EPISODE 1

[INTRODUCTION]

[00:00:13] ANNOUNCER: Welcome to SLP Learning Series, a podcast series presented by SpeechTherapyPD.com. The SLP Learning series explores various topics of speech-language pathology. Each season dives deeper into a topic with a different host and guests who are leaders in the field. Some topics include stuttering, AAC, sports concussion, teletherapy, ethics, and more. Each episode has an accompanying audio course on SpeechTherapyPD.com and is available for 0.1 ASHA CEU. Now, come along with us as we look closer into the many topics of speech-language pathology.

[EPISODE] 

[00:01:03] ANNOUNCER: Okay. Welcome, Dr. Elise and Melanie.

[00:01:08] EDM: Hello, and welcome to Ethics is Essential. I'm Dr. Elise Davis-McFarland, your host. Today, we're going to be talking about ethics in clinical supervision. Clinical supervision is a distinct area of practice within our profession of speech-language pathology. Students who aspire to become speech-language pathologists begin in the classroom, learning about typical communication development, various theories, and doing observations of therapy. From there, they're introduced to communication, cognitive, and swallowing disorders, and eventually to the intervention strategies which are used to correct disorders. A great deal of a student's preparation for the profession is in the actual doing; the interaction with clients, students, or patients. That is the intervention process.

This stage of the students and the clinical fellows' education is guided by the clinical supervisor, the person who has the knowledge and skills to not only teach but to mentor, encourage, correct, and critique in such a way as to allow the student or clinical fellow to gain the knowledge and skills needed to practice the profession successfully. The clinical supervisor must be able to connect academic knowledge and clinical application in a way that allows the student or clinical fellow to successfully transition from student or new graduate to an empowered clinician.

Ethics is very important in the supervision relationship. ASHA's Code of Ethics speaks directly to the supervisor's responsibility to maintain the highest ethical standards during the supervision process. We will learn more about the ethics of supervision from our guest for this podcast. Let me introduce you to Melanie Hudson, our guest for this ethics and supervision podcast.

Let me tell you about her. Melanie is the National Director of EBS Healthcare. She's a national fellow and a distinguished fellow of the National Academies of Practice. She served on ASHA's Board of Directors where I got to know her and she has also served on ASHA's Board of Ethics. She's the author of Professional Issues in Speech-Language Pathology and Audiology Fourth Edition, and a chapter author for the Clinical Education and Supervisory Process in Speech-Language Pathology and Audiology. She served as president of the Georgia Speech and Hearing Association and currently serves on the Georgia Board of Examiners for Speech-Language Pathology and Audiology.

Melanie, welcome to all things ethics. It's great to have you here to share your experience and ideas about ethics in clinical supervision. It's such an important topic because ethical failures with clinical supervision can be quite costly for the student, or the clinical fellow and for the clinical supervisor. You've given me some real-life scenarios for us to discuss. Let's get right to exploring some of the do's and don'ts of supervision.

Here's the first one. A clinical fellow has been working with a mentor for three months. The mentor has decided that he has too many other obligations piling up at work to continue serving as the mentor and he notifies the clinical fellow that tomorrow will be his last day as her mentor. Is there anything wrong with that?

[00:04:53] MH: Well, yes. It is a difficult situation. First of all, thank you for the opportunity to share my thoughts with you, at least. The clinical fellowship is a very important step in the process of becoming a speech-language pathologist. It's not always easy to establish a position, which is a job, where you're going to get a clinical fellowship that's done the right way. This example of abrupt termination is one of those scenarios that is not infrequent, because things do come up in positions where individuals may have too many hats that they're wearing and they're on their job. They get to the point where they just aren't able to fit in the time requirement that is involved with mentoring a clinical fellow. Because most states don't require the clinical fellowship to be completed, because you don't have to have your CCC in order to get a license. And certainly, if you work in schools, you don't have to have your CCC.

