According to the ASHA Ad Hoc Committee on Supervision's
Final Report on Knowledge, Skills and Training Consideration for Individuals Serving as Supervisors [PDF] (ASHA, 2013c):
A prevailing philosophy suggests that competency in clinical service delivery translates into effective clinical supervision. However, leaders in education have long argued that this is a flawed assumption and that effective supervision requires a unique set of knowledge and skills.
The Ad Hoc Committee acknowledges that supervision is a distinct area of practice and, as in other distinct areas, individuals must receive training to gain competence before engaging in the activity. Education in the supervisory process should begin early, with—as a minimum—an introduction to the subject as part of the graduate curriculum and more extensive training readily available to practicing and aspiring supervisors. Effective education for supervision should focus on unique aspects of knowledge and specialized skills for the supervisory process and should not be limited to regulatory aspects (e.g., observation time, clock hours) of the process. (pp. 3–4)
CAPCSD also recognizes that clinical supervision is a distinct area of expertise and practice, and that clinical supervisors of student clinicians need to have the requisite knowledge and skills (CAPCSD, 2013). As such, clinical education requires training to ensure that individuals gain the necessary competence (ASHA, 2013c). ASHA and other stakeholders agree that appropriate training programs need to be developed.
Knowledge and Skills For Clinical Educators
In their final report to the ASHA Board of Directors, the Ad Hoc Committee on Supervision (ASHA, 2013c) outlined the knowledge and skills required of individuals engaging in clinical training.
Overarching Knowledge and Skills
- Knowledge of clinical education and the supervisory process, including teaching techniques, adult learning styles, and collaborative models of supervision
- Skill in relationship development, including the creation of an environment that fosters learning
- Ability to communicate, including the ability to define expectations and engage in difficult conversations
- Ability to collaboratively establish and implement goals, give objective feedback, and adjust clinical education style when necessary
- Ability to analyze and evaluate the student clinician's performance, including gathering data, identifying areas for improvement, assisting with self-reflections, and determining if goals are being achieved
- Skill in modeling and nurturing clinical decision making, including (a) using information to support clinical decisions and solve problems and (b) responding appropriately to ethical dilemmas
- Skill in fostering professional growth and development
- Skill in making performance decisions, including the ability to create and implement plans for improvement and to assess the student's response to these plans
- Ability to adhere to the principles of evidence-based practice and conveying research information to student clinicians
Knowledge and Skills Specific to Student Training in the University Clinic or Off-site Setting
- Ability to connect academic knowledge and clinical application
- Ability to sequence the student's knowledge and skill development
Knowledge and Skills Specific to the Clinical Educator Working With Students in the Culminating Externship in Audiology
- Ability to provide a multifaceted experience across the scope of the profession
- Ability to serve as a liaison between the facility, student, and university
- Skill in guiding the student in reflective practice
- Skill in facilitating the development of workplace navigation skill (e.g., being part of a team and adhering to policies and procedures)
For more detailed information about the knowledge and skills needed by clinical educators, see the
Final Report on Knowledge, Skills and Training Consideration for Individuals Serving as Supervisors [PDF] (ASHA, 2013c) and CAPCSD'S white paper titled
Preparation of Speech-Language Pathology Clinical Educators [PDF] (CAPCSD, 2013). See also the American Academy of Audiology's
Clinical Education Guidelines for Audiology Externships (American Academy of Audiology, n.d.)
Both ASHA (2013c) and CAPCSD (2013) suggest the need for systematic approaches to the training and preparation of clinical educators, and both organizations outline the following issues related to the development of training:
- Development of, and options for, the delivery of educational products
- Use of a team of individuals skilled in clinical education as trainers and product developers
- Identification of potential consumers for the training
- Development of outcomes and incentives for those who engage in clinical education training
ASHA Professional Development Supervision Courses are currently available. See also
CAPCSD for additional resources.
Effective supervision ensures that new clinicians are well prepared and that individuals with communication disorders receive quality services (ASHA, 2013a).
Clinical educators integrate theoretical, evidence-based knowledge with clinical practice to help student clinicians
- acquire fundamental knowledge about normal and disordered communication;
- develop critical thinking and clinical decision-making skills;
- acquire an understanding of clinical practices and methodology and the ability to implement them;
- develop the ability to analyze research and apply evidence to clinical practice;
- become competent in using equipment and technology necessary for diagnosing and treating communication disorders;
- become competent in analyzing assessment and treatment behaviors to evaluate the effectiveness of clinical practices;
- become competent in charting and monitoring patient records;
- develop professional communication skills—both verbal and written;
- develop professional behaviors, including the ability to work with individuals and their families;
- develop skills necessary to function appropriately on an interprofessional team; and
- become competent in medical coding and billing.
Competency-based education focuses on student learning. It is a system of instruction, assessment, grading, and reporting based on students' ability to demonstrate expected learning of knowledge and skills as they progress through their education. The goal of competency-based education is to ensure that students acquire the knowledge and skills they need to be successful in school, in their careers, and in their adult lives (Hidden Curriculum, 2014).
Competency-based approaches to clinical education and assessment of student learning focus more on the knowledge, skills, and competencies that a student demonstrates than on a record of clinical hours obtained. This Practice Portal page is consistent with a competency-based approach to clinical education. See Frank et al. (2007) for a discussion of a competency-based approach in clinical (medical) education.
Anderson's (1988) Continuum of Supervision is a conceptual model of supervision often referred to in the communication sciences and disorders (CSD) literature. The model describes supervision as a continuum of stages (evaluation-feedback, transitional, and self-supervision) that allows a student to move from interdependence to independence. These stages are not time-bound; the student may be at any point along the continuum, based on his or her knowledge and skills, as well as situational variables.
The continuum comprises changes over time in the amount and type of involvement of both supervisor (clinical educator) and student clinician—as the amount of direct supervision (e.g., direct instruction; modeling or demonstration) decreases, the amount of student participation increases (e.g., the student directs by proposing clinical decisions).
Supervisory styles are adjusted in response to the needs of the student, expectations and philosophies of the supervisor and supervisee, and specifics of the situation (e.g., task difficulty; familiarity with the task or procedure; client needs and preferences; setting).
