Integration of simulated learning environments into speech pathology clinical education curricula: A...

Integration of Simulated Learning Environments into Speech

Pathology Clinical Education Curricula:

A National Approach

Prof. Deborah Theodoros

Dr. Bronwyn Davidson

Ms. Anne Hill

Chief Investigators

Dr. Naomi MacBean

Project Officer

The University of Queensland

[ Participating Universities ] Charles Sturt University | Curtin University | Edith Cowan University

Flinders University | James Cook University | La Trobe University | Macquarie University

The University of Newcastle | The University of Queensland | The University of Sydney

08 Fall

Health Workforce Australia

Simulated Learning Environments Project :: Final Report

November 2010

Simulated Learning Environments in Speech Pathology Curricula | November 2010

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Speech Pathology Collaborative Charles Sturt University

Ms. Libby Clarke

Curtin University

Assoc. Prof. Cori Williams

Edith Cowan University Prof. Beth Armstrong

Flinders University

Dr. Sue McAllister Assoc. Prof. Paul McCormack

James Cook University

Ms. Louise Brown

La Trobe University

Dr. Emma McLaughlin

Macquarie University

Dr. Elisabeth Harrison Dr. Eva Nemeth

The University of Newcastle

Prof. Alison Ferguson


Prof. Deborah Theodoros Dr. Bronwyn Davidson Ms. Anne Hill Dr. Naomi MacBean

The University of Sydney

Assoc. Prof. Kirrie Ballard Dr. Tricia McCabe Dr. Alison Purcell

Speech Pathology Australia Mrs. Vickie Dawson Senior Advisor Professional Standards Dr. Anne Ozanne Professional Standards Advisor Ms. Christine Stone National President Ms. Natalie Ellston Vice President Communications Ms. Gillian Dickman Vice President Operations Ms. Marguerite Ledger National Professional Standards Portfolio Coordinator Ms. Gail Mulcair Chief Executive Officer Acknowledgements This project was completed with the financial support of the Health Workforce Australia. Infrastructure support was provided by the School of Health and Rehabilitation Sciences, The University of Queensland.


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1 Executive Summary

Workforce clinical placement of allied health students is currently considered to provide the gold standard in clinical education. The rising demand for health professionals to service the Australian population requires greater student numbers and consequently increased university capacity for clinical education. Traditional models are rapidly becoming unsustainable, with student numbers soon to surpass availability of workforce placements. The profession of speech pathology engages in diagnosis, management and treatment of individuals who are unable to communicate effectively, or who have difficulty with feeding and swallowing (Speech Pathology Australia, 2010). The scope of practice of speech pathologists is such that clinical placements in the workforce comprise a significant component of speech pathology curricula in order to meet professional competency standards. Simulated learning environments (SLEs) are increasingly being used in the education of health professionals, particularly in medicine and nursing, and have potential for integration into the speech pathology curricula. However, the ability to generalise research regarding SLEs in other health professions to the speech pathology field is limited due to issues such as the quality of studies that have been undertaken, and the unique characteristics of the speech pathology profession. It is possible however to gain valuable insight into the types of SLEs available, their potential application to speech pathology and likely impact on learning outcomes. Indeed, SLEs appear to provide quality learning experiences which result in comparable or superior outcomes to traditional approaches to clinical education. The use of SLEs in speech pathology has the potential to provide additional learning experiences for students and possibly result in increased clinical education capacity for university programs. This report presents a nationally developed and endorsed approach to the potential integration of SLEs into speech pathology clinical education curricula. Detailed investigation was undertaken to determine the potential contribution of SLEs to expanding clinical training capacity and reducing load on workforce educators. Initial consideration was given to the current use of SLEs by Australian speech pathology programs (in terms of type, learning objectives targeted and barriers associated with their use). SLEs were reported to be in use in four of the ten universities, with a broad range of learning objectives being targeted. Universities reported an interest in further development of SLEs, however were restricted by insufficient funding. Opportunities for future integration of SLEs into the curricula were determined through extensive consultation with stakeholders (all universities offering accredited speech pathology programs, accreditation body, members of the profession and student body). It was agreed that SLEs had the potential to be integrated into the clinical education curricula, with priority elements identified as:

x Clinical skill enhancement prior to workplace placement x Additional coverage of specialised areas of speech pathology practice x Replacement of early clinical observation experiences x Facilitation of inter-professional learning

SLE modalities, e.g. mannequins, standardised patients or virtual reality, were considered to vary in their ability to assist speech pathology students to attain clinical competencies. The inclusion of standardised patients in clinical education appears to offer immediate benefit to speech pathology students. Benefit can also be seen in the development of virtual reality technologies. Medium-high fidelity mannequins, while widely available, are not thought to adequately address speech pathology practice at this time. Barriers to the future adoption of SLEs were found to be development costs and the need for recurrent funding, staffing, space, materials (e.g. mannequins and computer equipment), equitable access to existing SLEs, and lack of evidence base surrounding their use. It was considered that


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given adequate funding, integration of SLEs into the curriculum was feasible and possible to implement within three years. The integration of SLEs into speech pathology education curricula is considered likely to reduce the current load on workplace clinical educators and potentially increase clinical education capacity for university programs. Australian speech pathology programs have a proven history of successful collaboration in developing innovative practices and sharing of resources to enhance student learning. This report recommends a model for successful development and integration of SLEs into the speech pathology clinical education curricula. All ten universities offering accredited speech pathology programs in Australia have demonstrated consensus with the model and are committed to its implementation on receipt of adequate development funding and ongoing resources.


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Table of Contents

1 EXECUTIVE SUMMARY ............................................................................................................ 3

2 BACKGROUND ........................................................................................................................ 7

2.1 Operating Definition of SLE 7

2.2 Scope of Speech Pathology Practice 8

2.3 Accreditation of Speech Pathology Degree Programs in Australia 8

3 PROJECT APPROACH/METHODOLOGY .................................................................................. 10

3.1 Stage One 10

3.2 Stage Two 10

3.3 Stage Three 10

3.4 Stage Four 11

3.4.1 Meeting of Speech Pathology Collaborative and Speech Pathology Australia 11

3.4.2 Progress Report 11

3.4.3 Clinical Educator Feedback 11

3.4.4 National Forum on SLEs in Speech Pathology Clinical Education 11

3.5 Stage Five 12

4 FINDINGS .............................................................................................................................. 13

4.1 Current use of Simulated Learning Environments (SLEs) 13

4.2 Literature Review 13

4.2.1 Simulated Learning Environments in Speech Pathology Education 14

4.2.2 Transfer of Skills from Simulation to Clinical Practice 20

4.3 Outcomes of Stakeholder Consultation 20

4.3.1 Survey 1 21

4.3.2 Survey 2 23

4.3.3 Workplace Clinical Educator Views 41

4.3.4 National Forum 46

4.4 Curricular elements that could be delivered via SLEs. 48

4.5 Level of Agreement Obtained 49

4.5.1 Curricular Elements 49

4.5.2 Perceived Barriers to this Curriculum being Recognised and Adopted for Clinical Training Purposes 50

4.5.3 Likely Impact on Clinical Training Days should SLEs be Introduced 50

4.5.4 Likely Timeframes for Implementation 50

5 RECOMMENDATIONS ........................................................................................................... 52

5.1 Recommended Approach to Integration of SLEs into Speech Pathology Clinical Education 52

5.1.1 Case Bank 52

5.1.2 Modes of SLE 53

5.2 Approaches to Address Barriers to Effective Utilisation of SLEs in Delivering the Curriculum 55

5.2.1 Development of SLEs 55

5.2.2 Funding of SLEs 56

5.2.3 Development of Evidence Base 56

5.2.4 Equitable Access to SLEs 57

5.3 Concluding Statement 57

6 REFERENCES ......................................................................................................................... 59


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List of Tables

Table 1 Current Use of SLEs in Speech Pathology Programs ......................................................................... 13

Table 2 Mapping Potential SLEs into Current Clinical Education .................................................................... 25

Table 3 Resources for Implementation of SLEs ............................................................................................... 31

Table 4 Feasibility and Timeframe Required for Implementation of SLEs ....................................................... 32

Table 5 Ability of SLEs to Meet Clinical Education Objectives ......................................................................... 34

Table 6 Student Perception of Advantages and Disadvantages of SLEs ........................................................ 40

Table 7 Agreed Feasibility and Timeframe to Implementation of SLEs ........................................................... 51

List of Figures Figure 1 Will SLEs Impact on Clinical Placements? ......................................................................................... 24

Figure 2 Could SLEs Replace External Placements (Range Indicators)? ....................................................... 29

Figure 3 Could SLEs Replace External Placements (Clinical Skills)? ............................................................. 29

Figure 4 Could SLEs Reduce Hours on Placement (Range Indicators)? ........................................................ 30

Figure 5 Could SLEs Reduce Hours on Placement (Clinical Skills)? ............................................................... 30

Figure 6 Student Views on SLEs across Range Areas .................................................................................... 38

Figure 7 Student Views on SLEs to Obtain Clinical Skills ................................................................................ 39

Figure 8 Student Views on Usefulness of SLEs ............................................................................................... 39

Figure 9 Recommended Approach to SLE integration into Speech Pathology Clinical Education .................. 54


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2 Background

The application of theoretical knowledge to clinical situations is a primary goal of health science education. Traditionally, clinical competency across the health disciplines has been achieved through a combination of didactic and/or problem based teaching of theoretical knowledge and student placement within clinical settings. However, access to an appropriate range and number of clinical placements is becoming increasingly difficult (due to escalation in student numbers) and clinician time available for supervision and feedback on individual student performance is limited. An increasing number of higher education institutions, in Australia and internationally, are using simulated learning environments (SLEs) in an attempt to find more effective and efficient means of teaching and assessing clinical knowledge and reasoning skills (Williams & Schreiber, 2010). Indeed, simulation is now considered a ‘central thread in the fabric of medical education’ (McGahie, Issenberg, Petrusa & Scalese, 2010, p.51). Currently limited literature exists on the use of SLEs in speech pathology clinical education. However, initial findings are positive. Certainly research in other health disciplines suggests that the incorporation of SLEs into professional education programs has the potential to maintain quality learning outcomes, while reducing training demands on the workforce. Workforce placements currently form an integral part of speech pathology clinical education programs within Australia. Assessment of student performance within the workplace across required competencies (CBOS, Speech Pathology Australia, 2001) is a necessary component for accreditation of university programs by Speech Pathology Australia (SPA). For the purposes of accreditation, SPA does not mandate a minimum number of clinical hours to be completed prior to graduation but rather that graduating students meet minimum competency standards across a range of clinical practice. Each university has pedagogical freedom to determine how these competencies are achieved within their program. Consequently, speech pathology programs are well placed for integrating quality SLEs within the curriculum whilst maintaining accreditation requirements. This report has been commissioned by Health Workforce Australia as part of the workforce reform package. The objective is to present a nationally developed and endorsed approach to the potential integration of SLE into speech pathology clinical education curricula. The current report represents the agreed views of all universities offering accredited speech pathology programs within Australia and the national accreditation body (Speech Pathology Australia) on the following: • Aspects of speech pathology curricula that can be delivered via SLEs • Potential barriers to adoption • Feasibility and timeframes for implementation • Contribution of SLEs to expanding clinical training capacity and reducing load on workforce

educators.

2.1 Operating Definition of SLE

Simulation aims to offer a skills-based experience in a safe and secure environment through the imitation of reality. The objective of simulation is to enable students to more readily execute skills and manage scenarios when they occur in a clinical setting. The terms simulated learning environments (SLEs) and simulated learning programs (SLPs) are often used interchangeably in the description of simulations used in health professional education. For the purposes of this report, simulated learning environment will serve as an umbrella term to refer to the various modalities of simulation available to educators. That is, simulations such as standardised patients, virtual reality and mannequins will be referred to as modes of SLE.


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2.2 Scope of Speech Pathology Practice

Speech pathology involves the diagnosis, management and treatment of individuals who are unable to communicate effectively or who have difficulty with feeding and swallowing (Speech Pathology Australia, 2009). The scientific basis of the profession falls within the area of Human Communication Sciences.

Communication can be considered the process of being able to understand and to be understood. One in seven Australians has some form of communication disability, involving either difficulty with speech, using and understanding language, voice, fluency, hearing and/or literacy. The speech pathology profession recognises the rights of individuals to possess an effective form of communication and swallowing and the need for efficient and effective service provision (Speech Pathology Australia, 2001).

A broad range of clients can receive speech pathology services. Clients may include children who fail to develop normal communication and/or feeding skills or people who acquire communication and/or swallowing disabilities as a result of disease, injury or a stroke. A speech pathologist’s workload might include giving advice on feeding to a mother who has a baby with a cleft palate, working with a school child who cannot understand what his teacher says, rehabilitating a young man who has severe brain injury due to a motorcycle accident or treating a person who has speech problems following a stroke (Speech Pathology Australia, 2009). Primarily, speech pathology practice involves the facilitation of communication and swallowing rather than specific physical or technical manipulation of these disorders. As such, SLEs need to be designed to reflect this mode of practice.

