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Use of the Debriefing Assessment in Healthcare Simulation (DASH)© in Speech-Language Pathology Clinical Simulation Learning Experiences

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Title: Use of the Debriefing Assessment in Healthcare Simulation (DASH)© in Speech-Language Pathology Clinical Simulation Learning Experiences
Language: English
Authors: Joseph, Jenica (ORCID 0000-0002-4682-6612), Shilling, Tammy (ORCID 0000-0001-8775-7724), Ferguson, Heather L. (ORCID 0000-0003-2056-2695), Kijai, Jimmy (ORCID 0000-0002-5224-7027)
Source: Journal of Research on Christian Education. 2023 32(1-2):65-83.
Availability: Routledge. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
Peer Reviewed: Y
Page Count: 19
Publication Date: 2023
Document Type: Journal Articles
Reports - Research
Descriptors: Speech Language Pathology, Allied Health Personnel, Clinical Experience, Simulation, Learning Experience, Formative Evaluation
DOI: 10.1080/10656219.2023.2245933
ISSN: 1065-6219
1934-4945
Abstract: Research indicates facilitated debriefing is more effective than non-facilitated debriefing. However, limited published work on this topic exists within communication sciences and disorders. This study investigates speech-language pathology clinical simulation experiences examining formative assessment of debriefing sessions. Two groups of graduate students were compared to assess students' perceptions of simulated learning experiences over 6 consecutive weeks. Although no significant changes were noted, stability between-group ratings indicate students entered this experience with practical clinical skills. Future studies may consider students' ability to apply previous knowledge compared to those with no previous clinical experience.
Abstractor: As Provided
Entry Date: 2023
Accession Number: EJ1400404
Database: ERIC
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  Value: <anid>AN0171843077;gmh01jan.23;2023Sep12.05:38;v2.2.500</anid> <title id="AN0171843077-1">Use of the Debriefing Assessment in Healthcare Simulation (DASH)<sup>©</sup> in Speech-Language Pathology Clinical Simulation Learning Experiences </title> <sbt id="AN0171843077-2">Introduction</sbt> <p>Research indicates facilitated debriefing is more effective than non-facilitated debriefing. However, limited published work on this topic exists within communication sciences and disorders. This study investigates speech-language pathology clinical simulation experiences examining formative assessment of debriefing sessions. Two groups of graduate students were compared to assess students' perceptions of simulated learning experiences over 6 consecutive weeks. Although no significant changes were noted, stability between-group ratings indicate students entered this experience with practical clinical skills. Future studies may consider students' ability to apply previous knowledge compared to those with no previous clinical experience.</p> <p>In 2016, the Council for Clinical Certification in Audiology and Speech-Language Pathology (CFCC) revised the American Speech-Language-Hearing Association (ASHA)'s 2014 Standards for the Certificate of Clinical Competence in Speech-Language Pathology to allow graduate students to obtain up to 75 direct client contact hours out of a total of 375 hours through the use of clinical simulation experiences. Clinical simulation experiences were further clarified as opportunities that facilitated students' skills and ability to "(a) interpret, integrate, and synthesize core concepts and knowledge; (b) demonstrate appropriate professional and clinical skills; and (c) incorporate critical thinking and decision-making while engaged in the identification, evaluation, diagnosis, planning, implementation, and intervention" (American Speech-Language Hearing Association [ASHA], n.d.). The allowance for clinical simulation hours is a prudent decision permitting students to use the clinical simulation hours to prepare them for clinical placements while not replacing all direct client contact (MacBean et al., [<reflink idref="bib29" id="ref1">29</reflink>]). Benefits include multiple opportunities for trial and error to demonstrate the mastery of skills without the pressure of a face-to-face patient and the ability to interact with a broad range of patient types and disorders.</p> <p>Due to these relatively recent allowances for the use of simulation in Communication Sciences and Disorders (CSD), "Utilizing simulations for future Speech-language pathologists (SLP) is in its infancy...there is little research on computer-based simulated learning environments in speech-language pathology" (Carter, [<reflink idref="bib7" id="ref2">7</reflink>], p. 46). A recent report by Dudding and Nottingham ([<reflink idref="bib15" id="ref3">15</reflink>]) indicated that approximately 50% of CSD programs use computer-based simulation experiences. Long-established best practices of health care simulations will guide the field of Communication Sciences and Disorders. A successful clinical simulation has three critical components: pre-briefing, simulation experience, and debriefing with actual learning in debriefing (Dudding & Ingram, [<reflink idref="bib14" id="ref4">14</reflink>]).</p> <p>Currently, the limited scholarly work related to clinical simulation in the field of CSD has focused on student perception and preferences (Hill et al., [<reflink idref="bib20" id="ref5">20</reflink>]; Hill et al., [<reflink idref="bib21" id="ref6">21</reflink>]; Hill et al., [<reflink idref="bib21" id="ref7">21</reflink>]; Rose et al., [<reflink idref="bib31" id="ref8">31</reflink>]; Ward et al., [<reflink idref="bib39" id="ref9">39</reflink>]). Hill et al. ([<reflink idref="bib21" id="ref10">21</reflink>], [<reflink idref="bib22" id="ref11">22</reflink>]) focused on examining the effect of the clinical simulation experience on clinical knowledge, skills, and competency. However, there is evidence that facilitated debriefing is more effective than non-facilitated debriefing, little published work examining debriefer communication and the impact on small-group student learning. The Debriefing Assessment for Simulations in Healthcare (DASH)<sups>©</sups> is a valid and reliable instrument used to measure debriefing outcomes (Dreifuerst, [<reflink idref="bib13" id="ref12">13</reflink>]).</p> <p>The purpose of this study is to investigate the use of the DASH<sups>©</sups> in speech-language pathology clinical simulation experiences as a formative assessment of debriefing sessions. Research Questions:</p> <p></p> <ulist> <item> What are students' perceptions of clinical simulation learning experiences?</item> <p></p> <item> Is there a difference between the two groups of Student Debriefing Assessment for Simulation in Healthcare (DASH)<sups>©</sups> ratings over the 6 weeks?