Clinical supervision is an important component of graduate student education that should be a rewarding experience for both student and preceptor. However, for the supervisor, it can also be challenging and time-consuming to implement and fulfill the many requirements of a student program. 

Clinical sites with multiple preceptors and/or office locations, and sites that take a number of students per year, may be faced with additional organizational difficulties in simultaneously balancing workplace demands and expectations with the promise of providing the student(s) with quality clinical education. 

The challenge, ultimately, is to ensure each student a well-rounded practicum experience with the goal of achieving clinical independence upon completion of their externship year. This year was uniquely challenging as a result of the COVID-19 pandemic. Changes in the provision of clinical services made to accommodate social distancing and enhanced infection control guidelines required that the 2019–2020 audiology student externs complete their learning experience under difficult circumstances. 

Some students experienced an abrupt halt to their experience while others performed via non-traditional means. At the time of this writing, in areas such as New York City where our site is located, infection rates are declining, phased reopening continues to occur, and audiology students are beginning a more modified clinical externship experience for the 2020–2021 externship year. It is critical now, perhaps more than ever, for clinical preceptors to rethink their responsibilities to ensure students make appropriate progress throughout the year should further interruptions such as a “second wave” of the pandemic occur.

The Audiology Department at Weill Cornell Medicine (WCM) provides comprehensive pediatric and adult audiological services throughout New York City. Prior to the start of the 2019–2020 externship year, audiologists in our department created a new framework for the student externship program to better serve the needs of our students and support our preceptors. 

Clinical preceptors play a crucial role in graduate student education by helping to ensure student readiness for professional practice. We have found that our site faced specific challenges in organizing the student program: numerous clinical preceptors, multiple office locations, and several student externs. 

Over the 2019–2020 externship year, six fourth-year audiology students from five different audiology programs participated in the provision of care across all four of our office locations with our 13 audiologists, all of whom hold certificates of competency through the American Speech-Language-Hearing Association (ASHA). Our department acknowledged the challenge it faced in trying to provide each student with personalized feedback and goal-setting while juggling the varied clinical backgrounds and interests they hoped for in their placement. As a result, we felt a new framework for supervision was necessary. 

The Framework: Explained

Three main facets comprised this new framework: (1) student self-assessment, (2) educational experience and variability, and (3) ongoing continuous performance assessment. Student self-assessment was performed at the start of the internship experience by having each person rate their clinical skills in several key components of audiology (tympanometry, masking, ear-mold impressions, etc.). 

The students were asked to display these skills in test settings, and their performance was assessed by a team of audiologists using a standardized rubric. The students’ perception of their skills was compared with the audiologists’ observation and judgement and discussed between them. This information gave supervisors information on the student's proficiency immediately at the start of the externship year and, additionally, aided in goal-setting.

The second component of this model, educational experience and variability, was based on past experiences when it was observed that each student had had different classroom and practicum experiences and may not all be at the same skill and knowledge level for the placement. As a result, we created “educational sessions” for the students, led by staff audiologists who define the basic working knowledge we expect students to have at this point in their education. This allows students to re-evaluate their skill level and understanding in these specific educational areas. It is a requirement of the program that all students participate in these training sessions. 

The third component of our program, continuous performance assessment, occurs quarterly and allows the audiologists to continually re-evaluate each student’s skill level and gauge the experience each student is receiving. As a result of these continuous assessments, student schedules are modified to ensure they are provided with additional opportunities to improve areas deemed in need and provided with a solid audiology foundation prior to beginning their careers. 

Originally, it was our hope to share the details of this new preceptor framework at the American Academy of Audiology Annual Conference in 2020, to support clinicians working with student externs. We hoped to motivate clinical sites to assess how their supervising audiologists provide clinical education, guidance, and encouragement for their externs. Additionally, we were looking forward to utilizing suggestions and comments from our colleagues across the country to continually improve upon the organization of our own externship program. With the unexpected outbreak of the COVID-19 pandemic, we found ourselves forced to reevaluate our program as we had intended to do, albeit in an unexpected way. 

The Framework: Revised

Our audiology department was quickly affected by the outbreak of the COVID-19 pandemic in New York City. By the end of March, audiology services were limited to one office exclusively for the provision of urgent appointments. In early April, new cases of COVID-19 were reaching approximately 10,000 per day in New York State (Pearlman et al, 2020). 

Those audiologists who were working in office completed remote hearing aid and cochlear implant device repairs. The remaining audiology staff worked from home to provide virtual care to patients. Students were not permitted in the office, and ultimately, all five of our student externs’ graduate programs were suspended. 

Of our six externs, three had enough clinical hours to meet the graduation requirements of their school and the experiences required by our site. One student had < 20 hours remaining and was allowed by her graduate school to complete these hours virtually. Two of the six students, both from the same graduate program, needed to meet several requirements to qualify for graduation. Both students needed roughly 400 clinical hours and two additional months of full-time, in-person clinic. Their required hours were subsequently adjusted by their graduate program, leaving both students with < 100 required hours remaining. 

By the end of May, our organization allowed the two remaining students to return to clinic with staggered schedules to accommodate the need for social distancing within the office. They were given permission from their academic program director to return to clinic and approved to complete the remainder of their externship requirements in a hybrid model incorporating both in-person and remote learning. While at home, the students participated in additional “educational sessions” targeting specialty areas of audiology (e.g., auditory processing disorders) and other topics in which they felt they needed additional guidance (e.g., billing and coding).