Anderson (1988) emphasizes five components of the supervisory process to facilitate movement of the student along the continuum:
- Understanding the supervisory process — discussing the process, understanding respective roles, and sharing expectations and objectives
- Planning — joint planning for the clinical process (client and clinician) and the supervisory process (supervisee and supervisor)
- Observing — collecting and recording objective data by both supervisor and supervisee
- Analyzing — examining and interpreting data in relation to changes in clinician and client
- Integrating — integrating content from all components at various points throughout the experience
By actively participating in all aspects of the clinical process—including data collection, problem solving, and strategy development—the student ultimately develops the ability to use the strategies needed to function independently (Dowling, 2001).
Applications and research relevant to these components are discussed in McCrea and Brasseur's (2003) update of Anderson's seminal work.
The Supervisory Relationship
Success in facilitating clinical and professional development ultimately rests on the relationship between clinical educator and student clinician and on the ability of the clinical educator to communicate effectively with the student clinician.
Effective interpersonal communication requires
- knowledge of and ability to implement the basic principles of effective interpersonal communication;
- appreciation for the importance of listening and the ability to use behaviors that facilitate effective listening (e.g., silent listening, questioning, paraphrasing, empathizing, and supporting);
- knowledge of key principles of conflict resolution and the ability to use conflict resolution strategies appropriately (e.g., active listening, openness to discussion, and allowing for open-ended discussion);
- understanding different learning styles and having the ability to work effectively with each style within the supervisory relationship; and
- understanding different communication styles (e.g., cultural/linguistic, generational, gender) and having the ability to address potential challenges to successful communication related to these differences.
When clinical educators adopt an effective communication style, student clinicians are more willing to participate in conferences, share ideas and feelings, and positively change clinical behaviors (e.g., Hagler, Casey, & DesRochers, 1989; McCready et al., 1996; Pickering, 1987).
Clinical behaviors also change in positive directions when students perceive genuineness, empathetic understanding, positive regard, and concreteness on the part of the clinical educator (Ghitter, 1987 [building on the research of Caracciolo, 1976; Caracciolo, Rigrodsky, & Morrison, 1978a, 1978b; McCrea, 1980; and Pickering, 1979, 1984]).
Promoting And Enhancing Critical Thinking
Critical thinking allows the clinician to access knowledge about the field, determine how that knowledge can be applied in clinical situations, evaluate outcomes, modify his or her thinking, and make appropriate clinical adjustments.
"Educational and professional success require developing one's thinking skills and nurturing one's consistent internal motivation to use those skills" (Facione, 2000, p. 81). The clinical educator must not only teach critical thinking skills but also nurture the disposition toward clinical thinking (Gavett & Peapers, 2007). One way to accomplish these objectives is by asking questions that activate the student's knowledge and promote analysis, synthesis, and evaluation of the situation.
- provide a model for how practicing clinicians reason;
- provide a structure for student clinicians to connect theory and practice; and
- challenge student clinicians to apply their thinking beyond the specific client or situation (Gavett & Peapers, 2006, 2007; King, 1995).
Feedback is an informed (data-based), nonevaluative, objective appraisal of the student clinician's performance intended to improve his or her clinical skills (Ende, 1983). It is given to confirm or reinforce behavior, correct behavior, and promote improvement in future performance (Barnum, Guyer, Levy, & Graham, 2009; Ende, 1983; Nottingham & Henning, 2014a).
Common types of feedback (Dowling, 2001) include
- objective data — nonjudgmental data collected, analyzed and shared with the student clinician
- narratives — written descriptions of specific behaviors during a session, along with the clinical educator's impressions (e.g. field notes; Anderson, 1998)
- rating scales — ratings on a specified number of clinical skills; although criteria for judgment are sometimes provided, rating scales are subjective by nature and need to be paired with objective data to support the ratings
Factors that can influence the effectiveness of feedback include
- timing (immediate or delayed);
- frequency (more or less often);
- tone (positive, negative, or balanced);
- form (spoken or nonspoken); and
- specificity (more or less detailed/specific).
Each feedback exchange can include different combinations of these components; thus, each exchange is unique (Nottingham & Henning, 2014a, 2014b).
Ende (1983) offers the following guidelines for giving feedback:
- Undertake feedback so that the clinical educator and student clinician are working as allies with common goals.
- Ensure that feedback is well-timed and expected—feedback that comes unexpectedly, especially when it is negative, is almost always met with an emotional reaction.
- Base feedback on firsthand data, and phrase it in descriptive, nonevaluative language.
- Focus on specific performances, not generalizations.
- Address decisions and actions of the student clinician, not assumed intentions or interpretations.
- When offering subjective data, label it as such—use "I" statements that focus on the specific behavior and that allow the student to interpret (e.g., "I saw that you reversed the right and left earphones when fitting the headset.").
Factors that can affect how receptive a student clinician is to feedback include
- whether or not the student agrees with the clinical educator;
- the particular learning situation (e.g., if new skills are being learned);
- personalities of the clinical educator and student clinician that can set the tone for their interactions; and
- the timing of feedback (e.g., in the presence of a client/patient or in private).
See Nottingham and Henning (2014b) for a discussion of student preferences with regard to feedback.
Feedback-seeking behavior is a conscious effort to determine the correctness and adequacy of one's own behavior for the purpose of attaining a goal (Ashford & Cummings, 1983). Research suggests that feedback-seeking behavior can facilitate an individual's adaptation, learning, and performance (Crommelinck & Anseel, 2013).
Not all individuals seek feedback, possibly because of differences in the perceived value and costs associated with feedback seeking (Ashford, Blatt, & Vande Walle, 2003). However, given the potential benefits, encouraging feedback seeking is an important educational strategy (Crommelinck & Anseel, 2013; Bose & Gijselaers, 2013).
Mentoring in Clinical Education
Mentoring is the relationship between two people in which one person is dedicated to the personal and professional growth of the other (Robertson, 1992). In clinical education, mentoring focuses on building skills, influencing attitudes, and cultivating aspirations. Mentors model, advise, tutor, and instill a professional identity in the student clinician.
Some aspects of mentoring are involved in all supervisory relationships and, to varying degrees, at all stages of clinical education, depending on the supervisor's style and the student clinician's experience and skill level. Mentoring is less likely to be addressed when performance growth is the focus (i.e., "direct-active" style of supervision) and is more likely to be addressed in later stages of learning, when "collaborative" or "consultative" styles of supervision are used. Mentoring is most appropriate in the advanced transitional stage and the self-supervision stage of the continuum (Anderson, 1988).