</item> </ulist> <hd id="AN0171843077-3">Background and rationale</hd> <p>In 2016, The American Speech-Language-Hearing Association (ASHA's) revised its 2014 standards for the Certification in Speech-Language Pathology. This revision allowed students to obtain up to 75 hours of direct patient contact through clinical simulation (American Speech-Language-Hearing Association). The prescribed clinical simulation should allow for increased confidence among students while reducing anxiety. Further, the clinical simulation should provide repeated practice in a safe environment, increase preparedness for clinical placements, provide access to a broader range of client types for practical application and experiential learning (Dudding & Nottingham, [<reflink idref="bib15" id="ref13">15</reflink>]; Jansen, [<reflink idref="bib23" id="ref14">23</reflink>]; MacBean et al., [<reflink idref="bib29" id="ref15">29</reflink>]).</p> <p>Clinical Simulation (CS) may include standardized patients, virtual patients, high-fidelity mannequins, task trainers, and computer-based interactive experiences. The ASHA guidelines continue to require adherence to the clinical supervision requirement of 25% of the total time. ASHA also requires a debriefing component, including face-to-face discussion, self-reflection with feedback, or written self-evaluation with feedback.</p> <p>Best practices and essential components of clinical simulation experiences include a pre-briefing, the simulation experience, and debriefing session (Dudding & Nottingham, [<reflink idref="bib15" id="ref16">15</reflink>]; Dudding & Ingram, [<reflink idref="bib14" id="ref17">14</reflink>]; Ker & Bradley, [<reflink idref="bib25" id="ref18">25</reflink>]; Verkuyl et al., [<reflink idref="bib38" id="ref19">38</reflink>]) and clearly defined learning objectives (Hewat et al., [<reflink idref="bib19" id="ref20">19</reflink>]) with a facilitator to student ratio of one educator to six to eight students (1:6–8) (Decker et al., [<reflink idref="bib11" id="ref21">11</reflink>]; Hewat et al., [<reflink idref="bib19" id="ref22">19</reflink>]; Secomb, [<reflink idref="bib34" id="ref23">34</reflink>]). This structure, along with summative assessment and adherence to all accrediting body guidelines, provides a high-fidelity learning opportunity for students in a group‐based, peer‐learning environment (Decker et al., [<reflink idref="bib11" id="ref24">11</reflink>]; Hewat et al., [<reflink idref="bib19" id="ref25">19</reflink>]; Secomb, [<reflink idref="bib34" id="ref26">34</reflink>]; Schleicher, [<reflink idref="bib33" id="ref27">33</reflink>]).</p> <p>The DASH<sups>©</sups> has been used with medical (Cooper et al., [<reflink idref="bib10" id="ref28">10</reflink>]) and nursing students (Raney et al., [<reflink idref="bib30" id="ref29">30</reflink>]); however, no current publications use this instrument in CSD simulated learning experiences. The DASH<sups>©</sups> entails a facilitator, student, and observer version, which allows multiple formative assessment methods as clinical simulation learning experiences are developed and implemented.</p> <hd id="AN0171843077-4">Literature review</hd> <p>The purpose of this literature review is to examine and synthesize current literature and best practices for the use of simulation and debriefing in CSD, provide insight into the study design, and clarify the purpose and significance of this study within the field of CSD. Articles used in this literature review were primarily sourced through online databases accessed through the Andrews University's James White Library online resources such as ERIC and PubMed. Articles were also obtained through ASHA's learning and research portal and Google Scholar. Keywords searched included: simulation, Communication Sciences and Disorders, SimuCase™, Debriefing Assessment for Simulation in Healthcare (DASH)<sups>©</sups>, debriefing, pre-briefing, speech-language pathology, distance simulation, and simulated patients. Articles published in peer-reviewed journals were selected within the last 5 years; however, this was expanded to include articles published within the last 10 years due to limited current research published within the field of CSD related to simulation and debriefing. Articles were excluded if they referenced duplicate studies, were not peer-reviewed, or included populations not related to health and human service professions. Secondary sources included based on relevance to the topic and relevance to the research questions.</p> <hd id="AN0171843077-5">Simulation in CSD and allied health programs</hd> <p>A wide variety of research has been conducted within schools of medicine, nursing, allied health, and CSD related to simulation learning experiences and achievement of student learning objectives (Dreifuerst, [<reflink idref="bib13" id="ref30">13</reflink>]; Ferguson & Estis, [<reflink idref="bib16" id="ref31">16</reflink>]; Grillo & Thomas, [<reflink idref="bib18" id="ref32">18</reflink>]), student perceptions of simulated learning experiences (Blackstock et al., [<reflink idref="bib3" id="ref33">3</reflink>]), the debriefing component of simulations (Brown et al., [<reflink idref="bib5" id="ref34">5</reflink>]; Burns, [<reflink idref="bib6" id="ref35">6</reflink>]), and student perceptions of debriefing simulated patients (Adams et al., [<reflink idref="bib1" id="ref36">1</reflink>]; Cooper et al., [<reflink idref="bib10" id="ref37">10</reflink>]; Doherty-Restrepo et al., [<reflink idref="bib12" id="ref38">12</reflink>]; Levett-Jones et al., 2011).</p> <p>Early studies examined the benefit of simulated learning experiences (SLE) with findings comparable to direct clinical experiences. MacBean et al. ([<reflink idref="bib29" id="ref39">29</reflink>]) examined the use of simulations in Australian speech-language pathology students. The researchers found that simulation opportunities and resources for learning clinical skills could increase the subsequent quality of clinical experiences and outcomes. SLEs allow for practice with a broad range of specialized areas, remedial instruction for at-risk students, interprofessional learning, and improvement of clinical skills.</p> <p>Similar findings were noted by Blackstock et al. ([<reflink idref="bib3" id="ref40">3</reflink>]). The researchers found no significant differences between SLE and direct patient experience control groups. Students rated the SLE experience positively with self-rated increased confidence in communication and assessment. Management improved similarly and significantly in SLE and control groups in both models by the end of the clinical placement. While Blackstock et al. ([<reflink idref="bib3" id="ref41">3</reflink>]) notes several benefits, (Ward et al., [<reflink idref="bib39" id="ref42">39</reflink>]) indicates that limitations may include the inability to re-create a real-life scenario, expense, and lack of adequate training for facilitators. Kneebone et al. ([<reflink idref="bib26" id="ref43">26</reflink>]) also suggests simulated learning experiences may lead to students demonstrating overconfidence and clinical errors.