Many challenges and opportunities arise when a client and a student clinician share a language not spoken by the clinical educator who supervises the student clinician. Can a clinical educator meet the needs of both the student clinician and the client when supervising clinical interactions in a language he/she does not speak or understand?
Lauren Muckleroy (left), a monolingual SLP in the Fort Worth Independent School District, provides supervision to Sylvia Bilton, a bilingual speech-language pathology assistant.
Clinical educators (a term that encompasses speech-language pathologists and audiologists in a variety of clinical and academic environments) who supervise student practica are required to serve many roles as they meet the needs of a constantly changing stream of students and clients. According to the ASHA Position Statement on Clinical Supervision, "Effective supervision facilitates the development of clinical competence in supervisees at all levels of practice, from students to certified clinicians. Clinical supervision is a collaborative process with shared responsibility for many of the activities involved in the supervisory experience" (ASHA, 2008).
Additionally, the supervisor helps the student clinician transfer skills learned in one clinical experience to similar cases that give rise to new considerations (Newman, retrieved 2011). The supervisor serves as guide, mentor, facilitator, and often friend. The ability of an English-speaking clinical educator to fulfill these and other roles is challenged when clients and student clinicians speak languages other than English.
However, many opportunities for clinical training, particularly as related to multicultural clients, unfold when the student clinician speaks a language in addition to English. The impact of multilingual interactions on clinical educator, student clinician, and client relationships can be significant and require thoughtful attention to a variety of issues depending on who speaks which language(s).
The issue of whether a monolingual supervisor can meet the needs of a bilingual student clinician can be examined by merging best practice in supervision with concepts of non-biased assessment and treatment.
A Collaborative Relationship
Clinical educators have many supervisory and clinical skills that shape their relationships with student clinicians. Given that many professional clinicians feel inadequately prepared to work with culturally and linguistically diverse (CLD) clients, particularly those who speak a language other than English (Kritikos, 2003), supervisors may believe they cannot adequately meet the needs of either the client or the student clinician in a context in which he/she does not share the language spoken by the client and student clinician. In actuality, this context presents an opportunity for a truly collaborative relationship between the student clinician and the supervisor.
Most importantly, the clinical educator can collaborate with the student clinician to implement best-practice procedures for working with a non-English-speaking client. In the ideal situation, the first step would be to identify a speech-language pathologist or audiologist who speaks the client's language (ASHA, 1985) and to whom the client can be referred or who can supervise the clinical experience. If—as is often the case—a bilingual professional is not available or the nature of the client's communication disorder is not within the bilingual professional's scope of practice, then the student clinician and clinical educator must implement non-biased assessment and treatment. This process requires that both the supervisor and student clinician be knowledgeable about non-biased procedures.
There are many resources that the supervisor can review with the student clinician in preparation for the student's clinical work (e.g., ASHA, 2004; Goldstein, 2000; Roberts, 2001; Roseberry-McKibben & O'Hanlon, 2005). Also, because clinical educators become familiar with the communities they serve, the supervisor's prior experiences evaluating individuals from the client's CLD population will help in the preparation process. Given that training programs vary in their approach to multicultural training (Horton & Muñoz, 2010; Stockman, Boult, & Robinson, 2008), it is important to understand the nature of the student's prior preparation in multicultural issues as related to both general principles and specifically to the needs of the client at hand. In this instance, the clinical educator should help the student clinician learn and apply non-biased practices in the context of the student's prior clinical and academic experiences.
However, it may be the student clinician who enhances the knowledge and skills of the clinical educator. A student clinician with specific academic and clinical multicultural preparation, for example, can share that information with the supervisor. Also, the student clinician may act as a cultural-linguistic informant, allowing the team to make an assessment or design a treatment plan that is sensitive to the cultural norms of the client. An informant provides insight into the impact of the impairment on the client's communication skills and makes informed judgments regarding the client's speech and language structure (ASHA, 2004). The student clinician, serving as informant, also may advise on necessary cultural-linguistic modifications to existing tests, assessments, and procedures.
Clinical Educator/Student Clinician/Client Relationship
Because of the nature of the language barrier, the relationship between the clinical educator and the client will need to be, in part, mediated by the student. The student typically will provide direct services to the client in the client's language, and may interpret that information to the supervisor in real time and/or in a debriefing after the session for the supervisor to be able to guide the student's clinical decision-making. Videotaped clinical sessions may be reviewed afterwards as needed to enhance both the supervisor's and the student's understanding of student clinician and client behaviors.
As a result of these discussions and reviews, the monolingual clinical educator often improves his/her ability to identify and provide direction in treatment paradigms (e.g., stimulus ð response ð consequence), particularly when targeted communication behaviors are more easily identified (e.g., fluent speech, voice behaviors). The supervisor must use his/her knowledge of non-biased assessment/treatment and general principles related to the client's communication needs to ask questions that guide the student clinician's understanding and interpretation of the client's skills.
However, it is important to recognize that the supervisor–client relationship is not wholly mediated by the student. To foster a positive experience for the student clinician, the client, and the client's family, the clinical educator should maintain the leadership role on this clinical team and avoid perceptions that the student clinician is in charge. The supervisor can use nonverbal communication, such as appropriate eye contact, gestures, and body posture, to build a rapport with the client. Additionally, the supervisor's knowledge of normal and impaired communication can be used to generate hypotheses regarding the client's strengths and weaknesses that then can be compared with the student's observations.
Roles and Responsibilities of a Clinical Educator
Developing clinical competence and fostering the transfer of knowledge for student clinicians often requires specific guidance and feedback. Although observing sessions in a language one doesn't speak presents a unique set of challenges, the roles and responsibilities of the supervisor can still be met. It is important that supervisory processes in this clinical context are in alignment with current clinical certification/licensure and program accreditation standards (e.g., Standard 3.5A and B in the Standards for Accreditation of Graduate Education Programs in Audiology and Speech-Language Pathology: the manner and amount of supervision are determined and adjusted to reflect the competence of each student and the specific needs of the clients/patients served).
However, some modifications of traditional supervision practices may be required; for example, being in the room during the session affords the supervisor the opportunity to ask clarifying questions in order to make immediate adjustments to the student clinician's plans. Moreover, the supervisor's presence also demonstrates to the client his/her role on the clinical management team. The supervisor also may ask the student clinician to write down for later discussion and interpretation any response that does not match the intended target.
The student clinician and clinical educator may need to meet more frequently to review sessions and make adjustments for future sessions. Ultimately, the supervisor has much to offer in terms of shaping the student clinician's professional behavior and clinical expertise. After the student clinician has completed his/her assignment with the client, it is important for both the supervisor and the student clinician to build on the experience in future clinical interactions. It is more than likely that the bilingual student clinician will be supervised in a variety of work settings post-graduation and that the clinical educator may be supervising future clinician-client dyads that share a language that s/he does not speak. Debriefing about what worked and what did not work will benefit all, especially future clients.