Speech pathologists complete a university degree which encompasses all aspects of communication and swallowing. An entry-level speech pathologist in Australia must be able to demonstrate competence in paediatric and adult speech pathology practice across the areas of speech, language, swallowing, voice and fluency in relation to both developmental and acquired disorders (Speech Pathology Australia, 2010).

2.3 Accreditation of Speech Pathology Degree Programs in Australia

The Federal Government of Australia (Department of Education, Employment and Workplace Relations) recognises Speech Pathology Australia (SPA) as the professional body representing speech pathologists in Australia, and as being the accrediting body of university speech pathology programs. An accredited speech pathology degree program within Australia permits graduation of only those students who have achieved the entry-level standard specified in the Competency Based Occupational Standards (CBOS, Speech Pathology Australia 2001). Universities in Australia provide accredited programs for entry to the profession as Bachelor or Graduate Entry Masters degrees.

The Speech Pathology Australia CBOS document outlines the minimum skill, knowledge base and attitudes required for entry-level practice of speech pathology. These are the competencies that the public can expect of an entry-level speech pathologist (Speech Pathology Australia, 2001). CBOS includes a ‘range indicator statement’ which refers to the range of ages and areas of practice that a speech pathologist must be able to cover. It also stipulates the level of independence that is required for competent performance at entry-level to the profession. The


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‘range indicators’ are speech, language, swallowing, voice and fluency (Speech Pathology Australia, 2001). A speech pathologist must have competency in these range indicator areas with both adults and children across both developmental and acquired disorders. SPA defines entry-level for speech pathologists in Australia as: ‘the point equivalent to graduation with a degree from a course in speech pathology which has been accepted by Speech Pathology Australia from an Australian university or before any employment as a speech pathologist in Australia’ (CBOS, Speech Pathology Australia, 2001 p.1).

Each university maintains pedagogical freedom in designing programs to meet accreditation standards and unlike some other allied health professions, there is no requirement for students to attain a set number of clinical hours prior to graduation. Rather, accreditation of speech pathologists is competency based, relying on assessment of students’ clinical performance against the seven competency units competencies outlined in the CBOS (Speech Pathology Australia, 2001). These are:

x Assessment x Analysis and interpretation x Planning of speech pathology intervention x Speech pathology intervention x Planning, maintaining and delivering speech pathology services x Professional, group and community education x Professional development.

SPA views assessments of student performance as evidence of having achieved competency. This evidence may be of varying levels. Direct evidence of competency is provided by assessment based on direct observation of the student on practicum (i.e. in workplace clinical practice) and is the most desired level of evidence for accreditation. Assessment based on indirect report of the student on practicum or direct observation of a student in a simulated/videoed situation is classed as indirect evidence and used as supplementary evidence where direct evidence is incomplete.


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3 Project Approach/Methodology

The investigation into SLE inclusion in speech pathology clinical education in Australia involved five main stages. These are outlined below.

3.1 Stage One

x Ethical approval for the project was sought and obtained from the Ethics Committee of The University of Queensland.

x An initial meeting (via teleconference) was held with members of the Speech Pathology Collaborative (consisting of representatives from all Australian universities currently offering degree programs in speech pathology) to discuss the aims of the HWA project for speech pathology and to gain their cooperation and support to facilitate the collection of comprehensive data from Australian speech pathology programs.

x An initial meeting (via teleconference) was held with the executive and CEO of Speech Pathology Australia (SPA) to discuss the aims of the HWA project for speech pathology and the proposed plan.

x Survey 1: An online survey of all accredited speech pathology programs in Australia was conducted to obtain baseline information concerning their perception and use of simulated learning environments (SLEs) in the clinical education of speech pathology students. Information sought from the Universities with regard to their programs included: x The nature and current use of SLEs that meet their clinical learning and clinical placement

objectives within the curriculum x Perceived strengths and barriers to the use of SLEs in curriculum x Technical and non-technical elements of their clinical curriculum that could be delivered by

SLEs.

3.2 Stage Two

x A review of existing and current research (including projects in progress) on the use of SLEs to achieve clinical learning outcomes was completed. The review included the use of SLEs in medicine, nursing and other allied health disciplines, alongside speech pathology. In particular, evidence was sought for simulation experiences where learning outcomes have been achieved and are equivalent to clinical practice. Both technical and non-technical experiences were included.

3.3 Stage Three

x A briefing paper was developed, outlining the current use of SLEs in speech pathology education programs across Australia as well as examples of SLEs being used in other health disciplines that may have application to speech pathology clinical practice. This briefing paper served as a basis for ongoing discussion amongst all stakeholders, and served as background information for the second survey.

x Survey 2: The second survey was administered to gather the following information from each University: x Overview of curricula, with a particular focus on mapping aims, progression and timing of

clinical education x Curricular elements or professional competencies that could be delivered by SLEs with

particular attention to those elements/competencies that have the potential to meet clinical placement objectives and increase training capacity


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x Opinion as to how SLEs used in other speech pathology programs in Australia and internationally (described in the briefing paper) meet clinical placement objectives and how they may increase clinical placement capacity

x The feasibility, timeframe, and resources required in order to introduce SLEs into current curricula

x Student opinion regarding the curricula elements/competencies that might be effectively taught using SLEs

x Both qualitative and quantitative analyses were conducted on the data collected from this survey in order to clearly report the curricula elements and/or professional competencies deemed appropriate for simulated learning experiences, and the impact that the introduction of this type of learning might have on speech pathology clinical education.

3.4 Stage Four

The aim of stage four (comprised of four components) was to gain national agreement from key stakeholders (universities, SPA and members of the profession) on the following:

x The curricular elements identified in stage three that could be integrated into the curricula x Any perceived barriers to this curriculum being recognised by the universities for clinical

training purposes x The likely impact on clinical training days required in the course should these curricula

elements be delivered through SLEs x The likely timeframes for implementation should these curricula elements be adopted.

3.4.1 Meeting of Speech Pathology Collaborative and Speech Pathology Australia

x Representatives from each of the 10 universities and Speech Pathology Australia were invited to attend a face to face meeting to discuss the compiled results of the two surveys conducted in Stage 3 and discuss implementation of SLEs into speech pathology curricula and any impact on accreditation.

3.4.2 Progress Report

x A progress report, including the briefing paper and results from the two surveys, was distributed to all Heads of Speech Pathology programs across Australia and the CEO of SPA.

3.4.3 Clinical Educator Feedback

Each university was asked to gain feedback from their clinical educators regarding the following: x Aspects of clinical supervision which contribute most to clinical educator workload x Qualities of students that accompany a decrease in clinical educator workload x The likelihood of SLEs reducing clinical educator workload

3.4.4 National Forum on SLEs in Speech Pathology Clinical Education

x A forum was held to showcase current SLE activity in speech pathology programs and other SLEs that have potential for application in speech pathology clinical education. It aimed to demonstrate to academics and to members of the speech pathology profession the academic application of SLEs, the evidence supporting this method of clinical learning, and the potential scope of simulated learning activities in the future.

x The forum involved a face-to-face meeting of key stakeholders from university programs, Speech Pathology Australia, members of the profession (health, education and disability sectors), and new graduate representatives.

x Presentations from speakers, including an international guest speaker, regarding opportunities for SLE use in speech pathology education occurred.


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x Participants at the forum reached unanimous agreement on the following: x Curricular elements/professional competencies that may be taught by SLEs x Potential barriers to the integration of SLEs into curricula x Potential impact of SLEs on the number of external clinical training days within a

program x Likely timeframes for implementation should the curricular elements/professional

competencies within the programs be acceptable to the accrediting body.

3.5 Stage Five

Further consultation was conducted with the Speech Pathology accreditation body (SPA) on the following:

x The curricular elements meeting the accreditation standards for all Australian universities where Speech Pathology education is delivered

x Any perceived barriers to these curricular elements being adopted by Australian universities where Speech Pathology education is delivered

x That these curricular elements may replace the traditional delivery of clinical training through clinical placements

x The likely timeframes for adoption of curricula elements.

A draft of the final report was completed and distributed to members of the speech pathology collaborative and SPA for comment. This feedback was taken into consideration in the production of the final submitted report.


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4 Findings

4.1 Current use of Simulated Learning Environments (SLEs)

Simulated learning environments are not widely used in existing speech pathology clinical education. Role plays, peer learning and written case studies are reported to be used within academic courses across most universities, however only four of the 10 accredited universities reported current use of SLEs. These are shown in Table 1.

Table 1 Current Use of SLEs in Speech Pathology Programs

Simulations Used Range Indicators 1

Areas of Practice / Skills Targeted

x Standardised patients x Part task trainers x Low fidelity

mannequins x Environmental

simulations

x Adult and paediatric

speech x Adult voice x Adult and paediatric

fluency x Adult swallowing x Foundation clinical

skills.

x Communication skills x Professional

behaviours x Access and application

of information x Assessment skills x Clinical reasoning skills x Interview skills x History taking skills x Treatment planning

and implementation

SLEs were considered to have potential for integration into the speech pathology curricula. Overall, SLEs were thought best suited to developing foundation clinical skills (e.g. interaction, reasoning, communication, professionalism), providing additional coverage of range indicator areas (voice, speech, swallowing, language, fluency) when traditional clinical placements were difficult to source, and development of specific skill areas (e.g. tracheostomy, laryngectomy). Further details on potential use of SLEs in speech pathology clinical education are presented in Section 4.3.

4.2 Literature Review

Simulated learning environments afford substantial opportunities for enhancing student learning. They allow access to clinical variation and standardisation of the clinical curriculum across students and locations. Exposure to a wider range of clinical scenarios is possible, including rare and/or more serious health conditions which may have a low frequency of presentation in some settings (Aliner, 2007). This has the added benefit of affording greater equity to students in regional and/or remote locations where the range of real patients may be restricted. The provision of a safe, controlled learning environment may be particularly salient in such rare or serious cases, allowing learners to make, detect and correct patient-care errors with no adverse patient consequences; and for educators to focus on the learners rather than the patients (Aliner, 2007; Issenberg & Scalese, 2007). 1 ‘Range indicator’ is a term used in the CBOS (Speech Pathology Australia, 2001). ‘Range indicators’ refer to the range of ages of clients and areas of speech pathology practice. ‘To be considered competent as a speech pathologist at entry level in Australia, the practitioner must be able to function in all contexts outlined in the range indicators’ (p.1). The range indicators currently covered in the CBOS are adult and paediatric speech, language, swallowing, voice and fluency.


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Attainment of uniform educational outcomes, despite different rates of trainee progress, is possible with the use of simulated learning environments (SLEs). Complex clinical tasks can be broken down into components, allowing students to attain mastery in sequence at variable rates. Standardised educational experiences can be reproduced, enabling assessment of clinical skills across students on identical scenarios (Aliner, 2007). At the same time, learning experiences can be individualised and adapted to students’ unique learning needs (Issenberg & Scalese, 2007). Simulation then, has the potential to provide quality learning opportunities for students and also a method of assessing the attainment of clinical competencies. The adoption of this approach to teaching is appropriate for meeting a range of learning objectives, involving cognitive, psychomotor and non-technical skills (e.g. communication) due to the variety of simulation tools available (Aliner, 2007). Indeed, simulation has been reported to improve learning and clinical performance evidenced through increased safety, decreased error rates and improved clinical judgment (Bearnson & Wiker, 2005). It is said to be particularly effective in developing skills in procedures that require eye-hand coordination, increasing confidence, communication skills and team work (Brigden & Dangerfield, 2008). Despite simulated learning being embraced by the medical profession, and more recently nursing and allied health professions, there is not a strong body of conventional evidence to support its value (Flanagan, Clavisi & Nestel, 2007). However, alternative study designs eliciting qualitative and quantitative data (related to student learning outcomes and perceptions) have provided important insights into the use of various simulator-based activities in educating health professionals (Flanagan et al., 2007).

4.2.1 Simulated Learning Environments in Speech Pathology Education

Higher education providers in speech pathology are beginning to embrace the use of simulation to enhance student learning, however research in this area is in its infancy. Inclusion of simulated learning in speech pathology curricula is the subject of few published reports. In the following review, evidence from other health professions will be presented alongside existing speech pathology specific literature to outline current and potential applications of SLEs.

