Original Paper Folia Phoniatr Logop 2014;66:176–182 DOI: 10.1159/000366129
Published online: March 17, 2015
Competence-Based Curricula for the Education of Speech-Language Pathologists and Audiologists in Brazil Fernanda Dreux M. Fernandes Haydée F. Wertzner School of Medicine, Universidade de São Paulo, São Paulo, Brazil
Abstract Objective: The aim of this paper is to present the academic requirements for the education of speech-language pathologists (SLPs) and to discuss some of the challenges in providing quality supervised practice and the solutions proposed by some programs in Brazil. Methods: Brazilian proposals regarding the training of SLPs are reviewed, with guidelines provided by the International Association of Logopedics and Phoniatrics (IALP) and the Comité Permanent de Liaison des Orthophonistes-Logopèdes de l’UE (CPLOL), and descriptions of the specific experience of the oldest Brazilian program are provided. Results: The bachelor’s degree is the minimum level required for the independent practice of speech-language pathology and audiology in Brazil, where there are 75 undergraduate programs. In several programs, students are encouraged to enjoy the diversity at their university, enrolling in courses of different areas to broaden their experience. The basic areas of the undergraduate program are mandatory as per recommendation of the Ministry of Education and include competences related to the health
© 2015 S. Karger AG, Basel 1021–7762/15/0665–0176$39.50/0 E-Mail [email protected] www.karger.com/fpl
system, decision making, communication, leadership and continued education. Since practice training is part of the undergraduate programs, it is incorporated into the pedagogical concept and has a major role in it. Conclusion: The structure of the programs allows the dissociation of theory from practice to be attenuated; both educational strategies are used together as part of the pedagogical concept. © 2015 S. Karger AG, Basel
Introduction
Professionals in the field of communication sciences and disorders are called Fonoaudiólogos in Brazil and all of South America [1]. They are certified both as speechlanguage pathologists (SLPs) and as audiologists. The bachelor’s degree is the minimum level required for independent practice. Therefore, the educational programs have to encompass a large area of expertise to provide the necessary information and training during undergraduate programs. Opportunities for practical experience are not only essential to the development of professional practice competencies, they are also useful for the inclusion of issues such as problem solving, social and cultural awareness, independence and continued education. The Fernanda Dreux M. Fernandes Rua do Manjericão, 301 Granja Vianna 2 Cotia, SP 06706-240 (Brazil) E-Mail fernandadreux @ usp.br
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Key Words Competence-based curricula · Speech-language pathologists · Audiologists
Table 1. Number of undergraduate programs in the different regions of Brazil
Region State(s)
Population, n Programs, n (in millions)
1 2 3 4 5 6 7 8
16.4 43.6 17.6 33.5 23.3 30.2 11.1 22.4
Rio de Janeiro São Paulo Paraná, Santa Catarina Bahia, Pernambuco, Sergipe, Alagoas, Paraíba Acre, Rondônia, Amazonas, Roraima, Amapá, Pará, Tocantins, Goiás Mato Grosso, Mato Grosso do Sul, Minas Gerais, Espírito Santo Rio Grande do Sul Maranhão, Piauí, Ceará, Rio Grande do Norte
4 17 9 12 7 14 6 6
aim of this paper is to present the academic requirements for the education of SLPs and to discuss some of the challenges in providing quality supervised practice and the solutions proposed by some programs in Brazil.
There are 75 undergraduate programs in Fonoaudiologia in Brazil. Table 1 shows the number of undergraduate programs in each region according to the Conselho Federal de Fonoaudiologia (Federal Council of Phonaudiology). Although the programs still are not evenly distributed between the regions, the discrepancies are not too severe. In 2002, the Brazilian Ministry of Education [2] determined the minimum competences for the programs of fonoaudiologia (speech-language pathology and audiology). They are very similar to the ones proposed by the Comité Permanent de Liaison des Orthophonistes-Logopèdes de l’UE (CPLOL) and the International Association of Logopedics and Phoniatrics (IALP). One important difference between the Brazilian guidelines and the ones proposed by the international associations relates to the fact that the Brazilian document refers to just one country, while the others are directed to the international community. Therefore, even when considering the great diversity of a large and complex country such as Brazil [3], the social, cultural and educational variety is smaller than when several different countries are considered. The IALP [4], CPLOL [5] and Brazilian [6] documents recognize the complexity of the education of SLPs and
audiologists and suggest that it is a process that must be continued throughout the years of practice. They also point out the important purpose of improving the quality of life of people with communication and swallowing disorders by improving the quality of the services provided. Table 2 shows that the three documents state that speechlanguage pathology demands university-level training that takes into account values such as ethics and the awareness of cultural differences in research and practice. Similar basic and specific contents are described in all proposals, as well as the main educational roles that should be played by SLPs. In 2009, another resolution by the Ministry of Education [6] determined that the minimum workload for a program of fonoaudiologia is 3,200 h, to be completed in 4 years. Supervised practice, conducted at the university and accompanied by professors, must represent 20% of the total program workload. This experience aims to guarantee a solid scientific base that favors the integration of the competences needed by the various practices within the scope of speech-language pathology and audiology. Therefore, several of the programs in Brazil have workloads of more than 4,000 h, with over 800 h of supervised practice conducted in clinical schools and school hospitals, to be completed in 4 years of full-time training. These legal guidelines guarantee minimum standards for education in the whole country. Some flexibility is allowed in order to address the specific characteristics of different programs, universities and regions. Therefore, each university can propose specific theoretical and practical contents that may be associated with the specific needs of a certain region regarding its demands in social, cultural, health and education areas. For example, in
Education of SLPs and Audiologists in Brazil
Folia Phoniatr Logop 2014;66:176–182 DOI: 10.1159/000366129
Educating Professionals to Work as SLPs and Audiologists: The Brazilian Perspective
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Source: Conselho Federal de Fonoaudiologia. http://www.fonoaudiologia.org.br/cffa/index.php/ensinosuperior/.