In many jobs, it's basically a courtesy that the employer was providing for the clinical fellow to even have a mentor assigned to him or her that would serve as their supervisor for their completion of their clinical fellowship. For a supervisor or a mentor, to tell the CF one day, "I'm sorry, I just can't finish this. I've got too many responsibilities going on. You're at the bottom of my list of priorities," whatever the situation is, that is arbitrary. Unless the mentor has some sort of a reason, for example, they've lost their job, they're not going to be working there anymore, or they are in the military and have gotten transferred, or they have a sudden unexpected health issue that has come up and it's going to certainly affect their ability, possibly to keep their job or to maintain all of the duties and responsibilities that they have in their current job. Those are situations where it is sudden, but it's not necessarily arbitrary. 

Arbitrary is the word that we want to focus on here. What that means is, without any of those reasons for having to terminate the clinical fellowship relationship, it's just someone decided one day that, they didn't want to do this anymore. In this case, it was, "Work was piling up, I just can't keep up with the responsibilities." That was a commitment that was made to the clinical fellow at the start of this relationship. Yes, work does pile up, we sometimes get behind. But if that's the reason that the clinical fellow mentor is giving the clinical fellow, "That I've just got way too much on my plate now and tomorrow, by the way, is going to be the last day." That certainly doesn't give the clinical fellow enough time necessarily to find someone else, or for the employer to find someone else. 

That is where we would look at the word arbitrary, which is the key word we want to look at here. Termination can stand alone with some of the circumstances that I presented, but arbitrary is the key here. That is unethical. It's specifically stated that way that arbitrary termination of the relationship is unethical on the part of the mentor.

[00:09:03] EDM: Okay. Well, I have a couple of questions for you based on your response. My first is, what are the things that a potential clinical supervisor should consider when he or she is asked to take on that kind of responsibility? What are the things that they need to think about or consider before making a decision about whether or not they will become the supervisor for the person who's asking them to do that?

[00:09:38] MH: That's an excellent question. Any mentor should know exactly what they're signing up for when they say that they're going to assume that responsibility. It's surprising how many don't. What we sometimes see is individuals who did their clinical fellowships so long ago, they don't even really remember how many times their mentor visited, or how much time was spent with their mentor on conversations, emails back and forth, whatever. They've lost that sense of what the commitment really is. We sometimes see this if someone is a mentor that shares the facility was to clinical fellow. In other words, they work in the same building, which by the way is not a requirement of ASHA, but it sometimes happens that the mentor is in the building and the clinical fellow mentor says, "We know. I'm here all the time. I know I can pop in and see you when you need me to, et cetera."

They're not aware of the requirements in terms of the actual hours that ASHA requires for the direct observation. At a minimum, a CF mentor should look at the requirements for the mentoring process in terms of the time commitment. They're on the ASHA website, just very quickly, it's in the 1,260 hours that the clinical fellow was required to complete in order to get at a certification. Eighteen of those hours have to be where the mentor was directly observing. They were in their presence, then there are 18 other hours that can be looking at paperwork, and discussing cases, et cetera. There's a total of 36 hours of commitment on the part of the mentor. Not only the amount of hours needs to be considered, but how those hours are divided up.

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[EPISODE CONTINUES]

[00:12:10] MH: Back to the 18 hours of observation, those can all be saved for the last months and you do a marathon observation timeframe. Those have to be spaced evenly throughout the 1,260 hours. If an individual is working a full-time job 35 hours a week, for example, this would be six hours every three months on average, that a clinical fellow would be observed by their mentor. It has to be spaced out that way. The 18 other hours, which are the indirect, are also spaced out throughout the 1,260.

A fellow need to have this conversation with a mentor to make sure that they know that when they're initially together or when they're even having the conversation about whether or not an individual would be willing to serve as a mentor. The responsibility really is on the clinical fellow to make sure that the mentor is aware of what that responsibility is. They can't just take a job and assume that the mentor knows what that responsibility is. Because sometimes that's why the termination occurs, the mentor will say, "I had no idea when you asked me to do this or when our director asked me to take you on as a fellow that this is what I was signing up for." That conversation needs to be had before the clinical fellowship even begins.

[00:13:48] EDM: Okay. That makes a lot of sense. Question number two: given the scenario that we've been discussing, what penalties might a clinical supervisor have to contend with if they do terminate a clinical fellow abruptly?

