The changes in perceived self-efficacy, academic engagement, and empathy following simulation-based learning among undergraduate physiotherapy students: a quasi-experimental study

Ochandorena-Acha et al. BMC Medical Education https://doi.org/10.1186/s12909-026-09389-z (2026) 26:996 BMC Medical Education Open Access RESEARCH The changes in perceived self-efficacy, academic engagement, and empathy following simulation-based learning among undergraduate physiotherapy students: a quasi-experimental study Mirari Ochandorena-Acha1,2*† , Ramon Jolis-Prat2†, Anna Escribà-Salvans3,4*† , Vinicius Rosa Oliveira3,4 , Sandra Rierola-Fochs1,2 , Carles Parés-Martínez3,4 and Marc Terradas-Monllor1,2 Abstract Background Physiotherapy (PT) education must foster both clinical competencies and non-technical skills such as communication, empathy, and self-efficacy to prepare students for professional practice. Simulation-Based Learning (SBL) offers a structured and safe environment to develop these skills. While the benefits of SBL have been documented in nursing and medical education, evidence in PT programs, particularly across different academic years, remains limited. This study examined changes in perceived self-efficacy, academic engagement, and empathy following SBL participation, and to explore differences between second-, third-, and fourth-year PT students. Methods A prospective quasi-experimental study was conducted between December 2023 and June 2024 involving second-, third-, and fourth-year undergraduate PT students from a single Spanish university (corresponding to the fourth, sixth, and eighth semesters, respectively). Students participated in SBL sessions designed according to international standards and adapted to their academic level. Outcomes were assessed pre- and post-SBL through validated questionnaires: the Academic Situation-Specific Perceived Self-Efficacy Scale, the Utrecht Work Engagement Scale for Students, and the Jefferson Scale of Empathy. All instruments demonstrated adequate internal consistency in the study sample (Chronbach’s α ≥ 0.80). Post-SBL perceptions were further assessed using the Student Satisfaction and Self-Confidence in Learning Questionnaire and the Educational Practices Questionnaire-Spanish Version. Results Out of 451 eligible students, 409 participated in the baseline assessment and 378 completed post-SBL assessments. Statistically significant improvements were found in self-efficacy (p = 0.001), academic engagement † M irari Ochandorena-Acha, Ramon Jolis-Prat and Anna EscribàSalvans contributed equally to this work. *Correspondence: Mirari Ochandorena-Acha Anna Escribà-Salvans Full list of author information is available at the end of the article © The Author(s) 2026. 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To view a copy of this licence, visit http://creati vecommons.org/licenses/by-nc-nd/4.0/. Ochandorena-Acha et al. BMC Medical Education (2026) 26:996 Page 2 of 17 (vigor, absorption, and total score; p = 0.008; p = 0.007, and p = 0.023, respectively), and empathy (compassionate care and total score; p < 0.001, and p = 0.007, respectively) across the full sample. When results were examined by academic year, patterns of change differed, with third- and fourth-year students showing consistent improvements across most dimensions, while second-year students exhibited more variable responses, including small decreases in selected engagement and empathy subscales. Post-SBL evaluations indicated high levels of satisfaction and self-confidence in learning, with large effect sizes observed in the more advanced academic years. Students’ perceptions indicated strong endorsement of SBL practices, especially in high expectations and learning diversity. Conclusions SBL was associated with improvements in key learning-related competencies, particularly among students in more advanced academic years. Differences across cohorts highlight the need to tailor SBL design to students’ developmental stage, especially during early exposure. Future studies should incorporate control groups, qualitative data, and follow-up assessments to better understand the sustainability and contextual factors influencing SBL outcomes. Trial registration NCT06852482 (registered on 28 February 2025). Keywords Physical Therapy Modalities, Professional Education, Patient Simulation, High Fidelity Simulation Training I ntroduction – Background Physiotherapy (PT) education plays a fundamental role in developing core clinical competencies, essential communication abilities, and soft skills in future professionals [1]. These competencies, often referred to as social-emotional skills or non-technical skills, include empathy, problem-solving, critical thinking, adaptability, and teamwork. They are widely recognized as critical for effective and safe practice and are increasingly emphasized by professional and regulatory bodies as fundamental elements of entry-level PT education [2]. Compared with traditional pedagogical methodologies, simulation-based learning (SBL) has emerged as a promising approach to address these complex learning outcomes [3]. By offering experiential, interactive scenarios, SBL provides healthcare students with structured opportunities to apply cognitive knowledge, develop psychomotor abilities, and practice communication and clinical decision-making skills in a safe, controlled, and low-risk environment [4, 5]. To address quality and consistency, the Healthcare Simulation Standards of Best Practice (HSSOBP) from the International Nursing Association for Clinical Simulation and Learning (INACSL) offers frameworks to optimize simulation design, facilitation, and debriefing [6–9]. However, it is not clear to what extent PT programs systematically apply these standards [10]. SBL can take many forms, ranging from low-fidelity role-playing to high-fidelity simulations involving Standardized Patients (SPs) [11, 12]. SPs add realism and emotional nuance to the learning experience, modelling authentic human behaviour and adapting interactions based on student needs and learning objectives [13]. However, multiple factors such as facilitator variability, briefing/debriefing quality, and emotional demands of scenarios may influence the educational impact (...truncated)