5/11/2015
Setting the stage…
The CCCs of Clinical Supervision in SpeechLanguage Pathology:
Complexities, Challenges, Competencies
Presentation:
Sacred Heart University
May 19, 2015
Susan EM Bartlett, MA, CCC-SLP
• Supervision takes on a different look
depending on the circumstances:
– Academic training programs
– Externship of off-campus supervision of graduate
students
– SLP/Assistants
– Clinical Fellows (SLP)
– Clinical doctoral students in audiology (4th year)
– Colleagues/peers who are credentialed
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Today…
Agenda for presentation
• Begin to build a foundation of understanding, i.e.,
“gaining knowledge” , the components and elements of
supervision of graduate students
– Salient features of supervision
– Off-campus experiences for supervisors and
supervisees
– Somewhat generic approach to discussing the
“process of supervision”
• Incorporate suggestions that will help individuals who
are supervising or who plan to toward developing “skills”
• Reminiscence (“memories from the corners of our
minds”)
• Overview/review of the technical aspects that
influence, shape, oversee, circumscribe clinical
supervision (documents, requirements, standards,
etc.), i.e., “complexities”
• Enduring modelof supervision: Anderson’s continuum
• Identification of obstacles and some possible strategies
for managing them, i.e., “challenges”
• Planning outcomes, i.e., “competencies”
• ROI (Return on investment)
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Learner Outcomes
Take-away messages
• Gain exposure to pertinent ASHA and other documents
and research that relate specifically to the supervision
of students in clinical practicum experiences (i.e.,
“technicalities”);
• Describe and apply the seminal model of the
continuum of supervision developed by Jean Anderson;
• Apply at least one strategy for managing obstacles to
effective clinical teaching/learning; and
• Summarize the benefits and rewards of the clinical
supervisory experience.
• Clinical Supervision is a process; it is a component of Clinical
Education
• “Supervision” is not a synonym for “observation”
• Aspiring toward a “win-win” outcome
• Clinical educator’s outcomes, gains
• Supervisee’s outcomes, gains
•
•
•
•
Rooted in over 30 years of research
“One-size-fits-all” approach does not work
Off-site practicum: offering student clinicians EPB at its best!
You are not going to create “finished products”
– May be working toward “Clinical Fellowship-ready”
• Respect is a two-way street; essential to achieving
effective interpersonal relationships
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Breaking this down…
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“Complexities”, i.e.,Technicalities
• ASHA Documents
“Complexities”
• Technicalities that circumscribe the process/practice
• Details
“Challenges”
• Obstacles
• Realities
– Standards
•
•
•
•
CAA
CFCC
Knowledge and Skills for Supervisors (2008 a, b, c)
ASHA Code of Ethics (2010)
“Competencies”
• Acquisition and demonstration of knowledge and skills
• Outcomes and rewards
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• Clinical Education Guidelines for Audiology
Externships (ASHA)
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Other pertinent publications
• Focus Group Report: Externship Supervision
(2007)
• CAPCSD “White Paper” (April 2013)
• Ad Hoc Committee on Supervision
(December 2013) aka Blue Ribbon Panel on
Challenges out of the gate!
• Program & Site arrangements:
– Contracts (part of CAA standard, required by…)
– FERPA
– Matching students to sites (requirements for
preparedness)
• Site:
– Who can take on the role/responsibility of clinical
educator
Supervision
• Time, qualifications, caseload size/variety/consistency,
experience, and (soon) coursework or CE in supervision
• Liability
• Defining the role of field supervisors
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Family Education Rights & Privacy Act
“What does this have to do with
supervision of students?”
• 1974, amended 2008 Buckley Act
• School age: through 18 OR when student enters
college/university
• Students/families have the right to amend
information in a record (specific guidelines)
– Change factual information, not grades
• Educational record information CANNOT be
shared without the student’s permission
– May be waived
– Certain exceptions exist around safety, legal issues
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• Information cannot be given out about:
– Student’s grades
– Student’s coursework
– Anything that is part of her/his educational record:
• Files, reports, documents, samples of work, grades, etc.
• “What can I tell you?”
– Student’s academic standing, anything that is not a part of the record
•
Be aware:
•
•
•
Your written notes are your own; they are not part of the record
Keep only what is necessary/pertinent
Your written summary becomes part of the academic record
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Personal reflections
• What was the best thing that you remember
about your first clinical practicum
assignments?
