Challenges
In late February, when we first considered the potential impact of COVID-19 on clinical education, each wave of information contained profound implications for what might be coming. Each possibility seemed unbelievable- never before had clinical education as we knew it been essentially shut down. Two short weeks later, as we were preparing for spring break, the University of Maryland officially announced the closure of campus and the move to online instruction which took effect just 3 days later. Most externship sites were also dismissing their interns. We had a small window of time to restructure the entire clinical education program for all of our speech-language graduate students.
Strategies
The Speech-Language Pathology program at the University of Maryland, College Park (UMCP), like many programs, offers an on-campus clinical experience for first-year MA students, while second-year students are on outside placement. Each cohort has dramatically different goals and expectations that required a unique approach to continued clinical education. For the first-year students, the clinical faculty chose telepractice as the primary strategy and selected simulations for the second-year students.
Clinical Simulation
In March, second-year students were enthusiastic, confident, and optimistic about life and work after graduation. Many were profoundly disappointed to lose their placements but focused on completing clock hour requirements for graduation through clinical simulations. Students who needed more than the allowable 75 hours of simulation were given additional telepractice assignments similar to the first-year cohort.
The department purchased single-semester Simucase subscriptions for each student to complete a series of self-guided simulated evaluations and treatments for a wide variety of client populations and disorders. They moved at their own pace through many different clinical skills such as interviewing, goal writing, test administration, and data collection. Most importantly, we wanted the students to engage in active clinical problem solving and critical thinking.
We grouped simulations by common theme and distributed them among the clinical faculty based on interest and area of expertise. Faculty then scheduled teaching/debriefing meetings for each group. To reduce student stress during an already difficult time, no more than one debriefing was held on any given day. Students received a complete schedule of debriefings several days before the first session and managed their own clock hours to ensure all requirements were met. They completed all the simulations for a given thematic group and submitted a written reflection on each case prior to receiving an invitation to the teaching/debriefing on Zoom. Attendance and active participation in the meeting were required to earn credit for the simulated hours. Faculty members led debriefings using both Simucase discussion prompts and their own critical thinking questions. These discussions turned out to be excellent teaching opportunities in which students shared their unique experiences and provided relevant examples from their outside placements.
Telepractice
At the same time, the first-year students had just emerged from the fog that is common in the first semester and were just hitting their clinical stride. These students moved to a telepractice platform with their eligible clients using a therapy delivery modality that was completely new for most of them.
In the weeks before spring break, we took several steps anticipating the need to move all therapy online. We consulted with UMD’s IT division and legal office to ensure that we chose the most secure, most stable, and most user-friendly video-conferencing option available to us at the time (Cisco Webex). We then rearranged schedules to hold an intensive training for all clinical faculty and students on the platform technology, materials, behavior management, and more. Fortunately, one of our clinical faculty colleagues, Eusebia Mont, had substantial previous training/experience in telepractice and gave us a critical headstart in implementing a clinic-wide telepractice model; students were given digital access to a collection of telepractice materials and resources. Just hours after this training, UMD closed campus unexpectedly, effective the next day, and remains closed.
Implementation of Telepractice
Once the campus closed, it took two weeks to fully implement our plan. We notified all current clients of the shift to a telepractice model, monitored the near-daily emergency changes in state licensure laws, and then determined client eligibility for telehealth services. All our clinical faculty reside and are licensed in Maryland, but some clients (and many students) returned to residences outside of this jurisdiction. As a result, residency requirements in state licensure laws made several clients ineligible to continue therapy with us.
Next, the clinical faculty revamped their schedules to accommodate the 100% supervision mandate imposed by ASHA’s Council for Clinical Certification (CFCC) from March 30-May 15, 2020. Several additional clients did not receive therapy for this reason. Fortunately, this mandate was recently rescinded; clinical educators must provide a minimum of 25% direct supervision of the total contact time with each client/patient. Our clinical faculty used best practices in clinical education to determine the nature and degree of additional supervision required for each student. Clinical educators could supervise more than one telepractice session concurrently, and be available 100% of the time to each session.
Prior to starting sessions, clinicians conducted an initial “tech check” with clients/families to ensure that they had the necessary hardware (e.g., webcam, microphone, etc.) and understood how to participate in the video conferencing system. When tele-therapy sessions started, students scheduled their own Webex meetings and sent an “invitation” to the client and to the clinical faculty. The faculty signed in prior to the start of each session to ensure that students were conducting therapy from a secure and private location. Faculty joined sessions when necessary or sent brief comments/feedback to students via the chat function.
In addition to moving therapy sessions to telepractice, the Clinic team made other hard decisions about the clinical education program. The Clinic suspended diagnostics due to the major technological obstacles posed by a remote platform. During summer session, the clinical faculty engages in a problem-solving process to determine whether and how diagnostics can be resumed in Fall 2020. We also chose to streamline clinical report writing/lesson plan requirements significantly to better comply with HIPAA privacy regulations and to reduce student stress associated with the sudden shift in service delivery model. Clinical faculty created secure folders for each student and uploaded a de-identified version of the goals and objectives for each client. These documents are filed in a secure platform which requires a University username & password, dual-factor authentication, and folder permissions from the case supervisor.
Additionally, clinical faculty and students agreed that an essential element was missing in our all-digital clinical environment: the collaborative and spontaneous conversations and group cohesion that facilitates clinical teaching and group learning. In an effort to address this challenge, we created a Slack workspace, a business communication platform organized into channels or chat rooms. This platform allows students and clinical faculty to communicate more informally about everything from technology issues, to clinical successes, to emerging information about the SLP’s role in treating COVID-19 cases. HIPAA-sensitive information was not shared on this platform.
Outcomes
Simulation cases: Overall, the second-year students provided positive feedback about Simucase and the emergency procedures that we put in place. They reported that working at their own pace and analyzing the various clinical skills/processes in Simucase helped them understand the intricacies of the presented cases. They appreciated the ‘low pressure’ learning environment inherent in simulations yet conveyed that it was less than optimal to attain a full 75 hours in half a semester.
From a faculty perspective, students often disagreed with decisions/rationales included in the simulation software, but they were clearly analyzing the clinical process, thinking critically about the clinical cases, and engaging in active problem solving. Plus, all students earned enough hours to meet CFCC certification requirements in SLP and graduation requirements!
Telepractice Therapy: The clinical faculty were unanimously impressed with the first-year students’ rapid shift to a telepractice platform. From their experienced perspective, the sessions were targeted, effective, and creative. The results of a brief student survey conducted at the end of the spring semester indicated a generally positive experience with the new service delivery platform.
The next planned step is to survey all of our clients to discover their perceptions of telepractice therapy services. This step is especially important since, in light of current COVID-19 conditions, the UMD clinical faculty plans to continue the use of telepractice for the upcoming Fall 2020 semester.
Closing Thoughts
Like most graduate speech-language pathology programs in these unprecedented times, the clinical education program at UMD pivoted out of necessity. We made new plans, policies, and procedures that seemed to change almost daily. But students, faculty, and clients worked together to maintain best-practices in clinical work in the midst of all this change. These adaptations are spurring thought-provoking conversations about what may be the “new normal” in clinical education moving forward, for our program and the profession as a whole. We look forward to learning from the experiences of other clinical educators across the country. Finally, we thank all of our professional colleagues in our department, at other universities, and at ASHA for “leaning in” during our development and implementation of these significant educational/programmatic changes.