4.2.1.1 Standardised Patients

Medical education has embraced the use of standardised patients (SPs) since Barrows and Abrahamson’s (1964) report of their use in clinical neurology examinations. References to the use of SPs are now plentiful in the medical literature, with SP use designed to meet a variety of educational objectives including both formative and summative assessment. SPs are primarily used for teaching and assessment in the following areas: communication and interviewing skills, medical history content, and complete or partial physical examination (Stillman, Regan, Philbin & Haley 1990; Wallace, Rao & Haslam, 2002). They are frequently used in Objective Structured Clinical Examinations (OSCEs) and are considered a valid and reliable form of performance assessment (Howley, Szauter, Perkowski, Clifton & McNaughton, 2008). The use of SPs allows for more equitable learning opportunities (and subsequent assessment of clinical skills) through the ability to provide all students with access to the same information and experience. Indeed, patient scenarios can be developed to fit specific learning objectives and afford a high degree of control in terms of complexity of cases, reproducibility of information and patient attendance (Kneebone & Nestel, 2005; Ladyshewsky & Gotjamanos, 1997). Assessment of clinical skills through inclusion of SPs in OSCEs is now commonplace in medical education (Cleland, Abe & Rethans, 2009) and is also utilised in allied health professions, for example physiotherapy (Ladyshewsky, 1999). OSCEs are an assessment method that is based on objective testing and direct observation of student performance during planned, structured clinical encounters. OSCEs include several stations in which students are expected to perform specific clinical tasks within a specified time period. In stations involving SPs, students may be expected to perform a physical examination or procedure, take a case history or counsel the patient on assessment results or other similar tasks (Cleland et al., 2009).


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The inclusion of SPs across the health sciences is reflected in literature, including a clinical skills course in pharmacy (Austin, Gergory & Tabak, 2006), assessment and nutrition counselling in dietetics (Hampl, Herbold, Schneider & Sheeley, 1999; Henry, 2007), interviewing skills in dentistry (Stilwell & Reisine, 1992) and case history taking and physical examination in chiropractic education (Traina, Gour & Traina, 1994). SP interactions have been found to improve communication skills and allow more accurate identification of patient needs in nursing students (Yoo & Yoo, 2003). Physiotherapy and occupational therapy have also reported success in the use of SPs. Indeed, SP use could be considered widespread in physiotherapy, where it has been used to teach neurological exam techniques (Echternach, 2000), to prepare for full time clinical placements (Wojcik, 2000) and to evaluate clinical skills in history taking, communication and physical examination of shoulder pain (Ladyshewsky, Baker, Jones & Nelson, 2000). Anecdotal reports from occupational therapy studies suggest that students who have been involved in SP clinics prior to clinical placement are considered to be more client focused, more independent and more able to work collaboratively (e.g. Lindstrom-Hazel & West-Frazier, 2004). Standardised patients have also been used in the past in speech pathology education, with positive outcomes being noted. Within speech pathology, SPs have been used to simulate patients with aphasia (Edwards Franke & McGuiness, 1995; Zraick, Allen & Johnson, 2003), voice disorders (Syder, 1996), apraxia and Alzheimer’s Disease (Zraick, 2004). In terms of educational outcomes, an increase in student self-awareness rather than knowledge has been noted by some investigators (Edwards, McGuiness & Rose, 2000; Syder, 1996) while others simply concluded that the use of SPs in clinical education for speech pathology was possible and was acceptable to students (Zraick, Allen & Johnson, 2003). Hill, Davidson and Theodoros (2010) recently reviewed the use of standardised patients in clinical education and identified the challenges and implications for speech-language pathology programs. Hill et al. (2010) identified the need for specific assessment tools to document student learning outcomes in a SP program, and challenges such as the time, financial and organisational commitment involved to maintain the service. Advantages are salient though, with students regarding learning with SPs positively, reporting less stress, anxiety and embarrassment in learning clinical skills in a safe and controlled environment (Hill et al., 2010). Clinical educators are able to provide salient feedback and exploit teachable moments due to a focus on educating the student rather than education plus service to the real client (Edwards et al., 2000). However, while the use of standardised patients is now widespread within the health education curricula, it is still unclear if the use of SPs achieves the same clinical learning outcomes as would real-life clinical placement (Hill et al., 2010). Preliminary data from a randomised controlled trial (RCT) conducted recently across eight Australian physiotherapy schools suggests that SP clinics can indeed achieve comparable learning outcomes to traditional clinical placement (Jull et al., 2010). The study involved 720 volunteer students undertaking clinical placements in cardiorespiratory (SP + mannequins) and musculoskeletal (SP only) physiotherapy. Each student was involved in one of two models (intensive or mixed), each model replacing approximately 20-25% of traditional clinical immersion with SLEs. The intensive model involved replacing the first week of a block placement (4-5 weeks) with simulated learning experiences. The second model distributed the same number of hours spent in SLEs across the block placement. Preliminary findings indicated that students involved in the SLE trial achieved comparable or superior outcomes to traditional clinical immersion alone. These findings suggest that it may indeed be possible to replace traditional workforce placement to some extent, while maintaining quality learning outcomes for students.

4.2.1.2 Mannequins

Mannequin based simulation can be considered an adjunct to standardised patients. Mannequins can simulate abnormal vital signs, and are able to suffer acute life-threatening conditions and undergo drug treatment or invasive procedures without repercussions. The use of mannequins in health education, particularly in medicine and nursing, is well recognised as providing positive learning experiences that are able to replicate real-life cases (McGahie et al., 2010). Mannequins


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range considerably in technical capability and fidelity. Effective use of these simulation tools relies on alignment of educational goals with the appropriate level of technology. Basic procedural skills can be delivered using simple task trainers (which mimic body parts or regions), while complex clinical events (such as responding to hospital codes) require training on more sophisticated life-like mannequins (McGahie et al., 2010). Simple mannequins or part task trainers (PTTs) allow pinpoint training of basic skills, for example airway suctioning or intubation. Part task trainers are designed to represent only part of the real thing, aiding the acquisition of technical, procedural or psychomotor skills such as venepuncture, ophthalmoscopy and catheterization (Bradley, 2006). Low fidelity bench top models are in frequent use in medical education, often used in place of live animal or fresh cadaver models. Animals and cadavers, while being high fidelity are limited by availability, high costs, potential for transmission of disease and ethical concerns. Lower-fidelity models provide portability, lower cost and the potential for repetitive use (Grober, Hamstra, Wanzel, Reznick, Matsumoto, Sidhu & Jarvi, 2004). While providing less realism, these low fidelity bench models have been shown to be as effective as live animal models in training the acquisition of microsurgical skills in novice surgeons (Grober et al., 2004). Studies from physiotherapy have indicated that use of PTTs can result in effective learning of clinical skills and decision-making (Hassam & Williams, 2003; Kinney La Pier, 1997). Blackstock and Jull (2007) note that there is currently limited availability of suitable PTTs but consider there to be substantial potential application in the field. Particularly, they suggest that the combination of PTTs together with standardised patients (creating a high fidelity environment) would allow students to practise interview, clinical decision-making and interpersonal skills alongside specific technical skills. This approach (termed hybrid simulation) has been reported in nursing (e.g. Kneebone & Nestel, 2005) and may also be beneficial in speech pathology specific competencies, such as those required in tracheostomy (including suctioning and valve use), laryngectomy (including prostheses) and dysphagia management. Medium-high fidelity human patient simulators (HPS), such as Laerdal SimMan£, are life-sized technologically advanced simulators that have palpable pulses, heart, breath and bowel sounds and an IV arm. They are able to be intubated, programmed to speak, and respond to interventions such as administration of drugs. Depending on the model, vital statistics can be displayed on hospital monitors as would happen in a clinical setting. A realistic acute care simulation is possible, especially when the training takes place within a mock ward. Human patient simulators are used extensively within medical and nursing education (Issenberg, McGaghie, Petrusa, Gordon & Scalese, 2005). Applications to allied health professionals are starting to be recognised, for example preparing students for the care of seriously ill patients (e.g. in the intensive care or emergency ward) and in cardiorespiratory training for physiotherapists (Blackstock & Jull, 2007). The current range of HPS appears to offer limited benefits for speech pathology education. Some application to discrete skill areas exists (e.g. tracheostomy and laryngectomy management). With further development, additional areas could be targeted such as dysphagia and management of clients with cleft palate.

4.2.1.3 Virtual Reality

Computer based simulations provide students with interactive, safe environments which may be fully immersive, non-immersive or augmented (Jia, Bhatti & Nahavandi, 2008). Simulations range from simple multimedia learning contents (such as audio and video) to complex simulations providing physical feedback through haptic technologies (e.g. anatomical models for surgical training). Research suggests that learning outcomes depend more on the quality of the instructional design rather than on the medium used (Cook, Garside, Levinson, Dupras & Montori, 2010). Basic simulations have been shown to be effective in practical learning and have the benefit of being able to be distributed through existing e-learning platforms such as WebCT Blackboard (Moreno-Ger, Torrentea, Bustamanteb, Fernandez-Galazb, Fernandez-Manjona & Comas-Rengifob, 2010). Moreno-Ger and colleagues (2010) describe the use of a simple computer


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simulation, including a game-like element, to teach laboratory skills (e.g. centrifuge use for blood samples). Despite the low interactivity of the simulator, students who had prior experience with simulation reported being more comfortable during the hands-on practical session and performance of the targeted technical skill was higher than a control group. Actual handling of the equipment though, was not improved. In a recent attempt to find an alternative to accumulating fieldwork clinical hours (and potentially ease the demands placed on professionals), Brett Williams and colleagues (2010) posed the question - can DVD simulations transform clinical fieldwork? Simulated patients (actors) were filmed in a range of health care settings interacting with numerous health care professionals, through different stages of recovery. DVD presentations of cases (ranging in length from 15 mins to 3 hours) were designed to foster communication, teamwork and patient assessment skills. Students in the fields of nursing, occupational therapy, paramedics and physiotherapy reportedly found the DVD tool useful for preparation for clinical fieldwork placement and for reinforcing learning activities and objectives. The DVDs reportedly generated interest, concern and awareness of the role of other health care professionals. However, while identifying certain elements of clinical fieldwork that could be replaced by or supplemented with DVD simulation, students believed the DVDs should not replace placements entirely. Students wanted the DVDs to be more realistic (e.g. use real patients), be more interactive and technologically sophisticated. Student opinion in this report concurs with the general literature, which suggests that interactivity in e-learning materials is a pre-requisite for promoting active learning and critical thinking (Huwendiek et al., 2009).

4.2.1.3.1 Virtual Patients

The use of virtual patients (VPs) attempts to engage students in solving real world problems (clinical cases) in a virtual setting. A VP can be thought of as an interactive collection of attributes and symptoms which can be accessed by the student through a controlled clinical activity, including the patient interview, physical examination, lab tests, diagnosis, and therapy. Recommended results can be pre-determined by an instructor with feedback provided to students on submission of his/her own results (Stanford University School of Medicine, 2010). Access to VP programs may be designed to be direct via a personal computer or they can be web-based. Interaction with the virtual patients can be made more immersive through the use of a virtual cave environment (similar to a movie theatre) or a virtual world (via the internet on sites such as Second Life). Virtual patients are currently utilised by Stanford University for medical students. The WebSP system (web-based simulation of patients) is used in conjunction with human standardised patients, with VPs seen to offer greater opportunity for repeated practice needed in remedial cases (Stanford University School of Medicine, 2010). Zary and colleagues (2006) investigated the use of WebSP in comparison with more traditional teaching techniques (lecture and discussion). Students were asked to solve a clinical case by gathering information from patient interviews, physical examination and ancillary tests, in order to arrive to diagnoses and treatment sections (which were free text entries). Upon submitting the treatment, the students gained access to feedback with a detailed case discussion and actual patient follow-up. Use of the WebSP program resulted in higher student exam scores when compared to students involved in traditional lectures and discussions (Zary, Johnson, Boberg & Fors, 2006). An early foray into virtual patients in speech pathology was reported by Strang and Meyers (1987) who developed a tool for evaluating and training listening partners (including student speech pathologists and parents of clients) in the area of paediatric fluency. The student (or parent) was able to engage in an active verbal dialogue with a computer-defined preschool dysfluent child, with the fluency level of the child responding to the behaviour of the communication partner. The system relied on the input of an independent operator to code participant responses and input these during the simulation (e.g. ‘talks slowly’ and ‘models easy speech’). Efficacy of the training approach was determined using a survey, with clinicians and students rating their participation as enjoyable and helpful in skill development (Strang & Myers, 1987).


