Health Workforce Australia

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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

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Audiology Collaborative (Australian Audiology Programs Group)

Flinders University Dr Sarosh Kapadia

Dr Christopher Lind Ms Karen Sparrow Ms Sandra Buxton

Macquarie University Dr Catherine McMahon

Dr Mridula Sharma Ms Rebecca Summons Ms Yee-Foong Stone The University of Melbourne Prof. Richard Dowell Ms Angela Marshall Ms Jessica Vitkovic Ms Judy Lockie

The University of Queensland Assoc. Prof. Joseph Kei Dr Wayne Wilson Dr Carlie Driscoll The University of Western Australia 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.

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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.

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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

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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 wide-ranging, 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.

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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.

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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.

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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:

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 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

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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

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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

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• 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

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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-to-medium 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.

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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

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 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.

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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 roll-out 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

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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)

Learning of diagnostic & rehabilitative skills (n=26)

Learning of diagnostic & rehabilitative audiology skills (n=26) Computer based simulations [MF] (audiometry simulator)

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)

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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.

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22 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

Mid To teach and assess competencies for basic paediatric assessment

Some use of LF multimedia, CBS including game-like elements, and low fidelity mannequins

HF multimedia LF mannequins Basic adult

rehabilitation

Mid To teach and assess competencies for basic adult rehabilitation

Some use of LF-HF mannequins and LF standardised patients

LF-HF multimedia LF-HF virtual patients Basic paediatric

rehabilitation

Mid To teach and assess competencies for basic paediatric rehabilitation

LF-HF multimedia LF-HF virtual patients Complex adult

assessment

Later To teach and assess competencies for complex adult assessment

Some use of LF multimedia and HF mannequins. Some use of LF-HF standardised patients and MF virtual patients

HF multimedia LF mannequins Complex paediatric

assessment

Later To introduce and assess competencies for complex paediatric assessment

LF-HF multimedia LF-MF virtual patients Complex adult

rehabilitation

Later To introduce and assess competencies for complex adult rehabilitation

HF multimedia LF-HF mannequins LF-HF virtual patients Complex paediatric

rehabilitation

Later To teach and assess competencies for complex paediatric rehabilitation

LF-HF multimedia LF-HF virtual patients Table 4.2: An agreed general progression for mapping current and proposed SLEs into existing audiology curricula.

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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

Most programs 3 years LF multimedia High Funding to develop more case scenarios, train more educators and students, refine evaluation of

student progress, and conduct research and development

Most programs 3 years LF mannequins High Funding to develop more mannequins, refine evaluation of student progress, and conduct

research and development

Some programs 3 years 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

Some programs 3 years

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

Some programs 3 years MF-HF

standardised patients

Mid-high Funding to develop more case scenarios, train more educators and actors, refine evaluation of student progress, conduct research and development

Most programs 5 years

MF-HF mannequins

Mid-high Funding to purchase more mannequins, obtain more storage space, train more educators, refine evaluation of student progress, and conduct research and development

Some programs 5 years MF-HF

multimedia

Mid-high 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

Few programs 5 years

MF-HF virtual patients

Mid-high 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

Some programs 5 years

Virtual caves Virtual worlds Virtual reality with haptics

Low 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

No programs 5 years

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.

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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:

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• 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.

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