Table 1 Illustrative quotes

(i) Engaging learning environment: Part I-participant engagement and commitment

International students:

MP1: The [educators’] feedback would be more convincing; like I would trust their feedback and I would learn from their feedback

Domestic students:

FP2: We’ve barely been on campus, and I just wanted to be in person to get that confidence before actually being with a real patient

FP2: I knew there were learning outcomes and knowing when to try and let some of those pan out … and how much to push them versus doing what I would do as a clinical educator

FP3: It felt really positive … the students were a real credit to themselves. They really engaged and obviously it sounds as though it was a programme that the people who wanted to do it signed up for it

MP1: It’s like anything you do the more you put into it before you start the more you are going to get out of it

FP2: They [students] all understood why they were there and then got stuck in almost immediately

(i) Engaging learning environment: Part II—enabling learning activities

International students:

FP1: We were really pushed to kind of figure it out on our own and at the time I was like ‘oh my God please help me, this is awful.’ But then actually looking back now I think that was the best way

FP2: I found it useful to observe other people … because sometimes I’m not actually jotting down notes about the patients’ information, I’m jotting down how to ask the question instead

Domestic students:

FP4: having the case studies the night before was really helpful … I felt a bit more prepared

MP2: the thing I liked most about the timeout was being able to step out of the situation and get immediate feedback … and then you’d be able to go straight back into it and almost rewind the scenario and start again

MP1: I like the timeout thing, it seemed to make it a bit more safe … you could ask them how it felt in the moment and you could ask their peers that were watching to give some feedback … I really liked that because when I struggle with students on placement, it’s the ones that don’t have that ability to reflect and communicate how they are feeling, are the ones that struggle … and that’s hard to teach. I find that hard to teach on placement. So, I think that was a real plus

FP2: Anytime they felt uncomfortable they could time out and talk through the scenario. I feel like the support they had from their classmates was very much appreciated

(ii) Realism and relevance

International students:

FP4: During placement I got rejected by a few of the patients and because I’m on a simulation programme being told that … some patients might not want you to ask them questions or do anything to them and my supervisor thought I would be offended but I’m not because I already expect it

FP1: The frailty one; I’m in an acute setting so literally all of my patients are exactly like that … I had a patient exactly the same as the one that we saw and I was like, ‘wow I know what to do’ or if a patient is like ‘oh I can’t hear you’ in the simulation … we learnt techniques to move past that

FP1: I agree with the others I think personally one week is enough just like a little prep before placement, but I don’t think it should replace it

Domestic students:

MP1: It demonstrates that how effective it is because it felt quite real

MP1: In placement … the patients were quite similar … it prepared me for what the client would expect and how you would approach an OT intervention and process … It gave me an idea of what to look for … One of the clients was almost identical in terms of problems and everything

FP2: We even had ward noise going on in our room, so it tried to make it a bit more authentic and I even found it distracting and I’m used to it … I think it’s a nice opportunity to give them lots of different experiences

FP3: It added something foundationally from just how to act, how to adjust a bed, how to put somebody’s socks on and there were lots of questions that came out … ‘if I walk past this on the ward and it’s not a patient that I know what do I do?’

FP1: It would need to be extra rather than a replacement because what we’re generally seeing where I work as clinical educators it’s really hard to get everything in in that short space of time anyway

FP3: It’s definitely going to be so valuable in supporting them to feel confident and get the most out of their placement, but … The MDT we did today, I’ve never known a doctor be as nice as me [laughs] … it provides the graded exposure, but it can’t be counted as exposure

FP3: You could see that it affected them because I got a bit tearful the first time, I could see the student that was talking to me, I could see her getting upset and that does affect the rest of the group so they do understand it better when they see somebody like that, it’s not a mannequin that sits there and doesn’t have any emotion. They have to realise that when they do anything like this people react differently

MP1: I was absolutely as the patient, I was thinking if this person would come back weekly or whatever I have real confidence in my future now because there was this one person, I could really trust … They’re usually very subtle things they say and do … she was quite prepared to sit right next to me, hold my hand, do things with my hands: ‘Can you do this? Let’s move these’

(iii) Student confidence and communication

International students:

MP1: It still boosts my confidence to perform better, to build a rapport with my client … I know I’ve got the ability to achieve my goals instead of expecting nothing

FP4: I really learnt how to avoid specific language and just use simple words … I learnt so much … from my [domestic] students and also the clinical educators, which really helped me during my placement telephone consultations

FP1: It helped my therapeutic use of self because that’s something in my supervision my practice educator commented on. She said I was really learning how to use my personality more and I’m more aware of my positioning … we got taught that like when FP2 did her bit … and those stuck with me that I took on to placement

Domestic students:

FP5: I would have been completely different if I hadn’t been able to speak to patients

FP2: it’s made it much easier even just something as simple as … introducing yourself and what you do

MP1: Overall in general with patients … It kind of got me out of an observational role into more of an active role

FP2: It just gives me so much hope for when they go into their careers and they are able to treat real patients with the same amount of empathy and understanding, it’s wonderful to see

MP2: That was really valuable for them … that balance between you’ve got to strike a rapport with this person but then also maintaining a level of professionalism