[00:14:06] MH: Well, a clinical fellow would have to decide whether or not they want to take this to the Board of Ethics. There is guidance on the ASHA website with regards to how to file a complaint. I would suggest though, before you officially file a complaint, that a clinical fellow make the call to the ASHA Department of Ethics, the Office of Ethics actually is called, and have a conversation with someone in the office to present their situation and see what advice they would give them at that point.

Sometimes, not just in a scenario like this, but sometimes just having that conversation and then the clinical fellow would go back to the mentor and say, ÒBy the way, I've had a conversation with the Office of Ethics at ASHA, and they've advised me X, Y and Z." That might make the mentor more aware of what could happen. In some cases, they might say, "Well, I didn't realize that this was an ethical breach. I didn't realize that there could be consequences of an ethical nature. Let me reorganize my schedule, and find a way to not terminate the relationship.Ó

You don't want to jump full steam ahead and say, "I'm going to file a complaint" until you get that counsel.

[00:15:39] EDM: Great advice. Okay. All right. Let's move on to another scenario. A mentor has decided that before she can sign off on completion of her clinical fellow's clinical fellowship, there is just one more area of weakness that she would like to address before they are finished. This is the first time that the clinical fellow has had this concern brought to her attention. She has completed the required 1,260 hours, the 36 weeks, and has at least a three rating on each of the skill areas on the clinical fellow's skills inventory. Is there a problem here?

[00:16:19] MH: Yes, there is. Anytime a clinical fellow looks like they may not be finishing their clinical fellowship with regards to performance, not because of undue delays with employment or whatever. But we're simply talking about their performance here, which the clinical fellow mentor has identified as an area of weakness. That should have been addressed earlier. You don't wait until the day it's got the other requirements met, and say, "Oh, by the way, we're going to just wait a bit on this. We're going to withhold the paperwork,Ó which is what we're looking at in terms of a violation here.

We did have a scenario where this this happened, where a private practitioner owned a clinic and decided that because of the pay increase that her employees received once they got their C's, she was at a position at that point in time where she couldn't afford to give the clinical fellow the pay increase, which would happen if she got her C's. At the very end, she just told her that, "Well, there's an area that we still need to work on before we can sign off on the paperwork." At that point, because the clinical fellow had in fact met all of the requirements for CF completion to get her certification, that would be an ethical violation. Because again, it was an arbitrary withholding of paperwork. The real reason would not have been a valid reason to withhold the paperwork. But of course, the practice owner was not going to divulge what the real reason was.

If the practice owner had a reason, though, other than just to keep her bottom line in good shape in terms of her income, if she really did have concerns, that there's still an area that doesn't seem strong enough for me to be able to say, "I think you're ready for independent practice." There's a process that that would be used. Hopefully, it wouldn't be something that at this point has just popped up in the final hour. It would be something that they've been Ð there'd been a concern expressed and they'd had a chance to work on it, and to address it and to write goals that would address that area, goals of improvement. There would be a process by which, through the clinical fellowship working on those areas or that identified targeted weak area, that by the time they finish their clinical fellowship, and they've met the hours and the evaluations have shown that there's been improvement, this would not be something that's sprung on the clinical fellow at the last minute.

If, however, the clinical fellow feels that the outcomes have been achieved and the mentor is saying, "I don't think they have, and I'm not going to recommend approval of your clinical fellowship having been completed,Ó the mentor must submit a letter of explanation, along with the completed clinical fellowship report and rating form. That has to be submitted to the Council for Clinical Certification, the CFCC. That has to be shared with the clinical fellow. That has to be done within 30 days of the clinical fellow making that decision. At that point, the clinical fellow may complete an entirely new clinical fellowship if they want to or they can request an appeal by the clinical fellowship, the Council for Clinical Certification, for his or her clinical fellowship. There was a process that takes away that arbitrariness of a decision like that.

[00:20:23] EDM: There is some recourse that the clinical fellow has in a situation like that. They can, in fact, ask for this issue to be reviewed, and some action taken that might be in favor of the clinical fellow.

[00:20:40] MH: Absolutely. That's why it's very important for the clinical fellow mentor and the clinical fellow to maintain documentation all the way through the clinical fellowship. Everything should be documented in terms of the observations, conversations that took place in terms of identifying potential areas of relative weakness. The plan for improvement needs to be documented, what steps were taken to move the clinical fellow to a point where the mentor would feel that they feel the skills are strong enough in these areas.

