English (pdf)
Article in xml format
Article references
Automatic translation
Send this article by e-mail
Cited by SciELO 
Cited by Google 
Similars in
SciELO 
Similars in Google 
Permalink
Introduction
Clinical simulation as a didactic strategy has proven to be effective for health students to achieve different skills and abilities in the clinical setting, strengthen their decision-making capacity, and improve their attitudes of self-confidence and teamwork.1 Valencia-Castro et al.2 define clinical simulation as a learning experience that is used to practice the work of a profession through the direct interaction of the student with the object of study, implying the construction of the student's own learning through a reflective process.
In a simulated environment, students can access a variety of simulation modalities depending on their fidelity, which may be low, medium, or high.3 In health care, low-fidelity simulation teaching uses models that resemble a part of the human body and allow basic motor skills to be acquired in a simple procedure;3 the medium-fidelity simulation combines the use of an anatomical part with computer software to manage basic physiological variables, such as devices for cardiopulmonary resuscitation training;4 finally, high-fidelity simulation reproduces a real-world situation that generates a high level of interactivity with the student or simulation participants in complex situations, such as endotracheal intubation or emergencies in critical care.5
Therefore, clinical simulation has enabled the creation of realistic environments using simulated patients or clinical simulation equipment that help to reinforce theoretical knowledge and provide a safe environment for the patient.2 In physical therapy, simulated environments are often used to develop decision-making skills in the cardiopulmonary field.6
In a systematic review, Shoemaker et al.,7 described that the use of clinical simulation in this area is useful to prepare students for experiences in intensive care units, where a variety of challenges to overcome are anticipated, including functional instability of patients, monitoring physiological variables related to movement responses and physical therapy intervention, the complexity of invasive monitoring devices, among others. This has allowed them to work in a context similar to the real world and consider possible situations that explain the symptoms of a patient. In their case report, Bednarek et al.8 state that using clinical simulation to teach physical therapy students about intensive care increases their confidence and interest in patient care and allows for a better experience and ability to modify assessment and treatment.
Simulation-based learning experiences in physical therapy are not only limited to the cardiopulmonary area; on the contrary, this pedagogical strategy based on experiential learning9 is of great importance in a variety of physical therapy performance scenarios, such as outpatient care and home intervention for people with neuromuscular, musculoskeletal and integumentary disorders.10,11 Regarding the latter, the presence of high-fidelity simulators and controlled scenarios representing various situations that resemble actual clinical experiences is indispensable since, as noted by Mori et al.,12 they allow the student to interact and practice safely before confronting a real case.
Therefore, in order to create simulated scenarios in physical therapy, it is necessary to consider what the World Confederation of Physical Therapy has proposed about the standards for accreditation of professional programs in this field, since the nature of the education of physical therapists should, on the one hand, include clinical education experiences that maximize student learning and, on the other hand, contemplate an academic environment that fosters awareness of multiple perspectives, values, and social and ethical concepts.13
Similarly, for this purpose, the standards for best practices in clinical simulation established by the International Nursing Association of Clinical and Simulation Learning should be taken into account, including the construction of learning objectives and goals, the role of the teacher as a facilitator, the debriefing or feedback process, the assessment of participants, professional integrity, interprofessional work, and operational and logistical standards that enable such scenarios to be properly developed.14
Based on the above, the physical therapy teacher must recreate the problem situation during the planning of the simulated practices by developing a clinical case that contains sufficient elements to achieve the proposed learning objectives.14 This means that the content of such cases must clearly reflect real-world experiences, so that when students are faced with the simulated situation, they have the necessary information to make a decision and demonstrate their skills.
Given this scenario, knowing about the elements required for the creation of simulated environments in physical therapy is essential for teachers who wish to interact with simulation-based didactic strategies, making the validation of these procedures necessary. Consequently, the objective of this study was to determine the face validity of a low back pain clinical case as a clinical simulation tool for the training of physical therapy students.