The Influence of Power in Supervision
The clinical educator holds the power of grading, signing off on clinical hours, and conducting performance evaluations. Awareness and understanding of the influence of power can help avoid intimidation and a reluctance by the student clinician to participate actively in the supervisory relationship.
Cultural or linguistic background may influence a student's response to the power dynamic and may result in behaviors that can be interpreted as inappropriate (Coleman, 2000). Seek advice regarding effective strategies for culturally appropriate interactions.
Evaluating The Student Clinician And The Clinical Educator
"The goals of the supervisory process are the professional growth and development of [both] the supervisee and the supervisor, which it is assumed will result ultimately in optimal service to clients" (Anderson, 1988, p. 12).
To that end, the clinical education process incorporates self-assessment on the part of the student clinician and the clinical educator. Self-assessment enhances professional growth and development and provides an opportunity for each person to identify goals and determine whether these goals are being met.
The clinical education process also incorporates reciprocal evaluations—this encompasses the clinical educator's evaluation of the student clinician and the student clinician's evaluation of the clinical educator. Reciprocal evaluations are critical to the process and help both individuals improve their skills.
Deliberate practice is a highly structured activity directed at improving performance on a particular task or set of tasks (Ericsson, Krampe, & Tesch-Römer, 1993). It incorporates immediate, specific, and informative feedback, problem-solving and evaluation, and opportunities for repeated performance to improve and refine skills.
Training that utilizes deliberate practice can facilitate acquisition and maintenance of expert performance in a wide variety of fields (e.g., De Bruin, Smits, Rikers, & Schmidt, 2008; Krampe & Ericsson, 1996; Unger, Keith, Hilling, Gielnik, & Frese, 2009), including acquisition of clinical skills (Duvivier et al., 2011; Ericsson, 2004).
Duvivier et al. (2011) identified a number of study habits related to deliberate practice in the behavior of clinical (medical) students at various stages of skill development:
- Tendency to organize work in a structured way
- Increased concentration and attention span
- Tendency to practice
- Tendency to self-regulate learning
As students progressed through the curriculum, their use of these study habits increased, particularly in the areas of planning and organization of work.
Deliberate practice can facilitate acquisition of a broad range of clinical skills in audiology and speech-language pathology, including administering tests and interpreting results; conducting oral motor exams; using technology and equipment; and completing audiologic assessments.
Reflective practice involves critical self-analysis, self-evaluation, problem solving, and the ability to modify one's behavior. It is an important tool in practice-based professional learning where clinical skills are acquired through experience rather than from formal classroom teaching.
Reflection-on-action is the process of reflecting on what has been done. It allows the individual to reflect on a prior experience, evaluate how he or she contributed to the outcome, and determine what to do when a similar situation arises (Schön, 1983).
Tools that provide opportunities to reflect on performance include self-evaluation checklists, journals, diaries, portfolios, reviews of video recorded sessions, and clinical educator observations and evaluations.
Reflection-in-action is the process of "thinking on your feet" that allows an individual to make changes in his or her behavior while engaged in a task. It requires critical, in-the-moment evaluation and the ability to identify what is not going well or what needs to be changed and to modify behaviors accordingly (Schön, 1983).
Examples include modifying task instructions or cuing strategies during a therapy session or deciding to forego otoacoustic emissions testing in favor of multifrequency tympanometry to investigate possible causes of a conductive hearing loss.
For more information about reflective practice in clinical education, see Aronson (2011); Geller and Foley (2009); Mann, Gordon, and MacLeod (2009); and Ng (2012).
Supervision, Questioning And Feedback (SQF) Model Of Clinical Teaching
The Supervision, Questioning and Feedback (SQF) model of clinical teaching integrates supervision, questioning and feedback into clinical learning experiences. It is designed to help the student clinician become an autonomous clinician with sound clinical reasoning (Barnum et al., 2009).
The SQF model incorporates
- supervision (S) that changes in response to the needs of the learner and the situation;
- strategic questioning (Q) to facilitate development of clinical reasoning skills by providing a model for thinking; and
- meaningful feedback (F) to help shape learning and skill development.
Strategic questioning consists of consciously adapting the timing, order, and phrasing of questions to help the student process information at increasingly more complex levels. In order of complexity, questions require recall of facts; comparison, analysis, synthesis, and application of knowledge; and the ability to evaluate information, formulate plans, infer meaning, and defend decisions (Barnum 2008).
Three types of feedback can be utilized—confirming lets students know when knowledge and skills are being applied correctly; corrective lets them know when these skills are not on target; and guiding reinforces and advances current levels of knowledge and skills (Barnum & Guyer, 2015).
Specific questioning and feedback techniques depend on the clinical situation—the student clinician, the task he or she is trying to complete, the urgency with which the task must be completed, and the consequences for the patient/student/client and for the student clinician (Barnum & Guyer, 2015).
Cognitive Apprenticeship Instructional Model
Cognitive apprenticeship was introduced by Collins, Brown, and Newman (1989) as an instructional model for situated learning, in which students learn to apply skills by performing tasks and solving problems in a variety of authentic contexts.
The cognitive apprenticeship model applies the following teaching methods to promote situated learning:
- modeling — demonstrating tasks and explaining internal (cognitive) processes (e.g., decision making)
- coaching — observing students as they perform tasks and providing feedback, hints, models, and reminders
- scaffolding — tailoring support to students' current level of knowledge and gradually removing support as they become more competent
- articulation — encouraging students to verbally express their knowledge, reasoning, or problem solving
- reflection — encouraging students to reflect on their own skills and problem-solving abilities as compared with their cognitive model of expertise
- exploration — setting general goals for students and encouraging them to formulate and pursue personal goals of interest
Using these methods, the clinical educator makes tacit elements of expert practice explicit so that students gain a deeper understanding of the cognitive processes underlying clinical decision making (Dennen & Burner, 2008).
Simulation is a method that replaces or amplifies real client/patient experiences with scenarios designed to replicate real health encounters (Passiment, Sacks, & Huang, 2011). Simulation affords an opportunity to build knowledge and experience by rehearsing in a safe environment (e.g., clinical skills lab), where potential harm to the client/patient is minimized.
