Muñoz, et al.,5 surveyed clinical supervisors in AuD programs (N=205; 63% response rate) on their perceptions about teaching counseling skills and existing challenges (N=169; 82% of the participants). Understanding the challenges faced by clinical supervisors in graduate training may offer insights into improving counseling skill development.
Responses to the open-ended question: “What challenges do you [supervisors] experience in mentoring graduate students in their development of counseling skills?” revealed multiple themes that were grouped into general and sub-themes (Table 1). Three main themes emerged related to (a) students (n=164; 57%), (b) supervisors (n=87; 30%), and (c) AuD programs (n=37; 13%).
CHALLENGES INVOLVING STUDENTS
Acquiring skills. Supervisors reported that students usually focus on the technical aspects of service delivery and tend to overuse technical jargon. They found that students have difficulty addressing patient issues that go beyond the informational scope, neglecting to see the patients’ needs from a comprehensive perspective. The students also struggled with connecting with patients to create an effective working alliance.
Supervisors found that students feel uncomfortable and/or unprepared when they are with patients, especially in emotional situations. One commented: “Counseling is influenced by each supervisor's style, so it can be challenging to create continuity for the student. Students can be impatient with themselves and forget that it takes time to develop these skills.”
Disposition. Supervisors indicated the need to understand each student's personality, ability to relate to patients, and possible struggles with acquiring counseling skills. Age, maturity, and generational factors were also raised. Large generational differences between students and patients can exist, affecting students’ ability to relate to patients.
Similarly, small age differences between students and supervisors can exist, affecting the supervisory relationship and the supervisors’ ability to appropriately guide and support student learning. One supervisor stated, “I am still close in age with the AuD students. It's sometimes difficult to give constructive criticism—even though I know it's important. It can be awkward to have those important conversations.”
Experiences. The students’ lives or clinical experiences prior to beginning or within AuD programs also affected how supervisors needed to align their teaching with each student. Many supervisors also felt that students were afraid to ask questions but deferred to supervisors on more difficult counseling situations. “They have very little knowledge at the beginning of their clinic experience, and often defer to me rather than allow themselves to play a lead role in managing different situations.”
Teaching skills. Supervisors described challenges related to their ability to change their teaching styles based on students’ needs, teaching students to develop their own styles of counseling, and teaching effective communication skills. They had difficulty in teaching students to reduce usage of technical jargon and approach counseling comprehensively. One said, “I find it challenging to help students move beyond informational counseling since they are more comfortable with this topic than dealing with emotions related to the determination of hearing loss.”
Confidence. Some supervisors reported a lack of confidence in their own counseling skills, resulting in feeling unable to properly mentor students’ skills development. “I feel ill-equipped to educate students in this area, and I follow my instinct when faced with such situations.”
Others lacked confidence in their students’ abilities, making it difficult for supervisors to let students entirely take over counseling, despite knowing the importance of these opportunities in skill development. “Patients often look to the audiologist for answers, so I end up stepping in and completing the counseling.”
Lack of time. A few supervisors reported that there is not enough time in a busy clinical day to debrief with their students after appointments about how counseling was implemented.
CHALLENGES IN AUD PROGRAMS
Courses. Reported challenges included lack of a dedicated counseling course in AuD programs, or issues with an existing course, such as insufficient resources, coursework, materials, or time: “…in our curriculum, students do not learn counseling until their third year. Students are learning so many skills all at once and on the spot (with a patient) that it does not always allow for direct instruction.”
Environment. Challenges with the academic or clinical environment included a lack of opportunities for students to practice counseling in a variety of situations (e.g., “Providing a variety of experiences so their counseling skills are diverse”). One respondent said, “Our university clinic provides services to a unique but homogenous group of people.” Supervisors also had difficulties in creating an educational environment that promotes translation of knowledge into real world experiences (e.g., “Providing ‘real’ settings where students can practice and self-evaluate outside of the clinic”).
Counseling skills, like other audiological skills, need to be taught to be well grounded in theory that supports the health behaviors needed to achieve desired outcomes (e.g., audibility through the use of hearing technology). Insights from this study raise implications for counseling education and supervisor training.
Counseling Education. To help students gain necessary competencies, AuD programs need to consider how they structure and deliver coursework, mentor skill development, and foster attitudes that facilitate implementation of patient- and family-centered care. Students are forming attitudes and developing as professionals throughout their training. Skill development needs to be integrated into all clinical encounters, not treated as an add-on component of care. Even though more audiology programs are offering a dedicated counseling course, content varies4 and students report wide variability in counseling training received.6 In this study, participants raised challenges in AuD programs, particularly that counseling techniques are taught late in the curriculum. In another study, 63 percent of clinical supervisors reported that the counseling is taught in the second or third year in their AuD programs.7 If there is no mechanism to include counseling concepts in early clinical experience, programs may inadvertently promote the development of ineffective habits that could be difficult to change later on.
A recent Delphi study8 was completed with professionals who have audiological counseling expertise to obtain consensus on the knowledge, skills, and attitudes that audiologists need. The study found final consensus on 16 knowledge items (e.g., the psychosocial impact of auditory/vestibular disorders, developing therapeutic relationships), 35 skill items (e.g., empathic listening, identifying patient/family coping strategies), and 13 attitudinal items (e.g., empathy and respect for different patient/family world views/values). The profession of audiology would benefit from more explicit practice guidelines to support teaching and implementation of evidence-based counseling within audiology service delivery.
In this study, supervisors reported having difficulties teaching students who focused heavily on technical information to broaden their communication with patients. Learning support that includes a variety of methods (e.g., reflection, review of recorded sessions) can help students scaffold their experiences in an organized and clear manner. Supervisors must adjust their style to effectively meet the learning needs of different students.
Supervisor Training. Supervisor confidence in teaching counseling can affect student training and skill acquisition. In a study involving pediatric audiologists (N=350), about 33 percent reported to have taken a counseling course and 15 percent had consistent supervision during counseling skill development.9 In the present study, some supervisors reported that their low confidence in their counseling techniques interfered with their ability to teach students. AuD programs need to support supervisors in developing counseling skills through continuing education, in-service opportunities, and focused mentoring. Restricted teaching flexibility may be reflective of low counseling confidence, discomfort in emotion-based discussions, and inadequate foundational knowledge related to counseling. A supportive environment is needed for supervisors to accept the need for and engage in behavior change to improve their use of evidence-based counseling skills.
A recurring theme in audiology counseling research is discomfort and uncertainty related to addressing patient emotions.1,3 This is concerning because patients often have barriers related to their emotions and thoughts and addressing barriers has been shown to improve treatment adherence.
Further research can help audiologists fully embrace patient-centered care. Valuable information may include integrating essential counseling knowledge, skills, and attitudes into audiology training programs, developing teaching methods that increase consistent counseling behavior in practice, and investigating patient outcomes resulting from effective patient-centered care practices.
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4. (Hear J.
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5. Muñoz, et al., (2018).
6. (Semin Hear.
2018; 39(01): 067-073).
7. (J Am Acad Audiol.
2017; 29(10): 917-927).
9. (J Am Acad Audiol.
2017; 00(0): 1-12).
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10. Med Care 2009; 47(8): 826-834).