Again, the process would have taken place during that clinical fellowship and it wouldn't be something that on the last day of the last hour of the clinical fellowship that the mentor says, "And by the way, I'm not recommending that you get your Certificate of Clinical Competence." There's a process that they need to be aware of, both of them need to, and documentation will help

[00:21:45] EDM: Now, I think you make a very interesting point. It's something that I would not have thought of immediately when I looked at this scenario. But you said that documentation needs to be kept by the supervisor and the clinical fellow. It's this emphasis on Ôand the clinical fellowÕ that I'm interested in hearing a little bit more about. Because I'm wondering, if a new clinical fellow is aware of that, i.e., the need to maintain documentation as they might need to be starting off in this process.

[00:22:26] MH: That's a great question. The answer is not necessarily. It's surprising to me how many new grads walk into a job, and they've really had no preparation for what the clinical fellowship is. They still, in many cases, consider the clinical fellowship and extension of an externship that they had at their university. Many times, the universities have double checked the certification status of their supervisors, they've provided the setting, everything. All the student does is walk in and start getting the hours and they're done. They log those hours, but the university still has the oversight as far as setting up the situation, making sure the student is turning in those hours as needed, making sure the supervisor is turning in the assessments, etc. 

Many new grads think that the clinical fellowship is going to be done the same way, and they put all of their trust and faith in the employer, to make sure for example, that the clinical fellow mentor is an in fact eligible to supervise them for their clinical fellowship.

We tell students to verify on the ASHA website. All they have to do is go on the ASHA website, look at the whole page on certification. There's a link they can click where they can verify that their mentor is eligible to be a mentor for them. With the new certifications coming into effect in 2020, it's not only that the mentor be ASHA certified, but there's a new statement there that says the mentor has had this training that's necessary for them to be in supervision for them to be able to have a clinical fellow. It's also going to apply for graduate student clinician supervisors, but a new grad isn't necessarily going to have the university checking on that for them.

We remind students: this is your clinical fellowship. It is not your employer's. It is not your universityÕs. It is not your mentorÕs. It is yours and you have to take ownership. So you need to verify certification of your mentor, you need to verify that they're eligible to be your mentor. Once you start that clinical fellowship, you need to maintain documentation of the visits, the observations, what was discussed, et cetera.Ó If a situation like we've just been discussing arises, they can present that if they needed to, as an appeal to show that there was no discussion of a concern on the part of the mentor.

If the mentor, though feels that they've been unfairly accused or that the appeal is going to now go to them, they have to present their side of it, so to speak. That's why they also need to have that documentation maintained. These conversations need to occur all during the clinical fellowship.

[00:25:51] EDM: Sounds like excellent advice. I hope that some new grads who are beginning on the clinical fellowship path will have an opportunity to hear your advice here, because it certainly sounds like it's very, very important.

Alright. another scenario A clinical fellow is graduating and plans to return home to live with his parents to save money. His parents' home is in a very remote area of the state and it would be next to impossible to find an ASHA certified speech-language pathologist to mentor him. His mother is retired, but is still an ASHA certified speech-language pathologist, and has told him that she would be willing to mentor him if his employer doesn't provide him with a mentor. Can mom do that for him?

[00:26:43] MH: It's a very easy answer, no. Your mentor cannot be related to you in any way. The reason for that is something that we see in other areas of ethics, and the term that you use is conflict of interest. A parent, a relative, whether they're a blood relative or not, is not in a position to maintain the objectivity that is required for someone to provide this type of supervision. The answer is no. There's actually a statement on the paperwork, on the forms that are Ð or should I say, paperwork, everything's online now, but we still Ð the forms that have to be filled out. The mentor will have to check a box that verifies, that says that he or she and the clinical fellow are not related in any manner. 

[00:27:46] EDM: Well, I guess that that's pretty clear then. Interesting. What, if anything, can someone who's in the position that this new grad is in do if they are in a place where there is not someone other than a relative who is qualified to become the personÕs supervisor? Is there anything that the person can do other than being aware of that prohibition and making a different employment decision?

