Editor's note: This text-based course is a transcript of the Use Of Simulation In Graduate OT Coursework And As A Level I Fieldwork Experience Podcast, presented by Sarah Zimmerman, OTD, OTR/L, and Dennis Cleary, MS, OTD, OTR/L.
**Please use the handout to complete the exam.
- After this course, participants will be able to:
- Analyze the use of simulation across the occupational therapy curriculum, specifically the Simucase program.
- Examine the benefits of computer-based simulation experiences to promote clinical reasoning.
- Evaluate the benefits of simulations as an alternative to clinic-based Level I fieldwork experiences.
Dennis: Hello, everyone, and thanks for joining us today. I am joined by Dr. Sarah Zimmerman from Saint Louis University. Thanks for being with us. Could you tell us a little about your background and role at SLU, or do we say Saint Louis University?
Sarah: We can go with SLU. Thanks, Dennis. My name is Sarah Zimmerman. I am an assistant professor at SLU, and I teach in their undergraduate occupational science and graduate-level occupational therapy program. I have been 20 years in practice as a pediatric occupational therapist before assisting and "adjuncting" at the university. I loved teaching college students, so I went back and got my doctorate with my goal of teaching at SLU. I have been working there full-time since the fall of 2019. I started right before COVID, so most of my teaching was during the pandemic. I decided that if you can do that, you can do anything!
Dennis: Absolutely. That was when I stopped teaching. COVID has affected our culture, I do not know if you have heard this, but I digress.
You have some background in simulation. Can you talk about SLU and its size and environment? Additionally, how has SLU used this technology?
Sarah: SLU is a Jesuit university in St. Louis with a strong mission to be people for others. There is an extensive healthcare program, so our OT program sits on the medical campus in the Doisy College of Health Sciences. We align with speech therapy, physical therapy, and physician assistant programs, making for some terrific interprofessional collaboration. Additionally, our students work with nursing and premed students.
Dennis: In terms of that interprofessional collaboration, I think it makes simulation a little easier. Today, we are going to focus on video simulation. Do you want to talk a little bit about the types of simulation that you have at SLU and the opportunities that students have there?
Sarah: Absolutely. We have always incorporated a lot of hands-on simulations with live patients and case studies using various problem-based learning strategies. We had explored a little bit of the virtual-based simulation, but as we know, COVID turned everything upside down and caused us to take another look. During COVID, we were challenged with how to teach our students critical thinking, problem-solving, and clinical reasoning when they did not have access to live patients. They were not even in a classroom with us. We started looking at video simulation as necessary to promote these skills for our students. The speech-language pathology program at SLU has been using virtual simulation (Simucase) for a long time and thought highly of it. But sometimes, you need a significant change to force you to look at your best practices and what works for students. This is what COVID did for us. We decided to give that program a try.
Dennis: In the disclosure, it is mentioned that OccupationalTherapy.com and Simucase are in the same family of companies. I just wanted to point that out to our listeners. We will be talking about the principles of video simulation, but the particular product SLU uses is Simucase.
I am old, and I remember back in the days when you would go to YouTube to try to find something close to something that you wanted to have a student see. Then, the following year, the link would not be there. Have you had that experience, Sarah?
Sarah: It has only gotten worse with many more people on social media. You might be able to find a million things on a topic, but they might all be terrible. With video simulation programs, you can find exactly what you want. For example, I can find someone with autism who is being assessed with a tool or working on a particular skill we can incorporate into our class. It has been fantastic to have such a plethora of quality videos from which to choose.
Dennis: Could you explain to people that have not seen a video simulation before what it entails? Is there a case study background that students read? And, what is the experience both for the student and faculty sides?
Sarah: There are many ways you can use Simucase. Today, I will discuss how I use it in my pediatric coursework. For example, if I am teaching about doing activities of daily living with children, we can watch a clear video of a therapist working on hair combing with a little girl with autism. We can talk about the intervention highlighting backward chaining and behavior management. We can look at how the therapist uses these techniques and shapes behavior. The students and I can then discuss clinical reasoning during class.
