Clinical Supervision Student-Centered Learning Meets Patient-Centered Care

March 2018

Stephanie Adamovich

In the context of patient-centered care—in which audiology clinicians focus on and work collaboratively with patients/families to make decisions regarding health care—is it possible to create a concurrent student-centered learning experience? A student-centered learning experience is one in which the student clinician is actively engaged in a clinical appointment that allows him or her to further develop knowledge and skills. All too often, students report to university clinical placement coordinators that, when at the offsite placement, the student mostly observes and/or is allowed to complete only very basic assessment tasks. It is a challenge—perhaps what we might perceive as an ethical dilemma—to allow novice clinicians to administer complex assessments or complete complex device programming when our ethical guidelines admonish experienced clinicians to "hold paramount" the welfare of the patient. It can be unnerving to watch a first-year audiology student make an ear impression on the first day of clinic. Nevertheless, ASHA's principle of ethics 1.G states, "Individuals who hold the Certificate of Clinical Competence may delegate to students tasks related to the provision of clinical services that require the unique skills, knowledge, and judgment that are within the scope of practice of their profession only if those students are adequately prepared and are appropriately supervised. The responsibility for the welfare of those being served remains with the certified individual" (ASHA, 2016). It is easy to focus on the last part of this guideline and create a prioritized hierarchy wherein maintaining the welfare of the patient, and the integrity of the appointment, is mutually exclusive from the first part of the statement in that we may delegate tasks to students for which they are prepared. If the student has successfully completed the coursework and passed a practical assessment of ear impression techniques, has the student met the ethical benchmark?  

Let's step back for a minute and review the three common terms describing how an experienced clinician works with a student: (1) supervisor, (2) clinical instructor, and (3) preceptor (ASHA, n.d.). If we take the terms at face value, a supervisor is fundamentally someone who ensures that a certain task is completed. The root meaning of the word supervisor is "oversee." Moving on to the second term, a clinical instructor is one who teaches students about clinical procedures. The third term, preceptor, reflects a higher level of interaction with students. Merriam-Webster's Collegiate Dictionary (n.d.) gives the medical definition of preceptor as one who "gives personal instruction, training, and supervision to a...student." The process of training a student clinician contains elements of supervision, clinical instruction, and precepting, yet all three terms fall short of describing the ideal relationship between a student and an experienced clinician. Let's go one step further and look at the term facilitator. The goal of a facilitator is to bring about a specific outcome—typically, a change or improvement in a clinical behavior. The question we all need to ask ourselves when we work with students in our clinics is, "Are we simply overseeing, or are we personally interacting with students to facilitate application of knowledge to the clinical setting? Are we assisting the student in the process of 'becoming' an audiologist, or are we merely overseeing the completion of tasks?"

In contemplating the term facilitator in reference to clinical supervision, three important considerations present themselves. 

1. What is the target outcome of an appointment for the student clinician?
2. What are the desired behaviors in students that will enable student clinicians to eventually practice at the top of the professional license?
3. How do we balance our obligation to students with our obligation to clients/patients?

Consideration 1: What is the target outcome of an appointment for the student clinician?

First, the target outcome for a student will vary by appointment type, by setting, and by the student's level of training. However, the target outcome should not be a secret that only the clinical facilitator knows. Developing a shared goal, or outcome, for the student is as important as identifying the goal for the patient's visit through discussion with the patient/family. With a clear outcome in mind—one facilitated by the experienced clinician—the student is much more likely to be successful. For example, consider the following scenario. An audiologist working in a busy otolaryngology or ENT (disorders of the ear, nose, and throat) clinic is working with a second-year, second-semester doctor of audiology (AuD) student. This is the student's fourth semester of clinic, but it is his or her first semester off campus. The ENT physician has a very busy schedule, and 15 patient audiograms are anticipated throughout the day. The preceptor meets with the student in the morning and reminds her to move quickly through the audiograms. By the time the sixth patient checks in, there are five patients waiting to be seen and a physician wondering what is taking so long. In this case, the preceptor was nonspecific, and student/patient interaction did not result in the desired outcome (completing the audiograms in a certain amount of time). If we apply a facilitating approach to this scenario, the student is given specific guidance: "It is going to be a busy clinic today. We need to complete each audiogram in 20 minutes. Let's talk about ways you can be more efficient today and still provide excellent patient care. What are your ideas?" The student now has a tangible goal to work toward and has been asked to critically reflect on his or her skills to achieve the desired outcome. The desired clinical skill has been defined and can be more intentionally assessed.

Consideration 2: What are the desired behaviors in students that will enable student clinicians to eventually practice at the top of the professional license?

Second, what are the behaviors we want to foster in students to lead them to clinical independence and the ability to practice at the top of the license? In patient-centered care, how clinical decisions are made is closely scrutinized, as health care is increasingly focused on outcomes. Outcomes are based on the results of clinical decision making. It follows that clinical decision making must be a critical behavior for students to develop, yet formal training in clinical decision making does not appear to be standard across audiology graduate programs. The best opportunity for student clinicians to develop clinical decision making may be during on-campus and off-campus clinical placements. Clinical decision-making theory has been researched and discussed extensively in traditional health professions such as medicine and nursing, but not in audiology (Boisvert et al., 2016). Sound judgment is no less important in audiology or speech-language pathology. Clinical decision-making proficiency—and the ability to make appropriate and accurate decisions regarding patient assessment, management, or rehabilitation—may, in fact, be the pinnacle outcome for any student clinician. However, giving students the freedom to make decisions requires trust on the part of the preceptor. Price, Zulkosky, White, and Pretz (2017) assessed the accuracy of decisions made by novice nursing students when relying primarily on intuition. They found that when students were functioning in the primary nursing role in a clinical simulation, rather than taking the role of observer, reliance on intuition was positively associated with decision-making accuracy—particularly when presented with a familiar condition. When students acted as observers, there was a negative association between intuition and accuracy. In other words, the more engaged the novice clinician was in the simulation, the more accurate the clinical decision making, despite the relative inexperience. This is not to negate the value of thinking through decisions analytically using evidence and data, but new clinicians may not have a robust foundation of data to rely upon at first. Full engagement in the appointment appears to be one important step toward developing clinical decision making as a skill.  