– On-campus clinic
– Field site
• What was the most unsatisfying aspect of
your clinical practicum assignment?
• What did you want from your supervisor?
• What did you gain as a result of the
supervisor/supervisee relationship at the end
of the assignment?
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1990: Pannbacker et al “Am I a Good
Supervisor?”
Similarly Pickering (1990) found
• Student clinicians preferred supervisors to:
– Be available
– Be consistent
– Be fair
– Be flexible
– Provide feedback
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Three significant needs stood out in students’ writing
about their supervisory experiences. The expressed a
desire:
1) To feel support and encouragement from their
supervisors;
2) For supervisors to encourage two-way feedback
because the student would not feel free to give it
otherwise; and
3) To know what is expected. Lack of knowledge about
expectations evoked students’ decision not to ask
questions for fear of sounding ignorant.
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2007 Focus Group:
Externship Supervision
• Memories of being supervised in a health care
placement on the plus side:
– “…supported my coursework (i.e., made the
abstract concrete”
– “solidified my desire to work in a hospital setting
following graduation”
– “gained information that others have to go to
conferences for”
Supervisors’ interpersonal skills…
and their impact on supervisees’ clinical
effectiveness:
“…when supervisees perceive high levels of
unconditional positive regard, genuineness,
empathic understanding, and concreteness,
their clinical behaviors change in a positive
directions.”
(Ghitter, 1987)
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ASHA Documents
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Standards and Implementation
CFCC: Std. V-E
• CFCC (Council for Clinical Certification)
– 2014 Standards and Implementation Procedures
for the Certificate of Clinical Competence in
Speech-Language Pathology
• CAA (Council of Academic Accreditation)
• Code of Ethics
• Knowledge and Skills Needed by SpeechLanguage Pathologists Providing Clinical
Supervision (2008)
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The amount of direct supervision must be commensurate with the student’s knowledge, skills and
experience, must not be less than 25% of the student's total contact with each client/patient and
must take place periodically throughout the practicum.
Implementation: The 25% supervision standard is a minimum requirement and should
be adjusted upward whenever the student's level of knowledge, skills, and experience
warrants.
CAA: 3.5B Clinical supervision is commensurate with the clinical knowledge and skills of each
student, and clinical procedures ensure that the welfare of each person served by students is
protected, in accord with recognized standards of ethical practice and relevant federal and state
regulations.
Implementation: The program must have written policies that describe how the manner and
amount of supervision are determined and adjusted to reflect the competence of each student and
the specific needs of the clients/patients served.
3.6B Clinical education obtained in external placements is governed by agreements
between the program and the external facility and is monitored by program faculty.
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Web link to document
• http://www.asha.org/policy/KS200800294.htm#sthash.t7AC2XLV.dpuf
ASHA Documents Specific to Supervision in
Speech-Language Pathology
• Position statement:
American Speech-Language-Hearing Association. (2008). Clinical
supervision in speech-language pathology [Position Statement]
(Available from www.asha.org/policy)
• Technical report:
American Speech-Language-Hearing Association. (2008). Clinical
supervision in speech-language pathology [Technical Report]
• Knowledge and Skills:
American Speech-Language-Hearing Association. (2008). Knowledge and
skills needed by speech-language pathologists providing clinical
supervision [Knowledge and Skills]
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11 Fundamental Components of
“Knowledge and Skills” document
Knowledge and Skills Needed
Cluster into these core areas:
– Preparation
– Inter-personal
– Clinical teaching
– Diversity
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• I. Preparation for the Supervisory Experience
• II. Interpersonal Communication and the SupervisorSupervisee Relationship
• III. Development of the Supervisee's Critical Thinking and
Problem-Solving Skills
• IV. Development of the Supervisee's Clinical Competence in
Assessment
• V. Development of the Supervisee’s Clinical Competence in
Intervention
• VI. Supervisory Conferences or Meetings of Clinical Teaching
Teams
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Knowledge and Skills (cont’d):
• VII. Evaluating the Growth of the Supervisee Both as a
Clinician and as a Professional
• VIII. Diversity (Ability, Race, Ethnicity, Gender, Age, Culture,
Language, Class, Experience, and Education)
• IX. The Development and Maintenance of Clinical and
Supervisory Documentation
• X. Ethical, Regulatory, and Legal Requirements
• XI. Principles of Mentoring
Code of Ethics (2010)
Principles and Rules Relating to Supervision
• I. D. Individuals shall not misrepresent the credentials of
assistants, technicians, support personnel, students, Clinical
Fellows, or any others under their supervision, and they shall
inform those they serve professionally of the name and
professional credentials of persons providing services.
