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Resources For Clinical Educators

To assist Clinical Educators (CEs) in providing students with high quality practicum experiences we have developed a range of resources.

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The Collaborative Approach to Clinical Education

Jeanne Claessen, Former Head of Clinical Program (1995-2009)
School of Communication Sciences and Disorders
McGill University

The collaborative partnership between clinical educator (CE) and student prepares students to become autonomous professionals as they get involved early on in clinical reasoning and problem solving.

The premise of the collaborative approach1 between the CE and the student in a clinical practicum is that the learning process takes place on a continuum consisting of three main stages, each with its distinct characteristics. As the student gains competence, experience and confidence over the course of their clinical education (within a single practicum and throughout a series of clinical practica, culminating in the final internship) their learning needs and learning styles will change.

Initially, during the “Novice Stage” the student will be dependent on the CE for receiving information, instructions and extensive guidance for a wide variety of clinical tasks. The student’s role during this ideally short stage may be more passive and the CE’s role will be more active and dominant. Progressively, as new information becomes integrated with theoretical knowledge and experience, students will move into the longest stage, the “Advanced Stage”, and start to take increasing responsibility for clinical tasks, such as case history taking, test administration and therapy, while the focus of the relationship with the CE will become increasingly collaborative. Together they will engage in clinical reasoning during test analysis while trying to determine the nature and degree of the presenting problem, etc. Joint debriefing sessions, during which the student is expected to take the lead more and more as she/he gains more experience, will focus on both the client’s and the student’s performance. As students move along the continuum from the “Advanced Stage” to the final “Mentorship Stage”, they will rely more and more on self-analysis and self-supervision skills, and eventually take responsibility for their own caseload.

Where students find themselves on the clinical education continuum is determined by various factors, the most obvious being: level of knowledge, clinical experience, competence and confidence; more often than not they may be at different stages of the continuum for different skills and tasks. As students become more experienced they will always encounter novel situations (new populations, more complex cases) during which they may move back temporarily to the “Novice Stage”. This indicates that the learning stages are not just linear but also cyclical.

The challenge for the CE may lie in the need to be flexible, as she/he must be prepared to assume, at different times, the roles of traditional instructor/supervisor, collaborator/facilitator, and perhaps even that of mentor/advisor. This transformation may occur, in rare cases, over the course of one practicum (e.g. an internship) with one student, or across different practica with different students, depending on the levels of the students involved.

The collaborative approach can lead to higher satisfaction levels for the CE and the student as they witness the outcomes of the efforts involved in this collaborative partnership. In addition, especially in the case of a strong student, both parties may experience the relationship as collegial.

1The supervisor process in speechlanguage pathology and audiology. Boston: College-Hill.

A more developed version of this article can be found here. That article offers practical applications of the model for various levels of practicum.

The 2:1 Peer Coaching Model of Supervision

       

(This is an excerpt from an earlier article published by Jeanne Claessen in JSLPA 28(4) 2004.)

In this model the clinical educator has responsibility for two students who are working together in a collaborative fashion with one another and with their clinical educator (CE). As such it makes a good fit to the “Collaborative Approach”.

In this model the clinical educator has responsibility for two students who are working together in a collaborative fashion with one another and with their clinical educator (CE). As such it makes a good fit to the “Collaborative Approach”.

  • 2 students assume greater & joint responsibility for their learning; the CE becomes a facilitator.
  • It helps students to wean themselves from considering CEs as the sole source of knowledge.
  • It offers students an opportunity to explore alternative problem solutions in a safe environment.
  • It promotes development of social interaction and communication skills.
  • It enhances student satisfaction with the learning experience and confidence.

Activities that students may be involved in include:

  • learning through demonstration (to and from each other, and from the CE)
  • observing one another (and/or their CE)
  • performing clinical activities together (e.g., testing, therapy, analysing results, preparing materials, etc.)
  • providing each other with consultative assistance
  • discussing and problem-solving together
  • providing each other with feedback (peer-evaluation). The decision to incorporate peer evaluation will be guided by factors such as student and CE comfort levels, students being of similar strength, etc.