</p> <p>Rose et al. ([<reflink idref="bib31" id="ref44">31</reflink>]) examined twelve speech-language pathology students during their undergraduate experience. Students participated in simulated acute hospital clinical scenarios. Utilizing the Participant Perception Indicator (PPI) and the Satisfaction with Simulation Experience Scale (SSES), findings included statistically significant increases in students' self-reported levels of knowledge, experience, and confidence related to acute-care speech pathology practice. Qualitative feedback to open-ended questions indicated that all students reported that the simulated learning experience was highly valued.</p> <p>A study completed by Carter ([<reflink idref="bib7" id="ref45">7</reflink>]) was one of the first to compare CSD computer-based simulated learning experiences (CBLE) and traditional paper-based case studies in the focused area of pediatric developmental language disorders. Computer-based learning environments (CBLE) allow for a learner-centered approach. The student is actively constructing knowledge with formative feedback. SimuCase™, a commercially available simulation program, is the primary program being used in CSD programs. The benefits of SimuCase™ cases include but are not limited to (a) realistic interpersonal communication between learner and avatar, (b) immediate feedback during learner engagement, (c) client strengths and weaknesses embedded within the case, and (d) the availability and interaction with pediatric clients. Findings revealed that the group (<emph>n</emph> = 67) involved with CBLE's outperformed the traditional instruction group (<emph>n =</emph> 53) in several key areas: selecting relevant information from case history, identifying appropriate collaborators, formulating questions to ask those individuals, selecting assessment tools, formulating a diagnosis, and making recommendations. Findings also included a significant improvement in critical thinking with the CBLE group (57–77%) compared to the traditional paper-based case studies.</p> <p>Burns ([<reflink idref="bib6" id="ref46">6</reflink>]) conducted a simulation event for medical students. Qualitative data related to both the pre-briefing and debriefing sessions were recorded. Burns found that through the debriefing process, students developed self-reflection skills that facilitated the learning cycle and improved student outcomes on future simulations. Burns reported that "Providing a pre-brief at the beginning of the session was useful and helped to facilitate reflective practice by preparing students for the discussion at the end of their scenario and making them aware of how they would receive their feedback. It also alerted the students that they were equal partners in the feedback process and triggered internal feedback" (p. 118). The debriefing process, post-simulation experience, was critical components in ensuring simulation fidelity and student learning. Burns stated that "for feedback to be useful, it needs to lead to action which will improve the students' performance" (p. 119). Promoting self-evaluation promotes the student to function in a reflective mode in their daily practice.</p> <hd id="AN0171843077-6">SimuCase™ computer-based learning environment</hd> <p>SimuCase™is a Computer-based simulation program that was explicitly designed for CSD educational programs (SimuCase™, [<reflink idref="bib37" id="ref47">37</reflink>]). Each case is designed and developed by a Speech-language pathologist and a computer programmer. Learners interact with the case, continually make decisions as more information becomes available in a sequential manner. The learner adapts their interactions with the virtual client (avatar) accordingly (Johnson et al., [<reflink idref="bib24" id="ref48">24</reflink>]). In clinical simulation experiences, it is suggested that SimuCase™ be completed in "Learner Mode," as this mode provides immediate feedback regarding the appropriateness of the user's decisions (Carter, [<reflink idref="bib7" id="ref49">7</reflink>]).</p> <p>A recent article by Ghergel et al. ([<reflink idref="bib17" id="ref50">17</reflink>]) supports the use of computer-based clinical simulations. Thorough debriefings with clinical instructors help the learner to analyze and synthesize the information for future clinical interactions. As the student makes appropriate decisions, they receive feedback to scaffold learning effectively.</p> <p>SimuCase™ is a revolutionary technology that can improve the clinical skills of students in CSD; however, like any educational technology, it cannot stand alone. SimuCase™ is dependent upon solid curriculum planning and solid instructional guidance. The plan begins with a careful examination of the technology and considering how it can enhance the learning goals and objectives within the curriculum. SimuCase™ relies on instructors to implement the technology successfully by setting up clear learning objectives and expectations through pre-briefing, providing feedback throughout the simulation, and using a debriefing session to encourage students to reflect on the experience at its conclusion (Johnson et al., [<reflink idref="bib24" id="ref51">24</reflink>]).</p> <hd id="AN0171843077-7">Debriefing assessment for simulations in healthcare (DASH)©</hd> <p>A vital component of simulation-based learning is the debriefing process (Kolbe et al., [<reflink idref="bib27" id="ref52">27</reflink>]). There are a variety of resources available for facilitating student debriefing, but few resources provide formative feedback and evaluation of facilitators leading the student debriefing sessions. One such tool is the Debriefing Assessment for Simulations in Healthcare (DASH)<sups>©</sups>, developed by Harvard's Center for Medical Simulation. See Appendix A. Six main "Elements" of a debriefing are assessed. "These include whether and how the instructor (a) establishes an engaging learning environment, (b) maintains an engaging learning environment, (c) structures debriefing in an organized way, (d) provokes engaging discussions, (e) identifies and explores performance gaps, and (f) helps trainees achieve or sustain good future performance" (The Center for Medical Simulation, [<reflink idref="bib8" id="ref53">8</reflink>], p. 3).