From the Desk of Carol C. Dudding, PhD, CCC-SLP, CHSE
In 2016, the Council for Clinical Certification revised implementation language of Speech Language Pathology Standard V-B to allow for the use of simulations to count towards clinical clock hours. In this SimQ article, we will focus on the impact of this change and offer ways to assure that students are obtaining clinical clock hours in a manner that complies with the standard. This article is part of an ongoing series of articles on simulations in healthcare, specifically in Communication Sciences and Disorders (CSD). The SimQ format, allows us to explore the technological as well pedagogical aspects of simulation for clinical education through the words of the experts. It is anticipated that the audience will include university faculty, clinical educators, and professionals with interest in the use of simulations to enhance the clinical education of our students and practicing professionals. These articles are intended to address the needs of those considering the use of simulations, and those with varying experiences and level of skill.
After this course, readers will be able to:
Describe the forces impacting the use of simulations in CSD programs.
Apply the standards for use of simulations towards clinical clock hours for students, including supervision requirements.
Construct methods of documentation of hours through simulation.
It is a pleasure to have this opportunity to share your expertise with our readers. By way of disclosure, please tell us your relationship with Simucase.
I am employed full-time by Simucase. In my position as Managing Editor, I am responsible for the creation of clinical simulations and for supporting university programs in the integration and use of simulations both academically and clinically through education, training, and support. I have been involved in the development and tele-supervision of virtual clinical practica for programs seeking clinical hours, experiences, and competency development for speech-language pathology students.
Q. I know that prior to your current position, you had extensive experience with Simucase within a university system. Indeed, you are one of the pioneers of the use of Simucase for student training. Can you tell us about that?
Yes, prior to my position at Simucase, I was in a university position for many years. In that capacity, I was able to participate in both academic and clinical teaching of graduate students. Our curriculum included a three-hour diagnostic course covering many of the traditional topics associated with assessment including: assessment models, test construction, interviewing and case history collection, diversity considerations, analysis and interpretation of assessment data leading to diagnosis and treatment recommendations, and clinical writing for assessment. As you know, there’s a lot of information to cover in one course.
It was clear that we had to be creative to find a solution that would provide the students with the desired experiences in assessment, helping them to bridge the gap between academic content and application in a clinical setting. We decided as a program to explore clinical simulation. The benefits to the students included practice in a non-threatening situation that was free of high-stakes repercussions, receiving feedback about performance, and interacting with a variety of clients with diagnoses across content areas. This seemed the perfect solution except I was part of a small university without access to a high-fidelity simulation center.
So we decided to adopt Simucase, a computer-based simulation, into our curriculum. A second assessment course was created to include the use of Simucase. The course has been offered for seven or eight years now. Student, supervisor, and faculty reviews have been consistently and overwhelmingly positive. Students have displayed higher levels of confidence and reduced anxiety in live diagnostic situations. Clinical supervisors report that students improved at planning evaluations and interviewing families, as well as executing clinical skills during the session, and scoring and analyzing results. Teaching faculty have seen the successful integration of simulations into clinical work, and have begun to utilize simulations in their courses. Academic and clinical faculty have worked together to create individualized independent studies or remediation experiences utilizing simulated patients on an as-needed basis.
Overall, my university’s partnership with Simucase was a winning situation – we were able to solve a curricular student-preparation problem by utilizing the virtual patients. Students have the opportunity to practice clinical skills and apply academic information while gaining clinical hours, experience, and competency with patients across all nine content areas required by the current SLP standards. Students have been better prepared for live diagnostic evaluations, and the faculty has been able to integrate simulations into the curriculum both academically and clinically.
Q. What types of research did you conduct related to Simucase, and what did you find?
Anecdotally, it was very clear that utilizing the virtual clinical assessment simulations provided by Simucase was beneficial to both the students and the program. As we all know, however, anecdotal information is not strong enough evidence to change practice. While in my university position, a group of colleagues and I decided to collect efficacy data on the use of Simucase:.
