Teaching Physiotherapy Students to Provide Feedback Using Simulation

Healthcare professionals are responsible for providing education to both healthcare consumers and the peers with whom they work. As such, specific teaching skills must be developed during prelicensure training to facilitate the transition from classroom to clinical practise. The realistic environment that simulation-based learning (SBL) activities utilise is a powerful enabler of translating theory to practise. The aim of this study was to explore the experiences of prelicensure physiotherapy students acting in either peer teacher or peer learner roles during a peer-assisted learning (PAL) activity delivered using SBL. Following preparatory training, over two days in 2018, a group of six final-year physiotherapy students (peer teachers) taught concepts around communication to a group of 126 of their junior physiotherapy colleagues (peer learners) during an SBL activity. Data were collected from all participants using written reflections (peer teachers) and the “Measure of quality of giving feedback scale” (peer learners). Three themes emerged from open coding of written reflections: preparation and training, perceptions peer teachers held of themselves as teachers, and perceptions peer teachers held of their learners. These themes are described with verbatim quotations used to support coding choices. Peer teachers reported value from the training and teaching experiences and felt they met the challenges of peer teaching, particularly with respect to being adaptable to learner performance. Peer learners rated the feedback quality highly with frequencies of responses demonstrating an overall mean score of 6.3 out of a possible 7 (SD1.1) for all scale questions. Peer-assisted learning using simulation was a positive experience with a perception of reciprocal benefit from both groups. Introduction The ability to apply adult learning principles to facilitate learning by clients and their family members, other health professionals, peers, and students is a core competency for physiotherapists (Physiotherapy Board of Australia & Physiotherapy Board of New Zealand, 2015). Consequently knowledge of adult learning principles and development of teaching skills must be part of prelicensure physiotherapy training (Tai et al., 2016). One method of developing knowledge and skills in adult learning approaches is through peer teaching, whereby senior students engage in teaching junior students. For example, it has been identified that up to one third of medical students’ knowledge is attributable to junior doctors (Bing-You & Sproul, 1992) spending significant time with students teaching skills and providing feedback (Bardach, Vedanthan, & Haber, 2003). Assessing and providing feedback to peers offers cognitive benefits that result in deeper learning (Heckmann et al., 2008; Yu et al., 2011) as well as enhanced confidence (Ten Cate & Durning, 2007). Dennis, Furness, Hall-Bibb, and Mackintosh 37 Peer teachers need to develop their feedback skills. Feedback needs to be constructive, effective, timely, and in context to be useful to the learner. Those giving feedback require an ability to “think on their feet” and use active listening and questioning skills to promote learner self-reflection and insight (Chowdhury & Kalu, 2004). The key skills are to listen and ask, not to tell and provide solutions (Nestel & Kidd, 2005). Training programs on how to give feedback are essential for healthcare professionals to ensure that learning is facilitated and that learner confidence is not undermined (Nestel & Kidd, 2005). Learning experiences that require giving feedback to peers will also improve employability skills of both peer learners and peer teachers, such as problem solving, decision making, and effective communication (Cassidy, 2006). Peer teaching may be further enhanced if it is combined with simulation-based learning (SBL) activities. This modality is particularly relevant to students about to embark on their clinical career, with realistic immersive environments enabling the translation of theory to practise (Weller, 2004), and the development of self-reflection on performance through debriefing (Kneebone & Nestel, 2005). Most published evaluations of peer teaching have been within medicine (Burgess & McGregor, 2018). Building on a previous study (Dennis, Furness, & Parry, 2017), the current study aimed to (1) explore peer teachers’ experiences of providing feedback and (2) ascertain peer learners’ satisfaction with feedback when a group of final-year physiotherapy students undertook peer teaching of an SBL activity with more junior physiotherapy peer learners. Method Participants There were two groups of participants: peer teachers and peer learners. The peer teacher participants were six final-year Curtin University (CU) physiotherapy students who volunteered and consented to take part in the project as part of a self-directed fieldwork placement. These peer teachers were from Curtin