Utilisation of simulation-based learning to decrease student anxiety and increase readiness for clinical placements for speech-language pathology students

Abstract

Purpose

To investigate the use of two versions of a simulation-based learning experience (SBLE) to decrease speech-language pathology (SLP) students’ anxiety and increase their confidence and sense of preparedness for clinical placements.

Method

Two cohorts of third-year SLP students (n = 33) participated in a mixed-methods study with each cohort completing one version of the SBLE. Participants completed pre- and post-program quantitative ratings of anxiety, confidence, and preparedness for clinical placements and participated in focus groups. Three clinical educators also provided qualitative data in debriefs and interviews.

Result

Significant decreases in student ratings of anxiety, and increases in confidence and sense of preparedness, were found for participants from both versions of the SBLE. No significant differences were found between changes in each measure between the two groups. Qualitative data from the student focus groups and clinical educator interviews described affective changes in the students, which concurred with the quantitative results.

Conclusion

Results suggest this SBLE can be used to improve SLP students’ self-perceptions of readiness for clinical placements. Comparable outcomes can be achieved for students using the shorter, less resource intensive version of the SBLE program, with reduced costs, to overcome barriers to its implementation.

Keywords:

• simulation
• speech-language pathology
• clinical placement
• anxiety
• readiness

Introduction

Clinical placements are essential in the education and training of speech-language pathology (SLP) students. They provide a critical opportunity for students to apply theoretical knowledge to clinical practice and to demonstrate and be assessed on the competencies necessary for entry into the profession (Speech Pathology Australia, 2011). Universities offering SLP courses in Australia are currently facing a scarcity of clinical placements, with placement days being offered by the industry workforce failing to keep pace with increasing student numbers (McBride et al., 2020).

Clinical placements are one of the highest sources of study-related stress and anxiety for university health students (Delany et al., 2015). This placement-related anxiety is primarily driven by a lack of familiarity with the placement environment and uncertainty around the expectations of their clinical educators (CEs), rather than concerns with their knowledge or competency in performing clinical skills (Gallasch et al., 2022). The assessment component of a clinical placement also adds a specific source of “testing anxiety,” high levels of which are correlated with poor performance on assessment tasks (Brady et al., 2018; Maloney et al., 2014).

Low to moderate levels of anxiety can be beneficial to learning by promoting increased engagement with a task, increasing motivation to acquire knowledge, and encouraging more effective use of learning strategies (Brady et al., 2018; Cabrera, 2021; Warr & Downing, 2000). However, high levels of anxiety and highly stressful learning environments have well-established links to decreases in the efficiency of working memory and cognition, subsequently impacting negatively on capacity to learn (Maloney et al., 2014). Whilst there is little research specifically into the impact of placement-related stress or anxiety on learning for SLP students, studies in physiotherapy and nursing have found a correlation between high scores on measures of stress and anxiety for students and poorer performance on clinical placement assessments and clinical tasks (Al-Ghareeb et al., 2019, Gallasch et al., 2022).

Palethorpe and Wilson’s (2011) theoretical model of the “comfort-stretch-panic” zones of learning illustrates the close relationship between the degree of stress and challenge in a task, and an individual’s capacity for learning and performance. Tasks in the “comfort zone” are thought to lack sufficient stimulation for the participant, so minimal learning may take place. At the other end of the spectrum, in the “panic zone” a participant can be paralysed by overwhelming anxiety due to the degree of challenge in the task or learning situation (Palethorpe & Wilson, 2011). The model highlights the need for learners to be appropriately challenged, but not to an extent that causes excessive anxiety, in order to create an optimal learning experience in the “stretch zone” (Palethorpe & Wilson, 2011). Students who are commencing clinical placements in the panic zone, due to high levels of placement-related anxiety, may be ill-equipped to capitalise on the learning experiences being provided on their placements, or to adequately demonstrate the competencies on which they are being assessed by their CE.

