Preparation for Teaching in Clinical Settings

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4 Preparation forTeaching in Clinical

Settings

Jody Gandy

Undertaking New Challenges: Preparation for Teaching in Clinical Settings

!Calvin and Hobbes © 1995 Watterson. Distributed by Universal Press Syndi-

cate. Reprinted with permission. All rights reserved.)

119



120 PREPARATION FOR TEACHING IN CLINICAL SETTINGS

Mter 1 year of clinical practice, I was informed that I was now

ready to serve as a clinical instructor for a student. I was final

ly comfortable with flexibly managing a full patient caseload

and all related activities, including new evaluations, discharge

summaries, interim and progress reports, case and family con

ferences, utilization review coD.ferences, patient treatmentsand attainment of the patient's functional goals within the

expected time duration, establishing and seeking positive rela

tionships with other professionals, participating in journal

club and weekly in-services, training support personnel, and

attending monthly professional meetings. Now, without more

than a simple proclamation, I was to be assigned to a student

for her first clinical education experience from a 2-year post

baccalaureate physical therapist professional program. Just

when I was feeling like I finally had a handle on performing asa competent practitioner and meeting departmental expecta

tions, one more responsibility was 11dumped" on me.

The center coordinator of clinical education had reviewed a

copy of the academic program's curriculum and course objec

tives, dates of the clinical experience, name of the academic

coordinator of clinical education, and the evaluation tool to be

used to assess the student's performance for this first clinical

experience. In addition, there was. a brief student profile that

was written in the student's handwriting, albeit somewhat

illegibly, that indicated her address, preferred learning style,and housing and parking requests. I was informed that she

would be arriving at our clinical facility in 1 week and would

need an orientation, 11good" patients with whom to practice

her skills, and a schedule. The center coordinator asked me i fI had any questions.Mter a brief pause, I quietly replied, liNo."

Not only did I not know where to begin to ask the first ques

tion, but I was absolutely terrified and overwhelmed by the

responsibility. I assumed that everyone who was assigned a

student after 1 year of clinical practice must be capable to

serve as a clinical instructor, and I did not want to respond any

differently than my peers.

Mterwards, I realized that in 1 week I would be responsible

for this student's clinical learning experience and had not a

clue as to how to structure an experience or perform a student

evaluation, especially since I was not familiar with the instru

ment to be used, and at best I had only completed a new



Chapter Objectives 121

employee orientation. In reality, I knew very little about

teaching students in the clinic other than remembering what

it was like to be a student during my clinical experiences. For

the next week, I tried to informally question more experi-

enced physical therapists about how they taught their stu-

dents. I did not want them to know that I felt incompetent. Ialso tried to reflect on what my clinical instructors did during

my four clinical experiences by posing questions such as: How

did they provide an orientation to the facility and the specific

health care environment? What issues were discussed during

the first few days of the experience? What were their expecta-

tions for my performance? Did I get a schedule on the first day

and what was included on that schedulel What did they do to

make me feel comfortable or uncomfortable? What did I

remember most about my clinical educators that was positive

or negative? Based on my limited discussions with profes-sional peers and my personal reflections, I developed a better,

albeit limited, understanding of my perceived roles and

responsibilities. All too soon, it was time for me to teach my

first student.

This sketch is all too common in contemporary clinical education, but

it illustrates a situation that can be prevented or eliminated given adequate

training and resources. This chapter provides the clinical educator with

information and resources about the clinical education milieu; the roles andresponsibilities of faculty, clinicians, and students involved in clinical edu-

cation; how to prepare to be a successful clinical instructor; and alternative

models for delivery of clinical education.

ChapterObjectives

After reading this chapter the reader will be able to:

1. Understand the complexities of and the relationships between the

different contextual frameworks in which the students' academicand clinical learning occur.

2. Recognize the dynamic organizational structure of clinical educa-

tion and the roles and responsibilities of persons functioning within

this structure.

3. Define the preferred attributes of clinical educators that contribute

to enhanced student learning.



Higher Education and Health Care Environments 123

prehend these issues, it is helpful to examine some of the pervasive and

influential macroeconomic factors before focusing on more specific issues

related to physical therapy. Understanding the larger context of change in

health care and higher education facilitates greater awareness of some of the

issues challenging physical therapy clinical education and its teachers.

Both systems are in dramatic flux because they are responding to issuesof public accountability, credibility, cost containment, outcome measure

ments, service orientation, and cultural diversity.a-lO Each of these issues

has altered the systems in ways that most would have thought unimaginable

10 years ago. No longer is health care or higher education funded merely on

the basis of historical precedent, longevity, or reputation, but rather funding

also depends on consistently attaining explicitly defined outcomes. Both

systems must provide, for patients and students, services that are rendered

in a timely and cost-effective manner. Each system is held to a consistent

standard of performance that is based on predetermined or institutionally

defined norms that cannot be easily compromised, no matter how justifiable

the reasons, without consequences. Possible repercussions include loss of

funding or reimbursement and organizational restructuring, which can

result in a workforce reduction or reconstitution.llOutcomes assessment research, a relatively new term to contempo

rary society, began 15 years ago but has now become the predominant

health care buzzword of the 1990s. Health care facilities are expected to

describe and attain explicit and defined measurable outcomes for the facil

ity, patients, and patients' families. Likewise, inst itut ions of higher educa

tion are required to account for and be able to define measurable outcomesfor students in each of the programs offered that relate to the functional

needs of society at large and the demands of students and their parents for

future employment.

Not surprisingly, the outcomes assessment movement was initiated

during the sweeping business reform of the 1980s, when terms such as total

quality management and continuous quality improvement were coined,

which have now permeated higher education and health care.I2 The quality

movement in business streamlined the organization of middle management,

reduced unnecessary costs, improved customer services through technology,

and increased employees' vested interest in an organization by helping them

take pride in delivering better customer services.13- IS The fact that health

care and higher education are perceived as big business enterprises should no

longer be surprising given the influence of business on both of these systems.

The idea of If customer service" has profoundly influenced health care

and higher education. Customer service no longer applies exclusively to

traditional business services but also to all human services provided to



124 PREPARATION FOR TEACHING IN CLINICAL SETIINGS

persons of all cultures. Certainly the customer (whether a patient or a

student and his or her family) has become more enlightened and asks

more probing and sophisticated questions that translate into better quali

ty of service, value for his or her hard-earned dollars, and, at times, cyni

cism or distrust of the system. Consumers are no longer willing to pay top

dollar for services rendered by teaching assistants rather than the tenuredresearch professor or medical students rather than board-certified special

ist physicians. Like it or not, society demands that service providers be

more efficient and cost-effective while still delivering measurable out

comes to the recipient.16-18

Society has also become far more aware of and sensitive to issues of cul

tural diversity. Higher education and health care are confronted by issues of

a£fordability and accessibility. Society is struggling to create systems that

provide access to all but do not stigmatize or differentiate among individu

als. Students and patients are asking that educators and practitioners better

represent the cultural needs of society by bridging an understanding between

students and teachers and patients and practitioners and delivering better

services to persons of all customs, beliefs, and values. In addition, if teach

ers and practitioners in physical therapy are to be adequately prepared, it is

incumbent on the profession to provide culturally diverse role models who

can prepare future generations to provide services that better meet the needs

and demands of a multicultural society.19,2O

Many similarities between higher education and health care have been

described. Closer examination of the relationship between physical therapy

academic and clinical education, however, reveals significant differencesbetween the two environments.

Differences Between Academic

and Clinical Education

The greatest fundamental difference between academic edu

cation and clinical education lies in their service orientations. Physical

therapy academic education, situated within higher education, exists for

the primary purpose of educating students to attain core knowledge, skills,

and behaviors. In contrast, clinical education, situated within the practice

environment, exists first and foremost to provide cost-effective quality care

and education for patients, clients, and their families and caregivers. Aca

demic faculty are remunerated for their teaching, scholarship, and commu

nity and professional services. Clinical educators are compensated for their

services as practitioners by rendering patient care and related activities. In'

most cases, unless as a function of experience, clinical educators receive lit



125ifferences Between Academic and Clinical Education

tie or no compensation for teaching students.21 Physical therapy clinical

educators are placed in the precarious position of trying to effectively bal

ance and respond to two 11masters." The first master, the practice setting,

requires that the practitioner deliver cost-effective and quality patient ser

vices. The second master, higher education, wants the clinical educator to

respond to the needs of the student learner and the educational outcomesof the academic program.

Other differences between physical therapy clinical education and aca

demic education relate to the design of the learning experience. Educating

students in higher education most often occurs in a predictable classroom

environment that is characterized by a beginning and end of the learning ses

sion and a method (written, oral, practical) of assessing the student's readi

ness for clinical practice. Student instruction can be provided in numerous

formats with varying degrees of structure, including lecture augmented by

the use of audiovisuals, laboratory practice, discussion seminars, collabora

tive and cooperative peer activities, tutorials, problem .based case discussions, computer-based instruction, and independent or group work

practicums. With the emergence of technology, such as distance learning,

hypermedia, and virtual reality, the traditional archetype is being challenged

by some educators and may eventually lead to an alternative paradigm for

classroom learning.22, 23

Higher education has evolved in its.design to provide more active adult

learning that stresses the learner, not the teacher. Fundamental concepts

and theories and their application to physical therapy practice must be fully

developed in the academic program to ensure' that students are capable ofprogressing through each phase of the curriculum into the real world of

practice.24,25 Students, however, have found it difficult to divest them

selves of the conventional role of the professor as the expert or Ilsage on the

stage,,26 who transmits all the knowledge needed to move successfully

through the curriculum and accept responsibility and accountability for

their own learning.