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A more recent example with greater sophistication is currently being developed by Stacy Williams (Williams & Schreiber, 2010) in a program titled SimuCase¥. It is designed to improve clinical decision-making skills in the area of assessment of school-aged children. It enables students to practise assessment methods while interacting with virtual clients, family members and other professionals involved in the case. It is said to guide students in asking questions, collaborating with appropriate people, using appropriate assessment tools and interpreting data, and the completion of a formal diagnostic report. Virtual Case Creator, a software platform developed by Birmingham City University (BCU) is reported to enable learners to access more active, context rich and flexible training opportunities using online simulation technologies (Ewan, Howley, Riley & Wynne, 2010). It aims to promote the development of problem solving and decision making skills within a health care setting. Virtual scenarios are based around interactive spaces representing a work setting (e.g. a therapy room, home environment or office), with learners able to access information as would occur in a real clinic. As learners make decisions, feedback and supporting information is provided to encourage critical thinking. Four speech pathology specific simulations are integrated into the clinical education curriculum at BCU. Learners complete scenarios for developmental and acquired communication needs and two further simulations designed to prepare students for employment (Ewan et al., 2010). An interactive computerised system enabling face-to-face communication with a virtual agent developed at the University of Colorado has been utilised in teaching language skills (Cole, Wise & Van Vuuren, 2007), voice training through LSVT® for patients with Parkinson’s Disease (Cole, Halpern, Ramig, Van Vuuren, Ngampatipatpong & Yan, 2007) and remediating agrammatic sentence deficits in aphasics (Sentactics£; Thompson, Choy, Holland & Cole, 2010). This method of computerised aphasia treatment was reported to be similar to clinician-delivered therapy in terms of effectiveness. The use of this system for student learning, rather than therapy, would seem worthy of investigation. In general, students report VPs to support their learning and offer excellent preparation for clinical reasoning in real patient encounters (Huwendiek et al., 1999). General recommendations for simulations involving VPs:

x Include cases which are relevant and of appropriate difficulty x Use different media appropriately and include interactivity x Provide specific feedback x Assist focus on relevant learning points and foster reflection x Ensure VPs are authentic in terms of web-based interface and student tasks x Ask questions and offer explanations that enhance clinical reasoning.

4.2.1.3.2 Virtual Caves

A virtual cave is currently being used as a teaching tool within the speech pathology program at Case Western Reserve University (Ohio, USA). As well as being used for student education, The Virtual Immersion Centre for Simulation Research (VICSR) utilises an interactive 180 degree immersive virtual reality simulation theatre as a therapy tool. Therapy scenarios involve a visit to a McDonald’s restaurant designed to allow the client to interact freely with the staff and patrons at the restaurant. Interactions with the McDonald's workers and patrons (controlled by an instructor seated elsewhere) are determined by the questions, comments and social behaviours derived from the client in the simulator. Further scenarios are used for student learning designed for practice of diagnostic skills, including: speech and language case studies for a preschool and kindergarten aged client; and speech, language and hearing case studies for school aged and adolescent clients (Williams, 2006). Students are provided with a case history prior to entering the VICSR. An instructor controls the responses and behaviours of the VR patient / family members based on the questions and


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behaviours of the students. The student is able to complete an appropriate diagnostic assessment protocol, leading to diagnosis and subsequent explanation of results and treatment options to the virtual patient and family members. The VICSR includes an observation room for family members, teachers and other professionals to observe virtual experiences (Williams, 2006).

4.2.1.3.3 Virtual Worlds

A virtual world is a simulated multi-media environment, usually accessed via the internet, which is designed so that users can interact via their own representation (avatar) (Boulos, Hetherington & Wheeler, 2007). The environment (either 2D or 3D) can also include equipment which can be manipulated. Complex tasks are possible, whether it be participating in a team meeting or enacting case scenarios with the added feature of enabling synchronous or asynchronous involvement. Virtual worlds are becoming a popular way to facilitate learning including teamwork, collaboration, clinical judgement and skill practice in complex health care settings (Billings, 2009). The potential of Second Life (SL) as a learning environment has been recognised in the literature (Weicha, Heyden, Sternthal & Merialdi, 2010), with mention of the opportunities for student interaction, intense engagement, scripted immersive experiences, simulations, role playing and constructivist learning. It is said to improve student engagement and attention, while encouraging less inhibition and greater interaction between participants (Billings, 2009; Wiecha et al., 2010). Technical and security issues, significant computer system requirements, the steep learning curve for navigation and interaction, combined with the fact that many corporate or university firewalls do not allow access to public virtual worlds (including SL), pose some difficulties for integration of SL into the teaching curriculum. It is however being used with success in numerous sites, with over 300 colleges and universities being reported to teach courses and conduct research in SL builds (Weicha et al., 2010). For example, The Imperial College of London has created a game based simulation in SL for undergraduate medical students enabling interaction with virtual respiratory therapy patients. Students are able to listen to breath sounds, request further testing (e.g. laboratory or imaging), and access feedback on their diagnoses. Simple tasks, such as hand washing are included in the simulation, increasing the realism of the interaction. Interactive communication technology (virtual reality and SL) was recently found to be perceived similarly to standardised patients for clinical training exercises with dental students (Rothenberg, Williams & Victoroff, 2008). Third year dental students (n=66) were randomly selected to participate in one of three patient interaction conditions (standardised patients, second life or virtual reality). The students reviewed charts and interviewed patients regarding smoking habits and discussed strategies for reducing or discontinuing the behaviour. Students completed a questionnaire immediately after the interaction recording responses on the following: attitudes, realism, importance, usefulness, distress, anxiety, and plan to use the skills learned. Results indicated no significant differences between participant reports for the three simulation experiences. The investigators proposed that interactive communication technology, such as virtual reality and virtual worlds, could be easier more convenient and more cost effective than traditional standardised patient approaches and provide a similar benefit. They suggest that computer generated alternatives to standardised patients might complement and enhance training involving live-actors (Rothenberg et al., 2008). Further investigation involving speech pathology specific competencies is warranted in this area. Rothenberg et al.’s (2008) findings suggest that interactive computer based technologies such as second life and virtual patients may serve as a valuable addition to speech pathology education, in particular as a complement to standardised patient interactions.

4.2.1.3.4 Virtual Reality with Haptics

Virtual reality (VR) with haptic systems (touch feedback) is considered by some to be the ultimate computer based technology. VR aims to present an identical representation of the natural environment to all human senses. Haptics provide a feeling of resistance, simulating physical contact or VR can be combined with PTTs allowing a physical interaction within the virtual


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environment. Traditionally, this form of simulation has been utilised in laparoscopic and endoscopic training (Maran & Glavin, 2003). Educators in the field of dentistry have developed a haptics based VR periodontal simulator in an attempt to overcome limitations of traditional dental mannequins (Luciano, Banerjee & DeFanti, 2009). The VR simulator is said to provide greater cost effectiveness (no physical models need to be replaced) and the possibility of detecting when the student’s action is too aggressive for a real patient (Luciano et al., 2009). Students hold a haptic device stylus to manipulate a set of virtual instruments shown on a monitor screen. The tactile feedback produces sensations in the hand of the operator. Preliminary investigation of this new approach has yielded positive results, and is said to now form a ‘vital part of the curriculum’ (Luciano et al., 2009, p. 69). At this point in time, no clear applications of this technology are present for speech pathology education.

4.2.2 Transfer of Skills from Simulation to Clinical Practice

Overall, the literature suggests that simulation results in learning that can be utilised in the real clinical setting at a later date. However, further research in this area is required. Studies to date have noted that simulation promotes greater learner attention, engagement and motivation (Jia et al., 2008) resulting in improved learner outcomes when compared with traditional lectures. Specifically, simulated learning environments have been shown to improve acquisition and retention of knowledge (e.g. Jeffries, Woolf & Linde, 2003), allow quicker skill acquisition (Peterson & Bechtel, 2000) and enhance critical thinking (Jeffries et al., 2003) and problem solving skills (Bramble 1994; Peterson & Bechtel, 2000). Learners are reported to be more satisfied and confident (Engum, Jeffries & Fisher, 2003; Johnson, Zerwic & Theis, 1999). The literature suggests that transferability of skills from one form of simulation to another, and ultimately to the clinical setting appears to be successful, however more evidence is needed (Brigden & Dangerfield, 2008). Examples of successful transfer from simulation to real patients has been reported in the use of a simple bench model for fibreoptic intubation (Naik, Matsumoto, Houston, Hamstra, Yeung, Mallon & Martire, 2001) and with laparoscopic simulators which resulted in significantly improved performance in the operating room (Scott et al., 2000). Improved clinical ability has also been reported in a recent Australian study involving nursing students. The use of low fidelity simulators (e.g. a VitalSim¥ mannequin) resulted in improved physical assessments and decreased the time to proficiency for newly graduated RNs (Starkweather & Kardong-Edgren, 2008). Another recent investigation found that team management skills learnt in a single high-fidelity simulation based course were retained over the long term, translated into clinical practice and able to be transferred across the breadth of clinical activities (Kuduvalli, Parker, Leuwer & Guha, 2009). Similar research is warranted in speech pathology education to document the efficacy of SLE innovations in providing quality learning outcomes to students.

4.3 Outcomes of Stakeholder Consultation

Extensive consultation with stakeholders was completed during the course of the project. Members of the speech pathology collaborative were asked to complete two surveys and participate in two face-to-face meetings. Each participating university was asked to canvas student opinion for Survey 2, and new graduates contributed to the National Forum. Feedback from members of the profession was obtained at the National Forum and through a brief questionnaire (distributed by university representatives). Representatives from Speech Pathology Australia (SPA) were involved in two face-to-face meetings. Further consultation with SPA and the speech pathology collaborative occurred via teleconference.


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4.3.1 Survey 1

In Australia there are currently 10 universities offering a total of 15 speech pathology programs preparing students for entry-level practice (9 Bachelor degree programs and 6 Graduate Entry Masters (GEM) programs. The total number of reported students nationwide is 1898. Student distribution over these two programs is 86% Bachelor, 14% GEM. It is anticipated that an overall increase of 27% will occur in the next decade, increasing total projected students to 2423, with a similar spread expected 82% Bachelor, 18% GEM.

4.3.1.1 Current Use of SLEs in Speech Pathology

Current use of either SPs, PTTs, low fidelity mannequins and/or environmental simulations was reported by four of the ten universities. These simulations were used to target numerous clinical skills (e.g. communication, professional behaviour and client management) across the range indicators of voice, speech and fluency. Please see Table 1 for details (in Section 4.1). Numerous challenges were being faced in the implementation of SLEs, including:

x Availability of simulation facilities and clinical staff x Access to clinical space, SPs and clinical educators x Development of cases x Training of SPs and clinical educators x Purchase of simulators and equipment x Technical support x Time organisation and timetabling

4.3.1.2 Simulation Use in Universities- Other Health Professions

Speech Pathology Collaborative respondents reported that other health professions, including medicine, nursing, physiotherapy audiology, paramedics, midwifery and occupational therapy within their universities were using simulation, with all of the 10 universities having simulated learning environments (SLEs) present in at least one of the above professions. Eight of the 10 Universities reported a clinical skills centre (CSC) to be associated with the wider university and five universities had access to a standardised patient training centre. However, these resources were not always available to speech pathology programs, with only three reporting an ability to access either a CSC or SP training centre. Factors reported to limit access were:

x Cost, distance and staffing x Space and capacity restrictions x Mannequins not having relevant medical issues x Facilities being for the sole use of other disciplines x Multidisciplinary use not encouraged

4.3.1.3 Could SLEs increase quality of clinical placements?

All respondents agreed that simulation opportunities and resources for learning foundation clinical skills would increase the subsequent quality of clinical placement experiences and outcomes. Similar reasons were given by most, including:

x Increased knowledge and skill on entering clinic o Faster transition o Focus on higher level skills in clinic o Less direct clinic time required

x Helps link theory to practice in a safe environment o Reduced anxiety and increased confidence o Opportunity to refine skills before used on clients


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x Provides access to broader client groups o Hard to find placements in some caseload areas

x Allows remedial action before and during placements, thereby: o Reducing clinical educator workload o Less failures and repeat placements

4.3.1.4 Potential Curriculum Elements

Elements of the curriculum that could potentially be taught using SLEs were numerous. Some felt it would be possible to simulate all elements of the Competency Based Occupational Standards (CBOS, Speech Pathology Australia, 2001) across all range indicators. One respondent indicated that first priority should be using SLEs to ensure students attain competency across the range indicators with preference given to difficult-to-find areas e.g. fluency, voice and paediatric speech. Second priority then could be given to other areas such as developing assessment, providing progress feedback to clients, parents or team members, or a simulated forum to practise counselling skills. Specific areas identified included student assessment (e.g. through OSCEs), discrete skill areas such as tracheostomy including suctioning and valve placements, thermotactile stimulation, oromotor examination and hearing screening. Foundation skills, such as communication, case history taking, building rapport and report writing also featured. Inter-professional learning opportunities were identified, with the potential for multiple disciplines to interact with the same standardised patient, for example a child with cerebral palsy seen by occupational therapy, physiotherapy and speech pathology students.

