education

I Change: an educational experience

Read this
if you want to feel more positive about change understand models of learning help students think like therapists
Ann Parker and Myra Kersner

n the mid 1990s speech and language therapy courses around Britain reported increasing difficulties in securing the necessary clinical placements for their students (Morris & Parker, 1998). Change in the old system of acquisition was clearly needed. In many instances the situation required crisis management using short-term solutions such as increasing the amount of time spent procuring places. However, managing change is a complex process as change in one part of a system is inextricably linked not only to other parts of the internal system but also to external forces. Recognition therefore that change was occurring at that time in the NHS and in higher education led to the acknowledgement that, to effect real change, longer-term solutions would be needed. Individual colleges developed their own innovative approaches to clinical placements and professional learning (Grundy, 1994) and this paper describes some of the changes made at the Department of Human Communication Science at University College London.

Consultation
Initially a consultation process was undertaken with the local speech and language therapy services, supervising therapists, and past and present students in order to establish the departments strengths as well as to solicit suggestions for improvement. The joint involvement of University College London staff with clinic based supervisors from the different clinical contexts and services within which the students were placed enabled the development of a longterm strategic plan for professional studies (Kersner & Parker, 2001). This included plans for the management of clinical placements, changing aspects of the approach to teaching and learning and making changes in the curriculum of the two speech and language therapy programmes run by the department. Discussions revealed that some of the problems of placement acquisition were linked to assumptions that were being made about the type of learning experience needed for students and the level of supervision required from the clinicians. Speech and language therapy students traditionally have received comparatively close, direct, individual supervision. However, different professions have equally successful models and approaches to supervision involving less frequent and less direct supervision (Barnet et al, 1987). While there are advantages to close supervision, such as instant access to feedback and opportunities for close management of risk, there are also disadvantages. For example, there is the possibility of de-skilling the learner and encouraging overdependency on the supervisor so reducing the students confidence in their own abilities. There is also the implication of correct practice - as in the total quality management aspiration of getting it right first time (Collard, 1993). However speech and language therapy students need to develop the ability to test hypotheses, try different therapy options, and to adjust quickly when a change of direction is needed as described by Parker & Kersner (2001) in what is referred to as a navigation model.

A lack of clinical placements has created a critical time for speech and language therapy education. However, while reactive crisis management has its place, Myra Kersner and Ann Parker have seen the wider, long-term benefits of adopting a strategic approach to change.

Strengths
The consultation resulted in much positive feedback about existing strengths in the departments system and it was agreed that these should be maintained and developed. It also became apparent that there was a need to be more explicit about some of the positive aspects of existing clinical practice that were working well. There were suggestions for change in three main areas relating to students clinical learning on placement. These required: further development of the departments external relationships with the clinical supervisors; internal development to optimise college-based learning within the course curriculum; the development of evidence-based research into professional learning. A strategic plan for professional studies was developed to incorporate different approaches to learning aiming to integrate practice and theory more effectively; to encourage greater team work between University College London tutors, placement supervisors, and the students (Kersner & Parker, 2001), and to develop a professional research strategy.

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2004

education

Assumption
In many professional courses including speech and language therapy there has traditionally been an assumption that students professional development will follow a linear approach (Bines & Watson, 1992) often involving front loading of theory (Eraut, 1994) preceding closely supervised individual workexperience placements. Such placements often include long periods of observation before active involvement in practical work and will typically conclude with a summative examination at the end of the process. While there may be advantages to this technocratic approach (Stengelhofen, 1993; Parker & Kersner, 1998) there are some serious limitations for students professional learning such as the counterproductive risk avoidance described by Morris (2001). The sequence of theory observation supervised practice may oversimplify the acquisition of complex skills and ignores the fact that in many instances theory may be more easily assimilated after some active involvement in practical work. Such a model does not reflect real life work where therapists need to be innovative, adjusting to feedback from constantly changing circumstances and new information rather than following prescribed, correct routines (Parker & Kersner, 1998). In addition, there is the potential for students overdependency on feedback from the experts - placement supervisors and tutors - rather than from other sources such as clients and peers and this may hinder their abilities to develop confidence in their professional work (Parker & Kersner, 2001). This may then result in newly qualified therapists experiencing a giant step in the transition from final year student to newly qualified therapist as shown in Figure 1.
Figure 1 Student development in a dependency model: a giant step from final year student to newly qualified therapist.

