Health Workforce Australia

Health Workforce Australia Simulated Learning Environments in Audiology :: Final Report July 2011 A National Approach for the Integration of Simulated Learning Environments into Audiology Education Dr Wayne Wilson Dr Helen Goulios Dr Sarosh Kapadia Dr Robert Patuzzi Assoc. Prof. Joseph Kei Ms Jessica Vitkovic Dr Catherine McMahon Ms Karen Parfitt Ms Yee-Foong Stone Ms Sandra Buxton Ms Angela Marshall Chief Investigators [Participating Universities] Flinders University Macquarie University Melbourne University The University of Queensland The University of Western Australia

Simulated Learning Environments in Audiology Education July 2011 Audiology Collaborative (Australian Audiology Programs Group) Flinders University Macquarie University The University of Melbourne The University of Queensland The University of Western Australia Dr Sarosh Kapadia Dr Christopher Lind Ms Karen Sparrow Ms Sandra Buxton Dr Catherine McMahon Dr Mridula Sharma Ms Rebecca Summons Ms Yee-Foong Stone Prof. Richard Dowell Ms Angela Marshall Ms Jessica Vitkovic Ms Judy Lockie Assoc. Prof. Joseph Kei Dr Wayne Wilson Dr Carlie Driscoll Dr Robert Patuzzi Dr Helen Goulios Ms Karen Parfitt Audiology Australia (Federal Executive Council) Mr Jim Brown, President, Professional and Government Liaison Dr Catherine McMahon, Vice President, Education and Ethics A/Prof Robert Cowan, Treasurer, Budget & Financial Planning Ms Sharan Westcott, Past President, Professional and Government Liaison Mr Alexander Gouralnik, Councillor Ms Merren Davies, Councillor Mr Paul Hickey, Councillor Ms Sarah Love, Councillor Ms Monica Persson, Chief Executive Officer Dr Celene McNeill, State Councillor (NSW/ACT) Ms Armajit Anand, Territory Councillor (NT) Ms Jillian Sellars, State Councillor (QLD) Ms Sheridan Flint, State Councillor (SA) Mr Jonathan Gault, State Councillor (VIC) Mr Hugh Roberts, State Councillor (WA) Acknowledgements: This project was completed with the financial support of the Health Workforce Australia. Facilitation and infrastructure support was provided by Nova Projects Pty Ltd. 2

Simulated Learning Environments in Audiology Education July 2011 1. Executive Summary One in six Australians (3.55 million people) is affected by hearing loss and, with an ageing population this ratio is projected to increase to one in four by 2050. Audiologists are the primary health care professionals qualified to manage the non-medical aspects of hearing and balance disorders. Although there has been a progressive increase in the number of audiology graduates produced by Australian universities, there remains a chronic shortage of audiologists, both in Australia and worldwide. This is especially the case in rural and remote areas, where service needs are generally greater. To meet the current and future hearing health care needs of Australians, universities must significantly increase numbers of Audiology graduates. However, expansion of the existing Australian university programs that offer Masters degrees in (clinical) Audiology is severely limited by clinical training capacity. To address this limitation, all five accredited Audiology programs have formed the Australian Audiology Programs Group and collectively begun implementing and researching simulated learning environments (SLEs) to offer skills-based experiences to students safely and securely through the imitation of reality. This report presents a consensus position from the Australian Audiology Programs Group and Audiology Australia, the peak professional body for Australian audiologists, outlining an achievable and sustainable approach for consolidating and expanding the use of SLEs in audiology clinical education curricula. The key elements of this position are that: SLEs increase clinical placement capacity by (i) enabling students to develop competence in more basic (technological) elements of the curriculum prior to clinical placement enabling fast-tracking of professional development, (ii) increasing the breadth of exposure to different clinical experiences and (iii) replacing some types of clinical placement; Research into the use of SLEs in audiology is currently limited and more is needed; Clinical educators (university and workplace) support the use of SLEs while maintaining clinical placements as the ultimate learning tool; The Australian audiology programs individually are using some SLEs to increase clinical placement capacity and are therefore well placed to consolidate and expand this use over the next five years. It is recommended that the Australian Audiology Programs Group lead the consolidation and expansion of SLEs in audiology curricula in Australia, and that appropriate funding be provided to support this initiative. The specific recommendations derived from this consensus position were: Recommendation 1: Resources, tools, equipment, space, staffing and timelines required to deliver an agreed curriculum will be identified and a project budget established, Recommendation 2: A case bank of audiological scenarios should be developed and disseminated to all Australian audiology programs, Recommendation 3: Sufficient numbers of existing and preferred SLEs for use by Australian audiology programs should be purchased for adaptation / development and evaluation. 3

Simulated Learning Environments in Audiology Education July 2011 Contents 1. Executive Summary... 3 2. Background... 7 2.1 Operating Definition of SLE... 8 2.2 Scope of Practice for Audiologists... 8 2.3 The Audiology Workforce in Australia... 9 2.4 Accreditation of Australian University Audiology Programs... 10 3. Project Approach/Methodology... 10 3.1 Stage One... 11 3.2 Stage Two... 11 3.3 Stage Three... 11 3.4 Stage Four... 12 4. Findings... 12 4.1 Literature Review The use of Simulated Learning Environments in Audiology... 13 4.2 What are the Strengths and Weaknesses of Using SLEs in Audiology?... 14 4.3 The Views of Workplace Clinical Educators... 15 4.4 Existing Entry Level Curriculum for Professional Audiology Delivered by SLEs... 16 4.5 Could SLEs be used to increase clinical placement capacity?... 17 4.6 Mapping SLEs into Existing Curricula... 18 4.7 Feasibility and Timeframe Required for Implementation... 19 4.8 Perceived Barriers to this Curriculum being Recognised and Adopted for Clinical Training Purposes... 21 5. Recommendations... 24 5.1 Recommendation 1: Resources, tools, equipment, space, staffing and timeline required to deliver the agreed curriculum must be identified... 24 5.2. Recommendation 2: A case bank be developed and implemented... 24 5.3 Recommendation 3: Sufficient numbers of existing and preferred SLEs for use by Australian Audiology Programs should be purchased for adaptation/development and evaluation... 24 6. Concluding Statement... 24 7. Level of Agreement Obtained... 25 8. References... 26 Appendix A... 31 Literature Review - Use of Simulated Learning Environments in the Health Professions... 31 A.1 Simulated Learning Environments Using Humans... 31 A.1.1 Standardised Patients... 32 4

Simulated Learning Environments in Audiology Education July 2011 A.2 Simulated Learning Environments Using Mannequins... 33 A.3 Simulated Learning Environments Using Computers... 34 A.3.1 Multimedia... 35 A.3.2 Computer-based simulations including game-like elements... 35 A.3.3 Virtual Patients... 35 A.3.4 Virtual Caves... 36 A.3.5 Virtual Worlds... 37 A.3.6 Virtual Reality with Haptics... 38 A.4 Transfer of Skills from Simulation to Clinical Practice... 38 Appendix B... 39 The Views of Workplace Clinical Educators... 39 B.1 What takes up most of your time with a student on clinical placement?... 39 B.2 What could the audiology courses do to make clinical placements less of a burden and more efficient for you?... 40 B.3 What skills, knowledge and personal attributes do some students have that result in less of a burden for you as their clinical educator?... 41 B.4 Simulations are increasingly being used in audiology as well as other health care professions. How likely do you think that using simulations for students before clinical placements would reduce the burden on you as a clinical educator?... 42 B.5 Do you believe an increase in the use of simulations in audiology education would result in students requiring less time in clinical placements to reach competency? Why?... 43 5

Simulated Learning Environments in Audiology Education July 2011 Abbreviations CBS CE CKC GEM HF LF MF SLE SP Computer-Based Simulations Clinical Educator Core Knowledge and Competencies Graduate Entry Masters High fidelity Low fidelity Mid fidelity Simulated Learning Environment Standardised Patient 6

