The Changing Face of the University Clinic: Reaching Out to the Community

Vicki McCready, M.A.
The University of North Carolina at Greensboro


 In preparing to address the topic of the changing face of the university clinic, I have reflected on the changes in my own Communication Sciences and Disorders (CSD) program at the UNC Greensboro in the 17 years that I have been there.  In 1983, when I began my job as the first and only full-time clinical supervisor the program had ever had, I was faced with coordinating both undergraduate and graduate clinical practicum, preparing the program's clinical handbook,  and initiating an evaluation system for both supervisors and supervisees.  I recall our brand new facility overflowing with energetic preschoolers who were placed in one of four preschool language groups, four to five in a group.  I also remember struggling with the supervision of undergraduates, some of whom would not make it to the graduate level.  Not only were these undergraduates in our on-campus clinic, they also were placed for one semester with a public school speech-language pathologist (SLP) for student teaching.  On the client level, I recall the difficulty finding enough voice and fluency clients for our students to meet the ASHA hour requirements in those two areas.

By 1990, 10 years ago, the make-up of our on-campus clinic reflected both the national trend to phase out undergraduate practicum and the mandate in education to serve preschoolers.  We now ran only one preschool language group of three children and saw only two other preschoolers in individual therapy.  Since we no longer had undergraduate practicum, we did not serve public schools at all until students were in the second year of graduate school and went there as externs.

Now it's spring semester 2000 and I must say our clinic looks quite different from both the clinics of 1983 and of 1990.  We run no preschool language groups (they're all in the public school systems now) and of the 13 children we see on-campus, only two are preschoolers and 11 are school age.  Of the 11 who are school age, at least four have reading, spelling and/or writing difficulties, areas we weren't even treating in 1983 and 1990.  Although we see similar numbers of clients for fluency, voice, and accent reduction as we did 10 years ago, we are seeing more adults with aphasia and traumatic brain injury (TBI), clients whose insurance will no longer cover hospital rehabilitation out-patient services.  Of the 24 adults seen for therapy in our on-campus clinic this spring semester, four are university students with language based learning disabilities, a disorder that was not seen as frequently 10-17 years ago.  Although we're seeing more clients on campus this semester (37) compared to spring, 1990 (29), we have fewer clinicians (17 in spring 2000 vs. 22 in spring 1990).  These clinicians are carrying more hours on campus during their first year of graduate school to compensate for decreased hours in the healthcare settings used for externship sites in their second year of graduate school.  Finally, we have more supervisors now: two permanent full-time supervisors for the on-campus clinic and for coordination of all off-campus externship sites; two full-time supervisors on soft money:  one to coordinate an adolescent language grant and one to coordinate a distance education program; and two part-time supervisors to run an early evening clinic.  Ten years ago we had one full-time and one part-time supervisor.

Another significant area of change in clinical practicum that our spring semester 2000 schedule shows is our off-campus involvement.  We have service contracts with two high schools and one middle school four days a week with a supervisor and three first year graduate students.  We provide individual and group pull-out speech-language services to 26 students plus inclusion work in a cross-categorical classroom with 14 children and in two self-contained classrooms for children with autism.  All three classes are taught jointly by our supervisor, our graduate clinicians, and the special education teacher.  In fall semester 1999 as well as spring semester 1999, we also provided accent reduction therapy at a branch of the public library that specializes in English as a Second Language (ESL) for the increasing number of refugees and immigrants in the local neighborhood.  We would have continued that service this semester if we had enough students; we do plan to resume services this summer and for fall 2000.

And finally, a last area of change evident in our printed schedule for this semester is the assignment of our clinical practicum students into PODS or cooperative learning groups.   We began these small groups last year and have been very pleased at the opportunities for problem solving, support, and sharing they provide.  In 1983 and in 1990, clinical instruction took place in one-on-one supervisory conferences and in a large group meeting once a week.

Wanting another perspective on our changing university clinic, I interviewed Mariana Newton, our faculty member who has been around the longest and who was the first clinic director in 1969 (when, by the way, she tells me there were only 20 certified SLPs in the state).  When asked what first came to her mind regarding the changing face of the university clinic, she commented on the gradual shift in emphasis over time.  The shift has been from a sterile one-on-one clinical model in which we tried to simplify what was quite complex to a more quasi-natural clinical environment in which we grouped clients by disorder and focused on specific interventions.  It has been a shift to messier, more complex natural environments where communication occurs in real world situations of employment and living.