In contrast, the clinical classroom by its very nature is dynamic and

flexible. It is a more unpredictable learning laboratory that is constrained

by time only as it relates to the length of the patient's visit or the work

day schedule. Sometimes to an observer, delivery of patient care and educating students in the practice environment may seem analogous in that

they appear unstructured and at times even chaotic. Remarkably, student

learning in the clinical setting occurs with or without patients and is not

constrained by walls or by location (e.g., community-based services, walk

ing or driving to patients). Student learning is not measured by written

examination, but rather is assessed based on the quality, efficiency, and

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126 PREPARATION FOR TEACHING IN CLINICAL SEITINGS

outcomes of a student's care when measured against a standard of clinical

performance.27 Resources available to the clinical teacher may include

many of those used by academic faculty, such as instruction using audio

visuals, practice on a fellow student or the clinical educator, or review

and discussion of a journal article. Additional resources re!1dily available

to the educator in practice include collaborative and cooperative studentlearning among and between disciplines, video libra:ries of patient cases,

in-service education, grand rounds, surgery observation, special clinics

and screenings (e.g., seating clinic, scoliosis screening, community-based

education to prevent common falls in the elderly), presurgical evalua

tions, on-site continuing education course offerings, observation and

interactions with other health professionals, and participation in clinical

research. Rich learning opportunities are available in practice that com

plement and clarify much of what is provided in physical therapy acade

mic education.28

Because learning occurs within the context of practice and patient care,

the clinical teacher is characterized as a "a guide by the side"26 rather than

an expert. The clinical teacher teaches primarily through interactions and

handling of patients and assumes multiple roles, including facilitator,

coach, supervisor, role model, and performance evaluator.27 The clinicaleducator provides opportunities for students to experience safe practice.

She or he also asks probing questions that ~ c o u r a g e the student to reflect

by posing questions to herself or himself, reinforces students' thinking and

curiosity by fostering scholarly inquiry and by sorting fact from fiction,

and, by example, teaches students how to manage ambiguities (e.g., balancing functional and psychosocial need$ of the patient within the constraintsof the health care system).29-31

In summary, higher education and health care are confronted by many

of the same challenges, although strategies used to manage these chal

lenges may differ given their organizational and funding structures and

accountability measures. Not surprisingly, these environments differ in

relation to student learning because educators in each assume distinct

roles and responsibilities that are circumscribed by the context in which

learning occurs and the primary customer being served. Despite these dif

ferences, the two systems must communicate and interact on a regularbasis to fulfill curricular outcomes in physical therapy programs. In fact, a

concerted effort must be made by academic and clinical educators, as part

ners, to consciously bridge their differences. liThe frightening prospect is

that these forces, i f left to run their course without intervention, will like

ly drive education and practice further apart."32 To understand how these

systems currently interact to ensure that curriculum outcomes are real

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sider faculty's perspectives, because such experiences represent critical

stepping stones that will enable students to at tain desired program goals.

While physical therapy clinical education 1s largely managed by the

three primary players and the students, it is important to remember that

it is every physical therapy and physical therapist assistant educator's

responsibility to be vested in clinical education. Without a collaborativeeffort between academic and clinical educators and students, achieve

ment of programmatic outcomes would not be possible. Also, the acade

mic program has a responsibility to visibly demonstrate its commitment

to clinical educators by actively communicating and involving them in

relevant aspects of curriculum development and assessment. Roles and

responsibilities of individuals recognized as integral to clinical education

are defined below.

Rolesand

Responsibilitiesof

StudentsStudents, and their responsibility to actively contribute to

clinical learning experiences, provide the most critical link in the organi

zational structure. The true messengers in clinical education are students.

Students provide feedback to everyone involved in the clinical education

system. Given the configuration of clinical education, students bear a

heavy burden, because learning experiences are provided based on informa

tion received from academic programs that may be incomplete or inaccu

rate in relation to perceived learning needs. Only students can articulate

their needs to the CIon a daily basis; therefore, they must take responsibility for their learning i f they wish to maximize their time in practice. Stu

dents ultimately will be held accountable for their learning. They must

actively participate in the decision-making process of clinical site selec

tion38 and be willing to assume a risk in openly asking for available clinical

learning experiences that permit successful progression through the cur

riculum. This means that ongoing student self-assessment and reflection,

which recognizes the student's knowledge and performance strengths, defi

ciencies, and inconsistencies, must occur.39 As part of this responsibility,

students must feel comfortable providing constructive feedback to academ

ic and clinical faculty. This feedback can enhance the curriculum andensure that succeeding classes will benefit from their experiences.

Self-accountability for behavior and actions is critically important for

students as part of their learning contract. However, faculty should guide

and model appropriate professional behavior and be willing to confront

areas in which the students ' professional values and behaviors are consid

ered inappropriate or problematic.4o Faculty must remain open and flexible

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Organizational Structure of Clinical Education 1 2 9 ~ · · .

to student needs and be willing to modify the curriculum when revisions

are shown to be necessary.

Roles and Responsibilities of the Academic

Coordinator of Clinical Education

Since 1982, the roles, responsibilities, and career issues of the

ACCE in physical therapy education have been investigated and discussed

by several authors.41 -44 Even though issues associated with the ACCE have

been investigated, the role remains rather unique to higher education, with

comparable positions found primarily in professionally based academic pro

grams (e.g., occupational therapy, speech therapy). Although these studies

span more than a decade, the responsibilities assumed by the ACCE have

essentially remained consistent, except for those areas in which technology

and collaborative initiatives have enhanced administrative efficiency and

effectiveness and those times when the ACCE is on a tenure rather than aclinical track.

The ACCE is a pivotal faculty role in physical therapy education. She

or he serves as the liaison between the didactic and clinical components

of the program. In some programs, due to the number of students and the

resultant number of clinical education sites required, more than one per

son has assumed ACCE responsibilities jas co-ACCEs or as ACCE and

assistant ACCE). In some cases, the ACCE may also be called the direc

tor of clinical education. This occurs when the responsibilities are con

sidered to be commensurate with managing and directing a program(including its budget).

The ACCE's responsibilities are multidimensional and permeate class

room and clinical settings. She or he is challenged by a demanding role that

expects the same performance (if tenured or on a tenure track) as other fac

ulty members. This means the ACCE must teach students, engage in schol

arship, and provide community and professional service while balancing the

many other unique responsibilities associated with the position.45 If on a

clinical track, the ACCE is expected to teach on a limited basis and to per

form only those responsibilities associated with beingACCE.46 The distinct

responsibilities of an ACCE generally include:

1. Managing the clinical education program.

2. Coordinating and facilitating clinical education within the aca

demic program.

3. Developing and maintaining quality clinical education sites com

mitted to providing student clinical learning experiences.

.

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4. Educating and empowering clinical instructors to more effectively

fulfill their roles as clinical teachers.

5. Fostering and encouraging ongoing, open, and reciprocal c o m m u n i ~ cation between academicians, clinicians, and students by phone,

written and computer correspondence, and o n ~ s i t e visitations.

6. Developing policy and procedures associated with clinical education.7. Maintaining the academic program's records (including databases)

associated with all aspects of clinical education.

8. Coordinating student clinical placements with the CCCE.

9. Educating and advising students about clinical education, including

their responsibility to actively participate in the outcome of their

clinical learning experiences.

10. Counseling students about their clinical performance, including

strengths and limitations.47

11. Determining whether students have successfully met explicit

learning objectives for the specific clinical experience to enablecontinued progression through the curriculum.

12. Obtaining feedback about students' performance and the program's

curriculum to assist in ongoing curricular assessment and r e v i ~ sions.43, 44, 46

Additional activities that the ACCE may·be involved in include (1) par

ticipation in consortia activities (e.g., a group of regional academic programs,

clinical educators that sponsor collaborative initiatives), (2) accreditation

related activities, (3) curriculum committee activities, 14} clinical educationresearch, (5) management of budget allocations related to clinical education,

and 16} coordination of clinical education advisory committees. In some

cases, ACCEs assume a "broker" role in clinical education by linking c l i n i ~ cal educators to facilitate clinical education research, arranging creative

alternative student clinical experiences (e.g., forming cooperative relation

ships for solo or rural practices), and forming collaborative working rela

tionships with other academic institutions to increase access to clinical sites

by developing alternative supervisory designs to accommodate even greater

numbers of students.43

Deusinger and Rose challenged ACCEs to re-examine their role in phys

ical therapy education at their first national conference by saying, "Like the

dinosaur, the position of the ACCE is certain to become extinct in physical

therapy education. The viability of this position is threatened because of

the present preoccupation with administrative logistics and student coun

seling, a preoccupation that prohibits full participation as an academic

physical therapist." They go on to suggest that "the role of the ACCE must

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Organizational Structure of Clinical Education 131

be redefined in order for this faculty member to survive the demands of

academia and serve the needs of the profession."48 They expressed the hope

that ACCEs would not become extinct in this position but instead would

be transformed and emerge as an equal, valued, and respected member of

the academic community.