Table 2. Benchmarks for the education of SLPs and fonoaudiólogos
IALP education guidelines1
CPLOL minimum standards2
Brazilian guidelines3
Premises/ Independent profession; code competences of ethics; education with a general scope; appreciation of linguistic and cultural variety; specific knowledge, evidencebased practice; supervision; continued education
Studies at university level in accordance with the principles of the Bologna Charter; competences in clinical practice; working in and for an organization; developing the profession and the discipline
Education of fonoaudiólogos should be general, critical and humanistic; ethicalpolitical-philosophical basis; knowledge about the history, philosophy and methodology of intervention models; evidence-based practice
Principles
Awareness of the complexity of human communication; based on the foundation of normal communication and its development; practical and theoretical integration by supervised practice; awareness of multicultural and multilingual issues
Accordance with the code of ethics; expertise on the complexity of human communication; scientific approach; evidence-based assessment and intervention; awareness and respect for differences; general knowledge; ability to conduct basic research; problemsolving skills; ability to learn to study with autonomy; ability to enter a postgraduate program
Awareness of prevention, promotion, protection and rehabilitation actions in the health system; high quality standards; ethical and bioethical principles; problem solving; science-based decision making; proficiency in at least 1 other language; leadership; management skills; continued education; autonomy; ability to work with multidisciplinary teams
Content (supporting disciplines and specific content)
Linguistic, behavioral and biomedical sciences and ethical issues; varieties of normal and abnormal communication; theories of rehabilitation; methods for assessment and diagnosis; methods for assessing intervention results; social consequences of communication disorders; social settings for speechlanguage pathology work
Biomedical, language and behavioral sciences; speech and language pathology; research skills and public health
Biological sciences; human and social sciences, including language, ethics, behavior, psychology, education; normal and pathological processes of hearing, oral and written language, speech, fluency, swallowing and voice; history, principles and critical analysis of rehabilitation and clinical methods; public health; technical advances; integration with the health system
Education issues
Teaching provided by qualified SLPs, including practical work under supervision by qualified and experienced SLPs in a variety of settings and cases; continued evaluation of the student’s progress and practical examination
Speech-language pathology courses should be provided by SLPs; professional practice placements to develop clinical skills including prevention, assessment, diagnosis, intervention and evaluation as well as onward referral; collaboration with a multidisciplinary team; workout therapy plans adapted to clients’ needs; supervision by SLPs with the necessary expertise
Planning for a program of fonoaudiologia should be conducted by a group of fonoaudiólogos who will be the teachers of the specific courses; at least 20% of the workload designated to supervised practice in different environments within the university (hospitals, out-patient clinics, day care centers and schools); complementary activities such as internships, research collaboration, studies and projects; continued evaluation of students; possibility of individual options and flexibility; end-of-term paper with teacher mentoring
1 IALP education guidelines [4]. 2 CPOL revision of the minimum standards of education [5]. 3 National curriculum guidelines (Brazil)
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Fernandes/Wertzner
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[2].
