At the recent 29th Annual Council of Academic Programs in Communications and Disorders, a discussion took place regarding the quality and expertise of clinical educators in audiology. Many participants reported that a large number of preceptors do not stay current in evidence-based practice and research, and that university administrators are not accurately informed about what happens outside of the school clinic.
As an extension of classroom instruction, a quality clinical education is critical in achieving the goals laid out by the American Academy of Audiology (AAA) Clinical Education Guidelines (Packer, Friedland, Rahe, Vento, & Walden, 2011). These goals dictate that an AuD graduate must have the knowledge and skills necessary for professional practice, and "the ability to evaluate and integrate scientific research into clinical practice" (Packer et al., 2011). University faculty should also strive to provide specific training to those audiologists who volunteer to act as preceptors for students so they can provide an up-to-date clinical education and help the students attain the second goal of integration. In order to ensure a superior clinical education, the university clinic should be responsible for providing the foundation in clinical skills for all other placements.
AuD students work in clinical settings within their university clinics, in various outside rotations and during a clinical externship in their fourth-year of program study. This article will discuss how research is integrated into clinical practice, specifically at The Center for Audiology and Speech Language Pathology at Montclair State University (MSU), and will review suggested methods for training audiology preceptors in placements outside the school clinic.
What is a Preceptor?
The definition of a preceptor is essential to understanding the role he or she plays in training students. According to a 2011 Hearing Journal article by Craig Newman, Sharon Sandridge and Sharon Lesner, "Preceptors are experienced clinicians who share professional knowledge by teaching in the real world using a one-on-one tutorial relationship with the student. The teaching style is focused on interactive learning triads involving the student, clinician, and patient all within the clinical context" (p. 20).
In its guidelines, the AAA task force (Packer et al., 2011) defines the role and responsibility of the preceptor as being threefold:
- To provide the highest quality of service to the patient.
- To educate the student and provide feedback on the student's diagnostic, treatment and interpersonal skills.
- To maintain open communication with the student and the university.
In addition, the American Speech-Language-Hearing Association (ASHA) position statement (2011) on clinical supervision - which is available in full on the organization's Web site at asha.org - outlines the tasks and competencies for effective supervision. It is important to note that ASHA uses the term supervisor rather than preceptor. ASHA defines supervision as referring to the tasks and skills of clinical teaching related to the interaction between a clinician and client. Supervisors and preceptors are both clinical educators, and in many cases the same skill set is needed. According to ASHA, some highlights of the skill set needed to supervise include the ability to apply learning principles in the supervisory process and the ability to share current research findings in client assessment. The ASHA position statement should be reviewed at length by all preceptors.
From Classroom to Clinic
At MSU, first-year students enter the university clinic during the second semester, after completing coursework in basic diagnostic audiology as well as a hands-on lab course in which they practice basic audiologic techniques. This lab is taught by university clinical educators who are familiar with the theoretical coursework. The two courses are integrated, and therefore provide an evidence-based practice foundation. This is essential so first-year AuD student feel continuity between coursework and clinical practice. Additionally, they learn the ways that research translates into real-world practice.
Before students enter clinic, they are given a formal orientation to the physical setting and to clinic procedures. Students are shown where and how to introduce themselves and greet their patients. In addition, preceptors review and explain paperwork used in the charts so that the students are familiar and can navigate the paperwork with patients. Ethical best practices concerning medical records are explained and students are shown where patient files are stored whether they are working on or have finished with the files. The expected timeline for completing and submitting the clinical report should also be made clear.
Preceptors should review clinical practice objectives and expectations for each semester with each student. At MSU, the students have practiced using all clinic equipment in their lab course. If a student is not familiar with the diagnostic equipment, information and hands-on opportunities should be included in the orientation. The students are given a protocol to follow in the school clinic. This orientation is an excellent opportunity to jointly review the test protocols and have the supervisor available to answer any questions students may have up front.
The student evaluation protocol was developed by academic and clinical faculty and is based on the theory taught in diagnostic classes. At MSU, this protocol includes the following topics: biologic calibration, case history, otoscopy, immittance, pure-tone testing (air and bone conduction), masking for air and bone conduction, speech tests and speech masking (both for speech reception threshold and word recognition tasks), hearing loss classifications and audiometric configurations. All university preceptors are given this protocol to follow as well. It has been our experience that there is less confusion for the first-year students when they have a written protocol to follow and when all preceptors follow the same protocol and procedures.
