20Q: Clinical Education and Precepting - Training the Next Generation of Audiologists

From the Desk of Gus Mueller

It is estimated that there are around 600 or so 4^th year AuD students in clinical placements each year.  Additionally, most AuD training programs do not have the staff, facilities, or patient load to provide adequate clinical training for their 2^nd and 3^rd year students, so these too go out to part-time clinical placements. It’s probable, therefore, that at any given time, well over 1000 AuD students are receiving clinical training outside of the university by volunteer clinical audiologists.  That’s a sizeable portion of the clinical audiology workforce involved in this important task!

Being a good supervisor isn’t easy, and it may not be all that related to how good you are as a clinician.  Those of you who follow sports know that the best coaches and managers usually were only average players. In their playing days they had to work hard to stay on the team, which gave them a good understanding of the overall learning process. In my heyday, I think I was close to a superstar at masking, but when a student would ask me to explain how it was done, my typical reply was something like, “Keep plugging away, one of these days you’ll have an ‘aha’ moment, you’ll just ‘get it,’ and from then on it will be intuitive.”  Probably not the best mentoring!

Speaking of intuition, although it may occasionally be helpful, it actually takes some work to be good at supervision.  That’s why we have people like this month’s 20Q guest author to help us out.  Joanne Schupbach is an Assistant Professor at Rush University and the Manager of Audiology Clinical Education for the Department of Communication Disorders and Sciences’ AuD program in Chicago, IL. She is actively involved with graduate level teaching, managing the clinical education of the Rush AuD students (all 58 of them), as well as working with patients in the Rush Audiology Clinic.

In addition to her teaching and clinical duties, Joanne serves as a liaison to the University’s student disability program and sits on the Americans with Disabilities Task Force. She also has served on various university, hospital, state and professional organization committees and is a former member of the Illinois Speech Pathology and Audiology licensing board.  And, around the time of this publication, she was awarded the Honors of the Association from the Illinois Speech and Hearing Association (ISHA).

Joanne has lectured extensively on clinical education issues, assisted external sites with development of clinical training programs and teaches a course in supervision at Rush.  You may be familiar with her course here at AudiologyOnline from a few years ago.  We’re happy to have her back with more insights on the important topic of clinical audiology supervision. 

Gus Mueller, PhD
Contributing Editor
Februrary 2017

Browse the complete collection of 20Q with Gus Mueller CEU articles at www.audiologyonline.com/20Q

20Q: Clinical Education and Precepting - Training the Next Generation of Audiologists

 Joanne Schupbach

1. Is there one specific thing that is critical to ensuring high quality clinical training of students? 

Well this may sound a little too simple, but communication is fundamental to student training and to a successful student-preceptor experience.  Our field relies upon effective communication but miscommunication or inadequate communication related to student training can really change the dynamic of a clinical experience. Students and preceptors must develop a strong communication system at the beginning of their time together to ensure that expectations and goals of the experience are similar, realistic and achievable. Students should learn that to accomplish their goals during a clinical rotation, it is essential for them to develop clear, respectful and ongoing dialogue with their preceptors. This can be challenging for students, particularly when working with multiple preceptors in a given setting. As supportive preceptors, it’s our responsibility to develop a positive, clear and effective message for our students and to encourage them to communicate their thoughts and needs.

2. Is this easy to accomplish?

No, it isn’t.  As we all know, beginning something new can be very challenging and stressful. With more knowledge about the new situation, stress can be reduced greatly and the transition can be very smooth. Students train in various audiology settings during their academic experience and they learn from many different preceptors. It’s similar to changing “jobs” every 10-16 weeks. In each new setting the student must learn a great deal about the site, the professionals, and the patients in a short time span and still perform at his/her best ability while still on an extremely steep learning curve. It’s difficult to do. More information prior to beginning the clinical experience can be very helpful to the student.