Discussion, joint problem solving, and reciprocal coaching help students develop Clinical Reasoning skills, which may further enhance the learning experience and thus help students reach greater levels of competency and eventually autonomy. Clinical reasoning consists of the following elements

  • clinical decision-making
  • clinical problem-solving
  • diagnostic reasoning
  • clinical judgment
  • inductive and deductive reasoning.

A peer coaching model that includes clinical reasoning may

  • stimulate critical thinking
  • develop higher level thinking skills
  • encourage student responsibility for learning
  • create an environment of active, involved exploratory learning
  • help students clarify ideas through discussion and debate
  • use a team approach to problem-solving while maintaining individual accountability.

Such a collaboration may be realised by encouraging students, in an atmosphere of exploratory learning, to engage in the following clinical activities:

  • sharing and discussing cases
  • observing each other
  • evaluating clients together and engaging in decision-making following analysis of the evaluation results
  • planning therapy goals
  • carrying out therapy sessions together.

Click here to view the full article.

Tips for Creative Clinical Education

Below follow some tips for taking advantage of supervising students in busy places while instead of jeopardizing, possibly enhancing the quality of the placement!

  • Internship students often are able to work with greater independence and at some point in the placement can start carrying their own caseload.
  • If one of the clients is a child in a day care (or other type of program) the student might be asked to go and observe the child there and bring back notes/language sample, educator feedback, etc., which can give invaluable information and saves the SLP time.
  • In an adult rehab setting, in certain cases a student could work independently with a patient(s) who benefits from extra intervention and for whom a programme is already in place.
  • Utilising the 2:1 peer coaching supervision model may help SLP in several ways: 2 students can rely more on each while engaging in clinical reasoning and problem solving; and at a more advanced stage in a final internship students may be ready to have their own caseload so more clients can be seen in a day. (For more information on this supervision model, please Clinical Resources section of SCSD website.)
  • While SLP is involved in essential duties and does not have time for the student, student could be given that will enhance their learning experience. This refers to meaningful tasks they can carry out independently, such as familiarising themselves with assessment and therapy materials, taking notes, writing reports, and/or shadowing other professionals (in a setting with a multi-disciplinary team), or having opportunities to meet students from other disciplines and discuss joint cases with them, making AAC boards, researching information on the internet, etc. Of course these types of activities should not form the majority of a student’s learning experience.

Tips for supervising a student in private practice

Private practice is a branch of SLP service delivery that has grown extensively over the last decade and more and more students have an opportunity to undertake a clinical practicum in a private clinic. We often get asked by clinicians working in private practice how they can involve a student in their setting in light of some inherent restrictions (e.g. parents/clients paying for the service). Here are some tips:

1. For a new assessment:

  • While the SLP interviews the parents, the student can engage the child. This has two big advantages: a) the student is giving an important clinical task by collecting important information relevant to the assessment; and b) the child is kept busy and does not have to sit in on the case history (which in turn may make the parent(s) more comfortable sharing sensitive information about their child)
  • While occupying her/himself with the child the student’s role can be:
    • observing the child’s play, pragmatics, attention span, behaviour
    • taking a speech or language sample
    • administering (part of) a test (depending on student’s level and CE’s and parental approval)
  • For the actual test administration either the SLP or student gives the test while the other party does the scoring.
  • For the debriefing portion of the session the student can occupy the child while the clinician gives the results, makes recommendations, etc.

2. For therapy sessions:

  • In individual sessions the student forms the third party during a game.
  • The student caries out the activity while the SLP explains to the parent the rationale of the activity, how the child is doing, how the parent can implement the goal of the activity at home, etc.
  • In a Hanen type session the student may interact with the child while the SLP explains to the parent what is happening and why, and how they may incorporate the goals at home.
  • Students can engage in group therapy sessions with the SLP and provide individual attention to some children.
  • If a child benefits from twice weekly therapy, one session may be fully charged and the second session conducted by the student could be offered at a much reduced rate.

Some private practices have a sliding scale so parents pay a smaller fee when their child is working with a student who is ready to work with a higher level of independence.

As can be seen, involving a student actively in private practiced is possible and may give a more extended service to the parents and the child.

For other creative ways of involving students in service delivery, see “Tips for Creative Clinical Education” in the Clinical Education Resources section of the SCSD website.

