IMPACT OF COVID-19 ON HPE
On April 21, 2021, the forum met in a public session to look at the impact the pandemic had on four areas: the clinical learning environment, high-stakes testing, communication, and faculty development. Issues of diversity, equity, and inclusion; social determinants of health; and stress and burnout cut across all four areas. Participants broke into interprofessional groups to explore the four areas, with the objectives of identifying challenges and opportunities in these areas, discussing what happened in health professions education (HPE) during the pandemic, and exploring how stakeholders within HPE responded to the challenges posed during the initial and later stages of the crisis. On April 22, 2021, the leaders of each breakout group presented summaries of their small group discussions during a public workshop. The presenters focused on discussing areas of opportunity for change that were uncovered during the pandemic, and whether and how these changes could be sustained into the future.
Experiential Learning
The pandemic, said Pamela Jeffries, The George Washington University School of Nursing, introduced opportunities to expand the use of clinical learning methods such as telehealth and simulations. To capitalize on this opportunity, there is a need for faculty development in these areas, policy changes to accreditation standards, and alignment with state licensure requirements, said Jeffries. In addition, the clinical learning strategies used during the pandemic need to be evaluated to identify how to best incorporate these models into clinical learning moving forward. The pandemic also served as a wake-up call about the need to better prepare for the next crisis; at the beginning of COVID-19, health educators had to pivot to remote education and clinical learning without any preparation or plans in place. Jeffries said an interprofessional coalition should be created to respond, coordinate, and share information during times of crisis, and to plan and prepare before a crisis. Finally, Jeffries said, the pandemic
highlighted a critical need for greater focus on social determinants, health equity, and health disparities in clinical learning environments. To do so, it will be necessary to integrate these topics into the curriculum in all health professions programs, and to secure funding for new program development, integration of curriculum, and necessary infrastructure changes. All of these changes are sustainable, said Jeffries, but only if “we do not simply revert to pre-COVID practices.”
Testing
Senthil Kumar Rajasekaran, Wayne State University School of Medicine, said the pandemic introduced several opportunities for improving high-stakes testing and making HPE more flexible and responsive. First, remote testing can be expanded so students can take licensing exams at their own institutions. This could significantly reduce costs of student education, and also help with scheduling and access to test dates. Second, there is an opportunity to shift to a holistic admissions process, which places less emphasis on standardized test scores; Rajasekaran noted that many undergraduate institutions are already successfully using this model. Third, COVID-19 presents an opportunity to align high-stakes testing with the competencies learners are expected to have. Traditional testing tends to assess memorization and recall skills, he said, rather than “the learner’s ability to effectively access and use information through clinical reasoning at the point of care.” Finally, there could be a shift toward implementing more low-stakes assessments, which could prepare learners for high-stakes testing, and to report licensing examination results in a pass/fail format. Rajasekaran remarked that all of these changes are sustainable, but will require an investment in technology and ensuring all students have access to technology and an adequate connection to the Internet. In addition, there will be a need for test developers and institutions to align curriculum and assessments. He added that if a similar emergency situation occurs again in the future, there is a need for alternative pathways to licensure such as alternate testing methodologies or temporary alternatives to allow graduates to enter the workforce.
Communication
The pandemic revealed three areas in which communication could be improved in HPE, said Carole Tucker, University of Texas Medical Branch. First, there is a need to strengthen inter-institutional collaboration at the leadership and systems level. Tucker noted that when there is limited clarity on management of a public health crisis at a national level, health professions leaders have an opportunity to step in and provide a
consistent message. However, she said, this will require developing strategic mechanisms to foster deeper inter-institutional leadership. Second, there is a need to evaluate whether and how technologies employed during the pandemic met the needs of diverse groups of learners. For example, certain changes were forced upon educators due to pandemic physical distancing restrictions that demonstrated the continued value of technology for communication such as virtual “office hours.” Third, there is a need to look for flexible solutions to encourage and facilitate spontaneous interactions. During the pandemic, said Tucker, there was a lack of impromptu, informal conversations among faculty and students. A focus on these three areas moving forward could improve communication among HPE stakeholders.