When describing student attributes that contribute positively to success on clinical placements, CEs frequently describe characteristics such as confidence and a willingness in students to: take initiative, try new techniques, ask questions, and stray from their comfort zone (Chipchase et al., 2012; Hall et al., 2012; Torrington Eaton et al., 2022). A lack of confidence can be a barrier to learning and increased confidence can facilitate greater engagement with learning tasks, quicker adaptation to new situations, and an increased willingness and ability to take on more responsibility (Delany & Bragge, 2009; Norman & Hyland, 2003). These attributes can also facilitate positive relationships between students and CEs, which are key feature of a productive clinical placement environment (Fredrickson & Moore, 2014).

When student anxiety or a lack of confidence impacts on placement progression to the extent that the student is at risk of failing a clinical placement, there is an added burden on the CE to provide increased support (Lo et al., 2017) and potentially for universities to have to source additional placements from the already limited pool of availability (Davenport et al., 2018). Decreasing student anxiety and increasing confidence and preparedness for placements is crucial to optimise chances of student success and lower the burden on CEs and universities.

Simulation-based learning experiences (SBLEs) can be used to decrease student anxiety and increase readiness for clinical placements. SBLE programs involve the replication of aspects of real-life scenarios to facilitate student learning, and involve the creation of a safe learning environment where skills can be acquired and practiced whilst minimising risks to the client (Alinier, 2007; Ker & Bradley, 2014). High-fidelity SBLEs, which most closely mimic the real-world environment, are an effective way of creating emotional changes in participants by allowing students to engage in the emotional and interpersonal aspects of clinical practice (Roberts & Greene, 2011). High fidelity SBLEs can work to decrease anxiety through the habituation process, which allows participants to experience the source of their anxiety, such as the clinical placement environment, in a safe, successful, and supported context, so that repeated exposure can elicit lower anxiety and increased confidence over time (Benito & Walther, 2015).

In principle, university programs are generally supportive of increasing the use of SBLEs in their courses; however, the barriers of financial costs, access to facilities and infrastructure, availability of training and staff, and timing of delivery within already busy curricula often hinder implementation of these programs (Al-Ghareeb & Cooper, 2016; MacBean et al., 2013). The availability of ready-made, commercially available SBLE programs is a facilitator of their uptake (Dudding & Nottingham, 2018), however these may not be readily transferable between educational institutions due to mismatches between learning objectives and curricula or available resources and infrastructure (Al-Ghareeb & Cooper, 2016). To better facilitate the implementation of SBLEs there is a need to explore the modification of existing programs to better suit budgets, facilities, staffing, available time, and learning objectives of a range of university courses at different institutions.

As part of the Embedding Simulation in Clinical Training in Speech Pathology project, the University of Queensland (on behalf of Speech Pathology Australia) designed a 5-day SBLE program for SLP students. The program uses standardised patients, presenting with a range of acquired communication and swallowing disorders, in a simulated adult hospital setting (Hill et al., 2018). The program was investigated as part of a large randomised controlled trial (RCT) exploring its use as a replacement for a portion of clinical placement days across six Australian university sites. The RCT measured student performance on an evaluation of clinical competency at the midpoint and end of the students’ clinical placements. No difference was found in the development of clinical competency between students who completed the SBLE program with a shorter clinical placement and those who attended a traditional, full length clinical placement (Hill et al., 2021). Prior to the RCT, a 1-day pilot of some of the program’s simulation activities was completed by six SLP student participants. These students described feeling more confident and less anxious about clinical placements after participating in these activities (Penman et al., 2020a). Additionally, a small study with 13 SLP student participants explored student perceptions of the SBLE program and found that they perceived it to be a useful preparation for clinical placements (Penman et al., 2020b). However this study collected only qualitative data on student perceptions of the SBLE as described in focus groups and interviews.

Using a mixed-methods approach, the present study aims to contribute further evidence on the use of this SBLE program specifically as student preparation for clinical placements. It does this with a larger participant cohort than previous research, and with the inclusion of self-rated quantitative measures of student anxiety, confidence, and sense of preparedness, in addition to qualitative data collection on these topics. In acknowledgment of the previously mentioned barriers to the use of SBLEs, a modified, less resource-intensive version of the SBLE was also investigated for the same purpose. The following research questions were addressed in the present study:

• Does an existing 5-day SBLE, using standardised patients in a simulated adult hospital setting, create significant changes in SLP student anxiety, confidence, and sense of preparedness for clinical placements?

