SimQ: Simulations in Allied Health: Where We Are and What's Ahead?

From the Desk of Carol C. Dudding, PhD, CCC-SLP, CHSE

 

Welcome to the first article in a series of new monthly articles on simulations in healthcare, and specifically allied health. The SimQ format allows us to explore the technological as well as pedagogical aspects of simulation for clinical education through the words of the experts.  It is anticipated that the audience will include university faculty, clinical educators and professionals, with interest in the use of simulations to enhance the clinical education of our students and practicing professionals. These articles are intended to address the needs of those considering the use of simulations, and those with varying levels of experiences.

This SimQ article provides some key information regarding the current status of simulations in allied health, including a discussion of the factors which account for the emerging interest in this learning tool. This article will certainly help educators to better understand some of the background and evidence in support of simulations in healthcare education.

Future articles will focus on both the technologies and pedagogies involved in simulations. Just a few of the scheduled topics include standardized patients, Virtual Reality and Augmented Reality, the debriefing process, computer-based simulations, use of simulations for IPE and evaluation principles.

In the meantime, the readers can refer to the citations noted in the article and particularly to the following resources:

Council for Clinical Certification in Audiology and Speech-Language Pathology of the American Speech-Language-Hearing Association. (2013). 2014 Standards for the Certificate of Clinical Competence in Speech-Language Pathology. Retrieved Feb 13, 2018, from http://www.asha.org/Certification/2014-Speech-Language-Pathology-Certification-Standards/.

Dudding, C.C. & Nottingham, E. E. (2017) A national survey of simulation use in communication sciences and disorders university programs. American Journal of Speech-Language Pathology. doi:10.1044/2017_AJSLP-17-0015

 

Carol C Dudding, PhD, CCC-SLP, CHSE

Contributing Editor

SimQ: Simulations in Allied Health: Where We Are and What’s Ahead

1. Carol, the team at Simucase.com would like to welcome you to the first in a series of articles examining simulations for clinical education. As the new contributing editor for this series, and someone who advocates strongly in the use of simulations in allied health, what would you like us to know about yourself?

Thank you, Katie. I am thrilled for this opportunity...not only for the opportunity to share information about both the technologies and pedagogies related to healthcare simulations but also for the opportunity to connect with others with similar interests. I am a speech-language pathologist who has a PhD in instructional technology. This combination of skills has allowed me to research the use of various technologies (e-supervision, teletherapy, and online learning) in the education of students. My most recent work has involved examining the effectiveness of computer-based simulations in the clinical education of graduate students in speech-language pathology. I have had the opportunity to present on the topic and am excited about the recent growth in interest in this learning tool within allied health professions. Whether you are just considering the use of healthcare simulations in your courses or currently use simulations in your curriculum, I want to connect with you in ways that meet your needs.

2. Let’s start from the beginning. What is a simulation?

There are a number of definitions out there. The definition that I prefer is from a well-known researcher in the field. Gaba (2004) defines healthcare simulation as “a technique—not a technology—to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner." I like this definition because it puts the emphasis, rightfully so, on the learning experience. People tend to focus on the technologies and not the learning objectives. The technologies used in simulations offer a lot of options and have a “cool” factor to them. We can see the value in the use of standardized patients (actors) and digitized manikins to train students. And that's great.  The difficulties come into play when we focus on the technology and not the pedagogy and/or educational objectives.  Our society has learned over the centuries that technology for the sake of technology often falls short of our ideals.  While there has been a huge influx of technologies into America’s public school classrooms, test scores and student performance continues to decline in some key areas. We must remind ourselves to begin with well-constructed learning objectives in designing and selecting the appropriate simulation technology. We, in allied health, need to incorporate best-practices established by our colleagues in medicine and nursing when developing, implementing and evaluating healthcare simulations.