The standardized patient (SP) is a well-accepted and frequently used simulation tool. The SP is a layperson hired and trained to portray an actual patient within a clinical setting. He or she presents with faculty-defined patient history and physical symptoms and provides a consistent, controlled clinical experience for teaching and assessment purposes. Academic programs in CSD are beginning to employ SPs for clinical education purposes (e.g., Zraick & Allen, 2002; Zraick, Allen, & Johnson, 2003). Other simulation tools include computer avatars and lifelike mannequins (Zraick, n.d.).
Grand rounds are formal meetings at which cases are presented to student clinicians, clinical educators, and other medical and allied health professionals, followed by a discussion of each case. Students may review current literature to provide support for test protocols, test interpretation, and treatment options. Grand rounds originated as part of medical residency training but can be used in any clinical education setting to enhance clinical reasoning and decision-making skills.
Problem-based and Case-Based Learning Scenarios
Problem-based learning scenarios are experiences in which groups of students—with guidance from an instructor—learn through solving an open-ended problem by identifying what they know, what they need to know, and where they can access the necessary information to solve the problem.
Case-based learning scenarios are similar but use discussion of case studies and real-life scenarios to help students put their learning into practice in a clinical setting. Students work collaboratively to examine, analyze, and discuss problems related to the case.
Assessment is an essential component of any clinical education process. It involves
- defining expected knowledge and skills;
- developing learning goals;
- setting criteria for demonstrating learning;
- gathering and analyzing data regarding performance or verification of clinical outcomes;
- providing feedback; and
- documenting feedback and remediation opportunities.
Setting objectives is fundamental to subsequent evaluation; progress can be measured adequately only if clear objectives have been established and if behaviors relating to those objectives have been quantified (McCrea & Brasseur, 2003).
It is critical that the clinical educator and the student clinician be jointly involved in the evaluation process (Anderson, 1988; McCrea & Brasseur, 2003). Expectations for performance and evaluation tools need to be clarified at the beginning of the supervisory experience (Brasseur, 1989).
Types of Assessment
A variety of assessment mechanisms and techniques are used to evaluate progress in acquiring the necessary knowledge and skills. Assessments are conducted on an ongoing basis throughout training and at the conclusion of a defined instructional period.
Formative assessment is ongoing measurement and feedback yielding critical information for monitoring acquisition of knowledge and skill during the learning process for the purpose of improving learning.
Formative assessment in clinical education evaluates the individual's critical thinking, decision-making, and problem-solving skills; it typically includes oral and written components as well as demonstrations of clinical proficiency in actual or simulated settings.
Examples of Formative Assessment
- Observation – observing the student clinician during sessions and providing feedback (written or verbal) regarding mastery of a skill (e.g., branching to a less difficult task during the session or selecting an appropriate masking level during audiologic testing).
- Questioning – engaging the student clinician with questions that encourage open dialogue, critical thinking, problem solving, and exploration of new information.
- Learning logs – asking students to reflect on a session or learning experience by summarizing the experience, noting what they learned, posing questions that they still have, evaluating their clinical skills, and providing insight and suggestions for continued performance improvement. Learning logs allow the clinical educator to monitor student progress and provide feedback and concrete suggestions on ways to improve.
- Proficiency exams – evaluating student performance on a particular skill (e.g., pure-tone testing) to determine skill level at various points throughout training. Exam performance can help determine the need for additional practice and/or remediation.
Summative assessment is the comprehensive evaluation of learning outcomes at the conclusion of a defined instructional period (e.g., end of semester, academic year, or program of study).
Summative assessment in clinical education yields critical information for determining an individual's acquisition of knowledge and achievement of clinical skills, including the ability to integrate academic knowledge with clinical practice.
Summative assessments can serve as gateway measures prior to embarking on a more advanced clinical process stage. They often result in a score or grade that is incorporated into the individual's overall performance.
Examples of Summative Assessment
- Gateway clinical exams administered as benchmarks before more complex clinical procedures (or placements) are permitted.
- Examination of practical skills (e.g., demonstration of skills in use of technology; demonstrating diagnostic skills using simulated patients).
- End-of-semester final exams or evaluations.
- End-of-program comprehensive written and oral exams.
- Culminating demonstrations of learning, such as
- oral presentations (e.g., case presentations);
- capstone projects (e.g., case studies, surveys, and outcomes-based research) in which theory and knowledge are applied to a real-world setting; and
- portfolios of work (e.g., case reviews, treatment plans, reports, and academic papers) demonstrating evidence of academic and clinical achievements.
- Standardized tests (e.g., Praxis® exams).
Pitfalls To Avoid When Assessing Student Performance
It is important for the clinical educator to avoid the following common pitfalls when assessing student performance.
- Halo Effect — cognitive bias in which an observer's overall (positive or negative) impression of a person influences the evaluation of specific traits (Thorndike, 1920).
- Central Tendency — tendency to rate all individuals (or all performances of a particular individual) around the midpoint of the scale; this bias results in a failure to differentiate between individuals or between the skills of a particular individual (Heery & Noon, 2008).
- Similar-to-Me Effect — tendency for an individual to give a higher rating to someone who is similar, in some way, to the rater himself or herself (e.g., similar attitudes or demographics; Sears & Rowe, 2003).
- Judgmental Bias — tendency (usually subconscious) to judge someone based on factors (e.g., racial, gender, or political bias) unrelated to his or her performance (Kerr, MacCoun, & Kramer, 1996).
- Leniency/Strictness Error — error that results when consistently easy or strict criteria are applied in rating an individual, regardless of his or her performance (Lunenburg, 2012).
Clinical educators can use one or more of the following strategies to avoid these pitfalls and ensure objectivity, fairness, and accuracy when assessing student performance:
- Establish clear educational plans and objective goals.
- Set expectations with the student.
- Rate each expected behavior independently.
- Consider specific data to support performance judgments.
- Use full performance rating levels to accurately indicate strengths and areas for improvement.
- Separate oneself from the evaluation—recognize that someone can be different but still perform effectively.
- Conduct in-house reliability training to ensure that all clinical educators use rating systems in a similar manner.
Difficult conversations frequently pertain to the student's clinical performance but may also be related to other behaviors such as keeping commitments, being punctual, or demonstrating professionalism. These conversations often involve differing perspectives, opposing opinions, strong emotions, and potentially high-stakes outcomes (Patterson, Grenny, McMillan, & Switzler, 2012; Whitelaw, 2012).
