SIMQ: A Student Perspective of Simulations for Clinical Training

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

This article part of our series of articles on simulations in healthcare, specifically in Communication Sciences and Disorders (CSD). The SimQ format allows us to explore the technological as well as pedagogical aspects of simulation for clinical education through the words of the experts. This article explores the perspective of a recent graduate student who experienced several forms of simulation as part of her clinical education.  It is anticipated that the audience will include university faculty, clinical educators, and professionals with interest in the use of simulations to enhance the clinical education of our students and practicing professionals. These articles are intended to address the needs of those considering the use of simulations, and those with varying experiences and level of skill.

Samantha D Livengood, MS, CF-SLP is a recent graduate of James Madison University's Master of Science Speech Pathology program.  In the fall, Samantha will begin her Clinical Fellowship Year working as a Speech Language Pathologist at Ruckersville Elementary School (K-5) in Greene County, Virginia.  Samantha participated in evaluation and treatment-based simulations of various types throughout her graduate program at JMU and believes those experiences were an integral part in helping prepare her for becoming a confident and capable clinician.  

Carol C Dudding, PhD, CCC-SLP, CHSE
Contributing Editor

SIMQ: A Student Perspective of Simulations for Clinical Training

I have continuously sought to engage students in meaningful learning experiences through simulation, interprofessional education, and team-based learning since beginning my career as a speech-language pathology faculty member in 2004 at the University of South Alabama (South). I am currently Director of the TeamUSA Quality Enhancement Plan at South—a campus-wide initiative focused on implementing team-based learning (TBL) to improve student learning, critical thinking, communication, and collaboration. I enjoy working with colleagues from other disciplines to create engaging interprofessional simulation experiences for students and conducting research on the effectiveness of these approaches to learning.

1.  Tell us more about yourself?

I’m a recent graduate of a Master of Science Speech Language Pathology Program.  In the fall, I’ll begin my Clinical Fellowship at Ruckersville Elementary School, working with K-5. My specific interests within the field include the use of technology in treatment, school-based speech, and language practice, and work with the ASD population.  

2.  Congratulations on earning your degree and landing a job. As you are undoubtedly aware, simulation for clinical training in speech-language pathology is a topic of interest these days. I understand that you participated in simulations during your graduated program. What was that like?

Thank you!  Yes, I have had the opportunity to participate in simulations on quite a few occasions!  Many of the simulation experiences were part of research projects being conducted by faculty at my university.  I was excited to be part of something new and innovative, while a bit unsure of how I would perform! 

3.  Which types of simulations have you been involved with?

I’ve been involved in role-playing, manikin simulations, and computer-based simulations. They were spread out over the course of my program. 

4.  Wow, you sure do have a range of experiences with simulations. Let’s start with your experience with role-playing.
Just to clarify, I term what I did as role-playing instead of using the term standardized patients. I understand that what I was involved in didn’t meet all the requirements of a true simulation. It was mostly for demonstration purposes. I didn’t get hours or credit for it, or anything like that. 

For this particular experience, a classmate and I conducted a mock clinical bedside evaluation. This experience took place in a simulated hospital room, which felt very realistic with common medical equipment such as a hospital bed, monitors, gowns, and gloves! My classmate played the role of the patient while I played the role of a Speech Language Pathologist.  As we conducted the mock evaluation, faculty members were able to observe us via video cameras positioned in the simulation room.  Initially, it was hard to “play the part” seriously, but as time went on the task became easier.  The entire experience, from beginning to end, felt very realistic.  I guess that may account for some of our giggling at first. We were nervous and somewhat embarrassed. 

5.  What was your experience with manikins? Was that part of a simulation lab?

Two classmates and I were asked to pilot a manikin simulation for a doctoral student in our program.  It was going to be used later with current students.  Prior to beginning the simulation, each participant was given a very specific role; for example, I was asked to complete a bedside swallowing evaluation on a newborn infant (SuperTory -a manikin), student 2 was asked to do trial feedings with the infant, and student 3 was given the role of making final recommendations to the nursing staff at the end of the simulation.  Oh yea, there was a nursing faculty member in the room with us. She was playing the role of a nurse.  That made it feel very real. 

The manikin itself was impressive!  It was able to move, open its eyes, make noises, cry, experience a change in complexion, and react to our every move. These changes were made by a faculty member who was able to control the manikin from a remote location.  For example, I was amazed that as the baby’s O2 levels dropped, the manikin became cyanotic (turned blue).  When we changed the baby’s position or stopped feeding, the 02 levels on the monitor went back up. I was surprised by how real it all was. 

Yes, this simulation took place in a simulation lab at the university.  The lab is part of the School of Nursing. I think this was the first time SLP students were involved in a simulation in their lab space with manikins.  We were set up in a room that was equipped with realistic medical equipment such as a baby crib, monitors that displayed O2 sats, heart rate, blood pressure, etc., and other items commonly found in NICUs.  It was a lot like what we learned about in class but it was really different when we get to actually experience it in “real life”. I hope students get more opportunities like this. 