• Can comparable changes in student anxiety, confidence, and sense of preparedness be elicited for SLP students through completion of a 2-day version of the SBLE?

• Does modification of the SBLE from a 5-day to a 2-day program significantly compromise student satisfaction with the learning experience?

A cost analysis of each version of the SBLE program was conducted to provide context for the financial requirements of running the program as a potential barrier to its use.

Method

Research design

A convergent mixed-methods design was used where both quantitative and qualitative data were collected, analysed separately, then used together to answer the research questions (Creswell & Creswell, 2018). Quantitative data were collected from student participants in the form of pre- and post-SBLE program questionnaires, and qualitative data were collected from both student and CE participants through focus groups after the SBLE program and later after the completion of the students’ subsequent clinical placements. The Edith Cowan University (ECU) Human Research Ethics Committee granted ethical approval for this study (project code 20868).

Recruitment and participants

Student participants

A convenience sample was used, consisting of undergraduate SLP students enrolled in third-year clinical placement units in the 2018 and 2019 academic years at ECU. Students were in their third year of a 4-year degree. All students who were enrolled in the clinical placement units were invited to participate in the SBLE program and in the research with no exclusion criteria. Participation in the SBLE program was offered as a non-mandatory coursework component and research participation was voluntary, so students were able to complete the SBLE program without participating in the research. Participants were invited via email using their student email and verbal invitations given in class.

Group 1 participants (n = 16) from the 2018 cohort participated in the original 5-day version of the SBLE. This cohort had a mean age of 27 years (range 20–47 years). Group 2 participants (n = 17) from the 2019 cohort participated in the modified 2-day version of the SBLE and had a mean age of 31 years (range 20–49 years). All participants across both groups identified as female. Participants represented 95% of eligible third year students enrolled in clinical placement units in both 2018 and 2019.

Clinical educator participants

Three SLP CEs participated in the study in 2018 to provide a CE perspective regarding student anxiety, confidence, and preparedness for clinical placements after participation in the SBLE. Characteristics of these CEs and their level of participation in the program, with regards to facilitation of the SBLEs and student supervision on clinical placements after the SBLE, is outlined in Table I.

Table I. Clinical educator participant characteristics.

Clinical educator participant	Years of experience		Facilitation of SBLE^a		Supervision of students post-SBLE
	SLP	Student supervision	5-day	2-day
CE1	30	25	✓		✓
CE2	8	3	✓	✓	✓
CE3	2	1			✓

^a SBLE = simulation-based learning experience.

Interventions

Group 1 student participants completed the 5-day SBLE program during the intersemester break in the 2018 academic year in its original format from Hill et al. (2018). Third-year SLP students at ECU complete an adult clinical placement in one semester and a paediatric placement in the other semester, with about half the cohort in each placement at a time. Due to the midyear scheduling of the SBLE program in 2018, seven participants had already completed an adult clinical placement in the first semester with the remaining nine having completed a paediatric placement. Group 1 students then went on to complete the alternate placement (i.e. adult or paediatric) in the subsequent semester.

Group 2 student participants completed the 2-day version of the SBLE program in 2019, which was modified based on feedback and discussion with SLP academic staff (including the placement coordinator), CEs, and student participants from Group 1. Modifications primarily involved the removal of simulation activities involving dysphagia management, as this was not a focus of third-year clinical placements at this university. The program was run twice during the academic year in 2019 at the commencement of each semester, so Group 2 participants completed the 2-day program immediately prior to their adult clinical placement.

Both participant groups completed the SBLE program within the ECU Health Simulation Centre in a simulated hospital ward to increase environmental fidelity. Professional actors were used in the role of patients to heighten patient fidelity.