Materials and methods
Study carried out to determine the face validity of a low back pain clinical case presented to physical therapy students. This work is part of the project entitled "Simulation in physiotherapy students for clinical decisions during interaction with people with low back pain. Colombia", which was registered in ClinicalTrials.gov under identifier NCT04428892.
Nine essential items were taken into account in the construction of the case, which are listed and described below:
Identification of learning objectives to be achieved through the development of simulated practice.
Description of the situation the student was to encounter in the simulated scenario.
Information given to the student for the achievement of the stated learning objectives.
Medical history information related to contextual, occupational, socioeconomic, social factors and family, personal and pharmacological history, as well as the person's expectations. The following data were also collected: reason for consultation, medical diagnosis, and findings of diagnostic tests.
Review of cardiovascular, pulmonary, musculoskeletal, neuromuscular, and integumentary systems.
Evidence-based tests and measures that are applied to a person with low back pain.
Physical therapy intervention to be performed in a person with low back pain.
Evolution of the situation.
Elements of simulated practice: description of the environment that will be needed to develop the case, characterization of the simulated patient, and required materials and equipment.16
Face validity for this case was measured to establish agreement between raters17 on the content proposed in the clinical case (Annex 1) and on the concept of the case as a tool containing the characteristics required for the development of a simulated practice in physical therapy.
To this end, 5 expert raters with experience in physical therapy training processes and environments associated with clinical simulation were selected based on the criteria described by Escobar-Pérez & Cuervo-Martinez,18 (impartiality, and availability and motivation to participate). Thus, the experts included a physician with a PhD in education and a fellowship in clinical simulation; two physical therapists with more than 15 years of experience in clinical practice; a psychologist with a PhD in education and experience in psychometrics; and a nurse who is the coordinator of the clinical practice simulation center of a nursing school in Coimbra, Portugal.
Once the raters agreed to participate in the study, they were asked to evaluate the case independently according to its relevance, pertinence and coherence, as suggested by Escobar-Pérez & Cuervo-Martinez,18 as well as its clarity and sufficiency, as proposed by Vargas-Porras & Hernandez-Molina,19 using a Likert rating scale with the following response options: 1: does not meet the criteria, 2: low level of compliance, 3: moderate level, and 4: high level.
To establish agreement among raters, the values assigned to the responses given for each of the 9 items by the experts were recorded in a Microsoft Excel 2016 spreadsheet, and the Fleiss' Kappa coefficient was calculated based on these data using the Reliability Calculator (Re-Cal) version 3.20 The qualitative interpretation was made using the measure proposed by Landis21 to calculate inter-observer agreement reliability, which ranges from 0 (no agreement) to 1 (maximum agreement), with values >0.7 indicating an appropriate degree of agreement.
According to the observations made by the experts and researchers, adjustments were made to the number of learning objectives to be achieved during the simulation, to the description of the information provided to the student before interacting in the simulated environment, and to the organization of the information exposed in the simulated case to avoid distractions that could interfere with the development of the simulated practice.
As a final step in the validation process, according to Ramada-Rodilla,22 in a simultaneous session, the contents of the case study of low back pain were released to 40 fifth-semester undergraduate physical therapy students from the Universidad de Boyacá and the Universidad de La Sabana (20 students per institution) and 5 physical therapy professors from other institutions to calculate the percentage of comprehensibility of the case. A nominal variable with optional answer Yes (understands the exposed item) or No (does not comprehend the exposed item) was used for this purpose.
The study was approved by the Bioethics Committee of the Universidad de Boyacá, according to Memorandum CB 194 of June 9, 2016, and took into account the ethical principles for medical research involving human subjects of the Declaration of Helsinki23 and the scientific, technical and administrative standards for health research established in Resolution 8430 of 1993 of the Colombian Ministry of Health.24 In addition, all participants signed an informed consent form prior to the start of the study.