[00:28:22] MH: That's exactly what they would do. The employment decision may actually be, "Okay, I will take the job, but I'm just not going to get my CÕs." We know of individuals, you may even know of some yourself at least who did not get their C's when they first graduated, because they were in a situation like this and delayed getting their certification.

You certainly can delay getting your ASHA certification. We have information on that on the ASHA website. It's not necessarily easy. It depends on how long you've been out of graduate school. Sometimes, it is such a huge undertaking when people look at the website and say, "Oh my goodness! I didn't realize I was going to have to take the Praxis and I've been out of school five years" or "I didn't realize that the certification standards had changed since I graduated, and now I see, I have to take a course in chemistry."

Sometimes, when we have situations like that, the requirements at that point are so cumbersome. The individual may say, "Well, I guess I'll never get my C's then." My advice, and I'm sure yours would be as well, Elise is that, don't delay getting your certification. In this situation where this young man wanted to live at home to save money, he may be very tempted to say, "Well, the employer will hire me and I don't need my C's. I don't need to get my ASHA Certification in this state to have a license, so I'm just going to go ahead and take the job and delay getting my certification." He just needs to be aware of what that delay might require of him in later years if he decides that he would like to get his certification. 

Initially, the decision may be to postpone getting certified, but it also may be that I don't want to delay getting my certification, so I'm going to have to find another way to get my clinical fellowship. That may mean moving somewhere else where they can get another job, and incur the expense that they may need to do in terms of their living situation that will allow them to get their ASHA certification. A lot of decisions go into this.

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[EPISODE CONTINUES]

[00:31:24] EDM: One of the points that all of your responses seem to point to is that, before beginning a clinical fellowship relationship, that the new graduate really needs to fully understand all of the aspects of this relationship, the requirements and make their decisions accordingly, because they have a lot of responsibility in terms of understanding what the requirements are and acting accordingly. I think you're making a really good point in terms of the clinical fellow's responsibility to know and to do through this entire situation.

[00:32:14] MH: Absolutely.

[00:32:16] EDM: Time for another scenario. A school district has hired a new speech-language pathology graduate as a clinical fellow, and has assigned an experienced speech-language pathologist to serve as her mentor. The mentor tells the clinical fellow that, since she is planning to retire at the end of the school year, she had not planned to pay her ASHA dues and keep her certification. However, she tells the clinical fellow that she will serve as her mentor if the fellow will pay her dues for her, thereby allowing her to serve as her mentor for the last year of her employment. Is a clinical fellow going to have to pay to play?

[00:32:57] MH: That is a great question. That is basically what we're asking here. A clinical fellow may not reimburse the mentor or cover the expenses for the time that a mentor would be providing that time. There can be no direct compensation between a clinical fellow and his or her mentor. Now, there are situations where something like mileage might be able to be arranged, where the clinical fellow would help with that kind of an expense, but in terms of paying them for being their mentor, that is not compensation for mentoring is not permitted.

Now, an employer could compensate the mentor on behalf of the clinical fellow, that's a completely different situation. That often does happen, a private practice, or a company, or a hospital system may not have anyone that they have access to that works directly for them that they can assign. But they really would like to hire this new grad, and allow him or her to get their clinical fellowship, so they may be able to find someone through their network of their other speech-language pathologists who would be willing to do this and then they would compensate that individual on behalf of the clinical fellow just because that's how badly they want that clinical fellow to work for them. 

If the deal breaker for the clinical fellow is, "Well, I'm not going to take the job if you can't provide me with a mentor,Ó they may be very motivated to do that. If the clinical fellow has to find his or her own mentor though, which does happen and there's information on the ASHA website for the clinical fellow about things to look for and making sure that all the boxes are checked, should they have to do that, they could still Ð the clinical fellow could still ask the employer, "Look, I can find my own mentor. Would you be willing to have a conversation with that mentor about some kind of compensation?" The employer could have that conversation with a potential mentor, without the clinical fellow even having to know the specifics.

That certainly is a situation that can be and does occur. But the clinical fellow is not the individual who would be writing a check to the to the mentor for assuming that role.

[00:35:47] EDM: Okay. Question: can you think of other issues regarding money or finances that are off limits between clinical supervisors, and students or clinical fellows?