Students were asked to complete response journals as part of the course requirements for a diagnostic course employing Simucase. The journal entries were analyzed using qualitative methods. Overall the students reported high levels of satisfaction in the opportunity to: a) gain assessment experience in areas that they had not had yet with live clients, b) gain exposure to a variety of assessment tools and clinical settings, c) test their diagnosis skills, and d) practice interviewing clients, families, and collaborators.
I conducted another research study utilizing Simucase using a case study as the data collection instrument. All students in the cohort completed the traditional assessment course, followed by participation in two live-clinic diagnostic evaluations. Students were then given the opportunity to enroll in the Simucase elective course offered; about half of the cohort did so. After that, all students completed two more live-clinic diagnostic evaluations.
All students were then asked to complete a written case study assignment where they were asked to: (1) identify important facts from the case history, (2) identify the relevant collaborators for the case, (3) write reflective questions to ask each of the collaborators, (4) explain their clinical hypotheses, (5) identify appropriate diagnostic tools to utilize, (6) make a diagnosis(es) (provided with assessment results in part 2), and (7) write 5 recommendations for the client based on all of the information provided in the case. Statistical differences were found between the Simucase and the non-Simucase groups in their overall total scores, and specifically in factors related to case history and working with collaborators. This was exciting – finally some statistical evidence of the efficacy of the use of simulations in the clinical training of SLP graduate students! I am currently preparing a manuscript for this study.
Q. Sounds like your job is both exciting and challenging. As you aware, there has been a tremendous increase in simulations in CSD. Would you agree?
Absolutely! There are so many programs utilizing simulations for either academic coursework, for clinical experience, or for both. Each program is doing things differently, based on its needs and resources.
Q. And what factors do you believe are driving that?
I think there are many factors that come into play. Programs are experiencing numerous stressors that impact their ability to provide adequate experiences so that students can meet the certification standards. There are also funding and staffing issues – for most programs there are limitations in terms of budget and faculty, and programs have had to be very creative in order to adequately serve students within their existing faculty load and compensation structure.
Faculty in CSD programs have been trying to devise traditional solutions to these issues for some time now, some with limited success. At the same time, in 2016 the Council for Clinical Certification in Audiology and Speech-Language Pathology (CFCC) of the American Speech-Language-Hearing Association revised the Standards to include clinical simulation as a means for speech-language pathology students to obtain direct contact clinical hours. The implementation language states that up to 20%, or 75 hours, may be obtained via clinical simulation. Programs now have the ability to take advantage of what simulation technology has available to meet clinical training requirements in speech-language pathology programs.
Q. How has Simucase as a company responded to those needs?
Simucase has created a library of virtual patients that students can experience through a computer-based interactive simulation program to gain clinical competency and/or clinical hours. We have researched simulation learning theory, the existing literature on teaching and learning through healthcare simulations, and the successes of teaching with simulations in ours and other fields, such as nursing. That information has been utilized to create evidence-based virtual clinical experiences with clients spanning the age range from early intervention to geriatric, across the nine clinical competency areas outlined in the SLP Certification Standards. The virtual clinical experiences simulate either a complete assessment of a client, an intervention session with a client, or specific tasks such as administering and scoring a test or interpreting videostroboscopy results (task trainers). The speech-language pathology case developers and our tele-supervision team are all Certified Healthcare Simulation Educators (CHSE) and are experienced with developing critical thinking scenarios for students via virtual patient simulations.
Q. What are the remaining challenges that exist for programs considering the integration of simulations?
As programs consider whether or not they are going to incorporate simulations into their clinical teaching and practica, they face new challenges. What simulation experiences are available to the program? What is the cost? What are the logistics? How will simulations fit into the existing curriculum? Are faculty trained in the use of and teaching with simulations? Do the faculty have the time to create simulation experiences, facilitate the experiences, and appropriately utilize simulation learning theory to mediate the experiences? What documentation system will be utilized?
Once a program decides to utilize clinical simulations, programmatic procedures need to be determined. One major consideration is that in order for students to be able to “count” the simulation experiences for hours and competencies, the experiences must be supervised with the same level of quality as all other clinical experiences.
