Response By Sandra R. Ulrich

Sarah, the site supervisor, and the university coordinator face a number of questions and challenges. Fortunately, the Code of Ethics, Principle I, provides explicit guidance: "Individuals shall honor their responsibility to hold paramount the welfare of persons they serve professionally" (ASHA, 1994). Although ASHA does not apply the Code to individuals who have not yet applied for membership and/or certification, universities must provide opportunity for students to learn about the Code and most require that practicum students ascribe to the Code.

Sarah's performance can be considered from three perspectives:

1. For the on-site supervisor, the patients, and the facility, any student should be allowed to proceed with client management only when able to do so at a pre-determined and operationally defined level of competence. Clock hours are earned for satisfactory completion of clinical activity; the supervisor's signature on clock hours indicates her judgement that the hours shown represent satisfactory performance. The supervisor should be able to show that she has provided specific, direct feedback to this student throughout the 10-week placement, with opportunity and support for making necessary changes. She also must show that she has kept the university coordinator informed about the nature of Sarah's difficulties.

2. For the campus coordinator, Sarah's performance indicates that she should not earn clock hours or a satisfactory grade. As presented, the situation suggests that it is unlikely that she will be eligible to graduate this term. The program should be able to demonstrate that it maintained systematic and periodic contact with the off-campus facility, and with Sarah, regarding her performance. Steps taken to assist the facility and the student in modifying her clinical behaviors should be documented. The university's policy regarding unsatisfactory clinical activity should be reviewed with Sarah, the site supervisor, and others as appropriate (e.g., the academic advisor).

3. For Sarah, serious questions are raised about her basic sense of clinical responsibility and about her skills of self-analysis, problem-solving, and self-direction. Her difficulties in selecting materials, setting goals, and accurately administering routine assessment instruments indicate that her knowledge and clinical skills are not yet adequate for entry-level practice as a speech-language pathologist. Meeting clients on time, completing paperwork, and establishing appropriate relationships with clients and their families are competencies expected of students and professionals at all levels. It is particularly troubling that these areas have been problematic "throughout" the placement, and even more so that Sarah apparently has failed to engage in the kind of self-analysis that could lead to problem-solving.

Although action must be taken, some information that is critical to appropriate resolution of the situation is, unfortunately, not available. Specifically, what were the expectations of the facility, the supervisor, the university, and Sarah for this assignment? Does Sarah agree with the supervisor's evaluation? Are there external reasons contributing to her difficulties (e.g., illness, other responsibilities)? What analysis of her own performance has Sarah provided? What data has she collected relative to her work with clients and her general professional behavior? What plans did she present for modifying her performance? What were the objectives, the procedures to achieve them, the plans for their measurement, and the criteria for their evaluation? Has at least one other supervisor observed Sarah's sessions and reviewed her written work?

Available options

Any options at this point in time will depend on the university's policy and on Sarah's history. For example, does the university allow students to repeat unsatisfactory clinical assignments? Has Sarah already had a "second" chance? What will be necessary in another setting to assure Sarah's progress? How will Sarah be accountable for change?

At least three options exist:

1. Jointly develop and implement an action plan for additional practicum, with objectives, procedures, time lines, criteria, and so on. The plan must be precise in its operational definitions, and all parties must agree that there is a reasonable expectation of positive change.

2. Alter the practicum to a job-shadowing experience for a certain time period, with gradual introduction of clinical responsibilities. Again, objectives for the job-shadowing should be precise, and Sarah should be expected to participate with her supervisor in jointly writing chart notes, discussing patient plans and procedures, assisting in preparation of documentation, and so on.

3. Dismiss the student from the program on the basis of failure to complete an expected component of the curriculum satisfactorily.

The first two options may be implemented in the current site or in a different site that provides a similar population and experiences. With the permission of her program, Sarah may find it helpful to take some time for reflection before resuming additional practicum

Better strategies for managing a student's observed problems in practicum can be employed if difficulties are identified earlier in the placement. This would allow joint efforts by the student, the on-site supervisor, and the university coordinator to develop better description of the situation to explore reasons for the difficulty, and to design problem-solving action. For example, can Sarah function satisfactorily if she is responsible for a smaller number of patients or a different type of patient (disorder area, age, severity, complexity)? Will a different amount or type of supervision make a difference? Are there external reasons for her behavior (e.g., illness, financial problems)? Is Sarah familiar with the philosophy of care and with the general procedures of the facility (i.e., parking, security, charting, available resources)?

The answers to these and other questions can determine possible action, which may include a better statement of the expectations, job shadowing, observation of other clinicians, co-treatment and co-assessment, reduced number or type of patients, a leave of absence to resolve external problems, and so on. Regarding Sarah's problems in administering assessment tools, there should be a clear plan regarding what tools she is expected to manage skillfully. She should help to develop procedures for attaining and demonstrating skill with those tools, including resources, time lines, and a functional statement of what constitutes "appropriate" administration (e.g., amount of time, completeness, accurate directions, accurate scoring).

Additional Issues to Consider

Sharing information with the off-campus supervisor about Sarah's past difficulties is helpful only if it assists in understanding the current situation or in knowing strategies that are useful in working with Sarah to modify her behavior. A better strategy would be for Sarah to discuss her strengths and her needs with the off-campus supervisor, including those objectives she has selected for her own growth in the current placement, supervisory strategies that she finds helpful, and her concerns for the affiliation.

Similarly, if the site could provide Sarah with information regarding tasks and tools she will be expected to know and use within the first two weeks of the affiliation, she could begin preparing in advance of the assignment. Examples of charting, reports, and other expected documentation could also be provided in advance. Some negotiation of expectations and discussion of realistic constraints may be necessary and typically should include the university coordinator.

A mutual understanding of expectations and needs, and careful planning for the experience often can avoid the sad and non-productive circumstances described in Sarah's story.

Case Study

Responses

• Ken Bleile
• Marcy Rosenbaum

Annotated Bibliograhy