"Tell me and I'll forget; show me and I may remember; involve me and I'll understand."
Some attribute this incisive quote to the Chinese and some to American Indians. Regardless, it applies aptly to the charge of supervisors in speech-language pathology and audiology: Instill a culture of ethical conduct in budding professionals by involving them in your own hands-on work.
Various definitions of culture must be considered in the "culture of ethical conduct," including the concepts of knowledge, attitude, and patterns of behavior shared by a group of people. The culture of ethical conduct involves transmission of these ideas through socialization and from one generation to the next. As we think about cultural change in the ethical realm, it is time to let go of the old ways and act upon the ethical challenges we confront today.
Our professions are at the crossroads of embracing a culture of ethical practices fully or facing the alternative—strict regulation by state and federal agencies. It is critical for us to live up to more than minimal standards. The best way to do this is to make ethics a natural part of an emerging professional, modeled appropriately in a "real-world" environment. Passing on a culture of ethical practice to communication sciences and disorders students is the only way to ensure that the professions endure as we know them.
Four Common Considerations
Monitoring student work. Knowing the work of the student is crucial. Although a student may appear competent, or hold a provisional license, the supervising clinician still holds responsibilities to the patient or client. ASHA's "Issues in Ethics" statement (Supervision of Student Clinicians, 2010) provides a compelling reminder that, under Principle I of the Code of Ethics, we hold paramount those whom we serve professionally as clinicians. Therefore, it is critical to have a thorough knowledge of the student, the work he or she is performing, and the tasks that the student is able to perform independently. By monitoring the work of the student, we are honoring the patient who receives the final benefit of the services performed.
Tip: Self-assessment by students is an important component of a supervision model. It helps them understand personal limitations and involves them in the entire process.
Billing. Although client welfare is ultimately the responsibility of the certified supervisor, ASHA recommends professional fees be the same, regardless of whether a student or professional provides the service (ASHA, 2004a). Supervisees must be provided the appropriate amount and quality of supervision, and third-party payers may impose certain specifications when services are delivered by a supervised student clinician. Participation in federal programs such as Medicaid and Medicare places the professional in a fiduciary position—one of trust that quality services are provided and appropriate billing practices are followed. Medicare regulations regarding billing for work completed by students in speech-language pathology is dependent on the specific program (Part A or Part B; ASHA, 2012).
Although line-of-sight supervision is not always required for approved students to provide selected clinical services to Part A patients, 100% supervision in the room is required to serve Part B patients. Medicaid guidance for speech-language pathology services specifically addressing the "under the guidance of" rule may be found in the technical report developed by ASHA (ASHA, 2004b).
Tip: Involving supervisees in the billing process helps them understand their roles and responsibilities in the professional setting. To help students understand the "why" of supervisor conduct, supervisors need to discuss billing responsibilities explicitly with students, patients or clients, and payers.
Performance evaluation. Evaluating student performance can be both rewarding and challenging. In situations in which the student's progress meets or exceeds expectations, usually both parties are pleased. Challenges arise, however, when a supervisee's performance is not up to (the supervisor's) expectations. It is crucial that the supervising clinician consider multiple factors in the latter case. Questions with less complex answers include:
- Is the student's inadequate performance due simply to a lack of experience? The supervising clinician can set the stage to afford more clinical opportunities to the student by, for example, having the student rotate and work with other qualified clinicians, or understanding that the student might gain these experiences at another clinical rotation.
- Is the student's performance due to a lack of foundational knowledge that you know he or she will receive? Occasionally students may require additional coursework to deal with complex cases. In these situations, it is advised that the student be an "active observer," rather than take the lead in the clinical situation. This advice is consistent with clinical certification standards in both speech-language pathology and audiology (Council for Clinical Certification, 2005; 2012).
More challenging situations involve questions such as the following:
- Are there emotional, physical, or psychological barriers that may preclude student learning? In these situations, it is best to confer with the university program. The supervisor need not be alone in developing the solution for the student.
- Is there potential harm to patients/clients or students from student actions? Again, the ultimate responsibility lies with the supervising clinician, and not the student. Although the student may be covered by professionally liability insurance (either through the university or otherwise), it is the responsibility of the supervising clinician to ensure clients' welfare and stop service delivery if warranted. Again, it is advisable to confer with the university program.
