The COVID-19 pandemic has impacted every aspect of life including clinical education for Doctor of Audiology (AuD) students, resulting in rapid changes, challenges, and transitions. At this time, nearly every university in the United States has moved to online delivery of education. This certainly impacts faculty and AuD students, requiring didactic education to be quickly coordinated with a novel approach—one that they may not have utilized before. However, a greater challenge at the moment is how to continue to provide clinical education experiences.
ESSENTIAL VS. NON-ESSENTIAL
The initial issue that audiology education faced was that of essential vs. non-essential personnel. Some audiologists were identified as non-essential and are following stay-at-home orders, while others were identified as essential personnel. The American Academy of Audiology (AAA) stated that although the work of audiologists is life-changing, it is not life-sustaining, which is the definition of essential during this crisis (https://bit.ly/2Xxhl8X). AAA guidance supports the widespread public health message of encouraging non-essential workers to stay home and help reduce the spread of COVID-19. The current public health directive is to flatten the curve to avoid overwhelming the country's health care system. Additionally, some audiologists had responsibilities reassigned to tasks specific to COVID-19 activities, such as screening patients’ temperature as they enter a hospital.
These essential vs. non-essential considerations impact AuD student placements. During the best of times, audiology education relies on a triad approach between the student, the university's audiology program, and the external/clinical placement. Affiliation agreements between the university and externship placement sites outline legal and other aspects of the relationship and how this impacts the student(s) placed there. Most affiliation agreements focus on the student's role and assure that the student is not an employee from the university's perspective. In this case, the students’ guidance comes from the university, and they may be directed to suspend their clinical placement even though the facility remains open. Reassigning responsibilities for students may fall into one of two categories: (1) tasks that are related to facility operations for employees and (2) tasks that support audiology patient care. The second category may include telepractice services, such as hearing aid repairs done off-site. University programs following the guidance of these agreements support students performing tasks that are clearly audiology-related (e.g., follow-up phone calls for hearing aid questions) but limit tasks that are outside of the standard role of audiology (e.g., screening patients for COVID-19). These decisions may also involve the scope of the student's malpractice coverage, particularly if the university provides the insurance. Many externship sites have been creative in continuing and extending clinical education opportunities during this period—efforts that are much appreciated and beneficial to students and the profession.
DISRUPTIONS IN HANDS-ON TRAINING
Providing a strong clinical education during this time challenges the status quo. While the goal remains to provide quality education, educators must incorporate flexibility and patience into their plans. Many universities have already announced that their courses will continue to be delivered online through the summer semester in 2020. As in all other aspects of the pandemic, there is no playbook for clinical education during this time. Although classroom aspects of the program can be effectively delivered online, providing the type of hands-on experiences necessary for the development and mastery of foundational clinical skills is difficult. The ability to effectively distance from a patient during audiology service provision raises concerns for university programs, particularly the necessity for and availability of personal protective equipment (PPE). Unlike experienced audiologists, students lack the muscle memory of audiology and balance skills and require skill practice and repetition to develop mastery. This may be particularly true for students who are in the early stages of their programs and have limited experience and competency. In a joint statement on supporting audiology students, the AAA and the Student Academy of Audiology encouraged audiology programs to maintain standards while focusing on meeting competencies rather than merely accruing hours, asked externship placement sites to honor commitments to student education when possible, addressed the need to focus on student safety and well-being, urged creativity in facilitating degree completion without adding to students’ financial burden, and invited the profession to unify to support AuD students (https://bit.ly/2xsdwXR).
The fourth year or the externship year requires unique considerations during this time. Most externships have ended or been altered for the 2019-2020 academic year. Although audiology education has moved toward competency-based outcomes, some states continue to require a specific number of hours to grant licensure, which may limit students’ ability to obtain an audiology license if their experience ended earlier than anticipated. Other externships have shifted student responsibilities to clinical research projects, telepractice, or other remote audiology services. A few sites have continued in a business as usual manner, although some are reporting significantly reduced schedules.
The potential impact of the pandemic on the 2020-2021 externship cycle is evolving. Discussions with externship preceptors have indicated that some externship sites will have a later start than initially anticipated. These changes can also result in logistical challenges that may financially impact students. Additionally, changes in start dates may create a domino effect, such as postponing the start date or overlapping the schedule of future externships. Other externship sites are hopeful that placements will proceed as planned. To date, very few have canceled their externships, showing the commitment of many sites to clinical education while prioritizing the safety and well-being of students and patients.
OPPORTUNITIES & UNKNOWNS
Changes in audiology education also offer opportunities. Audiology faculty members have incorporated simulated and standard case approaches, such as SimuCase, in providing clinical experiences. Publishers, such as Thieme, have provided complimentary access to university programs that include access to case-based education. Faculty members have been sharing cases created for students, such as those in a Google doc at the Cheers for Ears Facebook group. Community audiologists have also volunteered to create cases and work with students to provide a valuable learning experience. Debriefing in all of these opportunities is a critical component of the learning process. A balance is required between standard patient experiences and simulated ones, which are new to many programs. The Council of Academic Programs in Communication Sciences and Disorders has developed information about the pedagogy of simulated learning experiences, which are an excellent resource for those interested in creating opportunities during this period and beyond.
The development of a virtual clinic is also significant in the current clinical education environment. Telepractice has historically been used in clinical service provision in the profession of audiology and provides opportunities for clinical education, particularly due to the loosening of regulations related to delivery platforms and HIPAA during the pandemic. Telepractice, as part of a clinical education program, provides a strong precepted clinic model that simultaneously addresses patient needs and allows AuD students to explore problem-solving using this tool in a supervised environment. An increased emphasis on telepractice will likely happen post-pandemic, particularly with the anticipation of the ability to bill for these services. Currently, audiology accreditors will be evaluating how to address competencies obtained by both simulated and telepractice experiences, hopefully with a vision toward flexibility and trust in the evaluation of audiology educators.
Many questions in this era of audiology education persist. Standards of education and preparation of students to enter the profession must be maintained, which will require creativity and flexibility. University programs are committed to providing their standard quality education, however, at this time, many unknowns may require that programs be extended. University programs must be resourceful in responding to current needs, such as frontloading courses that may be offered during the summer semester so subsequent semesters can provide more time for clinical externships.
The status of clinical sites is another unknown. Some have expressed concerns about how to reopen post-pandemic and their role in clinical education. Others anticipate that their businesses will be so busy once they reopen, providing students with a strong learning environments while supporting a greater degree of patient care. During this transition, students will require ongoing support for their mental and physical health from university programs.
At the start of the pandemic, some people noted that we were living in a gray area. When shelter-at-home orders were mandated in various U.S. states, the environment became black and white. Although faced with significant and new challenges, clinical educators, with their knowledge and skills, are prepared to tackle these challenges head-on. As the world comes to a new normal, gray areas emerge again. In clinical audiology education, these gray areas will require changes and provide opportunities for novel ways to provide quality clinical education. Students will have stronger education in areas such as infection control and telepractice, thereby benefiting patients and our profession in the long run. Most hopeful is that AuD students may find role models and learn to support each other—just as the entire profession unites to become stronger once the pandemic is over.
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