Education of SLPs and Audiologists in Brazil
Folia Phoniatr Logop 2014;66:176–182 DOI: 10.1159/000366129
Main Areas of Study: Individual Choices Leading to Individual Professional Profiles
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The basic areas of the undergraduate programs are mandatory and included in the recommendations by the Ministry of Education [1]. The programs must provide
opportunities for students to develop general competences in the following areas: (1) Health system: students should be able to work with the highest ethical and bioethical standards, critically considering the structure of the health system and proposing solutions to issues regarding all levels of health care in education, prevention, assessment and intervention (2) Decision making: students should also have the opportunity to develop the skills needed to make decisions based on scientific evidence and considering the proper use of resources and the cost-effectiveness of the procedures (3) Adequate communication: students should be encouraged to seek proficiency in at least 1 more language to have accessible communication with other professionals and with clients and their families, guaranteeing the confidentiality of data (4) Leadership: students should be provided with opportunities to work in multidisciplinary teams with responsibility, empathy and engagement as well as to use management skills (5) Continued education: students must learn how to learn, becoming responsible for their own continued education and cooperating with the area development through national and international networking In several programs, students are encouraged to enjoy the diversity at their university, enrolling in courses of different areas and broadening their experience. Within these programs, the students may choose specific areas and different periods to take classes or training courses. The result of such a diversity of options is that each student can build his/her individual professional profile according to personal preferences, interests or talents. However, whether there is an area of expertise or not, all fonoaudiólogos must be able to: – understand and critically analyze the theoretical and conceptual systems regarding the study of voice, speech, oral and written language, hearing, swallowing and the clinical methods of assessment and intervention; – understand human processes such as social relations, psychology, language and learning; – understand the complexity of human communication and hearing processes; – perform clinical and educational actions directed at preventing, assessing, diagnosing and intervening with hearing and communication disorders; – propose appropriate assessment and intervention methods for each situation or individual;
areas where there are only few programs and a small number of fonoaudiólogos providing services to the population, the programs usually have more comprehensive approaches. On the other hand, in areas where there are several programs at different universities, it is possible for each one to develop specific areas of greater expertise according to the characteristics of the university or even of the group of teachers. It is not surprising, therefore, that major experiences in distance education are being made at universities that are not located in the greater metropolitan areas. In some situations, a teacher with specific expertise may give a lecture to teachers and students of a program located in a region with fewer resources. Alternatively, systematic conferences or supervisions are programed for exchanging experiences and knowledge. In the last decades, with the implementation of the Sistema Unificado de Saúde (Unified Health System), all professionals in the health area were included in primary health care programs, and, therefore, speech-language pathology and audiology was included in the educational programs both as theoretical courses and as supervised practice with a focus on the prevention of hearing and communication disorders. After graduation, a fonoaudiólogo may opt for 1 of the 7 areas of specialization recognized by the Conselho Federal de Fonoaudiologia: language, audiology, voice, oral myology, dysphagia, public health and education. Master’s and doctoral degrees are also alternatives for continued education. The number of graduate programs in Rehabilitation Sciences and Fonoaudiologia has shown an important increase in the last decade as programs in new areas have been approved by the Ministry of Education [7]. The first graduate program was started in 1979, and until 2001 there were 6 programs at master’s and doctoral levels. In 2013 there were 11 programs, including 1 in the Northeast Region. Even so, many fonoaudiólogos do their master’s and doctoral studies in other areas such as linguistics, psychology, nutrition or education. There is significant variation in the profiles of Brazilian fonoaudiólogos that starts during undergraduate programs. This is further discussed in the following sections of the paper.
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Folia Phoniatr Logop 2014;66:176–182 DOI: 10.1159/000366129
most 5,000 h that includes many different places of work, opportunities to engage in different areas at different stages of the program and the flexibility that allows for individual profiles of education and training. This program is possible thanks to the efforts of all 15 teachers in the program, who are fonoaudiologos with at least a doctoral degree and significant national and international experience. In the next section, we provide more details on the experience gained by this group.
Building Competence through Practice
Since practice training is part of the undergraduate programs, it is incorporated into their pedagogical concept and has a major role in it. This way, the dissociation of theory from practice can be attenuated, and both educational strategies can be used together as part of the pedagogical concept. In accordance with the recommendations by the Ministry of Education [1], the program has almost 2,000 h of supervised practice that should be completed during the last 2 years of the program. All supervised practice activities are conducted in groups of 5 or 6 students under direct supervision of a fonoaudiólogo with a master’s or doctoral degree (90% of them) and with mentoring by a professor conducting the immediate discussions of clinical events and students’ performance. There are mandatory disciplines of supervised practice in the areas of public health that focus on speech and language and on audiology. The total workload of these disciplines is 950 h. There are also 2 other disciplines, conducted in public schools and day care centers in the university’s neighborhood. In these disciplines, with a workload of 75 h each, the students work with groups of children in activities related to the prevention and early diagnosis of language and learning disorders. In addition, students must choose 5 of multiple possibilities of supervised practice disciplines carried out at the school clinic or at one of the two school hospitals of the university. The model project proposes that the students enroll in 2 of these disciplines during the third year of the undergraduate program and in 3 disciplines during the fourth year; each of these has a total workload of 180 h. The options include the following areas: Language Development and Specific Language Disorders; Reading and Writing; Auditory Processing; Hearing: Primary Health Care; Human Hearing; Public Health; Auditory Evoked Potentials; Autism Spectrum Disorders; Syndromes and Sensory-Motor Disorders; Fluency; DysFernandes/Wertzner