Data collection and measures

Anxiety, confidence, and preparedness

Quantitative measures of student self-reported anxiety, confidence, and sense of preparedness for clinical placements were taken from the research protocol of the pilot of the original SBLE program (Penman et al., 2020a). The pilot study used measures developed specifically for the evaluation of the original 5-day SBLE program based on a literature review and expert opinion (Penman et al., 2020a).

Participants in the current study completed the measures at the commencement of the program on day one, and again at the end of the final day.

Participants were asked to rate their anxiety on a 5-point scale in response to a single item, “how anxious do you feel about working with adult clients?,” with response options of 1= not anxious, 2 = slightly anxious, 3 = moderately anxious, 4 = very anxious, and 5 = extremely anxious.

Participants were asked to rate their confidence regarding a range of skills and clinical behaviours, divided into six clinical areas, foundation skills, case history taking, interaction with others, language, speech, and swallowing, with between four to 12 items in each area. Ratings were on a 5-point scale with response options being 1 = not confident, 2 = slightly confident, 3 = moderately confident, 4 = very confident, and 5 = extremely confident. The confidence survey is included in the Supplementary Material.

Participants were asked to rate their sense of preparedness on a 5-point scale in response to a single item, “how prepared do you feel to work with adult clients?,” with response options of 1 = not prepared, 2 = slightly prepared, 3 = moderately prepared, 4 = very prepared, and 5 = extremely prepared.

Simulation design scale—student version (SDS; Jeffries & Rizzolo, 2006)

Participant perceptions of the SBLEs and satisfaction with the program were measured using the SDS, which is a reliable and valid measure of participants’ judgements about a simulation program (Franklin et al., 2014). Student participants completed the SDS at the conclusion of the final day, after completing the quantitative measures of anxiety, confidence, and preparedness. This tool asks participants to rate their perceptions of the SBLE program on twenty items across the areas of objectives and information, support, problem solving, feedback/guided reflection, and fidelity (realism). Items are rated on a 5-point scale of 1 = strongly disagree, 2 = disagree, 3 = undecided, 4 = agree, and 5 = strongly agree.

Focus groups (student participants)

Qualitative data were collected from student participants via multiple semi-structured focus groups. The first focus groups were held at the conclusion of the final day of the SBLE program for each group, after quantitative measures had been completed. Second focus groups were then held approximately 12 weeks later at the conclusion of subsequent clinical placements for each group. Focus groups for Group 1, who completed the 5-day SBLE, were divided into those who had an adult or paediatric placement scheduled in the following semester. Focus groups for Group 2, who completed the 2-day SBLE, were conducted with all participants who had completed the SBLE program that semester. Each focus group consisted of four to eight participants, with 29 of the 33 student participants attending at least one focus group.

Focus groups were facilitated by academic staff who were not involved in the facilitation of the SBLE program or in the direct grading of the third-year student cohort that semester. Following guidelines proposed by Gill et al. (2008), facilitators were given a schedule of broad questions to generate discussion but were encouraged to use flexibility to follow leads or topics raised by participants.

Debriefs and interviews (CEs)

CE1 and CE2 participated in a daily debrief with a member of the research team at the conclusion of each day of the 5-day program. CE1 and CE2 also participated in a joint interview after supervising some student participants from Group 1 on their subsequent adult clinical placement. CE3, who supervised some Group 1 participants at an adult hospital site clinical placement, participated in an individual interview at the conclusion of the clinical placement.

Data analysis

Quantitative data

Quantitative data were extracted from the measures using scores of 1–5 for the responses to questions along the 5-point scales. One item in each category of anxiety and preparedness was rated by participants with a maximum score of 5 on each item. Confidence scores were calculated for each of the six clinical areas by aggregating scores on the items in that area, with maximum potential scores between 20 and 60 across the six areas. An overall total confidence score was calculated, out of a potential maximum of 175, by aggregating scores across five of the clinical areas, with the exclusion of swallowing scores as this content was not included in the 2-day SBLE for Group 2. A total SDS score out of a potential maximum of 100 was calculated using ratings from the 20 items of the SDS. Data were analysed using IBM SPSS (Version 28.0). Descriptive statistics for each participant group were calculated. In each group between one and three participants provided incomplete data due to the non-completion of the reverse of some pages within the forms. Data from these participants were not included for analysis of these measures.