3. You have used the term “healthcare simulations” a few times. What do you mean by that term?

Simulations have an extensive history in military training. It is reported that the game of chess is an early form of simulation (Bradley, 2006) meant to teach battlefield strategy. Aviation uses high-tech flight simulators to train pilots without risk to humans or the aircraft.  Governments use simulations to train responders in the event of emergencies and in cases where the cost of equipment loss could be too high.  Businesses use simulations to teach employees leadership skills in a cost-effective, faster approach. This series of articles focuses on a different form of simulation - simulations used to train healthcare professionals to perform clinical skills, diagnose and work in teams.  Healthcare simulations are a form of simulations that “creates a situation or environment to allow persons to experience a representation of a real healthcare event for the purpose of practice, learning, evaluation, testing, or to gain an understanding of systems or human actions” (Society for Simulation in Healthcare). Healthcare simulations are used by a variety of healthcare professions, including medicine, nursing, occupational therapy, physical therapy, and speech-language pathology. Other terms you may see mentioned include clinical simulation and simulated-learning environments (SLE).   Clinical simulation refers to the provision of learning experiences that can expose students to many scenarios that they might encounter in the real world, without the stress or risk of harming a patient.  A simulated-learning environment is a place or location where the simulation takes place.  

4.  Is there evidence to support the use of healthcare simulations for clinical education?

There is a robust body of literature dating back many years, using different simulation technologies.  From the nursing literature, we know that up to 50% of clinical education experiences can be replaced with simulation and yield the same clinical outcomes (Hayden, J. K., Smiley, R. A., Alexander, M., Kardong-Edgren, S., & Jeffries, P. R., 2014). Researchers in physical therapy conducted a randomized control study (RCT) suggesting that 25% of clinical experiences could be replaced with simulations with no effect on student outcomes. Cook and colleagues (2011) performed a meta-analysis of more than 600 studies across multiple disciplines. The results strongly support the use of healthcare simulations as an effective teaching tool. Healthcare simulations have been shown to improve student performance and skills and positively impact confidence. Importantly, simulation training has also improved patient safety (Alinier, Hunt, & Gordon, 2004; Cook et al., 2011; Estis, Rudd, Pruitt, & Wright, 2015; Ward et al., 2015) . 

5.  What has been done in our fields of study?

Some of the earliest work on simulation in allied health was conducted by Syder in 1996. Soon to follow was the work of Richard Zraick and colleagues concerning the use of standardized patients. More recently, our colleagues have been busy conducting excellent research on the topic. For starters, those interested should look at the work of Benadom & Potter, 2011; Estis et al., 2015; Potter & Allen, 2013; Ward et al., 2014, 2015. I’m sure there are some that I have failed to mention. The point is that findings support those of our colleagues that simulations are an acceptable training tool for students.  Simulations allow students to complete routine procedures, and practice techniques before treating actual patients. 

 6. What are the different types of technology used in simulations?

The major types of simulation technologies include standardized patients, high-tech manikins and task-trainers, computer-based simulations and virtual/augmented reality. Standardized patients refer to the use of a person or actor who simulates a patient in a realistic and repeatable way. As the name implies, standardized patients are well-trained in carrying out scenarios in a standardized manner in order to elicit specific skills. This also allows standardized patients to serve as a form of objective measure. Standardized patients are particularly effective in practicing communication and counseling skills.  Standardized patients give students an opportunity to practice skills such as history taking, physical exam and communication skills.  

When people think about healthcare simulations, they often think about high-tech manikins that look like a full-bodied person. There have been rapid advances in that type of simulation technology. Digitized manikins have a heartbeat, breath sounds, and can even sweat, bleed and urinate. They respond to the actions of the learner in a timely and predetermined manner. This type of technology is programmed and controlled by a skilled computer technician.  You will find these technologies in simulation labs, which are most often associated with a nursing and/or medical school. They require considerable cost, space, and support. 

Another form of healthcare simulations involves the use of part-task trainers. Part-task trainers allow for practice of a particular skill. They can be high or low tech. For example, Rescucci Annie is a part-task trainer used to train individuals in CPR. An example of a low tech task trainer would be the use of an orange to practice needle injection. An example of part-task trainer use in the allied health field is in the administration of standardized testing.  This allows the learner to administer and score the test in a risk-free environment.

Computer-based simulations often take the form of a gaming platform. Do not let the term “gaming” fool you. Computer-based simulations must still rely on the same pedagogical tenants as other forms of simulations. Computer-based simulations also have a range of technical sophistication. There are a number of software applications that allow an individual to author simulations using an “unfolding” case study format.  Other commercially produced computer-based simulations utilize avatars or video to represent patients.

Immersive virtual reality (VR) is the next likely technology to be applied to simulations. Virtual reality is a three-dimensional representation of an environment that has a feeling of immersion. An example of VR for healthcare simulation would be interviewing an avatar in a virtual environment.  