[00:35:58] MH: It wouldn't be money per se, money changing hands, but we could have a situation, and I know situations where a type of bartering has taken place, where someone says, "Well, I can't leave my children. But if I pay for a babysitter, would you be willing to then babysit for me on other occasions? Then, I wouldn't have to have a babysitter for those occasions." ÒIf I could use your services as a babysitter or a dog sitter, and then I don't have to hire someone to do that when I'm coming to see you or not. Can we barter this?" That is a situation that I would not recommend to clinical fellow, or a mentor get into because now we're potentially engaging in what we would refer to as Ð one of the scenarios of what we would call a dual relationship.

Not only now is this individual your mentor for a clinical fellowship, but in some respects, you've become an employee, a household employee, if you're taking on the role of providing childcare. That dual relationship can cause some difficulties. A dual relationship can be one where there's no employment type scenario involved. It could be, you now get involved in a romantic relationship with your mentor. That's another type of dual relationship, but this would be one where you actually now, a mentor now is wearing two hats with this individual. They are their mentor for their clinical fellowship, but they are also their employer, if they're using them for something like babysitting.

Money isn't directly involved here, but it raises the possibility of this dual relationship, creating a situation that could create some difficulties and it came from a bartering situation. It's indirectly financial.

[00:38:33] EDM: All right. Another scenario. A clinical fellow in a private practice has a mentor who owns the practice and keeps a very tight schedule. It has been four months since her last direct observation. She has asked her mentor to schedule some time to complete the first segments, CFSI or Clinical Fellow Skills Inventory. The mentor tells the clinical fellow that because she is there every day, she has a "good idea" as to how she is performing without having to do the actual hours of direct observation required by ASHA, and that they can do the Clinical Fellow Skills Inventory anytime. Does the clinical fellow have reason to be concerned here? 

[00:39:22] MH: Yes. Even though the mentor may "have a good idea,Ó you can't let that be a substitute for those direct observation hours that ASHA requires. We talked about this earlier. When a clinical fellow mentor signs up for the job, so to speak, they are committing to the hours that are required to do a complete and thorough assessment to be in a position to do a complete thorough assessment of the performance of a clinical fellow. You can't do that if it's just a casual, "I've seen you passing in the hall,Ó or "I've popped my head in the door, I can kind of see how you're starting off your sessions occasionally.Ó

That's not the same thing as 18 hours of direct observation, where you are in a situation where your clinical fellow has your complete undivided attention and you're focusing solely on their performance. That's why the hours are designed that way.

Another thought is that, this does happen, and clinical fellow mentors will sometimes use reports from others who have been in a situation to observe the clinical fellow. They will let that serve as a substitute for their own observations. I just want to make sure that when mentors are considering providing that role, as far as the development of a new professional, they need to have a more direct hand in that development and not essentially be relying on someone else to give them their impressions. They signed up for this, they need to take it seriously and they're committing to having those direct observations and the indirect observations.

The indirect observations could be a conversation with someone who has more frequent access to observing the clinical fellow. In some cases, that wouldn't necessarily even be another speech-language pathologist, it could be a rehab director. It could be someone who's just in another position to observe their performance. It could be a school principal, who sees that the clinical fellow has chronic tardiness. It could be any anything like that.

The direct observations have to be done by the by the mentor and just, "I've got a good idea of what you're doing, because I have impressions that I formed by seeing you in other ways" is not the way it's designed.

[00:42:32] EDM: Let me ask you a question about the direct observations. You say that that's 18 hours of the 1,260. Does that mean that the mentor is either in the in the room or looking through an observation glass at the entire time of the interaction? Or does it mean that they can watch, let's say, 15 minutes of an interaction or have a therapy session here and another 15 there? Or does it mean that they have to be there for the entire amount of time?

[00:43:14] MH: Well, it means that it's those 18 hours have to be essentially with the clinical fellow. It doesn't have to be all treatment, or diagnostic. It could be watching them in a family, sitting in on a family meeting, and at the beginning of the meeting, the clinical fellow introduces the mentor, just as a courtesy, who this is. It could be observing them give a counseling session to a family member, not necessarily a formal meeting, but helping a family member with regards to how they can follow up at home, with their patient, their student, their client, etc.