Faculty Development
While there were many challenges brought by the pandemic, it also opened up opportunities for change and innovation, said Reamer Bushardt, The George Washington University School of Medicine and Health Sciences. Participants in Bushardt’s group described five areas in which the lessons of the pandemic could be leveraged to improve faculty development. First, “the world opened up” for development, connection, and engagement among faculty, both nationally and globally. Second, there was a dismantling of some of the logistical challenges to interprofessional education, and uptake of digital solutions to student collaboration. Third, the pandemic brought increased attention to faculty and student burnout and the need for investments in self-care and wellness. Fourth, the pandemic forced modifications of curricula (e.g., clinical skills development and experiential learning), with a focus on the most essential competencies. Fifth, the pandemic amplified the need for training in difficult conversations and action around diversity, equity, and inclusion, and the need to create and sustain safe learning environments for all students. Bushardt said these changes are sustainable, but it will require gathering evidence about what is and is not effective, retaining effective virtual and hybrid approaches, sustaining the “spirit of collaboration” across institutions, and empowering leadership to prioritize and integrate diversity, equity, and inclusion into institutional culture.
DISCUSSION
After the synopses of the previous day’s reflections were presented, workshop participants discussed and reacted to these reflections through a structured discussion about the impact of the pandemic in different health professions. Jody Frost, National Academies of Practice, and Miguel Paniagua, National Board of Medical Examiners, guided the conversation
by asking questions of four speakers: Dawn Mancuso, Association of Schools and Colleges of Optometry; JaNeen Cross, Howard University; Loretta Nunez, American Speech-Language-Hearing Association; and Clese Erikson, The George Washington University. The questions mirrored the four areas from the reflection session: experiential learning, testing, communication, and faculty development.
Experiential Learning
Frost began by asking “What [type of] supports proved helpful to academic programs in effectively transitioning and modifying clinical experiential learning opportunities during the pandemic?” Mancuso responded from the field of optometry saying programs shut down in-person learning in March 2020, at which time faculty realized new approaches and resources were needed to continue their learners’ education. In response, the Association of Schools and Colleges of Optometry (ASCO) created an online library of resources for members to use. The association also convened weekly meetings of the deans and a diverse group of faculty members to discuss and share resources and learning models. In addition, ASCO partnered with the American Academy of Optometry to develop and distribute a series of clinical training videos; these videos were released over the course of 28 weeks and ultimately resulted in a library of more than 200 videos available to the optometric education community.
Cross reported that at Howard University School of Social Work, social work educators were able to maintain agency-based experiential learning through a flexible approach. The rules about placements were broadened so students could identify agencies in their own states that were a good fit, rather than being required to work at a DC-based agency, said Cross. In addition, in accordance with the Council of Social Work Education’s COVID-19 guidance, the overall required hours were reduced, and those required hours were supplemented with online training modules and case studies.
Nunez said the certification body for audiology and speech-language pathology provided accommodations to allow flexibility in clinical learning and for using telehealth and simulations. The American Speech-Language-Hearing Association quickly disseminated best practice resources through town hall meetings and their website, including information on reimbursement and regulation changes related to telehealth, and infection control practices and the use of personal protective equipment. In addition, the Council of Academic Programs in Communication Sciences and Disorders supported faculty by providing webinars on best practices for teaching telehealth and the use of simulations. Erikson expanded on the notion of using simulation for clinical learning, saying it is an example of a practice
that should be continued beyond the pandemic. She relayed a story from a psychiatric residency program director who found more candid discussions during simulated exercises. For example, actors seemed to feel more at ease in giving candid feedback to learners than real patients in traditional experiential learning settings, particularly surrounding topics like race and racism. This is an opportunity, she said, to incorporate pandemic-era practices for improving “our ability to provide high quality care that focuses on equity and disparities.”