6.  Sounds like a wonderful experience. I certainly was never involved in anything like that when I was in school.  Okay so now please tell me about the computer-based simulations? Was that Simucase?

Yes, the computer-based simulations were through Simucase.  As I understood it, our involvement with Simucase was part of a research project.  The cases were really different. Some were diagnostic cases involving children, others involved adults. They have cases that depict interventions but we weren’t assigned those. As part of the research design, students worked in Simucase in groups of 4-5.  Before we got together as a group, we individually completed the diagnostic in learning mode.  Learning mode gives you feedback on the quality of your decisions. Then the groups convened and completed a single case in assessment mode based on lessons they had learned individually in learning mode.  Groups were required to attend a pre-brief and debrief session with their clinical educator for each Simucase.  In the debrief, we had to come up with our findings and recommendations. After discussing the case with our clinical educator, we had to write a diagnostic report based on those findings.  

7.  So you have indeed had exposure to several types of simulations. That makes you the right person to answer my next question.  Considering the different experiences with simulation technologies, what do you consider the benefits of each type?

The main benefit of role-playing is that you are working with a real person (in this case my classmate) and it feels almost like reality.  It made me kind of nervous even though I knew the other person was a student like me.  I’d like to participate in a similar experience with a true standardized patient. I think that would be really helpful in practicing communicating with others. 

The benefit, in my opinion, of a manikin simulation is that it feels like reality, but there is room for mistakes because you aren’t working with a live individual.  The feedback was immediate and real life. When the baby was repositioned, the color improved immediately.  It was a bit nerve-racking when the baby was crying and I couldn’t make it stop. But I guess that’s real life too. 

Lastly, the benefit of online/computer-based simulations is that you can learn from your mistakes, go back and fix the mistake quickly, and keep going until the simulation is complete.  It didn’t feel quite as real but it was great for repeated practice. It also was comprehensive. We completed the diagnostic beginning with chart review and consultation. We then selected assessment measures and viewed results. It required a final diagnosis and recommendations. It was a good experience in learning the full process. With the computer-based simulation in learning mode, you got instant feedback on whether you were right or not. Then you could go back immediately and revise your answer. That was important for learning.  I definitely got better at it over the course of the semester. It was a very different learning experience compared to the manikin lab. 

8.  Do you have a favorite experience to share with us? 

My favorite experience was the manikin simulation I took part in.  I was tasked with evaluating an infant’s (manikin) swallowing/feeding.  I worked as part of a team to accomplish the task and was pleasantly surprised with how “real” the simulation felt.  There were a few moments during the simulation where I felt significant emotions such as anxiety, concern, and/or relief as the simulation progressed.  

9.  Were the simulations part of a clinical assignment or part of a course?

We used simulations as part of our clinical assignment and one of my instructors used simulations as part of the academic course.  Most of the time the simulations were required as part of our clinical requirements. It served as my diagnostic assignment for my first semester but we also had a couple of simulations that were assigned within a particular course.  I wish I had more opportunities to complete some of the Simucases on my own. 

10.  That’s interesting. Tell me more about how it worked as your clinical assignment. Did you use the computer-based simulations in addition to your clients?

As I mentioned, some of my experiences were part of a research project. The faculty was researching the effectiveness of the computer-based simulations. We each were enrolled in Simucase. Half of my cohort completed computer-based simulations as their diagnostic assignments in the first semester (Fall). While the other half of students were assigned to real patients. We completed a Simucase for every live diagnostic that the other students completed. The next semester (Spring), we switched. 

11. Were you okay with not being assigned to live patients? Or did you feel like you were short-changed?

I did not feel short-changed at all!  I think that it was well-planned out to have half of my cohort working on simulations while others worked in the on-campus clinic.  I actually felt like I had a bit of an advantage in participating in online simulations during my first semester because I could take my time in making decisions for each patient.  I didn’t feel the typical “jitters” and “nerves” that may have been expected during a “live” diagnostic session on-campus.  I felt better prepared for the live patients in the second semester. It also allowed us to get more diagnostic experiences since there is a limited amount of diagnostics scheduled each semester.  Plus, our simulated cases never canceled.  Actually, a few of the students who had live patients first wished they had been assigned simulations. I think it helped us all to feel more prepared. Especially in regards to knowing what kind of questions to ask the client and/ or family members. 

12.  How were the simulations incorporated into your courses?

I recall one class in particular in which I was required to complete two computer-based simulations.  As part of my Fluency course, I was asked to work with a partner to complete the Simucase simulations, Ben and Fiona. Ben was the case of a school-aged child and Fiona was an adult. We worked through one case at a time to diagnose and create a treatment plan for a person who stuttered.  After everyone had completed the assignment, the class as a whole participated in the debrief led by our instructor. We discussed the case and what went well, what we would do differently, and treatment goals. This was an opportunity for me to reflect on the learning in class and what I would do with a client. It was a bridge of sorts. I found this mode of learning to be particularly helpful in that class because most of us had never had a chance to work with a disfluent patient before, and this gave us an opportunity to use all we’d learned that semester and apply it to a very realistic case.  It helped me to feel more confident in working with a real client who is disfluent. 

