In search of an evidence-based approach to occupational therapy practice education that would include simulation experiences


Simulation is a methodology used to replicate real-world tasks.  Simulation provides experiences that lead to direct learning or that can be used as an assessment of competence.  Such tasks have been used as a primary tactic in occupational therapy and other rehabilitation services since their inception - although they were generally applied in a therapeutic context.  For example, an individual would learn how to dress themselves out of context to develop skill, and then that skill would be transferred to contextual learning.  Sometimes, more esoterically, a simulated activity broken down into components would be used to practice parts of tasks that would then be scaffolded in a total practice method.  Either way, simulated experiences are a staple methodology used by occupational therapy professionals for many years.

Over time, preferences emerged for 'real-world' and 'contextually-relevant' experience - so much so that entire service delivery systems incorporated 'natural environments' as it was believed that this would help in the transfer of learning.  To the degree that completely 'natural environments' were not always available or perhaps had barriers themselves, incorporating contextually meaningful elements into simulation experiences became a staple of rehabilitation and habilitation approaches.

It is interesting that rehabilitation fields like occupational therapy that employ simulated learning experiences as their primary therapeutic methods have been slow to fully explore applying those same methods to the clinical training of its own workforce.  Simulation is heavily used as a pedagogy in the classroom.  Regularly, occupational therapy students complete mock evaluations on their classmates, practicing goniometry or muscle testing or transfers or interviewing skills.  Even complex skills like splinting are practiced on healthy peers in laboratory contexts - a full simulation of what that experience might be like in a natural clinical setting.  Although now moderately controversial, 'simulated' disability experiences are still used regularly as an educational method.  Those same methods of simulation are also employed in other empathy games - again somewhat controversially - but with widespread use.

Fieldwork education, or what I suggest should instead be called 'practice education,' remains mired in a very antiquated model that is more process-oriented than outcomes-oriented.  As a result, it is common for accreditation functions and state licensing to require prescribed experiences that are not evidence based.  For example, occupational therapy students must complete 24 weeks of on-site clinical training and there is no evidence that supports that such training has to be either 24 weeks long or completed on-site.  Therefore the emphasis remains on the process and not on the outcomes.  

A more correctly designed approach would identify skills and tasks that require competence, and then measure students abilities to complete those tasks with the requisite skill and proficiency.  Randomly designated timeframes in natural contexts does not guarantee competence with any skill - something that occupational therapists already know.  Occupational therapy practitioners would never apply such a teaching strategy in their own therapy, yet they apply those teaching strategies on their own students.

So, simulation as applied therapeutically can also be applied in education for both skill development as well as assessment, but the occupational therapy field has been slow to apply this knowledge in education.  In 2012 the National Board for Certification in Occupational Therapy began looking at simulation and 'serious gaming' as an assessment and competence-building methodology that could be applied to certification renewal (McNamara, Bent, & Grace, 2019).  I participated on the Board at that time and I recall how radical an idea this was - but in listening to the gaming and simulation applications that were already well-developed in military contexts it became evident that there were application opportunities to occupational therapy.  The Navigator product was launched in 2015 and included simulated learning and assessment activities that could be used for professional development and competency assessment.  I spent eight years working on that project, developing simulation experiences and helping to create this unique suite of products for the occupational therapy profession.  It remains a groundbreaking exemplar in professional development and competency assessment among health professions, winning several awards and now being accepted by over 43 states for occupational therapy licensing renewal (Bent, Carroll, & Grace, 2020; Myers, 2019).

Medicine and nursing fields have studied simulation education and studies consistently demonstrate the effectiveness of these methods (Alexander, et al., 2015; McGaghie, et al, 2011).  There is reason to believe that these same findings will apply to other health care disciplines. Since the release of the Navigator product, occupational therapists have begun to explore and document the use of simulation experiences in their pedagogy.  Shea (2015) described the intentional inclusion of high-fidelity simulation experiences in an occupational therapy curriculum, including aforementioned patient interviews, physical assessment techniques, and simulated case studies.

Imms, et al (2018) conducted an RCT comparing simulated clinical placement with traditional clinical placement and found that there were no significant differences between the groups related to learning outcomes.  The authors identify that in Australia up to 20% of all clinical placement hours can be completed by simulation training.  During the COVID-19 pandemic context the Accreditation Council for Occupational Therapy Education gave allowance for Level I fieldwork experiences to be completed with simulation methods.  However, they also clarified that simulation could not be used for any part of Level II fieldwork.  The primary reason for this, as identified above, is the process-oriented methodology that is hard-coded into both the accreditation standards and in many state licensing laws. (ACOTE, 2020).

New York State is considering a bill that would allow up to 30% of all clinical training to be completed in a simulation context - and this effort is supported by nursing, occupational therapy, physical therapy, and a number of other professions.  The bill was drafted by a working group of educators who were concerned about the constriction of clinical training opportunities during the pandemic, and has been championed by the Commision on Independent Colleges and Universities in New York.   It is unlikely to pass through the Higher Education committee as it is rather late in the legislative session, but it is something that all health care professionals in NY and elsewhere should be attending to.  Accreditation and licensing requirements remain process-oriented, but this kind of bill would be an important first step in breaking away to a more modern and evidence-based approach to practice education.


ACOTE (2020, April 21). COVID Update 4-14-20.

Alexander, M. et al (2015). NCBSN simulation guidelines for prelicensure nursing programs. Journal of Nursing Regulation, 6(3), 39-42.

Bent, M., Carroll, S., & Grace, P. (2020). One organization's journey to implement an innovative competency assessment platform: The NBCOT Navigator five years on. Clear Exam Review, 30(2), 24-34.

Imms, et al (2018). Simulated versus traditional occupational therapy placements: A randomized controlled trial. Australian Journal of Occupational Therapy, 65(6), 556-564.

McGaghie, W.C., et al (2011). Does simulation-based medical education with deliberate practice yield better results than traditional clinical education? A meta-analytic comparative review of the evidence. Academic Medicine, 86(6), 706-711.

McNamara, J. Bent, M., & Grace, P. (2019). Using applied game and simulation technologies to support continued practice competency: A case study. Journal of Applied Testing Technology, 20(S1), 69-77.

Myers, C. (2019). Occupational therapists perceptions of online competence assessment and evidence-based resources.  American Journal of Occupational Therapy, 73(2), 1-8.


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