WHEN FIRST-SEMESTER graduate students are assigned to provide assessment and/or treatment to their first client in the university clinic (e.g., one with childhood apraxia of speech [CAS]), it is likely that they do not have a great deal of either academic or clinical knowledge about the disorder. Academically, coursework related to this specific disorder (or any other) might have consisted of only a few class periods and not an entire course, and clinically, beginning students are often still trying to differentiate a goal from a procedure. To increase the student's knowledge base, historically (before the mid-1990s), the student's supervisor would send her or him to the library to search for books or articles on the topic or would give the student copies of articles or books in the supervisor's collection. The student would begin acquiring knowledge through those sources and then read additional books and articles cited in them. Currently, students can use their information literacy and information technology skills to access articles (and even some books) from their computer. That information, however, is of limited use without a framework in which to embed it. That framework for speech-language pathology and many other professions is evidence-based practice (EBP). The purpose of this article is to examine how EBP linked to information literacy and the supervisory process can be integrated into the university clinic with the goal of enhancing clinical practice knowledge and skills among student clinicians.

EVIDENCE-BASED PRACTICE

By now, most clinicians are familiar with the classic definition of EBP that has its genesis in medicine:

Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice. (Sackett, Rosenberg, MuirGray, Haynes, & Richardson, 1996, p. 71)

Evidence-based practice is by now so well ingrained into the fabric of the profession that knowledge about EBP is a requirement for certification from the American Speech-Language-Hearing Association (ASHA) (Standard III-F):

[horizontal ellipsis]the applicant must demonstrate knowledge of processes used in research and the integration of research principles into evidence-based clinical practice[horizontal ellipsis] (and) must demonstrate comprehension of the principles of basic and applied research and research design. In addition the applicant should know how to access sources of research information and have experience relating research to clinical practice. (American Speech-Language-Hearing Association, 2005a, p. 6)

One difficulty in implementing EBP is a general lack of research studies in many areas of speech-language pathology. That is, the scope of practice is larger than the evidence base. One practice area that exemplifies the problem of insufficient research evidence is CAS. This article will use the example of CAS to illustrate the process of integrating EBP into the university clinic.

In the recent position statement (ASHA, 2007a) and technical report (ASHA, 2007b) on CAS, the committee noted that "there are few recent articles that have addressed this topic and even fewer that have reported treatment efficacy findings" (ASHA, 2007b, p. 32). Thus, students need to utilize skills in information literacy to access the resources most appropriate to the clients and their disorders.

Information literacy

Before searching for resources relevant to the client and her or his disorder, students should pose the clinical question they are trying to answer. For example, in providing services to a child with CAS, the beginning student might initially conceptualize the clinical question as follows: "what treatment should I use?" The supervisor might help the student reframe the question to one that is more specific to the client and the disorder; for example, "what is the most effective treatment for preschool children with CAS?" Although at this point in their preservice training, students would likely have coursework in speech-sound disorders, their knowledge of CAS is likely to be relatively broad but not deep. Thus, they naturally would set about to complete background research in preparation for treating a child with CAS.

Through a literature search, students retrieve published resources that aid them in providing clinical services to their clients. Historically, there was but one option to complete such a search-going to a bricks and mortar structure (i.e., the library) and looking up resources. It was not possible to access searchable databases from a computer to locate research studies from which to answer the clinical question. Currently, there are many more options available to students who need to search the literature. Thus, students who are in the process of becoming speech-language pathologists need to be educated consumers of research and need to be well-versed in the research process and EBP.

One component to becoming an educated consumer of research is knowledge of information literacy (Nail-Chiwetalu & Bernstein Ratner, 2006). The supervisor needs to direct students in the tenets of information literacy to ensure that the search is sufficiently comprehensive to answer the clinical question. Nail-Chiwetalu and Bernstein Ratner outlined five standards that should be considered in information literacy, which can be used to inform clinical practice for students.

Standard 1 is "to determine the nature and extent of the information needed" (Nail-Chiwetalu & Bernstein Ratner, 2006, p. 158). Formulating an initial clinical question assumes some knowledge of the literature that will be searched. It also means that the initial clinical question will likely be altered as the search for information takes place. For example, as indicated above, the initial question for treatment of CAS was far too broad and needed to be narrowed somewhat.