</p> <p>The DASH<sups>©</sups> was developed by Harvard's Center for Medical Simulation in 2010. Brett-Fleegler et al. ([<reflink idref="bib4" id="ref54">4</reflink>]) initially established the internal reliability and validity of this tool. In addition, Dreifuerst ([<reflink idref="bib13" id="ref55">13</reflink>]) determined and described the reliability related to the validity of the DASH Student Version (DASH-SV) as good by a Cronbach's alpha coefficient of 0.82 (<emph>N</emph> = 6, <emph>M</emph> = 29.537, variance = 24.259, standard deviation = 4.925) (p. 330). Raney et al. ([<reflink idref="bib30" id="ref56">30</reflink>]) 's study implemented the use of the DASH<sups>©</sups> tool without raters or facilitators participating in the original, online DASH<sups>©</sups> training session. Results revealed high internal consistency with a Cronbach's alpha coefficient of >0.95, more significant than Brett-Fleegler et al. ([<reflink idref="bib4" id="ref57">4</reflink>])'s initial Cronbach's alpha coefficient of 0.89.</p> <p>The DASH<sups>©</sups> is a practical tool for various "domains and disciplines" (Schertzer & Rider, [<reflink idref="bib32" id="ref58">32</reflink>]). A brief review of the literature published within the last 5 years indicates that the DASH<sups>©</sups> has been used to measure debriefing outcomes for medical students (Cooper et al., [<reflink idref="bib10" id="ref59">10</reflink>]), residents (Adams et al., [<reflink idref="bib1" id="ref60">1</reflink>]), nursing students (Raney et al., [<reflink idref="bib30" id="ref61">30</reflink>]), and interprofessional students (Doherty-Restrepo et al., [<reflink idref="bib12" id="ref62">12</reflink>]; Brown et al., [<reflink idref="bib5" id="ref63">5</reflink>]). Through examination of scholarly journals in CSD, there are currently no publications using the DASH<sups>©</sups> in speech-language pathology graduate programs with simulated learning experiences. The Center for Medical Simulation (CMS) grants permission for anyone to use the DASH<sups>©</sups> on the condition that CMS receives a copy of any published research (Center for Medical Simulation, [<reflink idref="bib8" id="ref64">8</reflink>]).</p> <hd id="AN0171843077-8">Method</hd> <p></p> <hd id="AN0171843077-9">Participants</hd> <p>A convenience sample of graduate students enrolled in SPPA 608 Onsite Practicum III was invited to participate in this research study. This is a graduate course for the 2022 cohort in the School of Communication Sciences and Disorders at Andrews University in Berrien Springs, Michigan. The course was offered during the summer semester via Zoom. Enrollment for the Summer 2020 session included 23 female students and one male student. As an international university, the students enrolled in SPPA 608 represent a diverse sampling of students from within the United States of America and international students. The enrollment sample size of 24 graduate students was comparable to cohort sizes of CSD master's programs at other private and public universities (Communication Sciences & Disorders Education Survey Data Reports, 2021). Students received direct benefits from participation in the SPPA 608 course, including academic credit, meeting learning objectives, and partial fulfillment of ASHA academic standards for graduation. Students received an email inviting them to participate voluntarily with no direct compensation or incentives. Twenty-three students completed the informed consent form and participated in this study. Two faculty participants in the School of Communication Sciences and Disorders fulfilled the direct facilitation of pre-briefing and debriefing with students.</p> <hd id="AN0171843077-10">Measurement/instrumentation</hd> <p>The DASH<sups>©</sups> is one of the most frequently used tools for evaluating "behaviors needed to execute an effective debriefing as well as those characteristics of poor debriefings" (Simon et al., [<reflink idref="bib35" id="ref65">35</reflink>], p. 3). The DASH<sups>©</sups> was developed by Harvard's Center for Medical Simulation in 2010. Brett-Fleegler et al. ([<reflink idref="bib4" id="ref66">4</reflink>]) initially established this tool's internal reliability and validity. In addition, Dreifuerst ([<reflink idref="bib13" id="ref67">13</reflink>]) determined and described the reliability related to the validity of the DASH Student Version (DASH-SV) as good by a Cronbach's alpha coefficient of 0.82 (<emph>N</emph> = 6<emph>, M</emph> = 29.537, variance = 24.259, standard deviation = 4.925) (p. 330). Raney et al. ([<reflink idref="bib30" id="ref68">30</reflink>])'s study implemented the use of the DASH<sups>©</sups> tool without formal training demonstrated high internal consistency with a Cronbach's alpha coefficient of >0.95.</p> <p>Using a Likert-type effectiveness scale (1–7), participants rated statements in the following elements: "whether and how the instructor (<reflink idref="bib1" id="ref69">1</reflink>) establishes an engaging learning environment; (<reflink idref="bib2" id="ref70">2</reflink>) maintains an engaging learning environment; (<reflink idref="bib3" id="ref71">3</reflink>) structures debriefing in an organized way; (<reflink idref="bib4" id="ref72">4</reflink>) provokes engaging discussions; (<reflink idref="bib5" id="ref73">5</reflink>) identifies and explores performance gaps; and (<reflink idref="bib6" id="ref74">6</reflink>) helps trainees achieve or sustain good future performance" (Simon et al., [<reflink idref="bib35" id="ref75">35</reflink>], p. 3). A total score was calculated. For this study, the extended version of the student DASH<sups>©</sups> tool was selected to gather both dimensional and elemental data for formative assessment of the debriefing sessions (Simon et al., [<reflink idref="bib35" id="ref76">35</reflink>], p. 4). Students were required to complete the form in its entirety. Researchers then analyzed the mean rating of student responses.</p> <hd id="AN0171843077-11">Internal validity</hd> <p>In order to minimize the risk for type I and type II errors, all participants, facilitators, and independent observers were asked to review the DASH<sups>©</sups> rater handbook and participated in a training video on completion of the DASH<sups>©</sups>. Participants submitted their weekly DASH<sups>©</sups> form within 24–48 hours after the session.</p> <hd id="AN0171843077-12">Detailed study protocol</hd> <p>Internal Review Board (IRB) approval was obtained, and all students enrolled in the course were invited to participate. All participants completed a brief, prerecorded video training session that explained the elements of the DASH<sups>©</sups> form, instructions on completion of the form, and the structure of the simulation pre-briefing and debriefing sessions.