One approach for initiating and resolving difficult conversations is the learning conversation. It involves
- learning the story of the participants without assigning blame;
- inviting participants to express their views and feelings; and
- creating a partnership for problem-solving (
Harvard Negotiation Project, n.d.; Stone, Patton, & Heen, 2010).
The learning conversation requires willingness on the part of the clinical educator to put aside his or her views and listen to the student, with the goal of understanding and acknowledging the student's perspective. This nonjudgmental listening can provide a safe emotional environment and facilitate the problem-solving process (Luterman, 2006).
Performance Improvement Plan
A performance improvement plan—also referred to a remediation plan—is a formal process used to help the student clinician improve performance or modify behavior. The need for remediation can stem from performance on clinical examinations that identifies the student's areas of need.
As part of the process, the clinical educator and student clinician identify specific performance and/or behavioral concerns and develop a written plan of action to address these concerns. The following specific steps in developing and implementing performance improvement plans are adapted from the Society for Human Resource Management (2013).
Steps In Developing And Implementing A Performance Improvement Plan
I. Document areas of performance and/or behavior in need of improvement by
- providing objective and specific documentation;
- documenting performance and behavior regularly throughout the term; and
- providing examples for clarification.
II. Develop action plan for improvement that includes
- specific and measurable objectives;
- a timeline for completion of objectives;
- additional resources that might be needed; and
- a statement of consequences if objectives are not successfully met.
III. Meet with student clinician to review plan. Be sure to
- clearly explain areas in need of improvement and the plan of action;
- provide the student with an opportunity to give his or her feedback and modify the plan if needed; and
- sign the plan.
IV. Gather data
- Data specific to each objective are gathered by both student and clinical educator.
- Student maintains log of performance-related self-evaluations.
V. Meet regularly with the student clinician (e.g., weekly, biweekly) to
- provide opportunities for student to seek guidance or ask for clarification of expectations;
- discuss and document progress toward achieving objectives; and
- modify objectives and/or timeline if needed.
VI. Conclude plan when student clinician
- meets all objectives and continues/progresses in his or her training or
- fails to meet objectives, at which time agreed-upon consequences are implemented.
The rights of students with disabilities are protected by the Americans With Disabilities Act (ADA; 1990) and Section 504 of the Rehabilitation Act of 1973. The ADA and Section 504 of the Rehabilitation Act of 1973 define individuals with disabilities as
- persons with a physical or mental impairment that substantially limits one or more major life activities;
- persons who have a history or record of such an impairment; or
- persons who are perceived by others as having such an impairment.
Major life activities include caring for oneself, walking, seeing, hearing, speaking, breathing, working, performing manual tasks, and learning.
The Americans With Disabilities Act (ADA)
The ADA (1990) is comprehensive civil rights legislation that prohibits discrimination and guarantees that people with disabilities have the same opportunities as everyone else to participate in mainstream American life. This includes the opportunity to participate in higher education. Title II of the ADA covers state-funded schools such as universities, community colleges, and vocational schools. Title III of the ADA covers private colleges and vocational schools.
Section 504 of the Rehabilitation Act
Section 504 of the Rehabilitation Act of 1973 (hereafter, "the Rehabilitation Act") protects qualified individuals from discrimination based on their disability. The nondiscrimination requirements of the law apply to employers and organizations that receive financial assistance from any federal department or agency and include many institutions of higher learning, hospitals, nursing homes, mental health centers, and human service programs.
Section 504 of the Rehabilitation Act covers any school that receives federal dollars, regardless of whether it is private or public. A recipient of federal financial assistance may not, on the basis of disability,
- deny qualified individuals the opportunity to participate in or benefit from federally funded programs, services, or other benefits;
- deny access to programs, services, benefits, or opportunities to participate as a result of physical barriers; or
- deny employment opportunities, including hiring, promotion, training, and fringe benefits, for which they are otherwise entitled or qualified (U.S. Department of Education, 1980).
To be protected by Section 504, a student must be a qualified individual with a disability. In addition to meeting the above definition of individuals with disabilities—and for purposes of receiving services, education, or training—the term qualified means that the student meets essential eligibility requirements, with or without use of a reasonable accommodation.
Examples of discriminatory conduct by a college or university include
- denying a qualified individual with a disability admission because of her or his disability;
- excluding a qualified student with a disability from any course, course of study, or other part of its education program or activity because of her or his disability; and
- counseling a qualified student with a disability toward more restrictive career objectives than other students (U.S. Department of Education, 1980).
Institutions are required by law to provide reasonable accommodations. Specifically, they are required to make reasonable modifications in their practices, policies, and procedures and to provide auxiliary aids and services for individuals with disabilities—unless doing so would (a) fundamentally alter the nature of the goods, services, facilities, privileges, advantages, and accommodations that they offer or (b) result in an undue financial or administrative burden on the institution.
Colleges and universities are not required to provide personal attendants, individually prescribed devices, readers for personal use or study, or other devices or services of a personal nature, such as tutoring and typing.
A reasonable accommodation for a student with a disability may include appropriate academic adjustments (e.g., modifications to academic requirements) that are necessary to ensure equal educational opportunity.
- arranging for priority registration;
- reducing an individual's courseload;
- substituting a course;
- providing notetakers, recording devices, and/or sign language interpreters;
- allowing extended time for taking tests and completing clinic-related tasks (e.g., documentation and preparation);
- equipping school computers with screen-reading, voice recognition, or other adaptive software or hardware;
- modifying the environment to facilitate use of clinical equipment; and
- ensuring wheelchair access to clinical environments (e.g., for both examiner and patient side of sound suites).
The college or university is not required to lower or substantially modify essential requirements. For example, although the college or university may modify elements of the clinical practicum to meet the student's disability-related needs, it is not required to change the substantive requirements of the clinical experience in ways that can potentially interfere with quality of client care.
All students are held to the same standards and expectations. The presence of a disability may help explain how the student performs but does not excuse inadequate performance. All students deserve equal access to realistic performance assessment.
Jarrow (2012) for a discussion of students with disabilities and information about maintaining essential requirements for all students.