Simulated Learning Environments in Audiology Education July 2011 2. Background Hearing health is of vital importance to Australia. Access Economics (2006) indicated that one in six Australians (3.55 million people) is affected by hearing loss and, with an ageing population, this is projected to increase to one in four Australians by 2050. Access Economics estimated that the financial cost to the nation was $11.74 billion or 1.4% of GDP (a conservative estimate based on the prevalence of a hearing loss in the better ear), plus a further $11.3 billion in net cost of loss of wellbeing (disease burden). Audiologists are the primary health care professionals responsible for the non-medical management of hearing and balance disorders. They are university-trained professionals who identify, diagnose, manage and monitor disorders of hearing and balance. Audiologists perform behavioural and objective assessments of hearing and balance, counsel patients and families of patients with hearing loss, provide aural rehabilitation, prescribe and fit hearing aids and assistive listening devices as well as protective ear plugs, and recommend and map cochlear implants. Additionally, audiologists are key professionals in the design, implementation and management of hearing programs for multiple populations including: Indigenous Australians, newborns, school aged children, and the workplace and general communities. Audiologists also work in a research capacity to further our understanding of hearing loss and hearing health and contribute to the design of government policy. The minimum requirement to become an audiologist in Australia is a Bachelors degree followed by a 2-year Masters degree in Audiology. As part of the 2-year Master of (Clinical) Audiology degree, students must complete 150 hours of direct, hands-on, supervised clinical placements and a further 100 hours of indirect supervised clinical placements, and satisfy 166 Core Knowledge and Competencies (CKCs). This forms a requirement for full membership for Audiology Australia, the governing body for audiologists in Australia. To ensure that student audiologists meet these minimum requirements, all five Australian audiology programs provide extensive clinical placements in a variety of workplace contexts which are largely delivered by external hospital, government and private clinics. To achieve the required hands on hours, each student is placed in clinics for about 300-500 hours across the two years. This reliance on workplace placements poses several problems: the quality of training received by the students varies between the different clinical placements; the patients/clients attending these workplaces (clinics) are exposed simultaneously to a supervising audiologist and students-in-training (where, less efficient clinical and educational services are often provided when the student is less competent); the financial and time costs to the centres hosting the placements are high, and they are provided with little to no remuneration by the universities. Although the profession as a whole recognises the critical importance of offering student clinical placements, the latter two problems noted above are increasingly reported as reasons why individual workplaces do not. This has significantly limited the ability of Australian audiology 7

Simulated Learning Environments in Audiology Education July 2011 programs to graduate the numbers of audiologists required for Australia s growing need for better hearing health (Wilson, Hill, Hughes, Sher, & Laplante-Lévesque, 2010). To address these issues, all five accredited audiology programs at Australian universities have begun to use and research simulated learning environments (SLEs). This use of SLEs aims to improve the efficiency and effectiveness of clinical training and assessment (Williams & Schreiber, 2010), and to reduce the burden on workforce placements. While extensive research into the use of SLEs is lacking, the fact that all five audiology programs in Australia are already using and researching SLEs leaves them well placed to increase the integration of SLEs into their audiology curricula. This report was commissioned by Health Workforce Australia as part of its health workforce reform initiative aimed at enabling the health workforce to better respond to the needs of Australians, while maintaining the quality and safety of health services. The current report represents the views of all accredited Australian University audiology programs and the national professional accreditation body (Audiology Australia) on the following: curricular elements that can be delivered using SLEs, potential barriers for adoption of SLEs, implementation timeframes, likely impact on clinical training capacity. 2.1 Operating Definition of SLE A simulated learning environment (SLE) is an educational tool that offers a skills-based experience safely and securely through the imitation of reality. The aim of simulations is to consolidate the skills and knowledge required for clinical practice so that students are prepared for their application in workplace settings. Educators of health professionals often use the terms simulated learning environments (SLEs) and simulated learning programs interchangeably. For the purposes of this report, simulated learning environment has been used as the overarching term describing the various modalities of simulation used. They have been grouped into three categories for use in audiology education: (i) simulations using standardised patients, (ii) simulations using computers, and (iii) mannequins. These are detailed later in the report. 2.2 Scope of Practice for Audiologists The profession of audiology has evolved from many related areas of expertise, including engineering, medicine, physiology, psychology, speech pathology, and teaching (Bess & Humes, 2003; Burkhard, 2002) resulting in a broad audiological curriculum. The scope of practice for audiologists is wideranging, and includes the diagnosis, treatment and rehabilitation, and/or prevention of hearing and balance disorders in adults and children. Diagnostic audiology includes both behavioural and objective assessments. All assessments are preceded by interviews of the client/family/carer to obtain an appropriate in-depth case history relevant to the audiological needs of clients, and to develop hypotheses regarding the probable type and site of auditory pathology. The behavioural assessment of adults may involve pure tone and speech audiometric testing, tests of central auditory function and tests of other auditory disorders, including tinnitus and hyperacusis. The behavioural assessment of children involves the selection, administration and interpretation of developmentally appropriate tests of hearing including behavioural-observation audiometry, visual-reinforcement audiometry and play audiometry. 8

Simulated Learning Environments in Audiology Education July 2011 Objective assessments may be performed on both adults and children, and include otoscopy, immitance testing (of middle ear function), otoacoustic emissions testing (of cochlear function) and the electrophysiological assessment of the auditory and vestibular systems. Rehabilitative audiology focuses on the management of adults and children with permanent or long term hearing loss, and/or other auditory disorders including tinnitus, to maximise their communication and other environmental hearing needs. This includes the selection, prescription and evaluation of devices, including hearing aids, cochlear implants and other implantable devices, and the use of effective counselling in achieving appropriate rehabilitative outcomes. Audiologists working with paediatric clients are likely to be part of a multi-disciplinary team comprised of other health and education professionals working in a family-centred practice, and providing informed choice. For example, this may include working with ENT surgeons in assessing children for cochlear implantation, or with school teachers in recommending appropriate environmental acoustic modifications to enhance listening in the classroom. Australian audiologists working in the areas of hearing loss prevention and screening are typically based in community or workplace settings, and manage programs for specific populations. For example, they may be responsible for the design and delivery of universal neonatal hearing screening programs at maternity hospitals aimed at the early identification and intervention of children with permanent hearing loss, or the management of programs for Indigenous Australians in remote communities where the prevalence of chronic ear disease is high. In occupational settings they are responsible for noise management programs which encompass strategies that range from reducing the noise level at source to recommending personal hearing protection. Additionally they may undertake audiological evaluations for the purposes of occupational health and safety and workers compensation. 2.3 The Audiology Workforce in Australia There are over 1800 audiologists in Australia, and they are employed in equal numbers across the public and private sectors. Audiology Australia has experienced almost a doubling in its membership in the last 10 years, primarily as a result of the increase in audiology graduate numbers produced by the five Australian university programs. However, despite this increase, the Australian community has been chronically short of audiologists. This is especially the case in rural and remote areas, where service needs are generally greater, mainly due to the significantly higher prevalence of ear disease among Indigenous Australians. The Australian Government Department of Human Services (2011) recently commissioned research on the audiological workforce in Australia. The findings indicated that the workforce should continue to rise in total number, and relative to the total population. However, the findings also suggested that, even with the most conservative growth in employment opportunities for audiologists, and despite the increase in graduates, Australia is still likely to experience a shortfall in the number of audiologists in the next five years. Similar shortages are also evident world-wide, with an international survey on audiology education and practice highlighting that 86% of respondent countries (representing 78% of the total world population) have insufficient audiologists to meet their community needs (Goulios & Patuzzi, 2008). This further emphasises that the increase in the Australian audiologist workforce is most likely to be achieved through increased graduate numbers produced by the Australian universities. 9

Simulated Learning Environments in Audiology Education July 2011 The Australian university audiology programs have identified these ongoing difficulties in obtaining clinical placements as a major factor limiting increases in audiology graduate numbers. Additional factors were: the high cost of running clinical programs for relatively small numbers of students, the high cost of assessing students clinical competencies, and increasing course fees discouraging potential students from applying (Australian audiology programs are full-fee paying, currently costing students around $32,000). Although SLEs are likely to assist the capacity of universities to train more students, the university programs will also need extra resources to address the other factors limiting significant increases in graduate numbers. 2.4 Accreditation of Australian University Audiology Programs The Commonwealth Government Department of Education, Employment and Workplace Relations recognises Audiology Australia as the peak professional body representing audiologists in Australia, and responsible for the accreditation of Australian university audiology programs. The entry level qualification is a Master of (Clinical) Audiology degree, and all accredited programs within Australia only allow students to graduate if they have completed 250 hours of supervised clinical workplace placements (of which 150 hours are direct hands on clinical supervision of adult and paediatric cases), and they have met the specified competency standards as detailed in the Core Knowledge and Competencies (CKC) document (Audiology Australia, 2011). The Audiology Australia CKC document specifies 166 CKCs which are grouped into nine areas of practice: Foundations of audiology Hearing loss prevention and screening Diagnostic evaluation in adults Diagnostic evaluation in children Re/habilitation Rehabilitation in adults Re/habilitation in children Professional management Related knowledge for professional practice: audiology service delivery and professional practice The CKC document also stipulates the level of independence that is required for competent performance of each CKC at entry-level to the profession. Each university has pedagogical freedom in delivering programs to meet accreditation standards. 3. Project Approach/Methodology The investigation into the current and future use of SLEs in audiology clinical education in Australia involved four main stages. These are detailed below. 10