The next step is sending them home and saying, "Watch this different case where the client is working on a different ADL." Do the clinical reasoning on your own using the knowledge we analyzed in class. We are using prior knowledge to scaffold a new case. There are fantastic simulations that the students can do on their own. For example, there are videos using the Peabody Motor Developmental Scales. We can work on this in a lab with the materials. Then they can go on and "do" the Peabody with a child. The video has all the background information, including an Occupational Profile and history like other services they receive. They also have to pick out what questions would be appropriate to ask the parent, and it gives immediate feedback. If they pick the wrong question, the virtual parent says, "I do not know why you're asking me that."
Sarah: It is! They have to go through that process, and then they watch little clips of the child doing the Peabody, whether stacking the blocks or stringing beads. They have to score the Peabody, which gives them immediate feedback on whether they scored it right or not. And after they score it, they have to interpret the results, allowing them to take what they have learned in class and apply it in a very hands-on way with immediate feedback. After they go through the whole process, we debrief, asking the questions, "What was easy?" "What was hard?" and "How did you approach this task?"
The program also gives me feedback as a professor. If everybody asks incorrect questions, I can see a report of that information. We may need to talk about interviewing skills and how to develop an occupational profile the next time we are in class.
This is only one example. There are many different assessments and interventions to choose from across practice areas.
Dennis: Gotcha. I do not know how you were taught to do a Peabody, but I think I was sent home with a partial kit that was missing half the pieces. Then, I tried to find a nephew or a niece to test. Every student in the classroom had a very different experience. This sounds like a better way to learn how to do an assessment.
Sarah: It is. There are many assessments and variables in pediatrics. It has been a positive way for the students to do this. Before this, students were paired with classmates who pretended to be four-year-olds. However, it is not the same as having a child actively running away from the table or seeing how the therapist redirects this behavior.
Dennis: Maybe I would be a much better therapist now if I had exposure to that back when I was in school so many years ago. You have talked about Simucase. How does that fit with some of the other simulations you use? Do you have actors that you bring in or case studies that you are doing with other disciplines? Do you use a developmental progression where you start with Simucase and then go to a live situation? How do you use it in your classroom or the context of your larger curriculum at SLU?
Sarah: Within our OT program curriculum, we always have done a variety of things, including live actors, problem-based learning, and case studies, which are all great. The biggest thing with this virtual platform is that they are simulations with actual patients. They show a child who is two with autism or an adolescent working with an AAC device. These people are getting therapy, which is hard to replace or replicate. Having the actual person and therapist is terrific. Before using video simulation, the only way that they could get that experience was to go out on Level I and Level II clinicals. As we know, there are a lot of barriers to getting out into the clinical space, which we will discuss. Simucase has enhanced our students' abilities and confidence.
Going back to the example of the Peabody, if they have learned the Peabody in class, worked with the materials in a lab, and then have done an assessment virtually, including actively scoring and actively observing, then when they go into fieldwork, they feel a lot more confident. In clinical settings, we do not always have control over what the students get to do. But now, even if they never get this experience out in a clinic, we know they have been able to score the Peabody at least once.
Dennis: Back when I was an academic fieldwork coordinator, we used to sell that "everyone had different experiences," and we brought those together to learn from each other. This is true, but perhaps a student got to see six assessments compared to another who saw only one six times. It was a different experience for those Level I's. With video simulation, you have more control over that as a faculty member.
Sarah: Absolutely. Some kids are unique cases. For example, all my students may go for a one-week Level I but not see a student using an AAC device. I can be sure to build that into the curriculum via simulation, so they have the opportunity to think critically and problem-solve this type of case.
Dennis: In terms of Simucase, how many different pediatric cases would you say that they have?