3.  What should students know before they begin the experience?

It’s critical for the student to understand the basic expectations.  What time do I arrive?  Who is my main preceptor?  Will I be working with multiple preceptors? What is the patient population? What protocols do you use in this clinic? What equipment is used here?  What hearing aid manufacturers and cochlear implant products are utilized for your patients?  What should I review before the rotation begins? You get the idea. This type of information helps the student prepare for the new clinical challenges. Key information also reduces trepidation and assists with the student’s initial expectations.

4. How do you convey all of this upfront information to the student?

You could try the old fashioned way of speaking on the phone but it’s often hard to match preceptor and students’ schedules. Often this communication occurs via email. I’m a fan of written communication to reduce misconceptions about the experience. I’m always impressed when a preceptor has written information for the student that answers these types of questions. Some clinics have developed a student manual which covers topics from A to Z related to the clinical experience. This is so helpful to the student and to the site as the expectations have been clearly delineated. There is less room for misunderstanding. This is also a good time for the preceptor to discuss his/her philosophy on student training and to give some examples of how the preceptor approaches the student experience.

5. You’ve talked about the student, but what information should the preceptor have before the student begins?

Preceptors want information related to coursework completed by the student, previous clinical experience, and what specific populations the student has worked with during other rotations. They often ask for the student’s goals for the experience, information on how the student learns best and the student’s strengths and weaknesses. This is the student’s opportunity to clearly communicate this information to the preceptor(s) in an objective and self-reflective manner. This information can also initially help the preceptor plan for the student’s experience and to assist the preceptor with formulating some of the early goals for the student.

6. You mentioned that the student and the preceptor should set goals. How do they go about that?

Early students may have less ability to develop appropriate goals for initial clinical work so it may be necessary for the goals to be developed primarily by the preceptor. The goals are based upon the information the student has conveyed and the background that the university has provided about the student’s needs. Early students may write goals that are too broad, too high level and not reasonable for a beginning clinician.  But this begins the process of self-reflection for the student.  With the preceptor’s help, appropriate goals can be developed.   

7. Self-reflection?  How does that work?

To develop goals, it’s necessary for the student to learn the art of objective self-reflection or self-evaluation. As practitioners, we are constantly evaluating our work to determine our effectiveness with our patients. While self-reflection may seem second nature to experienced audiologists, it is generally not easy for early learners to assess their work. When asking an early student how he/she performed, you may hear a ”laundry list” of what the student didn’t do correctly. While it is important that a student is aware of the areas for improvement, it is equally critical that the student appreciates his/her areas of measureable improvement and determines what might be modified for additional learning growth.

8. Can a preceptor assist the student with self-reflection?

Certainly.  Preceptors can support students’ self-reflection by asking “Wh” questions after they’ve worked with a patient.

1. What went well?
2. What didn’t go well?
3. What would you do differently?
4. Why would you do that differently?

Cokely and DePlacido (2012) described a journaling technique for students to use in order to foster ongoing self-reflection. This useful exercise could be shared with the preceptor to gain the preceptor’s commentary on the student’s self-reflection and to foster ongoing dialogue regarding appropriate goals and achievement of those goals. This important feedback from the preceptor, as well as the student's ongoing clinical experiences, will help foster more sophisticated self-reflection. Improved self-reflection should translate to a student’s increasing ability to develop specific goals appropriate to the experience and to determine effective ways to measure goal achievement as learning progresses. Improved self-awareness leads to attainment of higher level skills such as problem solving, integration and critical thinking.

9. Is there a preferred way to give students feedback?

There are many ways to give feedback including verbal, written, or criteria or competency based. When considering feedback, there are a few foundational points. Learning evolves over time. Learning is best achieved when there is sufficient opportunity for practice, repetition of varied learning activities, and ongoing feedback. Feedback should also evolve over time as the student becomes more experienced. Feedback is most effective when given regularly, immediately, and when it is specific, constructive and positive. Feedback is essential in all areas of student clinical work including goal setting, developing effective communication, and refinement of assessment and treatment of patients. Feedback is equally necessary with report writing, with evaluation of student performance, and with promoting ethical and professional conduct.