In the campus clinic, the preceptor and AuD student meet before the patient arrives to discuss the case and review pertinent documentation. During the clinic session the preceptor prepares a formative assessment of each student; and after the patient leaves, discusses the assessment with the student, explaining the student's strengths and weaknesses. Though not a formal evaluation, this method of immediate feedback is an important part of the process, according to Dr. Jack Ende (1983), "Distinct from evaluation, feedback presents information, not judgment. Feedback is informative. As an integral part of the learning process, it allows the student to remain on course in reaching a goal," (p. 777). After the student and preceptor discuss the feedback together, they can agree on a goal and plan of action for the next session. For example, if a student had a problem with the immittance battery, she should make it a goal to practice tympanometry and the acoustic reflex battery on herself or another student before the next time she sees a patient.
Clinical Checklist
An effective way to monitor students' progress is to use a clinical checklist. At MSU, we have developed a clinical practice checklist that uses the following classifications of competence: did acceptably, failed to do, not applicable and see comment. We have found that when the checklist includes a written comment about the specific patient and situation it is a more valuable learning tool than a simple checklist without situation-specific comments. The MSU checklist can be found in Appendix A.
The university should provide clinical practice checklists to preceptors at outside rotations. Preceptors in a non-university practice may not have the time to complete an assessment sheet for each patient seen, but should be encouraged to complete one as often as possible. This feedback allows students to review areas in need of improvement and also allows the preceptor to evaluate the student's needs on an ongoing basis. These evaluations can be used to judge the student's progress. At MSU, students are formally evaluated at both midterm and end of semester. According to a 2008 online lecture by Sharon Sandridge, evaluation is "[how] learning outcomes are measured, further educational needs are identified [and] additional instruction provided...evaluation provides a means of ensuring accountability for quality of education and services."
At the Gold Standard Summit in 2009, attendees from more than 60 training programs - along with representatives from ASHA, the American Board of Audiology, the Accreditation Commission for Audiology Education and the Council of Academic Programs in Communication Sciences and Disorders - discussed the need for a universal form of assessment of student performance to help create a standard clinical skills experience for AuD graduates. The MSU checklist is provided as an example, but it should be noted that, currently, documents such as this may vary widely from university to university. The audiological community would benefit from a standardized process of AuD student evaluation.
The AAA strongly recommends continuing education on a regular basis in the area of supervision for externship preceptors. According to the AAA guidelines (Packer et al., 2011), the university should provide guidance to externship preceptors, in the areas of clinical skills, grading procedures, and best practices in clinical supervision In addition, ongoing preceptor education and training is needed even for those practitioners with many years of clinical experience.
The ASHA position statement on the preparation of clinical supervisors (2011) lists the following ways that the skills and competencies for effective clinical supervision may be acquired:
- Specific curricular offerings from graduate programs; examples include doctoral programs emphasizing supervision, other postgraduate preparation and specified graduate courses.
- Continuing educational experiences specific to the supervisory process (e.g. conferences, workshops, self-study).
- Research-directed activities that provide insight in the supervisory process.
Universities should offer free continuing education opportunities in preceptorship and current evidence-based practice. This benefits both the preceptors and the students because preceptors will receive continuing education credits and students will benefit from their preceptors having the most up-to-date knowledge. An additional method that allows for the continuation of evidence-based practice outside of the university clinic is having the university contract with local ENT or dispensing offices, and allowing one of the university preceptors to work there with second-year students as one of the first off-campus rotations. The setting is different, but the supervision is still controlled.
It is the responsibility of the university to maintain an ongoing collaborative relationship with the clinical preceptors working with their students and to ensure that the preceptors are qualified and meet documented department standards. An open dialogue between the university and the preceptor in the outside placement serves the needs of all involved. The university can support the student and the preceptor by sharing evidence-based protocols and standardized forms for assessment of clinical skills. In addition, the clinic director should review all assessment forms and how they are used. Preceptors should be encouraged to talk to clinic directors about the strengths and weaknesses of the students they supervise. Students should understand that conversations with their university clinic director are held in confidence and they can talk freely about any problems they are experiencing.