Sarah: I would guess about 15 cases. They break them down from zero to three and then three to 21. You can do part of an assessment, or you can do a full assessment. They are always coming out with new ones, which is excellent. That is just for pediatrics. They have many other areas, including mental health and community-based experiences.
Dennis: I had somebody reach out from Nebraska today looking for Level I mental health fieldwork for one of my affiliate programs. Maybe I will refer them to Simucase.
Even before COVID, there was a significant shortage in fieldwork sites. Maybe 10 or 15 years ago, at an AOTA meeting, ACOTE wanted to get people's opinions about simulation, explicitly looking at Level I's. With the issue of this shortage, especially in cities like St. Louis, Philadelphia, or New York, where there are multiple programs, there may be competition for Level I, Level II, and now capstone placements. ACOTE allows simulation as part of their Level I fieldwork. I am assuming SLU does as well.
Sarah: We do. Fieldwork placement was getting tighter and tighter pre-COVID, and academic fieldwork coordinators were being told to figure it out. There are only so many connections to be made. COVID forced that change. In fact, during the thick of COVID, we had a hard time getting our Level II students placed, and they needed to be out there, so Level I's essentially disappeared. How do we promote critical thinking skills when students cannot go out? This was when we started. And, of course, we thought the pandemic would last two weeks. We also thought, how will we survive being home together for two weeks? Now, we are here years later.
Dennis: Yeah, we were even washing the groceries.
Sarah: We also thought that once the vaccine rolled out, the restrictions would lift, and we would go back to normal. That has not been our experience at SLU. There has been a second bump. Initially, people took limited Level II students and no Level I students because of COVID. Post-COVID, there has been a massive shift in the workplace. Many sites we have traditionally used in the past now say, "We are sorry. We cannot take any Level I students because our therapists are brand new, as many have left the clinics." Now, we are dealing with a different issue.
At the same time, sites are getting much more competitive. We had to look creatively at solving this problem and not just say the academic fieldwork coordinator needed to figure it out. We needed to make a meaningful change. We are not saying, "Let's scrap Level I's completely or move all the Level I's to a nontraditional site." While those options have pros and cons, how do we promote student learning in pediatrics, my area, or community-based practice? How can we control and facilitate this?
Dennis: Right. Simulation has been used for clinical hours in nursing for at least ten years and even longer for physicians. We love our nursing and physician friends, but they often have more access to resources than occupational therapy, and occupational therapy assistant programs do. Due to this, they have had more years to perfect the use of simulations and have good evidence showing it is a better teaching and learning method.
Students are exposed to more specific skills and can practice and implement detailed assessments with feedback. Simucase and other products like Simucase provide automatic feedback. This is very different from the simulation they were doing 20 years ago. Older therapists like myself might be skeptical about these programs as students still need to learn psychosocial skills and what being an occupational therapist or an occupational therapy assistant entails. They will still have those experiences, but it is an excellent way to control access to what the students can see and learn. How do the students react to these experiences?
Sarah: The research on student satisfaction and perception has been pretty good thus far, but we need continued research as we use this more. Students often do not know what they know or do not know. It is the way we sell it. Initially, our OT students were like, "What? Are we not going on clinical? How are we going to learn?" But if you phrase it, "You will be able to do this (like a Peabody) that you might not see in clinicals." We know students learn via a traditional lecture and lab set-up with hands-on learning, but we need to engage them more.
For example, when everybody is done with a lecture, many start looking at their phones for studying, online shopping, or whatever. How do we engage them in active learning experiences? These simulations provide a dynamic learning experience. We know that hands-on experiences are great but take time to develop. You need to bring people in, like professors and people in academia, but they are stretched thin. How do we work smarter and not harder? I think virtual simulation programs push in some hands-on learning opportunities and active engagement in the classroom for our students without a considerable time commitment on the part of the professor. They have done a lot of background work to make it easy for us to use. That is a massive benefit because it does not matter how great something is. If it makes it harder to work, it will not be sustainable.
