Clinical Education and the Professions

By: Wren Newman, SLP.D, CCC/SLP, Nova Southeastern University

See also: Scenarios for Consideration The Role of Clinical Education Resources for Supervision

Speech-language pathologists and audiologists have been involved in clinical education since the beginning of the profession. Indeed, education seems to have been the one component that has affected everyone in the profession at some time (ASHA Committee on Supervision in Speech-Language Pathology and Audiology, 1978a).

Clinical education is a component of the professions of speech-language pathology and audiology at many levels. It is an aspect of the training that every speech language pathologist (SLP) and audiologist has experienced during his/her clinical preparation. Other supervisory relationships are less commonly encountered, but certainly exist in the professions. These include

• supervision of other SLPs or audiologists,
• supervision of those in other disciplines (i.e., PT, OT),
• supervision of doctoral students in audiology,
• supervision of assistants (where state law allows), and
• supervision of support staff.

Wren Newman, SLP.D Program Director Nova Southeastern University Steering Committee Coordinator for Special Interest Division 11: Administration and Supervision

The information included here will focus on the supervision of graduate student clinicians and clinical fellows and is directed to supervisors who may be supervising for the first time or who are interested in additional information that may be of assistance relative to the supervisory process.

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

Standards

As of 2005, certification standards including clinical requirements have been revised by the Council For Clinical Certification (CFCC) and supervisors are referred to this link for additional information.

Supervision of Graduate Students

For the graduate student and clinical fellow, supervision is a process where the learner is guided and supported through his/her clinical training with the goal of developing clinical and professional knowledge and skill. Graduate student clinicians often obtain their first clinical experiences at an on-site university clinic.

General Timeline/Process

• Clients/patients are assigned by the program's clinic director and generally the patient load for each student is considered to be "light" (students may have a caseload of 3-6 patients to begin their clinical training).
• Subsequent to the initial experiences in the university setting, graduate students are generally placed in off-site full-time placements enabling them to further develop clinical skills, experience a more "real-world" schedule, obtain clinical experiences in a variety of settings, and obtain the remaining diagnostic and intervention hours necessary to meet certification requirements.
• Typically, students are assigned to externship placements toward the end of their graduate program. Supervisors must be cognizant of the limited experience of supervisees and recognize that the student is not ready to "hit the ground running" at the initiation of any clinical experience. The supervisee is continuing to learn and is being provided the opportunity to apply the theory learned throughout the graduate curriculum to clinical practice.
• Graduate students should be assigned to practicum experience after they have had sufficient coursework to support the knowledge needed to work with the clinical population. Only direct contact with patient/client or the patient's/client's family in assessment, management, and/or counseling can be counted toward practicum.

Clinical Teaching vs. Classroom Teaching

Clinical education/clinical teaching differ from classic classroom teaching in a few ways:

• Clinical teaching is generally one supervisor with one graduate student clinician or one supervisor with a small group of graduate student clinicians. Sometimes, the supervisor will be assigned one graduate student extern to spend an extended period of time working with the supervisor (a semester), sometimes a graduate student will be assigned for part of a day once or twice a week.
• In a university setting, the supervisor may be assigned to supervise several students but will generally spend some time working individually with each graduate student extern. This is a different teaching scenario than that of the classroom where a professor's goals are centered on a larger group of students reaching defined competencies within a specific content area.
• In the clinical supervision area, graduate student clinicians may work with a variety of patients/clients across disorder types/ages. To some degree, clinical supervision works on the premise that the supervisee is working in a "criterion-referenced" paradigm.
• The supervisee works at his/her own pace and works to achieve target competencies.

Role of the Educator

A key role of the clinical educator is to develop skills in the student that will enable him/her to critically evaluate and use new information gained from one sort of diagnostic or treatment experience to another that may pose slightly different challenges.

Requirements of the Clinical Educator

• Only those professionals who hold the Certificate of Clinical Competence in speech-language pathology or audiology are eligible to serve as supervisors or clinical educators. Maintaining certification is of critical importance to the supervisory role.
• In the revision of the standards for certification, it is noted that the amount of supervision provided to the supervisee is not specifically defined for audiology; however, a minimum percentage of direct real time supervision is indicated. (Standard IV-E)
• The graduate 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."
• It is advisable that the supervisor monitor the number of clinical hours earned, although it is the student's responsibility to maintain a record of the earned hours.

Although ASHA has moved away from specific hour requirements within each disorder area, licensure requirements in many states have not changed to match requirements for clinical certification. Graduate student clinicians need to visit the ASHA Web site and become familiar with the particular state requirements that apply.

Orientation to the University Clinic

Ulrich (1995; October) has provided information as to the importance of a detailed orientation to the supervisory experience at any given setting. Graduate students at the university setting generally have a face-to-face orientation with clinical faculty or are provided with a detailed manual for the student outlining requirements for the assignment.