On occasion, a bilingual student clinician shares the language of the client/patient and/or family. When the clinical educator does not also share the language, a unique set of knowledge and skills is needed to understand, monitor, and evaluate the work of the bilingual student clinician. When this situation arises, it is important to consider the following:
- There may be a relationship between the student clinician and the client/patient stemming from a shared cultural and linguistic background, and this relationship is not an attempt to be exclusionary.
- Bilingual student clinicians who are in the process of being trained as professional service providers are not automatically considered bilingual service providers. Bilingual service providers must have adequate linguistic skills and must be appropriately trained to provide services to the individual with limited English proficiency (see
bilingual service delivery and
collaborating with interpreters, transliterators, and translators).
- The student clinician may be able to serve as an interpreter, transliterator, or translator, but additional consideration is necessary before this additional role is given (see
collaborating with interpreters, transliterators, and translators).
- Although the student clinician may be able to serve appropriately in multiple roles, it must be recognized that the roles of bilingual service provider, interpreter, transliterator, and translator are unique, with each serving a different function and requiring a different set of knowledge and skills (see
collaborating with interpreters, transliterators, and translators).
- The clinical educator and student clinician have a responsibility to collaborate in planning the session, selecting culturally relevant materials, and appropriately administering the services.
Accents are defined as English pronunciation that is not the result of pathology and that is perceived to be different from the listener's—whether the English was learned as a first, second, or other language. Accents include aspects of speech sound production, prosody, rate, and fluency (Celce-Murcia, Brinton, & Goodwin, 1996), all of which can affect intelligibility. A dialect is any variety of a language that is shared by a group of speakers (Wolfram, 1991).
All individuals speak with an accent and/or dialect, whether it is regional or influenced by another native language. Variation is the norm, and no single standard can be appropriately applied in every clinical interaction. Audiologists and speech-language pathologists (SLPs) manage cases across linguistic variation as a matter of routine.
Student clinicians who speak with accents and/or dialects can effectively provide speech, language, and audiological services as long as they have
- the expected level of knowledge in normal and disordered communication;
- the expected level of diagnostic and clinical case management skills, and when necessary; and
- the ability to model the target (e.g., phoneme, grammatical feature, or other aspect of speech and language) that characterizes the particular problem of the client/patient (ASHA, 1998)—modeling can be provided in a variety of ways, given current technology (e.g., computer applications, software, audio and video recordings).
Universities impose the same requirements on all student clinicians and consider the potential means by which students can successfully provide clinical services with the varied tools and resources now available. According to ASHA (1998), "the nonacceptance of individuals into higher education programs or into the professions solely on the basis of the presence of an accent or dialect is discriminatory" (p. 1).
When there are concerns about the impact of a student clinician's accent on the delivery of clinical services, the following strategies (ASHA, 2011) are offered to increase the likelihood of success:
- Provide early support, including opportunities for students to raise concerns.
- Offer an accent modification/intelligibility enhancement plan.
- Avoid communicating inferiority (e.g., by offering accent modification/intelligibility enhancement by a fellow student or allowing fellow students to observe the session).
- Be respectful of what the student brings to the profession (e.g., an understanding of culturally and linguistically diverse issues germane to the CSD discipline).
- Focus on the client's/patient's perception of accent—what matters is whether he or she can understand and learn from a student clinician with an accent.
- Address client/patient concerns—a client/patient or family member may indicate concerns about working with a student clinician who has an accent.
- Choose external placement sites with care (e.g., choose outside placements with clinical educators who are aware of and sensitive to the influence of cultural and linguistic diversity in the professions).
- Acquisition of self-awareness by students is key (e.g., being aware of a student's accent and its clinical impact and having resources to rely upon in various situations).
- Seek outside support and guidance—assess the support given to students with accents through exit interviews; ask for suggestions on improving the approach for future students.
Both the service provider and the client/patient bring a unique combination of cultural variables to the clinical interaction, including ability, age, sex, beliefs, ethnicity, experience, gender, gender identity, linguistic background, national origin, race, religion, sexual orientation, and socioeconomic status.
Just as audiologists and SLPs are required to consider each client's/patient's or caregiver's cultural and linguistic characteristics and values in order to provide the most effective services (ASHA, 2004), the clinical educator also considers those of the student clinician (Herd & Moore, 2012). Clinical educators and student clinicians demonstrate
cultural competence as they relate to each other and to the diverse populations they serve (ASHA, 2013d).
Culturally competent clinical educators successfully perform the following tasks:
- Discuss differences in cultures and the effect of differences on the relationship between clinical educator and student clinicians (Gardner, 2002).
- Discuss the unique influence of an individual's cultural and linguistic background that may necessitate adjustments in clinical approaches and interactions (e.g., interview style, assessment tools, and therapeutic techniques, feedback mechanisms, and critical evaluations).
- Gain an understanding of cultural norms and linguistic profiles—for example, what may appear to be an "unnecessary" amount of time "wasted" before beginning the session may actually reflect an awareness of the value of introductory talk in building rapport and showing respect before beginning the formal task.
- Give thoughtful attention to issues related to who speaks which language(s) (e.g., clinical educator, student clinician, client/patient, or family member. Such thoughtful attention provides opportunities for a collaborative relationship between student clinician and clinical educator (Muñoz, Watson, Yarbrough, & Flahive, 2011).
- Engage in discussions about expectations of performance and provide clear statements of evaluation criteria, including the influence of each person's cultural background.
Generational differences can present unique challenges in clinical education. Four distinct generations (traditionalists, baby boomers, generation Xers, and millennials) are currently working together in potentially stressful, competitive environments (Lancaster & Stillman, 2002). Each generation is defined by people, places, events, and symbols that profoundly influence expectations and values.
Different expectations and values between and among generations can result in misinterpretations and misunderstandings between clinical educator and student clinician in a clinical setting. McCready (2007) describes a number of ways to bridge the generation gap and facilitate improved communication, including
- increasing knowledge and understanding of potential generational differences, including defining events and values;
- avoiding the assumption that all members of a particular generation have a "collective personality;"
- developing an appreciation of potential strengths of each generation (e.g., technological experience and expertise);
- talking about generational differences in orientation meetings, in-service presentations, study groups, and the like;
- sharing generational stories; and
- having discussions with colleagues and student clinicians about generational characteristics that might lead to misunderstandings.