Simulated Learning Environments in Audiology Education July 2011 3.1 Stage One Detailed identification of SLEs currently being delivered at each accredited school for audiology located in Australia. Mapping focused on SLEs that met Audiology clinical placement criteria. An SLE Audiology Project Team comprising of at least two academic representatives from each of the five accredited Australian University audiology programs was established. An initial meeting (via teleconference) was held to discuss the aims and scope of the HWA project, and to secure the cooperation and support required for the collection of data from each of the Australian audiology programs. An initial meeting (via teleconference) was held with the CEO of Audiology Australia to discuss the aims of the HWA SLE Audiology Project and the proposed plan. A further meeting (via teleconference) was held with the Vice President of Audiology Australia regarding the project aims and plan. Project Team Members from each audiology program identified the SLEs (used in teaching and assessment) currently in use in each program, the areas of practice they covered, the competencies targeted and the advantages and limitations of each SLE. These were collated and distributed for review prior to discussion at the Project Team face-to-face meeting. The imposed project time constraints were too tight for the timeframes of the Universities Ethics Research Committees for a full research project requiring formal University ethics approval, however some feedback was obtained from experienced Clinical Educators and current students regarding their perceptions of SLEs. In addition, previously published literature on audiology students perceptions of SLEs was reviewed. A literature review of SLEs used in the education of health professionals and audiologists in particular was completed. 3.2 Stage Two Identification of additional curricular elements that could be delivered via SLEs in audiology education. These curricular elements met Audiology clinical placement objectives. A two-day face-to-face meeting of the Project Team was held, and the following completed: the collated summary of all SLEs currently used in Australian Audiology Programs was discussed and agreement reached on which SLEs could be used nationally, the literature review on SLEs used internationally was discussed and their implications for Australian programs noted, Audiology Australia s CKC document was reviewed, and agreement was reached on which CKCs could be delivered using SLEs for clinical teaching and assessment, resources required to develop and implement new SLEs were identified, the impact (on quality and time) of potential new SLEs on clinical training within each university was identified, The likely timeframes for implementation of SLEs were discussed and agreement was reached on different scenarios The SLE Audiology Project Progress Report from the face-to-face meeting was then prepared, and this was distributed to the Project Team for comment. 3.3 Stage Three Distribution of the Progress Report to the Heads of all accredited Australian University Audiology Programs for feedback, including comments specifically on: 11

Simulated Learning Environments in Audiology Education July 2011 whether the curricular elements identified in stage 2 (above) could be integrated, by agreement, into the Audiology professions curriculum; any perceived barriers to these curricula being adopted by the universities for clinical training purposes; the likely impact on clinical training days required in the course should these curricular elements be delivered by SLE; implementation timeframes. Presentation of the Progress Report to Audiology Australia for feedback, including comments specifically on: whether the curricular elements identified in stage 2 would meet the accreditation standards for schools in the audiology profession; any perceived barriers to these curricular elements being adopted by Australian schools in the audiology profession; the likelihood that these curricular elements would replace the traditional delivery of clinical training through clinical placements; the likely timeframes should the curricular elements be adopted. 3.4 Stage Four Comments from all Australian University Programs and Audiology Australia were then incorporated into a Draft Final Report. This was distributed to all stakeholders for comment prior to a national meeting. A meeting (via teleconference) was held with members of the Project Team, the Heads of the Australian University Audiology Programs and the ASA. This feedback was incorporated in the completion of the final report. 4. Findings All of the universities offer Graduate Entry Masters (GEM) programs in audiology as the only entry point into the profession. The total number of enrolled students nationwide is approximately 200. It is anticipated that an overall increase of approximately 25% will occur in the next decade, increasing total projected students to approximately 250. All of the programs are accredited by Audiology Australia, who assesses each program for re-accreditation once every five years. All five Australian Audiology Programs were asked to: Contribute to a literature review on the use of SLEs in audiology Report their views on the strengths and weaknesses of using SLEs in audiology Canvas the opinions of their Clinical Educators (university and workplace) on the use of SLEs in audiology Consider: What existing professional entry curriculum can be delivered via SLEs Whether SLEs could be used to increase clinical placement capacity How SLEs could be mapped into audiology curricula The feasibility and timeframe required for implementing SLEs into the curricula Any perceived barriers to the adoption of a curriculum containing SLEs Review a draft and a final report. 12

Simulated Learning Environments in Audiology Education July 2011 Representatives from Audiology Australia were asked to review the draft and final reports. 4.1 Literature Review The use of Simulated Learning Environments in Audiology A literature review of the SLEs used in the health professions in general and their implications for audiology education was performed, and these findings are shown in Appendix A. This section of the report reviews the SLEs that have been developed and used specifically in audiology education. Despite the potential benefits of using SLEs to train student audiologists, their use in this context has not been widely reported. Published reports of the use of standardised patients (SPs) to train student audiologists include: Researchers at the Centre for Experiential Learning and Assessment (https://medschool.vanderbilt.edu/cela) at Vanderbilt University in the USA have created a simulation suite containing a wide range of SLEs capable of high fidelity recreations of operating rooms, hospital wards, intensive care units, etc. They have used SLEs involving SPs to simulate events such as an audiologist working with parents and teachers to create an individualised education programs for a child in a school setting, or an audiologist delivering the news that the client s child is deaf and beginning the required counselling in a clinic setting. They report the SPs feel real to the students; English, Naeve-Velguth, Rall, Uyehara-Isono and Pittman (2007) described the use of SPs in the assessment of audiologic counselling skills whereby an SP portrayed the mother of a new baby diagnosed with hearing loss and the students had to break the bad news using guidelines developed by English, Kooper and Bratt (2004). Their report addressed the assessment tool used during this process rather than the use of the SPs specifically; Wilson et al. (2010) used a questionnaire to show that 25 first-year audiology students in Australia reported their interactions with SPs significantly (p<0.05) improved their performance in 10 out of 10 areas of client interaction. They also reported that the SPs portrayals of the cases and the content of the simulated cases were realistic, although further preparation for interacting with the SPs was desirable. These authors recommended the continued investigation of SPs as potential methods of training and assessing Australian audiology students in the areas of client interaction and basic audiometry. Published reports of the use of computer-based simulations (CBSs) to train student audiologists include: Slosberg and Levitt (1978), who described a computer system for simulating pure tone audiometry but did not report on its use; Sistrunk (2002), who created a CBS consisting of an instructional program with interactive case studies for teaching the diagnostic and recommendation processes needed to manage clients/patients. Nineteen first-year audiology students who used this CBS reported a positive attitude towards the CBS in the subsequent user survey and focus group discussions; Lieberth and Martin (2005), who assessed 194 undergraduate and post-graduate students in a communication sciences and disorders program, showed these students could learn basic audiometric testing skills equally well using a virtual audiometer compared to a real 13

Simulated Learning Environments in Audiology Education July 2011 audiometer, and that the skills learnt on the virtual audiometer generalised to the real audiometer; Wilson et al. (2010) used a questionnaire to show that 25 first-year audiology students in Australia reported their interactions with a CBS significantly (p<0.05) improved their abilities in 6 out of 8 areas of basic audiometry. These authors recommended the continued investigation of CBSs as potential methods of training and assessing Australian audiology students in the areas of client interaction and basic audiometry. 4.2 What are the Strengths and Weaknesses of Using SLEs in Audiology? There was agreement amongst all five Australian audiology programs regarding the overall strengths and weaknesses of using SLEs in audiology. The strengths of SLEs were considered to be: The provision of a safe environment for student learning and assessment with no direct impact on clients, Provision of better access to broader client groups (including hard to find placements in some caseload areas), Development of clinical competencies prior to workplace clinical placement Increasing knowledge and skill on entering the clinic (faster transitions, focus on higher level skills in clinic, and less direct clinic time required to reach competence) Better linking of theory to practice in a safe environment (including reduced anxiety and increased confidence, and the opportunity to refine skills before using them on real clients) Provides students with uniform exposure to more complex cases Allowance for remedial action before and during placements Modify behaviours prior to placement and identify at risk students earlier Reduced load on clinical educator May reduce clinical hours/placements needed The ability to structure the experience Built in feedback Valid and reliable assessment Develop skills from novice to entry level graduate Provide opportunities for repeated practice Provide extra assistance. Weaknesses of SLEs were considered to be: The reduced complexity of the simulation, e.g. difficulty capturing communication exchanges and complex clinical reasoning, difficult to train actors for complex client profiles The failure to replicate a real life clinical situation completely, e.g. nuances of interaction and real time interactions, ethical reasoning, contrived nature of case studies Uncertainty regarding recognition of SLEs as evidence of competency for accreditation The need for ongoing funding and resources Difficulties with timetabling A perception that SLEs were only suitable to early stages of clinical skill development 14

Simulated Learning Environments in Audiology Education July 2011 Potential risk that SLEs will be used as part of rationale to reduce availability and/or funding for practical placements rather than an integral part of the learning experience 4.3 The Views of Workplace Clinical Educators All five accredited Australian audiology programs rely heavily on audiology clinics (university and workplace) to take students for clinical placements. Each audiology student can expect to be placed in clinics for between 300-500 hours during their 2-year Masters course to achieve their required hands-on hours of supervised clinical practice. The majority of these hours are accrued in individual placements with workplace Clinical Educators (CEs) volunteering their time in both public and private sector clinics. These CEs are integral to the training of audiology students. University and workplace CEs supervising students from the Australian audiology programs were asked about their views on the impact of clinical supervision of audiology students on their current workload, and whether increasing the use of SLEs in audiology education would result in any changes. CEs were provided with a brief description of the types of SLEs that could be used and were asked to answer five questions about SLEs and clinical education. Written responses were received from 35 CEs. Appendix B summarises their responses in detail, and the following highlights their major conclusions. 4.3.1 What takes up most of your time with a student on clinical placement? CEs highlighted the following areas as taking the most time on clinical placement: Orientating students to the clinical placement Providing students with additional appointment time Case discussion and report writing Providing student with feedback on performance. 4.3.2 What could the audiology courses do to make clinical placements less of a burden and more efficient for you? CEs highlighted the following areas as ways of lessening the burden and increasing the efficiency of clinical placements: Better pre-placement preparation Additional practice of basic audiological competencies within the university setting (this included the use of SLEs) 4.3.3 What skills, knowledge and personal attributes do some students have that result in less of a burden for you as their clinical educator? CEs highlighted the following student skills, knowledge and personal attributes that lessen the burden on the CE: Skills: communication and computing Knowledge: of audiometric assessment procedures and of rehabilitation procedures Personal attributes: including flexibility, confidence, initiative, preparedness, motivation, time management, and self direction 15