University as this was the coordinating site for the project, and all had experience with simulation-based learning throughout their curriculum. The peer learner participants were physiotherapy students from Bellarmine University (BU) and the University of South Australia (UniSA) who were undertaking pre-clinical learning experiences and were in either their first or second year of study. All students in the relevant classes at BU or UniSA participated in the SBL activity as a compulsory part of the curriculum; however, only those who gave written informed consent were included in data collection. Ethical approval and participant consent This study was approved by the CU ethics committee (HRE2018-0036), as well as relevant ethics committees from Bellarmine University and the University of South Australia. All participants who completed the data collection aspects of the study provided written informed consent prior to participation. Participation or non-participation in the study had no effect on the students’ results for the course. Procedures Peer teachers were trained for the SBL activity. Prior to delivering the SBL activity at BU and UniSA, peer teachers were trained using a self-directed online learning module. This module was made up of four key components: adult learning, the provision of effective feedback, simulation as a teaching Dennis, Furness, Hall-Bibb, and Mackintosh 38 modality, and debriefing with good judgement in SBL. On completion of the module, there was a test of key learning outcomes. Successful progression to the next stage of training required achieving a score of 80% or above. In the final stage of training, the peer teachers practised debriefing the activity. This was undertaken using archived video recordings of previous iterations of the exercise. Peer teachers watched and practised debriefing actual scenarios and were coached in doing so, using the “see one, do one, teach one” surgicaltraining model (Kotsis & Chung, 2013). Peer teachers were taught how to deliver the SBL activity. The SBL activity was an established Curtin University teaching activity that involved junior physiotherapy students (peer learners) undertaking a subjective examination of a patient with elbow pain. During the subjective examination, the patient enacted an attitude or behaviour that provided a communication challenge; for example, a very chatty person constantly went off topic. Peer learners undertook the task in small groups of three to four members. The simulated clinical encounter was AV recorded, and debriefing and feedback from peer teachers occurred with review of the AV recording. Each peer learner group undertook two subjective examinations. More detail of the model of this SBL activity is described elsewhere (Dennis et al., 2017). Although the SBL activity was already familiar to the peer teachers—as they had participated as learners two years prior—they were unfamiliar with how to deliver it as peer teachers. They therefore learned and practised the implementation of the activity, especially in terms of participant (peer learner) flow. This involved understanding how to allocate peer learners into groups, becoming familiar with the timetable, and practising. Peer teachers delivered the SBL activity to two peer learner cohorts unfamiliar with the activity. Over two separate days, peer teachers delivered the activity on-site to peer learners at Bellarmine University (BU); Kentucky, USA; and the University of South Australia (UniSA), Australia. Outcome measures Peer teachers undertook an unstructured written reflection on the usefulness of the training and the implementation of the activity, particularly relating to their provision of a debrief to their peers. Peer learners evaluated the feedback provided by peer teachers during the SBL activity using the “Measure of quality of giving feedback scale” (Reiter, Rosenfeld, Nandagopal, & Eva, 2004) (Appendix 1). This survey consisted of 20 statements rated on a scale of 1 (“not at all”) to 7 (“very well”). Data analysis Qualitative data from the written reflections were analysed using a descriptive thematic approach. Data were coded independently by two authors (DD and AF). Agreement was then reached regarding the codes to be applied to all reflections. The themes and subthemes of the data were developed with supporting verbatim quotations (Polit & Beck, 2013). Descriptive statistics for each statement within quality of feedback questionnaires were calculated. Dennis, Furness, Hall-Bibb, and Mackintosh 39 Results Six Curtin University final-year students agreed to participate as peer teachers, and all successfully completed the online learning module relating to teaching adults and the delivery of education using SBL activities. In September 2018, 126 peer learner students participated in the SBL activity at either BU or UniSA. All peer learners consented to take part in the study, and 124 completed a quality of feedback questionnaire. Peer teacher reflections Analysis of responses reve