It doesn't have to be direct treatment or diagnostic with the client, the student, the patient per se, but it has to be watching them in action, essentially. It doesn't have to be something that is, as I said earlier, it's got to be spaced out. If they want to do two hours one month, they could do it that way. Or if they were to do six hours in one segment, which is 1/3 of the of the clinical fellowship, that's the requirement that ASHA has. It's six hours every segment which is 1/3 of the 1,260. 

A mentor could conceivably come and spend a six-hour day in that 1/3 of a segment, which is 420 hours, and that would that would take care of the requirement. We hope that our mentors will gauge those hours and the need for what they should be observing based on the what they see the need presenting itself with regards to the clinical fellow. They may realize, I need to spend more time watching this clinical fellow in diagnostics. So, they're going to schedule their observations accordingly. 

[00:45:32] EDM: Okay. You've given really good examples of the direct observation and things other than actually being in the room or observing through the glass. You also mentioned indirect observation. Can you talk a little bit more about that? Because earlier, you gave some really good examples of indirect observation. That can really be, I think, very helpful for the clinical fellow, how that can be done. Could you talk to us a little bit more about that?

[00:46:05] MH: Yes. Indirect observation, is really what you would be looking at when you're talking about going over the paperwork, looking at their report writing. If it's a school-based clinical fellow, they may have some questions about how to write an IEP for a student after they've evaluated a student. They're trying now to look at the evaluation results and the input from the team, so that they can put together an effective IEP. That would be time well spent with a clinical fellow mentor. Let's look at all the information we have here, and let's talk about how we would write goals, treatment goals here.

Those are the things that would not be done in front of the student in this case, but it would be something that the mentor and the clinical fellow would spend time doing together; reading the reports that have been written, going over SOAP notes, looking at how the clinical fellow is organizing their time in terms of scheduling, and helping them troubleshoot some of the caseload management issues that might be presenting themselves as a challenge to the clinical fellow. Those would all be hours that would be spent, as far as the indirect observations of that are also part of the total 36 hours that the clinical fellow needs to have in order to complete their requirements.

[00:47:34] EDM: Wow, very good. IÕm sure that's great instruction for people, even those who are currently clinical fellow mentors or those who will become. Alright. Let me ask you about a new requirement, which ASHA has for new students, new members, who are going to be certified in 2020, as well as ASHA members who are renewing their certification in 2020.

The two requirements are, first of all, one hour of continuing education in ethics. The other requirement is that persons who supervise or provide clinical instruction for students and or clinical fellows, for purposes of ASHA's certification must complete at least two hours of professional development in the areas of supervision, clinical education, or clinical instruction. What should ASHA members expect to get in those two hours, Melanie?

[00:48:38] MH: That's a great question. Right now, as you just described, it's just two hours in the area of supervision. There are many subsets of topics that come under the category of supervision. There's supervision specifically related to ethics, which is what we're talking about today. There's supervision and how that relates to cultural competence. There's supervision of graduate students specifically, when you're focusing more on the knowledge and skills that they need to be able to be competent, which is where they are when they graduate. Then, there's mentoring, which is what you're looking at when you have a clinical fellow. What is the difference between supervising a grad student and supervising a clinical fellow, when the focus is how to get them to become independent? That's a very different way of supervising.

These are just some of the subsets that come under the area of supervision and you can spend a minimum of two hours just on each of those topics. My recommendation is that, for this minimum requirement, which is right now a onetime requirement that supervisors are those who are contemplating supervising look at topics that specifically relate to the type of supervision that they're going to be providing. For instance, if they are being asked by a university to supervise grad students, they wouldn't necessarily be looking at something that would be more targeted for promoting independence per se. That's something that a clinical fellow mentor should absolutely be looking at, because that's going to be the way they supervise. That involves a lot more in the area of critical thinking, promoting reflective practice, and how to provide opportunities for your clinical fellow to engage in interprofessional practice.

A graduate student's supervisor may not have access to other for opportunities for interprofessional practice. They're going to be focusing more on the more specific technical skills and knowledge for a speech-language pathologist, which is absolutely appropriate when you're a student clinician. We certainly want to make sure that critical thinking skills are always a part of clinical education, not just waiting for that moment when you know you've got to help them become independent, but from the very beginning of their practice as a student clinician. 