Simulated Learning Environments in Audiology Education July 2011 4.3.4 Simulations are increasingly being used in audiology as well as other health care professions. How likely do you think that using simulations for students before clinical placements would reduce the burden on you as a clinical educator? When asked if the use of SLEs would reduce the burden on CEs, 32% responded very likely, 51% reported likely, and 17% reported the use of SLEs would have no effect. Although most comments were positive towards the increased use of SLEs, the comments did not reflect the full potential SLEs could offer as tools for improving clinical competence. Possible reasons for this might be that the CEs were not full-time educators, and were probably not fully aware of new developments in SLEs. 4.3.5 Do you believe an increase in the use of simulations in audiology education would result in students requiring less time in clinical placements to reach competency? Why? Clinical Educators were divided in their beliefs regarding use of SLEs to replace actual clinical placement time, with 46% saying no, 42% saying yes, and 12% being undecided. Many CEs, regardless of their response, also reported that the use of SLEs would better prepare students for clinical placements and would allow students to get more out of their clinical placements, but that substantial clinical time would still be needed to achieve full competency. In summary, the CEs were supportive of SLEs in clinical audiology education. Most CEs felt SLEs would bring students knowledge and skills up to speed at a faster rate than simply relying on clinical workplace placements. Although the majority of respondent CEs felt SLEs may be able to supplement clinical placements, they expressed some reservations about the types of placements they could replace. Finally, many CEs felt that SLEs would help towards reducing the amount of time students needed to spend in workplace placements, however substantial time would still be required in real life clinics to achieve the required graduate entry level clinical competencies. 4.4 Existing Entry Level Curriculum for Professional Audiology Delivered by SLEs The existing entry level curriculum for professional audiology was considered using the 166 audiological competencies defined by Audiology Australia s CKC document. These competencies are grouped into nine areas of practice (as described previously). All five Australian audiology programs agreed that they were already using SLEs to deliver parts of five areas of practice in the professional curriculum, as shown in Table 4.1. These areas included: Foundations of audiology (including pre-clinical knowledge and skills) Hearing loss prevention and screening Basic elements of diagnostic evaluation in adults and children Basic elements of re/habilitation in adults and children. The most commonly used SLEs were simulations using humans (standardised patients low and high fidelity), simulations using mannequins (low fidelity), and simulations using computers (low-tomedium fidelity). Most SLEs were being used in the first half of the curricula, when basic audiological skills were being learnt and assessed. All five Australian audiology programs are currently using SLEs to teach and assess elements of communication, professional behaviour, clinical reasoning, case history taking, basic audiological assessment, basic components of advanced audiological assessment, basic elements of planning treatment, basic elements of implementing treatment, and basic elements of evaluating treatment. 16

Simulated Learning Environments in Audiology Education July 2011 All five Australian audiology programs agreed that of the remaining parts of the professional curriculum, those most able to be delivered via the expansion of existing SLEs and/or the introduction of new SLEs, were: Hearing loss prevention and screening Elements underpinning the advanced elements of diagnostic evaluation in adults and children Elements underpinning the advanced elements of re/habilitation in adults and children Professional management Related knowledge for professional practice: audiology service delivery and professional practice. While all SLEs were considered in this regard, there was a preference for consolidating and expanding existing SLEs, and introducing some new SLEs such as high fidelity mannequins, CBS with more extensive multimedia options, CBS including game-like elements, and high fidelity virtual patients. The introduction of other new SLEs such as virtual caves, virtual worlds and virtual reality with haptics was considered to be less feasible given current funding and resource limitations. 4.5 Could SLEs be used to increase clinical placement capacity? All five Australian audiology programs agreed that it was possible for SLEs to increase clinical placement capacity in two ways: By improving student competencies in the basic elements of the curriculum prior to clinical placement. This would: Enable students to use their clinical placements more efficiently, which would reduce the number of clinical placements needed to attain competency, and potentially allow placement of other (extra) students in these clinics; Encourage more CEs to take students for clinical placements, which would increase the number of clinical placements available to students; By replacing some types of clinical placement, which would reduce the number of clinical placements needed to attain competency. All five Australian audiology programs agreed that they are already using SLEs to increase their clinical placement capacities, as evidenced by: The use of SLEs in the teaching and assessment of approximately 40% of the 166 Core Knowledge and Competencies required for graduation in Australia; The use of SLEs to provide greater remedial instruction to marginal/struggling students. Currently, students who fail to achieve the required competencies in a clinical placement must complete further training until they can either conclusively demonstrate competency or be found unable to do so. All five programs are using (or are beginning to use) SLEs to provide this further training. Early, anecdotal reports indicate that this strategy is beginning to contribute to increased clinical capacity by reducing the workload on workplace CEs, as it was estimated that 10 to 20% of audiology students are classified as being marginal at some stage during their training 17

Simulated Learning Environments in Audiology Education July 2011 The study by Wilson et al. (2010) who showed that 25 first-year audiology students in Australia reported their interactions with standardised patients and computer-based simulations significantly (p<0.05) improved their performance in 10 out of 10 areas of client interaction and 6 out of 8 areas of basic audiometry. The clinical educators in this study also reported that they were better able to identify and remediate marginal students during this SLE training, which had the potential to reduce the need for extra clinical placements. All five Australian Audiology Programs also agreed that there is a strong need to consolidate and expand their use of SLEs to further increase their clinical placement capacities, as evidenced by: Reports from CEs that students who had completed training using SLEs would make better use of their clinical placements and attain their clinical competencies more quickly (see Appendix B) The potential for SLEs to expand student access to a broader range of client demographics. Sourcing a broad range of clients for students was reported to be one of the most time consuming aspects of student supervision (see Appendix B). Using SLEs to expose students to a wider range of clinical cases would have a positive impact on clinical educator workload The potential for SLEs to substantially replace observational experiences for novice students early in the audiology programs. This would result in an immediate reduction in clinical placements and the ability to increase capacity of clinical educators to accommodate more advanced students The potential for SLEs to partially replace some external clinical placements for attaining basic audiological skills or the basic technical competencies underpinning more complex audiological skills. 4.6 Mapping SLEs into Existing Curricula All five Australian audiology programs agreed that: Five general types of SLEs are already mapped into their existing curricula, particularly in the earlier stages where students are learning the fundamental concepts that underpin clinical audiology Further mapping of expanded and/or new SLEs is needed SLEs should not be mapped as the sole assessment of higher-level competencies (including the ability to integrate multiple clinical concepts). Instead, these competencies must be assessed via external placements in real clinical environments Table 4.2 shows an agreed, general progression for mapping current and proposed SLEs into existing audiology curricula. 18

Simulated Learning Environments in Audiology Education July 2011 4.7 Feasibility and Timeframe Required for Implementation Overall responses indicated that it would be possible to consolidate and expand current SLEs and to introduce new SLEs into audiology clinical education over a 1-5 year period. Table 4.3 shows the general agreement reached on the SLEs, the required resources, and the feasibility and individual timeframes (shown as approximated times only) for this process. The models below show two general timeframes considered for implementing expanded and/or new SLEs into existing curricula. Model 1 has the advantage of confirming the validity and reliability of the expanded and/or new SLE before its insertion into mainline curricula and full roll-out for clinical education. It has the disadvantage of having a minimum 3 year delay between the introduction of the SLE and its full rollout for clinical education. Model 2 has the advantage of having a minimum 1 year delay between the introduction of the expanded and/or new SLE and its full roll-out for clinical education. It has the disadvantage of not confirming the validity and reliability of the SLE until after its insertion into mainline curricula and full roll-out for clinical education. All five Australian audiology programs agreed that the preferred model would depend on the circumstances surrounding a specific SLE. For example, Model 1 could be preferred for the expansion of existing SLEs, while Model 2 could be preferred for the introduction of new SLEs. MODEL 1 Introduce prototype of new and/or expanded SLE (3 months) Pilot trials and further development (6 months) Conduct main trials to confirm validity and reliability of SLE (24 months) Insert SLE into mainline curriculum (3 months) Full roll-out of SLE to further increase capacity for universities to provide clinical education (6 months) MODEL 2 Introduce prototype of new and/or expanded SLE (3 months) Pilot trials and further development (6 months) Insert SLE into mainline curriculum (3 months) Full roll-out of SLE to further increase capacity for universities to provide clinical education (6 months) Conduct main trials to confirm validity and reliability of SLE (24 months) 19