Quality of Experience
Quality control is easy to maintain within the university clinic, but is difficult to measure during outside placements. For most students, the quality of the clinical experience will be based on the excellence, understanding, and knowledge of the preceptor. Most audiologists working as preceptors lack formal training for this role. "At the present time, the only requirement for becoming a supervisor is having obtained a certificate via completing coursework and clinical hours. However, there is no routine of formal training provided to prepare one for the role of supervisor" (Carozza, 2011, p. 31). In this case, the certificate referred to is the CCC-A that is required of supervisors or preceptors in programs accredited by ASHA.
Some audiologists have suggested a specialty certification in preceptorship be required for all supervisors working with students. As far back as 1978 the ASHA Committee on Supervision noted a "need for special standards for supervisors, other than the [certificate of clinical competence] CCC" (ASHA, 1978). This already exists for other specialized training. For example, the American Board of Audiology offers a specialty certification for audiologists who specialize in cochlear implants or in pediatrics. A similar program for preceptorship training would enhance the hands-on experience AuD students get in clinical settings nationwide.
The university clinic is a place where we begin to join together theoretical knowledge and clinical competence. The clinical experiences that follow the university setting are off-site rotations and the fourth-year externship, and it is in these settings that the supervision process becomes an issue. University support of both the students and the preceptors can help the AuD graduates reach the goals of achieving a strong evidence-based clinical education that supports excellent clinical skills.
At the university level, we choose rotations where the preceptors have the necessary competencies to help the student clinicians develop their clinical as well as interpersonal skills. It is crucial that the university clinics do not send out students until they are strong enough in their theoretical education and clinical skills to work with other preceptors. If a student who is inadequately prepared is sent into the field too soon, it does nothing to help either that student or the other professionals with whom he or she will be working. Holding a student back until he is strong enough to work with non-university preceptors is beneficial in the long-run to the students, the professional community and most importantly, the patients.
Still, it is vital to remember that the priority for both students and preceptors should be the care of the patient. While it is important for the AuD student to gain experience providing clinical services, it is ultimately up to the preceptor to make all management and treatment decisions. According to the ASHA supervision of student clinicians issues in ethics statement (2010), "the responsibility for client welfare remains with the certified individual," (p. 2).
Summary
The quality of future clinicians begins during the AuD students' first year. Mastery of clinical skills and theoretical foundation can be achieved if they are integrated across the classroom and university clinical settings. At MSU, our clinical preceptors and the classroom faculty have begun the integration process. Open communication between the university and the non-university rotation preceptors can enable students to better meet the professional goals established by the AuD programs. Additionally, we could improve the overall training process for preceptors - and by extension, the students who train with them - by creating more opportunities for continuing education and standardizing the assessment and evaluation processes. Clinical education is best learned through actual patient interaction. It is an important part of the AuD experience, and it is in the best interest of the professional community to embrace the responsibility and appropriately train the next generation of audiologists.
Appendix A
Click Here to View APPENDIX A (PDF)
References
American Speech-Language-Hearing Association. (1978). Current status of supervision of speech-language pathology and audiology: special report. ASHA, 20, 478-486.
American Speech-Language-Hearing Association. (2010). Supervision of student clinicians [Issues in Ethics]. Retrieved September 20, 2011, from www.asha.org/docs/pdf/ET2010-00316.pdf
American Speech-Language-Hearing Association. (2011). Clinical supervision in speech-language pathology and audiology. Retrieved September 19, 2011, from www.asha.org/docs/html/PS1985-00220.html
Carozza, L. (2011). Science of successful supervision and mentorship. San Diego: Plural Publishing.
Ende, J. (1983). Feedback in clinical medical education. Journal of the American Medical Association, 250(6), 777-781.
Newman, S.A., Sandridge, C.W., & Lesner, S.A.. (2011). Becoming a better preceptor part 1: the fundamentals. The Hearing Journal, 64(5), 20-27.
Packer, B., Friedland, E., Rahe, F., Vento, B.A., & Walden, T. (2011). American Academy of Audiology: Clinical education guidelines for audiology externships. Retrieved September 19, 2011, from www.audiology.org/resources/documentlibrary/Pages/ClinicalEducationGuidelines.aspx
Sandridge, S.A. (2008, November 6). Precepting today's students - The Evaluation Process.
Walden, T. (2009, January). Gold standards summit 2009 and AuD program survey outcomes: transforming clinical audiology education. Paper presented at Gold Standards Summit, Orlando, FL.