The greatest challenge for ACCEs is to develop the body of knowl-edge called clinical education. This can be achieved by critically explor

ing research on clinical teaching, educating others about the clinical

science of clinical education, actively seeking equal status with and

recognition of other faculty members by embracing the demands of aca

demia rather than functioning as administrators, and by serving the pro

fession's needs by constantly challenging clinical educators to maximize

student learning experiences based on strong theoretical constructs and

experientiallearning.43 Confronting these challenges may allow ACCEs

to be thought of as valued, recognized, and integral members of the phys

ical therapy faculty.

Roles and Responsibilities of the Center

Coordinator of Clinical Education

The CCCE's primary role is to serve as a liaison between the

clinic_al site and the academic instit:utions. From the student's perspec

tive, the CCCE functions in a unique but critical capacity. The CCCE is

viewed as the neutral party at the clinical site who functions in the role

of active listener, problem solver, conflict manager, and ,negotiator when

differences occur between a student's perception of his or her performance

and the Cl's perception of the performance. In some situations, CCCEs

also function as mentors for individuals serving as or potentially interest-

ed in becoming Cls.2

Because of the current pressure in health care to maximize human

resources, it is as likely that the CCCE is a physical therapist or physical

therapist assistant as it is that the individual is a non-physical therapy pro

fessional (e.g., an occupational therapist or speech therapist). Whether the

CCCE is a physical therapist or another health care professional, certain

qualities are considered universal to the role. This individual should effectively demonstrate the following attributes:

1. Experience as a practitioner.

2. Ethical professional behaviors.

3. Experience in providing clinical education to professional students.

4. Interest in providing quality learning experiences.

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132 PREPARATION FOR TEAClfING IN CLINICAL SETTINGS

5. Good interpersonal and communication skills.

6. Knowledge of the clinical facility and it s resources.

7. Capability to consult in the evaluation process.

8. Administrative, organizational, and managerial skills.

9. Knowledge of contemporary issues in clinical practice, practice

management, clinical education, and scholarship.

If the CCCE is a physical therapy professional, it is expected that he or

she will have attributes commensurate with that of CIs (see description

below). CCCEs should assess their capabilities and competence by complet

ing the American Physical Therapy Association's (APTA) self-assessment for

the CCCE.2

Responsibilities that are considered specific to the CCCE role associat

ed with clinical site development include:

1. Obtaining administrative support to develop a clinical education

program by providing clinical site administrators with sound ratio

nale and evidence for development.

2. Determining clinical site readiness to accept students.

3. Contacting academic programs to determine if the clinical site's

clinical education philosophy and mission is congruent with the

academic program's.

4. Completing the necessary documentation to become an affiliated clin

ical education program le.g., legal contracts that define the roles and

responsibilities of the clinical site and the academic institut ion andclinical center information forms, which document all essentialinfor

mation about the clinical facility, its personnel, and available student

learning experiences). The CCCE ensures that all required documenta

tion is completed accurately and in a timely manner and is updated as

warranted by changes in personnel and the clinical facility.33

Activities of the CCCE that·are associated with preparing for and pro

Viding on-site student learning experiences include:

1. Coordinating the assignments and learning activities of students at

the clinical site.

2. Scheduling the number of students that can be reasonably accom

modated by the clinical site on an annual basis.

3. Developing guidelines to determine when physical therapists and

physical therapist assistants are competent to serve as CIs for

students.

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Organizational Structure of Clinical Education 133

4. Providing mechanisms whereby Cls can receive the necessary train

ing to provide quality student clinical instruction.

5. Reviewing student clinical performance assessments to ensure their

accuracy and timely completion.

6. Understanding legal risks associated with teaching and supervising

students in the clinic.49-51

Although this position is considered essential to the physical therapy

clinical education, a word of caution must be provided given the context in

which contemporary physical therapy clinical education occurs. As health

care reform contim,J.es, especially in hospital-based practices, the CCCE who

is on senior staff and carries a partial to full caseload may be the first to have

his or her position eliminated. It is also important to note· that the profes

sion is finding itself in precarious situations in which no CCCE is designated

or the individuals who serve asCCCEs lack the appropriate qualifications

and clinical teaching experience to serve in this capacity. Of even greaterconcern is the possible loss of qualified mentors in clinical practice to edu

cate the next generation of clinical teachers who are ultimately responsible

for ensuring the future quality and effectiveness of physical therapy ser

vices.ll The profession must be sensitive to this situation rather than mini

mizing or denying its existence. Therefore, it must be open to exploring

alternative and collaborative strategies that are mutually beneficial and that

ensure the continuation of this role and its essential functions by providing

support to the physical therapy department or by advocating and negotiating

a position with the clinical facility's administration.

Roles and Responsibilities ofthe Clinical Instructor

When asked if they can recall any of their Cls, most health care

professionals will invariably answer "yes." Many say they remember not

only the Cls who were exemplary but also those who were perceived to be

poor role models. Likewise, they will remember why a particular Cl was

remarkable or why they were disappointed in a Cl's clinical teaching perfor

mance. Impressions left by clinical educators are lifelong; a laudable tribute

and commentary on the role that the Cl plays in the life of every health pro

fession student.

The Cl is integral to clinical education and is involved with daily

responsibility and overall direct provision of quality student clinical learn

ing experiences. In the organizational structure, the Cl works at the center

of the clinical education process. Students often believe that the success or

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134 PREPARATION FOR 'TEACHING IN CLINICAL SETTINGS

failure of their clinicalleaming experience can be attributed to this indi

vidual. The Cl has also been called a clinical tutor, clinical supervisor, clin

ical preceptor, clinical teacher, and clinical educator. Each of these labels

can be identified with one or more roles that this individual routinely per

forms. Much has been written in the literature of health care about the Cl's

role and responsibilities and the attributes of the Cl that enhance student

leaming.27,52-57 Cls significantly contribute to students' understanding of

and competence in physical therapy clinical practice and serve as strong

role models that guide students' visions of how they would like to practice

in the future. The Cl should remember that the ultimate goal of clinical

education is to provide an environment that fosters students' professional

ism and encourages the development of an independent problem solver and

a reflective and competent practitioner.58 Entry-level practice expectations

for new graduates are fully described in the Normative Model of Physical

Therapist Professional Education, which represents a consensus-based view

of what the physical therapy profession believes are the preferred entrylevel practice expectations, content, and clinical education components in

physical therapist professional education.58

Skills and Qualifications of a Successful Clinical Instructor

In general, CIs' roles are multifaceted and include a range of

behaviors, such as facilitating, supervising, coaching, guiding, consulting,

teaching, evaluating, counseling, a d v i s i n g ~ career planning, role modeling,

and socializing. Before serving as a Cl for students in physical therapy,

competence should be demonstrated by the Cl in seven performance

dimensions:

1. Professional skills, including ethical and legal behavior.

2. Clinical competence demonstrated by critical inquiry, problem

solving skills, and reflective practice.

3. Communication skills, including the ability to address difficult situations.

4. Proficient interpersonal skills in relationships with patients,

clients, students, colleagues, and others.

5. Instructional skills, including organizing, facilitating, implement

ing, and evaluating planned learning experiences given the availablefacility resources.

6. Supervisory and observation skills leading to student perfor

mance expectations, timely feedback, periodic adjustments to.

structured learning experiences, and the development of reflec

tive practice skills.29

7. Performance evaluation skilis to determine professional compe

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135rganizational Structure of Clinical Education

tence, ineffective or unsafe practices, and performance deficits or

exemplary practices.2, 58, 59

In addition, individuals should evaluate their readiness for or competence in

serving as a Cl by completing the self-assessment for clinical instructors.2

Minimal qualifications for persons serving as Cls include (I) a mini-mum of 1 year of clinical experience (or less in special programs or areas

of expertise in which less experience has proved satisfactory); (2) a will

ingness to work with students by pursuing learning experiences in clini

cal teaching; (3) a current state license, registration, or both (as required

by specific state practice acts) or graduation from an accredited physical

therapist assistant program; (4) positive representation of the profession

by assuming responsibili ty for professional self-development and demon

strating this responsibility to students; and (5) willingness to act as a pro

fessional role model and the ability to recognize the impact of this role

on students.60

Developing skills as a Cl begins with an awareness of the parallels that

exist between the roles of practitioner and Cl. By recognizing these parallels,

one can better understand how to transfer knowledge, skill, and behaviors

used in delivering patient care to the task of designing a clinical student

learning experience. Understanding the relationship between the role of the

practitioner and the Cl role allows the instructor to analyze the Cl attributes

that can be used to augment the teaching experience. Table 4-1 illustrates

parallel relationships between practitioners and their management of physi

cal therapy service delivery and Cls and their coordination and implementation of student learning experiences. Furthermore, exploration of the

practitioner-patient relationship can serve as a useful tool in exploring the

Cl-student relationship and the learning process.61

Qualities of a Successful Clinical Instructor

A successful Cl develops a framework for the teaching-learn

ing model by determining characteristics of the teacher, student, and pat ient

and the dynamics between them to facilitate teaching and learning while

maintaining patient satisfaction with clinical services. Moore and Perry62

found that the follOWing factors were essential to enable all students to have

a successful clinical education experience: (1) an atmosphere that is recep

tive to students, (2) staff who are interested in teaching students, (3) an

opportunity for students to practice patient care, (4) students who have spe

cific goals, (5) feedback on performance provided, (6) clinical assignments

that are long enough to accomplish objectives, and (7) students who are well

prepared. Additional essential factors for advanced students are patient vari



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Table 4·1 Roles of the Practitioner and Clinical Inst ructor