SLE Flinders University Macquarie University The University of Melbourne The University of Queensland The University of Western Australia Standardised patients [LF] Learning of diagnostic & rehabilitative skills (n=20) Assessment of otoscopy & acoustic immitance, ear impressions (n=4) Learning of basic audiometric skills (n=31) Learning & assessment of basic & advanced audiometric skills, ear impressions, hearing aid fitting & rehabilitation (n=35) Standardised patients [HF] Assessment of case history taking, acoustic reflexes and hearing aid measurements (n=16) Assessment of case history, basic audiometric skills, interpretation and feedback of results & management skills (n=11) Learning & assessment of case history taking, results interpretation, feedback & management skills (n=64) Learning & assessment of basic audiometric skills (n=40) Mannequins [LF-MF] Learning & assessment of otoscopy and ear impression taking skills (n=3) Learning and assessment of otoscopy (n=3) Learning and assessment of real-ear measures for hearing aid fitting (n=2) Computer based simulations [LF] (multimedia) Computer based simulations [MF] (audiometry simulator) Learning of diagnostic & rehabilitative skills (n=26) Learning & assessment of basic audiometric skills (n=10) Learning & assessment of basic audiometric skills (n=5) Learning & assessment of basic audiometric skills (n=6) Learning & assessment of basic audiometric skills (n=40) Learning of diagnostic & rehabilitative audiology skills (n=26) Learning of foundation knowledge in hearing sciences (pre-clinical) (n=26) Table 4.1: Simulated learning environments currently in use in audiology programs at Australian universities as at May, 2011 (where n = number of competencies taught and/or assessed using the SLE, as per the 166 core knowledge and competencies required for a student to graduate from an audiology program in Australia; SLEs are described as either high-fidelity (HF), mid-fidelity (MF) or low-fidelity (LF) 20

4.8 Perceived Barriers to this Curriculum being Recognised and Adopted for Clinical Training Purposes All five Australian audiology programs agreed that the following are potential barriers to the expansion of currently used SLEs and the introduction of new SLEs in existing curricula: The lack of a sufficient evidence-base to support the use of SLEs in clinical education. The provision of initial funding to the Australian Audiology Programs Group would allow this research to be completed. Acceptance by the profession of the value of SLEs, their potential for student learning and assessment, and their potential to increase clinical capacity. The Australian Audiology Programs Group is currently liaising with Audiology Australia to provide continuing professional development on SLEs for audiologists practising in Australia. The need for a high level of trust between the Australian Audiology Programs using SLEs to teach and assess audiology students and the audiology profession as a whole that rightfully demands audiology graduates be clinically competent. This trust centres on the widely-held notion that while SLEs are a valuable adjunct to learning and assessing clinical competencies, the ultimate assessment should involve real patients/clients in real clinical settings (as reported in the CE feedback in Appendix B). Such a notion is a direct barrier to Model 2 shown in Section 4.7, as this model allows SLEs to be rolled out into the curricula before their validity and reliability has been confirmed by research. A potential solution is for the Australian Audiology Programs to maintain their current use of real patients/clients in real clinical settings in the assessment of student competencies until the research shows which clinical competencies could be assessed using SLEs only. Achieving equity of availability in SLE resources across all five Australian Audiology Programs. The provision of initial funding to the Australian Audiology Programs Group would allow the purchase of a full range of preferred SLEs (and the associated physical and virtual space and internet speed and bandwidth) for immediate use in existing curricula, clinical education and research. Accessing sufficient funds, space and resources to consolidate and expand the use of SLEs in audiology. 21

Type of clinical placement Early/late in the program Objectives SLEs currently used to support and/or partially replace clinical placements (to be consolidated and expanded) SLEs that could be used within 1 to 5 years Observation Very early To introduce students to a clinical setting. Analytical and reflective observation of clinical practice Some use of LF multimedia HF multimedia Basic adult assessment Early To teach and assess competencies for basic adult assessment Some use of LF multimedia, HF mannequins and CBS including game-like elements Some use of MF virtual patients Widespread use of LF-HF standardised patients HF multimedia LF mannequins Basic paediatric assessment Basic adult rehabilitation Basic paediatric rehabilitation Complex adult assessment Complex paediatric assessment Complex adult rehabilitation Complex paediatric rehabilitation Mid Mid Mid Later Later Later Later To teach and assess competencies for basic paediatric assessment To teach and assess competencies for basic adult rehabilitation To teach and assess competencies for basic paediatric rehabilitation To teach and assess competencies for complex adult assessment To introduce and assess competencies for complex paediatric assessment To introduce and assess competencies for complex adult rehabilitation To teach and assess competencies for complex paediatric rehabilitation Some use of LF multimedia, CBS including game-like elements, and low fidelity mannequins Some use of LF-HF mannequins and LF standardised patients Some use of LF multimedia and HF mannequins. Some use of LF-HF standardised patients and MF virtual patients Table 4.2: An agreed general progression for mapping current and proposed SLEs into existing audiology curricula. HF multimedia LF mannequins LF-HF multimedia LF-HF virtual patients LF-HF multimedia LF-HF virtual patients HF multimedia LF mannequins LF-HF multimedia LF-MF virtual patients HF multimedia LF-HF mannequins LF-HF virtual patients LF-HF multimedia LF-HF virtual patients 22

SLE Feasibility Resources required Current use Timeframe * LF standardised patients High Funding to develop more case scenarios, train more educators and students, refine evaluation of student progress, and conduct research and development LF multimedia High Funding to develop more case scenarios, train more educators and students, refine evaluation of student progress, and conduct research and development LF mannequins High Funding to develop more mannequins, refine evaluation of student progress, and conduct research and development CBS including game-like elements High Funding to develop more case scenarios, train more educators and students, refine evaluation of student progress, and conduct research and development LF virtual patients High Funding to purchase computer equipment, develop more case scenarios, train more educators and students, refine evaluation of student progress, and conduct research and development MF-HF standardised patients MF-HF mannequins MF-HF multimedia MF-HF virtual patients Virtual caves Virtual worlds Virtual reality with haptics Mid-high Mid-high Mid-high Mid-high Low Funding to develop more case scenarios, train more educators and actors, refine evaluation of student progress, conduct research and development Funding to purchase more mannequins, obtain more storage space, train more educators, refine evaluation of student progress, and conduct research and development Funding to purchase multimedia equipment, develop more case scenarios, train more educators and actors, maintain support staff (particularly IT support), refine evaluation of student progress, and conduct research and development Funding to purchase computer equipment, develop more case scenarios, train more educators and students, maintain support staff (particularly IT support), refine evaluation of student progress, and conduct research and development Funding to purchase/construct computer software and hardware and room and building facilities, develop more case scenarios, train educators and students, maintain support staff (particularly IT support), refine evaluation of student progress, and conduct research and development Most programs Most programs Some programs Some programs Some programs Most programs Some programs Few programs Some programs No programs Table 4.3: An agreement on the required resources, feasibility and timeframe for the consolidation and development of SLEs in audiology curricula. *Duration noted reflects the time needed to consolidate or create, expand and conduct research. 3 years 3 years 3 years 3 years 3 years 5 years 5 years 5 years 5 years 5 years 23

5. Recommendations It is recommended that the Australian Audiology Programs Group, consisting of all five Australian audiology programs, continue to lead the consolidation and expansion of SLEs in audiology curricula in Australia, and be provided with sufficient funding for this to be undertaken. This group has already introduced SLEs to audiology curricula in Australia, overseen the creation of the Core Knowledge and Competencies document for Audiology Australia (the document defining the competencies required of a graduate audiologist in Australia), and seen its members enjoy a long history of collegial collaboration across a wide range of academic and clinical matters. Each program has expertise in specific SLE areas (which differ between campuses), and each Program would be prepared to lead in further design, development, implementation and evaluation of specific SLEs that could then be shared across all five campuses. This would have the added benefit of promoting consistency between Programs. Specific recommendations agreed upon by the Australian Audiology Programs Group and Audiology Australia are: 5.1 Recommendation 1: Resources, tools, equipment, space, staffing and timeline required to deliver the agreed curriculum must be identified The Australian Audiology Programs Group will identify the full cost of purchasing, implementing and maintaining existing and preferred future SLEs. 5.2. Recommendation 2: A case bank be developed and implemented The Australian Audiology Programs Group will create a case bank where each case can be implemented via existing and preferred SLEs. The cases will cover all professional entry curricula deliverable via SLEs, and will include sufficient information for inter-professional learning. Guidelines for implementation into the curriculum will be developed to maximise adoption throughout all programs. Further funding for the evaluation, maintenance and upgrading of this case bank will also need to be considered. 5.3 Recommendation 3: Sufficient numbers of existing and preferred SLEs for use by Australian Audiology Programs should be purchased for adaptation/development and evaluation The Australian Audiology Programs Group will purchase sufficient numbers of existing and preferred SLEs so that each Australian audiology program can access each type of existing and preferred SLE. For those SLEs which are generic, the Australian Audiology Programs Group will adapt these to the audiological environment. The results of this work will be published in peer-reviewed scientific journals as a primary means of expanding the evidence-base for using SLEs to teach and assess clinical audiology competencies. 6. Concluding Statement This project was able to gain consensus and commitment from the Australian Audiology Programs Group, consisting of all five accredited Australian Audiology Programs, on the following: 24