• I. G. Individuals who hold the Certificate of Clinical
Competence may delegate tasks related to provision of clinical
services that require the unique skills, knowledge, and
judgment that are within the scope of practice of their
profession to students only if those services are appropriately
supervised. The responsibility for client welfare remains with
the certified individual.
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Ethics in Supervision
CAPCSD “White Paper…” (2013)
• Situations of potential misconduct can include,
but are not limited to: (King, 2003) Asha Leader:
– failure to provide a sufficient amount of supervision
based on the performance of the supervisee;
– failure to educate and monitor the supervisee's
protection of patient confidentiality;
– failure to verify appropriate competencies before
delegating tasks to supervisees;
– failure to demonstrate benefit to the patient based on
outcomes, and
– failure to provide self-assessment tools and
opportunities to supervisees.
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Recommendations:
1) “The time has come to require formal education in the
supervisory process to ensure that supervisors are prepared
to assume this demanding, complex and important role in
our profession.”
2) “…the required clinical educator training should follow a
standard curriculum with primary focus on the supervisory
process which can be adapted to meet the needs of
supervisees at all levels.”
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Recommendations (cont’d):
• Training content should be structured around the Knowledge and
Skills Needed by Speech-Language Pathologists Providing Clinical
Supervision (2008c) described in this document.
– Establishing an effective relationship with the supervisee
– Utilizing effective communication skills
– Structuring learning experiences to facilitate critical thinking and
decision-making skills
– Using questions to develop clinical reasoning skills
– Using objective observation techniques and sharing feedback
– Understanding the impact on diversity of supervisory
interactions
ASHA Ad Hoc Committee (12/13)
Areas of training for all persons engaged in supervision
(generic):
Knowledge: Supervisory process and clinical education
• Collaborative models of supervision
• Adult learning styles
• Teaching techniques (reflective practice, use of questions)
• Definition of ‘sor and ‘see roles and responsibilities
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Ad Hoc committee (cont’d):
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Specific to Student Training
Committee (cont’d):
• Supervisor will:
Skills:
•Relationship development (“supportive and trusting”)
•Communication skills
•Establishing and implementing (supervisory) goals
•Analysis
•Evaluation
•Clinical decisions (ethical dilemmas, apply regulatory guidance)
•Performance decisions
•Research/
•Evidence-Based Practice
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– Connect academic knowledge and clinical procedures
– Sequence student’s knowledge and skills development
– Facilitate student’s ability to respond to various clinical
settings and supervisory expectations
– Build professional identity and engagement
– Facilitate student’s utilization of information to support
clinical decision making and problem solving
– Understand the contractual agreement with the sending
program and adhere to the requirements (when
applicable)
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Anderson’s model (1981)
• Joint problem solving
• Use of objective data collection and analysis
• Recognizes the interrelatedness of the clinical
process and supervisory process
• Dual role of student clinician: supervisee and
novice clinician simultaneously
• ‘Sors and ‘Sees “must grow and develop and
improve their own skills as they participate in
the supervisory process”
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Evaluation - Feedback Stage
•
•
•
•
•
Supervisor (‘Sor) plays dominant role
Less assertive role by Supervisee (‘See)
‘Sor organizes and directs
Supervisory style is direct and active
Appropriate for clinician with emerging or no
experience and/or knowledge
• ‘See requires varying amounts of assistance
• Goal is to move out of this phase
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Transitional Stage: (Sharing responsibilities)
• ‘See gains knowledge and skills (and
confidence)
• ‘Sor enables ‘See’s participation in problemsolving, decision-making
• ‘See increased responsibility for analyzing,
modifying and working toward independence
• ‘Sor continues to provide feedback but it may
be negotiated
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Self-Supervision Stage
Components of Supervision
(Anderson, 1988)
• ‘Sees demonstrate competency on a consistent
basis
Understanding
– alters own behavior independently and accurately
– may consult with peers
Planning
Integrating
• ‘Sors reinforce independence and use of
resources
– listens, supports, participates in some problem solving
– may continue to collect data
Analyzing
Observing
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“Challenges”
Institutional
• Productivity expectations (billable time)
• Release time for clinical education
responsibilities
• Scheduling (patients and practitioners)
• Resources
• ?? Policies and procedures for accommodating
students
• Institutional
• Interpersonal
• Intrapersonal
– Student clinician’s
– Supervisor’s
– Manuals to guide externship experiences for
students?