Results
The face validity process showed that a simulated low back pain clinical case had a significant degree of agreement with a total Fleiss' Kappa index score of 0.67. Regarding the agreement of each of the case items, it was found that the score of this index was 0.97, 1.0, 0.89 and 1.0 for items 1, 2, 3 and 9, respectively, indicating almost perfect agreements. This demonstrates that, in the experts' opinion, the face validity of this simulated case is appropriate, as set out in Table 1.
Table 1 Degree of agreement among experts for the 9 items of the clinical case as measured by Fleiss' Kappa Index.
| Items | Fleiss' kappa index | |
|---|---|---|
| 1 | Learning Objectives | 0.97 |
| 2 | Description of the situation | 1 |
| 3 | Student information | 0.68 |
| 4 | Medical Record | 0.89 |
| 5 | Review of systems | 0.80 |
| 6 | Tests and measurements | 0.64 |
| 7 | Intervention | 0.80 |
| 8 | Situation/case evolution | 0.70 |
| 9 | Elements of simulated practice | 1 |
| Total result for simulated low back pain case | 0.67 | |
Source: Own elaboration.
Likewise, the comprehensibility percentages were high, indicating that the case is appropriate for developing a simulated practice in physical therapy students (Table 2 and 3).
Table 2 Percentage of students' comprehensibility.
| Items | % comprehensibility | |
|---|---|---|
| 1 | Learning Objectives | 98.9 |
| 2 | Description of the situation | 92.5 |
| 3 | Student information | 90.0 |
| 4 | Medical Record | 84.4 |
| 5 | Review of systems | 98.7 |
| 6 | Tests and measurements | 96.6 |
| 7 | Intervention | 97.5 |
| 8 | Situation/case evolution | 100 |
| 9 | Items of simulated practice | 98.3 |
Source: Own elaboration.
Discussion
This study demonstrates that this low back pain clinical case as a clinical simulation tool is useful for training physical therapy students since it has a significant degree of agreement across all of its components and an almost perfect agreement in the sections related to learning objectives, description of the situation, medical record, and simulated practice items.
These findings corroborate Fernandez-Rodriguez's assertion9 that the cases or situations used to contextualize the simulation-based learning experience must contain sufficient information to enable students to apply their knowledge and demonstrate how they would use it in a real-world situation.9
Furthermore, the Manual de Casos Clínicos Simulados by Abellan-Hervas et al.,16 was taken into account in the preparation of this case, which states that when designing a simulated case, cognitive learning domains should be addressed so that students can analyze the data provided and demonstrate comprehensive application of their knowledge.
According to Abellan-Hervas et al.,16 the structure of the simulated case should allow students to demonstrate attitudes related, on the one hand, to the affective domain during the interaction with the patient or simulated actor, and, on the other, to the psychomotor domain during skill development and acquisition. The present study shows that the formulation of the learning objectives to be achieved by the students and data from the medical record that provided information about the patient's personal, work, family, and health context were considered when elaborating the case.
Also, studies such as those by Barragan-Becerra et al.25 and Hernandez-Ruiperez et al.26 emphasize the importance of incorporating content and face validity processes into tools that facilitate learning in clinical simulation scenarios, where the comprehension, content, sequence, and layout of the documents are observed in such a way that specific cases can be standardized for the development of simulated practices. The above is consistent with the items evaluated in the simulated case here, specifically in the sequence of the physical therapy approach for a person with low back pain through the guidelines proposed by the American Physical Therapy Association (APTA),27 such as examination (medical record, review of systems, selection and application of tests and measurements), physical therapy diagnosis and prognosis, and intervention.
Simulation-centered learning experiences, according to Urra-Medina et al.,28 are based on assessing clinical judgment and developing reflective thinking skills in students. The authors also state that there are two key concepts in clinical simulation teaching: loyalty and instructors. The first refers to the degree of realism projected on the scenario, as evidenced by the fidelity of the equipment and the physical and psychological environments in which the perception of learning should be as close to the reality of the practice as possible, while the second refers to teachers who have received training and are capable of incorporating simulation into the classroom. This was considered in the case simulated here, particularly in the information presented, in the control of an outpatient scenario involving the care of a person with low back pain, and in the selection of instructors (professionals with certified experience in clinical simulation).