The review of the SLE literature in audiology highlighted a strong need for further research in this area The general strengths and weaknesses of using SLEs in audiology The opinions of clinical educators (university and workplace) on the use of SLEs in audiology highlighted a general support for SLEs for training basic competencies early in the audiology programs, and a need to maintain clinical placements as the ultimate learning and assessment tool for clinical competencies. The Australian Audiology Programs are already delivering some professional entry curriculum via SLEs, and are in a sound position to consolidate and expand this delivery The Australian Audiology Programs are already using SLEs to increase some of their clinical placement capacity, and are well placed to consolidate and expand this use The Australian Audiology Programs have already mapped some SLEs into their audiology curricula, and are well placed to consolidate and expand this mapping The feasibility and timeframe required for consolidating existing and implementing new SLEs into the curricula The potential barriers to the consolidation and expansion of a curriculum containing SLEs The primary pathway to achieve the recommendations is the appropriate funding of the Australian Audiology Programs Group. Audiology Australia agreed with the findings of this report and indicated that they will continue to accept SLEs as an accredited part of the clinical education curricula for developing entry-level competencies, as per their current acceptance of SLE training towards a maximum of 50 indirect hours within the 250 hours (direct, indirect and professional) required for graduation from an Australian audiology program. 7. Level of Agreement Obtained Unanimous agreement was obtained from the Australian audiology programs (consisting of all five Australian audiology programs) and Audiology Australia on all points reported in this document. 25

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Appendix A Literature Review - Use of Simulated Learning Environments in the Health Professions Simulated learning environments (SLEs) have been used to train students in the health professions for approximately 50 years. This section reviews the published literate describing this use. It draws heavily on a review of SLEs written by Theodoros, Davidson, Hill and McBean (2010). The advantages of using SLEs have been reported to include the ability to: Standardise the clinical curriculum across students and locations. This includes the ability to reproduce standardised educational experiences, enabling assessment of clinical skills across students on identical scenarios (Aliner, 2007). Individualise and adapt learning experiences to students unique learning needs (Issenberg & Scalese, 2007). Expose students to a wider range of clinical scenarios, including rare and/or more serious health conditions which may have a low frequency of presentation in some settings (Aliner, 2007). Provide greater equity to students, especially to those in regional and/or remote locations where the range of real patients may be restricted. Provide a safe, controlled learning environment, particularly for rare or serious cases. This can allow 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). Attain uniform educational outcomes, despite different rates of trainee progress. The use of SLEs allows complex clinical tasks to be broken down into components, allowing students to attain mastery in sequence at variable rates. The use of SLEs appear to be particularly advantageous in training cognitive, psychomotor and nontechnical (e.g. communication) clinical competencies (Aliner, 2007). This has been evidenced by reports of improved learning and clinical performance in the form of increased safety, decreased error rates and improved clinical judgment (Bearnson & Wiker, 2005), as well as improved eye-hand coordination, confidence, communication skills and team work (Brigden & Dangerfield, 2008). Despite these advantages, the body of conventional evidence supporting the use of SLEs remains small, and mostly limited to the fields of medicine and nursing (Flanagan, Clavisi, & Nestel, 2007). A.1 Simulated Learning Environments Using Humans We have defined SLEs using humans as any SLE where the key medium of simulation is a human subject. The prime example is standardised patients (SP) where a real patient is replaced by another human who simulates the real patient in a standardised manner, with the SP able to be played by a professional actor, a health care professional, a teaching staff member, or another student. In this regard, different SPs could be ranked from high-fidelity (e.g. professional actor with experience in a health profession) to low fidelity (e.g. a fellow student in the early stages of training). 31

A.1.1 Standardised Patients The first reported use of standardised patients (SPs) is attributed to Barrows and Abrahamson (1964) for clinical neurology examinations. The use of SPs is now widespread in the health professions, with examples including: Simulating patients with aphasia (Edwards, Franke, & McGuiness, 1995; R. I. Zraick, Allen, & Johnson, 2003), voice disorders (Syder, 1996), apraxia and Alzheimer s Disease (R. Zraick, 2004) in speech pathology. A clinical skills course in pharmacy (Austin, Gregory, & Tabak, 2006). Assessment and nutrition counselling in dietetics (Hampl, Herbold, Schneider, & Sheeley, 1999; Henry, 2007). Interviewing skills in dentistry (Stilwell & Reisine, 1992). Case history taking and physical examination in chiropractic education (Traina, Gour, & Traina, 1994). In general, students regard learning with SPs as being a positive experience, reporting less stress, anxiety and embarrassment in learning clinical skills in a safe and controlled environment (Hill, Davidson, & Theodoros, 2010). Similarly, clinical educators report they are better 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, McGuiness, & Rose, 2000). More specifically, the use of SPs has been successful in both learning and assessment, particularly in the skill areas of: Communication and interviewing, medical history taking, and complete or partial physical examination (Cleland, Abe, & Rethans, 2009; Ladyshewsky, 1999; Stillman, Regan, Philbin, & Haley, 1990; Wallace, Rao, & Haslam, 2002). Self-awareness rather than knowledge in speech pathology (Edwards, et al., 2000; Syder, 1996). Communication skills for more accurate identification of patient needs in nursing (Yoo & Yoo, 2003). Neurological exam techniques (Echternach, 2000), preparing for full time clinical placements (Wojcik, 2000) and evaluating clinical skills in history taking, communication and physical examination of shoulder pain in physiotherapy (Ladyshewsky, Baker, Jones, & Nelson, 2000). Client focus, independence and ability to work collaboratively in occupational therapy (Lindstrom-Hazel & West-Frazier, 2004). SPs have also been widely used in Objective Structured Clinical Examinations (OSCEs) where they are considered a valid and reliable form of performance assessment (Howley et al., 2008). Their reported advantages include their ability to provide more equitable learning and assessment opportunities, with patient scenarios able to be fitted to specific learning objectives with a high degree of control regarding case complexity, information reproducibility and patient attendance (Kneebone & Nestel, 2005; Ladyshewsky & Gotjamanos, 1997). (Note: OSCEs are an assessment method based on objective testing and direct observation of student performance during planned, structured clinical encounters. They typically include several stations in which students are expected 32

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). Perhaps the strongest evidence in support of the use of SPs in student training comes from a randomised controlled trial (RCT) conducted recently across eight Australian physiotherapy schools (Jull et al., 2011). This study involved 720 students undertaking clinical placements in cardiorespiratory and musculoskeletal physiotherapy. For each student, 20-25% of the traditional clinical placement was replaced by intensive or mixed SP training. The intensive model replaced the first week of a block placement (4-5 weeks) with SP training. The mixed model distributed the SP training 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 traditional workforce placement could be replaced to some extent by SP training, without compromising learning outcomes for students. For some clinical skills, the high cost of high-fidelity SPs could be offset by using low-fidelity SPs, without a concurrent reduction of training outcomes. Such an effect was seen by Mounsey, Bovbjerg, White and Gazewood (2006) who reported similar improvements in motivational interviewing skills (for smoking cessation) in medical students whose SPs had been professional actors versus those whose SPs had been fellow students. While the reports on SP use in the training of health professionals is generally positive, Hill et al. (2010) identify several remaining challenges. These included: The need for specific assessment tools to document student learning outcomes in SP programs. Time, financial and organisational commitments involved in providing SP programs. The fact that it remains generally unclear whether the use of SPs achieves the same clinical learning outcomes as the real-life clinical placement (Hill et al., 2010). A.2 Simulated Learning Environments Using Mannequins We have defined SLEs using mannequins as any SLE where the key medium of simulation is a mannequin. Mannequins can simulate abnormal vital signs, and are able to demonstrate signs of acute life-threatening conditions and undergo drug treatment or invasive procedures without repercussions. Different mannequins can be ranked from high-fidelity to low fidelity. High fidelity mannequins can provide physical feedback through haptic technologies (e.g. anatomical models for surgical training), while low fidelity bench top mannequins are in frequent use in medicine because of their portability, lower cost and potential for repetitive use (Grober et al., 2004). An example of a mannequin human patient simulator (HPS) is the Laerdal SimMan. This is a lifesized, technologically advanced simulator that has palpable pulses, heart, breath and bowel sounds and an IV arm. It can 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 using such a mannequin, especially when the training takes place within a mock ward. 33