</p> <p>Students (<emph>n</emph> = 24) were randomly divided into two equal groups. Previous research suggests a facilitator ratio of one facilitator to six to eight students (Decker et al., [<reflink idref="bib11" id="ref77">11</reflink>]; Hewat et al., [<reflink idref="bib19" id="ref78">19</reflink>]; Secomb, [<reflink idref="bib34" id="ref79">34</reflink>]) to maximize student learning opportunities. The same two clinical facilitators led both group pre-briefing and debriefing sessions each week. The groups participated in 6 weekly identical debriefing sessions via Zoom. Pre-briefing and debriefing sessions followed the same format and simulated learning experiences. Each week participants completed and submitted a DASH<sups>©</sups> form 24–48 hours after each session.</p> <hd id="AN0171843077-13">Results</hd> <p>The weekly DASH<sups>©</sups> forms were stored on the Andrews University Learning Hub course webpage, a secure online database, and information was coded to ensure the anonymity of participants. A quantitative statistical analysis was completed using SPSS between Group 1 (<emph>n</emph> = 12) and Group 2 (<emph>n</emph> = 11) to compare students' perceptions of six different elements related to an instructor's facilitation of clinical simulation learning experiences over 6 consecutive weeks. Data analysis in Table 1 indicates no significant differences between the two groups, between the six elements, or between the weeks.</p> <p>Table 1. Student perceptions as measured by the DASH<sups>©</sups>.</p> <p> <ephtml> <table><thead><tr><td>Element</td><td>Group</td><td>Statistic</td><td>Week</td><td>Effect</td><td><italic>F</italic>(5,17)</td><td><italic>p</italic></td></tr><tr><td char=".">1</td><td char=".">2</td><td char=".">3</td><td char=".">4</td><td char=".">5</td><td char=".">6</td></tr></thead><tbody valign="top"><tr><td>1 Set stage for engaging learning experience</td><td>1 (<italic>n</italic> = 12)</td><td><italic>M</italic></td><td>5.58</td><td>5.96</td><td>6.56</td><td>5.92</td><td>6.50</td><td>6.58</td><td>Week</td><td>1.38</td><td>.28</td></tr><tr><td /><td><italic>SD</italic></td><td>2.02</td><td>1.93</td><td>0.50</td><td>1.93</td><td>0.52</td><td>0.51</td><td /><td /><td /></tr><tr><td>2 (<italic>n</italic> = 11)</td><td><italic>M</italic></td><td>6.77</td><td>6.55</td><td>6.72</td><td>6.64</td><td>6.82</td><td>6.23</td><td>Weeks*Group</td><td>1.80</td><td>.17</td></tr><tr><td /><td><italic>SD</italic></td><td>0.41</td><td>0.69</td><td>0.47</td><td>0.67</td><td>0.40</td><td>2.09</td><td /><td /><td /></tr><tr><td>2. Maintain an engaging context for learning</td><td>1 (<italic>n</italic> = 12)</td><td><italic>M</italic></td><td>6.55</td><td>6.54</td><td>6.67</td><td>5.92</td><td>6.56</td><td>6.75</td><td>Week</td><td>0.55</td><td>.74</td></tr><tr><td /><td><italic>SD</italic></td><td>0.50</td><td>0.50</td><td>0.49</td><td>1.98</td><td>0.50</td><td>0.45</td><td /><td /><td /></tr><tr><td>2 (<italic>n</italic> = 11</td><td><italic>M</italic></td><td>6.73</td><td>6.74</td><td>6.73</td><td>6.82</td><td>6.82</td><td>6.18</td><td>Weeks*Group</td><td>0.86</td><td>.53</td></tr><tr><td /><td><italic>SD</italic></td><td>0.65</td><td>0.65</td><td>0.65</td><td>0.60</td><td>0.60</td><td>2.14</td><td /><td /><td /></tr><tr><td>3. Structure debriefing in an organized way</td><td>1 (<italic>n</italic> = 12)</td><td><italic>M</italic></td><td>6.23</td><td>6.33</td><td>6.58</td><td>6.04</td><td>6.54</td><td>6.63</td><td>Week</td><td>2.28</td><td>.09</td></tr><tr><td /><td><italic>SD</italic></td><td>0.58</td><td>0.78</td><td>0.67</td><td>2.00</td><td>0.66</td><td>0.64</td><td /><td /><td /></tr><tr><td>2 (<italic>n</italic> = 11</td><td><italic>M</italic></td><td>5.91</td><td>6.55</td><td>6.91</td><td>6.55</td><td>6.73</td><td>6.18</td><td>Weeks*Group</td><td>0.60</td><td>.70</td></tr><tr><td /><td><italic>SD</italic></td><td>2.02</td><td>0.69</td><td>0.30</td><td>0.69</td><td>0.47</td><td>2.08</td><td /><td /><td /></tr><tr><td>4. Provide in-depth discussions that reflect on performance.</td><td>1 (<italic>n</italic> = 12)</td><td><italic>M</italic></td><td>6.06</td><td>6.08</td><td>6.29</td><td>5.71</td><td>6.40</td><td>6.29</td><td>Week</td><td>1.37</td><td>.29</td></tr><tr><td /><td><italic>SD</italic></td><td>0.72</td><td>0.67</td><td>0.62</td><td>1.94</td><td>0.78</td><td>0.75</td><td /><td /><td /></tr><tr><td>2 (<italic>n</italic> = 11</td><td><italic>M</italic></td><td>6.55</td><td>6.36</td><td>6.73</td><td>6.36</td><td>6.64</td><td>6.18</td><td>Weeks*Group</td><td>0.59</td><td>.71</td></tr><tr><td /><td><italic>SD</italic></td><td>0.82</td><td>1.03</td><td>0.47</td><td>0.67</td><td>0.67</td><td>2.14</td><td /><td /><td /></tr><tr><td>5. Identify what was done well, poorly, and why</td><td>1 (<italic>n</italic> = 12)</td><td><italic>M</italic></td><td>5.75</td><td>6.00</td><td>5.67</td><td>5.83</td><td>5.67</td><td>5.67</td><td>Week</td><td>0.71</td><td>.63</td></tr><tr><td /><td><italic>SD</italic></td><td>1.92</td><td>0.95</td><td>1.23</td><td>1.95</td><td>1.87</td><td>1.92</td><td /><td /><td /></tr><tr><td>2 (<italic>n</italic> = 11</td><td><italic>M</italic></td><td>6.00</td><td>5.64</td><td>5.18</td><td>5.00</td><td>4.55</td><td>4.18</td><td>Weeks*Group</td><td>0.39</td><td>.85</td></tr><tr><td /><td><italic>SD</italic></td><td>2.09</td><td>2.80</td><td>2.48</td><td>2.45</td><td>2.84</td><td>3.22</td><td /><td /><td /></tr><tr><td>6. Help how to improve or sustain good performance.</td><td>1 (<italic>n</italic> = 12)</td><td><italic>M</italic></td><td>6.25</td><td>5.88</td><td>5.92</td><td>5.75</td><td>6.25</td><td>6.42</td><td>Week</td><td>0.95</td><td>.47</td></tr><tr><td /><td><italic>SD</italic></td><td>0.62</td><td>0.86</td><td>0.90</td><td>2.00</td><td>0.62</td><td>0.67</td><td /><td /><td /></tr><tr><td>2 (<italic>n</italic> = 11</td><td><italic>M</italic></td><td>6.73</td><td>6.64</td><td>6.64</td><td>6.82</td><td>6.64</td><td>6.18</td><td>Weeks*Group</td><td>0.68</td><td>.65</td></tr><tr><td /><td><italic>SD</italic></td><td>0.65</td><td>0.67</td><td>0.67</td><td>0.40</td><td>0.50</td><td>2.09</td><td /><td /><td /></tr></tbody></table> </ephtml> </p> <p>There were no significant differences between Groups 1 and 2 when rating how the instructor established engaging learning experiences (Element 1). Group 2 reported slightly higher mean ratings and standard deviations than Group 1; however, this difference is not statistically significant. See Table 2. Based on the mean ratings and standard deviations, the differences in changes over weeks did not vary significantly between the groups. Descriptive statistics indicates that 41% of Group 1 and 66% of Group 2 reported that the instructor was extremely effective in their ability to set the stage for an engaging learning experience.