4.3.1.5 General Opinion of SLEs

The main strengths of SLEs are largely those identified above (Section 4.3.1.3): x The provision of a safe environment for student learning with no direct impact on clients x Enable provision of a broader range of experiences

o Coverage of range indicators x Development of clinical competencies prior to workplace clinical work

o Increasing confidence o Able to work with more complex cases o Reduced load on clinical educator o May reduce clinical hours/placements needed o Modify behaviours prior to placement and identify at risk students earlier

x The ability to structure the experience o Built in feedback o Valid and reliable assessment o Develop skills from novice to entry level o Provide opportunities for repeated practice o Provide extra assistance

Survey respondents considered that the weaknesses of simulated learning environments revolved around:

x The reduced complexity of the simulation o e.g. difficulty capturing communication exchanges and complex clinical reasoning,

difficult to train actors for complex client profiles x The failure to replicate a real life clinical situation completely

o Nuances of interaction and real time interactions, ethical reasoning, contrived nature of case studies

x Uncertainty regarding recognition of SLEs as evidence of competency in the accreditation process

x Ongoing funding and resources needed x Difficulties with timetabling


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x Perception of suitability only to early stages of clinical education x Potential risk that SLEs will be used as part of rationale to reduce availability and/or funding

for practical placements. In terms of application, survey respondents differed in their opinions as to which fields SLEs were most suited. While some cited all range indicators, other respondents did not consider SLEs to be suited for swallowing, fluency, or language. In terms of inter-professional learning opportunities, communication skills and professional issues such as ethical dilemmas were mentioned. A further option involved simulated clients (actors or virtual) being studied (face-to-face or online) by students from a range of disciplines (separately or in interdisciplinary groups), with students completing case histories, and participating in team meetings and family conferences. In terms of increased capacity for universities to provide clinical education for students, respondents differed in their opinion as to which models they thought would be successful. In general, the majority indicated that SPs, high fidelity mannequins, virtual reality technology, part task trainers, hybrid simulation and environmental simulation would likely lead to increased capacity. The majority thought medium and low fidelity mannequins would not. In order to integrate SLEs into the curricula, most respondents indicated a need for significant support, including:

x Establishment and maintenance funding x University space x Access to a pool of SPs and training x Simulation facilities and equipment x Technical support and staff to run simulations.

Access to a clinical skills centre was thought to be required by half of the respondents.

4.3.1.6 Additional Comments

Survey respondents generally expressed an eagerness to explore the possibilities of SLEs for teaching and learning. Comments were made about the great potential of virtual reality using avatars, and the likelihood that integrating SLEs would indeed reduce the load on clinical educators. It was suggested that development of generic SLEs that could be used across all universities, rather than university specific ones that needed to be maintained by individual sites, would be beneficial. The usefulness of computer based simulations not specifically included in the survey, such as interactive CDs and DVDs, for pre-clinical education preparation was mentioned. It was suggested that existing resources could be expanded upon or ‘optioned up’, enabling student practice of assessment, online data recording, transcription and analysis.

4.3.2 Survey 2

Survey 2 was designed to obtain information on potential future use of simulated learning environments (SLEs) in the speech pathology curriculum. It was distributed to representatives of the 10 universities currently offering accredited speech pathology programs in Australia. Universities were instructed to complete a separate response for each entry-level program currently offered at their institution, that is one response for a Bachelors program and one response for a Graduate Entry Masters (GEM) program. This allowed for variation to exist between responses from the same university for different entry-level programs. Currently there are 15 speech pathology programs being offered in Australia, comprised of 9 Bachelors programs and 6 GEM programs. Responses were obtained from 9 of the 10 universities (13 responses in total) within the timeframe allowed. Participants had previously completed Survey 1, outlining the current use of simulated learning environments / programs within their university and within their speech pathology program. Before completing Survey 2, respondents were asked to refer to a briefing paper which provided background information on the types of SLEs available and current applications within speech


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pathology education and other health professions. A summary of Survey 1 results was also provided. Results from Survey 2 are reported below. Where possible, responses have been combined to provide an overall response from participants. If a field was not completed, this was not included in the calculation of percentages (i.e. a reduced total number of responses was used). Where variation existed between responses, all responses have been included.

4.3.2.1 Mapping Potential SLEs into Existing Curriculum

Respondents were asked to map potential SLEs onto existing clinical education placements present in their curriculum. Information was gathered on program level, the range indicator/s targeted, whether the placement was external, the clinical education aims and potential SLEs that could be used to target clinical skills. Please refer to Table 2 for the results. Each university differed in the timing and delivery of clinical education within the broader curriculum. For this report, responses have been grouped under the range indicator and program level reported. Differences also existed in the use of external placements (clinic is off campus and students are supervised by workplace clinicians) and internal placements (students may be on or off campus, supervised by an educator employed by the university). For each clinical education experience listed by respondents, at least one university reported that an external placement was required. As such, all clinical education experiences have been listed as requiring external placements for the purposes of this report.

4.3.2.2 Potential Impact of SLEs on External Placements

Respondents varied in their opinions about the potential impact of SLEs on placements. All respondents indicated that the introduction would have some impact on clinical placements, with most considering SLEs capable of increasing capacity for student numbers and reducing total hours spent on external placements (see Figure 1). Figure 1 Will SLEs Impact on Clinical Placements?

While the majority of respondents thought SLEs could replace an external placement in the development of foundation clinical skills, other skills were thought to require real life experience (see Figures 2 and 3). Around half of the respondents indicated that external placements for voice management (both adult and paediatric) also had the potential to be replaced by SLEs.

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Table 2 Mapping Potential SLEs into Current Clinical Education Placement & Range Indicators Covered

Currently external placement?

Clinical Education Objectives For This Clinic

Potential SLEs & Skills Targeted

Initial Observation Clinic Speech or Language Adult or Paediatric

Yes To introduce students to a clinical setting, analytical and reflective observation of clinical practice Novice level CBOS Unit 7 (professional role and clinical education) Familiarisation with clinic structures and client demographics

Standardised Patients x Observation of verbal and non-verbal behaviour x Data collection x May occur in simulated ward environment

Computer Based Simulations x Observation of speech pathology assessment and treatment sessions

with a variety of clients in a range of settings to increase understanding of the role of the speech pathologist

x Use high quality interactive video presentations Virtual Cave and Virtual Worlds

x Students could explore different clinical settings (e.g. an acute hospital ward, a private practice office or a school room) before attending a clinic to minimise time spent in orientation and becoming accustomed to a new environment.

Paediatric Speech & Language

Yes Communication skills Speech / language assessment Speech / language treatment Case history CBOS Units 1-4

Interactive Computer Based Program x Case history x Scoring of test results and interpretation x Report writing x Management planning x Oral peripheral examination x Practice Assessment

Standardised Patient x Parent interview, feedback of results, home program training

Second Life Mannequins (PTTs)

x Oral peripheral examination (OPE)


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Table 2 cont’d. Mapping SLEs into Current Clinical Education Placement & Range Indicators Covered




Adult Speech & Language

Yes Communication skills Language therapy

Standardised Patients x May occur in simulated ward environment x Case history and assessment x Interaction skills

Interactive Computer Based Program x Case history and management planning

Mannequins x OPE, motor speech assessment, positioning

Paediatric Fluency

Yes Communication skills Case history Behaviour management Rating of stuttering

Second Life x Child avatar

Interactive Computer Based Program x Case history x Observe behaviours, suggest / choose options for managing - result

of the observation could be programmed in for student to see. x Computer based rating exercises with immediate feedback to student

Adult Fluency Adolescent Fluency

Yes Case history Communication skills Fluency assessment Fluency treatment

Standardised Patients x All clinical skills except for full implementation of fluency treatment

Interactive Computer Based Program/Virtual Reality x Case history, diagnosis and management planning x Report writing x Fluency assessment including syllables stuttered counts/practice /

description of behaviours x Interpretation of assessment results


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Adult Swallowing

Yes Assessment - Cervical auscultation Make recommendations re feeding

Standardised Patients x All dysphagia related skills except intervention.

Interactive Computer Based Program x Case history x Medical history, chart reading, interpretation of blood gas results,

chest x-rays, MBS/FEES results etc. x Clinical reasoning/decision making based on observation of a

simulated assessment. x Observe a recorded feeding session, assess, and make

recommendations on this basis. Different outcomes of the feeding programmed in for student to follow through programmed responses to recommendations, feedback available to student.

HPS / Mannequins x Positioning of both patient and student. x Tactile feedback for student x Oral motor examination x Practise skills for physical examination – suction, trache x Chart reading, medical history. x Respiratory monitoring/feedback

Adult Voice Yes Voice assessment and treatment Interactive Computer Based Program x Case history x Perceptual evaluation & diagnosis x Management planning

Standardised Patients x All clinical skills except for full implementation of voice treatment


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Final Placement – Assessment, diagnosis and treatment across all range indicators is possible

Yes Entry level for CBOS 1-7 for child and adult

Standardised Patients x All clinical skills except for full implementation of fluency treatment x Complex case management x Could be IPL opportunity

Interactive Computer Based Program / Virtual Patients

x Case history x Fluency rating x Management planning x Interpretation of assessment results x Report writing x Oral peripheral examination

Mannequins/ Part Task Trainers

x Oral peripheral examination x Voice prosthesis management x Tracheostomy management x Dysphagia


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Figure 2 Could SLEs Replace External Placements (Range Indicators)?

Figure 3 Could SLEs Replace External Placements (Clinical Skills)?

Overall, SLEs were thought to have the potential to reduce hours spent in external clinics. This was found across all range indicators (adult and paediatric) and clinical skill areas (see Figures 4 and 5).

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Figure 4 Could SLEs Reduce Hours on Placement (Range Indicators)?

Figure 5 Could SLEs Reduce Hours on Placement (Clinical Skills)?

4.3.2.3 Resources Required for Implementation

Respondents identified a range of resources required for implementation of SLEs into the existing curriculum. Overall, required resources did not vary greatly between the types of SLEs, with most respondents indicating a need for adequate staffing, funding, appropriate teaching space and appropriate materials. Further details are provided in Table 3.

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100



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10

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60

70

80

90

100

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ment

Rx Eva

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NoYes


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Table 3 Resources for Implementation of SLEs SLE Resource required Standardised Patients

Development Ń Case scenarios Ń Training for educators and actors Ń Ways to evaluate student progress

Staffing Ń Suitable personnel Ń Clinical educators to train actors, support and implement

program Ń Actors to be the standardised patients Ń Administration support

Funding Ń Develop case scenarios Ń Develop and maintain training program for SPs Ń Develop and maintain training for educators Ń Hire actors Ń Purchase materials

Appropriate teaching space Mannequins

Funding Ń Develop and/or purchase mannequin Ń Pay for programming and maintenance Ń Training for staff and students

Space Ń Storage and use

Materials Ń Mannequins/part task trainers

Staffing Ń Clinical educators to support program, Ń Evaluate student progress Ń IT personnel Ń Hardware development Ń Educators to support and implement the programme, Ń Administrative support

Interactive computer based programs including Virtual Reality / Virtual Patients

Funding Ń Development, set up and maintenance Ń Purchase of materials Ń Train staff and students Ń IT support

Staffing Ń IT support to develop, implement, update and sustain programs. Ń Educators to support and implement program Ń Administrative support

Materials Ń Computers and associated hardware and software for developing

the programme Ń Allow adequate student access to the programme (internet

access, a lab)


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4.3.2.4 Feasibility and Timeframe Required for Implementation

Overall responses indicated that it would be possible to implement SLEs into speech pathology clinical education. Considerable variation between the universities was present in terms of perceived feasibility and likely timeframes to implementation. Where responses varied, all responses are listed in Table 4. Table 4 Feasibility and Timeframe Required for Implementation of SLEs SLE Feasibility Timeframe Standardised Patients Low – High

Dependent on funding and resources

Currently in use 1 year 2 years 4 years

Mannequins x Human patient simulators x Part task trainers

Low – high Dependent on sufficient resources / appropriate mannequin available

1-2 years 10 years 3 years ‘Long term’

Interactive computer programs x DVDs x Virtual patients

High Dependent on resources Medium

1 year 2 years 3 years Pilot program in 2 years

SLE for English language proficiency for clinical purposes

Medium 2 years

Environmental

Moderate 2years

Virtual reality x Haptics x 2nd life

Unsure 1-2 years if feasible

Laboratory simulations for incorporation of technologies for instrumental assessment

Medium 4 years

SLE for skill review, skill building

Medium 2 years

4.3.2.5 Ability of SLEs to Meet Clinical Education Objectives

Respondents were asked to consider a range of SLEs in terms of the clinical skills that could be targeted and whether or not using the SLE could obtain the objective required. The SLEs included in the survey were sourced from the literature review, NHWT survey results and Survey 1 responses. Respondents varied in terms of which clinical skills they thought could be targeted by the SLEs and to what degree objectives could be attained. Responses have been summarised in Table 5. Where agreement existed, one response has been included. Where responses varied, the main responses are listed. For example, some respondents considered written simulations to achieve all objectives, others thought to some degree, while others commented in terms of relation to other SLEs listed. Please see Table 5.