In general, mannequins are used extensively within medical and nursing education (S. B. Issenberg, McGaghie, Petrusa, Gordon, & Scalese, 2005) where they are well recognised as being able to replicate real-life cases and provide positive learning experiences (McGahie, Issenberg, Petrusa, & Scalese, 2010). Effective use of mannequins is thought to rely on the aligning of educational goals with the appropriate level of technology. In this regard, low fidelity mannequins or part-task trainers (PTTs, designed to represent only part of the real thing) could allow pinpoint training of basic technical, procedural or psychomotor skills. Examples include airway suctioning, intubation, venepuncture, ophthalmoscopy and catheterization (Bradley, 2006). High fidelity mannequins could be required to train for more complex clinical events, such as responding to hospital codes (McGahie, et al., 2010). Some authors report, however, that while low fidelity mannequins provide less realism, they can be as effective as live animal models in training the acquisition of microsurgical skills in novice surgeons (Grober, et al., 2004). More specifically, the use of mannequins has been successful in both learning and assessment, particularly in the skill areas of: Clinical skills and decision-making in physiotherapy (Hassam & Williams, 2003; Kinney La Pier, 1997). Caring for seriously ill patients in intensive care or emergency wards and in cardiorespiratory training for physiotherapists (Blackstock & Jull, 2007). Blackstock and Jull (2007) note that there is currently limited availability of suitable mannequins but consider there to be substantial potential application in physiotherapy. 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 (Kneebone & Nestel, 2005). A.3 Simulated Learning Environments Using Computers We have defined SLEs using computers as any SLE where the key medium of simulation is computerbased. These computer-based simulations can be ranked from high-fidelity (e.g. virtual reality) to low fidelity (e.g. simple multimedia learning contents such as audio and video). The first report of computer assisted instruction is attributed to Suppes and Jerman (1968) for tutorial and drill-and-practice programs in elementary mathematics, logic and algebra, spelling, beginning reading, and elementary Russian at the college level. The use of computer-based simulations is now widespread in the health professions, with specific examples discussed below. In general, computer based simulations provide students with interactive, safe environments which may be fully immersive, non-immersive or augmented (Jia, Bhatti, & Nahavandi, 2008), although learning outcomes may depend more on the quality of the instructional design rather than the fidelity of the computer-based simulation (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 et al., 2010). 34

A.3.1 Multimedia Williams, Brown, Scholes, French and Archer (2010) investigated whether DVD simulations could transform clinical fieldwork. They filmed simulated patients (actors) through different stages of recovery in a range of health care settings with numerous health care professionals, and created DVD presentations ranging in length from 15 minutes to 3 hours that highlighted 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. They also found the DVD tool useful for generating interest, concern and awareness of the role of other health care professionals. They did not, however, believe the DVDs should replace placements entirely, and they wanted the DVDs to be more realistic (e.g. use real patients), more interactive, and more 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). A.3.2 Computer-based simulations including game-like elements Moreno-Ger et al. (2010) describe the use of a simple computer 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. A.3.3 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). Some specific examples of the use of virtual patients include: Stanford University s Web SP system (web-based simulation of patients) (Stanford University School of Medicine, 2010). This is used in conjunction with human standardised patients in the training of medical students and is thought to offer greater opportunity for repeated practice needed in remedial cases. Zary, Johnson, Boberg and Fors (2006) found higher exam scores for students who had used the Web SP compared to traditional teaching techniques (lecture and discussion) in the areas of gathering information from patient interviews, physical examination and ancillary tests, and recommending diagnoses and treatment. A VP tool in speech pathology for evaluating and training listening partners (including student speech pathologists and parents of clients) in the area of paediatric fluency (Strang & Meyers, 1987). This tool allowed the student (or parent) 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 35

input of an independent operator to code participant responses and input these during the simulation (e.g. talks slowly and models easy speech ). A survey of clinicians and students rated their participation as enjoyable and helpful in skill development (Strang & Meyers, 1987). SimuCase ( Williams & Schreiber, 2010). This program is designed to improve clinical decision-making skills for assessing 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 (Ewan, Howley, Riley, & Wynne, 2010). This 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. 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. Sentactics (Thompson, Choy, Holland, & Cole, 2010). This interactive computerised system, developed at the University of Colorado, enables face-to-face communication with a virtual agent. It has been utilised in teaching language skills (Cole, Wise, & van Vuuren, 2007), voice training through LSVT for patients with Parkinson s Disease (Cole et al., 2007) and remediating agrammatic sentence deficits in aphasics (Sentactics) (Thompson, et al., 2010). This method of computerised aphasia treatment was reported to be similar to cliniciandelivered therapy in terms of effectiveness. In general, students report VPs to support their learning and offer excellent preparation for clinical reasoning in real patient encounters (Huwendiek, et al., 2009). General recommendations for simulations involving VPs: Include cases which are relevant and of appropriate difficulty. Use different media appropriately and include interactivity. Provide specific feedback. Focus on relevant learning points and foster reflection. Ensure VPs are authentic in terms of web-based interface and student tasks. Ask questions and offer explanations that enhance clinical reasoning. A.3.4 Virtual Caves Virtual caves utilise interactive, 180 degree, immersive, virtual reality simulation theatres as a training tool. An example of such a cave is the Virtual Immersion Centre for Simulation Research (VICSR) within the speech pathology program at Case Western Reserve University (Ohio, USA). Scenarios designed for students to practise their diagnostic skills include 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 36

patient/family members based on the questions and behaviours of the students. The student must complete an appropriate diagnostic assessment protocol and provide a diagnosis and subsequent explanation of results and treatment options to the virtual patient and family members (Williams, 2006). A.3.5 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 in the form of an avatar (Boulos, Hetherington, & Wheeler, 2007). In this environment, their avatar can complete real world tasks such as participating in a team meeting or enacting case scenarios with the added feature of enabling synchronous (real-time) or asynchronous (delayed) 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). For example, Imperial College, London has created a game based simulation in Second Life (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. The potential of SL as a learning environment has been recognised in the literature (Wiecha, 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). Virtual worlds were also 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. A post-interaction questionnaire indicated no significant differences between the three groups with regards to attitudes, realism, importance, usefulness, distress, anxiety, and plan to use the skills learned. The investigators proposed that interactive communication technology, such as virtual reality and virtual worlds, could be 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). Challenges for integrating virtual worlds into teaching curricula include technical and security issues (e.g. firewall issues), significant computer system requirements, and the steep learning curve for navigation and interaction. Despite this, over 300 colleges and universities now report teaching courses and conducting research in SL builds (Wiecha, et al., 2010). 37

A.3.6 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 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). A.4 Transfer of Skills from Simulation to Clinical Practice Where relevant literature is available, it tends to suggest that skills learnt in a SLE do transfer to other SLEs and to real clinical settings, although more evidence is needed (Brigden & Dangerfield, 2008). Examples of successful transfer from simulation to real settings include: A simple bench model for fibre optic intubation (Naik et al., 2001). Laparoscopic simulators (Scott et al., 2000). Low fidelity simulators (e.g. a VitalSim mannequin) for physical assessments in RNs (Starkweather & Kardong-Edgren, 2008). High-fidelity simulation for team management skills (Guha, Kuduvalli, Parker, & Leuwer, 2009). Other studies 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 (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). 38

Appendix B The Views of Workplace Clinical Educators All five accredited Australian University audiology programs rely heavily on audiology clinics to take students for clinical placements. Each audiology student can expect to be placed in clinics for between 300-500 hours during their 2-year Masters course in order to achieve their required hands-on hours of supervised clinical practice. The majority of these hours are accrued in individual placements with external Clinical Educators (CEs) volunteering their time in both public and private sector clinics. These CEs are integral to clinical audiology education. Workplace CEs supervising students from the Australian audiology programs were asked about their views on the impact of clinical supervision of audiology students on their current workload, and whether increasing the use of SLEs in audiology education would result in any changes. Clinical Educators were provided with a brief description of the types of SLEs that could be used and were asked to answer five questions about SLEs and clinical education. Written responses were received from 35 CEs. Their responses are summarised in detail below. B.1 What takes up most of your time with a student on clinical placement? Orientation to the clinical placement Explaining individual clinic policy and procedures Completion of clinic specific paperwork Lack of knowledge on specialised clinics e.g. cochlear implants Students don t seem to know anything about implantation, and I think an improved knowledge of the technology, outcomes and how to identify candidates would help them to better manage patients. Additional appointment time Linear history taking e.g. I find the questions asked during a case history follow a list. Students take very pedantic histories, and need more practice to hone in on the relevant aspects more quickly. Longer time to complete clinical tasks e.g. The most time consuming element is usually just the pace of the student. They have an understanding of what needs to be done but lack of practice and confidence results in basic procedures taking a lengthy time to complete The allocation of extra time is perhaps the greatest burden to a clinic. Where a clinician may be able to see 10 clients per day, a student only allows for 4-5 clients to be seen. 39

