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Cover Story: Simulation Clears Path from Education to Real-World Practice

Shaw, Gina

doi: 10.1097/01.HJ.0000427110.18184.42
Cover Story


At Columbia University Medical Center in New York, plans are under way for a massive new medical education building that will include as its crown jewel a high-tech patient simulation center featuring the latest hands-on learning tools for use in realistic settings by future doctors, nurses, and dentists. Needless to say, there's nothing like this state-of-the-art simulation facility in today's audiology programs.

Figure. Vic

Figure. Vic

“There's a great desire out there for clinical simulation in audiology training programs—there's need, there's demand—but not nearly as much has been done in clinical simulation for audiology as you see in other healthcare and allied health professions,” said Victor Bray, PhD, the dean of the George S. Osborne College of Audiology at Salus University in Elkins Park, PA.

In the United States, audiology has much smaller training programs compared with other healthcare professions, Dr. Bray said.

“There are roughly 70-75 AuD programs in the country, and they have ten seats per class on average. Compare that with medical schools, which usually have about 100 students or more in each class. Our sister program in optometry has 160 students per class.”

It makes a lot more sense to invest the money needed to create multiple dedicated patient simulation systems—at least $250,000 to $500,000—when you have 50 or more students in a class who will be using such systems.

“Simulation is also more necessary with large class sizes and large student bodies,” Dr. Bray said. “There are fewer than 3,000 audiology students total in the entire country. Our fragmented system of lots of programs with small class sizes lacks the critical mass to spur people to develop these systems internally, or for outside vendors to do it.”

That situation appears to be changing, however, as more audiology programs in the United States and overseas begin to explore innovative ways to add clinical simulation to their students’ learning experiences.

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One way for audiology programs to incorporate clinical simulation is by piggybacking on existing facilities at the larger health sciences schools with which they're affiliated.

That's the approach taken by the Department of Hearing and Speech Sciences at the Vanderbilt Bill Wilkerson Center. Students in the AuD program can make use of a partnership with the Vanderbilt University School of Medicine Center for Experiential Learning and Assessment, which has an 11,000-square foot facility offering 12 simulated exam rooms where students can work with standardized patients (see FastLinks).

At the brand-new School of Audiology within the College of Health Professions at Pacific University in Hillsboro, OR, which just this past September welcomed its first class—one of the largest in the country, with 23 members —students will have access to the campus's existing simulation lab, run by the physician assistant program.

Figure. David

Figure. David

“The main thing we will utilize is the counseling room,” said associate professor of audiology David Brown, PhD. “We can use standardized patients, videotape the students’ interactions, and review the videotape with them or even interact immediately with the students by broadcasting feedback right into the room.”

The audiology program also has a simulation tool of its own. Students will be able to practice newborn hearing screenings on Baby Isao, an infant mannequin from Intelligent Hearing Systems that can be used with any brand of auditory brainstem response (ABR) or otoacoustic emissions (OAE) equipment. Ultimately, it would be ideal to have an adult-sized mannequin, Dr. Brown said.

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In Australia, larger audiology class sizes—the University of Queensland's master's program enrolls up to 40 new students each year—has spurred more rapid growth in clinical simulation (see FastLinks).



“We needed to source over 10,000 clinical placement hours per year from fewer than 25 external clinics that were able to support our students,” said Wayne Wilson, PhD, a senior lecturer in audiology at the University of Queensland. “We simply had to find alternative ways of training and assessing our students’ clinical skills.”

In 2006, the simulated learning environment (SLE) program was born. It began by using standardized patients and computer-based simulations to assess students’ competency in basic diagnostic assessment—-taking a case history; performing pure tone audiometry, speech audiometry, tympanometry, and acoustic reflex testing; giving feedback; writing reports; and maintaining professionalism.

Early success on this front led to the adoption of simulations for training as well as assessment. Some simulation tools are less high-tech than others. For example, in one exercise, a faculty member holds a teddy bear on the lap to simulate a child and acts as the “parent.”

“We use this to give our students their first experience of conducting a complete visual reinforcement orientation audiometry assessment, with the students even having to put the headphones and bone conductor on the ‘child’ and some ‘children’ being more cooperative than others,” Dr. Wilson said.

Today, all first-year Queensland students must complete a full SLE clinic in which they perform basic diagnostic assessments on adult clients played by other students.

The program hasn't come cheap. Using professional actors as standardized patients has cost more than $5,000 per semester. Dr. Wilson and his team economize by combining these more expensive elements with bargain software packages for computer-based simulations.

“We continue to use both ends of the scale because our funding for SLEs remains a year-by-year prospect,” Dr. Wilson said. All five audiology programs in Australia are using some form of SLE, he added.

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Of course, not every audiology program has access to full simulation facilities or even standardized patients. That doesn't mean clinical simulation is out of reach, though.

Given the limited profitability, there has been no mass stampede by industry to develop clinical simulation software programs for audiology, but there are a few options out there.

One is Parrot Software's Audiology Clinic. The full version, which runs on Windows, costs $450. It features 100 simulated cases using basic audiological tests such as pure-tone audiometry, speech-reception threshold, and immittance.

Otis, the Virtual Patient, simulates a range of complex hearing defects and possible patient behaviors. Training programs can add their own patient cases to the software's database of test subject profiles. The software, from Liechtenstein-based InnoForce, costs from EUR 399 to EUR 799.