MP2: If you are a first-year student, the communication interaction is more important because the clinical skills depend on the area that you are working in

FP1: I’ve worked with the same group of students on both days, and they were a very different group on the second day … Even within the hour with the male student on the first day, having been quite weak to start with, he was much stronger by the end

MP1: There was one girl … she was quite vocal … she wasn’t going to volunteer … but towards the end of the day, I think they’d run out of options, so she said, ‘oh I’ll go and do it then’. She was absolutely awesome, absolutely amazing because suddenly, I don’t know, I [the simulated patient] just clicked with her

(iv) International students’ needs

International students:

FP2: Because we are not locals [laughs] … our mother tongue is not English so it’s very useful to observe how the locals really ask the questions

FP2: My brain is so tired to process so many English and so much information [laughing]

FP4: It’s really important that I have maybe a partner with me … someone to stand next to you and he or she can always jump in to help me if I am just stuck there

FP2: It’s quite overwhelming so if I have a long lunch I can rest more and then I can perform better in the afternoon

FP3: That was quite a long lecture in the morning so there was quite a lot for me to take in and it was just hard for me to digest

FP2: They put themselves forward and they’ve got the knowledge but again it’s the confidence and the ability to adapt

MP2: One particular international student that spoke to me a lot I think it was almost like ‘if I could just practice this more, I’d feel more comfortable.’

MP1: One of the key learning objectives … is around communication … the international students need more of this

FP3: We’re talking about communication and how intelligent and bright these students are and the potential that they have … it’s important to factor that in when making plans … practising what we preach and communicating with these students and seeing what do you feel you need rather than deciding for them

MP1: One girl from Hong Kong she volunteered to do a subjective assessment, but it was painfully hard for her to do. Once we timed out and had a discussion … it transpired that it’s just her culture would not allow her to talk in a friendly intimate way with a person of my age

(v) Recommendations to facilitate further preparation for placement

International students:

FP1: [the assessment form] says for placement 1 … the lead comes from the practice educator… The simulation was independent … So it doesn’t match what we were expecting really … If we wanted to make it specifically tailored for P1 placement I definitely think that a supervisor actor should be included

FP2: It would be more useful if we have a worksheet about the SOAP notes like maybe a sample

FP1: Sticking to time because for example on the first day my educator spent nearly a full hour with one of the students and let them repeat … and then I didn’t get an opportunity to have a turn that day … that was the actual case that was most similar to the placement I’m on now

Domestic students:

MP2: Sometimes they’d [students] get stuck and wouldn’t know what to do and the educator would just, and like I said not all the time, but the educator would just give the answer. Whereas you may as well just come back to the group and ask if anyone else might know what to do

FP1: The students in our group were suggesting that it would be valuable to do it at different stages of their training so before each of their placements as they develop through their course, they’d be, probably be looking at slightly different things as they go through

(vi) The importance of preparation to engage in SIM

International students:

FP1: I actually felt the simulation was a bit last minute personally

FP4: I kind of disagree because [name] told us a few weeks ago before and she said oh you’ll be having a simulation week practising your subjective and your objective skills for physio

FP2: We know what we will be doing but we don’t know how it will be carried out, like how we would do it

Domestic students:

FP4: In the weeks leading up to it, it was quite uncertain what was happening purely because I think there was ethics approvals or something being waited for … But actually once we did find out it felt like, well I personally felt like I had a lot of information … I knew how the week was going to pan out which I really liked

MP2: The simulations that we had earlier in the year probably made me feel a bit more ready to participate

MP1: My roommate didn’t know much about it, I think he didn’t realise how useful it was or how good of an experience it would be so I think if it would have been explained better a lot more people would have actually signed up

MP2: It later revealed itself that [the case study] needs to be relevant for OT, physio and podiatry … someone with those needs is going to be super complex and make all the first years’ brains explode … it was fine in the end but I did have a concerns that all the OT stuff was going to be diluted … because of having to make it relevant for everyone

MP1: University to write it [the case study] and then we can edit it

FP × 3: Yes

MP2: It seemed to rely quite heavily on how the students in that session responded … I felt like I wasn’t that prepared but actually in the moment it worked itself out

FP3: It’s quite tricky to understand what the day is going to look like until you are doing it … I maybe would have appreciated having a real structure of what the days were going to look like and what was expected of us a little bit sooner

FP4: I couldn’t make the educator training day but [name] sent me a recording of it … that was really valuable … I know [name]; we’ve worked together well that took some of the stress out

FP1: So that is maybe something that needs to be clearer whether we should or shouldn’t [laughs] be working as the clinical educator

FP2: There was a lot of detail placed into how Rose acted to other people, the kind of body language that she portrayed … I very much based the character off those details rather than her diagnosis

FP1: The first scenario where I was the daughter of the 83 year old lady, yes that was all very clear. I could also relate personally to that role in a way … The second day … My character there was very little information … we had a quick discussion beforehand and it was decided that I was going to be more negative … It was a much more difficult role for me because I had no background knowledge

MP1: So if you do some research it just makes it more comfortable for you and you’ve got a better understanding of what the problems are that’s facing whoever you are acting

FP3: I was OK because I can just react to how MP1 feels. I mean the information I had was fine, I didn’t really need that much