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– have information about the methods and techniques of scientific research, and – use, follow up with and integrate new technical and scientific developments in their practice [1]. These abilities and competences may be developed in different settings and learning scenarios that are associated with the environment surrounding the programs and with the university’s traditions. We present some examples: – The program at a university located near downtown São Paulo (a city with a population of more than 11 million people) and with a tradition of serving the urban underserved population has a project directed to the workers of a popular clandestine market that only functions at dawn in some streets of the central region, selling all kinds of products to persons on their way to work commuting in the central region between different means of transportation. The market is called the ‘dawn fair’, and many of its workers are clandestine immigrants who do not seek formal services because they are afraid of being deported. This program focuses mainly on the hearing and voice issues of those persons who work in a noisy environment and frequently put their voice under stress because they advertise their goods by commending their wares and shouting prices – Another program, located at a large university that has a traditional program of dentistry that extends to the Amazon region (State of Tocantins), includes a project of fonoaudiologia that takes information regarding education and prevention to the population living on the shores of the rivers of the Amazon basin – Still another program brings students from different disciplines (engineering, agriculture, architecture, physical therapy, nutrition, occupational therapy, dentistry, medicine and fonoaudiologia) to small cities in underserved regions as part of multidisciplinary programs of education, prevention, early identification and intervention These experiences increase students’ awareness of the different challenges they may face in their professional practice. It also encourages other initiatives designed to address the needs of underserved populations through alternative methods and actions. The authors of this paper work in Brazil’s oldest fonoaudiologia program. This program is located at the School of Medicine of the Universidade de São Paulo (FMUSP) and was started in 1958. Throughout the years, many changes were proposed to the curriculum and several pedagogical innovations were implemented. This development led to a training proposal with a workload of al-
characteristics of personality and that takes advantage of prior or concomitant experiences. These strategies and opportunities demand constant self-evaluation based on individual goals and achievements, including the use of different support alternatives and the development of self-consciousness and autonomy. Integration and facilitation skills are essential in comprehensive contexts such as clinical and hospital environments. These settings provide a diversity of options that depend on self-monitoring and result in individual outcomes. Integration skills are stimulated in situations where students of different levels and with different demands interact, creating opportunities of exercising exchanges and teaching abilities. Facilitation abilities are exercised in situations of group work that must develop efficient communication and reach shared solutions through experiences of leadership, collaboration and cooperation. The diversity of options allows changes in courses to adapt the learning process to each student’s needs or demands. The settings where these activities take place provide high-quality services without charge and are therefore available to a large part of the population. The contact with underserved groups also helps in developing an awareness regarding social and cultural differences that will contribute to critical perspectives on the social impact of the work of the fonoaudiólogo. Most of the services and projects are involved with applied research (which provides almost all of the equipment of each laboratory), and, therefore, students have many opportunities to participate in their first individual scientific projects, with sponsorship or a grant, or to collaborate with larger projects. They also have the opportunity to deal with the ethical issues involved in research and clinical practice.
Conclusion
The different areas of practice training and problembased learning result in a learning process that is individualized and based on a specific focus of interest and
In the undergraduate program of the FMUSP, the triad of teaching/learning, assistance and research is the base of the academic structure. The inclusion of students in all these areas from the first semester of the undergraduate program helps to educate fonoaudiólogos who are attuned to, and aware of, the national reality and able to perform good practice in different environments and to maintain continued education. The program generates a fonoaudiólogo who is ethical (i.e. respects differences), an expert (i.e. has practical experience) and scientific (i.e. acts based on evidence and is critical and reflective).
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phagia; Neurologic Disorders in Adults and the Elderly; Educational Audiology; Voice; Articulation; Language and Cognition, and Primary Health Care. There are other opportunities of contact with clinical practice beginning in the first semester of the program. Problem-based learning is developed from the first semester in disciplines where the students make contact with the first steps of clinical rationales and discuss practical issues with professionals working in different areas outside the university. Students also have an early start at the hospital from the second semester, when they start rotations of observation in areas such as head and neck surgery, neonatology, geriatrics, neurology and otorhinolaryngology. Starting in the second year, students may for short-term periods enroll in research laboratories, where they have activities planned according to their abilities and theoretical background. Therefore, learning opportunities for clinical observation and clinical practice result in different levels of activities and demands based on each student’s previous experiences and choices. Students’ activities in these settings vary and evolve from neutral observation and observation reports over therapeutic planning and assisted therapeutic practice to the assessment of specific abilities, enrolment in projects of scientific initiation or critical literature review, diagnostic procedures in several areas including audiology, assessment and therapy, family orientation as well as contacts with schools and other professionals or participation in interdisciplinary meetings. The programed activities include supervising sessions, case discussions, study groups and programed seminars that lead to an end-of-term paper in one of the areas chosen by the student and with mentoring by a teacher. This way, by the end of the undergraduate program, each student has gone through the experience of assessing and providing therapy for an average of 20 patients (children and/or adults), performing audiological evaluations of an average of 70 subjects and working with 35 children in schools and day care centers. This set of opportunities educates students in the three main pillars of academic structure: learning, research and assistance. These points are discussed in the next section.
References
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nities. This way, each institution can develop programs designed to educate fonoaudiólogos who are able to work in different environments but are also aware of regional, social and cultural differences.
1 Fernandes FD, Andrade CR, Befi-Lopes DM, Wertzner HF, Limongi SC: Ermerging issues concerning the education of speech and language pathologists and audiologists in Brazil and South America. Folia Phoniatr Logop 2010;62:223–227. 2 Conselho Nacional de Educação, Câmara de Educação Superior: Resolução CNE/CES 5, de 19 de fevereiro de 2002. Institui diretrizes curriculares nacionais do curso de graduação em fonoaudiologia. 2002. http://www. fonoaudiologia.org.br/cffa/wp-content/ uploads/2013/07/dc.pdf (accessed January 8, 2014). 3 Fernandes FD, Behlau M: Implications of the World Report on Disability for responding to communication disorders in Brazil. Int J Speech Lang Pathol 2013;15:113–117.