Roles of the practitioner Roles of the clinical instructor

Patient referral and taking a patienthistory

Performing initial patient evaluationand problem identification

Determining long-term goals mutuallywith the patient

Defining short-term patient goals

Clarifying patient treatment plan

Performing patient re-evaluations andassessing the level of progression

Performing patient outcomes assessment and discharging patientsfrom physical therapy

Preplanning for the learning experienceand providing an orientation to theclinical site

Assessing students by identifying theirstrengths, learning needs, and previous

experiences

Setting overall student objectives andclarifying learning expectations withthe assistance of the students and theacademic program

Defining specific student behavioral andlearning objectives

Designing creative student learning expe-

riences

PrOviding formative student evaluationsand assessing the level of progressiontoward defined outcomes

ProViding summative student evaluationsand assessing students' readiness forcontinued progress through the cur

. riculum or entry into practice

Source: Adapted from The New England Consortium of Academic Coordinators of Clini

cal Education, Inc. The Role of the Clinician as Clinical Educator. Boston: The New Eng-

land Consortium of Academic Coordinators of Clinical Education, 1994i3.

ety, talented staff, a variety of educational experiences, and an opportunity

for th e students to explore their own objectives.

Clinical Instructor: Communication Skills

Sheets and Schwenk focused on one or more components of

the triangular relationship between the teacher, student, and patient or one

or more of the relationships within that triangle.63 However, a number of

studies have focused on factors related to affective behaviors that are critical

to effective learning experiences.52, 56, 63, 64 Affective characteristics of phys

ical therapists found to contribute positively to patient care as well as effec

tive clinical teaching include a positive attitude toward work, flexibility,



137

,

Organizational Structure of Clinical Education

compassion, sense of humor, openness to ideas and suggestions, friendliness,

discipline and organization within the setting, and confidence in abilities

and knowledge.65 Studies have examined students' and clinical instructors'

perceptions of attributes contributing to the Cl's effectiveness.52,66, 67 In sev-

eral studies, students consistently ranked communication, interpersonal

relations, and teaching behaviors as the most valuable instructor behaviorsin the clinical learning process. Communication and interpersonal relations

include intrapersonal, small group, conflict, organizational, and professional

types of communication.66 The smallest statistical differences found

between "best" and "worst" clinical teachers were demonstrated in profes-

sional skills and knowledge.52, 67, 68

Asa component of a comprehensive study of clinical education in phys-

ical therapy in the early 1970s, Moore and Perry62 surveyed clinicians who

ranked selected behaviors of communication and interpersonal relations as

the most essential traits of an effective Cl. However, in actuality, Cls were

shown to demonstrate these behaviors less frequently. They offered one

explanation for the discrepancy seen between those traits ranked as impor-

tant and the actual behaviors demonstrated by the Cl. They postulated that

this divergence resulted from a lack of adequate preparation on the part of

the Cl rather than from a lack of appreciation for the importance of those

behaviors. This was supported by the fact that at that time only 25% of CIs

surveyed had attended any type of teacher training.

In a study by Emery, students ranked many of the behaviors identified

to be necessary for effective clinical teaching as weak in their Cls.52 Since

more Cls are attending clinical education training courses,21 it might beassumed that these deficiencies would be reported less frequently. One must

probe further to determine if there are other explanations for inconsistencies

between affective behaviors desired in a Cl and affected behaviors actually

demonstrated by Cls.

The area of student performance most frequently cited by Cls as lack-

ing is also in the affective domain, specifically interpersonal relations and

communication.69, 70 However, ACCEs have reported that they are unlikely

to fail students for solely affective problems unless they occur in conjunc-

tion with psychomotor or cognitive deficiencies or both.71 Perhaps a flaw

exists in physical therapy education, which does not adequately define spe-

cific behavioral expectations for students and then assesses those profes-

Sional, affective behaviors throughout the curricular process in classroom

and clinic settings. If students are provided with clear behavioral perfor-

mance expectations and held accountable for their behaviors, perhaps they

will demonstrate better interpersonal relations and communication skills

as practitioners.

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Successful Clinical Instructors: Other Factors

Other factors that contribute to the success of clinical teach

ing and supervision are Ul the provision of student-centered teaching strate

gies that encourage activities such as reflection 26, 29-31; (2) support for

increased student autonomy; (3) application of situational leadership theo

ries applied in clinical learning that help students participate more responsibly in their learning experiences 72• 73; (4) belief in a model of the best

clinical practices in physical therapy; and 15) explication of the models of

problem solving and decision making, which are used to assist students in

making better management decisions with sound clinical judgment, espe

cially under ambiguous situations.74-80 Clinical teaching has also been

shown to be more effective when systematic instructional strategies (e.g.,

preparation, briefing, planning, practice, debriefing) and repeated learning

opportunities are available to students to reinforce learning.73, 81 Enhance

ment of student learning occurs when the purpose of the learning experience

is defined, expectations for student and Cl performance are clarified, the

level of commitment is determined for all persons involved in the learning

experience, and the timing, structure, frequency, and method of formative

and surnmative evaluations are provided.63, 78 One of the greatest challenges

for the Cl is to find a balance in the relationship with students between nur

turance and separateness: This is not unlike the delicate balance needed

with patients when providing physical ther:apy services.82 Specific tech

niques for teaching in clinical settings are presented in Chapter 5.

In a qualitative case study examining the outcome of the clinical learn

ing experience, Harris and Naylo:r83 showed that student motivation andenthusiasm were enhanced when the learning experience was focused on

education and feedback rather than socialization into the environment. The

physical therapy student with 11good clinical experiences" became patient

focused rather than technique-focused. This change of focus is a critical tran

sition that students must make to become effective practitioners.

Preparation for Clinical Instmction

To develop the requisite knowledge, skills, and behaviors

needed to effectively perform their responsibilities as clinical educators, Cls

must have adequate formal preparation in the areas of teaching, supervision,

interpersonal relations, communication, evaluation, and profesSional skills

and competence. Montgomery84 believes that in addition to lack of formal

training, many CIs also lack the "experience, maturity, and wisdom" to

serve as mentors to physical therapy students. In an ideal world, there would

be an abundance of trained and experienced persons willing to teach the

ever-increasing numbers of physical therapy students in the clinical setting.

/,


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139rganizational Structure of Clinical Education

However, evidence shows the contrary. Cls report on average between 1 and

2 years of clinical experience before beginning to teach, and only slightly

more than half 153.4%) having attended a clinical training course.21

Development of national Clinical Education Guidelines in Physical

Therapy2 has influenced clinical training courses for Cls to use the seven

performance dimensions described previously in this chapter under "Skillsand Qualifications of a Successful Clinical Instructor" as a basis for defining

training objectives. Nevertheless, the development of formal training pro

grams for Cls does not adequately address issues of quality in clinical

instruction. In addition to academic programs and consortia that provide for-

mal training programs for CIs, students can also be better prepared by aca

demic programs and clinical educators for their eventual role as Os by

teaching them about learning and evaluation processes.

Many Cls believe that they are inadequately prepared for teaching.27, 84

Preparation for clinical teaching requires experiences that relate to teaching

issues. This includes (1) application of questioning and problem-solving

techniques; /2) application of levels of questioning in the domains of learn

ing (see Chapter 2); /3) application of behavioral questioning to address affec

tive issues and ways of improving the quality of questions; (4) application of

learning theory, including domains of learning and their hierarchies and an

understanding of the elements of and methods used to assess learning

styles85; (S) application of educational methodology, including adult learning·

and teaching theories and principles86; and (6) understanding of the context

in which learning occurS.84 Clinical teaching provides opportunities for

obtaining knowledge and developing skills in articulating and writing measurable cognitive, psychomotor, perceptual, and affective performance objec:'

tives; revising performance objectives64; and clarifying academic, student,

and Cl performance expectations. Aspects related to performance. expecta

tions and objectives are discussed in the section entitled "Student Objec

tives and Expectations of Clinical Learning Experiences."

Training Programs for Clinical Instructors

Training programs for Cls should provide specific information

about selecting appropriate, creative, and effective teaching methods that

actively involve learners in self-directed and guided experiences.30, 86, 87

These approaches should guide students to use available resources to access

information, maximize learning opportunities, assume responsibility for

self-directed and lifelong learning, apply critical thinking skills to solve

problems,88 apply skills learned to new situations, communicate learning

needs effectively, enhance observation skills, and develop as professionals.