Student clinicians typically gain practical experience in the field by "interning" at one or more external practicum sites (e.g., schools, rehabilitation centers, skilled nursing facilities, private practices, hospitals). Academic programs work together with external practicum sites to help provide these experiences.
Clinical Affiliation Agreements
The clinical affiliation agreement is a formal contract between an academic institution (college or university) and an external practicum site. Most academic programs require a clinical affiliation agreement before sending students to external practicum sites.
The clinical affiliation agreement identifies the responsibilities and liabilities of each party and ensures an appropriate learning experience for the student clinician. Agreements typically include the responsibilities listed in the boxed information below:
Mutual responsibilities of the academic institution and practicum site
- Determine the length of time that the agreement will be in effect and options for renewal
- Agree on terms for appropriate discipline or dismissal of a student clinician
- Provide reasonable accommodations to student clinicians with disabilities so that they can perform essential job functions and acquire the necessary clinical knowledge and skills
Responsibilities of the academic institution
- Select qualified student clinicians
- Advise student clinicians of their rights and responsibilities under the agreement
- Require student clinicians to comply with the site's health status requirements and provide appropriate documentation
- Ensure that student clinicians have the necessary professional liability insurance
- Educate student clinicians regarding the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
- Provide the practicum site with expected learning objectives for the student clinician and necessary evaluation forms
Responsibilities of the practicum site
- Provide student clinicians and academic institution with the rules and policies of the practicum site
- Provide student clinicians with the necessary experiences to attain learning objectives
- Maintain student records and protect the confidentiality of these records as dictated by the Family Educational Rights and Privacy Act (FERPA, 1973)
- Gather data regarding clinical performance
- Evaluate performance and provide feedback to the student clinician and academic institution
- Provide the student clinician with any necessary credentialing information (e.g., requirements for provisional licensure from the state)
Administrative Tasks Prior To Student Clinician Placement
The practicum site needs to complete a number of tasks prior to student clinician placement, including those listed below:
- Obtain any necessary approvals from the facility for serving as a clinical educator and placement site.
- Determine if the university offers or requires clinical educators to have taken university or professional development courses on clinical supervision or specific clinical topics.
- Review the agreement that the facility has established with the university.
- Contact human resources staff members at the facility regarding requirements and orientation processes, including
- procuring required ID badges;
- ensuring that student background checks, if required, are complete;
- ensuring that students complete required facility orientations; and
- ensuring that immunization requirements have been met.
- Confirm dates for student clinician practicum.
- Schedule periodic "check-in" meetings with the university clinic director.
- Facilitate site visits by university clinical faculty over the course of the student clinician's placement.
- Confirm grade submission policies and procedures.
There is no official ASHA policy regarding payment of students for clinical practicum. However, because it is acceptable to charge for supervised services provided by students, it follows that it is acceptable to pay students in practicum settings. See
Issues in Ethics: Ethical Issues Related to Clinical Services Provided by Audiology and Speech-Language Pathology Students (ASHA, 2013e) for more details.
Students work with their academic program and practicum site to determine whether a stipend is available and/or appropriate. Important considerations include
- the academic program's policy on student stipends;
- compliance with state licensing or other regulatory agency policy; and
- the potential impact of the stipend on the student's financial aid package.
Even if a student is being paid a stipend, he or she requires the appropriate level of supervision and teaching necessary for training. Make clients, patients, and families aware that services are being rendered by a student clinician under the supervision of a credentialed and/or licensed practitioner.
Clinical Educator Compensation
It is not uncommon for clinicians serving as external practicum site clinical educators to be offered incentives or compensation for the additional work involved in being a clinical educator. ASHA does not have a policy on payment of externship clinical educators. Some academic institutions may offer compensation in the form of a stipend or in-kind services (e.g., continuing education opportunities) or, for example, a "thank you" lunch at the end of the semester.
In some cases, the employer (practicum site) might offer compensation or incentives to the employee for working with student clinicians. For example, when practical, the employee may be given a temporarily reduced caseload while working with a student clinician.
If the audiologist or SLP receives payment from the university for serving as an externship clinical educator, he or she will need to disclose this to the employer. As the direct beneficiary of this payment, the individual will also need to declare the income when filing his or her personal income taxes.
Clinical educators who are members of ASHA are expected to abide by the
Code of Ethics (ASHA, 2010r) and have the unique opportunity to reinforce and model the importance of the Code of Ethics to their student clinicians.
There are also a number of Issues in Ethics Statements published by ASHA's Board of Ethics that provide guidance in addressing some of the challenges inherent in clinical education. See
Ethical Issues Related to Clinical Services Provided by Audiology and Speech-Language Pathology Students (ASHA, 2013e) and
Issues in Ethics: Supervision of Student Clinicians (ASHA, 2010) for more details.
Clinical educators and mentors working with speech-language pathology clinical fellows can also review
Issues in Ethics: Responsibilities of Individuals Who Mentor Clinical Fellows in Speech-Language Pathology (2013a) for guidance.
The standards for certification for audiology and speech-language pathology are established by audiologists and SLPs, respectively, who are members of ASHA's Council for Clinical Certification in Audiology and Speech-Language Pathology (CFCC). It is important for clinical educators to be familiar with the Standards and Implementation Procedures for the
Certificate of Clinical Competence in Audiology (CCC-A) and the
Certificate of Clinical Competence in Speech-Language Pathology (CCC-SLP) when working with students interested in seeking ASHA certification.
Council on Academic Accreditation in Audiology and Speech-Language Pathology (CAA)
To embark on a career as an ASHA-certified audiologist or SLP, students must complete the necessary entry-level graduate degree from a program accredited by the
Council on Academic Accreditation in Audiology and Speech-Language Pathology (CAA; ASHA, 2014).
Medicare Coverage Of Students And Clinical Fellows
Clinical educators must comply with Medicare guidelines related to coverage of student and clinical fellowship services. ASHA has compiled information about these regulations in the following sources:
Audiology and speech-language pathology are recognized as covered services under the Medicaid program. The federal government establishes broad guidelines, and each state then administers its own program. Review and approval is conducted by the federal Centers for Medicare & Medicaid Services (CMS).
Medicaid coverage of services provided "under the direction of" a qualified professional varies by state. See
Medicaid Coverage of Speech-Language Pathologists and Audiologists for professional and state-specific information.
