August 16, 2005 Feature

The Basics of Supervision

Supervision affects the professions of audiology and speech-language pathology at many levels. It is an aspect of the training that every clinician has experienced during graduate preparation. Other supervisory relationships are less commonly encountered, but certainly exist in the professions. These include: supervision of other SLPs or audiologists, of those in other disciplines (i.e., PT, OT), of clinical fellows, of doctoral students in audiology, and supervision of assistants (where state law allows), and of support staff.

Basic Supervision for Graduate Students

Students who are working to become SLPs, audiologists, or AuDs must be supervised in a variety of settings and have experience with clients across the age span presenting with a variety of communication disorders.

For the graduate student, supervision is a process where the learner is guided and supported through clinical training with the goal of developing clinical and professional knowledge and skills. Toward the end of their graduate program, student clinicians are typically assigned by their university's faculty to off-site placements enabling them to obtain diagnostic and intervention experiences with a variety of disorder types.

Supervisors must be cognizant of the limited experience of supervisees and recognize that they are not ready to "hit the ground running" upon arrival at off-campus sites. Supervisees are continuing to learn and are being provided the opportunity to apply the theory learned throughout the graduate curriculum to clinical practice. A key role of the supervisor is to develop skills in students that will enable them to critically evaluate and use new information gained from one sort of diagnostic or treatment experience to another that may pose slightly different challenges.

It is important for externship supervisors to meet with the prospective supervisee before initiating the assignment. Supervisees benefit from knowing the expectations of the supervisor who should, in turn, explore the supervisee's expectations for the experience. This first meeting should provide the participants some sense of what will develop over the time at the site.

If this preliminary meeting determines that the student will be a good match for the culture of the setting and that it could be a positive learning opportunity, then the university will typically establish a contract with the site. The contract should outline the responsibilities of the university and the clinical site and serve to protect all parties. The university will generally have a coordinator of externships (or similar title) who will follow through in setting up the details of the student's experience.

Often these placements are established up to a year in advance of the assignment. Start and end dates are determined and any requirements of the particular setting are reviewed. For example, a hospital setting might require that the student be available to work weekends or that the student have completed coursework in the area of dysphagia. Some settings may be considered best suited for a student who can manage a schedule that changes hour to hour, or some settings may involve patients who are critically ill.

Students should be assigned to practicum experiences after they have had sufficient coursework to support the knowledge needed to work with the clinical population. Direct contact with the client or the client's family in assessment, management, and/or counseling can be counted toward practicum.

Although it is the student's responsibility to maintain a record of the earned hours, it is advisable that the supervisor monitor the number of hours recorded as earned. The university should provide the externship supervisor with information as to the number of hours needed at the placement site and experiences required (e.g., specific patient disorders, ages).

As of 2005, certification standards, including clinical requirements, have been revised by the Council for Clinical Certification (CFCC). As only those professionals who hold the CCC in speech-language pathology or audiology are eligible to serve as supervisors, the importance of maintaining certification is critical.

In the revision of the standards, it is noted that the amount of supervision to be provided is not specifically defined. The student should receive supervision based on the "student's level of knowledge, experience, and competence. Supervision must be sufficient to ensure the welfare of the client/patient."

The Externship Experience

On day one of the externship experience, the supervisee should be provided a thorough orientation to the site including billing procedures, dress code, emergency procedures, paperwork requirements, and the policies and procedures unique to the placement. With this foundation, the supervisor and supervisee can move to the core of what supervision is all about. Anderson (1988) created a model of the supervisory process referred to as the Continuum of Supervision that provides a framework from which the supervisor and the supervisee can view the process together.

Initially, the supervisor should be directive. The supervisee will benefit from specific input and feedback for each client assigned for intervention or diagnosis. The supervisor will be the lead in planning for the needs of the clients with whom the supervisee is working. Typically, this is a comfortable start for the supervisee; however, it is hoped that the student will move through this stage of development relatively quickly.

For many supervisees, the directive role of the supervisor is a comfortable one. The transition to independence can create anxiety. The supervisor is wise to recognize that fact, and be sensitive to any signs of unusual stress exhibited by the supervisee. The desired outcome is that the supervisee moves along the continuum and begins to demonstrate the required clinical and professional skills with increasing independence. It is expected that the supervisee will become more participatory in all aspects of client management and will begin to self-analyze clinical behavior.