In fact, many simulations use a combination of simulation technologies to provide a realistic simulated learning environment. For a full discussion of the types of simulation technologies refer to Lopreiato (2016).

7.  Can you give us an example of how each of those types might be used in allied health education?

Sure thing. A search of literature will show that allied health has a long history with the use of standardized patients (Zraick, 2002, 2003, 2012). A standardized patient (actor) can be used to simulate a counseling session in which the examining allied health professional provides a family member with the results of testing.  High-tech manikins can be programmed to simulate a person in the hospital setting. It is especially useful in training team competencies associated with interprofessional education. For example, a team of OT, SLP, nursing and respiratory therapy students may participate in a simulation explaining the placement of a speaking valve on a patient (Estis, Rudd, A. B., Pruitt, B., & Wright, T., 2015).  Part-task trainers are used in audiology training programs to provide skill practice in the use of an otoscope, or in SLP, OT or PT to complete a standardized assessment tool. Simucase is an example of a computer-based simulation specific to the area of assessment and intervention in allied health professions, including OT, SLP, and PT.  Currently, I am unaware of any commercially available VR simulations in allied health. However, I did participate in a project that used the virtual world known as SecondLife and avatars to engage students in collaborative practice (Dudding, Hulton & Stewart, 2016).

8.  There are so many terms that our members may not be familiar with. Where do you suggest learners go to look up new terms?

I agree.  This is a new area of practice for many of us in allied health. The terms can be confusing and may change depending on what discipline you may be communicating with.  I would certainly suggest a couple of resources for you. One resource that is a great starting point is a series of articles published by The International Nursing Association for Clinical Simulation and Learning (INACSL). The articles include information about how to design, implement and evaluate healthcare simulations.  One of the articles in the series is specific to the terms used in simulation. Here is the link http://www.nursingsimulation.org/article/S1876-1399(16)30133-5/fulltext.  Another great reference that I often recommend is the Healthcare Simulation Dictionary, published by the Society for Simulation in Healthcare (http://www.ssih.org/Dictionary). I use both of these sources extensively and encourage you to get more familiar with the terms.  As more simulations become available to the allied health profession, you will benefit from a better understanding of the terminology.

9.  What’s an OSCE? And how would that apply to simulations?

OSCE is an acronym that stands for “Objective Structured Clinical Evaluation.” OSCE’s are commonly employed in medicine, nursing and healthcare professions to assess clinical competencies in undergraduate and graduate programs. Traditional OSCEs may include a series of stations to assess a variety of clinical skills against a standard of performance. I believe Objective Structured Clinical Evaluations are an area of great promise in our fields. Simulations will provide an opportunity to evaluate a student, and unlike traditional examinations, will allow for assessment of students' abilities to handle the unpredictable things that pop up during treatment.

10.  To what do you attribute the recent interest in simulations in allied health?

I believe there are a number of factors leading to the current interest in healthcare simulations for clinical education.  We often read and hear about the stressors being placed on graduate programs in allied health to provide students with quality, clinical education experiences across a variety of disorders.  With the changes in reimbursement, supervision requirements, and productivity requirements, it is reportedly more difficult to secure outside clinical experiences for our students, especially in healthcare settings.  Some large rehab companies have begun charging students/universities for the fieldwork student placements.  Another contributing factor is that healthcare and service delivery systems, in general, are becoming more complex. University programs are seeking ways to provide students with training in an environment that is safe for the students and the patients/clients.  Simulation also plays nicely into the recent mandates for interprofessional education and practice.  

11.  How prevalent is the use of healthcare simulations in allied health?

Well, I’m glad you asked. I recently published the results of a survey of graduate programs in allied health about the prevalence and use of healthcare simulations for clinical education.

We provided the readers with the full citation early in this interview. Here is the citation again: Dudding, C.C. & Nottingham, E. E. (2017). A national survey of simulation use in communication sciences and disorders university programs. American Journal of Speech-Language Pathology. doi:10.1044/2017_AJSLP-17-0015.  

12. What were the key findings of your study?

Well, it turns out it was a very timely study. Fifty-one percent of the 69 university programs (for communication sciences and disorders) reported the use of simulations. That was more than expected.  Programs most often employ standardized patients or computer-based simulations.  We are still very early in the healthcare simulation arena. The majority of respondents (85%) reported beginning using simulations within the last 5 years. I believe that speaks to the factors we discussed earlier.  In most cases, there is a single or small group of faculty involved with simulations - early adopters.  Those are the people we need to support and encourage if our field is to mature in its use of simulations. Currently, simulations are being used more often for diagnostics than treatment. That may be due to the current products available (e.g., Simucase). I have a feeling that will change in the future.