Q. So that leads us to our topic for today. Tell me about supervision and how it relates to simulations.
In the case of “live” simulations, such as high tech manikins and standardized patients, supervision takes place in real-time, much like traditional supervisory experiences. Supervisors must be ASHA certified, they must be trained in supervision, and they must have expertise in the content areas in which they are providing clinical teaching and supervision. Formative and summative assessment must be completed so that students are provided with appropriate ongoing feedback about preparation, performance, and clinical decision-making. Building rapport and a trusted mentor/mentee relationship with supervisees is just as important in supervision of clinical simulations as it is in face-to-face situations.
The differences in supervision of clinical simulations, such as Simucase, that don’t allow for real-time supervision (e.g., asynchronous) require additional interactions; specifically the pre-brief and debrief. In addition to the simulation experience itself, supervisors must provide a pre-brief and facilitate a debrief after the experience. A debrief of a clinical simulation is the time for the clinical supervisor to facilitate and mediate learning, and for the students to engage in self-reflection. Students must be provided with the opportunity to reflect on the simulation, discuss it with the other participants, make connections between academic content and clinical skills, analyze clinical decision-making, identify how the knowledge and skills of the simulation can be applied to future clients and clinical experiences, and self-evaluate their performance. Please note that the time spent in pre-brief and debrief may not be included in clinical clock hours.
Q. So how does supervision work for other types of simulations, like manikins and standardized patients?
Good supervision is good supervision, no matter what the clinical work is. We need to work for superior quality supervision and clinical teaching, no matter if the experience is face-to-face or a simulated experience. For all simulated experiences, whether it is a virtual computer-based case, a part-task trainer, or a high-fidelity manikin interprofessional experience, supervisors need to follow best practice and add in the pieces discussed above to their supervision. There will be varying levels of pre-brief, or student preparation, based on the technology and case scenario utilized, of course. The repeatability of the experience depends on the scenario as well: a virtual computer-based simulation can be repeated many times easily, whereas a multi-disciplinary high-fidelity experience in a simulation center may not be as easily repeatable. Nonetheless, supervision of a simulated clinical experience needs to always include the highest quality debriefing, as this is where much learning, application of concepts, and self-reflection occurs.
Q. What has Simucase done to respond to the need for supervision of simulations that do not occur in real-time?
Simucase has done several things. We have educated academic programs, faculty, and clinical supervisors about supervision of clinical simulations. We have done this through presentations at ASHA and CAPCSD conventions. In addition, we have created several courses, available at speechpathology.com, related to the integration of clinical simulation into graduate curricula, as well as supervision of these experiences. SimQ, which you are taking part in right now, is another venue for education. Simucase has also made available completion times for specific cases to be used as suggested guidelines in counting clinical clock hours.
In addition, Simucase now offers an optional service for programs. Simucase will provide customized program experiences and provide the supervision required to allow students to count their experiences towards clinical hours. The students are guided through the Simucase experience by SLPs specifically trained in teaching and supervising with clinical simulations. The SLPs will also track and approve clinical clock hours; rate student competencies for targeted ASHA standards; and provide grade recommendations.
Q. What has been the response?
The response has been extremely positive! Faculty from many programs have attended our educational sessions, completed the online coursework at speechpathology.com, have utilized the resources available in the Faculty section of the Simucase website, have chatted with our customer service representatives, or have emailed/spoken with the Simucase team to get information about supervision.
Several programs have utilized our tele-supervision services and created a virtual practicum experience for their students. Both programs and students have been very pleased with the experience. Students are receiving clinical hours and competencies in areas they need, they are engaging in meaningful discourse about assessment and treatment of individuals with disorders of communication and swallowing, and they are integrating ethical issues, contemporary professional issues, and evidence-based practice into virtual clinical experiences.
Q. How have the Simucase supervisors been trained in teaching and supervising with clinical simulations?
All Simucase supervisors have obtained Certified Healthcare Simulation Educator (CHSE) status. This is a certification awarded by the Society for Simulation in Healthcare (SSH). It is intended for individuals who perform healthcare simulation in the educator role and who demonstrate focused simulation expertise with learners in undergraduate or graduate allied health or healthcare practitioner programs, and who have two years of continued use of simulation in healthcare education, research or administration. It is a rigorous certification process, and we are proud that our team has obtained this level of expertise.