Clinical teaching methods can include demonstration-performance, teacher

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140 PREPARATION FOR TEACHING IN CLINICAL SETI'lNGS

exposition, seminars, case analyses, case incident studies, role playing, jour

nals, conferences, brainstorming sessions, reflective discussions, self-direct

ed activities, and so on.89-91

Clinical training programs should also address the process of clinical

evaluation. Basic concepts of clinical evaluation include (1) feedback, sum

mative, and formative evaluations; (2) evaluation terminology, such ascompetency-based evaluations and outcomes performance assessment;

(3) methods and techniques of evaluation, such as competency-based eval

uations, outcomes performance assessments, use of portfolios,3l,39 and

student self-assessment; (4) problems in and legal aspects of clinical eval

uation50; and (5) a basic understanding of different evaluat ion instruments,

including how to critique their relative strengths and limitations and how

to determine the most appropriate evaluation instruments for the specific

clinical setting.89, 92-95

Development of effective communication and conflict management

skil ls should also be included as part of clinical training programs. Specific

content to be addressed includes components of and barriers to communica

tion; ways of improving interpersonal, profeSSional, and organizational com

munication; sources of conflict in the clinical setting; and techniques for

identifying, managing, and resolving conflict.89

Fundamental components of clinical training should include an under

standing of the roles, characteristics, and responsibilities of the Cl and the

organizational structure of clinical education within the total curriculum

and management of the clinical environment and students' experiences

within that environment. 96, 97 Management of the environment includes:

1. Assessment of available learning resources.

2. Establishment of guidelines for a safe environment for pat ients and

students.

3. Understanding federal regulations related to the Americans with

Disabilities Act.

4. Creation of a filing system for confidential documents and other

forms.

5. Development of a schedule for students.

6. Motivating students to perform required tasks.

7. Development of a policy and procedure manual for students.

8. Selection of a student orientation method that is efficient and

comprehensive.

9. Understanding the management of patients wi th diverse backgrounds.

10. Promotion of positive learning experiences through learning con

tracts or other approaches.89 f"

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141rganizational structure of Clinical Education

Successful clinical training programs are reported to be most frequent

ly accessed by clinical educators at physical therapy academic programs,

clinical education consortia, and individual clinical facilities.21 Frequent

ly, academic programs, clinical education consortia, or other clinical edu

cation special interest groups will sponsor 1- to 2-day annual, biannual,

or concurrent multisite disciplinary and interdisciplinary continuingeducation training programs for their clinical faculty at little to no

cost.21 , 98, 99 In addition, continuing education training programs are gen

erally offered as basic or advanced courses in clinical education. Training

issues addressed in this chapter, in general, reflect content found in basic

Cl training courses.

Some training programs offer state or regional certification or recogni

tion, continuing education units, or recognition by APTA as a course deliv

ered by an approved provider. However, many continuing education Cl

training programs do not have a mechanism for assessing the ability of the

program to instil l knowledge, skills, and competence,lOO, 101 To address this

concern, a 1994-1995 pilot study, which was funded by APTA and direct

ed by principal investigator Michael Emery in collaboration with Nancy

Peatman and Lynn Foord, was assigned to develop a valid and reliable

training and assessment system for credentialing clinical educators.102 The

outcome of this study has yet to be determined, but it may have far-reach

ing implications in providing quality training programs for physical therapy

clinical educators.

In addition to continuing education programs in clinical education,

formal postprofessional graduate programs specializing in education andtraining for academic and clinical faculty exist in physical therapy. Like

wise, self-instructional programs available in clinical education in other

health profeSSions !e.g., occupational therapy's Self-Paced Instruction for

Clinical Education Series [SPICESP03 or Health Occupations Clinical

Teacher Education Series for Secondary and Post-Secondary Teachers89)

could also provide an alternative mechanism for clinical educators in phys

ical therapy to further their continuing education. Another method for

enhancing clinical teaching skills is through formalized mentor or precep

tor programs, which are similar to teacher education programs. In such

programs, the clinical teacher and mentor jointly identify specific goals

and expectations for learning and performance. Once engaged in the clini

cal teaching process, the mentor provides ongoing feedback and evaluation

of the teacher's performance used in conjunction with teacher self

appraisals. 104, 105 However, a significant limitation to this approach is that

an experienced clinical educator must be available and willing to give time

and energy to the mentoring relationship.

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142 PREPARATION FOR TEACHING IN CLINICAL SE'ITINGS

Realistically, developing expertise as a Cl requires knowledge, skill,

and experience with positive and problematic student learning situations.

Not unlike the learning experiences designed for students, Cls require

opportunities to practice and reinforce knowledge and skills learned in

clinical training programs and to apply this knowledge to real student s i t ~ uations, preferably with the guidance of a clinical teaching mentor. 106

Thus, the process of learning to become a master clinical teacher is not

unlike that of learning to become an expert clinician.107 Mastery of the

subject matter related to prOviding effective clinical education, under-

standing the context in which clinical learning occurs, competence and

confidence in one's ability as a practitioner, and the ability to translate

educational theory into the practice of providing quality clinical instruc-

tion through reflective practices all contribute to developing qualities of a

master clinical teacher.108-110

Student Objectives and Expectations

of Clinical Learning Experiences

Designing a clinical education program for students requires a

structural framework, or road map, for ensuring that each planned learning

experience meets the expected performance outcomes. In addition, the aca-

demic program must determine, in the aggregate, how progressive clinical

experiences will, in conjunction with the didactic curriculum, accomplish

the curricular performance outcomes required of students for entry into

practice. Although at times the road may wind and even detour, i f students,clinicians, and academic faculty can clearly articulate specific, expected

learning and performance outcomes, the program can be adjusted through-

out the clinical experience according to the student's needs.

Determining student performance outcomes for clinical education

requires coordinated effort from students and faculty within academia and

practice. Each party must be actively involved in developing learning objec-

tives and setting performance expectations for each clinical experience pro-

vided within the curriculum. Academic programs determine objectives that

students must achieve and those that students can choose for progression

through the curriculum. In certain circumstances, students and academic

faculty may have curricular gaps and needs that can only be addressed by the

clinical site.

The clinical site must determine what experiences it can offer and objec-

tives for those experiences that can be accomplished within the specific clin-

ical setting and available time frame. The clinical site must also consider

how the academic program's objectives coincide with or differ from the c l i n ~



143

.

\

Student Objectives and Expectations

ical site's learning objectives. Ultimately, the Cl's function is to make stu-

dent learning experiences coherent.

Students are accountable for setting specific learning objectives for each

clinical experience and adjusting them accordingly during the experience.

These objectives are based on the expected knowledge, skills, and behaviors

they hope to acquire within a particular setting. Objectives are influenced byfactors such as area of special interest or patient care provided, congruence

with organizational structure provided for learning, and personal knowledge

of the facility and it s reputation. Students must actively seek learning expe-

riences in areas in which their knowledge is deficient or with which they

have no prior exposure.

The literature is consistent in considering the determination of objec-

tives in clinical education as fundamental to planning learning experiences.

Although several methods can be used to provide objectives, many authors

prefer the use of objectives expressed in behavioral terms.64 In this format,

the objectives describe the learner's behavior at the completion of the learn-ing experience, the conditions under which the learner must function, and

the evaluation method/sI that will be used to assess the learning. Thus, the

Cl is explicitly aware of the planning and evaluative components required to

determine student competence, and the students understand precisely what

is expected of them during the experience.58

Objectives for clinical education serve four purposes: (1J design and

development of the clinical education program, (2) help in determining the

teaching methods to be used, (3) a method for assessing the learning experi-

ence and students' achievement of the objectives, and (4) augmentation ofthe abilities of persons involved in developing the objectives.64 Objectives of

a learning experience may be culled from multiple sources, all of which

result from some type of evaluative process involving questions about what

is needed, what is available, and where gaps in knowledge exist.37, 92

The four major factors that determine the objectives in health profes-

sional programs are 11) the health needs and demands of society, (2) the

nature of the subject matter , (3) characteristics of the learners, and (4) pro-

fessional standards.64 Obviously, with the rapidly changing and expanding

need for physical therapy services, dramatic shifts in technology, and fluc-

tuations in health care, it is critical that academic programs continuallyreassess performance outcomes, reflected by curricular objectives, to ensure

their relevancy. Curriculum content must be adjusted accordingly to equip

graduates with the tools necessary to cope with contemporary and future

health care. Evidence shows that in the past 5 years, characteristics of

learners within physical therapy programs have remained essentially

unchanged. I I I However, faculty report anecdotally that learners have changed

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144 PREPARATION FOR TEACHING IN CLINICAL SETI1NGS

their values and attitudes about their education, and this has subsequently

influenced curricular design, implementation, and performance out

comes.16 Lastly, as part of a profession's responsibility, it must, on a regular

basis, determine those behaviors that are believed to be essential for all

graduates when entering practice.58

Behavioral objectives in clinical education should address all domains oflearning at multiple hierarchical levels to ensure that learning experiences

are incremental and comprehensive (see Chapter 2). As students progress

through successive clinical experiences, consideration should be given to

defining behavioral objectives that progressively move up the hierarchy

within each domain. For example, early student experiences may define

behavioral objectives in the cognitive domain at the levels of knowledge,

comprehension, and basic application, compared to later clinical experiences

that expect students to perform in the cognitive domain at the levels of

analysiS, synthesis, and evaluation. This process can be used to identify the

degree to which students are able to successfully meet expected levels of per

formance for entry into practice.