CSD Programs in the Broader Context of Higher Education

Just as our professional programs and clinics are undergoing change, so is higher education.  According to Zlotkowski (1997), millennial expectations in higher education are demanding "a reshaping of some basic academic structures and assumptions"  (p. 362).  Writing about what the future may hold, Boyer (1990) envisions a different kind of educational institution that will reflect a paradigm shift in the direction of teaching and service.  His  "New American College" will decrease the "gap between values in the academy and the needs of the larger world" (1990, p.22) and will be:

an institution that supports teaching and selectively supports research while also taking special pride in its ability to connect thought to action, theory to practice.   This New American College would organize cross-disciplinary institutes around pressing social issues, classrooms and laboratories would be extended to include  health clinics, youth centers, schools, and government offices.  Faculty members would build partnerships with practitioners who would, in turn, come to campus as lecturers and student advisers.  The New American College, as a connected institution,  would be committed to improving, in a very intentional way, the human condition (1994,  p. A48).
In addition to Boyer, other scholars are calling for universities to regain the public trust by emphasizing service as a moral/civic obligation (Zlotkowski, 1997), to become engaged in meeting community needs (Christina, in press; Kellog Commission, 1999), and to reward faculty for engaging in new kinds of academically based community scholarship (Lawson, 1997).  With this new paradigm shift, universities can address the problem identified by Robert Coles (1989): "Students of almost any age make the distinction between going to class and living their lives, as if all the time in 'home rooms' or lecture halls isn't a real part of their existence" (p.130).

The Workplace/Community/Real World Versus. Academic Programs and Clinical Education in CSD:  A Gap in Perceptions and Expectations

While Coles refers to the 'real' existence of students versus their classroom experiences, writers and practitioners in our field distinguish between the “real world” of clinical practice and “the ivory tower” environments of the university clinic and faculty.  As deans and administrators on our campuses confront the challenges of new directions and trends in higher education, so must CSD university faculty acknowledge the changing characteristics of the workplace and the conflicting expectations of educators and employers.  According to Pickering and McAllister (1997), "it is as if the tectonic plates of professional work and cultural life are undergoing continual movement" (p. 253).

As reported in ASHA's Briefing Paper for Academicians, Practitioners, Employers, and Students (2000), "in response to the impact of external factors such as technology, demographics, changing practice patterns, and scope of practice," ASHA conducted a study in 1997 to identify the clinical activities and knowledge areas important for competence in newly certified SLPs.  More than 2,800 SLPs responded to a survey that was sent to educators in our field as well as to practicing SLPs.  Results indicated that practitioners believed that most clinical activities and knowledge areas were not being learned in the appropriate place (i.e., school) while educators thought that both were being learned where they should be learned.  This discrepancy in perceptions as to  when and where students should learn skills may account for the conflicting expectations of academicians and employers regarding the skills a beginning SLP needs to enter the workplace.

In order to address this conflict, ASHA (2000) recently published an online Briefing Paper  to inform members about the changing characteristics of the workplace, the related competencies required by the workplace and new ways academic programs and practitioners can work together to help develop these competencies in our graduate students.  According to ASHA (2000) the question we must all address is:  "How can we best prepare our graduates to have the myriad of skills necessary to be successful in the workplace and to become leaders in the clinical arena?"

Given the new vision for higher education to become engaged in meeting community needs and committed to improving the human condition, I would suggest the following addition to the question posed by ASHA:  How can we best prepare our graduates to collaborate across disciplines to help meet the pressing social needs of the society-at-large?

Before attempting to address this question, let's look briefly at the changing workplace for new SLPs and audiologists and the specific skills graduate students need to learn in order to achieve success in that workplace.  As summarized in the ASHA Briefing Paper  (2000), some of the characteristics of the current workplace are as follows:

There is little tolerance for new employees learning skills as part of the job; new clinicians need to already know how to navigate reimbursement systems, understand the complexities of managed care and recent legislation and advocate for services using efficacy and outcomes data.  There is a new appreciation for the multi-skilled, the multifunctional, and the cross-trained professional.