Need for CEs to be involved in appointments e.g. Regardless of a student s competency, the clinician still needs to be involved with their patient, otherwise they feel left out. Explanation of clinical procedures Case discussion and report writing Integration of results e.g. Talking with the students, debriefing after the session and explaining the decisions you made during the appointment regarding the running of the appointment. Students take longer to run an appointment as they need to think each step out carefully while we can multi-task on occasions. Report writing e.g. I need to check/read through all reports and patient notes written by students I find the most time consuming thing, other than just getting the work done, is the writing of reports Providing student with feedback on performance Verbal feedback to the student directly Written feedback to the university If anything, the clinical feedback form could be made more concise, as it s currently quite a lengthy and detailed document. Filling out evaluation forms can be a bit time consuming during clinical placements. B.2 What could the audiology courses do to make clinical placements less of a burden and more efficient for you? Additional practice within the university setting Practice on other students Do students get a lab manual with exercises on the subject? They could then practise on each other or with simulation programs before their first placement. Practice using SLEs Students need to already be proficient in techniques prior to arriving in busy hospital clinics. The speed of their technique is a great burden on the system and really prevents clinics taking students more frequently. Masking and the time it takes to work out masking is perhaps one of the big areas where additional practice would be beneficial. Having students go through role play type situations in preparation for patients seen in placements 40

Pre-placement preparation Clinic policy and procedures Maybe you could have a handout for each clinic which describes the type of clinic and the patients that usually attend. This could be filled out at the start of every year by the clinic and then given to a student before they start their placement. Ensuring students have a certain level of understanding of both equipment and administration processes having to run through this every time with a new student wastes time, especially if the student has already worked at the clinic before. Student Summary Sheets Generally, I would like every student who enters our clinic to have their own cheat sheets and scripts for all the basic activities: routine assessments (what to do, in what order, when to do certain things...they could write these and try them with standardised patients and get feedback. Perhaps you could have a script, or a format of a script for the interpretation of results. B.3 What skills, knowledge and personal attributes do some students have that result in less of a burden for you as their clinical educator? Skills Communication If the student develops instant rapport with a client, it relieves some of the burden. Good communication skills are most helpful. Students who do not have the confidence in what they are saying or how they are saying it are more difficult. They need to know the value of good, clear speech and how to interact with oldies as well as children. Computing However, most students have good computer skills these days. Knowledge Assessment Procedures Competency in basic testing AC, BC, Speech, masking, tymps. An organized student who has rules, formulae, ranges, etc, available on hand saves time and ensures the student takes responsibility for their learning. If the students have an in depth knowledge of audiometric testing and awareness of keeping to time restraints it makes it easier. Rehabilitation Procedures Experience in hearing aid fitting. Students who have a variety of clinic placements are more knowledgeable and adaptable the the ones with limited exposure particularly amongst the 2 nd years. 41

Personal attributes Flexibility Confidence Initiative Preparedness Motivation Time management Self direction Many CEs identified all the above personal attributes and their comments tended to include a combination of the above as being important. For example: I think the students that have more confidence in themselves seem to be much quicker and easier to supervise as they just go for it. It's a fine line though - too much confidence can be more of a burden as you need to keep a close eye on them and pull them up on things! Obviously the best students are those that are motivated and willing to have a go. This again comes down to confidence. Most students have the basic knowledge - the better students are keen to implement it and learn more. Initiative to review files prior to sessions and plan what might need to be done. Confidence. Willingness to listen and take on feedback, respecting that the experience the educator has and not being defensive. Understanding that at times we have work which we have to do on our own, and that they need to have tasks of their own which they can get on with during these times. When students participate fully in clinical life, including helping with jobs around the clinic that is always of assistance and gives you time back that you may have lost supporting them throughout the day. B.4 Simulations are increasingly being used in audiology as well as other health care professions. How likely do you think that using simulations for students before clinical placements would reduce the burden on you as a clinical educator? Clinical Educators were asked to indicate whether this was (i) Very likely, (ii) Likely, or (iii) Make no difference, and their responses are shown below: Very likely 32% Likely 51% No Difference 17% Over 80% of CEs believed SLEs would reduce the burden. They also gave very positive comments about the use of SLEs in improving efficiency and effectiveness of clinical placements, although 42

expressed some reservations in SLEs reducing real-world clinical placement hours. Typical comments were: Simulations would be likely to add experience and increase the variety of cases the student sees. I think this will make it more likely that they will become flexible and insightful clinicians. The cycle, more practice = more skills = more confidence, would lead to a better (more effective) environment for both supervisor and student. It would familiarise them with equipment making an appointment less tedious. Actors? Could be good...some students do need more practice as they aren t as intuitive in communicating with clients. Others won t need it...the appointments are enough. Likely, but it definitely needs to be combined with real experience. I found practising in the booth with friends more useful. Only 17% of CEs did not feel SLEs would reduce the burden of having students on clinical placements. Typical comments were: I do not think it will bear directly on the burden on supervisors, but should improve the quality of the students experience. You know me I am old school. The primitive masking machines we used were never a replacement for a real patient. Skills are important but exposure to people is a main way to advance students. Although most comments were positive towards the increased use of SLEs, and CEs had been given a brief description of SLEs, the responses did not reflect the full potential SLEs could have with further development. This highlights a need to provide the profession as a whole with more detailed information on the SLEs currently being used and the potential of newly created, developed and researched SLEs. B.5 Do you believe an increase in the use of simulations in audiology education would result in students requiring less time in clinical placements to reach competency? Why? Clinical Educators were divided in their beliefs regarding use of SLEs to replace actual clinical placement time. Although most CEs (46%) did not believe less clinical time would be needed, even those CEs (42%) that felt that less time could be spent in clinics were concerned that significant clinical time would still be required. A smaller proportion of respondents (12%) were undecided about whether SLEs could be substitutes for real life clinical experiences. Typical quotes for each of the three groups of responders are shown below. No Responders (46%) Having hands on in a real life clinic cannot be replicated. It is a good practical tool; however it shouldn t replace clinical time. No, because clinical placement such as ours is all about people/patients not paying punters or just PTA prac. 43

I don t think simulations would necessarily reduce the amount of clinic time required, but they may get more out of the clinic and get better feedback. Simulations are in the end simulations and students have to demonstrate competency with real folks. Unless someone is really looking at what they are doing, any kind of fudging and finding of short cuts will happen. As discussed above, simulations should be a useful supplement but will never replace actual clinical work under the watchful eye of a supervisor and in the 'real World'. They are therefore something to welcome but their presence should not be invoked as a 'reason' for reducing clinical contact hours. No, you can t beat the real thing. I feel that simulations should be used as an adjunct to clinical training, rather than replacing the hours of clinical placement required. No. At the end of the day, no matter how good the simulations are or the actors, it will never replace real-life clinic situations. Simulations do not take into consideration so many things, including but not limited to behaviour/ attitudes of clients and their family, time constraints, difficult/ non-textbook cases, etc. They are a good idea to begin with and get them perhaps more confident with both equipment/ processes and technique, but after a time they need to have hands-on experience with real clients. Simulations cannot provide students with the variability from patient to patient, and is not a good aid with regards to assessing information that is given to patient, be it in the form of instructions to patients or counselling of patients/families. In short, simulators lack the dynamics found in true testing situations. Yes Responders (42%) Yes, however practise in real situations is also very important as students benefit from experience and the client interaction as well as the clinical skills. Theoretically yes but of course it does come down to the individual. I believe that the most important factor in a clinical setting is genuine rapport which is very hard to teach let alone simulate. I think the use of simulations may decrease the time they require in clinical placements to reach competency as by the time they get to placements they have practiced more of the necessary skills. But, simulations aren't the real thing and how well a student goes with a simulation task may not be a true indicator of how they go in a real life clinical setting, so for some students that may not be the case! Yes, it should allow for a significant increase in practice without the pressure of a real patient. Increasing practice with successful outcomes (i.e. students see that they have obtained accurate results) should assist in building confidence. If students arrive at placements with a very strong foundation in the actual test procedures, supervisors could focus more on the development of interpersonal skills, as well as interpretation of results, development of treatment plans and counselling of patients. 44

Yes I do. Even when I was a student (in the bronze age) we had audiometric simulators. I found them very useful as I separated the acquisition of clinical skills from the clinical environment. One could learn how to mask, say, without having to worry about the client. Maybe Responders (12%) Possibly - this is tricky. I think it s important for the students to be in the clinics for periods of time to put theory to practice - in real time. If simulation were to move forward it must be timed because that is reality. In addition to the timing they need to be faced with clients who are real and not forgiving of them being students. I think it s a fabulous idea for REM, impressions, and audiometry but I find real life people to be necessary. Maybe: it could even-out the differences b/w the really good students and the weaker ones when they start their placements. The really good ones might then progress to demonstrate higher levels of competence. Perhaps though once a student has the technical skills some still need to develop interpersonal skills and I believe that can really only be achieved by seeing real patients. Possibly. As long as simulations provide a sample of the variety of caseloads that a clinician could face in the real world. Repeat simulations with straightforward clients does nought to increase competency in managing different and/or difficult clients. Compare with the Learner Driver who completes the 100hour log book on dry days in Sunday traffic, who manages to pass the driving test and gets his/her license, and has an accident the first time they drive in rain. Was this Learner Driver really competent to begin with? The responses to this question may again reflect the lack of understanding some of the CEs may have of the potential of SLEs if appropriate research and resource is given into the design, development, implementation and evaluation of new SLEs. 45