Dennis: I used to be affiliated with a program with an excellent neuro class and lab. We would invite stroke survivors from the community to tell their stories and conduct assessments with them, but it was so much work. The lab had ongoing stroke research and had access to 100 different stroke survivors. This is not a situation to which every program has access, and it did not happen during COVID. They had to figure out other options, as you mentioned. I think "active learning" is such a key component of it.
I watched a video in school about how one should behave on Level I fieldwork. This was cutting-edge technology back then. I remember we were told to be "a fly on the wall" and only observe. And, if anyone interacted with you, you were to redirect them back to the therapist. Level I's were entirely observational. Over the last 20 years, we have tried to make Level I's more and more hands-on. With simulation, you cannot sit in the back of the room because you are interacting with the program and are being asked questions. In some ways, skeptics can see the opportunity that Simucase or other programs offer. I do not know if you were instructed on your Level I's not to interfere with things. You are younger than I am, so maybe you were not taught the same way.
Sarah: That is too funny how that was your Level I experience. Many programs require that you have many observation hours already before you even apply to the program. Students that do not get to participate in Level 1's actively are bummed out, but it does depend on the personality and age of their professor/mentor. Some of them will go on Level I's and are hands-on with every patient, while other students are very hands-off. Simulation helps to equalize things and puts their brains to use.
Dennis: Some Level I experiences may need to be more observational if they involve sick and acutely involved individuals. An example might be in a NICU. Does Simucase have NICU cases?
Sarah: There are no NICU simulations, but that will be valuable when they have that.
Dennis: Almost every student I have ever placed has wanted to be in the NICU for their Level II fieldwork. My typical response was, "If you had a child in a NICU, would you like a Level II student working with your child?" My thought was typically not.
Did you start using Simucase during COVID, or were you already starting down that path within your curriculum?
Sarah: It had been presented to us as something that we should explore by our Speech Language and Communication Science Department, but there was not a lot of incentive to start it at the time. The pandemic forced our hands to do something differently. When I came to SLU, the pediatric curriculum needed some shaking up. When you teach something for a long time, people get into patterns of how they teach it. I was ready to shake it up and was excited about this opportunity. With simulations, we get more hands-on opportunities incorporated into the regular curriculum. I think the original idea was to use it as a Band-Aid during COVID, but the benefits were so great that I saw how it could be used consistently to supplement our courses and be adapted for fieldwork.
Dennis: Can you talk briefly about how you freshened up the pediatric curriculum with Simucase?
Sarah: Yes, I can discuss how we use it explicitly as a Level I fieldwork and how I have incorporated it into course design. When we rolled it out, our students were assigned four cases in four different areas: pediatrics, community-based health, et cetera. They were given an orientation of the program and then worked through the other simulations independently. They then did a debrief through the program. This is critical so that the student can problem-solve. We can also look at their strengths and weaknesses to guide where we go next. As they work through the case, they take a test.
Dennis: How does that work?
Sarah: They take a test at the end, but they can always work through it before submitting something to me. I think we set it up that they needed to earn 90% or go back and redo it. This is how it was initially arranged. They had four cases, met and debriefed, and received feedback. As for my course design, I tried to scaffold these cases throughout the curriculum. For example, when I teach ADLs, we do it as a group and then look at the video. We talk about the different interventions we have seen, and the different strategies therapists use. We build that as we move through the curriculum. They may learn about an assessment like the Peabody or another assessment, and then we follow up with a case about it. I like to use assessments that are limited in scope, like a visual perceptual assessment, before I look at a more holistic assessment.
In their final project for my class, they must do a complete evaluation on Simucase, looking at ADLs and sensory and motor function. They have to develop an intervention plan and develop goals. The feedback has been positive. The final project of them working through this full assessment and developing the intervention has nicely developed their critical thinking skills.
Dennis: In terms of the simulations, are they learning discrete skills like transfers and patient handling?