Tips for giving students feedback and for encouraging self-reflection and self-evaluation

Setting the (self-)feedback/evaluation stage:

When completing the Practicum Contract at the outstart of the practicum discuss your and the student’s preference for who will provide feedback during feedback sessions (ideally both the student and you). Students are often not comfortable doing it but it is highly recommend that CEs facilitate and encourage students to develop self-reflection and self-evaluation skills. (McGill expects students to do regular written self-reflections and a self-evaluation for the 2 formal evaluations.)

It is also important to discuss early on when feedback will take place (after the session, at the end of the day). As a general guideline, the sooner after the session the better, but caseload pressures may make this difficult.

We recommend that supervisor and student develop early on a common understanding as to what skills will be evaluated (usually the learning objectives outlined in the Contract, i.e. Interpersonal/Communication, Professional skills, Clinical Reasoning and Clinical Skills).

Tip: You may ask the student to list specific goals on a separate sheet after each day and then you and the student can provide specific feedback for these learning goals during feedback/debriefing session. This ensures that the goals are always kept in mind and that ongoing feedback for these goals takes place.

CE intervening during the session:

Ask if the student is comfortable with it. Usually students like it because they can fix on the spot. They don’t like it when:

  • CE intervenes too quickly (student needs to be given time to fix their own mistake)
  • CE does it abruptly
  • CE does it in a critical/criticising way in front of the client

Especially the latter 2 are not helpful for the student and can undermine their learning and confidence levels.

Positive feedback:

Give plenty of it but only if it is true and it has been observed – don’t do it to flatter the student. Also try to be specific. “Good job" doesn’t tell the student anything; instead tell them what they did well; e.g. "The activity you chose addressed the client’s goals well".

To help students to self-evaluate, you could first ask them to share what went well (both in the performance of the client and their own). However, if they focus more on the client (they may feel uncomfortable addressing their own performance), bring the student back to discussing their own performance.

Constructive (critical) feedback:

Clinical educators often find it difficult providing critical feedback, but students want it and need it (in appropriate doses!).

Tips:

CE starts by asking the student to debrief or self-evaluate. Once this habit is in place in general students become comfortable with it. Procedure: CE asks student what went well during the session and then asks for other things that could have been done differently.

  • Or CE can ask the student to list 3 things that went well and 1 that could have gone better (especially useful for weaker students, for students who tend to focus on the negative, or with students who have low confidence).
  • Constructive feedback may be less confrontational when presented in a clientcentered manner: "Tommy might have done better in that session with a few more activities to keep his attention."

If student finds it hard to come up with something you can prompt, “Could you comment on your interactional skills when assessing the new patient”. (Note: this could have been an appropriate interaction but you’d be able to get a sense of the student’s selfawareness and insights, and student could share their perspectives: I think I did well but I felt really nervous”, and then this could be further explored.)

Specific feedback:

Tips:

Students want feedback that is specific to their behaviour and tied in with the learning objectives. Examples of specific areas for you and the student to comment on:

  • appropriate choice or not of selected test or therapy materials in relation to the presenting problem or goal.
  • appropriate choice or not of selected test or therapy materials in relation to the presenting problem or goal.
  • presenting stimuli at an appropriate rate,
  • showing awareness of and acting appropriately re client’s physical or mental state (fatigue, attention, anger, excitability)
  • modifying treatment materials during a session, showing creativity in choice of materials, or how they were used
  • counselling skills with client/caregiver, etc.
  • setting appropriate goals;
  • charting a client’s progress;
  • report writing skills: relevant case history information; relevant and accuracy assessment results; analyzing; summarizing results; -making appropriate recommendations

Ongoing feedback

Ongoing feedback is important as helps the student to grow and it prevents surprises at the mid term or final evaluation. Also, the midterm evaluation is very important as it helps focus the rest of the practicum and it will avoid surprises at the final evaluation.

Both students and clinical educators need reassurance!

Clinical educators want feedback from their students as well. Ideally, both the student and the clinical educator will be able to solicit feedback from each other that helps make for a successful practicum.