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4.3.2.6 General Comments

Respondents were asked for comments at various points throughout the survey. The potential of SLEs to encourage inter-professional learning was noted. For example, exposing students to the roles of team members in client care through a computer based simulation. “Speech pathology students could observe a team meeting or joint assessment, and then answer questions about their roles and the other team members' roles. This could reduce the amount of time spent attending team meetings etc on clinical placements. Virtual patients could also be used in the tertiary setting to allow for practice with joint assessment and treatment sessions with other health professionals.” The benefit of using SLEs immediately following academic coverage of a topic was identified, thereby reducing the ‘time-lag’ between knowledge acquisition and practical application. University IT policy was identified as a potential barrier to implementation of computer based SLEs, alongside issues of recording / accessing student information for assessment, and the potential need to moderate sites. The issue of comparability of speech pathology education with other health professions, such as medicine and nursing was mentioned. One respondent indicated that speech pathology students are expected to graduate with a higher level of independence than nursing and medical students, and as such it is difficult to generalise findings from other professions to speech pathology education. Ideas for SLEs that had not been previously mentioned in the survey were suggested. These included:

x Laboratory simulations for incorporation of technologies for instrumental assessment x SLEs to assist development of English language proficiency for clinical purposes – identify

needs early with clear reference to demands of clinical practice x SLEs to review child clinical skills prior to fourth year – i.e. to assist with the problem

associated with time lags between coverage of academic content and placements for different populations.

x SLEs designed to assist 'marginal' or at risk students to transition from one level of expectations to the next - i.e. reduce 'wastage' of available clinics due to repeated failure


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Table 5 Ability of SLEs to Meet Clinical Education Objectives SLE Classification

Example used in Speech Pathology

Clinical Skills Targeted Objective Attained (Y/N)

Standardised Patients

Pre-clinical exposure to: x Adult voice disorders

x Paediatric speech (parent interview)

Case history taking Interpersonal skills Professional behaviour Assessment Intervention

x Planning and Implementation

Yes (both) – case history, interpersonal skills, professional behaviour, assessment, intervention planning No – implementation of treatment Yes for adult, no for paediatric Somewhat, would need further exposure to other clients

Computer-based Simulation

A Sound Judgement: x Perceptual

assessment of voice

Dynamic Swallow: x Assessment of

dysphagia

Assessment Clinical reasoning Intervention

x Planning and Implementation

Somewhat, needs updating Yes – assessment and reasoning No – implementing intervention Yes for adult voice, no for paediatric voice


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Table 5 cont’d. Ability of SLEs to Meet Clinical Education Objectives SLE classification



Computer-based Simulation - Virtual Patients

SimuCase¥ x Paediatric speech &

language

Sentactics� x Currently used in

therapy for aphasics, consider how it could be used as teaching tool

Case history taking Interpersonal skills Professional behaviour Assessment Intervention

x Planning and Implementation Outcome measurement Don’t know enough to comment

Yes (SimuCase¥) No (Sentactics�) x Case history, interpersonal skills,

professional behaviour, assessment, intervention planning

Yes (SimuCase¥ and Sentactics�)

x Intervention implementation Possibly - not sure whether programming is sophisticated enough Don’t know enough to comment

Computer-based Simulation - Virtual Reality

Virtual Cave Virtual Worlds (2nd life)

Case history taking Interpersonal skills Professional behaviour Assessment

x Plan and implement Intervention

x Plan and implement Outcome measurement Don’t know enough about it CBOS Unit 5 skill development

Both examples achieve all Dependent on case Possibly - not sure whether programming is sophisticated enough No – intervention implementation Potential for partial achievement Don’t know enough about it


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Written simulations

Case scenarios, including motor speech disorders and dysphagia

Assessment x Interpret x Diagnostic reasoning

Management x Clinical decision making x Report writing and documentation x Intervention planning x Data analysis and interpretation x Data collection (if written simulation

conducted with accompanying video) x Resource development e.g., handouts

for clients x Inter-professional x Holistic view of client

Yes for all Somewhat - process works well but material needs much more development Does not assess students' demonstrated performance competency sufficiently to be used instead of real people interaction - as opposed to alternative simulations above

Models / Part task trainers

Tracheostomy model Practical skill for management of tracheostomy / valves Assessment

x Reasoning x Analysis and interpretation

Intervention

x Planning x Implementation

Partly Very poor needs development ++ Yes for assessment and intervention


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Role Play (students)

Case history Fluency Voice Counselling

Interviewing skills (case history) x Active listening

Interpersonal communication skills Professional behaviour Assessment

x Data collection & interpretation x Diagnosis, hypothesis development

Implementing standardised assessments

x Taking language samples Planning intervention Professional skills

x Conflict resolution, giving 'bad news x Ethical behaviour x Counselling skills x Problem solving

Not considered to be a simulated learning environment as defined by HWA

Partly Yes for all Somewhat for problem solving


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4.3.2.7 Student Opinion - SLE use in Speech Pathology Education

Each university was asked to consult students for opinions of the use of SLEs in speech pathology education. Students were able to access the briefing paper for information on SLEs prior to completing the survey. Respondents indicated difficulty obtaining student input, largely due to the timing of the survey coinciding with student break. Six partial responses to the survey were obtained, the results are presented below. Students were asked to indicate whether or not they perceived SLEs to be suited to coverage of the speech pathology range indicators and inter-professional learning (see Figure 6). Overall, students perceived SLEs to be suited to application across the range indicators. Figure 6 Student Views on SLEs across Range Areas

Students were asked to nominate which clinical skills they felt could be learnt through a simulated activity (see Figure 7) and what models of SLEs they considered would be useful in clinical education (see Figure 8). Responses indicated a positive perception of SLEs, with students reporting possible acquisition of most clinical skills (except implementing treatment and professional behaviour).

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Figure 7 Student Views on SLEs to Obtain Clinical Skills

Figure 8 Student Views on Usefulness of SLEs

All students surveyed considered standardised patients and environmental simulations to be useful in speech pathology education, while medium or low fidelity mannequins were not perceived to be useful. Most thought high fidelity mannequins and virtual reality could be used.

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SPs HiFiMannequins

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4.3.2.7.1 Student Perceptions of Advantages and Disadvantages of SLEs

Students were asked to nominate advantages and disadvantages of SLEs in relation to their learning. Please see Table 6. Table 6 Student Perception of Advantages and Disadvantages of SLEs SLE Advantages Disadvantages Standardised patients

x Ability to interview, take case histories

x Develop on-line clinical skills x Application and transfer of

knowledge in safe environment x Increase preparation and

facilitate transfer to clinic experiences

x Technical skill development in voice assessment can be achieved

x Intervention planning can also be promoted

x Doesn't necessarily mirror real life x Need a huge range of even one

disorder type x Variety of cases or exposure very

limited x Clinical learning may depend upon

how accurate standardised patient is represented

x Interventions cannot be implemented

Mannequins Medium – high feedback

x Maybe for a few specialised areas (dysphagia, voice prosthesis, feeding

x Targets very specific procedural,

medical skills

x Limited use and variety x Perhaps more useful in other fields

(e.g. physiotherapy) x Targets very specific procedural,

medical skills

PTTs None N/A

Hybrid None x Not close enough to real life Computer based simulation – Low interaction

x Laryngectomy CD (New Voice) very helpful, especially as case studies were included to consider and apply knowledge

x Access multiple times x Creates interest and awareness

Computer based – High interaction

x Technical skill development in voice assessment can be achieved

x Intervention planning can also be promoted and possibly also implemented if the computer programme is sophisticated enough

x Get a chance to react and respond to potentially more complex cases/scenarios

x Can't replace real clinical situation or experience


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Table 6 cont’d. Student perception of Advantages and Disadvantages of SLEs SLE Advantages Disadvantages Written Simulations

x Might be applicable for standardised testing practice and different types of reports

x Time to consider (not requiring on-line decisions may reduce pressure)

x Could be used as stepping stone to role play/clinic work

x Not flexible enough to replace real life clinical experiences in different workplace settings with multiple client types

x Not interactive x Not realistic

Peer role play

x Get some limited chance to practise some skills e.g. counselling

x Interactive

x Simulated still is not the same as the reality of working with a client and different client types

4.3.2.7.2 Additional Student Comments

Students were given the opportunity to make comments about the place of SLEs as a component of the clinical education program. Both positive and negative viewpoints were expressed, with some expressing concern over losing clinical placement time. Selected comments are listed below: “During the GEM program, the clinical experiences seem limited. Additional SLE in any area would increase knowledge application in any range indicator, and better prepare us as Entry Level Graduates. This would be especially useful for range indicators that do not occur frequently during clinical placements (e.g. adult voice)” “A huge concern for us (students) is that SLEs shouldn't replace clinical practicums because clinical practicums afford irreplaceable real life clinical learning opportunities with numerous client types and in workplace settings where we will be working upon graduation. SLEs should be used as an adjunct to academic subject assessment rather than replacing clinical pracs.” “Those SLE we have already come across in the GEM program have facilitated learning and have contributed to increasing clinical skills.”

4.3.3 Workplace Clinical Educator Views

Clinical Educators (CEs) in various settings across Australia were asked to provide their opinions on the workload associated with supervision of students and whether or not they considered the integration of SLE into the clinical education curricula likely to result in decreased workload and increased student capacity. CEs were provided with background information on SLEs and their possible use within speech pathology education for reference. Written responses to the questionnaire were obtained from workforce clinical educators associated with 4 of the 10 universities. In addition, input was gained from CEs at the National Forum. Responses are listed under the four questions posed. Quotations are highlighted in italics.


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4.3.3.1 What do you consider takes you the most time with a student on a clinical placement?

Placement Coordination

x Timetabling x Orientation to setting and caseload

x Policies and procedures x Completing statistics x Working in a specialised area (e.g. Cerebral Palsy) requires additional training for

the student and more guidance initially so that the student feels comfortable, confident and competent to work with this client population

x Communication with stakeholders o Aware of current clinical issues including the university, other supervisors and the

student o Discussing student performance with other team members if student has been

working independently x Organising additional tutorial/sessions to facilitate development of clinical areas of concern.

Sourcing adequate experience for student

x Clients/Patients x Broader range x Increased number of clients so student gets more contact hours x Arranging assessments not typically used so that the student gets experience in

assessment administration Student Feedback and Correspondence

x Time to directly observe sessions x Performance - after client contact

o Particularly if they struggle to be objective in assessing their performance x Written reports and progress notes x Responding to queries regarding resources and assessment x May need to be after hours in email form (no time during day) x Goal setting

Planning of Client Management

x Problem solving different options with students o e.g. Often they will think of one option and stick to this instead of various options

and then considering the pros & cons to each option (this can be in relation to setting therapy goals or increase & decrease steps depending on where the student is at)

x Teaching student to take a holistic approach to the client o e.g. learning how to consider the environment that the child is in and how this can

impact therapy intervention; looking past the immediate child and their abilities x Extra assistance required for complex cases or infrequently seen impairments x Providing information on specific strategies, typical presentations, aetiologies


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Student Assessment x Completion of student clinical assessment on COMPASS® (McAllister, Lincoln, Ferguson &

McAllister, 2006) o Analysing the document o Establishing appropriate mark for student o Online COMPASS® streamlines process o Translating CBOS (Speech Pathology Australia, 2001) / COMPASS® assessment

into AAC treatment (specific areas) x May occur out of work time

4.3.3.2 What are the skills that some students bring to a placement that result in a reduced load / reduced time for you as an educator?

Knowledge

x Theoretical models underpinning treatment x Formal assessments x Developmental norms x Theory of impairments

Personal Attributes

x Initiative x Pro-active x Confident x Independent (appropriate degree) x Incorporate feedback into following sessions x Self- motivated

Clinical Skills

x How to write progress notes (SOAP2

x Organisation and time management format) and reports

x Reflection on own performance and how to modify if needed x Observation skills x Reasoning skills x Application of theory into practice x Prepared for sessions x Able to make own resources x Administration of assessments x Goal setting x Communication skills

o Client interaction o Other professionals

4.3.3.3 Simulated learning environments (e.g. standardised patients and computer based programs) are used in other professions to prepare students for clinical placement. How likely is it that preparation (using SLEs) prior to clinical placement would result in reduced load for you as an educator?

2 Format for recording case notes: Subjective impressions, Objective information, Assessment, and Plan (SOAP).


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Responses largely fell into two categories of reduced workload and impact on student. One additional benefit posed was the possibility of clinicians themselves being able to access SLEs as professional development. Positive and negative responses are reported under these headings. Reduced workload Positive Responses x Students more advanced at start of placement

o Earlier independence o Require less support o Reduced time to competency o Less training time in initial days

x Less need to source variable caseload

x Reduced need to see as many clients x Coverage of range indicators x Could use SP cases as examples to support planning

x Less need to provide remedial support to marginal / failing students

Negative Responses x Unlikely given tasks that take the most time x Not with some caseloads (e.g. autism spectrum disorder) (Note: other CEs felt SLEs could be

particularly relevant to specialised areas such as these).