Sarah: Yes, they are asked those via questions during the simulation, if that makes sense. Discrete skills like a child's safety, the type of grasp being used, or their communication style are asked through questions. They watch a video clip and then answer specific questions about that interaction.
Dennis: Nice. If they are writing goals or doing a note, do you get access to that to grade? Is there some artificial intelligence within Simucase that gives them feedback?
Sarah: All of the above. Some of the questions are multiple-choice, while others are open-ended. I can go back and look at it, but the program will score their competence in that area. I can also take that skill to the next level and expand upon it in class what they have done on the Simucase.
Dennis: That is a dream come true for the faculty.
Sarah: That is why it is working.
Dennis: We love grading. (Laugh)
Sarah: I always tell my students, "I love teaching you, but I hate grading your work." I know it is essential, but it is so time-consuming.
Sarah: I feel like this is working smarter, not harder.
Dennis: My most significant contribution to teaching within occupational therapy is making the students do lots of the work. Do you use portfolios as part of what you are doing at SLU? We used to test students on skills like scoring the Peabody, taking blood pressure, doing transfers, or completing manual muscle testing. There were maybe 60 different things that they had to videotape themselves doing. Having to practice those skills physically helped them to build competency. I would randomly check three of them; the rest were on their own.
Sarah: We do not use portfolios, as you mentioned. However, Simucase will ask the student what type of grasp pattern they observed.
Dennis: You can always add this next year. The students will be thrilled. I remember one group of students went to one of the Hill Days and did a video of various grasps and pinches they used during that trip. They made it fun.
Sarah: That is fun.
Dennis: I would let them do groups, but they had to be "extra cool" to get points. We are all about getting students to do more work as faculty. I am kidding, but I always said the more I talk, the less students learn. Occupational therapy is an applied profession, and the more we can get students doing, the better for everybody.
Can you talk a bit about how other faculty are using simulation as part of their courses?
Sarah: Absolutely. I took over the academic fieldwork coordinator position during COVID.
Dennis: You were the guinea pig.
Sarah: Exactly! When redesigning the pediatric class, I was all in. I then had to sell it to the other groups. Now, students in the graduate program have a class called Clinical Conditions, where they learn about different conditions. It is hard to plan for each clinical condition. Speakers are so powerful to use, but they are also time-intensive. You might not have a whole lecture to devote to one diagnosis, so video simulation is crucial for that class. They also get simulations in pediatric courses in different intensities and our mental health class. The classes look at task and occupational analysis. They can watch each other jumping rope or wrapping a present, but looking at a client doing that task will be much different. Again, we also use it for community-based practice primarily because there are not many sites, and we can not always control the experiences there. There are multiple classes now using it.
Dennis: Yes, in mental health settings, we always had a spattering of students who were able to be with an OT in a mental health setting, but sites are without an OT or are nontraditional. It is great when they can see an OT practicing mental health. While we love our recreational therapy friends, we provide different types of assessment and intervention than other professions do. Mental health practice has been around for a long time, and hopefully, we can continue to expand that.
I do not know if you have check-offs, but I think that can be useful for students. They may forget some of the things they learned as they are so busy with coursework and clinicals. Can students go back and review Simucase to prepare for Level II's?
Sarah: They have access to all of them. For example, if they are getting ready to go out on Level II's and the therapist says, "These are the different assessments we do," they can look on Simucase. For example, if a speech-language pathologist comes and talks about AAC use, there is a virtual case that can expand their knowledge. Students have access to all of them, and you can use the program in different ways. They do not always have to do it in a test mode, as there is also a learning mode. They can also watch a video as there is an extensive library.
Dennis: Gotcha. Do you have a checklist before they go to Level II fieldwork, or is that up to the individual student? We have two check-offs. They have to do a multiple choice test that is ridiculously involved and physical check-offs that they have to complete as a refresher before they leave.