When there is a problem

General principles & procedure for problem solving:

  1. Always, first, and as soon as possible, bring up the concern(s) with the student (or the student with the CE). The more open the communication is the better prognosis for a positive outcome!
    [Bringing up concerns first with the party involved before contacting the university is fair towards the other person and avoids unpleasant surprises and very importantly, may sometimes be sufficient to clear the problem.]
  2. Try to determine through discussion with the student what the underlying reason(s) for the problem(s) may be and if it is necessary make a concrete action plan, with criteria for success and a realistic time frame.
  3. If initial attempts at solving the problem are not effective, CE or student contacts McGill to share concern and to help problem solve; ideally, the other party should be made aware of this.
  4. In the process of helping a student deal with their problems, a collaborative approach is preferred over a 'direct' 'advising' role on part of the CE. Encouraging self-reflection and self-evaluation throughout the clinical process is strongly recommended in the supervision process of any student, and especially when students are experiencing problems.
  5. If a student is at risk of failing a practicum, the University must be notified as soon as possible, and definitely by the mid-term evaluation.

Kolb's Theory of Learning Styles

First Kolb showed that learning styles could be seen on a continuum running from:

  1. concrete experience: being involved in a new experience
  2. reflective observation: watching others or developing observations about own experience
  3. abstract conceptualization: creating theories to explain observations
  4. active experimentation: using theories to solve problems, make decisions

Hartman (1995) took Kolb's learning styles and gave examples of how one might teach to each them:

  1. for the concrete experiencer: offer labs, field work, observations or videos
  2. for the reflective observer: use logs, journals or brainstorming
  3. for the abstract conceptualizer: lectures, papers and analogies work well
  4. for the active experimenter: offer simulations, case studies and homework

Although Kolb thought of these learning styles as a continuum that one moves through over time, usually people come to prefer, and rely on, one style above the others. And it is these main styles that instructors need to be aware of when creating instructional materials.

Types of Learners

(Adapted from Kolb, 1986)

CONCRETE EXPERIENCE (CE):

A receptive, experience based approach to learning that relies for a large part on judgements based on feelings. CE individuals tend to be empathetic and people oriented. They are not primarily interested in theory; instead they like to treat each case as unique and learn best from specific examples. In their learning they are more oriented towards peers than to authority and they learn best from discussion and feedback with fellow CE learners.

  • Labs, field work, videos, observations

REFLECTIVE OBSERVATION (RO):

A tentative, impartial and reflective approach to learning. They rely on careful observation of others and/or like to develop observations about their own experience. They like lecture format learning so they can be impartial objective observers. Introverts.

  • Self-reflection exercises, journals, brainstorming(?)

ABSTRACT CONCEPTUALISATION (AC):

An analytical, conceptual approach to learning: logical thinking, rational evaluation. These learners are oriented to things rather than to people. They learn best from authority-directed learning situations that emphasize theory. They don’t benefit from unstructured discovery type learning approaches.

  • Lectures, papers

ACTIVE EXPERIMENTATION (AE):

An active, doing approach to learning that relies heavily on experimentation. These learners learn best when they can engage in projects, homework, small group discussion. They don’t like lectures, and tend to be extroverts.

  • Simulations, case studies, homework

Summary of Learning Styles

(based on Kolb, 1986, adapted from Litzinger & Osif [1992])

1) ACCOMMODATOR Learning Style

Accommodator’s dominant learning abilities are Concrete Experience (CE) and Active Experimentation (AE). This person’s greatest strength lies in doing things and involving oneself in the experience. This person can be more of a risk-taker and tends to adapt well in specific circumstances. This person tends to solve problems in an intuitive trial and error manner, relying often on other people’s information rather than on own analytic ability. Suited for action-oriented jobs (business, marketing, sales). These learners are good with complexity and are able to see relationships among aspects of a system.

A variety of methods are suitable for this learning style, particularly

  • anything that encourages independent discovery
  • allowing the learner to be an active participant in the learning process
  • instructors working with this type of student might expect devil's advocate type questions, such as "What if?" and "Why not?"

2) ASSIMILATOR Learning Style

Assimilator’s dominant learning abilities are Abstract Conceptualization (AC) and Reflective Observation (RO). They are motivated to answer the question, "what is there to know?" They are good at creating theoretical models. Less interested in people more concerned with abstract concepts. This learning style is more characteristic of basic sciences and mathematics. They like accurate, organized delivery of information and they tend to respect the knowledge of the expert. They aren't that comfortable randomly exploring a system and they like to get the 'right' answer to the problem.