In this transition stage, the supervisor provides input and feedback but the tone of the supervisory relationship becomes more collaborative. The supervisee may be able to become more independent when working with clients having some disorder types sooner than with other disorder types (e.g., the supervisee may work effectively in setting short- and long-term goals with children with phonological disorders but may have difficulty establishing reasonable goals for children with autism).

By the end of the externship experience, the supervisor is expected to collaborate in a consultative role with the supervisee. The supervisor listens and supports the supervisee in problem solving. The supervisee manages the case with greater independence; however, the supervisor is ultimately responsible for the primary management of the caseload.

ASHA's position statement relative to Clinical Supervision in Speech-Language Pathology and Audiology (1985) highlights 13 tasks and skills of supervision considered basic to successful clinical teaching. One task, basic to the success of the experience, notes the importance of establishing and maintaining an effective working relationship with the supervisee. Supervision is evaluative and the supervisee is in a position of reduced power in the relationship. Supervisors need to be sensitive to the power differential. The supervisory relationship is a unique one, and because of its fragility, it is usually not beneficial to exert power.

On the other side of the supervisory relationship, it may not be healthy to develop a close "friendship" with the supervisee. The supervisee needs to understand that the supervisor is a teacher and too much social comfort may not allow for objective evaluation. A balance where the supervisor and supervisee are "friendly" and mutually respectful and supportive is optimal.

Other tasks of supervision address the clinical and professional skills required of the SLP or audiologist. Supervisors are encouraged to determine ways to assist the supervisee to address these skills. Demonstrations by the supervisor may be an effective strategy for clinical teaching; however, supervisees need to develop their own clinical style. The goal of supervision is not to create clones. The supervisee requires self-awareness to eventually work independently.

Some supervisees may not recognize their own clinical strengths; others may not recognize their weaknesses. Supervisory feedback is critical to the development of self-awareness and clinical and professional skills. Ongoing oral and written feedback is recommended. Be cognizant that a comment in the hallway between patients may not be understood, remembered-or be confidential. Written feedback provides a lasting record of information provided to the supervisee (and to the supervisor).

Provide a balance of things that the supervisee is doing well with the areas to be targeted for improvement. A long list of things that are not going well will be overwhelming. Schedule regular supervisory meetings to assure understanding of feedback provided. Development of supervisee self-awareness may be enhanced through review of patient/client sessions, and through ongoing planning for future sessions incorporating information from prior sessions.

Evaluation of the supervisee typically follows a schedule provided by the university setting. The supervisor should receive information about the grading process including the evaluation tool. Universities provide a campus contact, and supervisors should feel free to discuss questions and problems with the university liaison. Many universities will have a scheduled visit to the placement to review how the externship is progressing. At that time, any concerns of the supervisee or the supervisor should be discussed. It is not the off-site supervisor's responsibility to manage difficulties with the supervisee independently. The university liaison will provide support in problem-solving strategies and in managing issues or concerns.

Supervising the Fellowship Experience

Supervisors who are participating in the supervision of a fellowship experience are encouraged to review the SLP Clinical Fellowship Handbook for complete details relative to the management of the fellow. The Clinical Fellowship Report and Rating Scale, which includes the Clinical Fellowship Skills Inventory (CFSI) for Speech-Language Pathology and Audiology, provides ongoing evaluation and direction for the clinical fellow at intervals during the fellowship period.

As in all aspects of the professions, ethical behavior must oversee all actions associated with the supervisory process. The Code of Ethics (ASHA, 2001a) addresses the supervisory process as noted by:

  • Principle I-Individuals shall honor their responsibility to hold paramount the welfare of persons they serve professionally.
  • Principle II-Individuals shall honor their responsibility to achieve and maintain the highest level of professional competence.
  • Principle IV-Individuals shall honor their responsibilities for the professions and their relationships with colleagues, students, and members of allied professions. Individuals shall uphold the dignity and autonomy of the professions, maintain harmonious interprofessional and intrapro fessional relationships, and accept the professions' self-imposed standards (ASHA, 2001a).

The Code of Ethics guides supervisors to continually assure that the patient is optimally served, that supervisees are provided quality supervisory input, and that the supervisee is respected throughout the experience.

Wren S. Newman, is program director at the Programs in Communication Sciences and Disorders at Nova Southeastern University in Davie-Fort Lauderdale, Florida. She is the Coordinator of Division 11, Administration and Supervision. Contact her by e-mail at newmanw@nova.edu.

cite as: Newman, W. S. (2005, August 16). The Basics of Supervision. The ASHA Leader.