Datasets were checked for normality with pre- and post-SBLE program comparisons of anxiety, confidence, and preparedness made using paired samples t-tests where data were normally distributed, and Wilcoxon signed rank tests where normality of distribution was violated. Differences between Group 1 and Group 2 on pre- and post-SBLE ratings and SDS ratings were explored using independent samples t-tests where data were normally distributed, and Mann-Whitney U tests where normality was violated.

Qualitative data

Audio recordings of focus groups and interviews were transcribed verbatim and analysed using QSR NVivo (Release 1.7.1). Four student focus groups from each participant group were analysed, ranging from 16 to 60 min in duration. Five CE daily debriefs were analysed, one from each day of the  5-day SBLE program, which were 15–37 min in duration. Two post-clinical placement CE interviews, of 10 and 16 min duration, were also analysed. No further data were collected from CE2 after the facilitation of the 2-day version of the SBLE program.

Qualitative analysis was conducted using a qualitative descriptive approach, which focuses on organising and summarising content in a descriptive manner, without attempting to overlay deep or abstract interpretations of participant responses (Sandelowski, 2000). A directed content analysis approach was employed with coding categories in place for anxiety, confidence, and preparedness to answer the first research aim (Hsieh & Shannon, 2005). Focus group transcripts were read and participant comments were allocated to the above themes during the coding process.

Coder reliability was checked with the researcher revisiting earlier coded transcripts and checking for consistency in quantity and nature of codes (Richards, 2009). A second researcher also coded a sample of transcripts and compared these to the initial researcher’s coding, with discussion of variations between researchers to check for any inconsistency, illumination of blind spots, and to overcome any potential individual coder bias (Patton, 1999).

Cost analysis

A cost analysis of both versions of the SBLE program was conducted using the framework utilised within the initial RCT (Ward et al., 2022). This approach included actual costs incurred across the categories of pre-program training, personnel, room hire, equipment, and consumables. Total cost was calculated along with cost-per-student for each version of the program. Comparisons were made between the cost of running the 5-day program at this site compared to the six universities who participated in the original RCT, and between the 5-day and 2-day versions of the program. All costs are reported in Australian dollars (AUD).

Result

Descriptive statistics were calculated for quantitative measures of anxiety, confidence, and preparedness for each group before and after participating in the SBLE program. Descriptive statistics are displayed in Table II.

Table II. Descriptive statistics for measures of anxiety, confidence, and preparedness.

Category (max score)	5-day SBLE (n = 16) Mean (SD)			2-day SBLE (n = 16) Mean (SD)
	Pre-SBLE	Post-SBLE	p value	Pre-SBLE	Post-SBLE	p value
Anxiety (5)	2.63 (1.03)	1.94 (0.57)	.035	2.69 (0.79)	2.25 (0.68)	.035
Foundation skills (55)	29.53 (5.81)	37.53 (4.76)	<.001	33.50 (3.81)	39.00 (4.69)	<.001
Case history taking (35)	14.80 (4.35)	21.73 (3.61)	<.001	18.06 (3.10)	24.63 (4.22)	<.001
Interaction with others (30)	14.94 (3.59)	20.81 (3.37)	<.001	17.25 (3.59)	20.56 (3.90)	<.001
Language (35)	12.88 (6.45)	23.00 (5.82)	<.001	16.31 (4.57)	23.31 (5.31)	<.001
Speech (20)	7.19 (2.88)	12.50 (2.85)	<.001	8.94 (2.32)	13.00 (2.80)	<.001
Swallowing (60)	13.69 (3.40)	35.19 (8.63)	<.001	Content not covered in two-day SBLE
Preparedness (5)	2.31 (0.79)	3.13 (0.72)	.004	2.25 (0.78)	3.31 (0.60)	<.001
Confidence total, excluding swallowing (175)	79.13 (21.10)	116.20 (18.92)	<.001	94.06 (13.49)	120.50 (19.49)	<.001

Note. SBLE = simulation-based learning experience. 