The Council on Academic Accreditation (CAA) and the Council for Clinical Certification (CFCC) recently reported, “…because of the essential health-care and education roles that these students will be expected to assume upon graduation; we believe that it is in the best interest of graduate students and ultimately client/patient care and safety to uphold these accreditation and certification standards. 

CFCC and CAA are trusting that programs will ensure that students are safe and ready to participate in clinical education experiences and that they will graduate with entry-level knowledge and skills. We believe that any further accommodations would not be responsible considering the assurances these standards are designed and expected to provide to the public, employers, and taxpayers (CAA, 2020b). 

While the required 12 months of full-time experience has remained unchanged, both organizations acknowledged the impact that the pandemic has had on student learning. As such, permission was granted for hours obtained via telepractice to count toward practicum hours until June 30, 2021. Guidelines stipulate that more than one student may participate in the same session, and that clinicians may supervise more than one telepractice session at a time (ASHA, 2020). 

The effects of the COVID-19 pandemic highlighted several of the challenges clinical sites faced when taking multiple students from different programs; namely, the students did not have a uniform start and end date for their externship. In fact, the start dates for these students ranged from May to August 2019. While we strive for all students to gain clinical independence by the end of their externship year, we cannot expect them do so at the same time or pace, particularly in light of varied start dates. 

This reinforced the importance we placed on tracking each student’s progress throughout the year. With an accurate judgement of initial skills, along with educational sessions provided in the beginning of their residency year, we ensured basic core competencies were achieved with all of our students. We were confident that our framework provided a foundation to allow our students to successfully improve over time. While it was not applicable to our 2019/2020 cohort of students, we were forced to face the very real possibility that some students may not have developed adequate clinical skills at the time of site closures. As such, we adapted the final facet of our student program to rethink the order in which skills are acquired over the year.

The CAA Standards for Accreditation of Graduate Education Programs in Audiology and Speech-Language Pathology classify an “effective” audiology program as one that “allows each student to acquire knowledge and skills in sufficient breadth and depth to enable the student to function as an effective, well-educated, and competent clinical audiologist (i.e., one who can practice within the full scope of practice of audiology)… and that prepare each student for independent professional practice as an audiologist” (CAA, 2020a). 

We feel it is our responsibility as a clinical externship site to adhere to this same goal and strive to offer a well-rounded experience for all students; however, we understand now, perhaps more than ever, the need to continuously re-evaluating how that experience is provided. When creating the student schedule, we switched our focus to first ensure the students’ mastery of basic audiometry, with some initial exposure to specialty areas. In the past, we have allowed students a greater mix of basic audiometry and specialty testing even at the onset of their externship. 

To meet this new goal, we paired students with preceptors performing primarily hearing and hearing aid evaluations. We feel that these skills are the foundation of audiological practice and hope to first improve student confidence and performance in these areas. With satisfactory acquisition of these skills, it is then reasonable to increase exposure to specialty areas of audiology, allowing for diverse clinical experiences and providing our students with the opportunity to better evaluate their own specific interests as they move toward independent clinical practice. Additionally, should the need arise, we have planned for ways in which students can continue to participate in clinical care and learning from a distance. 

Each of our locations is equipped with a webcam and/or tablet device to allow students to virtually join in-person appointments. Furthermore, it is our intention to continue to offer tele audiology services for patients who have that preference or need. This can include hearing counseling, hearing aid follow-up, and instrument programming. Trainings hosted by device manufacturers have all been scheduled to occur virtually. Our staff compiled a collection of case studies for students to evaluate and critically think on at home, with follow-up discussions to occur remotely. A summary of this plan can be seen below in TABLE 1.

TABLE 1. A Summary of Student Learning Priorities
 

IN-PERSON LEARNING PLAN

REMOTE LEARNING PLAN

STEP 1: MASTERY OF BASIC SKILLS

  • Comprehensive hearing evaluations
  • Hearing aid evaluations, troubleshooting, and repairs
  • Students are paired with audiologists who exclusively or primarily perform these appointments 
  • Students are paired with audiologists who exclusively or primarily perform these appointments
  • Trainings provided by hearing aid manufacturers will occur virtually to allow for social distancing
  • Case studies and virtual discussion with fellow externs and supervising audiologists
  • Participation in the provision of hearing aid services via telehealth 
  • In the event that student programs are suspended for in-person learning but audiologists remain on-site for in-person visits, students can participate via video
  • Trainings provided by hearing aid manufacturers will continue to occur virtually

STEP 2: EXPOSURE TO SPECIALTY AREAS

  • Vestibular Assessment 
  • Cochlear Implants 
  • Tinnitus 
  • Auditory Processing 

Students continue to complete hearing and hearing aid evaluations while increasing their weekly exposure to and participation in specialty appointments

Case studies and virtual discussion with fellow externs and supervising audiologists 

In the event that student programs are suspended for in-person learning but audiologists remain on-site for in-person visits, students can participate via video 

NOTE: Student schedules and their assigned preceptor may vary daily. As a result, each week, students will have several days to exclusively or primarily focus on complete audiological evaluations (CAE) and various hearing aid appointments. This is done to prioritize these core skills.

 

It is difficult to prepare for all possible future situations, as evidenced by the truly unprecedented nature of the COVID-19 outbreak. Nonetheless, it is important to learn from past experiences and utilize our new framework for supervision to prepare for the unexpected, as we strive to support our students and encourage their success, both remotely and in-person.