Teri Hamill, PhD, a professor of audiology at Nova Southeastern University in Fort Lauderdale, FL, and her husband, Tom Barron, a computer specialist, designed the audiometer simulation software AudSim, which can be downloaded for $19.99.

“With simulation, I think one challenge is to make sure that students can't just readily cheat or do the program once and remember enough of it to get the right answer,” Dr. Hamill said. “When I developed the module, I wanted to make sure students could practice as many times as they liked because it's a mastery-based program.

“Even if a student doing the same case over and over gets the same findings—moderate sensorineural hearing loss—the thresholds will vary from trial to trial, and they have to properly use the techniques.”

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Of course, a discussion about how to expand clinical simulation opportunities assumes that audiology education would benefit from such an approach. Not everyone shares that perspective.

“A roadblock that we encountered early in our SLE program was the acceptance, or lack thereof, of SLEs by some members of the wider audiological community,” Dr. Wilson said. “Their skepticism was often justified since their experiences as students were dominated by plentiful placements in external clinics well resourced to take on student training, something that is harder to secure nowadays.”

It's also true that, to date, research is limited as to whether clinical competencies achieved via simulated learning environments are equivalent to those garnered through real clinical placements.

“Research into this question should be a priority for those of us working with SLEs in audiology,” Dr. Wilson said.

Clinical simulation exposes patients to a wider breadth of conditions than is possible through real-world practice alone.

“People are going to realize that if you want your programs to grow, you need to use some kind of simulation,” Dr. Brown said. “We can't give enough practice to all our students with enough different types of hearing disorders.

“Clinical simulation doesn't substitute for real patient experience, of course, but if students practice in a simulated environment, they will be more confident and prepared when they get out to work with patients in the real world.”

With the rapid evolution of technology, the sky is the limit for audiology simulation, Dr. Wilson said, using what is happening in other areas of healthcare education as an example.

“Our colleagues in pharmacy at the University of Queensland and nine other universities around the world have developed a three-dimensional virtual world that allows students to create their own avatars and explore a virtual island called Pharmatopia,” he said.

The game resides within the online community Second Life (see FastLinks). Pharmatopia is divided into four zones—manufacturing, clinical, community, and industrial—and each has specific teaching and learning objectives.

“Such a program seems eminently amenable to a similarly technology-driven profession such as audiology,” Dr. Wilson said.

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In order to disseminate clinical simulation more broadly among audiology training programs, there must be some sort of collaborative effort involving both educators and industry, said James W. Hall III, PhD, extraordinary professor in the department of communication pathology at the University of Pretoria in South Africa and adjunct professor in the department of audiology at Nova Southeastern University. [To read more about the current state of clinical simulation in audiology education, please see Dr. Hall's article on page 16.]

“I think we need a task force of about ten or so audiology programs who want to pursue clinical simulation to put together our priorities,” Dr. Hall said. “There must be attention to this issue as a priority in audiology.

“Everyone agrees it's the only way we're going to have enough students in each class to train enough audiologists for our workforce needs. Otherwise we'll keep creeping along with tiny little classes and falling further behind on our workforce needs. A group could also establish national standards so that the clinical training quality of simulation could be improved, tracked, and evaluated.”

After putting in order the priorities for simulation in audiology education, the task force should approach industry, Dr. Hall said.

“We should contact some of the major companies that produce pure-tone audiometers and other basic hearing test devices, hearing aids, cochlear implants, and so on. Most of these industries are not in competition with one another, so we could get them sitting around the table together and try to persuade them to sponsor the effort and lend their expertise.”

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By James W. Hall III, PhD

Both the beginning of simulated practice in medicine and the beginning of audiology as a profession can be traced back to the United States military (J Crit Care 2008;23[2]:157).Most readers of The Hearing Journal know the story of how audiology evolved from the efforts of Raymond Carhart, PhD, and other officers in the army and navy during World War II to provide nonmedical help to military personnel with mostly noise-induced hearing loss.

Clinical simulation in medical training began in 1960 with the birth of Resusci Anne. Anyone who's undergone cardiopulmonary resuscitation training involving mouth-to-mouth breathing and chest compressions has become good friends with one of Annie's descendants. Much of the early work in clinical simulation was initiated in anesthesiology and other medical disciplines with responsibility for performing life-or-death tasks. Real patients have little enthusiasm for helping medical personnel in training learn how to perform such tasks for the first time! Standardized patients (SPs), who act out the role of real patients, also entered the medical education arena in the 1960s.

Five categories of clinical simulation are now recognized (Qual Saf Health Care 2004;13:i11):

  • 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.
  • 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.
  • 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.

As shown in this month's cover story, starting on page 12, clinical simulation is an efficient and cost-effective way to provide audiology students the practice they need to develop the many and varied skills behind high-quality hearing healthcare. Clinical simulation also offers a key to the educational challenge of cultivating problem-solving and decision-making skills in future audiologists. Widespread application of clinical simulation in audiology education is essential if we are to increase the number of Doctor of Audiology graduates and meet the current and future demands for clinical services.

Figure. D

Figure. D

Dr. Hall is extraordinary professor in the department of communication pathology at the University of Pretoria in South Africa and adjunct professor in the department of audiology at Nova Southeastern University.

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© 2013 Lippincott Williams & Wilkins, Inc.