Effective clinical educators use global and behavioral objectives. Global

objectives describe the broader, more general outcome expectations for stu

dent performance, while behavioral objectives are more specific and help to

further define each incremental learning experience.64 For example, a global

objective in the psychomotor domain fi1:ight state, 1/ • • • the student will be

able to evaluate a patient." A specific behavioral objective accompanying

this global objective might state, 1/ • • • the student will accurately evaluate a

patient with complex shoulder pathology in 30 minutes using a systematicapproach substantiated by the literature." The progression of a set of behav

ioral objectives should lead to achievement of global objectives. Four essen

tial components of a written behavioral objective are a behavior, condition,

criterion, and. the audience or leamer.64 Each of these four components is

clarified in Table 4-2 with examples provided for each component.

Well-written objectives should be leamer-centered rather than teacher

centered, be outcome-oriented rather than process-oriented, be outcome-ori

ented rather than a statement of the material to be addressed, be a

description of only one outcome, be specific rather than general, and be

observable and measurable. Table 4-3 illustrates each of these requirements

and contrasts correct and incorrect methods of writing an objective.

Global objectives should provide broad experience or overall structure

for determining behavioral objectives in each of the learning domains. With

subsequent clinical experiences, some global objectives will be cumulative

in nature, while others may be distinctive. However, the sum total of all

global objectives in clinical education, in conjunction with the didactic cur

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146lternative Supervisory Patterns in Clinical Education

Table 4·2 Components of a Behavioral Objective

Component Description Examples

Behavior

Condition

Criterion

Learner or audience

Describes what the learnermust specifically do

Describes the circum-stances under whichthe objective will beachieved and the meth-ods used

Describes the level ofacceptable performance

Focuses on the learner oraudience rather thanthe instructor

Palpate the greater trochanter.Describe the signs and symp-

toms of rheumatoid

arthritis.Following a patient demon-

stration...Given a skeleton ..

Student completes an evalua-tion of the shoulder within10 minutes.

Student completes an evalua-tion thoroughly.

The student will...

The learner will ..

Source: Adapted from The New England Academic Coordinators of Clinical Education, Inc.

The Role of the Clinician as Clinical Educator. Boston: The New England Consortium of

Academic Coordinators of Clinical Education, 1994;14.

riculum, should adequately address those performance aspectsthat

arerequired of students to satisfactorily progress through the curriculum and be

prepared for init ial clinical practice.

In summary, it is critical that behavioral objectives in clinical education

are sequenced in light of didactic components that have been completed;

achievable within the specific clinical setting; comprehensive, in that they

address all domains of learning and progress students through each of the

respective hierarchies; and congruent with the philosophy, goals, mission,

and outcomes of the academic program.

Alternative Supervisory Patterns

in Clinical Education

To do justice to alternative supervisory patterns in clinical

education would require space beyond that which can be allocated in this

chapter. Therefore, only salient points will be highlighted. An attempt has

been made, however, to provide the reader with a table that consolidates




Table 4·3 Appropriate and Inappropriate Constructs for

Writing Behavioral Objectives

Requirement Appropriate example Inappropriate example

Learner centered vs The student will perform The teacher will show the

teacher centered goniometric measurements. student how to perform

goniometric measurements.

Outcome oriented The student will collect five The student will gather

vs process oriented articles on cystic fibrosis. information on cysticfibrosis.

Outcome oriented The student will evaluate The student will look at

vs merely stating biomechanics of the knee. biomechanical knee

the material to be problems.

addressed

Describes only one The student will conduct a The student will list theoutcome vs de- patient interview. questions to be asked in

scribing multiple an interview, conductoutcomes the interview/ and

assess the results.

Specific vs general The student will accurately The student will perform

perform manual muscle manual muscle testing.

testing on the ankle.

Observable and The student will provide a The student will know whymeasurable vs rationale for the treatment he or she is providing

not observable delivered based on research. treatment.and quantifiable

Source: Adapted from The New England Academic Coordinators of Clinical Education,Inc. The Role of the Clinician as Clinical Educator. Boston: The New England Consor-tium of Academic Coordinators of Clinical Education, 1994;14.

information into a quick and functional user-reference (Table 4-4). Never-

theless/ the reader is encouraged to further explore references cited in this

section. Propelled by changes within health care delivery, this issue has now

become one of the most exciting and explosive areas of clinical education

research within health professions disciplines.

Frequently/ physical therapy clinical educators will comment that alter

native student supervisory patterns were implemented in practice in the

1960s and 1970s and that this issue is no t altogether new. However, during

that time, little or no empirical evidence was reported that described these

supervisory patterns, their benefits or limitations, or their outcome effec




tiveness. More recently, however, physical therapy clinical education

research has focused on an examination of the effectiveness of various

approaches to student supervision to determine how best to provide student

clinical education given limited personnel, patient, financial, and space

resources. Il2 In the 1995 issue of PT Magazine, Gandy113 provides a context

for understanding why the profession is confronted with the need to providemore collaborative and interdependent methods for providing high-quality

student learning experiences in varied practice settings. The fundamental

basis for these changes lies in the need to 11adjust our focus-even replace

the lens-and explore alternatives that more efficiently use available limit

ed practice and education resources and provide an environment for learning

that more closely approximates current and future practice. 1 113 In the past

decade, pervasive changes have occurred in the configuration of practice and

the delivery of physical therapy services, the design of physical therapy cur

ricula to accommodate increased numbers of students, and the level of expe

rience of persons providing on-site student clinical supervision. Collectively,

these changes have forced the profession to rethink the one Cl to one stu- .

dent supervisory model and to consider and evaluate the use of other super

visory designs.

Like the variance within physical therapy curricular configurations and

health care delivery systems, there are equally as many innovative and col

laborative approaches to the supervision of students in the clinic. Many of

these designs offer distinguishing features reflecting philosophical bent and

professed outcomes (e.g., active learning, collaborative peer teaching, coop

erative teaching, mentoring, clinical decision making and problem solving,and reflective practice). Some of these designs have been implemented mere

ly by happenstance or due to creative problem solving.114, 115 Others have

been intentional decisions to engage in an empirical and critical inquiry

process to systematically develop, implement, or evaluate specific supervi

sory approaches with an explicit outcome of expanding our knowledge of

supervisory patterns in clinical education.116-121 126 Although this list is by

no means fully inclusive, some of the supervisory designs used in clinical

education include:

• One Cl to one student (traditional designJ• One Cl to two or more students !collaborative-peer designJl16-126 t 142, 143

• A physical therapist and physical therapist assistant team to one phys

ical therapist and physical therapist assistant student team (supervi

sor-delegator designl1l4

• One Cl to two or more students paired from the same academic pro

gram where a student with more clinical experience supervises a



PREPARATION FOR TEACHING IN CLINICAL SE1TINGS48

Table 44 Strengths, Considerations, and Limitations of Alternative

Supervisory Designs in Clinical Education

Design Strengths Considerations and limitations

One Cl to one

student Itra

ditional designl

One Cl to twoor more students {collabor-ative-peer designj116-125,142,143

One PT and

PTA/Cl teamto one PT andPTA student

team {super-

visor -delegatordesignJl14

Allows the Cl to maintain

greater control of the

learning experienceCan easily monitor student

performance

Familiar student learning

design

Fosters collaborativelearning through peerinteractions

Enhances clinical competence related to clinicaljudgment

Develops greater selfreliance, independence,and interdependence

Teaches students to use

and maximize limited

resources

Allows the Cl to facilitate

and guide the learningexperience

Fosters student problem

solving and criticalthinking skills

Makes orientation lesscostly and time consuming

Teaches students grouppresentation skills by

providing collaborativeprojects or in-services

Enhances service producti

vity in some settings{e.g., acute careJl21

Is useful for structured part

time group learning experiencesl43

Enhances understanding

and skills associated

with supervision anddelegation

Enhances understanding ofthe roles and responsi

bilities of the PTA

Student less likely to learn from

other clinicians

Limits opportunities for collaborative learning

Fosters student dependence on

the Cl

Requires more plamring, effort,and organization time

Requires that the total patientload is able to accommodatestudent needs

Requires additional time to com

plete s tudent evaluationsPresents the possibility that too

many patients will remain for

the available clinicians afterstudents have completed thei r

training

Use more likely as an experi

enced Cl

Requires that the Cl be highly

flexibleCan be problematic for a s who

wish to control learning expe

riencesMay be problematic for "needy"

students

Assumes that a PTA works at

the clinical site

Requires that the PT/PTA/Clteam clearly understands the

appropriate delegation, supervision, and use of the PTA and

role models behaviors that



Alternative Supervisory Patterns in Clinical Education 149


Provides opportunities for demonstrate this under-

PT students to learn standing

appropriate utilization of Assumes that the PTA and PT

the PTA through role value and respect each other

modeling by the PT/PTA/ as coworkers

Cl team Requires that PTA and PT stu-Provides for collaboration dents are comfortable with

and sharing of informa- their respective roles,

tion between PT and PTA strengths, and limitations sostudents that they can learn from each