13.  You may have mentioned this in your earlier answers. But please expand. Did you complete the simulations individually or part of a group? 

I was required to do preparation of the simulation experience both individually and in groups. The simulations often occurred with a group of students. For example, I was often required to, first, work on a simulation individually, and then join a group to complete the simulation and then meet as a group afterward to compare/discuss results and write reports.  We were not graded on our performance in the simulations, so I don’t know how that would have worked for the group work. I do know that our participation overall was considered as part of our final grade for the semester.  For the manikin and role play experience, I worked with other people but had to make decisions on my own.  But that's okay. That was real-life practice. 

14.  What aspects were challenging for you and your classmates?

I believe one of the most difficult parts of participating in simulations is taking it seriously.  For the online simulations, my classmates and I sometimes felt like it was just an assignment to “pass” rather than a great learning experience.  Unfortunately, if you don’t view the simulations as a learning experience rather than just a grade, it is more likely to feel like a game than clinical experience. I think there are things that could have been done so that we would have taken it seriously. Looking back, if we were graded individually and as part of a group, that would have motivated us. As it was, some group members just coasted while others with “Type A” personalities did most of the work. The debriefings were really important. Maybe we could have been graded for that. I know we were required to write a report and sometimes an intervention plan. That helped us focus and give the deserved amount of effort. But I think this is something instructors should be aware of. 

15.  Did you obtain clinical hours for any of these experiences?

Yes. But only for the computer-based simulations. In order to count the hours, we had to participate in a pre-brief and debrief. The debrief was conducted with my clinical educator. We discussed results and reflected on our performance. We also had to score at least 90% on the simulation for it to count towards clinical hours.  We received the number of hours that are posted on the Simucase site.  We documented our simulation hours in the Typhon system.  We were allowed a max of 75 hours, but I think I earned less than 10 hours as part of my program. I am glad we did simulations even if we didn’t earn a lot of hours.  From what I understand, the current group of students is using Simucase not as part of a research project so they are able to earn more hours. 

16.  Are you in agreement with the standards allowing up to 75 clinical hours through simulation? 

Most definitely.  I feel that I learned just as much, if not more, during all of the simulations as I did in the clinic or during externships.  Additionally, completing a simulation required just as much time, so in my opinion, I don’t know why it wouldn’t be appropriate to allow accrual of up to 75 clinical hours.

17.  How did simulations compare to other teaching methods?

Simulations gave me hands-on learning with an opportunity to make mistakes without harming another person.  It was helpful to my learning to not worry so much about getting it right and to think about what is the best response and why. The feedback with simulations was often immediate and the opportunities to complete the simulations were essentially infinite.  Like I mentioned earlier, I wouldn’t have had the opportunity to experience a client who stuttered without completing the course assignment.  I think it’s great that they are building new cases all the time. That will help to be sure that we at least get exposure to these less common disorder types. The experience in the simulation lab with manikin SuperTory was awesome. I learned so much that I will never forget. I also learned about communicating with a nurse. She wasn’t as scary or mean as I thought. She was really interested in what we had to recommend regarding feeding. 

18.  What aspects of the simulation experience was most helpful?

The ability to step back, see my mistakes as they happened, and fix them immediately.  Our clinical faculty encouraged that type of self-reflection for all our assignments but with simulations, it was built into the process.  It helped me to feel more confident about my ability to work with a live client and their families. 

19.  Do you think you experienced the right amount of simulation in your clinical education? Do you think there should be more or less? 

I think for my program, the number of simulations provided was just right.  The use of simulations in clinical education is just beginning to take-off and I think it is wise for programs to take it at a reasonable pace in order to ensure students are effectively learning from the simulations. I know the current students at my university are doing more.  I do believe an increase in the use of simulations in clinical education would be terrific, but should certainly be well-planned out by programs beforehand. I hope my comments will help.  

20.  Thanks, Samantha. I can assure you that others will consider your insights when integrating simulations into their curriculum. What do you want programs considering implementing simulations into clinical education to know about your experience?

I’d want programs to know that students will ENJOY this experience.  In my opinion, most students don’t know what simulations are all about, but given the opportunity to use their knowledge in this realm will create buzz and excitement!  I feel that I learned more from my experiences with different forms of simulations than I would have learned just working in a clinic.  I felt like I was able to be more authentic, allow myself to make mistakes, and then learned lessons that I was able to apply later in real-life situations.  

Carol: Thank you and best wishes as you move forward in your career. Keep that enthusiasm for learning.