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Are they ready?

That seems to be the question we ask ourselves when we consider graduate students as they prepare for clinical externship. The question of how to bridge the gap between the academic environment and the real world clinical setting is not a new one. Survey data has been collected, standards have been put in place, and courses have been updated to reflect current clinical practice; however the question remains – Are they ready?

The statistics

According to ASHA’s 2015 Health Care Survey, more than half of a Speech-Language Pathologist’s (SLP) clinical time is spent providing services to adults. SLPs in hospitals spend more than half of their clinical service time on swallowing. The need to re-evaluate the readiness of our graduate students is even greater when we consider that more than 80% of SLPs in rehab hospitals and skilled nursing facilities (SNFs) have productivity requirements, (ASHA’s 2015 Health Care Survey) which can affect how SLPs educate and mentor graduate students. The fast pace of a medical setting coupled with productivity requirements for staff can negatively impact the clinical education of a graduate student.

The use of SPs provide endless opportunities for training and feedback in real-life clinical situations. Simulated learning incorporates multiculturalism, interprofessional collaboration, and immediate clinical feedback.

Prior to clinical externship and even graduation, many graduate students find themselves having had limited exposure specific to dysphagia. As the scope of practice continues to evolve and the knowledge base widens, how do we provide students with an opportunity to apply academic knowledge across multiple domains? Limited access to real-life patients restricts a student’s ability to build upon content learned in the didactic classroom and can therefore affect the development of clinical reasoning skills and clinical competence. Simulated learning opportunities, however, allows a student to apply content knowledge and navigate through a clinical scenario in a safe environment.

Peer labs

Most graduate education programs support a course devoted to dysphagia and many provide hands-on opportunities for students. Students participate in mock clinical assessments with peers. Unfortunately, peer labs do not expose graduate clinicians to a diverse ethnic and socioeconomic population, sensitive subject matter, or even difficult personality types. Student reports confirm that peers tend to simplify the actual assessment and treatment process. Graduate students require enhanced simulated learning, exposure to a varied patient population within a safe and supportive environment. Peer labs lack authenticity in both the clinical presentation and the interaction. Additionally, feedback is often limited in a peer lab due to the preexisting student relationship.

Standardized patients

Many aspects of the clinical world can be evoked using a standardized patient (SP). An SP is a person who is carefully trained to portray a patient scenario for educational purposes (Zraick, 2012). An SP is often an individual with experience in the realm of acting but not always. An SP assumes the characteristics of a real patient, and allows students the opportunity to practice and review feedback in a safe clinical environment. First introduced in the early 1960’s, medical education programs have long relied on SPs for clinical training and student assessment. When students are not afforded contact with live patients across diagnostic presentations, medical and other allied health programs rely on clinical simulations with SPs as their effectiveness as an instructional strategy is well established. Clinical interactions with SPs are used to assess a student’s ability to effectively interview a patient, complete an assessment, and most importantly develop a therapeutic relationship with the patient (Norcini & McKinley, 2007). Current research supports the use of SPs in clinical skill development and competency assessment of students in the fields of nursing, pharmacy, dentistry, and chiropratic care. Positive outcomes have also been reported specific to the use of SPs in allied health fields including community health education, dietetics, physical and occupation therapy (Association of Standardized Patient Educators, 2006).

Benefits

The value of incorporating SPs into clinical practice is evident across disciplines (May, Park, & Lee, 2009). Students’ assessment measures following simulation activities were more accurate when compared those following review of a written case scenario (Brunner, Probst, Meichtry, Luomajoki, & Dankaerts, 2016). Incorporating SPs into the clinical training of graduate speech-language pathology students provides additional opportunities for the student to build knowledge and experience through practice and rehearsal in a safe environment, while patient distress or harm is minimized (Cantrell & Deloney, 2007, Syder, 1996).

Cantrell and Deloney (2007) highlighted the advantages of using SPs:

  • Availability almost anytime, any place
  • Comparable to real patients
  • Faculty can control the learning objectives
  • Faculty can integrate psychosocial issues into a case
  • Learner can receive immediate and constructive feedback
  • Learners can rehearse clinical situations they are not ready to manage
  • Learners’ performance can be compared
  • Limits inconvenience, discomfort or potential harm to real patients
  • May provide a longitudinal experience in a compressed time frame
  • Portrayals are standardized and reproducible (reliable)
  • Safe environment minimizes learner anxiety

Perceived Benefits

Student perceptions of SP interactions are positive across allied health disciplines. Studies reveal a significant positive change in student perceived confidence when speaking with patients and physicians (Davies, Schonder, Meyer, & Hall, 2015). Students also reported perceived positive outcomes when reviewing the role of SPs in clinical training (Giesbrecht, Wener, & Pereira, 2014). The ability to pause an interaction for feedback or clarification and a sense of safety was most valuable. The SP interactions served to build clinical confidence. Learning from and practicing with SPs was preferable to didactic strategies and was superior to practicing with peers (Giesbrecht et al., 2014). Speech-language pathology students reported a decrease in anxiety levels in addition to increased confidence in a range of clinical skills post SP focused case studies (Hill, Davidson, and Theodoros, 2013).

Building a program

Developing an SP training program requires a significant amount of time and effort. Cases have to be developed, SPs have to be recruited and trained, and an objective structured clinical examination has to be developed.

Basic case development should include:

  1. Case summary
  2. Clinical setting
  3. Time frames
  4. Specific skills to be demonstrated
  5. Evaluation checklists (to be filled out by faculty and the SP)

The amount of training will depend upon the case. Training should include:

  1. Written notes for the SP
  2. Review of the case
  3. SP checklist for student feedback
  4. Rehearsal of the case

This process will ensure consistent presentation of the case as was prescribed by the faculty who generated the case.

Conclusion

The use of SPs provide endless opportunities for training and feedback in real-life clinical situations. Simulated learning incorporates multiculturalism, interprofessional collaboration, and immediate clinical feedback. Experiential learning activities allow student clinicians to practice and repeat activities to correct mistakes, develop basic clinical competencies, and optimize outcomes (Bridgen & Dangerfield, 2008).

Additional Resources of Interest

References

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  2. Bethea, D. P., Castillo, D. C. & Harvison, N. (2014). Use of simulation in Occupational Therapy dducation: Way of the future? American Journal of Occupational Therapy, 68, S32-S39
  3. Brigden, D. & Dangerfield, P. (2008). The role of simulation in medical education. The Clinical Teacher, 5, 167-170.
  4. Brunner, E., Probst, M., Meichtry, A., Luomajoki, H., & Dankaerts, W. (2016). Comparison of clinical vignettes and standardized patients as measures of physiotherapists’ activity and work recommendations in patients with non-specific low back pain. Clinical Rehabilitation, 30(1) 85–94.
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  9. Hill, A. E., Davidson, B. J., & Theodoros, D. G. (2013). Speech-Language Pathology students’ perceptions of a standardised patient clinic. Journal of Allied Health, 42(2):84-91.
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