1. Shelley B. Brundage, Ph.D., CCC, BCS-F George Washington University Washington DC, USA Gail M. Whitelaw, Ph.D. The Ohio State University Columbus, OH CAPCSD, San Antonio, 2016

2. Shelley received a waiver of her conference registration Gail is a CAPCSD Board Member Disclosure

3. Goals for today’s talk 1. A brief history of simulation in education 2. Review types of simulations for use in clinical education and research 3. Guiding principles for developing, designing, and testing learning experiences using simulation 4. A call to action in CSD clinical education

4. Gail’s ghost talk: Here in spirit (thank you, Shelley!) Gail’s daughter, Merritt, is being inducted into Sphinx, a Senior honorary at Ohio State—one of 24 students selected…it’s a secret until 11 AM on April 1 And Gail is going to surprise Merritt by being at the induction ceremony

5. But first, a walk down memory lane

6. We’ve come a long way from the grapefruit

7. Remember these?

8. Remember ResusciAnne?

9. External forces impacting thinking outside “the box” (e.g. booth or therapy room) Medical schools using these models for 50+ years Interesting that military audiology started to use simulated audiology approaches in the 1950’s too Outcome based education Regulation Expectation for expanding educational options in communication sciences and disorders, both for students and for practicing professionals

10. External forces specific to communication disorders Need to expand capacity in communication disorders programs Demand for more professionals Limitations of class size: These are real issues and what can be done to possibly expand this Providing breath and depth of experiences to meet ever changing/expanding demands

11. Benefits of Simulations Allow for repeated practice in environments that are: Safe Controlled Confidential

12. Benefits of Simulations Allow for clinical education that is: Cost-effective Effective

13. Adult learning principles Important to approach this as a procedure that allows for adult learners to practice in a consistent and safe environment Opportunity to self-evaluate (can watch video of their own interactions, for example) and can have consistent feedback from preceptors Consistency of evaluation across learners More to come later in the presentation

14. Five categories of clinical simulation (Quality Safety Health Care 2004;13:i11, as cited in Hall, 2013) Verbal simulation is role-playing. An audiology example of this is when one student assumes the role of a mother of an infant with a newly-identified hearing loss and another student plays an audiologist who is counseling the family. Standardized patients are the second category. They can be employed to help develop students’ skills in history taking, patient-caregiver communication, and healthcare examinations, including hearing assessment. SPs generally are paid.

15. Five categories of clinical simulation (Quality Safety Health Care 2004;13:i11, as cited in Hall, 2013) Part-task trainers are nonhuman mechanical or computer- based devices that represent normal or abnormal conditions. For audiology, a part-task trainer might be a synthetic outer ear used for developing skills in otoscopy and earmold impression making.

16. Five categories of clinical simulation (Quality Safety Health Care 2004;13:i11, as cited in Hall, 2013) Interactive and adaptive software representing computer patients is now available in audiology. Perhaps the best examples of this are computer programs that simulate an audiometer, with software that simulates patients with normal hearing and different types and degrees of hearing loss. The final category of clinical simulation is an electronic patient that takes the form of a mannequin or a virtual reality entity in a realistic clinical setting.

17. Standardized patients Integrated Simulators Simulated environments Virtual reality systems Many types of simulation Adapted from Yeung, Dubrowski, & Carnahan, 2013, p. 230

18. Newer Simulation Technologies

19. Critical skills in audiology: ABR and OAE

20. Standardized Patients

21. One of the keys in standard patient is the OSCE Objective Structured Clinical Examination (OSCE) Has been used since the 1970s Miller’s pyramid requires that student must demonstrate what they have learned Standard patient and standard exam provides strong foundation

22. Miller’s pyramid

23. Integrated Simulators: Mannequins that mimic physical and/or physiological signs of a disease

24. Mannequins have become more sophisticated & realistic

25. GW’s CLASS Center Labor and delivery Hospital room

26. Ohio State’s Clinical Skills Education and Skills Center The Ohio State University Costs reasonable Services, such as standard patient, can be used at the Center OR in our Department Fortunate to have one of our AuD grads as Education Resource Specialist at the Center http://medicine.osu.edu/orgs/clinicalskills/aboutcenter/ pages/videotour.aspx

27. Virtual reality systems: Recreation of complex (3-D) environments via human-computer interface

28. Software over time

29. Simulated environments: Re-creation of clinical environments where the learner engages in some form of learning activity. Typically 2-D.