Folia Phoniatr Logop 2014;66:176–182 DOI: 10.1159/000366129
4 IALP: Education guidelines. 2009. http:// www.ialp.info/rs/sites/user_uploads/File/ downloads/Educ-Guidelines/Final2009.pdf (accessed January 6, 2014). 5 CPLOL: Revision of the minimum standards for education. 2007. http://www.cplol.eu/ eng/Revised_Min_Standards_2007_la.pdf (accessed January 8, 2014). 6 Ministério da Educação, Conselho Nacional de Educação: Aguardando homologação. 2009. http://portal.mec.gov.br/cne/arquivos/ pdf/2009/pcp002_09.pdf (accessed January 11, 2014). 7 Coordenação de Aperfeiçoamento de Pessoal de Nível Superior. http://conteudoweb.capes. gov.br/conteudoweb/ (accessed January 7, 2014).
Fernandes/Wertzner
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The combination of all these specific areas in one undergraduate program is possible because the national curriculum guidelines allow and encourage the flexibility of proposals that respond to regional needs and opportu-
Published online: March 17, 2015
Competence-Based Curricula for the Education of Speech-Language Pathologists and Audiologists in Brazil Fernanda Dreux M. Fernandes Haydée F. Wertzner School of Medicine, Universidade de São Paulo, São Paulo, Brazil
Abstract Objective: The aim of this paper is to present the academic requirements for the education of speech-language pathologists (SLPs) and to discuss some of the challenges in providing quality supervised practice and the solutions proposed by some programs in Brazil. Methods: Brazilian proposals regarding the training of SLPs are reviewed, with guidelines provided by the International Association of Logopedics and Phoniatrics (IALP) and the Comité Permanent de Liaison des Orthophonistes-Logopèdes de l’UE (CPLOL), and descriptions of the specific experience of the oldest Brazilian program are provided. Results: The bachelor’s degree is the minimum level required for the independent practice of speech-language pathology and audiology in Brazil, where there are 75 undergraduate programs. In several programs, students are encouraged to enjoy the diversity at their university, enrolling in courses of different areas to broaden their experience. The basic areas of the undergraduate program are mandatory as per recommendation of the Ministry of Education and include competences related to the health
© 2015 S. Karger AG, Basel 1021–7762/15/0665–0176$39.50/0 E-Mail [email protected] www.karger.com/fpl
system, decision making, communication, leadership and continued education. Since practice training is part of the undergraduate programs, it is incorporated into the pedagogical concept and has a major role in it. Conclusion: The structure of the programs allows the dissociation of theory from practice to be attenuated; both educational strategies are used together as part of the pedagogical concept. © 2015 S. Karger AG, Basel
Introduction
Professionals in the field of communication sciences and disorders are called Fonoaudiólogos in Brazil and all of South America [1]. They are certified both as speechlanguage pathologists (SLPs) and as audiologists. The bachelor’s degree is the minimum level required for independent practice. Therefore, the educational programs have to encompass a large area of expertise to provide the necessary information and training during undergraduate programs. Opportunities for practical experience are not only essential to the development of professional practice competencies, they are also useful for the inclusion of issues such as problem solving, social and cultural awareness, independence and continued education. The Fernanda Dreux M. Fernandes Rua do Manjericão, 301 Granja Vianna 2 Cotia, SP 06706-240 (Brazil) E-Mail fernandadreux @ usp.br
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Key Words Competence-based curricula · Speech-language pathologists · Audiologists
Table 1. Number of undergraduate programs in the different regions of Brazil
Region State(s)
Population, n Programs, n (in millions)
1 2 3 4 5 6 7 8
16.4 43.6 17.6 33.5 23.3 30.2 11.1 22.4
Rio de Janeiro São Paulo Paraná, Santa Catarina Bahia, Pernambuco, Sergipe, Alagoas, Paraíba Acre, Rondônia, Amazonas, Roraima, Amapá, Pará, Tocantins, Goiás Mato Grosso, Mato Grosso do Sul, Minas Gerais, Espírito Santo Rio Grande do Sul Maranhão, Piauí, Ceará, Rio Grande do Norte
4 17 9 12 7 14 6 6
aim of this paper is to present the academic requirements for the education of SLPs and to discuss some of the challenges in providing quality supervised practice and the solutions proposed by some programs in Brazil.
There are 75 undergraduate programs in Fonoaudiologia in Brazil. Table 1 shows the number of undergraduate programs in each region according to the Conselho Federal de Fonoaudiologia (Federal Council of Phonaudiology). Although the programs still are not evenly distributed between the regions, the discrepancies are not too severe. In 2002, the Brazilian Ministry of Education [2] determined the minimum competences for the programs of fonoaudiologia (speech-language pathology and audiology). They are very similar to the ones proposed by the Comité Permanent de Liaison des Orthophonistes-Logopèdes de l’UE (CPLOL) and the International Association of Logopedics and Phoniatrics (IALP). One important difference between the Brazilian guidelines and the ones proposed by the international associations relates to the fact that the Brazilian document refers to just one country, while the others are directed to the international community. Therefore, even when considering the great diversity of a large and complex country such as Brazil [3], the social, cultural and educational variety is smaller than when several different countries are considered. The IALP [4], CPLOL [5] and Brazilian [6] documents recognize the complexity of the education of SLPs and
audiologists and suggest that it is a process that must be continued throughout the years of practice. They also point out the important purpose of improving the quality of life of people with communication and swallowing disorders by improving the quality of the services provided. Table 2 shows that the three documents state that speechlanguage pathology demands university-level training that takes into account values such as ethics and the awareness of cultural differences in research and practice. Similar basic and specific contents are described in all proposals, as well as the main educational roles that should be played by SLPs. In 2009, another resolution by the Ministry of Education [6] determined that the minimum workload for a program of fonoaudiologia is 3,200 h, to be completed in 4 years. Supervised practice, conducted at the university and accompanied by professors, must represent 20% of the total program workload. This experience aims to guarantee a solid scientific base that favors the integration of the competences needed by the various practices within the scope of speech-language pathology and audiology. Therefore, several of the programs in Brazil have workloads of more than 4,000 h, with over 800 h of supervised practice conducted in clinical schools and school hospitals, to be completed in 4 years of full-time training. These legal guidelines guarantee minimum standards for education in the whole country. Some flexibility is allowed in order to address the specific characteristics of different programs, universities and regions. Therefore, each university can propose specific theoretical and practical contents that may be associated with the specific needs of a certain region regarding its demands in social, cultural, health and education areas. For example, in
Education of SLPs and Audiologists in Brazil
Folia Phoniatr Logop 2014;66:176–182 DOI: 10.1159/000366129
Educating Professionals to Work as SLPs and Audiologists: The Brazilian Perspective
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Source: Conselho Federal de Fonoaudiologia. http://www.fonoaudiologia.org.br/cffa/index.php/ensinosuperior/.
Table 2. Benchmarks for the education of SLPs and fonoaudiólogos
IALP education guidelines1
CPLOL minimum standards2
Brazilian guidelines3
Premises/ Independent profession; code competences of ethics; education with a general scope; appreciation of linguistic and cultural variety; specific knowledge, evidencebased practice; supervision; continued education
Studies at university level in accordance with the principles of the Bologna Charter; competences in clinical practice; working in and for an organization; developing the profession and the discipline
Education of fonoaudiólogos should be general, critical and humanistic; ethicalpolitical-philosophical basis; knowledge about the history, philosophy and methodology of intervention models; evidence-based practice
Principles
Awareness of the complexity of human communication; based on the foundation of normal communication and its development; practical and theoretical integration by supervised practice; awareness of multicultural and multilingual issues
Accordance with the code of ethics; expertise on the complexity of human communication; scientific approach; evidence-based assessment and intervention; awareness and respect for differences; general knowledge; ability to conduct basic research; problemsolving skills; ability to learn to study with autonomy; ability to enter a postgraduate program
Awareness of prevention, promotion, protection and rehabilitation actions in the health system; high quality standards; ethical and bioethical principles; problem solving; science-based decision making; proficiency in at least 1 other language; leadership; management skills; continued education; autonomy; ability to work with multidisciplinary teams
Content (supporting disciplines and specific content)
Linguistic, behavioral and biomedical sciences and ethical issues; varieties of normal and abnormal communication; theories of rehabilitation; methods for assessment and diagnosis; methods for assessing intervention results; social consequences of communication disorders; social settings for speechlanguage pathology work
Biomedical, language and behavioral sciences; speech and language pathology; research skills and public health
Biological sciences; human and social sciences, including language, ethics, behavior, psychology, education; normal and pathological processes of hearing, oral and written language, speech, fluency, swallowing and voice; history, principles and critical analysis of rehabilitation and clinical methods; public health; technical advances; integration with the health system
Education issues
Teaching provided by qualified SLPs, including practical work under supervision by qualified and experienced SLPs in a variety of settings and cases; continued evaluation of the student’s progress and practical examination
Speech-language pathology courses should be provided by SLPs; professional practice placements to develop clinical skills including prevention, assessment, diagnosis, intervention and evaluation as well as onward referral; collaboration with a multidisciplinary team; workout therapy plans adapted to clients’ needs; supervision by SLPs with the necessary expertise
Planning for a program of fonoaudiologia should be conducted by a group of fonoaudiólogos who will be the teachers of the specific courses; at least 20% of the workload designated to supervised practice in different environments within the university (hospitals, out-patient clinics, day care centers and schools); complementary activities such as internships, research collaboration, studies and projects; continued evaluation of students; possibility of individual options and flexibility; end-of-term paper with teacher mentoring
1 IALP education guidelines [4]. 2 CPOL revision of the minimum standards of education [5]. 3 National curriculum guidelines (Brazil)
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[2].
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Main Areas of Study: Individual Choices Leading to Individual Professional Profiles
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The basic areas of the undergraduate programs are mandatory and included in the recommendations by the Ministry of Education [1]. The programs must provide
opportunities for students to develop general competences in the following areas: (1) Health system: students should be able to work with the highest ethical and bioethical standards, critically considering the structure of the health system and proposing solutions to issues regarding all levels of health care in education, prevention, assessment and intervention (2) Decision making: students should also have the opportunity to develop the skills needed to make decisions based on scientific evidence and considering the proper use of resources and the cost-effectiveness of the procedures (3) Adequate communication: students should be encouraged to seek proficiency in at least 1 more language to have accessible communication with other professionals and with clients and their families, guaranteeing the confidentiality of data (4) Leadership: students should be provided with opportunities to work in multidisciplinary teams with responsibility, empathy and engagement as well as to use management skills (5) Continued education: students must learn how to learn, becoming responsible for their own continued education and cooperating with the area development through national and international networking In several programs, students are encouraged to enjoy the diversity at their university, enrolling in courses of different areas and broadening their experience. Within these programs, the students may choose specific areas and different periods to take classes or training courses. The result of such a diversity of options is that each student can build his/her individual professional profile according to personal preferences, interests or talents. However, whether there is an area of expertise or not, all fonoaudiólogos must be able to: – understand and critically analyze the theoretical and conceptual systems regarding the study of voice, speech, oral and written language, hearing, swallowing and the clinical methods of assessment and intervention; – understand human processes such as social relations, psychology, language and learning; – understand the complexity of human communication and hearing processes; – perform clinical and educational actions directed at preventing, assessing, diagnosing and intervening with hearing and communication disorders; – propose appropriate assessment and intervention methods for each situation or individual;
areas where there are only few programs and a small number of fonoaudiólogos providing services to the population, the programs usually have more comprehensive approaches. On the other hand, in areas where there are several programs at different universities, it is possible for each one to develop specific areas of greater expertise according to the characteristics of the university or even of the group of teachers. It is not surprising, therefore, that major experiences in distance education are being made at universities that are not located in the greater metropolitan areas. In some situations, a teacher with specific expertise may give a lecture to teachers and students of a program located in a region with fewer resources. Alternatively, systematic conferences or supervisions are programed for exchanging experiences and knowledge. In the last decades, with the implementation of the Sistema Unificado de Saúde (Unified Health System), all professionals in the health area were included in primary health care programs, and, therefore, speech-language pathology and audiology was included in the educational programs both as theoretical courses and as supervised practice with a focus on the prevention of hearing and communication disorders. After graduation, a fonoaudiólogo may opt for 1 of the 7 areas of specialization recognized by the Conselho Federal de Fonoaudiologia: language, audiology, voice, oral myology, dysphagia, public health and education. Master’s and doctoral degrees are also alternatives for continued education. The number of graduate programs in Rehabilitation Sciences and Fonoaudiologia has shown an important increase in the last decade as programs in new areas have been approved by the Ministry of Education [7]. The first graduate program was started in 1979, and until 2001 there were 6 programs at master’s and doctoral levels. In 2013 there were 11 programs, including 1 in the Northeast Region. Even so, many fonoaudiólogos do their master’s and doctoral studies in other areas such as linguistics, psychology, nutrition or education. There is significant variation in the profiles of Brazilian fonoaudiólogos that starts during undergraduate programs. This is further discussed in the following sections of the paper.
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most 5,000 h that includes many different places of work, opportunities to engage in different areas at different stages of the program and the flexibility that allows for individual profiles of education and training. This program is possible thanks to the efforts of all 15 teachers in the program, who are fonoaudiologos with at least a doctoral degree and significant national and international experience. In the next section, we provide more details on the experience gained by this group.
Building Competence through Practice
Since practice training is part of the undergraduate programs, it is incorporated into their pedagogical concept and has a major role in it. This way, the dissociation of theory from practice can be attenuated, and both educational strategies can be used together as part of the pedagogical concept. In accordance with the recommendations by the Ministry of Education [1], the program has almost 2,000 h of supervised practice that should be completed during the last 2 years of the program. All supervised practice activities are conducted in groups of 5 or 6 students under direct supervision of a fonoaudiólogo with a master’s or doctoral degree (90% of them) and with mentoring by a professor conducting the immediate discussions of clinical events and students’ performance. There are mandatory disciplines of supervised practice in the areas of public health that focus on speech and language and on audiology. The total workload of these disciplines is 950 h. There are also 2 other disciplines, conducted in public schools and day care centers in the university’s neighborhood. In these disciplines, with a workload of 75 h each, the students work with groups of children in activities related to the prevention and early diagnosis of language and learning disorders. In addition, students must choose 5 of multiple possibilities of supervised practice disciplines carried out at the school clinic or at one of the two school hospitals of the university. The model project proposes that the students enroll in 2 of these disciplines during the third year of the undergraduate program and in 3 disciplines during the fourth year; each of these has a total workload of 180 h. The options include the following areas: Language Development and Specific Language Disorders; Reading and Writing; Auditory Processing; Hearing: Primary Health Care; Human Hearing; Public Health; Auditory Evoked Potentials; Autism Spectrum Disorders; Syndromes and Sensory-Motor Disorders; Fluency; DysFernandes/Wertzner
