November 10, 2022By Lance Baily

Research: PIER Framework for Healthcare Simulation Physiotherapy Education Integration

Healthcare simulation is employed across medical education to help learners gain greater insight into what the care and treatment of patients in real life are like. From training learners on how to perform surgical procedures to how to administer respiratory intervention, there are numerous uses for this learning strategy, such to develop a thorough physiotherapy curriculum. Relating to this topic, healthcare simulation research was recently published discussing the Planning, Implementation, Evaluation, and Revision (PIER) framework for the integration of healthcare simulation in an undergraduate physiotherapy program. This explains the framework and key takeaways from the overall research.

Titled “The PIER framework for healthcare simulation integration in undergraduate physiotherapy education,” the study’s authors emphasize the undeniable need for healthcare curricula renewal to facilitate a continuum in education from classrooms to diverse healthcare settings. While the practice of healthcare simulation has expanded across the different sectors of medicine, they explain that one area in which clinical simulation is still lacking is physiotherapy education. Thus, authors Anke van der Merwe, Roline Yvette Barnes, and Mathys Jacobus Labuschagne set out to describe the finalization of a framework for the integration of healthcare simulation in an undergraduate physiotherapy program.

During their study, they utilized a qualitative descriptive research design, obtaining contributions from five South African experts in the fields of healthcare simulation and/or physiotherapy education. Each expert added their input to the finalization of the framework during a consensus meeting, which was followed by a content analysis – ensuring credibility through double-coding.

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Using this methodology, the research authors reported that structural coding yielded five themes: Planning, Implementation, Program Evaluation, Program Revision, and Framework. The five themes consisted of fifteen categories, two sub-categories, and 44 codes.

According to the research, the study’s result ultimately assisted in the adjustment and refinement of the conceptual framework. They conveyed that the Planning theme was the most robust, with a total of seven categories identified, and that the category of Needs Analyses was the only one to include sub-categories.

Another takeaway was that two category name changes were required to better reflect standard healthcare education terminology. Curriculum development and outcomes were changed to responsive curriculum and learning outcomes, reflecting a more adaptable curriculum with specific educational outcomes, the researchers noted.

“Student preparation was adjusted to student-centered preparation and moved to the Planning theme, demonstrating the student-centeredness of the educational methodology,” the research stated. “The category competent facilitator was created by merging the previously identified categories of training and educator role.”

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Also of importance, the previously identified categories, instructional method, and resources were collapsed within the responsive curriculum and simulation design categories respectively. The categories of feedback initially included in the Planning theme, and student goal setting was collapsed within the debriefing category in the implementation theme as well. Other healthcare simulation research takeaways included:

  • Mastery learning/Deliberate practice (ML/DP) also collapsed within the debriefing category, due to ML/DP requiring constant self-regulation, self-reflection, and goal setting.
  • The suitability of including assessment within the framework was questioned by participants.
  • Program evaluation and revision were identified as two separate themes with validation, evaluation, and review as respective categories.
  • Within the Framework theme, the practicality and impact of the framework emerged and revealed the collaborative and interprofessional nature of the presented framework, with the use of SBLEs to supplement clinical hours not supported by participants.

Following a consensus meeting, the PIER framework for simulation integration was finalized through an in-depth exploration of participant opinion and included two independent member-checking processes. The authors concluded that “collaboration through resource and knowledge sharing is vital in developing a responsive curriculum integrating simulation.” They added that facilitator and learner preparation is paramount in ensuring active engagement in simulated-based learning experiences.

Additionally, the research article determined that the PIER framework is “generic in nature “and represents the continuous process of healthcare simulation integration for any medical program. The authors emphasized that the interconnectedness of all framework elements and integration phases is crucial to healthcare simulation learning.

Additional Healthcare Simulation Frameworks

ROI Framework for Healthcare Simulation: Although the role of medical simulation in improving patient safety outcomes and healthcare education is well established, the Return on Investment (ROI) for healthcare simulation activities is sometimes harder to quantify. A recent complex article by Bukhari, Andreatta, Goldiez, and Rabelon (2017) provides a detailed methodology for determining the monetary return on investment for medical simulation. The authors were interested in creating a new framework that could be used to measure not only the tangible and quantitative benefits of simulation but the intangible and qualitative benefits as well.

PEARLS Debriefing Framework with Debrief2Learn Tool: Many educators consider debriefing as the most important step in healthcare simulation. has previously published several guides to debriefing including the GAS method and Debriefing with Good Judgement. In 2015, Dr. Walter Eppich and Dr. Adam Cheng published a blended approach to debriefing entitled Promoting Excellence and Reflective Learning in Simulation (PEARLS) (Sim Healthcare, 10, pp 106-115), which Dr. Kim Baily Ph.D., MSN, RN, CNE shares about, with key online links to tools.

Simulation Design Framework to Promote Professional Identity Formation: As part of’s webinar series platform, A.J. Kleinheksel, Ph.D., MEd, CHSE-A, the director of research and evaluation for educational simulation at the Medical College of Georgia at Augusta University, shared an informative presentation of why simulationists should design healthcare simulation for professional identity formation (PIF). Referring to the personal growth over time in becoming a skilled medical professional, PIF can be conceptualized as the ability to meet certain criteria. Within their medical simulation webinar, Kleinheksel touched on the new PIF design framework that their institution has developed as a result of research into PIF in healthcare simulation, and how other simulationists might apply that framework to their own clinical simulation case design.

The Two-Team Training Approach and Healthcare Simulation Do-overs: guest author, Timothy C. Clapper, Ph.D. shares how certain strategies, such as the use of a two-team approach, clinical simulation do-overs, and active observers, can help educators achieve such improvement. For example, the prebrief-simulation-debrief framework is likely the most recognized framework in the medical simulation community. This framework has many benefits including its relative simplicity in design. It has been in use by the military and other institutions long before it was considered for use by healthcare educators. Absent an instruction phase (the assumption is that you have already been trained), the framework consists of a case that will be used to provide an experience for the participants.

Read the Full PIER Framework Research Article Here

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