Changes in the workplace naturally require a different set of skills for graduate students to learn.  So, in addition to having a solid academic knowledge base, our students need "the ability to access, analyze, and effectively use information" (ASHA, 2000).  The ASHA Briefing Paper  goes on to list nine specific "workplace success skills graduate students need to learn" which are as follows:

  • Planning and priority setting
  • Organization and time management
  • Managing diversity
  • Team building
  • Interpersonal savvy and peer relationships
  • Organizational agility
  • Conflict management
  • Problem solving, perspective, and creativity
  • Dealing with paradox and learning on the fly
  • As I look at this list, I realize that in our clinical education program for first year graduate students, we have not been addressing all of these areas directly; we have left them to our externship supervisors to handle with the students in their second year.  Instead, our focus has been primarily on the technical knowledge of the field and on clinical competencies with clients.  As we move out into the community with our first year students, however, we are beginning to stress more of the other skills such as time management, organizational agility, and the management of diversity.

    How to Close the Gap: Changing our Model of Clinical Education

    Let's return now to the question posed earlier: How can we best prepare our graduates to have the skills necessary for success in the workplace, to become leaders in the clinical arena and to collaborate across disciplines to help meet the pressing social needs of the society-at-large?  According to ASHA (2000), the answer "may lie in adapting our current model of clinical education to better meet the external demands imposed by society and the marketplace."

    My next question to this group is: What is your clinical education program doing to meet these external demands and at the same time to help meet the social needs of your local communities?  Or put another way:  How is your clinical education program closing the gap between the 'real world' and 'the ivory tower'?  What is working well as we reach out to the community?

    (At this point in the presentation, participants broke into small discussion groups. Their task was to address the above questions and to share examples from their own programs of ways to close the gap.  Please refer to the Appendix for a Summary of Group Discussions.)

    Conclusion: A Challenge and A Caution

    In adapting old and present models of clinical education to meet the challenges and changes of the new millennium, we must be careful not to "throw the baby out with the bath water."  We need to decide what elements of our current model we value and want to keep and what new elements we want to add.  This decision may be our biggest challenge.  I would also like to offer a caution.  As we extend ourselves and reach out to the community, we must think of ourselves as partners with others rather than as one-way providers of a service.  We will enrich our students, our clients, and ourselves by engaging in partnerships.  In conclusion, I would like to quote from the Book of Rites, 206 BC-AD 25:  "Before entering a country, learn about its customs."


    American Speech-Language-Hearing Association (2000, March).  Responding to the changing needs of speech-language pathology and audiology students in the 21st  century (A briefing paper for academicians, practitioners, employers, and students).  <http: // students/changing.htm>.

    Boyer, E. L. (1990).  Scholarships reconsidered:  Priorities of the professorate.  Princeton, NJ: Carnegie Foundation for the Advancement of Teaching.

    Boyer, E. L. (1994, March 9).  Creating the new American college.  The Chronicle of Higher Education,  A48.

    Christina, R. W. (in press). Advancing engagement in kinesiology and physical education.  Quest.

    Coles, R. (1989). The call of stories:  Teaching and the moral imagination.  Boston: Houghton and Mifflin.

    Kellog Commission on the Future of State and Land-Grant Universities (1999).  Returning  to our roots: The engaged institution (3 report).  Washington, DC: National Association  of State Universities and Land-Grant Colleges, Office of Public Affairs.

    Lawson, H. L. (1997). Children in crisis, the helping professions, and the social  responsibilities of  universities.  Quest, 49 (1), 8-33.

    Pickering, M., & McAllister, L. (1997).  Clinical education and the future:  An emerging mosaic of  change, challenge and creativity. In L. McAllister, M. Lincoln, S. McLeod, &  D. Maloney (Eds.). Facilitating learning in clinical settings (pp. 252-295). Cheltenham,  United Kingdom: Stanley Thornes.

    Zlotkowski, E. (1997). Millennial expectations:  Creating a new service agenda in higher education. Quest, 49 (4), 355?368.

    Appendix: Summary of Group Discussions

    The following examples of ways clinical education programs are reaching out to the community were shared:

    Participants also offered the following suggestions for closing the gap between clinical educators on campus and SLPs serving as extern supervisors off?campus: