I believe finally, that education must be conceived as a continuing reconstruction of experience; that the process and the goal of education are one and the same thing. - —John Dewey (1897)
In this issue of Topics in Language Disorders, issue editors, Laura Epstein and Elizabeth Peña, and their authors offer a collection of thought-provoking articles on clinical education. The discussion covers recommended practices, emerging frameworks, and technologies that have implications for changing the face of clinical education, and possibly, its deeper principles. The authors of these articles shed light from varied angles and through different colored lenses to illuminate the challenges and opportunities of clinical education in the 21st century.
The articles should stimulate conversations among university faculties about curricular planning, allocation of resources, and the need for empirical research on clinical education. Some of the competing thoughts generated while reading the pages of this issue can be framed as traditional conflicts between the art and science of clinical practice, the overlapping and complementary roles of clinical and academic faculty in university programs, and the way university clinics and students might play a role in addressing the pressing need for empirical evidence about clinical practices.
It also should become clear that there is a pressing need for empirical evidence about the best ways to conduct clinical education. In this case, the foreground PICO question (standing for population, intervention, comparison, and outcomes) would stipulate a population of graduate clinicians at varied points in their graduate training. Outcomes would be expressed in terms of independent, effective and competent clinicians who are prepared to deliver evidence-based practices (EBP) to a variety of populations, with sensitivity to their unique needs, values, and circumstances (Dollaghan, 2007; Straus, Richardson, Glasziou, & Haynes, 2005). Contrasting “interventions” discussed in this issue and ripe for further investigation are whether it is better to provide supervision that (a) focuses on EBP processes more than on specific practices, (b) engages students in implementing procedures that are more or less prescribed, (c) focuses on clinical discourse or other aspects of clinical practice, or (d) uses technology in different ways to bring students' clinical experiences into the academic classroom.
This column opened with the final item from John Dewey's pedagogical creed (Dewey, 1897). The quotation captures the essence of Dewey's philosophy as the father of experiential education. Supervised clinical practicum is, at its core, experiential education. Thus, Dewey's comments are apt today for describing the process and outcome for students in clinical preparation programs as one and the same. Added to this, clinical educators must provide educational experiences that are relevant to a student population of adult learners.
Just as John Dewey was responsible for many “firsts” in the education of children, Malcolm S. Knowles is credited for several “firsts” related to the education of adults. Smith (2002) described Knowles as the “first to chart the rise of the adult education movement in the United States; the first to develop a statement of informal adult education practice; and the first to attempt a comprehensive theory of adult education (via the notion of andragogy).” Knowles (1975) described andragogy as a process:
… in which individuals take the initiative, with or without the help of others, in diagnosing their learning needs, formulating learning goals, identifying human and material resources for learning, choosing and implementing appropriate learning strategies, and evaluating learning outcomes. (p. 18)
In other words, Knowles viewed adult education and self-directed learning as one and the same, just as Dewey viewed the process and goal of childhood education as one and the same. As adult educators, clinical supervisors have to make choices about at what stages and how much help they should provide to graduate clinicians to guide them to diagnose their learning needs; formulate learning goals; identify resources for learning; and choose, implement, and evaluate the outcomes—and how much and at what stages they should teach clinicians to move through those steps on their own.
Evidence-based practice offers an explicit template for accomplishing just this. As emphasized by the authors of the first two articles in this issue, gaining independence in implementing the steps of EBP is an essential component of today's clinical education experiences. Teaching EBP offers a perfect example of implementing much earlier recommendations by both Dewey and Knowles. The examples and steps outlined by Goldstein and by Gillam and Gillam offer slightly different slants on how to teach scientific thinking and EBP. The result is a well developed picture of how clinical supervisors can help students bring the process to life. These articles should provide the basis for many and deep conversations by academic and clinical faculty seeking to increase the effectiveness of their complementary efforts to prepare clinicians with the knowledge, skills, and attitudes for lifelong learning.