Information to be included in the orientation typically includes, but may not be limited to, the following:

• time requirements for the assignment (days of the week, time needed prior to scheduled client/patient responsibilities)
• dress code
• emergency procedures (what should the graduate student do if ill or unable to attend a session)
• paperwork and timelines (diagnostic reports, lesson plans, plans of care, progress notes, discharge summaries, SOAP notes, etc.)
• weekly supervisory meetings (schedule, responsibility for agenda)

Establishing and Maintaining an Effective Working Relationship

ASHA's position statement on Clinical Supervision in Speech-Language Pathology and Audiology (1985) highlights 13 tasks and skills of supervision considered basic to successful clinical teaching. One of the tasks notes the importance of establishing and maintaining an effective working relationship with the supervisee. This task is basic to the success of the experience. Clinical education is evaluative and the supervisee is in a position of reduced power in the relationship.

• Clinical educators need to recognize the power differential and be sensitive to it. The supervisory relationship is a unique one, and because of the fragility of the relationship, it is usually not beneficial to exert power when working with the supervisee.
• An atmosphere where learning is supported should be provided.
• The supervisee should feel comfortable in presenting thoughts and ideas relative to clinical challenges.
• 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 provide for a situation where the supervisor can evaluate performance independently of the relationship.
• A balance where the supervisor and supervisee are "friendly" and where the relationship is one of mutual respect and support is optimal.
• Open and ongoing communication between the supervisor and the supervisee is central to the success of the supervisory relationship.

It is important for clinical educators to meet with each supervisee prior to initiating the clinical assignment/experience. This preliminary meeting should "set the stage" for the clinical/supervisory experience. Supervisees benefit from knowing the expectations of the clinical educator, and the clinical educator should, in turn, explore the supervisee's expectations for the experience and for the supervisor. This first meeting should provide the participants some sense of what will develop over the time the graduate student is assigned to this clinical educator.

Externships

Much like a new job, the arrival at an externship experience is both an exciting and stressful experience. By orienting the supervisee to things like the introduction to the site will be a smoother process. Some settings may be considered to be best suited for a student who can manage a schedule that changes hour to hour, or some settings may involve patients that are critically ill. It is important to understand the needs of the graduate student, the clinical educator, and the requirements of the setting in order to avoid potential issues before the student is assigned to a specific facility. The university should provide the externship clinical educator with information about the number of hours needed at the particular placement site and types of experiences required (e.g., specific patient disorders, ages).

For placements that are off-campus, the university will

• typically establish a contract, which should outline the responsibilities of the university and the clinical site and should serve to protect all parties
• generally have a coordinator of externships (or similar title) who will then follow through in setting up the details of the student's experience
• establish placements up to a year in advance of the assignment
• determine start and end dates and review any requirements of the particular setting. 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.

Orientation information to supervisees includes

• information as to where to park, requirements for health screenings/examinations, background checks
• time schedule for the days in clinical experience (lunch break)
• information on grading of performance of graduate students and information on evaluation process for clinical fellows
• billing procedures, dress code, emergency procedures, paperwork requirements, and the policies and procedures that are unique to the placement
  

Anderson's Model

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. This tool provides a framework from which the supervisor and the supervisee can view the process together. The continuum provides a fluid model that supports the individual student's growth.

Get Anderson's Continuum of Supervision in PDF format

Anderson defines three stages on the continuum.

1. Evaluation-feedback stage :

• The supervisor is dominant and directive in working with the supervisee.
• The supervisee benefits (and appreciates) specific input and feedback for each client assigned for intervention or diagnosis.
• The supervisor serves as "the lead" in planning for the needs of the clients with whom the supervisee is working.
• The supervisory feedback is considered to be "direct-active" in that the supervisor controls and the supervisee follows direction.
• The marginal student, the student who evidences difficulty in planning, critical thinking, time management, and/or other areas of the therapy process may remain in the evaluation-feedback stage for an extended period of time.

Typically, this is a more comfortable start for the supervisee; however it is the hope that the student will move through this stage of development relatively quickly. Be aware that for many supervisees, the direct-active supervisor is the easiest to work with for most, movement on the continuum to the transitional stage is anticipated,

2. The transitional stage : Some of the responsibility for case and client management shifts to the supervisee.

• This process is seamless and allows the supervisee the opportunity to begin participating in the planning, implementing, and analyzing the course of treatment for patients/clients. The transition to independence can create anxiety for the supervisee and the supervisor.
• The supervisee is anxious relative to the increased responsibility and planning required for the patient/client.
• The supervisor may feel anxious relative to "giving up control" for the patient and family. In addition to the new clinical student, a supervisee who is working with a new clinical population will generally begin in the evaluation-feedback stage. The supervisor needs to be sensitive to any signs of unusual stress exhibited by the supervisee.
• In this transition stage, the supervisor provides input and feedback; however the tone of the supervisory relationship becomes more of a joint project between the supervisor and the supervisee.
• 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). The desired outcome of the transitional stage is that the supervisee begins to demonstrate clinical and professional skills with some degree of 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. It is possible that with certain skills (i.e. session planning) the supervisee may require little direction from the supervisor. However, the same supervisee may consistently evidence difficulty at communicating at an appropriate language level with clients/patients. In this case, the supervisor can provide collegial mentoring providing additional ideas or reinforcement as the graduate student establishes short term goals for sessions, selects materials, etc.
• The supervisor may need to be directive in supervisory style when working with the same student in "scripting" information to be provided for the family emphasizing appropriate vocabulary choices, definition of professional terminology, etc.