Involvement
Normally speech and language therapy students are selected for their effective communication skills, and many have relevant prior work experience. Involvement in action and practice at an early stage of the course enables effective use to be made of students pre-existing skills, so that they do not feel de-skilled but are able to build confidence in their work by taking some level of professional responsibility from the start. The importance of active involvement in the learning process while on placement was underlined during the consultation process by many of the students supervisors. These practising clinicians reported their own studentdays experiences of falling asleep during protracted observation placements - not through lack of interest, but rather through lack of involvement. Often they were kept awake only through fear of not knowing what to observe and trying to guess what they might be required to report. Of course, opportunities to observe an experienced speech and language therapist at work are valuable at any stage of students training but it may often be even more valuable for final year students who, having experienced practical work, have a clearer idea of what to learn from their observations. The students themselves reported that they had gained more confidence and learned more effectively through active task participation from the earliest stages of the course and through opportunities to observe experienced therapists at all stages of their learning. Students also reported they learned more when they had opportunities to take part in the whole range of the speech and language therapists work, including administration, timetable construction, staff meetings and case conferences as well as client contact. Then the giant step shown in figure one became just another step as shown in figure 3. This was endorsed by supervising clinicians who agreed that students worked better and learned more quickly when they were integrated and involved in all aspects of the speech and language therapy teams work from the outset.
Figure 3 Active learning: reducing the step between student and qualified therapist NEW THERAPIST STUDENT Lifelong THERAPIST learning continues... Integrated STUDENT practice, THERAPIST theory, observation, STUDENT Integrated reflection ACTIVELY practice, INVOLVED theory, observation, Integrated reflection practice, theory, observation, reflection

NEW THERAPIST

STUDENT THERAPIST OBSERVER THEORY

Of course there are situations when adult learners will benefit from learning the theory prior to their work experience. For example, phonetic transcription in clinical work requires pre-existing knowledge. However, in many cases, it is important to consider alternative models such as the learning cycle based on Kolb (1984) shown in figure 2.
Figure 2 Learning cycle An alternative model of professional learning: integrating theory and practice

different professions have equally successful models and approaches to supervision involving less frequent and less direct supervision

Practice

Rehearsal

Reflection

Theory
In this model the student may enter at any point of the cycle so that practical learning, rehearsal and reflection may precede theoretical learning (Parker & Kersner, 2001). For example, a student having interacted and conversed with a person with neurological problems may then find it easier to learn neurological theory. Such a model reflects the real work of speech and language therapy as reported during the consultation by managers responsible for appointing therapists to first posts. They commented on the importance of students developing the ability to investigate, problem solve, devise creative ways of working in new situations and take responsibility for clinical management decisions.

Curriculum changes were made within the University College London courses, aiming to: encourage peer learning and reduce dependence on supervisors; encourage students to use feedback from a variety of sources not only their supervisors and tutors; ensure that observation was embedded at all stages of clinical practice; change the nature of observation in placements; consider and encourage concurrent practice and theory; develop even closer links between university tutors and placement supervisors; focus more on reflection in the learning process; encourage risk assessment and management, rather than risk avoidance; develop a hypothesis-testing approach and problem-solving skills; seek placements where students could be involved in more real work in teams; give more feedback to students by developing new formative assessments; establish an evidence base for the philosophy and practice of the learning process; change the assessment process in order to examine aspects of clinical practice students have not directly experienced as well as those they have; involve the supervisors more in the assessment process.
SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2004

education

Workshops were run for the students in addition to those already being provided for supervising clinicians. The workshops emphasised the teaching philosophy and the development of practical skills with tutors taking more of a facilitating role aiming for more independent learning for the students. Thus for example students were enabled to manage their own tutorials, taking responsibility for planning, time management, problem solving and feedback and developing other group skills. Wherever possible within the curriculum, theory and practice were further integrated so that there was an even closer link between the type of clients seen and the content of students concurrent college-based learning. Students discussed approaches to a diversity of placements, including paired and group placements and special team projects, as well as individual ones in a variety of settings (Parker & Cummins, 1997; Parker & Emanuel, 2001).

as students are able to become active learners contributing to real work as members of the speech and language therapy team. In addition, it also seems important for students to have time to reflect on the models and processes underlying their own professional learning. This is reflected by the action research described here which embraces the continuous learning cycle of action - reflection - theory - rehearsal. Within University College London, as with any speech and language therapy department responding to its internal and external environment, there is the need for an ongoing monitoring and feedback process to highlight current strengths and identify areas for change. Myra Kersner and Ann Parker are at University College London, Department of Human Communication Science, 2 Wakefield Street, London WC1N 1PF, e-mail m.kersner@ucl.ac.uk or a.parker@ucl.ac.uk.

Outcomes
Changes made as a result of the strategic plan were regularly monitored and specific outcomes noted. Placement offers increased with significantly more paired and group placements; supervising clinicians reported favourably on their closer involvement in the assessment process, and new and innovative placement projects continue to be offered each year. Recognising the importance of the constant need for monitoring and change, a permanent audit was put into place to facilitate the regular gathering of qualitative data from the students and placement supervisors. Some examples of student comments are given in Figure 4. This type of feedback, showing advantages to paired and individual placements, supported the decision to maintain a diversity of placement experience so preparing them for the diversity of real work.
Figure 4 Examples of Students Feedback

Acknowledgements
We would like to acknowledge and thank the students for their involvement and feedback, as well as our colleagues in University College London and the South East speech and language therapy services. Special thanks also to Clare Morris and Heather Anderson.

References
Barnet, R.A., Becher, R.A. & Cork, N.M. (1987) Models of professional preparation: Pharmacy, nursing and teacher education. Studies in Higher Education 12 (1) 51-63. Bines, H. & Watson, D. (1992) Developing Professional Education. Buckingham: Society for Research into Higher Education and Open University Press. Collard, R. (1993) Total Quality: Success Through People (2nd edition). London: Institute of Personnel Management. Eraut, M. (1994) Developing Professional Knowledge and Competence. London: The Falmer Press. Grundy, K. (1994) Peer Placements: Its easier with two. College of Speech and Language Therapists Bulletin (October) 10-11. Kersner, M. & Parker, A. (2001) A strategic approach to clinical placement learning. International Journal of Language and Communication Disorders 36 (Supplement) 150-155. Kolb, D. (1984) Experiential Learning. Englewood Cliffs: Prentice Hall. Morris, C. (2001) Student Supervision: Risky Business? International Journal of Language and Communication Disorders 36 (Supplement) 156-161. Morris, C. & Parker, A. (1998) Exploring the crisis in clinical training: looking to the future. International Journal of Language and Communication Disorders 33 (Supplement) 244-248. Parker, A. & Cummins, K. (1997) Group placements and student practice: a project in under fives centres. Speech and Language Therapy in Practice (Winter) 13-14. Parker, A. & Emanuel, R. (2001) Active Learning in service delivery an approach to initial clinical placements. International Journal of Language and Communication Disorders 36 (Supplement) 162-166 Parker, A. and Kersner, M. (2001) Developing as a speech and language therapist. In M. Kersner and J.A. Wright (eds) Speech and Language Therapy: The decisionmaking process when working with children. London: David Fulton Publishers. Parker, A. and Kersner, M. (1998) New approaches to learning on clinical placement. International Journal of Language and Communication Disorders 33 (Supplement) 255-260. Stengelhofen, J. (1993) Teaching Students in Clinical Settings. London: Chapman and Hall.

Some Learning Advantages of Paired Placements Theres someone at your own level to discuss things with. You get more support and backup from a colleague. One comes up with information the other hasnt thought of. A peer is very honest in the feedback they give. More responsibility given to a pair than individual. Sometimes you achieve more with another person. You become more adept at negotiation and teamwork. Its not so scary, therefore its fun.

Some Learning Advantages of Individual Placements Not able to rely on peer so had to work independently. Had more individual time with the therapist. You see more of what the therapist does. It feels more like reality - on your own in the team. More feedback from the therapist. Get to do everything yourself, dont have to negotiate so much. Gives you a different type of confidence, no peer to lean on. More secure to work closely with the therapist.

A permanent process
Change is a permanent process, small changes leading to bigger ones. As changes are made so they need to be constantly monitored and further changes made in the light of the feedback received. However, when assessing such a process it is always important for strengths to be acknowledged as well as identifying areas for improvement. There needs to be strong communication links between the students, the college-based tutors and the supervising clinicians within the speech and language therapy services, and an explicit openness about actions taken, so enabling feedback and facilitating links between philosophy and practice. The variety and diversity of learning opportunities and experiences facilitates students in their confident development in the real world of speech and language therapy. On placement students need to be encouraged to think like a therapist. Diversity and difference are to be encouraged so long

5 steps to effective change

1. Consult widely, maintaining strong and transparent communication links. 2. Challenge assumptions! 3. Develop a strategic plan. 4. Audit outcomes and acknowledge strengths. 5. Put in place an ongoing monitoring and feedback process to identify areas requiring change.

10

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2004