</p> <p>Table 2. Element 1 changes over time in mean rating and <emph>SD.</emph></p> <p> <ephtml> <table><tbody valign="top"><tr><td><graphic href="urce_a_2245933_ilg0001_c.jpg" content-type="color" /></td></tr></tbody></table> </ephtml> </p> <p>No significant differences in mean ratings are noted between groups for how the instructor maintained an engaging learning environment (Element 2). See Table 3. Although there was a lower mean rating in Week 4 for both groups (Group 1: MR = 5.92, <emph>SD</emph> = 1.98, Group 2: MR = 6.18, <emph>SD</emph> = 6.14), changes in ratings were not dependent upon the group. Descriptive statistics indicates that 50% of Group 1 and 75% of Group 2 reported that the instructor was extremely effective in their ability to maintain an engaging context for learning.</p> <p>Table 3. Element 2 changes over time in mean rating and <emph>SD.</emph></p> <p> <ephtml> <table><tbody valign="top"><tr><td><graphic href="urce_a_2245933_ilg0002_c.jpg" content-type="color" /></td></tr></tbody></table> </ephtml> </p> <p>There were non-significant changes in ratings between groups for the instructor's ability to structure debriefing in an organized way (Element 3, Table 4), and the instructor's ability to provoke engaging discussions (Element 4, Table 5). Results revealed a lower mean rating for both groups on week 4 (Group1: MR = 5.71, <emph>SD</emph> = 1.94; Group2: MR = 6.36, <emph>SD</emph> = 0.67) for element four; the instructor's ability to provoke engaging discussions. These changes in ratings did not depend upon groups. Descriptive statistics reveal that 25% of Group 1 and 42% of Group 2 reported the instructor was extremely effective in structuring the debriefing session in an organized way. In addition, 25% of Group 1 and 67% of Group 2 reported that the instructor was extremely effective in their ability to provide in-depth discussions that lead to reflection on performance.</p> <p>Table 4. Element 3 changes over time in mean rating and <emph>SD.</emph></p> <p> <ephtml> <table><tbody valign="top"><tr><td><graphic href="urce_a_2245933_ilg0003_c.jpg" content-type="color" /></td></tr></tbody></table> </ephtml> </p> <p>Table 5. Element 4 changes over time in mean rating and <emph>SD.</emph></p> <p> <ephtml> <table><tbody valign="top"><tr><td><graphic href="urce_a_2245933_ilg0004_c.jpg" content-type="color" /></td></tr></tbody></table> </ephtml> </p> <p>Overall, there were no significant changes in how groups rated the instructor's ability to identify and explore performance gaps (Element 5, Table 6). Group 1 shows mean ratings and standard deviations that remain relatively constant throughout the 6 weeks. Group 2 shows a gradual but consistent decline in mean ratings from week 1 to week 6. Although there were slight changes, it did not depend on the group. Descriptive statistics indicate 33% of Group 1 and 58% of Group 2 reported the instructor was extremely effective when they identify and explore performance gaps. Debriefing sessions for both groups were held on the same day of the week. Group 2 followed Group 1, and it may be possible that facilitators did not emphasize what was done well, poorly, and why in the second group as the weeks progressed.</p> <p>Table 6. Element 5 changes over time in mean rating and <emph>SD.</emph></p> <p> <ephtml> <table><tbody valign="top"><tr><td><graphic href="urce_a_2245933_ilg0005_c.jpg" content-type="color" /></td></tr></tbody></table> </ephtml> </p> <p>There were minimal differences between groups ratings of how instructor's help students achieve or sustain good future performance (Element 6, Table 7). Changes are not statistically significant, indicating that changes are not dependent on group assignment. Descriptive statistics reveal that 33% of Group 1 and 75% of Group 2 reported the instructor was extremely effective in their assistance to achieve or sustain good future performance. Findings may indicate that Group 2 benefited from the debriefing in Group 1 for this element. Debriefers may have anticipated questions or areas of weakness during the first group's debriefing that were addressed more entirely in the second group.</p> <p>Table 7. Element 6 changes over time in mean rating and <emph>SD.</emph></p> <p> <ephtml> <table><tbody valign="top"><tr><td><graphic href="urce_a_2245933_ilg0006_c.jpg" content-type="color" /></td></tr></tbody></table> </ephtml> </p> <hd id="AN0171843077-14">Discussion</hd> <p>The present findings with this specific population are not reflected in the literature within the field of CSD. This study compared two groups of students' perceptions of clinical simulation learning experiences (Adams et al., [<reflink idref="bib1" id="ref80">1</reflink>]; Cooper et al., [<reflink idref="bib10" id="ref81">10</reflink>]; Doherty-Restrepo et al., [<reflink idref="bib12" id="ref82">12</reflink>]) by elements on the student version of the DASH<sups>©</sups> (Simon et al., [<reflink idref="bib36" id="ref83">36</reflink>]) over 6 consecutive weeks. Similar to a study conducted by Blackstock et al. ([<reflink idref="bib3" id="ref84">3</reflink>]), results showed no statistically significant changes in elements for either group. Based on mean rating scores, both groups reported the instructor was effective or extremely effective in their ability to create and maintain an engaging learning experience, structure sessions that facilitated learning, and provided in-depth discussions with help to sustain good future performance. Student mean ratings were slightly lower when evaluating the instructor's ability to give constructive feedback and identify areas of strength and need for improvement. In addition to being slightly lower than the other elements, the ratings decreased for this element over the 6-week period. While there were no significant differences, the descriptive analysis identifies this area in need of improvement. Students benefit from consistent feedback that helps them identify areas where they did well and may have performed poorly. The participant groups in this study felt that the instructors could have been more effective in providing feedback during the debriefing session. Overall, the participant's perceptions of the DASH<sups>©</sups> were reported via qualitative feedback as a positive tool for facilitating and engaging in debriefing sessions, which is comparable to previous studies conducted with other health and human service graduate student populations (Brown et al., [<reflink idref="bib5" id="ref85">5</reflink>]; Doherty-Restrepo et al., [<reflink idref="bib12" id="ref86">12</reflink>]; Kolbe et al., [<reflink idref="bib27" id="ref87">27</reflink>]; Raney et al., [<reflink idref="bib30" id="ref88">30</reflink>]).