Impact on Student All responses were positive.

x Better prepared for clinical placement o Increased confidence and more independent o Improved knowledge, reasoning skills, transfer of theory into practice o If better prepared, could spend more time refining skills rather than just achieving

entry level o Useful in specialised placements (e.g. cerebral palsy) for increased prior knowledge

before the placement. o Gain increased exposure and familiarisation of the client group and the various

presentations o Better prepared to manage difficult situations

x Builds experience/ repertoire of clients 'seen' across areas o Client observation o Interacting with clients o Conducting physiological assessments (e.g. bedside swallow assessment)

x Able to access remedial support


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4.3.3.4 Could the use of SLEs reduce the total hours needed to reach competency in a clinical placement? Responses to this question ranged from an affirmative across all areas to not at all. Different models were discussed at the forum, including options of replacing a total of one week of a block placement with simulation (either intensive or split between morning and afternoon for example). Specific responses are listed below.

x Yes o In general o Specifically, undergraduate 3rd year or masters 3rd semester

x Possibly / In some areas o e.g. planning and assessment o Dependent on the setting and service delivery type.

x No o Professional areas and communication skills. o Students would just get more/better exposure o Not for undergraduate 4th year or masters 4th semester o They need the complexity and they won't fully understand our clients if reduced

placement time

4.3.3.5 SLEs could be used to expose students to range indicator areas (speech, language, voice, fluency, swallowing) that may be difficult to find in clinical placements. Would this reduce your workload (i.e. finding a broad range of clients) as a clinical educator?

CEs made mention of the perceived benefits of including SLEs in clinical education, even if they did not feel their individual workload would be reduced. Some considered the benefits to extend past the individual student to the profession as a whole. Specific responses are listed below. x Yes

o If they require fewer clients to gain competency o Difficult to source range of clients currently

x No o Based on existing caseload only o Potentially, however students may still benefit from actual experience on placement in

addition to an SLE experience Perceived benefits x To the profession

o More students able to access these clinical populations consistently in their undergraduate coursework, especially given the demands of competency-based assessment of students entering the profession.

x To the student o Assist the students in developing holistic view of clients

4.3.3.6 Other Comments from CEs

CEs indicated overall positivity towards the integration of SLEs into the speech pathology clinical curriculum. Some posed ideas for specific SLEs, while others made note of personal concerns. Particular mention was made by some of the positive experience that having students within a workplace provides which often results in increased workplace productivity and the ability to expand service delivery. Specific comments and ideas are reported below.


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Specific Ideas for SLEs x A video recorded assessment of a client conducted by an expert clinician, during which

students who are observing the recording have to score and interpret findings on the relevant assessment forms. If this type of learning opportunity could be aligned with the curriculum (academic and practical) in such a manner that the times between gaining the knowledge, practising the skill and then integrating a range of skills in the clinical placement could be seamless (follow on soon after, or overlap to an extent) this could assist in the process.

x Revision materials which were pass/fail and students had to pass before starting the placement.

x Online self-tests which give immediate feedback on correct and incorrect responses x Self teaching packages, online case examples for skills development such as transcription,

counting stutters, doing oral exams x Involve actual parents of children with disabilities in training students Timing of SLEs in relation to clinical placement x Would be good if they had specific SLE skills training and then did a focussed placement

immediately after o This was discussed by the group who decided that might be possible for voice, fluency

and dysphagia but not speech and language as these should be experienced longitudinally and there would not be enough places to accommodate all students.

Concerns

x I do not see this as accommodating for all learning styles x I would not like this to decrease the role of the clinical educator and the need for

supervision of students x There is less scope for 'standardised' patients in Speech than in professions such as

Physio. As I student, I was looking for the 'cookbook' approach to therapy, and it was a shock to find that each patient was different, and treatment had to be planned very much on an individualised level.

4.3.4 National Forum

The National Forum provided opportunity for members of the speech pathology collaborative, representatives of the profession, student body and Speech Pathology Australia to discuss SLEs in depth and come to agreement on their potential use in speech pathology clinical education. Results presented in subsequent sections will reflect this consensus. Key outcomes of this forum included unanimous agreement on the following:

x SLEs are likely to reduce the load of workforce CEs by: o Providing access to a range of clients o Teaching basic skills prior to placement o Removing the need to host students for observation placement o Preparing graduates for the workforce

But cannot replace direct assessment of student performance in the workplace in terms of accreditation.


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x SLEs relevant to speech pathology:

o SPs – integrated into a clinical learning program o Virtual reality o Hybrid simulation o Simulated physical environments o Mannequins

� Required substantial further development to be of benefit to speech pathology

� Potential in the areas of dysphagia and cleft palate

x Development of a Case/Scenario Bank o The use of the above modes of SLE is reliant on the development of a large pool of

case resources o Existing resources of video-taped interactions were considered to be of benefit o Ability to update scenarios based on latest evidence o Include enough data to allow for IPE

� Disorder specific cases, e.g. stroke case that could be used by PT, OT and SP

x Barriers to Implementation

o Funding o Staffing o Materials o Space o Equitable access to existing SLEs o Internet access (speed & bandwidth) o Lack of evidence base

x Resources Required o Funding

� Development � Recurrent

o Staffing o Materials o Space

� Dedicated physical spaces for SP clinics � Virtual space, data storage for case bank and virtual reality SLEs

o Research into efficacy of SLEs

x SLEs provide the opportunity to exploit technology

x Potential for additional use of SLEs in o Continuing professional development o Assessing applicants for re-entry to the profession and overseas qualified speech

pathologists o Blended learning (distance)


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4.4 Curricular elements that could be delivered via SLEs.

The Speech Pathology Collaborative and SPA determined that SLEs had the potential to assist students in achieving clinical placement objectives and contribute to increased placement capacity. It was decided that SLEs would be best suited to:

x Improving clinical skills and preparing students for workforce placement o Communication o Professional behaviour o Assessment o Clinical reasoning o History taking o Planning treatment o Implementing treatment o Evaluating treatment

x Expanding student access to a broad range of client demographics x Providing observational experiences to novice students x Providing remedial instruction to marginal students x Inter-professional learning

An improvement in clinical skills prior to workforce placement was predicted to result in more effective and efficient student learning. Existing research suggests a positive impact of SLEs on students’ skills and confidence on entering a subsequent clinical setting. Survey results supported this contention, with responses indicating a likely increase in student confidence, independence, knowledge and ability to transfer theory into practice. Both clinical educators and university representatives agreed that increased student preparation for clinical placement was likely to result in reduced workload for workplace clinical educators both in terms of total hours needed for students to reach competency and in requiring less intense supervision and orientation of students (particularly in the early stages of a placement). Indeed, CEs noted that the presence of students in the team can result in improved workplace productivity. It was thought that should students be more skilled in these areas prior to placement, CEs would be more willing to take additional students and students earlier in their degrees. Expanding student access to a broad range of client demographics was considered to be beneficial to the students, educators and the profession. In order to graduate from an accredited speech pathology program, students must have demonstrated competency across the lifespan (paediatric and adult) in five range indicator areas (speech, language, voice, fluency and swallowing). Currently, CEs report sourcing a broad range of clients for students to be one of the most time consuming aspects of student supervision. Using SLEs to expose students to clinical cases from each of the range indicator areas would positively impact on clinical educator workload. It also has the potential to benefit the student, by providing experience across a broader range of cases than otherwise may have been possible in traditional placements alone. SLEs were considered particularly useful for the provision of observational experiences to novice students. Currently, students across the universities undertake external placements early in their degree program to observe a speech pathologist in the workforce. All stakeholders agreed that this experience could be replaced entirely through the use of SLEs. Not only would this result in a decrease in clinical training days in the workforce but also potentially provide a richer learning experience for students. Providing remedial instruction and additional clinical learning opportunities to marginal students was consistently identified by CEs as having a large impact on workload. The use of SLEs for this purpose has the potential to reduce the load on workplace CEs and increase their ability to take more students. In order to determine which SLEs were most likely to reduce CE workload, the following considerations were taken into account:


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x Aspects of clinical supervision which result in greatest increase in workload x Current levels of SLE development in relation to speech pathology

The SLEs determined to be most likely to result in increased capacity and reduced CE workload were determined to be (in order of priority):

1. Standardised Patient (SP) programs integrated into a clinical learning program 2. Virtual patients and other interactive computer based programs 3. Hybrid simulation (involving part task trainers with standardised patients) 4. Simulated physical environments

x e.g. mock hospital ward, virtual worlds 5. Mannequins - part task trainers and human patient simulators

4.5 Level of Agreement Obtained

4.5.1 Curricular Elements

Full agreement from each accredited speech pathology program and SPA was achieved regarding the potential for SLE use on each of the curricula elements identified above (Section 4.4). Specifically, each university agreed that SLEs had the potential to replace early clinical observation placements, provide students with access to a broader range of cases in terms of client demographics, increase skills prior to workforce placement, and provide remedial instruction to marginal students. Representatives from SPA have stated that accreditation of speech pathologists is competency based, relying on assessment of students against the competencies outlined in the Competency Based Occupational Standards (CBOS, Speech Pathology Australia, 2001). These assessments are viewed by the Association as evidence of the competency having been achieved by the students. This evidence may be of varying levels. Direct evidence of competency is provided by assessment based on direct observation of the student on practicum and is the most desired level of evidence for accreditation. Assessment based on indirect report of the student on practicum or direct observation of a student in a simulated/videoed situation is classed as indirect evidence and used as supplementary evidence where direct evidence is incomplete. Examples of curricular elements that SPA considers acceptable for delivery by SLEs (thus providing indirect evidence for accreditation) are:

x Observation experiences for novice students x Attainment of discrete skills requiring practice, e.g. tracheostomy management, involving

suctioning and valve replacement; oromotor examination; fluency rating; hearing screening x Development of foundation clinical skills, e.g. professional communication style, building

rapport, case history taking, report writing Each university is required to provide a holistic program that develops competencies outlined in the CBOS, however each university has freedom of pedagogy and students are not required to reach a set number of clinical placement hours. At this stage, due to the lack of research surrounding the use of SLEs in speech pathology, SPA has stated that direct evidence of the achievement of competency is still required. Complete replacement of workplace clinical placement with SLEs alone is not currently acceptable. High quality SLEs will be regarded by SPA as strong indirect evidence of professional competency. No set percentage of clinical practicum in SLEs has been agreed on.


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4.5.2 Perceived Barriers to this Curriculum being Recognised and Adopted for Clinical

Training Purposes

Both the speech pathology collaborative and SPA perceived the lack of existing evidence base to be a significant barrier to the effective use of SLEs in clinical education. All stakeholders considered that substantial further research is required in this area. In addition, recognition by the profession of the value of SLEs and their potential for student learning was thought to be a potential barrier. Further education of the speech pathology profession regarding SLEs and their potential use in speech pathology education was considered to be beneficial in this regard. Barriers to adoption, as reported earlier (Section 4.3) were agreed by all stakeholders to be funding (development and recurrent), staffing, materials (e.g. mannequins and computer equipment), space (both physical and virtual), equitable access to existing SLEs, sufficient internet access (speed & bandwidth) for students and universities, and achieving uniformity of cases and access to cases by all programs.

4.5.3 Likely Impact on Clinical Training Days should SLEs be Introduced

Complete replacement of early clinical observation experiences with SLEs was agreed by all to be possible. This would result in an immediate reduction in clinical training days and the ability to increase capacity of workplaces to place more advanced students.

The use of SLEs to provide additional coverage of range indicator areas was considered by all as likely to result in reduced workload for workplace CEs and possibly decrease the required training days in workplace clinics. Enhancing skills prior to placement through the use of SLEs was considered by all to provide greater opportunity for effective and efficient use of workplace training days. Most considered that the potential existed for a reduction in length of block placements, e.g. replacing a 5-week block placement with 1 week SLE and 4 weeks traditional placement. Preliminary results from the RCT in physiotherapy would suggest this approach to be valid (Jull et al., 2010). Further investigation would be required to determine efficacy in speech pathology clinical education. All stakeholders agreed that clinical training days could be further reduced through the use of SLEs to provide remedial instruction to marginal / struggling students. Currently, students who fail to achieve the required competencies in a clinical placement are required to complete further training days until they can either conclusively demonstrate competency or be found unable to do so. SLEs could reduce the need for a workplace CE to provide direct instruction, and thereby result in decreased workload and possibly fewer training days.