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Site specific challenges
• Student’s knowledge-experience gap (skill set)
• Time management
• Record keeping/documentation (brevity and
relevance)
• Data: collection, analysis, interpretation, application
• Flexibility
• Long-term and short-term goal planning
• Reading and understanding charts/records (EMR)
– Terminology, abbreviations, reporting styles, familiarity with EMR
•
•
•
•
•
•
Cont’d:
• Devising relevant sequence of intervention
goals/activities
• Determining functional outcomes with EBP
foundation
• Site’s expectations for productivity: ‘Sors and
‘Sees
• Competency for specialized procedures
• Liability issues: More “touch” greater the risks
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Cont’d:
Interpersonal
Team participation
Universal precautions
Patient/client etiquette
Student’s quest for specialty “hours”
Billing
Balancing “direct” feedback with student’s
developing/emerging/evolving competence
(confidence)
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• Cultural
– Age
– Gender, gender identity/gender expression
– Religion (beliefs, practices, traditions)
– Race or ethnicity
– National origin
– Sexual orientation
• Power status and authority
• Generational cohorts
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Interpersonal: What is the impact on the
experience?
Generational Cohorts
The Greatest (Silent) Generation
Baby
Boomers
• Cultural:
– Intergenerational
– Traditional: ethnic, race, religion
The Milleniuns – Y and “Z”
• Positions of power
- Boundaries
What affects the learning experience and
delivery of services to patients? Can it be
changed?
Gen X
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Seeking a balance
Potential “Slippery Slopes”
Effective clinical teaching
Effective interpersonal interactions
(and level of rapport)
• Self-disclosures
• Boundary crossings
– Accidental
• Continuum from “benign” to “harmful”
- Blurring the lines
• Supervisor as a friend or peer (or “buddy”)
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Power
• Supervisors hold the power of:
– grading,
– signing off on clinical hours,
– conducting performance evaluations, and
– making promotion decisions.
Lack of awareness of the influence of power can
result in intimidation and a reluctance on the part
of the supervisee to participate actively in the
supervisory experience.
Interpersonal communication
• Reference to technical documents and citation of
importance of effective inter-personal communication
• Multi-directional
– Supervisor and Supervisee (supervisory process)
– Supervisee and Supervisor
– Supervisee (as clinician) and patient
• Inter-generational
– Older and “very old” clients
• Their “children” who are older (60’s +)
• Necessary to have an explicit discussion about what is
appropriate communication relative to the cohorts’
characterizations
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Implications for
Clinical Instruction and Education
Supervisor
Technology
Support
Experiential
Learning
Guidance
Patient/Client/Pupil/Others
Hands on
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Group
Discussion
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What the millenium cohort values
Direction and
Guidance
Immediacy
Provide structure
(rules, priorities,
procedures) and
consequences.
Make expectations
clear from the
beginning.
Be the model.
Be a non-judgmental
sounding board.
Point them toward
resources.
Be responsive.
Set realistic
expectations.
Help them
understand the
slow nature of
recovery.
Shaughnessy, 2009
•
•
•
•
•
•
•
•
Intrapersonal (Supervisor)
How can I do my job AND teach a student to do it
without doing twice the work?
How do I make time to teach a student how to do
all the little things that I do in a day?
How can I answer all of the student’s questions
with the (crazy!) schedule I have?
How do I know what the student knows or needs
to know?
How do I support the student’s progression to
independence (critical thinking and problem
solving)?
Adapted from: Peterson, Lulai, & DeRuiter, 2012
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Parallels between client intervention
and student “intervention”
Preparing for the supervisory
experience
Assessing level of knowledge & skills
Determining strengths & needs
Devising goals and outcomes
Establishing strategies to accomplish outcomes
Assigning responsibilities
Collecting data
Analyzing
Evaluating
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•
Interview
– Selection by the site’s practitioners/administrators
– What do you want to learn about the student’s level of readiness to
participate in a placement at this site? Prior experiences?
