofessional Education & Practice, 2020.

Discussion

This was the first Sim-IPE experience at our institution.  The experience involved individual discipline assessments of SPs with the primary objective to determine an appropriate discharge disposition.  By creating the Sim-IPE experience around the objective, communication between disciplines was necessary. 

The first benefit of our design was that the students had similar experiences thus far in each of the curricula.  Both disciplines had completed the majority of their didactic curriculum, with both having minimal clinical experiences.  PA students had had integrated clinical experiences, which involved three semesters of four hours / week, however considering that this was part of their didactic year, was mostly observation.  PT students had completed one outpatient orthopaedic clinical experience. 

Secondly, the methodology promoted effective communication, and ultimately learning, between students of each discipline.  This granted greater autonomy and ownership of the patient’s care to the students, compared to a faculty member facilitating the discussions.

An unexpected occurrence was that the SPs became a support system within themselves.  When not actively participating in an encounter, the additional SPs would watch live feed of individual encounters.  This allowed them to learn and improve their own skills, provide feedback to each other, and collectively problem solve, as each brought personal healthcare experiences to their acting.

While we consider our institution’s first Sim-IPE experience a success, it was not without three basic challenges.  First, faculty had to create a scenario where PA and PT would realistically interact.  Second, the authenticity had to be maintained despite a discrepancy in class sizes and within the confines of academic schedules, as both cohorts of students were still engaged in curricula.   Lastly, identification of common time for faculty to meet and evolve the Sim-IPE experience was challenging.  Neither set of faculty were provided buy out for their contributions to the project.           

Future directions of Sim-IPE are dependent on expansions into education and research.From an education perspective, Sim-IPE should involve students of multiple disciplines placed in various healthcare situations, both clinical and non-clinical. The simulations should occur in multiple clinical settings.From a research perspective, further work is needed to identify the most effective methodology, including most appropriate simulation technique, electronic management system, and outcome measures.

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