The Fleiss' Kappa Index (0.67) results support the face validity of this case of lumbar pain, and it is also evident that the experts' suggestions improved the design and thus the development of the simulation. However, the most divergent aspects among evaluators were those related to the number of learning objectives to be achieved and the initial description of the situation. In this regard, Fonseca et al.29 state that at the start of a simulated activity, known as prebriefing, the rules of the simulation, the roles to be played, confidentiality, the guidelines of mutual respect, the environment, the operation of the equipment, and the general objective to be developed in the simulated scenario should be discussed. Once the learning objectives are clear, the debriefing or feedback process occurs, which, according to Almeida et al.30 is an essential part of the simulation experience, as teachers and students assess the clinical situation and foster the development of critical judgment through reflective learning.
Therefore, the description given to the students about the situation with which they will interact should be concise and free of distracting elements for decision making, with realistic objectives for the development of the simulation within the established times, as demonstrated in the elaboration of the simulated case in this research.
In the present study, the items with the greatest agreement were those related to the information on the physical therapy examination for a person with low back pain, which were based on what was established by the APTA guidelines.27
With regard to other research addressing the validity of clinical cases used in simulated environments, the literature found that Fonseca et al.,30 in a study that developed and validated a maternal-child clinical simulation scenario related to humanized childbirth, established that validation had a level of agreement among evaluators >80% in all aspects evaluated, and that, as a result, this simulated scenario can strengthen the articulation between the disciplines involved in women's and children's health. In that research, as in the present study, the validation of the scenario took into account the observations of experts in the field about the information that guides the student to solve the situation to be faced, the alignment with the scientific evidence, realism, and the resources used.
In physical therapy, simulation scenarios have been validated worldwide, as described by Silberman et al.6 in their study, in which 23 physical therapy doctoral students were included and 2 researchers with 10 years of experience in simulation established face validity. The simulated scenario was a physical therapy consultation with a post-operative knee replacement patient in an inpatient setting. Students identified 4 learning objectives that were met during the simulation experience, namely, interprofessional communication, preparation of the treatment environment, patient safety, and discharge planning. They completed a perception survey that was validated by 3 professors with clinical experience in hospitalization, which differs from the present study in that the process of validating the exposed case did not include students' perceptions.
There were no studies found in Colombia that validated this type of learning experience. However, the study by Cárdenas-Sánchez et al.31 describes physical therapy students' perception of clinical simulation; it emphasizes the opportunity for students to integrate multiple concepts and the ability to make decisions in a clinical environment similar to the real one, as well as the fact that these scenarios may foster metacognition processes in which errors and successes are recognized. Likewise, these authors highlight areas for improvement in the debriefing phase and in relation to the time required to complete the activity in order to accomplish the proposed objectives, a factor that was also mentioned by the evaluators who participated in the validation of the simulated case presented here.
One of the limitations of the present study is that, although the validation of the simulated low back pain case was evaluated by peers experts in clinical simulation, the students were not involved in the design and content feedback process.
Based on the above and on the results found in this research, it is critical that all elements proposed by Sittner et al.,14 for best practices in clinical simulation are considered when simulation-based learning strategies are included in physical therapy training plans and that they are consistent with the learning objectives to be achieved. This will allow to respond to the various specific and cross - cutting competencies of physical therapy professionals.
Conclusions
Face validity was established for the simulated low back pain clinical case exposed in this study, indicating that its use in clinical simulation practices in physical therapy programs at Universidad de La Sabana and Universidad de Boyacá is valid and can serve as a model for the development of simulation scenarios in other physical therapy programs throughout the country.