– What do you want the student to know about this placement/site?
•
Inventory
– Skills and knowledge – “book knowledge”, experiential knowledge
– “What is your comfort level with…?”
– “What has your experience been with…?”
•
Student’s self-evaluation
–
–
–
–
Strengths
Needs (knowledge and skills)
Learning strategies
Preferences
•
•
Feedback
Conferencing
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Getting to competence
Where on the (Anderson)continuum?
• Point on the continuum will affect the
approach to changing the behavior
– For most, it’s at the “Direct/Active” stage in each
new setting
• Does the skill/behavior require direct
feedback? Indirect feedback?
• Student’s self evaluation
•
Create a list: Identify what needs to be worked on (changed)
–
–
–
–
•
Sending program’s skills/knowledge/outcomes materials
Site’s skills/knowledge/outcomes material
Supervisee self-evaluation
Supervisory feedback (look for patterns, repetition)
Categorize– joint process ‘see and ‘sor plan together
– Technical, Institutional, Intrapersonal, Interpersonal
• Knowedge? Skills?
•
Prioritize: Choose the top three (identify time period)
•
Choose the one that will yield the most immediate impact
– Consider the amount of time available for working on the behavior/skill
– “Generalizability” is key consideration
– Determine how much time will be allocated
•
•
•
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Devise an action plan
Action plans – “macro” and “micro”
Identify the goal: make it measurable
Identify a criterion for mastery; acceptable performance level
Identify a strategy for determining whether the goal was achieved
– Consider external validation
•
•
Identify how (frequency of occurrence, %age, ratings) and what kind of
data will be collected, documented
Create a timeline, including a scheduled, focused discussion time relative
to progress toward the goal
– Communication with program liaison (updates, evaluation)
•
• Essential elements of the clinical process: Documentation Data collection,
Assessment plans, Implementation of assessment procedures, Implementation of
treatment, Supervisory process, Interpersonal/professional skills, Analysis,
interpretation, evaluation
• “Micro” plans :
– Weekly
Contingency plans
– If goal is met, what’s next?
– If goal is not met, what is next?
•
• “Macro” plan: Long range planning
• Each week
• Two week period
• Three week period
Identify who will do what:
– Supervisee’s responsibilities
– Supervisor’s responsibilities
– Liaison’s responsibilities
– Daily
• Use of personal journal, notebook
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Clinical “teaching”
• Planning
• Observation of clinician (‘Sor demonstration)
– Model the clinical behavior, implementation of an assessment or
treatment activity, data collection, modifications
• Phasing in ‘See’s participation; specify ‘Sor’s role
- Prompt as necessary
-
Adjust amount of support, immediacy of feedback
Determine ‘See’s readiness to assume responsibility
• Independence
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Giving feedback
Promes (adapted from Berquist & Phillips, 1975)
It is …
• descriptive rather than evaluative.
• specific rather than general.
• focused on behavior rather than on the person.
• accountable to the needs of both the receiver and the giver .
• directed toward behavior that the receiver can do something about.
• solicited rather than imposed.
• well-timed.
• focused on sharing information, rather than giving advice.
• considerate of amount of information the receiver can use.
• specific to what is said and done, or how, not why.
• confirmed to insure clear communication.
• validated by others as necessary.
• followed by attention to the consequences.
• an important step toward authenticity.