Standard 2 is to "access needed information effectively and efficiently" (Nail-Chiwetalu & Bernstein Ratner, 2006, p. 158). When in search of information, most people "Google" it. Google might be a beginning, but it surely is not the end, especially if one does not look past the first page of results or uses only "classic" Google (http://www.google.com) and not Google Scholar (http://scholar.google.com) or advance Google Scholar search (http://scholar.google.com/advanced_scholar_search?hl=en&lr=). As Nail-Chiwetalu and Bernstein Ratner pointed out, peer-reviewed research is almost always absent in the results emanating from a general search engine. That is, the user is more likely to access information that has not been vetted for scientific review. Search engines do exist, however, for locating peer-reviewed materials. Individuals who are members of ASHA or National Student Speech-Language-Hearing Association have online access to all ASHA journals dating back to 1980. PubMed, a service of the National Library of medicine and the National Institutes of Health at http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed, also provides access to a large number of peer-reviewed journals. However, the site only provides the title and abstract. Once a relevant source is located, the user must obtain the entire article from another source (e.g., local library, university library, or publisher). Libraries also might have access to other searchable databases such as EBSCOhost (http://search.ebscohost.com), OVID (http://www.ovid.com), Linguistics and Language Behavior Abstracts (http://www.csa.com/factsheets/llba-set-c.php), and Psyc INFO (http://www.apa.org/psycinfo/).

Standard 3 is to "evaluate information and its sources critically and incorporate selected information into your knowledge base and value system" (Nail-Chiwetalu & Bernstein Ratner, 2006, p. 163). All information is not necessarily equal. Articles that appear in scholarly journals undergo rigorous peer review in a fashion that other types of publications might not (e.g., handouts at conferences or textbook chapters). This is not to say that information contained in such material is not reliable or valid. However, painstaking peer review helps readers ensure that the information in the article has been vetted by other experts in that area. Moreover, reading information in primary sources (e.g., the initial study itself) will allow students to judge the quality of the study rather than reading it as a summary in a secondary source (e.g., chapters and conference handouts).

Standard 4 is to "use information effectively to accomplish a task" (Nail-Chiwetalu & Bernstein Ratner, 2006, p. 164). Information provided in primary and secondary sources must then be applied to clinical practice. For example, discussing the literature in a group supervisory conference (detailed later in the article) might aid in bridging this gap and allow an easier transition from research to practice.

Finally, Standard 5 is to "understand the economic, legal, and social issues surrounding use of information, and access and use information ethically and legally" (Nail-Chiwetalu & Bernstein Ratner, 2006, p. 164). Keeping up with the literature across a number of different areas is difficult. Students who are in university settings often have an advantage over others in this regard. Thus, they have free access to a number of databases from which to access full-text journals on-line. With that access comes the responsibility to use that information in responsible ways to prevent academic dishonesty such as plagiarism (Nail-Chiwetalu & Bernstein Ratner, 2003). Students need to understand how to properly cite the references they locate, thus giving appropriate attribution to the source of their information. These sources include quotations, especially if they are incorporated into official legal documents (e.g., evaluation or progress reports), facts, and ideas. In general, all sources must be identified as clearly, accurately, and thoroughly as possible. When in doubt about whether to identify a source, the student should either cite the source or consult with the supervisor who should be available to direct the student in this regard.

PICO procedure

It is necessary for students to not only acquire information literacy skills but also utilize a schema to organize and interpret that information. One such schema is the PICO (patient characteristics, intervention program, comparison treatment, and outcome) procedure, which can be used to integrate science into clinical practice (e.g., Gillam & Gillam, 2006). Using the PICO procedure will aid students in determining the relevance of a particular study to the client with whom they are working.

Patient characteristics are those that are exhibited by the individual with whom the student is working. Having a broad and deep knowledge of the speech and language characteristics of the individual to whom the student is providing services will allow a more parsimonious search of the intervention program for which one is seeking evidence.

Using CAS as an example, a focus on the P and I components in the PICO procedure would likely result in a number of sources focusing on apraxia in children. Such a search would result in locating historical sources such as Bashir, Grahamjones, and Bostwick (1984), Chumpelik (1984), Crary (1984), Rosenbek, Hansen, Baughman, and Lemme (1974), and Rosenbek and Wertz (1972); and more current sources such as Davis, Jakielski, and Marquardt (1998); Forrest (2003); Shriberg, Aram, and Kwiatkowski (1997); Shriberg and Campbell (2002); Velleman (2002); Velleman and Strand (1994).