10. I think I’m okay with providing feedback to the students, but I’m not sure the students always understand what I’ve told them.

That’s probably true for all of us at some point. Sometimes we give too much feedback at once or the feedback we give isn’t specific enough. We may not validate that the student has understood our message. Pfeiffer and Jones (1972) discussed that feedback should be:  (a) descriptive, (b) specific, (c) responsive to the needs of the system, (d) oriented to modifiable behavior, (e) solicited rather than imposed, (f) well-timed and (g) validated with the receiver. So using their criteria, a preceptor might say to the student immediately after the appointment, “Bill, I really liked how your case history was very detailed related to the patient’s primary complaint. With your next case history, you might consider asking more about the frequency of the patient’s vertigo. For example, ask how many episodes the patient has experienced over the last six months. Do you understand why this would be important?” Or using a more reflective approach, a preceptor might say, “Sally, can you give me one specific thing that you might change with your counseling of this patient and why?"

11. I remember having a preceptor who always seemed to give me negative feedback. It seemed that I couldn't do anything right in her eyes.

Most of us respond best when feedback is objective and honest and isn’t peppered with demeaning or sarcastic commentary. A student who is provided with positive, helpful and encouraging feedback will likely apply that information better and will continue to develop increased confidence with his/her work. We want students to feel energized and excited about their clinical work and their progress and not to dread the experience. It is about how the message is delivered.  A preceptor can get the important messages across while still maintaining a positive and thoughtful dialogue with the student.

12. How about when I’m doing clinical teaching?  Do you have a recommended approach for that?

It really depends upon the level of the student. Early learners require significantly more guidance and assistance than a later learner. So that means more hand holding early on and more independence with advanced learners.  The teaching strategies should match the level of learner but also be flexible enough to match the pace of the student’s learning.  

13. Pace of learning?  Aren’t I the one who sets the pace?  

Maybe not.  Adult learning principles state that teaching/learning should be an individualized process that is influenced by the readiness and motivation of the learner. The learner must be actively involved in the process, be able to integrate knowledge with performance and be facilitated by positive and timely commentary. Students learn at different rates and our pace of teaching should be commensurate with the rate of progress our students demonstrate. I think we assume that an early learner has a slower pace and a more experienced learner should have a faster pace. This may not be true as more advanced students are developing higher level skills of synthesizing, integrating, problem solving and critical thinking. Their pace may actually slow for a period of time as they begin to pull it all together, so to speak.  

14. Okay, let’s say I have an early student. What should I do?

I really like Burns and colleague's (2006) article as a resource for teaching strategies.  They discuss that with an early student, you might try a more passive approach. You share your impressions of the cases and think them through together. You point out the common practice patterns across patients. You carefully select easier patients for the new student to evaluate. You model how it is done.  You may choose to have the student do only part of the evaluation and let them observe part. You may also assign directed readings that apply to your specific patient population. As the student progresses, you may try direct questioning for the student to share their observations and interpretations. For example, “Susan, tell me one important point that you picked up on during the patient’s case history?” The goal is to engage the early student in the clinical setting in a progressive manner without overwhelming the student.

15. What about a 4^th year student?  How do teaching strategies change?

While the 4^th year student still needs supervision and guidance, it takes on a different form. The preceptor steps back a bit by providing less input on the basic components of care, and offering more support and information related to patient management.  The preceptor is confident in the student’s proficiency with assessment and evaluation and now focuses on the student’s ability to manage the patient overall. The student is challenged to stretch his/her knowledge and skill to move toward independent practice.  The student is allowed to establish the priorities of the patient interaction and determine relevant information, while working to become more efficient and effective with their time. These students are given more independence with patients as their clinical reasoning skills expand. “Why” becomes a very important question asked by the preceptor. Why did you do that test?  Why did you choose that particular pair of hearing aids? Why did you make that recommendation, and please discuss your rationale and the appropriate evidence for that recommendation.