Maximizes clinical site re- othersources and minimizescompetition for limitednumbers of clinical sites

when PT/PTA programs

provide the student clin

ical education concurrently

One Cl to two Same as one Cl to two or Same as one Cl to two or morestudents more students design students designpaired from Allows the experienced stu- Can be problematic i f studentsthe same pro- dent to develop supervisory are not compatible in theirgram at diff- skills learning styles or interpersonerent clinical Allows students to use each al interactionslevels {stu- other as a resource and ac- Requires alternative leadershipdent-peer cept feedback more easily design situations in which onementor Allows the experienced stu- student is the leader and thedesign1127-129 dent to orient the inexper- other the aide, and vice versa

ienced student when be

ginning times are staggered

Allows the experienced stu

dent to serve as the lead in

situations in which the in

experienced student has

not completed the didactic

content

Is useful in situations in which

the inexperienced student

has a shorter clinical experi

ence

Two part-time CIs Maximizes opportunities for Requires excellent communicaor two CIs on dif- part-time personnel to be in- tion between Clsferent rotations volved as Cls (often experi- Can confuse students if expectato one or more enced clinicians) tions of the Cls differstudents13o,144 Increases opportunities for Requires additional planning and

clinical s i ~ e s with part-time organization

clinicians to participate in Requires greater coordination




Table 4-4 (continued)


clinical education

Exposes students to multiple

approaches to care delivery

Allows part-time and full-time

CIs to show comparableabilities in providing learn

ing experiencesl44

Permits students in the same

setting to be exposed to dif-

ferent learning experiences

with different Cls

Allows a clinical site toac-

commodate more students

by using multiple rotations

within the same setting

Allows for greater variability

in length of the clinical ex

perience

Increases Cl productivity in

comparison with clinicians

that are no t involved

Reduces supervisors' direct pa

tient-related responsibilities

Decreases the number ofsuper-ficial questions posed by

students

TWo CIs (one high- Provides a mechanism to men

ly experienced to r and develop an inexper

and one less ienced Cl through role

experienced) to modeling and teaching

two or more Allows students to learn using

students parallel processes as inex

(teacher-mentor perienced Clsdesignll23,m, 132 Ensures that the experienced

Cl's knowledge is passed on

to others

Allows students to be part of

a positive lea:pling CI model

that can be emulated

Multiple rural or Permits solo practice settings

single practices to network with other sites

offering collab to provide student clinical

omtive clinical experiences

learning experi- Provides a support system for

ences (coopera clinical teachers in rural

between CIs in completing

student evaluations

Allows the possibility that stu

dents may compare CIs or CIs

may compare studentsCan make it difficult for stu

dents to achieve their learning

objectives

Can decrease the variety and

number of patients in the stu

dents' caseload

Requires an open and trusting

relationship between CIs

Requires that the inexperienced

Cl is comfortable with stu

dents knowing that he or she

is inexperienced

Confuses students as to which

Cl they are accountable

Requires excellent communica

tion and clarity of roles be

tween CIs

Requires coordination and excel

lent communication between

practice settings and CIs

May be more difficult to imple

ment because of different

practice sett ing protocols and





tive-networkdesign)l33-136

One or more CIs

to one or more

students from

different disci

plUles (interdisciplUlaryIco-

operative des i ~ I I 3 3 , 136, 137

settings

Networking provides a mech

anism to access clinical fac

ulty training

Enhances opportunities for

students to be exposed torural and solo practices

Augments student learning ex

periences through interac

tions with multiple clini

cians who provide care in

different clinical settings

Provides a learning model that

teaches collaborative team

learning among different

disciplUles

Gives students a better understanding of the roles and re

lationships between differentdisciplines in real practice

Teaches students team leader

ship and follower skills

Models a more ideal learning

environment to learn how to

work more effectively in an

interdisciplinary setting

Assists in minimizing "turf

battles" that affect qualitylearning

regulations

Requires more complex coordi

nation by the academic pro

gram with different legal con

tracts

Applies only i f different disci

plUles exist at the clinical site

Requires excellent commurtica

tion between and among the

different wsciplUlesRequires exceptional planning

and organizational skills

Requires that CIs trust, respect,

and value each other'S exper

tise and contributions to the

learning process

May cause problematic llturf

battles" i f interdisciplUlary

cooperation does not exist or

where 11 turf battles" already

exist

Cl = clinical instructor; PT = physical therapist; PTA = physical therapist assistant.

student from the same program with less clinical experience Istudent

peer mentor designJl27-129

• Two part-time eIs (or on different rotations) to one or more students130, 144

• Two eIs (one highly experienced and one inexperienced) to two ormore students Iteacher-mentor design)l23, 131, 132

• Multiple distinct rural or single practices collaborating to offer stu

dent clinical experiences (cooperative-network designJ133-136

• One or more eIs to one or more students from different professional

disciplines to provide an interdisciplinary clinical learning experience

linterdisciplinary-cooperative design)133, 136, 137



152 PREPARATION FOR TEACHING IN CUNICAL SETI'lNGS

For each of the designs listed in Table 4-4, specific strengths, considera

tions, and limitations have been summarized to assist clinical educators in

determining if an approach is relevant for their particular practice setting.

Table 4-4 is useful in beginning the investigative process to determine what

alternative supervisory designs might be possible in any given clinical site.

The majority of these designs are variations on the one Cl to two or morestudents design, which stresses active student learning through peer teach

ing and collaborative and cooperative learning.

Collaborative and cooperative learning were originally developed for

educating people of different ages, experience, and levels of mastery of inter

dependence. Cooperative learning was principally designed for primary

school education to assist children in becoming more efficient and effective

in learning to work together successfully on substantive issues, to hold stu

dents accountable for learning collectively rather than in competition with

one another, and to provide social integration regardless of issues of diver

sity. Collaborative learning is similar to cooperative learning in that the goalis to help persons work together on substantive issues. However, collabora

tive learning was developed primarily to make students emolled in higher

education more efficient and effective in aspects of education that are not

content driven, to shift the locus of classroom authority from the teacher to

student groups, and to facilitate structural reform and conceptual rethinking

of higher education.13B

Although perceived by some to be synonymous and interchangeable ter

minology, collaborative and cooperative learning within the context of small

gronp learning are markedly dissimilar. Dist inctions between collaborative

and cooperative learning are generally drawn between the nature and author

ity of knowledge. The major disadvantage of collaborative learning is that,

in attaining self-directed and peer learning, it sacrifices learner accountabil

ity.la8 Whereas, cooperative learning's major flaw is that by emphasizing

accountability it risks replicating within each small group the more tradi

tional model of teacher autonomy.139 These two approaches also differ in

terms of style, function, and teacher involvement; the extent to which stu

dents need to be trained to work together in groups; different outcomes, such

as mastery of facts, development of judgment and construction of knowl

edge; the importance of different aspects of personal, social, and cognitivegrowth among students; and implementation concerns (e.g., group forma

tion, task construction, and grading procedures).140

However, collaborative and cooperative learning are based on the fun

damental assumption that knowledge is a social construct and open-ended

tasks that facilitate collaboration and control by learners restructure the

classroom environment.138 The two philosophies also argue that learning in



Summary 153

an active mode is more effective than passive reception-the teacher is a

facilitator, coach, or 11guide by the side"26-teaching and learning are shared

experiences between teachers and students; participating in small group

activities develops higher-order thinking skills and enhances abilities to use

knowledge; accepting responsibility for learning as an individual and as a

member of a group enhances intellectual development; articulating one'sideas in a small group setting enhances students' abilities to critically

reflect on their own thOUght processes and assumptions; belonging to a

small group and supportive community increases student success and

retention; and appreciating diversity is essential for survival in a multicul

tural society.139 Although there aredistinctions between these two types of

learning, for the purposes of exploring and implementing alternative

designs in physical therapy clinical education, it is preferable to unite both

learning approaches by drawing on each of their strengths to enhance the

achievement of desired outcomes.

It is important to note that merely placing two or more students together during a clinical experience does not connote cooperative or collaborative

learning. Specific components must be present for small group learning to be

truly cooperative and collaborative. As Johnson et al. stated, "[a] group must

have clear positive interdependence and members must promote each other 's

learning and success face to face, hold each other individually accountable to

do his or her fair share of the work, appr9priately use interpersonal and small

group skills needed for cooperative efforts to be successful, and process as a

group how effectively members are working together. fl141

Finally, assessment of any approach should be considered in light of(1) the context in which learning must occur; (2) the academic program ex

pectations; (3) the available resources; (4) the availability of patients; (5) the

support of administration for clinical education specifically addressing pro

ductivity and cost-effectiveness of care delivery; (6) the expertise, experience,

and attributes of individuals serving as clinical educators; (7) the relationship

between all individuals involved in the teaching-learning process; (S) the

characteristics of students; (9) strengths, limitations, and considerations of a

particular supervisory design; (10) the time available for planning and evalu

ating the alternative design; (11) the desired outcomes of the learning experi

ence; and (12) the strategies for ensuring successful implementation.