From readings such as these, CAS is presented as a speech disorder resulting from impaired motor planning/programming with the following core patient characteristics (ASHA, 2007b, p. 4): (a) inconsistent errors on consonants and vowels in repeated productions of syllables or words, (b) lengthened and disrupted coarticulatory transitions between sounds and syllables, and (c) inappropriate prosody, especially in the realization of lexical or phrasal stress. Once students have identified the patient characteristics, then their focus can turn to the I (intervention program) in the PICO procedure. Using CAS as an example again, students would likely come across linguistic approaches, motor-programming approaches, and linguistic-motor programming approaches (Hall, 2000).

Beginning students would likely be able to incorporate information relating to the P and I components from these sources and the recommended intervention approaches and their associated strategies into their treatment plans, but their weakness at this point in their knowledge base and training might be an inability to extend the procedure to include the C (comparison treatment) and the O (outcome) components of the PICO procedure in their search. Ideally, there should be research related to a comparison treatment allowing a judgment of several intervention options for the same disorder/constellation of behavioral characteristics.

Even if there are articles on the intervention of a particular disorder, supervisors need to implore students to examine the type of evidence on which the study's conclusions are based. That is, there is a hierarchy of levels of evidence (ASHA, 2007a, adapted from the Scottish Intercollegiate Guidelines Network [http://www.sign.ac.uk]; Table 1). This hierarchy, with Level Ia indicating the strongest level of support, can aid students (and practicing speech-language pathologists) in judging the quality of the information they have gathered.

Table 1. Levels of evidence

It is likely, however, that there will not be Level I and Level II studies that specifically address the intervention students are considering using with a particular population. For example, the authors of ASHA's technical report on CAS note that the existing treatment studies of CAS were ones with relatively low levels of evidence (ASHA, 2007b). It should be noted that although there might not be research studies that address intervention specifically, studies often exist, for example, which describe the population, in this case those with CAS (e.g., Davis et al., 1998; Shriberg et al., 1997) or provide a valid assessment protocol (e.g., Crary, 1995; Davis & Velleman, 2000). Results from these types of studies can usually be applied to intervention.

One way to judge the quality of intervention studies (clinical trials, specifically) is to use the checklist put forth by the Consolidated Standards of Reporting Trials (CONSORT) group (http://www.consort-statement.org/mod_product/uploads/CONSORT%202001%20checklist.) (Altman et al., 2001). This checklist includes characteristics that should be described in an article focusing on the results of a clinical trial (Table 2). Using such a checklist aids students in judging the quality of the intervention studies they read as part of their practicum assignment. Moreover, it allows for a more seamless transition from research to practice. That is, the gap between academic teaching and clinical teaching is reduced.

Table 2. Adapted Consolidated Standards of Reporting Trials checklist

Once the student has gone through the P, I, and C components of the PICO procedure, the outcome of the intervention must be judged to determine the efficiency, effects, and effectiveness of intervention (e.g., Williams, 2003). Efficiency relates to the duration of time it takes for the client to achieve the goals and how much effort was needed to facilitate changes. This might include the number of treatment sessions or months in treatment. To gauge the effort, students might examine a child's response level (e.g., Was imitation always needed or was there a move to spontaneous production?); determine the hierarchy needed to produce change (many incremental steps or a few gradual steps?); or note how much cueing was needed to learn the new behavior. Evaluation of effects includes noting whether the change was significant. In this area, students might graph data from the session and note the trend, take pre- and posttreatment measures, and ask familiar and/or unfamiliar listeners to gauge the client's speech and language. Finally, effectiveness indicates whether therapy was responsible for the change witnessed during the intervention process. Here, students would take baseline data, treatment data, and withdrawal data (i.e., What happens to the behavior once the intervention is removed?); utilize generalization probes to determine whether the client is using old forms for new functions (e.g., production of previously mastered /l/ in clusters as opposed to correct production in singletons only); or new functions for old forms (e.g., accurate production of present progressive in questions as opposed to in declarative sentences only); and collect follow-up data (weeks to months after working on the behavior).

Schlosser and O'Neil-Pirozzi (2006) have suggested adding two components to the PICO procedure, thus making it the PEISCO procedure. First, they would add E for environments. Environments include the situations in which the disorder occurs and/or changes. In their example, for people who stutter, the frequency and types of dysfluencies can change dramatically depending on the situation. In children with CAS, the environment might be a phonotactic one in which long, complex words are more difficult for these children than are short, less complex words (Velleman, 2002). Second, they would add S for stakeholders. Stakeholders include the individual with the disorder along with those who have direct and indirect contact with that individual. Considering the environment and the stakeholders adds to the depth of the EBP procedure.