Facilitating student clinician decision making has a flip side, which presumes that students may—and likely will—make wrong decisions. Clinicians worry that students will make a decision resulting in harm or an unsatisfied client/patient; however, it has been my experience that there are few unrecoverable, catastrophic errors in audiology. We are not violating our ethical commitment to the client when we allow students to make decisions if we are engaged with the student in approving those decisions. ASHA Ethics guidance states, "The supervisor must oversee the clinical activities and make or approve all clinical decisions to ensure that the welfare of the client is protected" (ASHA, 2017, paragraph 1 under "Guidance"). Student clinicians need experience making clinical decisions to become experienced decision makers. This is where the facilitating approach becomes important, in that experienced clinicians have an obligation to (a) engage student clinicians in a discussion regarding the outcome of specific decisions and then (b) allow student clinicians the opportunity to make those decisions. Consider the following scenario: A first-year, second-semester AuD student is working with an adult cochlear implant recipient in a university clinic. The client/patient is anticipating an upcoming surgery and is wondering how she will communicate with doctors in pre-op or the operating room once when her sound processor is removed. A "supervisory" approach to this scenario could end with the student clinician, who has been a passive observer to the visit, lacking confidence to offer a suggestion that has not been vetted by the supervisor. A facilitated approach might go something like this: The student, who has been actively engaged in the appointment by running the cochlear implant programming computer and interacting professionally with the client, feels confident in expressing her intuition, despite having no specific experience, to counsel the patient to take a pad of paper on the day of surgery. The clinical instructor validates the suggestion, and the student learns a valuable lesson regarding making decisions.

Consideration 3: How do we balance our obligation to students with our obligation to clients/patients?

Third, how do we balance our obligation to students and clients? ASHA ethical guidelines mandate that "The supervisor should inform the client or the client's family about the supervisory relationship and the qualifications of the student supervisee" (ASHA, 2017, paragraph 1 under "Guidance"). Furthermore, the audiologist "shall inform those they serve professionally of the name, role, and professional credentials of persons providing services" (ASHA, 2017, paragraph 1 under "Guidance").

Through proper and respectful disclosure of the skills of student clinicians, appropriate expectations are established, and the client is reassured that although the student clinician might steer the ship, ultimately the experienced clinician is at the helm. I observed a fourth-year AuD extern develop strong relationships with patients through use of decision-making language. She would tell patients, "I would like to do this with your hearing aid today," and then confirm the course of action with the patient. The use of "I" statements that are specific and easy to understand resulted in consistent development of clinical decision-making skills.

The ASHA Clinical Education and Supervision Practice Portal topic (ASHA, n.d.) offers many suggestions on how to facilitate clinical learning. In the section titled "Promoting and Enhancing Critical Thinking," which addresses the ability to make clinical decisions, we are reminded that teaching the student these skills is not enough; a good clinical educator will guide or facilitate the student's disposition toward thinking critically. One suggestion is to "provide structure for student clinicians to connect theory and practice" (ASHA, n.d., paragraph 3 under "Promoting and Enhancing Critical Thinking") through use of guided questions. Consider the first-year, second-semester audiology graduate student in his first clinical rotation on campus. When staffing for the first appointment of the semester—a comprehensive audiological evaluation—the clinical educator asks the student his plan for the patient. The student clinician draws on his diagnostic audiology knowledge and decides to complete bone conduction first because he wants to be sure about the need for air conduction masking. The clinical educator corrects as necessary before the appointment even begins; then, during the appointment, the student can execute the plan. This leads into discussions of test efficiency after the appointment, wherein the student can then make clinical decisions regarding how to modify the plan for the next patient. The cycle of questioning, putting theory into practice, and executing clinical decisions allows for a student-centered learning experience while maintaining patient-centered care.

About the Author

Stephanie Adamovich is clinical associate professor at Arizona State University, where she focuses on facilitating audiology graduate student skill mastery in areas of cochlear implant management, group aural rehabilitation, and central auditory processing. She has supervised all levels of audiology undergraduate and graduate students in hospital-based and university clinic settings for over 10 years, and served on the ASHA Ad Hoc Committee on Supervision Training.

References

American Speech-Language-Hearing Association. (n.d.). Clinical education and supervision [Practice Portal]. Retrieved from www.asha.org/Practice-Portal/Professional-Issues/Clinical-Education-and-Supervision.

American Speech-Language-Hearing Association. (2016). Code of ethics [Ethics]. Available from www.asha.org/policy/.

American Speech-Language-Hearing Association. (2017). Supervision of student clinicians [Issues in Ethics statement]. Available from www.asha.org/practice/.

Boisvert, I., Clemesha, J., Lundmark, E., Crome, E., Barr, C., & McMahon, C. M. (2016). Decision making in audiology: Balancing evidence-based practice and patient-centered care. Trends in Hearing, 21, 1–14.

Preceptor. (n.d.). In Merriam-Webster's online dictionary (11th ed.). Retrieved from https://www.merriam-webster.com/dictionary/preceptor.

Price, A., Zulkosky, K., White, K., & Pretz, J. (2017). Accuracy of intuition in clinical decision-making among novice clinicians. Journal of Advanced Nursing, 73, 1147–1157.