30. Ellie, the virtual psychologist Skip Rizzo’s group at USC’s Institute for Creative Technologies

31. Google Cardboard & Oculus Rift

32. Simulations can be combined with other tools to provide context & feedback

33. How have simulations been used in healthcare education?

34. Simulation Applications: Medical Procedures Laparoscopic surgery (Bashir, 2010) Coronary bypass surgery/rehab (Chuang et al., 2006) Hip replacement surgery (Handels et al., 2000) Dental Anesthesia (Hanson & Shelton, 2008) Cardiac Life Support (Tubaishat, A., & Tawalbeh, 2015)

35. For Improving: Interviewing Skills (Sweigart, et al., 2014) Clinician-client interactions (Riva, et al., 1998) Inter-professional competencies (King et al., 2014) Simulation Applications: Skills Training

36. Realistic and immersive Scaffolded for student learning Interactive Able to assess student learning Repeatable And perhaps…fun Simulations should be…

37. “How to” 1. Guiding principles 2. Designing simulations 3. Creating and testing the simulations Focus on clinical applications

38. Guiding Principles 1. Be mindful of learning taxonomies 2. How does your target audience learn? 3. Start with the end in mind 4. What is the goal of the experience?

39. Learning Taxonomies Bloom, 1956 Bloom’s Taxonomy of Learning-Revised

40. Actively engage in solving problems Are confronted with contradictions and uncertainty Solve problems of varying content and complexity Receive assessment & feedback on performance Self-reflect on their performance Adults learn best when they… Chinn & Brewer, 1993; Dewey, 1916; Graesser & McMahen, 1993; Kruger & Dunning, 1999; Spiro et al, 1991)

41. Start with the end in mind What will the end result be? Who is the target audience? (new clinicians or ‘seasoned’) What defines ‘successful use?’ Do you need a simulation to achieve this result? Is it important that the lesson be repeatable? Is the learning environment potentially unsafe for either the student or client?

42. Setting goals for simulations Write student learning goals in behavioral terms Write a hierarchy of goals if possible Are some situations more difficult than others? Are some concepts more difficult to learn? Be mindful of Vygotsky’s “zone of proximal development”

43. Designing Simulations Guiding Principles: Use research to guide design Map out what the student will see, hear, and do during the activity, and write scripts that define interactions that will occur How much immersion is necessary to support learning? Level of interactivity What type of sensory feedback is necessary? (haptic, visual, auditory, scent) Test it! Hanson & Shelton, 2008; Brundage & Graap, 2004

44. Design: Use research as a guide

45. Designing Simulations: Scripts Write scripts to describe what will occur Define the answers and reactions of standardized patients or virtual persons: “It happened two weeks ago” Surprise, laughter, crying, disagree, ‘yea, right’ Almost impossible to “over-script” the simulation

46. Design: Immersion and Feedback Cost considerations Simulation centers “vs.” darkened room and computer screen Sensory feedback necessary for learning? Yes in some cases: virtual dental anesthesia training No in other cases: public speaking Types of feedback

47. There will be issues with whatever you build, though careful design can reduce frequency of problems Best to find these and deal with them before students enter the simulation Test by having team members play student role “Road test” before using

48. Recent meta-analyses indicate that using virtual patients, either as stand-alone learning opportunities or in conjunction with classroom-based instruction, improves students’ Knowledge and Skills outcomes Confidence Clinical reasoning Ethical decision making and Communication skills SoTL and simulation (Consorti, et al., 2012; Cook, et al., 2010; Harder, 2010)