Testing
For the second part of the discussion, Frost noted that testing during the pandemic was either cancelled or severely restricted. She asked speakers if the pandemic had an impact on admissions testing or licensure exams in their professions. Nunez responded that many programs in audiology and speech-language pathology had already been moving toward a more holistic admissions process with less reliance on standardized admissions tests. When testing was disrupted, some programs chose to either omit or waive the requirement for test scores, while other programs weighted the scores differently relative to other admission criteria. The licensing exams for audiology and speech-language pathology are administered by the Educational Testing Service (ETS), said Nunez, and because of the infrastructure of ETS, it was able to quickly modify processes to provide alternative administration of tests. For example, ETS offered limited in-person testing that followed health and safety protocols, and also arranged for students to be able to take tests on their own computer while being monitored by an online human proctor.
Mancuso reported on how testing was impacted in the optometry profession. She said there are both computer-based tests as well as clinical skills exams, which are required for licensing. The computer-based tests were repeatedly cancelled and rescheduled as the pandemic shifted, and this resulted in some students having to travel hundreds of miles and cross state lines to take required exams. The clinical skills exams are offered in only one location in the country, said Mancuso. The National Board of Examiners in Optometry (NBEO) created a task force to look into alternative testing mechanisms, but concluded “there were no acceptable alternatives that wouldn’t impact negatively on test security or reliability and validity.” As a result, students were required to travel from around the country in the midst of a pandemic. However, she said, NBEO did shift its practices and hours in order to accommodate test takers while respecting health and safety protocols.
Communication
Frost asked the speakers to describe some of the ways communication was used effectively by education leadership to inform and assist faculty and students. Good communication, said Cross, is routine, regular, clear, and transparent. During the pandemic, it was critical to have good communication about the operations of campus, changes to policies, available resources, and health and safety protocols. This was achieved through regular email messages, faculty meetings, virtual town halls, and other approaches, she said. In addition to communication from leadership to others, it was important to also listen to the needs of faculty, staff, and students through evaluations and surveys, and then to provide the resources necessary to meet these needs. For example, said Cross, the school connected faculty and students with the local community for additional support and counseling services. Erikson added another important component to communication, which is ensuring there is a diverse and representative set of perspectives working on communication. She further noted why this is critical: first, to identify and consider the needs of the diverse community, and second, to change the institutional culture by challenging the systemic racism that has persisted for too long.
Faculty Development
The final question Frost asked the speakers was how faculty could have been better prepared to transition in the midst of a pandemic. Erikson began by saying burnout among faculty, students, and providers was a big issue even before the pandemic, and the pandemic highlighted a critical need for more resources and training in this area. Nunez agreed and said faculty would have benefited from more thoughtful preparation on managing their own self-care and work–life demands during the pandemic. Additionally, faculty needed resources and support to help students who were experiencing high stress levels and mental health issues. Cross concurred with both Erikson and Nunez, and said that moving forward, there is a need for schools to “start the semester off with self-care at the forefront,” and to incorporate self-care and mental health awareness throughout the year. She also pointed out there are opportunities for HPE schools to partner with communities and researchers to promote well-being among faculty and staff, to further the evidence in this area, and to improve provision of services. In addition to the issues surrounding burnout and well-being, Nunez added, faculty needed support for shifting to online and hybrid learning models, for developing skills to guide learners in the use of telepractice, and for effective use of simulations.
Final Thoughts
Frost asked each speaker to share one critical take home message. Nunez said one lesson learned is the need for building greater capacity for clinical education, including a more diversified repertoire of educational methods and opportunities. The pandemic, said Erikson, presented an opportunity to try out “a whole new host of things that a lot of people have been advocating for,” for example, reducing the emphasis on testing results as a way to diversify the student body. However, moving forward there is a need for research on the long-term outcomes of these types of shifts. Mancuso said there is a need for stakeholders from all health professions to work together to identify what worked and what didn’t work, and to prepare a “game plan” for the next crisis so the same challenges aren’t repeated. The pandemic “threatened our peace of mind” and emphasized the importance of self-care support and resources, said Cross. If we capitalize on this lesson learned, we can be “better coming out of this pandemic” than where we started, she said. Frost closed with an observation that we can make “lemonade out of lemons.” The pandemic presented an opportunity to learn from an unexpected situation, take the best of what happened, and use these lessons to transform HPE.