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Supervisor feedback
•
•
•
•
•
•
Written (narratives, check-lists, bullet points)
Verbal
In the moment (i.e., immediately) and on-site
Following a session
End of day
Weekly
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“Letting go”
• Timing is planned and negotiated
– Increasing independence
– Meeting standards for direct observation &
supervision
• Determining when and how to step back
• Fear of failure (both supervisor and
supervisee)
– Recognizing obstacles
– Planning contingencies
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Role of the program’s liaison
• Maintain contact with the off-campus supervisor
– On-site visits when possible, neccesary
• Ensure that the standards that steer the supervised experience are
met (i.e., CFCC, CAA)
– Minimum percentage of direct observation is met
– Adjusted upward as necessary
• Assist in interpreting the regulations that guide supervisory
practices
– ASHA
– The sending program’s
• Assist in the student’s performance review process
• Intervene when issues surface (interpersonal, intrapersonal,
institutional) that are of concern (to supervisor, to student, to liaison)
Research
•
•
•
•
•
•
•
•
•
•
•
•
Jean Anderson
Elizabeth McCrea
Judith Brasseur
Stephen and Judy Farmer
C. Vicki McCready
Ruth Peaper
Elizabeth Gavett
Barbara Solomon
Wren Newman
David Shapiro
Sandra Ulrich
Judith Rassi
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Reference material and resources
References (cont’d):
(ASHA) Special Interest Group 11: Administration and Supervision
American Speech-Language-Hearing Association. ( 2008). Knowledge and skills needed by speechlanguage pathologists providing clinical supervision [Knowledge and Skills]. Available from
www.asha.org/policy
American Speech-Language-Hearing Association. (2010r). Code of ethics [Ethics]. Available from
www.asha.org/policy - http://www.asha.org/Code-of-Ethics/#sthash.XjKoA9GT.dpuf
Anderson, J. L. ( 1988). The supervisory process in in speech-language pathology and audiology.
Boston, MA: College Hill.
Durkin, D. ( 2008). March-April). Youth movement. Communication World, 1– 4 (cited in SchoberPeterson et al)
Ghitter, R. (1987). Relationship of interpersonal and background variables to supervisee clinical
effectiveness. In S. Farmer (Ed.), Proceedings: Clinical Supervision: A Coming of Age,
CUSPSPA, Jekyll Island, GA (June)
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Herd, C., Kerins, M., and Matrangola, D. (2012). Generational Spin: How Supervisors View the Millennials, SIG
11 Perspectives on Administration and Supervision, October, Vol. 22, 74-84. doi:10.1044/aas22.3.74
Herd, C. & Moore, R. (2012) Multicultural Issues: Supervisors and Supervisees. SIG 11 Perspectives on
Administration and Supervision, March, Vol. 22, 33-39. doi:10.1044/aas22.1.33
King, D. (2003, May 27). Supervision of student clinicians: Modeling ethical practice for future professionals.
The ASHA Leader, 8, 26
Lancaster, L. and Stillman, D. (2002). When Generations Collide, New York: Harper Business
Levine, A. & Dean, D. (2012). Generation on a Tightrope: A portrait of today’s college student, San Jose: Jossey
and Bass
McCrea, E. & Brasseur, J. (2003). The supervisory process in speech-language pathology and audiology.
Boston: Allyn & Bacon
Pfiefer, G, (2012). Attitudes Toward Piercings and Tattoos, American Journal of Nursing. (May) Vol. 112, Issue 5,
doi:10.1097/01.NAJ.0000414303.32050.99
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References (cont’d):
Pannbacker, M., Middleton, G., & Lass, N. (1993). Am I a good supervisor? That depends on who’s asking! The
Supervisors’ Forum, 1, 57
Pickering, M. (1990). Establishing and maintaining an effective working relationship: The first task of supervision. In
Clinical Supervision Across Settings: Communication and Collaboration. Rockville, MD: American Speech-LanguageHearing Association
Schober-Peterson, D., Lulai, R., & DeRuiter, M. (2012). Supervision: The New Clinical Supervisor: Tools for the Medical
Setting. SIG 11 Perspectives on Administration and Supervision, (October) Vol. 22, 85-90. doi:10.1044/aas22.3.85
Shaughnessy, P. (2009). Embracing Generational Diversity, Presentation to CAPCSD, Newport, CA, (April)
Smith, L. , Herd, C. and Cohn, T (2009) Constructing and Maintaining Appropriate Boundaries within Clinical
Supervision Relationships. SIG 11 Perspectives on Administration and Supervision, March, Vol. 19, 30-35.
doi:10.1044/aas19.1.30
Walden, P. & Gordon-Pershey, M. (2013). Applying Adult Experiential Learning Theory to Clinical Supervision: A Practical
Guide for Supervisors and Supervisees, SIG 11 Perspectives on Administration and Supervision, Vol. 23, 121-144.
doi:10.1044/aas23.3.121
Wilson, D. and Emm, M. (2013). Opportunity for Effective Feedback: A Supervision Tool, SIG 11 Perspectives on
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