4.5.4 Likely Timeframes for Implementation All stakeholders agreed that implementation of SLEs into the speech pathology curricula was reliant on the provision of adequate resources, both for development and ongoing maintenance of the programs. The timeframes reported as likely for the implementation of the SLEs listed, are based on the assumption of provision of adequate resources. In addition, it was considered that the development of the different modes of SLE would be greatly facilitated by the existence of a bank of quality cases and related case material (as reported in Section 4.3). Table 7 outlines the agreed feasibility and timeframe for implementation of SLEs into the speech pathology curricula, should adequate resources be available and subsequent to the collation of case resources. While considerable variation existed in survey responses (reported earlier in Section 4.3), members of the speech pathology collaborative were able to come to agreement at a subsequent


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face-to-face meeting. The timeframe of 2-3 years represents what was considered likely for implementation of SPs into speech pathology programs. While mannequins are readily available given adequate funding, it was considered that at present they are not able to provide a sufficient number of scenarios relevant to speech pathology. An extended period of time (10 years) was thought to be required to allow for further development of mannequin capabilities relevant to speech pathology practice. Table 7 Agreed Feasibility and Timeframe to Implementation of SLEs SLE Feasibility Timeframe

Standardised Patients High

2-3 years

Interactive computer programs including virtual patients

High 2-3 years

Hybrid Part task trainer + Standardised patient

Moderate – High 2 -3 years

Environmental x Physical & Virtual

Moderate

2 -5 years

Mannequins x Human Patient Simulator

x Part task trainer

Low Moderate-High

10 years 2 years


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5 Recommendations

The use of SLEs in speech pathology education appears to have great potential, however further research is needed to document the validity of individual SLEs in producing quality educational experiences for students. It is likely that integrating simulated learning into the speech pathology curricula could result in reduced workload for workplace clinical educators and an overall reduction in workplace clinical training days per student. Providers of speech pathology education in Australia have a documented history of collaboration and provision of high quality programs to students. This investigation has established a consensus and commitment amongst all Australian universities offering speech pathology programs to work together to achieve continued improvement in student education, through the shared development of SLE resources and subsequent access to these. Simulated learning environments are currently being employed in some speech pathology programs, however additional resources are required to develop further SLEs and maintain their use within the curriculum. Priority elements of the curriculum able to be targeted using SLEs have been identified as:

x Clinical skill enhancement prior to placement x Additional coverage of specialised areas of speech pathology practice x Replacement of early clinical observation experiences x Facilitation of inter-professional learning

The integration of SLEs into speech pathology education curricula is likely to reduce the current load on workplace clinical educators, and potentially increase capacity for clinical education.

5.1 Recommended Approach to Integration of SLEs into Speech Pathology Clinical Education

Figure 9 displays the proposed model of SLE development for speech pathology. A case bank would be developed initially, with these cases then used in different modes of SLE (e.g. standardised patients or virtual reality). Each mode of SLE would then be developed, resulting in a comprehensive collection of SLE resources for the use of Australian university speech pathology programs as per their respective curricula. This set of resources would be continually evolving. The integration of these SLE resources into the curriculum is considered likely to result in favourable outcomes for workforce clinical educators (reduced load), increased university capacity for clinical education (increased number of placements available) and students (superior clinical learning outcomes).

5.1.1 Case Bank It is strongly recommended by the Speech Pathology Collaborative that initial resources be devoted to the development of a central repository of high quality case scenarios and related materials. This repository should be able to be accessed by accredited speech pathology programs with appropriate security provisions. Universities could then use this case material in their preferred modes of simulated learning (e.g. virtual reality or standardised patients) which are considered most relevant to their needs and best suited for integration into their curriculum. A minimum of two cases for each range indicator area within speech pathology practice (speech, language, voice, fluency, swallowing) is required to represent paediatric and adult caseloads. Further development of cases covering a wide range of disorder severity and case complexity within these specific areas should follow. All aspects of client management should be covered, including case histories, assessment results, details of therapy undertaken and outcomes achieved. Real case data including high quality video and audio recordings as well as written information should be used to inform the SLE. Adequate data should be included in the cases to


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allow for use in inter-professional learning, for example a case detailing a child with cerebral palsy could involve medical, nursing, physiotherapy and occupational therapy students. The development of a case bank has the potential to result in significant learning outcomes for students, including development of clinical reasoning skills, intercultural competency and working with other professions. Potential benefits also extend to ongoing professional development. Resources will be required to ensure adequate access to and maintenance of the case bank. The development and collation of high quality case resources would require initial funding for dedicated staffing, with ongoing funding required for maintenance of content and ongoing review and development of updated material where required (e.g. integration of changing evidence base). Advice regarding specific information technology requirements will need to be sought, and is likely to include:

x The purchase and/or development of a knowledge management system supported by a virtualised environment spread across multiple university sites (allowing for redundancy and content ownership)

x Content should be available across AARNET for security and speed of content delivery x Physical infrastructure is likely to be available at each university, with the ability to cross

charge for the provision of the virtual environment x A specialised IT consultation would be required to plan and develop exact configuration of

the system, set up requirements, and ongoing use and maintenance of the case bank

5.1.2 Modes of SLE

Subsequent to the compilation of a case bank, individual modes of SLEs could then be developed by individual universities according to needs and expertise. It is recommended that the collaborative then share these resources amongst members to enable each university to make use of a comprehensive set of SLEs. Speech pathology programs within Australia have a long history of successful collaboration in development and distribution of innovations in ways that promote shared access. For example, COMPASS® (McAlister et al., 2006), CBOS (Speech Pathology Australia, 2001), three Australian Learning and Teaching Council (ALTC) projects and The Australia Pacific Education Collaboration in Speech Language Pathology (APEC SLP) which specifically aims to support and foster innovation in speech pathology education. Existing collaborative networks are in existence and will expedite the process of development and integration of SLEs into the curriculum. The initial development of a case bank has significant generative potential. Case scenarios and associated resources could be used across SLE modalities. In terms of increased clinical education capacity and reduced workload on workplace CEs, the following SLEs were identified as having the greatest potential:

x Standardised patients in an integrated clinical program x Virtual reality including virtual patients x Hybrid simulation involving standardised patients with part task trainers x Simulated physical environments

o e.g. mock ward in a clinical skills centre or a virtual representation in second life or other computer based program.

Each mode of SLE would require resources for development and maintenance. These include funding (development and recurrent), staffing, training space and materials. Medium – high fidelity mannequins currently do not appear to offer substantial benefit to clinical education in speech pathology. Potential exists however given adequate funding and development expertise to develop mannequins with relevant capabilities.


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Figure 9 Recommended Approach to SLE integration into Speech Pathology Clinical Education


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5.2 Approaches to Address Barriers to Effective Utilisation of SLEs in Delivering the Curriculum

The proposed plan for development and integration of SLEs into speech pathology clinical education minimises the impact of barriers on effective implementation. The main barriers to effectively implementing SLEs are considered to be (1) the paucity of high quality simulated learning environments and technologies specific to speech pathology practice, (2) the lack of adequate funding for SLE development and ongoing provision of simulated learning, (3) the absence of a strong evidence base for the use of SLEs in speech pathology clinical education, and (4) equitable access to SLE resources.

5.2.1 Development of SLEs

The paucity of high quality SLEs and associated technologies that reflect speech pathology practice is a primary barrier to the implementation of SLEs into speech pathology curricula. Furthermore, the variable delivery of curricula amongst universities offering speech pathology programs poses a potential barrier to effective implementation of SLEs into clinical education and accreditation of programs. The recommended approach (Figure 9) takes this into account, with the initial compilation of high quality cases to be used by all universities in subsequent development of modes of SLEs. This would ensure relevance of content to all university programs and equity of access to the resource. Development of SLEs using differing modes can occur according to need and expertise and subsequent embedding of SLEs into a university’s speech pathology programs can be individually determined by each university to best suit requirements.

Recommendation 1: Development of Case Bank

• All university speech pathology programs contribute to the compilation of case scenarios and related material to ensure relevance of content to all university programs and equity of access to the resource

• A minimum of ten cases (adult and child cases across speech, language, voice, fluency

and swallowing) be developed in the first instance

• Sufficient information for each case is included to enable scenarios to be used for inter-professional learning

• High quality video and audio files be included alongside documents pertaining to client

management such as assessment results and therapy outcome measures

Recommendation 2: Maintenance of Case Bank

• Continual evaluation and further collation of resources is to occur

• Additional cases representing varying levels of complexity and disorder severity are to be included in the bank


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Recommendation 3: Development of SLE Modalities

• Differing modes of SLE (e.g. standardised patient programs, virtual reality environments) are developed based on the case scenarios in the case bank

• Each university program develops appropriate modalities according to need and expertise

• Developed SLEs be open to fair and equitable access by all contributing university

programs

Recommendation 4: Evaluation of SLE Modalities

• Quality improvement processes be used in the ongoing evaluation and development of SLEs

• Research to be undertaken by universities to document the efficacy of each SLE modality

5.2.2 Funding of SLEs

The recommended approach is designed to reduce required development funding through the exploitation of existing expertise in member universities and the sharing of developed resources amongst members. However, the following key funding recommendations are critical to the successful deployment of the agreed model (Figure 9). Recommendation 5: Funding for SLE Development

• Recurrent funding is provided to universities for staff, equipment, and technical resources for the initial development and ongoing maintenance of the case bank

• Funding is provided to universities for the development of various SLE modalities based on

developed cases Recommendation 6: Funding for Implementation of SLEs

• Recurrent funding is provided to universities to staff the implementation and ongoing provision of simulated learning within speech pathology curricula

• Funding is provided for the training of staff in the use of SLEs and associated technologies

• Funding is provided to universities to source appropriate space (physical and virtual) for the

implementation of simulated learning in their respective environments

5.2.3 Development of Evidence Base

The lack of existing evidence base is a substantial barrier to effective use of SLEs in clinical education and to recognition of SLE in the accreditation process. While substantial literature exists, particularly in medicine and nursing, generalisation of findings to speech pathology is difficult given the low quality of existing evidence and the differing nature of education and assessment amongst the health professions. It is recommended that universities undertake concurrent research alongside the development of SLEs in order to expand the evidence base for their use.


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Recommendation 7: Funding for Research

• Funding is provided for research to document the application of SLEs in speech pathology clinical education, with particular regard to the efficacy of their use and contribution to student learning

• Research is to occur concurrently with the development of SLEs and form a continuing

quality cycle

5.2.4 Equitable Access to SLEs

Equity of access to SLEs was highlighted as an existing barrier to use in speech pathology programs. While SLEs were in use at all universities in other health professions, few speech pathology programs were able to gain access to these existing resources. Furthermore, all members of the Speech Pathology Collaborative agreed that equity and ease of access to speech pathology specific SLE resources was essential to effective utilisation of SLEs.

Recommendation 8: Policy Governing Access to SLE Resources

• A policy to govern access to future resources to be agreed upon by all health professions in Australia.

• This policy should ensure open and fair access to developed SLE resources for all health professional programs.

• Such a policy provides a basis for the facilitation of inter-professional learning.

Recommendation 9: Equity and Ease of Access to Speech Pathology Resources

• Consideration must be given to ease of access by regional and rural speech pathology programs to developed resources.

• The case bank is to be stored in a manner allowing ease and equity of access to all

university programs.

• Developed SLEs, such as virtual patient programs and virtual simulated environments will be accessible via internet links, or portable hardware such as DVDs.

5.3 Concluding Statement

This project was able to gain consensus and commitment from all Australian universities offering accredited programs in speech pathology. All universities agreed to fully investigate the capabilities of SLEs in reducing load on workforce clinical educators and increasing clinical education capacity for university programs. Speech Pathology Australia representatives have indicated potential acceptance of future integration of SLEs into the clinical education curricula as part of a holistic program which develops entry-level competencies. In the absence of an evidence base demonstrating equivalence of SLEs with workplace clinical placements, SPA will regard SLEs as strong indirect evidence of students’ attainment of competency. Agreement has been obtained on curricular elements that SPA considers acceptable for delivery by SLEs, including early clinical observation experiences for novice students, attainment of discrete clinical skills, and development of foundation clinical skills.


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This project has established the following:

x SLEs appear to have great potential for clinical learning and once developed could be integrated into speech pathology programs in as little as two years.

x Funding is required for the development, evaluation, and implementation of quality SLEs in

the education of speech pathology students

x Initial priority should be given to the development of an online bank of cases specific to speech pathology clinical practice. These case scenarios will then be delivered in various modalities of SLE (as per Model in Figure 9) dependent on individual needs and expertise of each university program. Sufficient case information will allow for inter-professional learning.

x University educators and Speech Pathology Australia are committed to collaborative

development and integration of SLEs into the clinical education curricula and to building an evidence base that evaluates the utilisation and integration of SLEs in speech pathology clinical education.

A comprehensive approach to the development and integration of SLEs within speech pathology clinical education curricula has been developed. All Australian universities offering speech pathology degree programs have agreed to its implementation. The provision of funding for this initiative is vital for instigating innovative change in speech pathology clinical education.


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Prof. Deborah Theodoros

Dr. Bronwyn Davidson

Ms. Anne Hill

Chief Investigators

Dr. Naomi MacBean

Project Officer


Health Workforce Australia

Simulated Learning Environments Project :: Final Report

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