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
HIPAA is a law designed to improve the efficiency and effectiveness of the nation's health care system and health care operations. HIPAA
- protects health insurance coverage when someone loses or changes his or her job;
- addresses issues such as pre-existing conditions;
- includes provisions for the privacy and security of health information;
- specifies electronic standards for the transmission of health information; and
- requires unique identifiers for providers.
Health Insurance Portability and Accountability Act (1996) for additional information and resources.
Student Clinicians and HIPAA
HIPAA regulations apply to all
covered entities [PDF]. These include health care operations or systems "conducting training programs in which students, trainees, or practitioners in areas of health care learn under supervision to practice or improve their skills as health care providers."
Student clinicians providing services in such health care settings will need to learn about HIPAA regulations and should be introduced to the facility's HIPAA policies and procedures. Facilities may require that student clinicians receive HIPAA training as part of their orientation. Just as any employee in the facility, student clinicians are expected to abide by HIPAA's Privacy Rule which applies to all forms of protected health information (PHI) whether oral, paper, or electronic.
Family Educational Rights and Privacy Act (FERPA)
FERPA (1973) protects the privacy of student education records and applies to all schools that receive funds under an applicable program of the U.S. Department of Education. FERPA gives parents certain rights with respect to their children's education records. These rights transfer to the student when he or she reaches the age of 18 years or attends an institution beyond the high school level.
Student Clinicians and FERPA
Rights of students receiving services in the practicum setting. In education practicum settings (i.e., schools), student clinicians under the supervision of a qualified professional may generally be considered a "school official" with a "legitimate educational interest" and, as such, may have access to an individual's education records under this legislation. FERPA requires that schools specify the criteria for determining which parties are school officials and what the school considers to be a legitimate educational interest. Student clinicians should be made aware of their responsibilities under FERPA not to disclose personally identifiable information from education records unless authorized to do so, either with parental consent or under one of the conditions in FERPA permitting disclosure without consent. For more information, see
FERPA General Guidance for Students.
Rights of the student clinician. The education records of student clinicians are also protected under FERPA; the student clinician has the right to access his or her own education records, seek to have those records amended, control the disclosure of personally identifiable information from the records, and file a complaint with the school or department if he or she feels that these rights have been violated.
Although there are some exceptions, the university generally may not disclose personal identifiable information from the student clinician's educational records without the student's written consent. One exception is when the information is of legitimate educational interest. A clinical practicum site might be allowed access to a student clinician's personal identifiable information and must protect the confidentiality of this information, along with any other educational records generated during the practicum experience (e.g., performance evaluations and grades). For more information, see
FERPA General Guidance for Students.
Telesupervision of student clinicians occurs when a qualified professional observes, from a distance, the delivery of services by the student and provides feedback or assistance as needed. Telesupervision offers the potential to expand students' access to clinical placements and to reduce travel and scheduling conflicts for clinical educators. Although telesupervision and telepractice are related due to their use of technology, ASHA's definition of telepractice does not include supervision.
ASHA's resource on telepractice for information on technology, security, licensure, and other tips.
Regulations and Laws
The use of telesupervision as an alternative to in-person supervision may depend on the policies, regulations, and/or laws of various stakeholders such as universities, clinical settings, ASHA, state licensure boards, and state and federal laws and regulations.
Increasingly, state licensure laws include a definition of telepractice and regulations related to it, which may or may not include guidance regarding telesupervision. States may vary in terms of whether they specifically address the issue of supervising students from a distance.
The clinical educator has an ethical responsibility for the welfare of the individual receiving clinical services and must determine if telesupervision is an appropriate means to supervise a particular student clinician in view of the type of setting, client population, and level of independence of the individual delivering the service.
When implementing telesupervision practice and policies, consider the security of the telesupervision transmission in light of relevant state and federal laws such as HIPAA and FERPA. Policies about safety, liability, and whether a certified and/or licensed professional needs to be on site are also important and relevant considerations.
Knowledge and Skills
Like telepractice, delivering supervision services from a distance requires additional knowledge and skills for issues such as managing technology, complying with licensure and security requirements, providing feedback, and so forth. Training may be necessary for clinical educators regarding how to provide telesupervision so that quality and effectiveness of the supervision is equivalent to in-person supervision.
Tips And Considerations For Telesupervision
ASHA offers several guidelines for the implementation of telesupervision:
- Conduct a trial prior to the scheduled observation to identify and resolve technical and logistical issues (e.g., connectivity location of the microphone and camera).
- Always have an alternate means for the telesupervisor and clinician to communicate in case there is a problem with connectivity or equipment.
- The telesupervisor shares his or her web camera when being introduced to the client/student/patient at the beginning of the session but may stop sharing the web camera after introductions in order to minimize distractions.
- Providing the background case information as well as an outline for the test plan/lesson plan in advance helps to plan camera/microphone placement so that the telesupervisor can have an optimal view of the client/student/patient and materials.
- If online feedback or instructions are being provided during the session, the telesupervisee can receive communications via an earpiece to avoid distracting the client/student/patient.
According to the World Health Organization (WHO; 2010), "Interprofessional education (IPE) occurs when two or more professions learn about, from, and with each other to enable effective collaboration and improve . . . outcomes" (p. 7). IPE is an essential first step in preparing professionals to work collaboratively in response to client/student/patient needs.
Interprofessional practice (IPP) allows workers from a variety of professional backgrounds to work together with clients/students/patients, families, caregivers, and communities to provide the highest quality and most comprehensive services possible (WHO, 2010).
Interprofessional education and collaborative practice align with national efforts toward a more interprofessional and collaborative service delivery model that centers on the individual and family with the aim of educating populations, improving health and safety, and enhancing the overall cost effectiveness of educational and health care services.
Clinical educators have the opportunity to engage In IPE/IPP and can reinforce best practices in this area. ASHA has compiled a number of
interprofessional education/interprofessional practice (IPE/IPP) resources. Clinical educators and CF mentors may want to familiarize themselves with
Core Competencies for Interprofessional Collaborative Practice [PDF], a report published by an expert panel of the Interprofessional Education Collaborative (IPEC, 2011), as well as ASHA's
Interprofessional Education (IPE): Final Report, Ad Hoc Committee on Interprofessional Education [PDF] (ASHA, 2013f).