PICO procedure and supervision

Supervisors can integrate the PICO procedure throughout the supervisory process, using a model of supervision such as the three-stage model outlined by Anderson (1988). This model assumes three stages of supervision. In the initial evaluation-feedback stage, the supervisor dominates and provides direct and voluminous feedback to the student. The second stage is the transitional stage. Here, the student begins taking on more responsibility in terms of planning, implementing, and evaluating all aspects of the clinical process. Finally, in the self-supervision stage, the supervisor's role is more of a consultant with less direct feedback in which the supervisor helps the student engage in problem solving.

Beginning students should be encouraged to focus particularly on the P and I components of the PICO procedure. Focusing on specific aspects of the PICO procedure for beginning students relates well to the first stage in supervisory process, the initial evaluation-feedback stage. In this stage, students go through a series of general orientations to clinical teaching, then orientations to their specific clinical assignment, and then individual meetings with the supervisor. For assessment, there is a planning period before the client comes in for the evaluation activities. At that planning meeting, the case history is discussed (typically mailed to the client/client's family and returned before the assessment) and the assessment is planned. After the assessment, the supervisor and the student(s) meet to discuss the disposition of the case, and the supervisor provides feedback. For intervention, a planning session is held. After each intervention session, the supervisor and the student(s) meet to discuss the client's performance and progress and the student's strengths and weaknesses in that session. The next session is then planned.

In the evaluation-feedback stage, the supervisor dominates and provides direct and voluminous information and feedback to the student. The feedback is explicit, relating to all aspects of assessment or intervention. Students who are at this stage need direct feedback in terms of the literature search they need to do and how to accomplish it successfully. Students are expected to follow the suggestions and bring P and I information to bear on the service they are providing.

Students might expect that the supervisor will provide starting references (books and articles) from which they can begin to gather information on patient characteristics and the intervention program. Thus, a direct-active style of supervision would be most appropriate here at the beginning stage of the supervisor-supervisee process (McRea & Brasseur, 2003). In this style, supervisors assume a more controlling position in which they tell, criticize (constructively), and evaluate; supervisees are assumed to be inexperienced or unskilled and thus are relatively passive and minimally participatory in the process. McRea and Brasseur cautioned that, although this style might be necessary to a degree, it also can lead to modeling in which the student becomes a "clone" of the supervisor, limiting problem solving and critical thinking (p. 23). In using this style at this point in the process, the supervisor would need to introduce (or review) the PICO procedure and require students to seek out information covering all four of its components.

The evaluation-feedback stage is designed to last a relatively short time (unless a student is having difficulty in adjusting to the clinical process). Once students become adept at locating and integrating the first two components of the PICO procedure, they can extend their search to the other two PICO components: C and O. Students who are more experienced either in terms of time in the program or in working with similar clients should be able to move quickly into the transitional stage or perhaps in the self-supervision stage.

In the transitional stage, students begin taking on more responsibility for planning, implementing, and evaluating all aspects of the clinical process. Students are also expected to self-monitor their skills and discuss their strengths and weaknesses with the supervisor. Thus, constructive criticism becomes more of a joint venture over time, with the supervisor and the student both contributing to that aspect of clinical teaching. It is expected that during this stage the student becomes increasingly independent. Typically, even during this stage, students tend to show strengths in certain areas and weaknesses in others. Supervisors help students focus on those aspects of clinical management that need more input and feedback. Thus, feedback may continue to be direct in those weaker areas. Supervisors also might suggest that students go back to their evidentiary sources (i.e., the I and C of the PICO procedure) for support for their clinical strategies.

Finally, in the self-supervision stage, the supervisor's role is more of a consultant who provides less direct feedback. As Walters and Geller (2002) noted, this stage is one in which "[s]tudents are challenged to move from being 'receivers' of knowledge from an expert (i.e., the supervisor tells the student what to do) to becoming 'active' participants in constructing knowledge (i.e., the student initiates clinical decisions)" (pp. 187-188). Here, the supervisor helps the student engage in problem solving, assessment, and intervention, and can discuss the student's supervisory preferences. Although the student is primarily responsible for the clinical procedures at this stage, the supervisor continues to provide support and feedback.