Anxiety

A Wilcoxon signed rank test showed a significant decrease in anxiety ratings from pre-SBLE to post-SBLE for participants in both Group 1 (p = .035) and Group 2 (p = .035). There was no significant difference in levels of anxiety between the two groups either before (p = .659) or after (p = .224) the SBLE program. A Mann-Whitney U test showed no significant difference in the change in anxiety ratings pre- versus post-SBLEs between Group 1 and Group 2 (p = .724).

Students suggested the SBLE program had a noticeable effect on decreasing their anxiety about their upcoming clinical placements. Decreased anxiety, and other similar emotions such as “fear,” “worry,” and “concern” were mentioned frequently by participants from both Group 1 and Group 2: “[the SBLE] definitely took a lot of that fear away. So for [clinical placement] I’m a lot less concerned about that kind of situation, I feel I’ll almost know what I’m walking into” (Student 8, Group 1, 5-day SBLE).

Some students demonstrated insight into the impact that heightened anxiety could have on their learning and performance on a clinical placement, and the role the SBLE played in reducing that anxiety.

It just helps when you actually get to your [placement] if you are not quite as anxious about it, then you’re in a better situation to take on all the things that are happening, rather than just think of myself (Student 27, Group 2, 2-day SBLE).

Similarly, CEs commented on how the SBLEs seemed to reduce student anxiety about clinical placements, and highlighted the importance of anxiety not being the primary focus of students during their placements: “exercises like this are so powerful, because if they do it a few times then their nerves just start to take the back seat instead of the front seat” (CE1, daily debrief day 5).

Confidence

A paired sample t-test found a significant increase in total confidence ratings after completing the SBLE program for participants in both Group 1 (p < .001) and Group 2 (p < .001). Group 2 showed a significantly higher mean baseline level of total confidence before the 2-day SBLE program (p = .025), however there was no significant difference between the groups in mean rating of confidence after the SBLE (p = .538). An independent samples t-test found no significant difference between the change in total mean confidence between the groups (p = .096).

After completing the SBLE program, both groups showed a significant increase in their confidence ratings in all individual clinical content areas covered in the program. Findings remained statistically significant following application of the Bonferroni correction for multiple comparisons.

Participants from both groups talked about having a sense of increased confidence for clinical placements after completing the SBLE program. Students drew direct links between the overall content and experience of the SBLEs and their confidence for their upcoming clinical placements: “[the SBLE] pushed us to our limits and we got out of our comfort zone. I think that’s been good for everyone, to build our confidence” (Student 3, Group 1, 5-day SBLE) and “you get something to take away and work on so you’re a bit more confident when you start that first day [of placement]” (Student 19, Group 2, 2-day SBLE).

During daily debriefs, CEs made multiple references to observations of increased confidence in students across the course of the 5-day program: “you can see the difference already from the start of the week on their confidence levels, I think it’s been fabulous” (CE1, daily debrief day 3).

CEs who supervised some students from Group 1 on their subsequent clinical placement commented on increased confidence in students at the commencement of their placements, compared to previous cohorts of students who had not completed the SBLE program: “in the first couple of weeks the difference that I noticed was that students did come in more confident” (CE3, post clinical placement supervision) and “coming into the placement there was a discernable difference. I thought they had a more holistic overview of the adult placement … that really impacted on their confidence coming in” (CE1, post clinical placement supervision).

Preparedness

A Wilcoxon signed rank test showed a significant increase in sense of preparedness ratings for participants in both Group 1 (p = .004) and Group 2 (p < .001). There was no significant difference in mean ratings of preparedness between the two groups prior to the SBLE program (p = .640) or after the program (p = .463). A Mann-Whitney U test showed no significant difference in the change in preparedness ratings pre– to post-program between Group 1 and Group 2 (p = .445).