Supervisory Scenarios

#1. You are a SLP at an outpatient rehab facility and the supervisor of a clinical fellow (CF) who began at your site approximately three months ago. You have designed a caseload for the CF providing a variety of experiences with pediatric clients. The CF works effectively with several clients with articulation and/or language delays but problems arise when the CF works with a small group of children on his schedule who have been diagnosed with autism. The CF indicates "the children are not sitting through the session nor are they interested in the activities I am presenting." You schedule a meeting with the CF and explain that he is working independently with some disorders but children with autism present some unique challenges. You collaborate on a plan to address specific areas needing development-establishing alternatives to extended periods of sitting, and establishing activities to address targeted objectives based on the interests of the children. You observe a few sessions and note improvement in the children's participation based on these modifications. The CF leads the next meeting with you and recognizes the positive changes. He correctly identifies other areas to address in the planning for the children.

How was this situation successfully managed? What other strategies might be considered?

#2. You are a full-time audiologist working at a large metropolitan hospital. You have agreed to supervise an AuD student from the state university. The student is scheduled to work with you in the newborn hearing screening program in addition to several other assignments. Screenings are scheduled for 6 a.m. three mornings a week. The student has arrived late for four of six scheduled screenings. You meet with the student and tell her that she must arrive at the site by 5:45 on the mornings of the screenings as a requirement for successful completion of the experience and follow up with a memo indicating the same information. The following week the student arrives late again saying, "it's just too difficult for me to get here by 6 a.m." You contact the faculty liaison for externship experiences for strategies on managing the problem from this point.

Should the supervisor have contacted the university? How might that be a solution to this situation?



Medicare/Medicaid: Student & CF Supervision

Keep in mind that many private health plans and state Medicaid programs selectively adopt Medicare coverage policies.

Medicare Supervision of Students.  In 2001, the Centers for Medicare and Medicaid Services (CMS) determined that student-assisted outpatient (Part B) speech-language pathology and audiology services are covered only when the "qualified practitioner is present and in the room for the entire session…directing the service, making the skilled judgment, and is responsible for the assessment and treatment" and "is not engaged in treating another patient or doing other tasks at the same time." For Part A services in a skilled nursing facility, the patient and the student must be within line of sight of the supervisor. There are no specific rules for other Part A settings. While students may enter notes in the patient's medical record and sign them, the supervisor's counter-signature is always required. 

Medicare Supervision of Clinical Fellows.  A clinical fellow (CF) is fully qualified under Medicare if state-licensed.  Many states issue temporary, provisional, or interim licenses to CFs. For those states in which licensure is not granted to CFs, there may be a predicament because Medicare (1) does not consider the CF a student and (2) does not cover speech-language pathology or audiology services rendered by support personnel or assistants.

State Medicaid Programs

Students: Each state is free to adopt its own policy regarding coverage of services by students.

Clinical Fellows: Federal Medicaid regulations consider CFs fully qualified, thus no additional supervision requirements apply. If a state requires licensure to practice but does not allow licensure of CFs, the CF services could be covered under the federal Medicaid regulation that allows services to be rendered "under the direction of" a qualified SLP or audiologist. Although each state is free to determine the supervisory conditions for "under the direction of," CMS has outlined its expectations, which include the supervisor's responsibility to be familiar with each case, and see the patient at the beginning of treatment and periodically throughout. The expectation is that supervisors take professional responsibility for services provided under their supervision.

—Mark Kander, ASHA's director of Health Care Regulatory Analysis



References

American Speech and Hearing Association. (1978). Committee on Supervision in Speech-Language-Pathology and Audiology. Current status of supervision of speech-language pathology and audiology [Special report]. Asha, 20, 478–486.

American Speech-Language Hearing Association. (1985). Committee on supervision in speech-language pathology and audiology. Clinical supervision in speech-language pathology and audiology. A position statement. Asha 27, 57–60.

American Speech-Language Hearing Association (2003). Code of ethics (revised). ASHA Supplement 23, 13–15.

Anderson, J. (1988). The supervisory process in speech-language pathology and audiology. Boston: College-Hill.

McCrea, E.   S., & Brasseur, J.   A. (2003). The supervisory process in speech-language pathology and audiology. Boston: Pearson Education, Inc.



  

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