Summary

This chapter discusses topics perceived to be most critical to

understanding how to adequately prepare effective physical therapy teachers

in clinical settings. It is understandable how situations like the one present



154 PREPARATION FOR TEACHING IN CLINICAL SETI1NGS

ed at the beginning of this chapter might readily occur, but such is not the

preferred approach for preparing future clinical educators. Many aspects of

clinical teaching have been shown to be grounded in literature that provides

conceptual models and investigative studies that help to define components

essential for quality education and training programs for clinical teachers.

The reader is encouraged to explore references provided in the annotated bibliography at the end of this chapter to learn more about clinical

instruction. As more clinical educators critically investigate the use of

alternative supervisory models, the profession will derive greater knowl

edge and understanding about the evidence-based differences between these

designs and their resultant outcomes and effectiveness. Perhaps then, dis

cussions espousing the benefits of one design over another will be resolved

based on empirical evidence rather than intuition, historical precedent, and

personal anecdotes. Before becoming a clinical educator, opportunities for

self-assessment, professional development and enhancement, and. mentor

ship should be made available to specifically address the learning needs ofclinical educators. ,

I t is my belief that advocating clinical teaching professional develop

ment programs is not sufficient. To pervasively impact the larger interests of

the physical therapy profession, the process of becoming a Cl should begin

when educating students during their profeSSional studies.58, 145 Students

should be oriented as part of their active participation in clinical education

to understand the roles and responsibilities of the ACCE, CCCE, and Cl

Students should also learn how to give feedback, critically evaluate their

learning experiences, and routinely perform self-assessments to monitortheir growth and development throughout progressive learning experiences.

They should also begin to develop an understanding and appreciation for the

analogous processes used in providing clinical teaching and physical therapy

services. In this way, students will learn to translate the process of service

delivery, which is the primary focus of their clinical education and initial

practice, to teaching students in clinical settings, which is one of the first

roles they will assume as practitioners.

Clinical educators must be held accountable for role modeling those

behaviors that they would like future practitioners to aspire to, and for

demonstrating good clinical teaching practices to ensure that students learnthe things that the profession believes are required for entry into practice.

Understanding the principles of pedagogy (i.e., that graduates will often

teach in the clinical setting in the way that they were taught) means that

CIs must critically examine their teaching to determine if their current

approach is the legacy they wish to pass on. Andragogy, principles of adult

learning, applies to physical therapy students and how they learn.86 Perhaps

http://slidepdf.com/reader/full/studies.58


http://slidepdf.com/reader/full/learn.86






References 155

if Cls can recall their clinical education experiences as students, it will

remind them of the pivotal role they play in the lives of all students. If Cls

live by this rule, they can begin to reshape clinical education. More impor

tant, individuals who serve to benefit most from these changes are the

future graduates of physical therapy and physical therapist assistant pro

grams who will deliver quality and cost-effective physical therapy care topatients in an uncertain health care environment.

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122. Ladyshewsky R, Healey E. The 2:1 Teaching Model in Clinical Educa

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Annotated Bibliography

American Physical Therapy Association. Clinical Education: An Anthology

(Voll). Alexandria, VA: A m ~ c a n P h y s i c a l Therapy Association, 1992.This resource is a collection of 79 articles compiled primarily from the

physical therapy literature that collectively describes five critical

di.ri::tensions in clinical education. These dimensions include clinical fac

ulty (ACCl!.s, CCCEs, and CIs}, clini<;al. environment and resources,

design of clinical education, evaluation and research, and academic

resources. This is an excellent reference for persons involved in clinical

education because relevant literature is consolidated into one publica

tion. Volume n of this publication is a companion publication that

updates the physical therapy literature in clinical education since 1992

and includes articles from other disciplines.

American Physical Therapy Association. Clinical Education Guidelines and

Self·Assessments. Alexandria, VA: American Physical Therapy Associa

tion, 1993. This reference lists guidelines for clinical education sites,

CCCEs, and CIs that were endorsed by the APTA House of Delegates in

1993. These voluntary guidelines were designed to describe the funda

mental and essential performance criteria that shQuld guide the selec

tion and development of clinical sites and individuals who serve as

clinical educators. These guidelines are accompanied by three self

assessment documents that allow the clinical site and clinical educatorsto evaluate their areas of strengths or needed improvement. Information

gleaned from the self-assessments may be used by academic programs

for clinical si te and faculty development programs.

Fife J. ASHE·ERIC Higher Education Reports. Washington, DC: The

George Washington University, School of Education and Human

Development. These annual series of education-related publications



Annotated Bibliography 165

feature contemporary and forward-looking topics relevant to teaching

adults in higher education. Although the orientation of these publica

tions is directed toward the classroom environment, concepts, ideas,

and suggested examples are easily modified to enhance teaching in

the clinical environment. The five specific volumes listed below are

extremely relevant and applicableto content

presentedin this

chapter. The titles are self-explanatory and reflect the content provided in

the publication.

• Claxton CS, Murrell PH. Learning Styles: Implications for Improving

Educational Practices. ASHE-ERIC Higher Education Report No. 4.

Washington, DC: Association for the Study of Higher Education, 1987.

• Kurfiss GJ. Critical Thinking: Theory, Research, Practice, and Possi

bilities. ASHE-ERIC Higher Education Report No. 2. Washington, DC:

Association for the Study of Higher Education, 1988.

• Whitman N. Peer Teaching: To Teach is to Learn Twice. ASHE-ERIC

Higher Education Report No. 4. Washington, DC: Association for the

Study of Higher Education, 1988.

• Johnson D, Johnson R, SmithK. Cooperative Learning: Increasing Col

lege Facu1ty Instructional Productivity. ASHE-ERIC Higher Education

Report No. 4. Washington DC: The George Washington University,

School of Education and Human Development, 1991.

• Bonwell C, Eison J. Active Learning: Creating Excitement in the

Classroom. ASHE-ERIC Higher Education Report No. 1. Washington,

DC: The George Washington University, School of Education and

Human Development, 1991.

Grossman P. The Making of a Teacher: Teacher Knowledge and Teacher

Education. New York: Teachers College Press, 1990. This text provides

an insightful and deeper understanding of educational practice and

how to improve i t through a sound conceptual framework and the use

of case sketches. Her cutting-edge research provides an understanding

of the differences in what teachers believe and value, how those values

are actually enacted in the classroom, and how beliefs and values

affect content that teachers teach. At first glance, clinical educators

may perceive that an examination of six English teachers, as the subjects of this text, have little to no relationship to their roles in clinical

practice. However, of great significance is the realization that teacher

education programs that provide a coherent vision for teaching and

learning do influence the quality of teaching in any setting. In addi

tion, these teacher education programs ultimately affect how students

construct their emerging and evolving knowledge and understanding




of content, which subsequently facilitates the integration of that

knowledge into practice.

Ladyshewsky R, Healy E. The 2:1 Teaching Model in Clinical Education. A

Manual for Clinical Instructors. Toronto: Department of Rehabilitation

Medicine, Division of Physical Therapy, University of Toronto, 1990.

This manual describes the two-student to one-clinical instructor collaborative clinical teaching design and provides the necessary steps to

implement this supervisory approach in the clinic. The manual is user

friendly, easy to understand, and provides a conceptual framework for

understanding some of the issues described in this chapter. This manu

al assists the Cl in organizing, planning, implementing, and evaluating

the collaborative learning design. This manual can be purchased through

the University of Toronto, Department of Rehabilitation· Medicine;

Division of Physical Therapy, 256 McCaul Street, Toronto, Ontario,

Canada M5T 1W5.

New Directions for Continuing Education. San Francisco: Jossey-Bass. Thevolumes in this series of quarterly sourcebooks address a broad range

of diverse topics of interest to instructors and administrators involved

with adul t and continuing education and higher education. Topics are

focused. on such issues as ways of involving adults in the learning

process and·selecting and developing instructional materials. Although

many of these volumes are relevant to clinical teaching and the

enhancement of adult learning, the three listed below are specifically

recommended. The titles are self-explanatory and reflect content pro

vided in the publication.

• Brookfield S. Self-Directed Learning: From Theory to Practice. New

Directions for Continuing Education INo. 25). San Francisco: Jossey

Bass, 1985.

• Hayes E. Effective Teaching Styles. New Directions for Higher Educa

tion (No. 43}. San Francisco: Jossey-Bass, 1989.

• Merriam S. AnUpdate on Adult Learning Theory. New Directions for

Adult and Continuing Education (No. 57). San Francisco: Jossey-Bass,

1993.

Watts N. Handbook of Clinical Teaching. New York: Churchill Livingstone,1990. This book provides a practical and user-friendly resource for

health professionals to augment their knowledge and skills in providing

clinical education for students. For illustrative and teaching purposes,

Watts uses a multidisciplinary approach to understanding clinical

teaching and encourages the completion of practice exercises in part

nerships or collaborative interdisciplinary teams to reinforce learning.



Annotated Bibliography 167

She facilitates learning through three essential teaching components-

acquiring information, providing practice exercises, and giving imme-

diate feedback. Some of the topics addressed include planning for

student practice, performing a learning needs assessment, designing a

learning contract, supervising practice of a complex skill, influencing

student attitudes and values, giving effective feedback, and analyzingone's teaching style.

Preparation for Teaching in Clinical Settings

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