The theme “preparedness” was used to code student comments that related to increased readiness for clinical placements, but which were not specifically related to anxiety or confidence. These comments were often broad in nature and focused on general perceptions of readiness. For example, Student 24 (Group 2, 2-day SBLE) stated that “we just feel more prepared now for when we come on prac” and Student 3 (Group 1, 5-day SBLE) described how they would have felt “lost” and “wouldn’t know what to do with myself” if they had to attend a hospital placement without first attending the SBLE, and that the experience had “shown exactly what kind of things [we’ll] be expecting to see.” Student 13 (Group 1, 5-day SBLE) said, “we were better prepared. On the first day we didn’t have to spend too much time on orientation or explaining the hospital structure. We just jumped straight into it.”

After supervising some Group 1 students on a clinical placement that took place after the 5-day SBLE program, observations were made by CEs regarding the students’ improved preparedness compared to previous cohorts. Comments were made regarding their willingness to attempt new clinical tasks and perform clinical skills that had been covered in the SBLE content: “particularly with assessment I felt they were more prepared. And with note writing as well. I think they were quicker at that because they’d had practice on the simulation week” (CE2, post clinical placement supervision).

Student satisfaction

Overall scores on the SDS showed no significant differences in participant perceptions of the SBLE program between Group 1 (n = 14) and Group 2 (n = 13; p = .162). There was no significant difference in the five subcategory scores between groups, except for the objectives and information category, which scored significantly higher amongst Group 2 participants after completing the 2-day program (p < .001).

Student participants were positive about the opportunity to participate in the SBLE program with comments such as “I think it’s the best thing we could have done before going into prac” (Student 15, Group 2, 2-day SBLE). Student and CE participants both praised the high level of fidelity that was achieved, with comments such as “the first one felt so real! I actually thought they’d got someone with dysarthria to come” (Student 18, Group 2, 2-day SBLE), and numerous other statements about the realistic nature of the environment and the standardised patients.

Cost analysis

An analysis was conducted of costs incurred in the implementation of the 5-day and 2-day versions of the SBLE program. Costs are presented in AUD in Table III. The 5-day program incurred a total cost of $10 261. This was above the mean of costs incurred by the six university sites that participated in the RCT investigation of this program as a replacement for clinical placement days ($8077), but within the range of costs across those sites ($4717–$11 425; Ward et al., 2022). For the 5-day program the cost per student ($641) and cost per student per day ($128) were both below the mean for those reported from the RCT sites ($859 per student, $171 per student per day). The total cost for the 2-day program in this current study was $3387, with a cost per student of $211 and a cost per student per day of $105.

Table III. Costs incurred in implementation of the SBLE ($AUD).

	Randomised controlled trial sites mean (range)	5-day	2-day	5-day (minus training costs)	2-day (minus training costs)
Total cost	$8077 ($4717–$11 425)	$10 261	$3387	$6679	$3140
Cost per student	$859 ($683–$1087)	$641	$211	$417	$196
Cost per student per day	$171 ($137–$217)	$128	$105	$83	$98

A substantial cost in the implementation of the 5-day program related to the training of CEs and actors. These costs were also incurred at the RCT sites, as it was the first implementation of the original program. These costs were not incurred to the same degree in the second iteration of the program in the current study, due to the repeat use of previously involved personnel. For a more equitable comparison of costs between each version of the program at ECU, the analysis is also presented without training costs for each version of the program.

Discussion

This study investigated whether an existing SBLE program could be used for the purposes of decreasing SLP student anxiety and increasing student confidence and sense of preparedness for clinical placements. A modified version of the SBLE program, designed to overcome some barriers to implementation, was also investigated to explore whether similar outcomes could be achieved without compromising student participant satisfaction with the program.

This study expands on the findings of Penman et al. (2020b), whose qualitative study found students described feeling more confident and prepared for clinical placements after participating in the original 5-day SBLE program. The present study adds quantitative data from a larger participant group, with results that concur with these previous qualitative findings.