49. Learning in simulated environments transfers to real- world environments Without loss of clinical effectiveness, simulation offers an alternative that can be as or more efficient, available, and scalable SoTL and Simulation Emmelcamp, et al., 2002; Gallagher, et al., 2013; Huet et al., 2009; Rose, et al., 2000; Seymour, et al., 2002; Watson et al., 2012)

50. Some examples: Tracheostomy training (Ward et al., 2014) Dealing with difficult behaviors (Bressmann & Eriks-Brophy, 2012) Pediatric dysphagia (Ward et al., 2015) Communication skills (Quail et al, 2016) SoTL and Simulation in CSD See Hill et al, 2010; Zraik, 2012 for reviews of standardized patients in CSD

51. Low tech vs. high tech What meets the needs of the students, program,etc. Does not need to be costly but can be very effective How to get started….

52. Critical skill: Addressing “breaking bad news” counseling skills Great example provided in terms of verifying counseling skills Video of skills for students providing self evaluation Naeve-Velguth et al (2013) Low tech option

53. Clinical skill assessment for first year AuD students as part of their required first year evaluation (must pass in order to move on in the program) Standard patient approach provides consistency for student Frees faculty member to observe and assess, using the OSCE model, rather than having to role play with the student Low tech option

54. Higher tech options: Critical skill: Audiologic evaluation http://audsim.com/  Simulated cases on which to practice  Audiogram interpretation  Standard cases  Auditory pathology simulated cases

55. Higher tech approach: Critical skill: Audiologic evaluation http://www.parrotsoftware.com/home/shop/audiology.ht m Fifty to one hundred cases, pending level of software purchased Useful for beginning students, such as undergraduates, to practicing clinicians

56. Critical skill: Otoscopic examination for audiology students Jacob Johnson, M.D., Medical director for Lyric and a physician at San Francisco Otolaryngology Medical Group, works with AuD students at Phonak University program each summer Dr. Johnson tells students that they must look in as many ears as possible, that approaching 1000 looks begins to get you on the level of expertise How long would it take to get 1000 examination of ears as an AuD student in clinic?

57. https://www.youtube.com/watch?v=Blo UtzVUSZ4 https://www.youtube.com/watch?v=Blo UtzVUSZ4

58. Simucase™ Jack Kyle www.speechpathology.com

59. Take home message #1 Simulation allows students to learn in environments that are: Safe Controlled Confidential Repeatable

60. Changes in ASHA, 2016 regarding simulated/standard patient responses 1)Expanded definition of supervised clinical experiences: These experiences should allow students to: interpret, integrate, and synthesize core concepts and knowledge; demonstrate appropriate professional and clinical skills; and incorporate critical thinking and decision-making skills while engaged in identification, evaluation, diagnosis, planning, implementation, and/or intervention. Take home message #2

61. Changes in ASHA, 2016 regarding simulated/standard patient responses 2) Acceptance of Alternative Clinical Education for up to 20% (75 hours) of direct client hours: Up to 20% (i.e., 75 hours) of direct contact hours may be obtained through alternative clinical education (ACE) methods. Only the time spent in active engagement with the ACE may be counted. ACE may include the use of standardized patients and simulation technologies (e.g., standardized patients, virtual patients, digitized mannequins, immersive reality, task trainers, computer-based interactive). Debriefing activities may not be included. Take home message #2 (continued)

62. Photo credits sq85.org armytechnology.armyalive.dodlive.mil golfersavenue.com www.anwresidency.com www.northshore.org smhs.gwu.edu www.simply-sim.com c3ny.org www.nursingmodel.com Breakthroughs.kera.org aliexpress.com file.scrip.org www.businesstocommunity.com www.slashgear.com www.spine-health.com www.mnn.com en.wikipedia.org mkmccartney.wordpress.com blogs.ubc.ca

63. Questions? brundage@gwu.edu whitelaw.1@osu.edu