</p> <p>This practicum experience was conducted entirely on Zoom via simulation. Although no changes were present over the 6 weeks, the stability between-group ratings (ratings of 5–7) across weeks indicates similar debriefing session experiences based on the DASH<sups>©</sups> student rater form. However, while not statistically significant, descriptive statistics indicate Group 2 evaluated the instructor's effectiveness at a higher level when leading the debriefing sessions. Since the same instructors facilitated the debriefing sessions for both groups sequentially, it is plausible that the second group benefited from the duplicated experience, thus higher ratings of effectiveness. It is unknown whether students may have reported similar results should this practicum experience have been completed in person with a similar debriefing structure.</p> <hd id="AN0171843077-15">Limitations</hd> <p>While a convenience sample was selected, the small sample size (<emph>n</emph> = 23) is a limitation of this study. Results should be interpreted with caution due to the limited number of participants.</p> <p>A visual outline of the session, including video clips of critical points of the simulation, was added to the debriefing sessions on Week 3. Although a non-measured intervention, this addition did not show significant changes pre- or post- addition to the debriefing sessions. Student qualitative responses indicated that the visual framework and interactive measures increased their ability to follow and engage in the debriefings. Future debriefing sessions may benefit from including a visual framework and interactive measures during each session.</p> <p>As this was not the first practicum experience for students in this course, it is possible that previous debriefing experiences related to face-to-face clinic assignments may have biased their responses. It should also be noted that students were previously familiar with both the faculty facilitators and observers; thus, students' potential response bias must be considered as a limitation of this study.</p> <hd id="AN0171843077-16">Implications for the field</hd> <p>The overall structure of the debriefing sessions indicated that instructors and programs benefit from formative student feedback which supports and informs teaching practices (Cooper et al., [<reflink idref="bib10" id="ref89">10</reflink>]; Raney et al., [<reflink idref="bib30" id="ref90">30</reflink>]). This study is the first within literature to apply the DASH<sups>©</sups> to graduate students in Communication Sciences and Disorders simulation programs. Results indicate that the DASH<sups>©</sups> can be used within the profession with similar results consistent with programs already utilizing this instrument such as nursing and medical schools (Adams et al., [<reflink idref="bib1" id="ref91">1</reflink>]; Cooper et al., [<reflink idref="bib10" id="ref92">10</reflink>]; Raney et al., [<reflink idref="bib30" id="ref93">30</reflink>]).</p> <p>An instructor's effectiveness in facilitating a debriefing session that encompasses elements of engagement, structure, feedback, and successful future performance is considered a best practice. This study's results support the work of Burns ([<reflink idref="bib6" id="ref94">6</reflink>]); through an effective debriefing process, students developed self-reflection skills that facilitated the learning cycle and ultimately improved student outcomes. Promoting self-evaluation allows the student to function in a reflective mode in their daily practice.</p> <hd id="AN0171843077-17">Conclusions</hd> <p>The results of this study support Simon et al. ([<reflink idref="bib35" id="ref95">35</reflink>]) and agree that the elements of the DASH© are useful to assess effectiveness of teaching behaviors during activities that promote a pre-briefing and debriefing process. This work contributes to the literature as it examined the instructor's skills in structuring and conducting a debriefing session and the impact on small group student learning conducted synchronously via Zoom. This study contributes to the current literature in which the DASH<sups>©</sups> has been used to measure debriefing outcomes for medical and nursing students (Adams et al., [<reflink idref="bib1" id="ref96">1</reflink>]; Cooper et al., [<reflink idref="bib10" id="ref97">10</reflink>]; Raney et al., [<reflink idref="bib30" id="ref98">30</reflink>]).</p> <p>It is concluded that students perceive structured debriefing sessions as beneficial and rated instructors consistently to extremely effective. Based on the results, it supports the idea that students prefer structure, organization, engagement, discussions, and feedback.</p> <hd id="AN0171843077-18">Recommendations and future research</hd> <p>These findings provide several recommendations for future research in clinical education and debriefing. Future use of the DASH<sups>©</sups> student rating forms should be completed at the end of each debriefing session. This may result in greater accuracy of student ratings instead of a delayed response time between the debriefing session and student submission of the DASH<sups>©</sups>. Students may also report more reliable ratings if the expectation is that form completion is part of the class and not an additional requirement outside of class time.</p> <p>The six elements of the DASH<sups>©</sups> are extremely useful as formative feedback for new and experienced faculty who provide clinical education and provide supervision in clinical experiences. Ensuring that effective, engaging, and structured communication has occurred between the clinical educator/supervisor and student is essential. Future studies may wish to include supplementary questions comparing students with previous experience and no experience with debriefing sessions related to clinical assignments. The addition of qualitative comments with semi-structured interviews and written feedback would strengthen further research in this area.</p> <p>It is also suggested that participant response bias could be controlled for future studies through unfamiliar clinical supervisors as facilitators. While debriefing was utilized for simulated learning experiences in this study, future studies could examine this debriefing format for in-person clinical experiences and compare and contrast the DASH<sups>©</sups> with other forms of debriefing.</p> <p>Additional research should be conducted to determine if the DASH<sups>©</sups> may be useful in other allied health professional programs and with larger sample sizes. While the facilitators were aware of the elements on the DASH<sups>©</sups>, they were not asked to rate themselves each session. 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Ferguson and Jimmy Kijai</p> <p>Reported by Author; Author; Author; Author</p> <p></p> <p>Jenica Joseph is a speech-language pathologist and assistant professor at Andrews University with research interests in trauma-informed methods, metacognitive learning strategies, and peer-assisted learning.