Present study results to answer the first and second research questions suggest that, irrespective of whether the SBLE program ran at its original 5-day or modified 2-day length, both versions resulted in decreases in self-reported levels of placement-related anxiety and increases in confidence and sense of preparedness for clinical placements for SLP student participants. No significant differences were found in the extent of these changes between groups completing each version of the program. The third research question was answered with results finding no significant difference in ratings of student satisfaction with each version of the program.

While the original SBLE program has been found to be a suitable replacement for a portion of clinical placement days without a loss of clinical competence for SLP students (Hill et al., 2021), the present study provides data to support a novel use of this existing resource for an alternative purpose of student preparation for clinical placement. With high levels of anxiety being strongly associated with decreased efficiency of learning (Maloney et al., 2014), poorer performance on assessment tasks (Brady et al., 2018), and poorer student results on clinical placements (Gallasch et al., 2022) there is a clear need to decrease student placement-related anxiety so they can capitalise on the learning opportunities provided and deliver optimal performance on assessment tasks. The present study suggests this specific SBLE program may be used to bring students out of the theoretical panic zone, where learning is compromised, and into the stretch zone, where they can be appropriately challenged by the learning environment (Palethorpe & Wilson, 2011).

Attributes associated with student confidence are often cited as positive contributors to clinical placement success, both for student learning and performance as well as for the development of relationships with CEs (Chipchase et al., 2012; Delany & Bragge, 2009). The increased placement-related confidence reported by participants after completing this SBLE program can be a means of contributing to student preparation for clinical placements. This increased confidence and preparedness can decrease the burden on CEs to provide support to otherwise struggling students (Lo et al., 2017) or the burden on universities to provide additional clinical placements from a pool where demand is beginning to outweigh supply (McBride et al., 2020).

Financial costs, suitability to the curriculum, and access to staff and facilities are all described in the literature to be barriers to the implementation of SBLE programs for universities (Al-Ghareeb & Cooper, 2016; MacBean et al., 2013). This study demonstrates that similar impacts for students can be achieved using a shortened SBLE program, which incurred substantially lower costs and required fewer resources to run. Scheduling complexities were also alleviated with decreased demands on staff availability and fewer consecutive days being needed in the Health Simulation Centre. A substantial portion of the cost for the original implementation of the program was incurred for CE and actor training, which equated to about one-third of the total for the 5-day version. The use of the same personnel the subsequent year greatly decreased costs as the same duration of training was not required. This was a specific advantage of the implementation at this site, it is acknowledged that training costs would be incurred again should new personnel be required.

Limitations and future research

Drawing comparisons between students’ perceptions of anxiety, confidence, and sense of preparedness for clinical placements and subsequent performance on clinical placements was outside the scope of this study. A further research avenue would be to use student performance outcomes from clinical placements to investigate whether the affective change reported by students after participation in the SBLE program translated into increased performance and decreased student failure rates on clinical placements.

The use of quantitative measures which were purposefully developed for the pilot of the original SBLE program is an aspect of this study that limits the generalisability of the results. The use of standardised measures of student anxiety and confidence would allow for more accurate comparison between the results achieved in this study against changes resulting from other strategies used to increase student readiness for clinical placements.

Conclusion

This study identified that an existing SBLE program could be used for a novel purpose: to reduce placement-related anxiety for SLP students, and increase their sense of confidence and preparedness for their clinical placements. The results showed that similar participant outcomes could be achieved using a modified version of the SBLE program to overcome barriers to its implementation, without compromising participant satisfaction with the program. These findings offer a new way that university SLP courses can prepare students for clinical placements to optimise their learning and performance on assessments, and decrease supervisory demands on CEs and universities. Further research could clarify whether these affective changes in students are reflected in improved competency attainment in clinical placements.

Acknowledgements

The authors would like to acknowledge all students and clinical educators who participated in this research. Thanks and appreciation are extended to all those involved in the original Embedding Simulation in Clinical Training in Speech Pathology project, for generously sharing their knowledge and expertise.

Disclosure statement

No potential conflict of interest was reported by the author(s).