3. The self-supervision stage : It is the goal for each supervisee to move to the self-supervision stage. When the student reaches this stage of the continuum, the supervisor serves in a consultative role with the supervisee.

• The supervisee grows in clinical independence.
• The supervisee is better able to plan and implement therapy with less direct supervisory input.
• The supervisor begins to serve in a more collaborative role and feedback at this stage mirrors the change in the supervisory role. The supervisor listens and supports the supervisee in problem solving.
• The supervisee is responsible for the primary management of the caseload.

Significantly, Anderson notes that the continuum is not time-bound. This means that there is no set period of time that a supervisee should achieve a particular skill. The continuum is designed to support the supervisee in the development and self-recognition of clinical and professional strengths as well as the development and self-recognition of those areas requiring additional development of skill.

Evaluation of Supervisee

At University Clinic

Other tasks of clinical education address the clinical and professional skills required of the SLP or audiologist. Demonstrations by the clinical educator may be an effective strategy for clinical teaching; however, be aware that the supervisee needs to develop his/her own clinical style. The goal of clinical education is not to create a clone of the clinical educator. The supervisee requires self-awareness to eventually work independently. Some supervisees may not recognize any of their own clinical strengths; others may not recognize any of their weaknesses.

Providing Feedback

Feedback is critical to the development of self-awareness and to the development of the clinical and professional skills of the supervisee. Ongoing oral and written feedback is recommended.

• Be cognizant that a comment in the hallway between patients may not be understood, remembered, nor are such comments 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 that the supervisee should target for improvement. A long list of things that are not going well will only overwhelm the supervisee in a negative way.
• 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.

At the Externship

Evaluation of the supervisee typically follows a schedule provided by the university setting. The clinical educator should receive information about the grading process including the evaluation tool. Universities provide information as to the contact at the university, and clinical educators should feel free to contact the university liaison with questions and problems relative to the experience. 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 and/or the clinical educator should be discussed. It is not the off-site clinical instructor's responsibility to manage any difficulties with the supervisee independently. The university liaison will provide support in problem solving strategies in managing issues or concerns.

Supervision of Clinical Fellows

Clinical education of the clinical fellow differs in that the clinical fellow is generally an employee of the site. The clinical fellow will have applied for a position with the facility and has typically interviewed for a position. There should be a job description outlining the responsibilities of the position. An orientation as a new employee of the site should be provided. The clinical fellow should meet with the mentor/supervisor at the initiation of the employment. It is not a requirement of the experience that the mentor/supervisor be on-site or that the mentor/supervisor be employed at the setting where the clinical fellow is employed.

• The clinical fellow requires 36 supervisory contacts including 18 hours of observation of provision of clinical services.
• Eighteen other monitoring activities are required. Examples of these activities are e-mail communication between the mentor/supervisor and the supervisee, phone conferences between the mentor/supervisor and the supervisee, and/or review of written reports.
• The term mentor/supervisor is used to acknowledge that the role of the supervisor for the clinical fellow is different from that of the supervisor of the graduate student clinician. To some extent, the supervisory relationship is taken to the next level in the clinical fellowship experience. The mentor/supervisor is a resource, a support, a sounding board for ideas or for discussion of particular cases or professional issues.
• The Clinical Fellowship Report and Rating Scale, which includes the Clinical Fellowship Skills Inventory (CFSI) for Speech-Language Pathology and Audiology is completed to provide ongoing evaluation and direction for the clinical fellow at intervals during the fellowship period.
• The process of supervision of the clinical fellowship experience is one which emphasizes monitoring, conferring, and evaluating of continued clinical development and independence.

Additional information on clinical fellowship requirements is available in ASHA's certification handbooks .

Professional Ethics

As in all aspects of the professions, ethical behavior must oversee all actions associated with the supervisory process. The Code of Ethics (ASHA, 2010) addresses the supervisory process as noted by:

• Principle I - Individuals shall honor their responsibility to hold paramount the welfare of persons they serve professionally or who are participants in research and scholarly activities, and shall treat animals involved in research in a humane manner.
• Principle II - Individuals shall honor their responsibility to achieve and maintain the highest level of professional competence and performance.
• Principle IV - Individuals shall honor their responsibilities to the professions and their relationships with colleagues, students, and members of other professions and disciplines.

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

References

American Speech and Hearing Association. (1978a). 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. (1985b). 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 (2010). Code of ethics. Rockville, MD: American Speech-Language Hearing Association.

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

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

Ulrich, S. R. (1995, October). Great expectations: The lives, loves, and worries of clinical supervision. Paper presented at Nova Southeastern University, Fort Lauderdale, FL.