Another dominant thread woven through this issue is the importance assigned to the actual words and patterns of clinical discourse. The effective use of language is both a primary goal and a primary tool of the practice of speech–language pathology; yet, the role of language in intervention is often treated as transparent, rather than the direct object of reflection. Leahy and Walsh show how professors and supervisors are attempting to change this picture by teaching student clinicians at Trinity College in Ireland to reflect on the use and misuse of words in clinical interactions. Their article raises consciousness about the ebb and flow of clinical conversations as genuine exchanges among equals, periodically shifting to differential power structures that characterize traditional clinician–client interactions. This raises additional questions that are ripe for further investigation about sources of authority, what forms of discourse are best for achieving desired clinical outcomes, and how explicitly the differences should be discussed with adult and child clients.
Another form of discourse that is highlighted within this issue is that between student clinician and supervisor. A foreground PICO question in this case might be posed regarding the population of novice clinicians and outcomes of clinical effectiveness when students have only a bare list of ingredients for what goes into successful intervention of a certain type versus having a more well-developed script about what to do and say at a particular point in the intervention process. The articles by Peña and Kiran and by Bedore, Méndez Pérez, and White provide frameworks related to this question and some preliminary insights into results.
Peña and Kiran emphasize the need of students who are in the early stages of clinical education to learn detailed, prescribed protocols, recommended by their supervisors and implemented with modeling, scripts, and feedback regarding fidelity to the protocol. According to this view, student clinicians should be engaged in implementing well-defined procedures at an early point in their graduate education, when they are deemed to need more direction. This is consistent with Anderson's model (Anderson, 1988) of gradual shift of responsibility from supervisor to supervisee in decision-making responsibility. It is consistent with a shift to learning to identify and apply evidence-based clinical protocols using a standard format and does not remove responsibility from the student clinician to implement the protocol well and to gather data on its effectiveness. Traditional debates about the art and science of clinical practice will no doubt be stimulated by this article.
In anticipation, Peña and Kiran point out problems with knee-jerk reactions to “cook-book” approaches, and suggest that it is time for more reasoned reflection on student clinician's needs at different points in their education. Overemphasis on the need for individual creativity by student clinicians could be akin to encouraging physician interns to construct their own interventions to treat a particular disease or even to allow them to turn to the supply closet and select the most attractive kit that happens to be on the shelf at the moment. Physicians are expected to be aware of standard protocols that vary by condition and to be able to implement them with fidelity. Is it possible that speech–language pathology could develop enough evidence about intervention protocols for selected conditions, especially language disorders, to allow the same? At present, the step of searching for scientific literature regarding EBP might be pursued with diligence only to find inadequate evidence to inform decisions at the end of the trail. A subtext of the article by Peña and Kiran is that university clinics actually might provide the data for future EBP, as well as using what is currently available.
In their article on the development of bilingual clinicians, Bedore and colleagues note that the needs of students studying to become bilingual clinicians pose a special set of challenges. Learning best practices for applying clinical discourse to address specific language intervention needs is challenging enough in one's own language, but learning to do so in a second language can be even more challenging. Even native speakers of another language, such as Spanish, need to learn to use their native language to achieve instructional and intervention goals. Bedore and her colleagues describe how they structure educational experiences to make this possible.
In her article, Epstein focuses on teaching deeper thinking about the analytical and evaluative aspects of clinical practice. She emphasizes the value of teaching students to make reasoned decisions about what they should observe, document, and count and describes it as a critical route to developing their clinical insights. This contributes to the component of EBP in which clinicians learn to evaluate the outcomes of their own practices.
Baharav offers a slightly different view of how students can learn to enhance their observational skills by focusing an actual camera lens on their clinical efforts. By teaching students to choose video clips selectively for an authentic purpose and audience of peers and professors, Baharav points to possibilities for using technology to help students achieve deeper understandings of clinical populations and relevant practices.
At this point, the evidence on the outcomes of various models of clinical supervision is modest, but the authors of this issue pose theory-driven questions that are ripe for empirical investigation. The articles differ in emphasis, but to a degree, all follow a path toward self-directed adult education. We have found them thought provoking and expect that our readers will too.
—Nickola Wolf Nelson, PhD, Editor
—Katharine G. Butler, PhD, Editor Emerita