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– have information about the methods and techniques of scientific research, and – use, follow up with and integrate new technical and scientific developments in their practice [1]. These abilities and competences may be developed in different settings and learning scenarios that are associated with the environment surrounding the programs and with the university’s traditions. We present some examples: – The program at a university located near downtown São Paulo (a city with a population of more than 11 million people) and with a tradition of serving the urban underserved population has a project directed to the workers of a popular clandestine market that only functions at dawn in some streets of the central region, selling all kinds of products to persons on their way to work commuting in the central region between different means of transportation. The market is called the ‘dawn fair’, and many of its workers are clandestine immigrants who do not seek formal services because they are afraid of being deported. This program focuses mainly on the hearing and voice issues of those persons who work in a noisy environment and frequently put their voice under stress because they advertise their goods by commending their wares and shouting prices – Another program, located at a large university that has a traditional program of dentistry that extends to the Amazon region (State of Tocantins), includes a project of fonoaudiologia that takes information regarding education and prevention to the population living on the shores of the rivers of the Amazon basin – Still another program brings students from different disciplines (engineering, agriculture, architecture, physical therapy, nutrition, occupational therapy, dentistry, medicine and fonoaudiologia) to small cities in underserved regions as part of multidisciplinary programs of education, prevention, early identification and intervention These experiences increase students’ awareness of the different challenges they may face in their professional practice. It also encourages other initiatives designed to address the needs of underserved populations through alternative methods and actions. The authors of this paper work in Brazil’s oldest fonoaudiologia program. This program is located at the School of Medicine of the Universidade de São Paulo (FMUSP) and was started in 1958. Throughout the years, many changes were proposed to the curriculum and several pedagogical innovations were implemented. This development led to a training proposal with a workload of al-
characteristics of personality and that takes advantage of prior or concomitant experiences. These strategies and opportunities demand constant self-evaluation based on individual goals and achievements, including the use of different support alternatives and the development of self-consciousness and autonomy. Integration and facilitation skills are essential in comprehensive contexts such as clinical and hospital environments. These settings provide a diversity of options that depend on self-monitoring and result in individual outcomes. Integration skills are stimulated in situations where students of different levels and with different demands interact, creating opportunities of exercising exchanges and teaching abilities. Facilitation abilities are exercised in situations of group work that must develop efficient communication and reach shared solutions through experiences of leadership, collaboration and cooperation. The diversity of options allows changes in courses to adapt the learning process to each student’s needs or demands. The settings where these activities take place provide high-quality services without charge and are therefore available to a large part of the population. The contact with underserved groups also helps in developing an awareness regarding social and cultural differences that will contribute to critical perspectives on the social impact of the work of the fonoaudiólogo. Most of the services and projects are involved with applied research (which provides almost all of the equipment of each laboratory), and, therefore, students have many opportunities to participate in their first individual scientific projects, with sponsorship or a grant, or to collaborate with larger projects. They also have the opportunity to deal with the ethical issues involved in research and clinical practice.
Conclusion
The different areas of practice training and problembased learning result in a learning process that is individualized and based on a specific focus of interest and
In the undergraduate program of the FMUSP, the triad of teaching/learning, assistance and research is the base of the academic structure. The inclusion of students in all these areas from the first semester of the undergraduate program helps to educate fonoaudiólogos who are attuned to, and aware of, the national reality and able to perform good practice in different environments and to maintain continued education. The program generates a fonoaudiólogo who is ethical (i.e. respects differences), an expert (i.e. has practical experience) and scientific (i.e. acts based on evidence and is critical and reflective).
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phagia; Neurologic Disorders in Adults and the Elderly; Educational Audiology; Voice; Articulation; Language and Cognition, and Primary Health Care. There are other opportunities of contact with clinical practice beginning in the first semester of the program. Problem-based learning is developed from the first semester in disciplines where the students make contact with the first steps of clinical rationales and discuss practical issues with professionals working in different areas outside the university. Students also have an early start at the hospital from the second semester, when they start rotations of observation in areas such as head and neck surgery, neonatology, geriatrics, neurology and otorhinolaryngology. Starting in the second year, students may for short-term periods enroll in research laboratories, where they have activities planned according to their abilities and theoretical background. Therefore, learning opportunities for clinical observation and clinical practice result in different levels of activities and demands based on each student’s previous experiences and choices. Students’ activities in these settings vary and evolve from neutral observation and observation reports over therapeutic planning and assisted therapeutic practice to the assessment of specific abilities, enrolment in projects of scientific initiation or critical literature review, diagnostic procedures in several areas including audiology, assessment and therapy, family orientation as well as contacts with schools and other professionals or participation in interdisciplinary meetings. The programed activities include supervising sessions, case discussions, study groups and programed seminars that lead to an end-of-term paper in one of the areas chosen by the student and with mentoring by a teacher. This way, by the end of the undergraduate program, each student has gone through the experience of assessing and providing therapy for an average of 20 patients (children and/or adults), performing audiological evaluations of an average of 70 subjects and working with 35 children in schools and day care centers. This set of opportunities educates students in the three main pillars of academic structure: learning, research and assistance. These points are discussed in the next section.
References
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nities. This way, each institution can develop programs designed to educate fonoaudiólogos who are able to work in different environments but are also aware of regional, social and cultural differences.
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4 IALP: Education guidelines. 2009. http:// www.ialp.info/rs/sites/user_uploads/File/ downloads/Educ-Guidelines/Final2009.pdf (accessed January 6, 2014). 5 CPLOL: Revision of the minimum standards for education. 2007. http://www.cplol.eu/ eng/Revised_Min_Standards_2007_la.pdf (accessed January 8, 2014). 6 Ministério da Educação, Conselho Nacional de Educação: Aguardando homologação. 2009. http://portal.mec.gov.br/cne/arquivos/ pdf/2009/pcp002_09.pdf (accessed January 11, 2014). 7 Coordenação de Aperfeiçoamento de Pessoal de Nível Superior. http://conteudoweb.capes. gov.br/conteudoweb/ (accessed January 7, 2014).
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The combination of all these specific areas in one undergraduate program is possible because the national curriculum guidelines allow and encourage the flexibility of proposals that respond to regional needs and opportu-