That's an area that I would suggest you consider, no matter what kind of supervision you're providing, something that targets critical thinking. But just being aware of what type of supervision you're providing, who you're supervising, and look at topics in supervision that relate specifically to what you need or you would like to develop your skill area in.

[00:52:04] EDM: Folks will have three years, the three-year process or certification window in order to get these two hours in the supervision and clinical instruction. You raised Ð

[00:52:21] MH: Well, actually, Elise, they have three hours to get their one hour in ethics. I'm so glad you said that, because the three hours is for the ethics, for the one hour in ethics. For the supervision. That's going to actually take effect this January, you said this, January 1, 2020.They have to have the two hours in supervision by January 1 of 2020. Your timing here is excellent.

[00:52:51] EDM: Okay. Thank you very much for that input. I want to just follow up on a couple of the things that you said in terms of what it is that a clinician should be looking for in terms of these two hours of instruction. I thought you made a very good point about the difference between what it is that we're working toward in the supervision of graduate students versus the clinical fellow, and the critical thinking and the independence. Can you talk just a little bit more about that, about the differences in terms of supervision, and mentorship and education for those two different groups?

[00:53:38] MH: Yes. For student clinicians, supervisors need to use a much more direct style of supervision. Any supervisor always needs to remember that their primary responsibility is the welfare of the client, the patient, the student. In order to make sure that that welfare is paramount, they do need to be very direct with the early clinician, with the student who's just learning. That's why the requirements for them to have that line-of-sight supervision is very important. Of course, that decreases over time as the student clinician becomes more skilled in whatever setting they are they are in and whatever type of situation they're in as a student providing services. A skilled supervisor knows how to incorporate a continuum of supervision which Jane Anderson first described back in 1988 as a continuum.

The initial focus first supervisor is to make sure that the student is doing everything the way they should do it. They have to be standing there, essentially, or observing very closely to make sure that that's done. As the student acquires the skills, they can back off. As the student acquires skills, there's more of a conversation with the supervisor with regards to what the student thinks about their own performance. There's more of a conversation with a supervisor asking the student, "What do you think would happen if?" or "Why would you choose that approach?", etc. By the time a student graduates, and they've got their basic technical skills and knowledge, so at that point, there wouldn't be a concern about harmful effects as far as the treatment is concerned. You're able to look at a new grad and know that, in many situations, as I already said, they don't even have to have a license. They are considered independent.

The whole point of the clinical fellowship is to bring them from more than just a level of competence, but to a level of proficiency. That would be the independent practitioner. A clinical fellow mentor isn't going to be spending as much time on the technical skills and knowledge, teaching them one more test or one more therapy approach. Those are important things too. But the focus of a clinical fellow mentor, unlike the supervisor of a grad student, is to have more of a 10,000-foot view and help them learn to question what they're doing. I often say that the supervisor of the student clinician is teaching them the what and the how of what they do. The mentor of a clinical fellow is teaching them how to address the why of what they do, asking themselves the questions, "Why am I using this test? Why am I using this therapy approach?"

That transition naturally occurs from the student clinician as they enter the end of their graduate work and their graduate student clinician work. A good supervisor is already incorporating at that point a lot of critical thinking. By the time they're clinical fellow, critical thinking should be second nature, but the mentor needs to capitalize on that, and continue that growth, and development and the reflective practice.

[00:57:45] EDM: Okay. Really, some distinct differences there that are important, that are very important. I really like your analysis in terms of competency versus proficiency, competency for the grad students, proficiency for the clinical fellow. Then the what and how for the graduate student as opposed to the why for the clinical fellow. I think that's great information and I'm sure our listeners can certainly benefit from that.

Well, Melanie, thank you so much for being with me today. I know our listeners have benefited from your information about ethics or the ethics of clinical supervision, and the importance of ethical mentorship for clinical fellows, because ethics really is essential. Thank you so much.

[00:58:40] MH: Thank you, Elise. It was my pleasure.

[00:58:42] ANNOUNCER: Thank you, Dr. McFarland and Melanie. 

[END OF EPISODE]

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