What if the student and clinician do not agree on the student's performance evaluation? This challenging situation is not uncommon. Students simply may not understand the depth of the work they are performing. It is critical for the supervising clinician to have a frank discussion as to the "why" of the student's performance, providing as many examples as possible where improved performance is necessary.
Tip: Providing feedback by initiating the discussion with: "I wouldn't be doing my job as your professional supervisor and mentor if I didn't tell you..." can open up a positive discussion with students who require detailed feedback about inadequate performance.
Tip: As with monitoring, the student's self-assessment should lead the supervising clinician to specific areas where student perception and observed clinical skill are not aligned. This self-evaluation helps involve the student in the process.
Preceptor credentials. Supervising clinicians must hold the required credentials for supervision. In nearly all states, the supervisor must have a license to practice from the appropriate regulatory agency. Additionally, supervisors should want to work with students so that the experience is mutually positive. Finally, students seeking ASHA's Certificate of Clinical Competence in Audiology or Speech-Language Pathology must be supervised by clinicians who hold the corresponding credential.
Tip: Some states, or even employers, may have specific requirements regarding credentials of those who provide clinical supervision. These requirements may go beyond those in ASHA's certification standards. ASHA's Special Interest Group 11, Administration and Supervision, the ASHA Board of Directors, and other interested parties are examining the state of supervisor credentialing.
Three Important Considerations
Use of student titles. It is important to identify a student consistently in the work setting, so that patients/clients clearly understand the qualifications of their provider. In speech-language pathology, this typically isn't hard to do, as students hold their student titles until after graduation. Audiology presents some different challenges, however. In some states, audiology externs may be eligible for provisional licensure during the externship experience. This licensure may (or may not) allow the student to use the title of "audiologist." Note, however, that the "AuD" degree designator should not be used until the student has earned the doctoral degree.
It is critical that the student, mentor, and university understand the appropriate and legal use of titles, as well as the AuD designator, as errors could potentially harm a student's eligibility to practice independently in the future.
Tip: Involving students in the discussion of titles at the facility helps them to understand the decision-making process. Assigning the student a task of weighing "What is appropriate for our patients?" gets them involved in the discussion and allows for ownership of the decision.
Dual relationships. Dual relationships can occur when the supervisor has other distinct relationships with the client or the individual being supervised (Carroll, Schneider, & Wesley, 1985). For example, a student or supervisee is also a relative of the supervisor or is in a personal relationship with a client. As professionals, we should heed the complexity that such relationships can impose. The possible negative consequences of dual relationships are impairment of professional judgment, exploitation, and nepotism. Most workplace policies have specific procedures to avoid these and other negative consequences of dual relationships.
Boundary issues may arise when there are conflicts between professional and social duties (Reamer, 2001). One trouble spot can be social networking, which allows students and supervisors to interact beyond the workplace.
Tip: Consider both the positive and negative aspects of social networking opportunities with students, and the timing of these connections. It is recommended that you complete the supervisor/supervisee relationship before interacting on social media.
Accepting gifts from students. Today, most educational institutions have a conflict-of-interest policy to deter academic and clinical professionals from accepting gifts from those in industry. This policy has implications for the supervisor-student relationship as well. Research in social science has revealed that gift giving induces a feeling of obligation to reciprocate (Gouldner, 1960). The reciprocal behavior is unrelated to the value of the gift (Lévi-Strauss, 1969). A concept related to reciprocity is self-serving bias—the common notion among professionals that gifts influence others but not themselves.
Most research has examined gift giving's influence on professional-patient interactions, but we also should reflect on its potential influence in supervision. Student skills need to be assessed objectively throughout the duration of the practicum or externship. In many instances, students may also request supervisors to serve as references for future jobs. Acceptance of gifts from students may impinge on the supervisor's professional judgment, including future professional reference activities.
Tip: Consider instituting a "no-gifts" practice before accepting a student for supervision. This avoids uncomfortable situations in the future.
Ultimately, ethical behavior is not just about staying within one's professional boundaries. It's also about preserving an ethical culture among the next wave of professionals. It's a way to keep the professions viable and strong. And it requires the understanding that supervision is more than a process. It is a commitment to the field.