In the transitional and self-supervision stages, the supervisor would expect that the student would take some responsibility in asking what information is needed to be collected and thus come to the session prepared with this type of information or at least some of it. Thus, a collaborative style would be most appropriate at this point (McRea & Brasseur, 2003). This style utilizes a problem-solving approach in which both participants share responsibility for and provide input to the clinical process. Here, the supervisor might direct the student but is more likely to encourage the student's ideas and encourage self-analysis. The student not only accepts this direction but also questions the supervisor, takes initiative, and works toward independence. For example, the student and the supervisor might discuss a research study that the student procures and believes germane to the client. The supervisor would ask the student to interpret the research using the PICO procedure. Then the supervisor might do the same. It is likely that their interpretations will not be identical. In such a case, the supervisor and the supervisee would discuss how their interpretations are similar and different and come to a mutual agreement as to how to apply the research on the client.

Supervisory feedback

Students utilize the information gathered from the PICO procedure in the clinical management of the client. Subsequently, students require feedback on their ability to incorporate that information into the clinical process. During the three stages of supervision (Anderson, 1988), supervisory feedback should be written and verbal. This feedback is both formative, after each session, and summative, at midterm and the end of the semester. In addition, that feedback should include the way in which the student is utilizing the literature in the provision of clinical services. For example, for assessment, students might be rated on their ability to select and implement evaluation procedures (nonstandardized tests, behavioral observations, and standardized tests) in accordance with the prevailing literature. Within that goal, they can be rated on a scale from 1 (low) to 3 (mid) to 5 (high) on their ability to achieve that goal (Temple University, 2007):

Rating of 1: The student requires supervisory guidance to select evaluation procedures that are appropriate and complete. Those procedures are not commensurate with prevailing literature. The student may administer and/or score tests inaccurately and does not seek supervisory guidance when needed.

Rating of 3: In most situations, the student independently selects an adequate assessment battery, with consideration for all relevant factors. Those procedures are generally commensurate with prevailing literature. The student administers the battery, scores tests accurately, and usually seeks supervisory guidance when needed.

Rating of 5: The student independently selects a comprehensive assessment battery with consideration for all relevant factors. Those procedures are commensurate with prevailing literature. The student efficiently and accurately administers the battery and consistently scores tests accurately. Student seeks supervisory guidance if needed.

A similar 5-point rating scale applies to intervention. For example, one of the goals for intervention might be to "select/develop and implement intervention strategies based on the prevailing literature for treatment of communication and related disorders." Ratings in attempting to achieve that goal might include the following:

Rating of 1: The student requires supervisory guidance to select/develop and/or implement intervention strategies relevant to the needs of the client. Those strategies are not commensurate with prevailing literature. The student does not seek supervisory guidance when needed.

Rating of 3: In most situations, the student independently selects/develops and implements intervention strategies relevant to the communication disorder and the unique characteristics of the client. Those strategies are generally commensurate with prevailing literature. The student usually seeks supervisory guidance when needed.

Rating of 5: The student independently selects/develops and implements comprehensive intervention strategies that take into consideration all unique characteristics and communication needs of the client. Those strategies are commensurate with prevailing literature. The student seeks supervisory guidance if needed.

One other means of tailoring feedback to students during the supervisory process is to utilize both group and individual conferences. A weekly group conference, which typically takes place immediately after a session, provides a means to discuss general issues germane to all the student clinicians. It also serves as an avenue for both supervisor and peer mentoring and as one means to discuss research related to the clients with whom the students are working (Pickering, 2005). Such a group model has been used for groups of students working with diverse populations, such as people who stutter (Murphy & Quesal, 2004) and individuals from culturally and linguistically diverse populations (Walters & Geller, 2002). (It should be noted that these programs do not provide specific evidence of their effectiveness but the models are linked to current theory and practice in the field.) In the group conference, it is commonplace for a student member to have read a relevant research paper relating to one of the clients. If students have not read a paper in the area, one is assigned for discussion at the next group conference. Subsequently, information is shared following the tenets of the PICO procedure.

Searching for evidence other than research

Completing an exhaustive literature search in an area of inquiry such as CAS might not result in direct research evidence for answering the clinical question. Thus, it will be necessary to use other types of evidence. Systematic reviews, practice guidelines, clinical judgment, and the client's goals can be used to direct student clinicians in the absence of specific evidence.

