INT. J. LANGUAGE & COMMUNICATION DISORDERS, 1998, VOL. 33, SUPPLEMENT

EXPLORING THE CRISIS IN CLINICAL TRAINING: LOOKING TO THE FUTURE

Clare Morris and Ann Parker

Speech and Language Services, Enfield Community Care Trust, Rowan Court, St. Michael’s Hospital, Chase Side Cres., Enfield EN1

email: 117731.2253@Compuserve and Dept. of Human Communication Science, University College London,

Chandler House, 2 Wakefield Street, London WClN 1PG email: a.parker@ucl.ac.uk

How can the crisis in training be understood? How can it be resolved? A context for thls paper is provided in terms of relevant professional and educational policy. A critical review of nationally available data is presented. It will be argued that commonly cited reasons for not offering student placements might have obfuscated underlying dynamics, which are related to the model of education adopted in the United Kingdom. It will be argued that a shift in emphasis in initial and continuing professional education is relevant.

Exploring the crisis in clinical training

Throughout the early 1990s there was an increased level of concern and discussion about the availability of clinical placements for speech and language therapy (SLT) students in the UK (Royal College of Speech and Language Therapists (RCSLT) 1994, Dicker 1995, Spence 1995, Morris 1997). This paper explores some ofthe issues involved.

RCSLT guidelines: provision of placements

The most significant factor to consider when exploring a crisis in clinical training is the policy of the professional body with respect to provision of placements. There has been considerable movement in the past 20 years, in terms of the definition of acceptable levels of clinical experience. In 1976 the required minimum hours/ sessions were at their lowest but most tightly defined, not only in relation to client- groups and settings, but also in relation to the amount of hands-on experience needed (approximately 83 sessions). In the 1980s, as the professional education of SLT moved into Higher Education (HE) and the College of Speech Therapists had to reconsider its role, there was no definition of either minimum sessions or client- groups. In the 1990s, as the 1991 White Paper (Department of Education and Science (DES) 1991) heralded the shift from an elite to a mass HE system, we see the professional body asserting its role and in 1993 giving a guiding figure of 200 sessions, more than twice the amount stipulated in 1976, but with no breakdown in terms of client-groups or contexts. Most recently in 1995 the minimum number of sessions was significantly reduced to 150 sessions and a new distinction between clinic and non-clinic based sessions was introduced. In addition the breakdown of clinic-based activity became greatly prescriptive, both in location of clinical activity and client group (RCSLT 1995).

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Although it is tempting to criticise the reduction in sessions, these guidelines can be seen as an attempt to ensure a broad-based (if not in-depth) clinical experience for SLT students.

The provision of placements

If anecdotal evidence suggests a crisis in clinical training, what do we have in the way of hard evidence to support or refute this claim? The RCSLT has routinely kept data on student numbers for many years. 1990 was the first year for which they sought mformation on the actual numbers of sessions of supervised clinical activity (i.e. clinical placement data.) and these data have been collected in some form since. These data and evidence collected on behalf of the RCSLT Working Party: Clinical Experience (RCSLT 1995) has been used as a basis for the following analysis.

A detailed interpretation of the figures available is difficult to achieve owing to a level of inaccuracy inherent in a changing system. Variables effecting the data include: changes in definition of minimum sessions required; the clinic based versus non-clinic based distinction; English versus UK data; National Health Service (NHS) and non-NHS data; geographical location of students and courses; variation between 2, 3 and 4 year initial qualifying courses and variations in the pattern of clinical placements used.

More detailed statistical evidence and analysis is presented elsewhere (Morris 1997). Broad generalisations can be made however. Firstly, there is evidence to suggest that the spirit of the 1991 White Paper (DES 1991) and subsequent act, Higher Education: A New Framework, impacted on SLT training. There was approximately an 8% increase in student numbers between 1991 and 1992 (with entry figures remaining around 580 in subsequent years) and likewise in their exit from the system in 1994/5. Between 1992 and 1996 whole time equivalent (WTE) figures for NHS-employed SLTs (England only) show an increase of approximately 14% in the workforce. The student : qualified SLT ratio is approximately 1: 2. These figures are at odds with an interpretation of the clinical placement shortage being mainly related to an increase in student numbers as the simultaneous increase in workforce figures should have been adequate to assimilate any increase in demand. However, examination of the returns for placement requirements and offers throughout the period 1993 to 1996 shows that supply was barely coping with demand. Furthermore it was the authors experience throughout this period that in the London area less than 30% of placement requests were met by returns. There was considerable investment of time and resources by the HE establishments to ensure the shortfall was addressed.

Table 1 shows that there is considerable variation in terms of number of sessions of clinical experience offered to students throughout England. These figures are based on information held at RCSLT. Overall it can take between one and three WTE staff to provide the annual placement needs of one undergraduate student and between two and five WTE to meet the needs of a postgraduate student. Of course these examples do not take into account geographical location of students, HE establishments and placement offers.

Within regions, evidence submitted to the RCSLT Working Party: Clinical Experience (RCSLT 1995) suggests even greater variation at a service level. A number of services reported that no offers of placements had been made, in marked contrast to four services which offered more than 30 sessions of placement per WTE member of staff in one year. The average offer made by clinicians was approximately five days per year.

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Table 1. Clinical placement sessions offered in 8 NHS regions 1993-4

Region

Northern &York Trent Anglian /Oxford North Thames South Thames South &West West Midlands

No of sessions 8143 3475 5132 12268 8825 4903 3925

% of total sessions 15.4 6.6 9.8 23.1 16.6 9.2 7.3

WTE staff

423 3 04 308 507 500 385 316

% of WTE . 13 10 10 16 16 12 10

Sessions per WTE. 19.25 11.43 16.66 24.2 17.65 12.74 12.42

North West 6354 12.0 446 14 14.25 England total 53025 100 3 189 101 16.63

The limited and in some cases absent commitment to offering placements was in iirect opposition to NHS Priority 7 (NHS 1995) and RCSLT guidelines (RCSLT 1996a). The 1988 Review of Pay and Conditions incorporated what was a separate student training allowance into the salaries of all staff Grade 2 and above, but it seems that student training was seen as an option. Why then were clinicians, in effect, breaching professional and contractual specifications?

Factors related to the provision of clinic-based experience

In order to attempt an explanation of the situation, numerous sources have been drawn upon (e.g. responses to the RCSLT (1995) Working Party, the authors experience in organising clinical placements for two London-based universities and their experience running approximately 45 training courses for clinical supervisors within three NHS Regions.) The main factor cited by service managers was the increased requests for clinical placements, as discussed above. There is little evidence however to support the idea that increased demand from educational establishments accounts for the whole situation.

A second factor frequently cited by service managers in the RCSLT (1995) survey is the availability of appropriately trained andor appropriately qualified staff. This wording is clearly ambiguous and could mean one of a number of things. Firstly there have been changes in SLT organisation in the past decade that have increased the overall demand for clinical supervision. Changes to the grade structure have identified the need for supervision of the newly-qualified. In addition there has been a change in skill mix in SLT departments, specifically in relation to the increase in SLT assistants in post (RCSLT 1996b)

Secondly, it may refer to the availability of staff who have undergone some training in student supervision as is an apparent requirement of registered members of RCSLT (RCSLT 1996a). Although the RCSLT clearly states the need for training, no documentation is available on what this training should entail or what outcomes would be. A RCSLT survey (RCSLT 1996c) of educational establishments revealed that there is currently great diversity in what is offered. If managers see training as a prerequisite for offering placements, few clinicians will be in a position to do so. In support of this position, the experience of the authors is that the provision of training courses in 1995- 1998 may have had a major impact on the number of placements offered.

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A third possibility is that the availability of suitably qualified staff may well be a result of recruitment difficulties. More than 50% of managers responding to the survey conducted on behalf of the RCSLT (1995) Working Party cited unfilled vacancies as a factor. A further informal survey carried out by the professional body (RCSLT 1996d) revealed that more than half the SLT posts advertised in the professional journal remained unfilled three months later and some had failed even to attract one applicant. Interestingly, greatest recruitment difficulties were reported in filling Grade 2 posts, (spine points 23- 27) this being the group most likely to be involved in training students. In addition there is evidence to show that workforce figures have yet to meet Quirk (1972) recommended levels let alone those suggested by Enderby and Davies (1989).

Behind the cited factors: role, status and worth

Despite a two-fold obligation, coded in terms of salary scales and professional guidelines, there has been a significant shortage and difficulty in achieving required numbers of clinical placements. There have been services unable to provide any clinical supervision at all and at best we see services where one clinician’s commitment would barely meet the minimum annual placement needs of one student. The various reasons offered do not seem to account for such a level of difficulty. The fact that many clinicians did not provide placements, despite a specific remit to do so, suggested that clinical placements are given low worth and status and the training role is undervalued. Why should thls be the case? Perhaps some of the answer is to be found in the traditional ways students have been prepared for professional life.

Three additional factors are argued to be significant when explored in conjunction with the other influencing variables considered above. Two of the three factors are explored elsewhere in this volume. Firstly, Parker and Kersner (in this volume) have argued that traditional methods of clinical supervision may encourage a dependency in learning. In addition they may also be heavily time-consuming. Secondly Moms (1997) argues that there are previously unexamined perceptions of ‘risk’ involved in students’ practice that dictate the amount and type of learning a student is exposed to in clinical practice. Both of these factors, when considered in the context of heavy workload, high demands for supervision and limited training in working with students would explain a reticence to offer placements. The third, and closely-linked factor, the technocratic model of professional education (Bines and Watson 1992) classically adopted in SLT will be explored in remainder of this paper.

The technocratic model is based on the principle of t e c h c a l rationality. This model implies a somewhat idealistic view of professional life, where the practitioner has at hisher disposal a range of techniques, which are derived from scientific knowledge and are selected to suit the problem facing them. This principle leads to a curriculum where ‘theory’ is taught almost independently of ‘practice’. In a classic example therefore, academic elements would be taught withm the HE context, largely through traditional lectures and seminars, possibly by non-clinicians or those who no longer practice. The practical elements on the other hand, would be for the most part delivered in clinical placements in a range of workplace settings of SLT.

The technocratic model with its emphasis on theory-driven practice underlines the idea of the specialised professional knowledge-base which is key to most discussions of the professions, and for many years has gone unchallenged. A major criticism to be levied at ths model is that it results in the fragmentation of overall learning into discrete and

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unrelated parts, including a disjunction between theory and practice. This fragmentation is underlined in a physical sense with the implicit linking of educators and institution with knowledge and supervisors and clinic with practice. Such a disjunction appears to imply that theory is given higher value than practice and ignores the idea that theory may in fact derive from practice or be learnt through practice (Parker and Kersner in this volume).

There is increasing evidence to suggest that technical rationality does not reflect the realities of clinical practice. If, as it is increasingly argued (e.g. by Schon 1987, Stengelhofen 1993) professional life encompasses a key element, i.e. the generation of new knowledge through practice, one would logically expect to see clinical practice at the centre of cumculum design. The technocratic model splits theory from practice and underlines this with different sites of delivery as well as the different status, pay and working conditions of the academic/educator and the clinical supervisor. In light of the pressures described above it further exemplifies the low incentive to offer students placements.

Future directions

As we approach the millennium forces acting upon SLT initial and post qualification training are set to change. The shift of funding from education to health would suggest that health regions would feel increasingly able to make demands upon the design and implementation of training courses. The potential shift to membership of the Council for Professions Supplementary to Medicine raises questions about the composition of future accrediting bodies and the continued influence of the RCSLT per se. As new splits and tensions threaten the system, it is important that as a professional group we are clear about the education and training needs of our future colleagues, whilst supporting current post holders as they struggle to balance increasingly competing and complex demands.

The technocratic model of education is being challenged. New ways to shape and deliver the curriculum are being developed and traditional views about content revisited. Those involved in working with students in all contexts are increasingly working together, examining traditional practice and developing models and methods of working with students that foster student independence, critical thinking, problem solving ability and collaborative practice. By challenging the traditional ways of working, a new and exciting fiture is available to all.

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