Q. Do all supervisors who are or are going to supervise clinical simulations need this certification?
No. While all supervisors need to be trained in supervision, as well as simulation learning theory and practice if they are supervising simulations, it does not need to be at the level of SSH study and training. The Simucase team has been creating a repository of simulation supervision resources for faculty that are more focused on simulation use in communication sciences and disorders.
Q. What if a program wishes to conduct their own supervision?
Programs can certainly provide their own supervision. The Simucase team is happy to provide resources, many listed above, to assist programs with supervision of simulations.
Q. What models have you seen programs use?
There is a range of how programs are using Simucase for teaching and clinical education. Some programs are using simulations for both demonstrations and assignments in academic courses. Some use simulations for remediation activities when students are struggling. Some programs assign students simulations for experience, without allowing them to count towards clinical clock hours. Others are providing students with simulation experiences, engaging in pre-brief and debrief activities, and counting them for clinical hours and demonstration of competency toward meeting the certification standards.
Q. So that leads to my next question. What do the CFCC guidelines say about documentation of hours?
The Council for Clinical Certification has revised the standards to include hours gained via simulation toward certification, as was discussed earlier. The language specifies that the number of simulation hours allowed is 75. The CFCC does not, however, provide guidelines for documentation of these hours. That is something each program will need to consider based on their own needs and comfort level with simulations.
Q. What practices are you aware of?
As you are aware, programs have a wide variety of record-keeping systems already. Some are using commercial software programs such as Typhon or Calipso to track student hours and competencies. Others use their own university programs or excel spreadsheets to track the data. Still, others are using paper forms for record-keeping. One is not better than the other; each program has a system that has been approved by the CAA and is useful to it. When we bring hours gained from simulations into the record-keeping system, they need to be documented in the same way: number of hours, disorder area, age of the client, diversity factors. The only documentation piece needed to be added is a coding that the hours were obtained via clinical simulation so that programs can keep track of the total number obtained via simulation.
Q. What do you see in the future for simulations in general?
I see an increase in the use of simulations in clinical training in speech-language pathology and audiology. We have learned about successful use of simulations and their efficacy for clinical teaching from other healthcare disciplines, and now we are running with this in communication sciences and disorders. As was discussed, programs are already using a variety of clinical simulations for a variety of reasons, and they are pleased with the added value simulations bring to clinical education. More and more faculty are being trained in teaching methodologies for use of simulations, and we are focusing on research documenting effective use of simulations in our field.
Q. What should we look forward to in terms of Simucase?
Simucase is always moving forward. We are continually creating and adding new simulations to our library that will be of benefit as learning tools and for clinical experience. This includes all types of simulations: assessment cases, intervention cases, and task-trainers for specific skill development. We are increasing the diversity of our simulations in terms of the client demographics, their disorder areas, and their clinical settings, as well as the types of task-trainers available. We will soon be releasing clinical simulations in the discipline of occupational therapy. Our newest feature is a video observation library. Anyone with a membership can access the entire library containing over 300 client videos in addition to the complete simulation library. It is definitely an exciting time in CSD education, with academic programs finally having new and diverse opportunities to expand and optimize clinical education.
Q. How can CSD Programs further the use of simulations in CSD education?
Programs can explore how simulations can further their clinical teaching and the clinical experiences they have available to students. They can learn more about simulation technology and what is available to them. They can begin to or increase integration of clinical simulations into their curricula. They can utilize clock hours obtained via clinical simulation to fulfill certification standards. They can create simulations to fill needs in clinical training. They can design research studies and collect data to build the evidence base for efficacy of clinical training via simulation. If we all work together, we can revolutionize clinical teaching in speech-language pathology and audiology.
Thank you for your time. This was very informative.
Szymanski, C. (2018). SIMQ: Telesupervision SpeechPathology.