Systematic review is defined as the process by which "a critical assessment and evaluation of research (not simply a summary) that attempts to address a focused clinical question using methods designed to reduce the likelihood of bias" (Guyatt & Rennie, 2002, p. 431). The purpose of such reviews is to draw conclusions from a relatively large group of studies that can not be drawn from individual studies (McCauley & Hargrove, 2004). One quantitative extension of the systematic review is the meta-analysis. A researcher conducting a meta-analysis of studies identified in a systematic review uses statistics to answer a clinical question to show treatment efficacy (Robey, 2004). These types of analyses are more comprehensive and transparent and less prone to bias than other methods of research synthesis such as textbook summaries, review articles, and expert opinion (McCauley & Hargrove, 2004).

Derived from systematic reviews are practice guidelines (McCauley & Hargrove, 2004). Practice guidelines result from a series of steps in which experts complete a "comprehensive review of the professional literature, grade levels of evidence using pre-set and accepted criteria, develop flow charts and decision trees to assist in evidence-supported decision-making during the clinical process, and creat[e] tables of evidence used to support the development of the guidelines" (Frattali, 2004, p. 13). ASHA has published Preferred Practice Patterns for the Profession of Speech-Language Pathology (ASHA, 2007b) and Preferred Practice Patterns for the Profession of Audiology (ASHA, 2007b). American Speech-Language-Hearing Association maintains a list of practice guidelines and systematic reviews at http://www.asha.org/members/ebp/compendium/. Such a report now exists for CAS (ASHA, 2007b). This report includes a discussion of terminology, a definition of CAS, prevalence of the disorder, scientific foundations (e.g., overview of typical and atypical speech development, research in CAS, genetic and neurobehavioral research in CAS, and research related to the assessment of and intervention for CAS). Specific to treatment, the report provides suggestions for treatment intensity, length, and strategies. Finally, the report outlines future basic and applied research needs in this area (e.g., epidemiological studies of CAS and cross-linguistic studies of CAS).

Two other components of EBP (beyond literature-based evidence) should be incorporated into the clinical process-clinical judgment and the client's goals (ASHA, 2005b). Using the criteria for evidence noted in Table 1, these two components would be considered relatively weak forms of evidence, but they are part of the EBP framework. The desire to ensure that all three components are included in the process, Dollaghan (2007) recommended abbreviating evidence-based practice as E³BP. Using this abbreviation is a reminder that (1) clinical judgment and (2) client goals should be used in concert with (3) research evidence. Using clinical judgment and client goals in the treatment of CAS is required given that "[t]here have been few treatment studies of CAS since approximately 1995. Four treatment studies were identified, none of which met the highest level of evidence" (ASHA, 2007b, p. 52). So, for example, a supervisor, through significant experience in providing services to those with CAS, might suggest a supplemental intervention strategy for a particular child such as melodic intonation therapy (e.g., Helfrich-Miller, 1984) as opposed to a motor programming approach (Velleman, 2002). Furthermore, a family might want an initial intervention target to be bilabial sounds given that the child's name begins with /b/.

Integrating all three aspects of E³BP means that the accumulated experience of the supervisor (and perhaps other mentors with whom the student has contact), the goals of the client, and science can interact in ways that guide the intervention process. Dollaghan (2007) included a checklist for appraising patient/practice evidence (p. 116) and one for appraising evidence on patient preferences (pp. 128-129) that can guide practitioners in evaluating evidence from clinical practice. This process guides one in asking the clinical question, determining issues related to the validity and importance of the evidence, finding shared goals between client, clinician (and perhaps significant others), and preparing information on clinical options, during and beyond university training (Lincoln & McCabe, 2005). Finally, as Dollaghan (2004) pointed out, "[t]he lesson of EBP is not that clinical experience and patient perspectives should be ignored; rather, they are considered against a background of the highest quality scientific evidence that can be found" (pp. 392-393).

SUMMARY AND CONCLUSIONS

Many student clinicians experience a disconnect between theory and research discussed in academic courses and application of that information in the clinical setting. To bridge that gap, a knowledgeable partner (i.e., the supervisor) must make or allow the student to make a connection between scientific evidence and practice. That evidence will likely take many forms. First and foremost is the research literature. When at all possible, specific research studies that inform clinical practice for a particular client with a specific disorder at a given time need to be paramount. Students should use the PICO/PEISCO procedure to form and answer their specific clinical question and keep their clinical goals informed. Unfortunately, the literature in speech-language pathology and audiology is not so replete. Thus, supervisors must direct students to other sources such as systematic reviews and practice guidelines. In addition, students should avail themselves of the other two components of evidence-based practice: clinical judgment (theirs and their supervisor's) and the client's and/or family's goals. In these ways, supervisors can guide students toward an outcome of enhanced communication skills in the individuals they assess and treat.

REFERENCES