13.  What were some of the reported benefits of simulations for clinical education?

I was glad to see that, of the respondents, the majority have an overall receptiveness to the use of simulations. Most of the folks currently using simulations reported a desire to increase use. So those are all good things to move forward with. When asked to rank the benefits, respondents cited: (1) increased student confidence and reduced anxiety, (2) repeated practice in a safe environment, (3) increased preparedness for off-campus placements, and (4) access to a broader range of experiences and client types.

14.  What were the barriers that people reported?

Lack of training, lack of time, and lack of facilities and staff were reported barriers.  In OT literature, faculty listed challenges of time to prepare the simulations or scheduling time in the labs as issues.  Also, learning new technology was listed as both time consuming or intimidating to faculty (Bethea, Castillo, & Harvison 2014). An interesting finding is that of the programs that have simulation labs on campus, less than half of the allied health programs reported using the facilities. This finding is what really got me advocating for quality training on healthcare simulations. We have bright and dedicated individuals who, with training and support, can help to move our field ahead.

15.  I have heard that ASHA has changed its standards to allow the use of simulations to count towards clinical clock hours in speech therapy and other professional organizations may be following soon.  Is that true?

I am very happy to report that is true…with one slight caveat. Some forward-thinking leaders on the Council for Certification in Clinical Competency (CFCC) were open to considering the evidence supporting the use of healthcare simulations for clinical training. Following the evidence, in 2016 the implementation language (not the standard itself) for Standard V-C was revised to allow for up to 20% of clinical clock hours to be obtained through simulations.  Here is the exact language: Up to 20% (i.e., 75 hours) of direct contact hours may be obtained through clinical simulation (CS) methods. Only the time spent in active engagement with the CS may be counted. CS may include the use of standardized patients and simulation technologies (e.g., standardized patients, virtual patients, digitized mannequins, immersive reality, task trainers, computer-based interactive). Debriefing activities may not be included.  

16.  These are indeed exciting times. I am happy we can be part of it. Where can our readers learn more about simulations?

Well, I would encourage readers to seek the information available to them through Simucase, SpeechPathology.com, and OccupationalTherapy.com – including this SimQ series that will be updated monthly. In addition, I am aware that the major professional organizations such as ASHA, CAPCSD, and AAA are creating professional development opportunities for their members. I would also encourage you to look around for opportunities through our colleagues in OT, Nursing and Medicine. I recently became aware of an online certificate program in simulations available through the College of Nursing at the University of Central Florida.  If you have a simulation lab on campus, I’d suggest you begin the conversations to link in. This might be a good topic for a later article. 

17.  I noticed that you have the letters CHSE after your name. What does that mean?

CHSE is an international designation from the Society for Simulations in Healthcare (www.ssih.org). It means that I have passed the requirements as a Certified Healthcare Simulation Educator.  The process included a review of my experiences and passing a certification exam. While there are over 1000 CHSE's across the world, there are only about half a dozen SLPs with the certification and a handful of OT professionals as well. I believe this is a great way for our fields to engage in advocacy and have our place at the “simulation” table. I strongly encourage anyone in an allied health profession, who meets the qualifications, to obtain this credential.  

18.  What do you see as the next steps for the allied health professions in the area of simulations?  

That’s an easy question. I see three major areas.  The first is quality training in the pedagogy and technologies. The next area involves advancing research on the effectiveness of simulations in allied health. As is the case with all new paradigms, advocacy is necessary to increase understanding of both the process and the benefits of simulation as a learning tool.  In allied health professions, simulation use is on the rise, and simulation growth is expected to continue within all practice areas.  As professional organizations continue to consider simulation a valuable resource for experiential learning, more resources will become evident.  Our professions will continue to realize the benefits of working in a risk-free environment where the opportunity for practice and feedback are so valuable. 

19. Thank you for your time today. Any other thoughts to leave us with?

Yes, I want to remind people to check back regularly for other topics focused on the use of healthcare simulations. I will be interviewing experts in allied health and in other areas regarding the latest research, technologies, and best practices in simulation. Thanks Katie.

References

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