16. Much our work with 4^th year students revolves around development of higher level clinical skills, but what other skills are important for these students?

Healthcare is changing at a rapid pace and our students need experiences that also develop their flexibility, adaptability and creativity. They need to learn how to deliver all of the necessary services in this ever-changing climate, in a cost effective manner while maintaining best practices. This is the incidental learning that our preceptors teach to students that is equally essential for students’ professional development.

17. I can understand how flexibility and creativity are important. What kinds of changes in the profession do you envision our current students will encounter during their careers?

Teleaudiology will likely be a significant part of their future practice. As we know, telemedicine has been around for many years and has developed into a viable service delivery model in many practice areas.  This is where the ability to be creative and flexible will serve our future professionals well. Rather than view different delivery models as potential obstacles, it will be important for future professionals to figure out how teleaudiology can be a viable delivery model for our patients and in what areas of practice. Administrators are looking to all healthcare professionals to develop programs that can serve our patients well at a lower cost. I think the saying is “turning lemons into lemonade”. Future audiology practitioners must use their creativity to develop innovative ways to deliver service. If we don’t, healthcare administrators will do it for us in ways that may not be in our patients’ or our profession’s best interest.

18. What else do you see in your "crystal ball"?

Well my crystal ball is not that clear, but interprofessionalism will continue to be important. Certainly healthcare teams have been critical over the years for providing comprehensive care to special populations, such as Cleft Palate teams. The resurgence of this model to encompass all of healthcare is a crucial opportunity for our students to learn the value of different professional team members in providing comprehensive quality care to all patients. Our patients are living longer with a better quality of life.  This is wonderful but many of them also have very complicated medical conditions. It takes a team approach to adequately address all of a patient’s needs, and our future colleagues will be important members of many such teams. Our students will need to acquire the skills to navigate these teams by demonstrating effective communication about shared knowledge and goals for the patient while demonstrating mutual respect for other healthcare colleagues. Everyone must come to the table prepared to mutually achieve the best outcomes for those we serve.  As large as the professional scope of practice is now, it will likely expand as these interprofessional teams work collaboratively.

19. It seems that preceptors have a lot on their plates when it comes to training students.  What's in it for the preceptors?

You’re right - as audiologists today, we all have a lot on our plates. We are being asked to do more with less regardless if we work in a private practice, hospital, or educational setting. Increased productivity is a common goal for most facilities and the rapid pace of our clinical settings only adds to the daily demands. With that being said, in order for our profession to serve the ever increasing number of patients, our commitment to high quality training for our future professionals is necessary.  These future colleagues will be providing services to you and me, and I’m confident that our mutual professional goal is to have all students trained to the highest level of expertise. This is a shared responsibility between the academic training institutions and all practicing audiologists. Training the next generation of audiologists is not only exciting, but an honor. 

20. I'm with you! Any final thoughts?

Each of us owes much to those preceptors and mentors who committed their time and expertise to ensure our knowledge and skills were outstanding. If not for the countless numbers of devoted and dedicated practitioners who trained us, our profession would not be what it is today.  I am excited to see our next generation of audiologists begin their careers and become outstanding preceptors for those who will follow them. 

References

Burns, C., Beauchesne, M., Ryan-Krause, P., & Sawin, K. (2006). Mastering the preceptor role: Challenges of clinical teaching. Journal of Pediatric Health Care, 20(3),172-183.

Cokely, C., & DePlacido, C.  (2012). Fostering reflective skills in audiology practice and education. Seminar in Hearing, 33, 65-77.

Pfeiffer, J., & Jones, J. (1972). Openness, collusion and feedback. The 1972 annual handbook of group facilitators.  University Associates, 197-201.