</p> <p>Tammy Shilling is a speech-language pathologist and associate professor at Andrews University with research interests in student engagement, active learning, metacognitive learning strategies, and peer-assisted learning.</p> <p>Heather L. Ferguson is an associate professor and the chair and graduate program director for the Andrews University School of Communication Sciences and Disorders. Her research interests are in student achievement, motivation, and resiliency in higher education.</p> <p>Jimmy Kijai is a Professor of Research & Statistical methodology in the Department of Graduate Psychology and Counseling at Andrews University. Research interests are in institutional effects on attitudes, beliefs, and values.</p> </aug> <nolink nlid="nl1" bibid="bib29" firstref="ref1"></nolink> <nolink nlid="nl2" bibid="bib15" firstref="ref3"></nolink> <nolink nlid="nl3" bibid="bib14" firstref="ref4"></nolink> <nolink nlid="nl4" bibid="bib20" firstref="ref5"></nolink> <nolink nlid="nl5" bibid="bib21" firstref="ref6"></nolink> <nolink nlid="nl6" bibid="bib31" firstref="ref8"></nolink> <nolink nlid="nl7" bibid="bib39" firstref="ref9"></nolink> <nolink nlid="nl8" bibid="bib22" firstref="ref11"></nolink> <nolink nlid="nl9" bibid="bib13" firstref="ref12"></nolink> <nolink nlid="nl10" bibid="bib23" firstref="ref14"></nolink> <nolink nlid="nl11" bibid="bib25" firstref="ref18"></nolink> <nolink nlid="nl12" bibid="bib38" firstref="ref19"></nolink> <nolink nlid="nl13" bibid="bib19" firstref="ref20"></nolink> <nolink nlid="nl14" bibid="bib11" firstref="ref21"></nolink> <nolink nlid="nl15" bibid="bib34" firstref="ref23"></nolink> <nolink nlid="nl16" bibid="bib33" firstref="ref27"></nolink> <nolink nlid="nl17" bibid="bib10" firstref="ref28"></nolink> <nolink nlid="nl18" bibid="bib30" firstref="ref29"></nolink> <nolink nlid="nl19" bibid="bib16" firstref="ref31"></nolink> <nolink nlid="nl20" bibid="bib18" firstref="ref32"></nolink> <nolink nlid="nl21" bibid="bib12" firstref="ref38"></nolink> <nolink nlid="nl22" bibid="bib26" firstref="ref43"></nolink> <nolink nlid="nl23" bibid="bib37" firstref="ref47"></nolink> <nolink nlid="nl24" bibid="bib24" firstref="ref48"></nolink> <nolink nlid="nl25" bibid="bib17" firstref="ref50"></nolink> <nolink nlid="nl26" bibid="bib27" firstref="ref52"></nolink> <nolink nlid="nl27" bibid="bib32" firstref="ref58"></nolink> <nolink nlid="nl28" bibid="bib35" firstref="ref65"></nolink> <nolink nlid="nl29" bibid="bib36" firstref="ref83"></nolink>
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  Data: Use of the Debriefing Assessment in Healthcare Simulation (DASH)© in Speech-Language Pathology Clinical Simulation Learning Experiences
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  Data: English
– Name: Author
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  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Joseph%2C+Jenica%22">Joseph, Jenica</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0002-4682-6612">0000-0002-4682-6612</externalLink>)<br /><searchLink fieldCode="AR" term="%22Shilling%2C+Tammy%22">Shilling, Tammy</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0001-8775-7724">0000-0001-8775-7724</externalLink>)<br /><searchLink fieldCode="AR" term="%22Ferguson%2C+Heather+L%2E%22">Ferguson, Heather L.</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0003-2056-2695">0000-0003-2056-2695</externalLink>)<br /><searchLink fieldCode="AR" term="%22Kijai%2C+Jimmy%22">Kijai, Jimmy</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0002-5224-7027">0000-0002-5224-7027</externalLink>)
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  Data: <searchLink fieldCode="SO" term="%22Journal+of+Research+on+Christian+Education%22"><i>Journal of Research on Christian Education</i></searchLink>. 2023 32(1-2):65-83.
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  Data: Routledge. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
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  Data: Y
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  Data: 19
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  Label: Publication Date
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  Data: 2023
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  Data: Journal Articles<br />Reports - Research
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Speech+Language+Pathology%22">Speech Language Pathology</searchLink><br /><searchLink fieldCode="DE" term="%22Allied+Health+Personnel%22">Allied Health Personnel</searchLink><br /><searchLink fieldCode="DE" term="%22Clinical+Experience%22">Clinical Experience</searchLink><br /><searchLink fieldCode="DE" term="%22Simulation%22">Simulation</searchLink><br /><searchLink fieldCode="DE" term="%22Learning+Experience%22">Learning Experience</searchLink><br /><searchLink fieldCode="DE" term="%22Formative+Evaluation%22">Formative Evaluation</searchLink>
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  Label: DOI
  Group: ID
  Data: 10.1080/10656219.2023.2245933
– Name: ISSN
  Label: ISSN
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  Data: 1065-6219<br />1934-4945
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Research indicates facilitated debriefing is more effective than non-facilitated debriefing. However, limited published work on this topic exists within communication sciences and disorders. This study investigates speech-language pathology clinical simulation experiences examining formative assessment of debriefing sessions. Two groups of graduate students were compared to assess students' perceptions of simulated learning experiences over 6 consecutive weeks. Although no significant changes were noted, stability between-group ratings indicate students entered this experience with practical clinical skills. Future studies may consider students' ability to apply previous knowledge compared to those with no previous clinical experience.
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  Data: 2023
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        PageCount: 19
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      – SubjectFull: Speech Language Pathology
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      – SubjectFull: Allied Health Personnel
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      – SubjectFull: Clinical Experience
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      – TitleFull: Use of the Debriefing Assessment in Healthcare Simulation (DASH)© in Speech-Language Pathology Clinical Simulation Learning Experiences
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