Instructional methods that suit Assimilators include:

  • lecture method, followed by a demonstration
  • exploration of a subject in a lab, following a prepared tutorial (which they will probably stick to quite closely) and for which answers should be provided
  • These learners are perhaps less 'instructor intensive' than those of some other learning styles. They will carefully follow prepared exercises, provided a resource person is clearly available and able to answer questions.

3) CONVERGER Learning Style

Converger’s dominant learning abilities are Abstract Conceptualization (AC) and Active Experimentation (AE). They are motivated to discover the relevancy or "how" of a situation, and their greatest strength lies in the practical application of ideas. Application and usefulness of information is increased by understanding detailed information about the system's operation. They are relatively unemotional and prefer to deal with things rather than people. They like to specialize in the physical sciences and this learning style is characteristic of many engineers.

Instructional methods that suit Convergers include:

  • interactive, hands-on, not passive, instruction (labs, field work)
  • computer-assisted instruction
  • problem sets or workbooks for students to explore

4) DIVERGER Learning Style

Diverger’s dominant learning abilities are Concrete Experience (CE) and Reflective Observation (RO). Their greatest strength lies in imaginative ability. This person is very good at viewing concrete situations from many perspectives. They prefer to have information presented to them in a detailed, systematic, reasoned manner. Flexibility and the ability to think on your feet are assets when working with Divergers. Counsellors, managers are typical professions they are well suited to.

Instructional methods that suit Divergers include:

  • lecture method
  • hands-on exploration
  • brainstorming

References for Clinical Education

Recommended Textbooks (* = highly recommended)

Dowling, S. (2001) Supervision – Strategies for successful outcomes and productivity. Boston: Allyn & Bacon

* McAllister, L. and Lincoln, M. (2004) Clinical education in speech-language pathology. London and Philadelphia: Whurr Publishers.

* McCrea, E. & Brasseur, J. (2003) The supervisory process in speech-language pathology and audiology. Boston: Allyn & Bacon

Recommended articles

* Claessen, J. (2006). The Collaborative approach to clinical education. SAC Communiqué, Volume 20, No. 4, Fall 2006

* Claessen, J. (2004). A 2:1 Clinical Practicum, Incorporating Reciprocal Peer Coaching, Clinical Reasoning, and Self- and Peer Evaluation, JSLPA, 28 (4), pp 156- 165

* Lincoln, M., McLeod, S., McAllister, L., Maloney, D., Purcell, A, & Eadie, P. (1994) Learning Styles of SLP students: A longitudinal investigation. In: M. Bruce (Ed.), Proceedings of the 1994 International & Interdisciplinary Conference on Clinical Supervision: Toward the 21st Century (pp 133-140). Council of Supervisors in SLP and Audiology. Cape Cod, MA.

Additional references

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

American Speech-Language Hearing Association. (1978) Committee on Supervision in Speech-Language Pathology and Audiology. Current status of supervision of speechlanguage Pathology and audiology [special report] ASHA, 20, pp 478-486.

American Speech-Language Hearing Association (2000) Background information and standards and implementation for the certificate of clinical competence in speechlanguage pathology [special report] Rockville, MD: ASHA Council on Professional Standards in SLP & Audiology

Caracciolo, G., Rigrodsky, S. and Morrison, E. (1978) Perceived interpersonal conditions and professional growth of master’s level SLP students during the supervisory process. ASHA, 20, pp 467-477

Cogan, M. (1973) Clinical supervision. Boston: Houghton Mifflin.

Kolb (1984) Experiential learning: Experience as the source of learning and development. Englewood Cliffs: Prentice Hall.

Oratio (1977) Supervision in speech pathology: A handbook for supervisors and clinicians. Baltimore: University Park Press.

Pickering, M. (1987) Supervision: A person-focussed process. In: M. Crago & M. Pickering (eds.) Supervision in human communication disorders: Perspectives on a process. San Diego: College-Hill Press

Pickering, J. and McCready, V. (1990) Interpersonal communication skills: A process in action. In: Communication and collaboration (pp 23-25). Rockville, MD: ASHA

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