Sarah: Our students have been successful on Level II's, but it might be something to consider, especially for things like transfers. It might help their confidence as there can be a lot of anxiety and uncertainty before they head out for their Level II's.
Dennis: How does your program handle funding Simucase? Is that something students cover, or is it part of the tuition?
Sarah: It is tied to their curricular costs, like textbooks or things like that. The more courses that utilize it, the more we get out of the program. I showed some recent graduates the program, and they were blown away. They said, "These students have no idea how lucky they are to have this." They felt the students would be much better prepped going out into the world with this virtual simulation.
Dennis: I wish I had access to it for sure. Do you use the program to do some interprofessional collaboration? Does Simucase have cases that are interprofessional?
Sarah: We are just starting to look at that. Our students have an interprofessional education course with medicine, nursing, physical therapy, and speech pathology. In theory, it sounds like a great class, but the feedback told a different story. The OT students felt that the medical students took it over. The medical students also did not know what OT was, and the cases did not apply to OT. We have this class every year and are looking at expanding it using simulation. The available simulations have multiple disciplines in them. For instance, the SLP students were shown a Simucase video on AAC, and I showed my students a few weeks later. This sparked conversation.
The next step is to see if we can use the case across disciplines. The students can view the simulation and then debrief on the content collaboratively. It is one thing to see what an SLP does and another thing to debrief a case together and talk about that. Students can struggle with knowing their role or "their lane." We help the students brainstorm how each discipline sees the child and how education and theories guide our treatment. This debriefing helps them better understand that piece.
Dennis: There seem to be great opportunities for interprofessional collaboration, especially for PT and speech pathology, as we get each other. We know what each discipline does, but not so much with other disciplines. Simulations may help level the playing field.
Sarah: Absolutely. In interprofessional education, there might be a hierarchy of what is the most important, and often, the therapies tend to feel that they are at the bottom of that, which is not always true.
Dennis: Yes, it is about quality of life and supporting clients.
Dennis: If you started Simucase in 2019, do the fieldwork educators feel that the students are better prepared?
Sarah: The fieldwork educators have felt the students are better prepared in recent years. I think a lot of it is that confidence.
Dennis: Nice. I think it would also be an excellent value add for the clinical sites to have students tested on different assessments. Is the COPM on Simucase?
Sarah: The COPM is on Simucase. I have not used it, but it is on there.
Dennis: I know at Cincinnati Children's, they do the COPM with everyone they evaluate. Is there anything else you would like to share about your experience with simulation? Was there anything that surprised you or you would like to see in the future for clinical simulation?
Sarah: Before COVID, I was not interested in examining the benefits of simulations. I always thought someone had to be in person to develop clinical thinking skills. After using Simucase, I can see how the students have changed. I can control their experience and provide them with more meaningful experiences that enhance their clinical thinking. It has been really powerful, so I will not use it. I will use it in all my classes to provide active engagement and learning. I also love that Simucase always adds new cases in different practice areas. I would encourage anybody to incorporate into what you are already teaching.
Dennis: How was the Simucase onboarding?
Sarah: There was a lot of support. One person we worked with laid it out for us very well. There was also a lot of help from the organization. The more you use it, the better and more comfortable you get. The onboarding was not challenging. The first time you use it, it is a lot of work to incorporate it into the curriculum. Over time, it gets easier to tweak and add to other courses.
Dennis: Are there other types of scenarios that you would like to see Simucase do?
Sarah: I would love to see cerebral palsy in a young child as you can talk about tone and how it impacts movement, but it is hard to see it in real time.
Dennis: Thanks, Dr. Sarah Zimmerman from SLU, for sharing your experience with Simucase and clinical simulation. It was a very interesting conversation.
Sarah: Thanks for having me, Dennis.
Available in the handout.
Zimmerman, S., & Cleary, D. (2022). Use of simulation in graduate OT coursework and as a level I fieldwork experience podcast. OccupationalTherapy.com, Article 5551. Available at www.occupationaltherapy.com