Clinical Education Models

Original Editor - Angela Patterson

Top Contributors - Ewa Jaraczewska and Jess Bell  

Introduction

Clinical education prepares health professionals to work effectively in the healthcare environment. Developing clinical education programmes can be a complex process. It requires an in-depth understanding of available resources, stakeholder needs and responsibilities and the many different theoretical models of clinical education. Some clinical education models may focus on early exposure to the clinical context while others wait until students complete their full academic curriculum. Clinical education models might emphasise the individual learner's knowledge and abilities or they might support "collective competence", where an individual's competence depends on shared knowledge and teamwork. This article overviews various clinical education models and key stakeholder responsibilities in clinical education programmes.

This optional short video explains the importance of clinical education:

Key Clinical Education Stakeholders

There are a number of stakeholders who play a key role in a successful clinical education experience.

Academic Institution

The academic institution has several responsibilities in clinical education, including:

• establishing the curriculum for students to meet entry-level practice competencies and accreditation standards
  • curriculum sequence determines the timing of the clinical education experiences for appropriate placements to apply theory to practice
• it provides a foundation for linking theoretical and practical aspects of healthcare programmes, ensuring that course content corresponds with professional practices, workforce planning and recruitment
• it facilitates the transition between academic education and professional working life
• the academic clinical education coordinator (ACEC) is part of the academic institution's team (see below)

Clinical Education Healthcare Site

The role of the clinical education healthcare site is complex. It has several responsibilities, which help to ensure the success of the clinical education programme.

The responsibilities of the clinical education healthcare site include the following:

• identifying and providing academic institution placement opportunities for students to complete their clinical education training
• setting the standards for the placement and other requirements, including prerequisite training / requirements (e.g. CPR, first aid, immunisations, etc.)
• providing clinical instructors
• ensuring that clinical instructors meet the criteria to clinically educate students in their area of expertise
• establishing a plan to welcome and orient students
• ensuring that the objectives of the student's experience are met

The clinical education healthcare site collaborates with the academic institution on shared responsibilities. These shared responsibilities include an affiliation agreement (a legal document that includes the scope of the clinical education experience and liability protections), orientation procedures, and procedures for accidents and / or injuries that may occur during the placement.

The Academic Clinical Education Coordinator (ACEC)

The academic clinical education coordinator is assigned by the academic institution. The person fulfilling this role is responsible for ensuring that shared responsibilities between the academic institution and clinical education healthcare site are undertaken. This person becomes the link between the academic institution and the clinical education healthcare site. Additional responsibilities for the ACEC may include the following:

• communicating with the clinical instructor to ensure they are informed of the placement details and have the resources for a successful student placement
• visiting the healthcare site to confirm the site is an appropriate learning environment
• verifying that the student has completed: 1) all the required courses, 2) an orientation to meet the objectives of the placement, and 3) the requirements to pass the clinical education placement

Site Coordinator of Clinical Education

Some clinical education healthcare sites may have a site coordinator of clinical education. Their responsibilities include:

• administration and management of the clinical instructors at the site
• providing additional oversight of learning activities for students during their clinical experiences
• selecting clinical instructors and ensuring they are ready to educate students
• communication with academic institutions

In the absence of a site coordinator of clinical education, the complete responsibility of the clinical training falls on the clinical instructor, with assistance from the site administration.

Clinical Instructor

Clinical instructors (CI) play an important role in helping students achieve the objectives of their clinical programme. CIs must have the necessary communication and teaching skills to create a learning environment that meets the objectives of the experience.

The CI's responsibilities include:

• providing patient interactions in the placement speciality
• assigning the student's responsibilities
• providing constructive feedback
• completing the student’s evaluation and a final recommendation for pass / fail based on the placement objectives
• responding to risks that may arise with a student placement, including patient safety
• collaborating with the coordinator to address issues with a student's performance or their ability to meet objectives

Student

Clinical education experiences are established for the student, and the student must meet the expectations of the clinical education programme.

These expectations include:

• meeting the academic course objectives and requirements to begin learning in the healthcare facility
• completing all required orientation materials tasked to them by the healthcare facility
• demonstrating professional skills by arriving on time, engaging in communication, following the facility requirements, and taking the initiative for their learning
• taking care of themselves to ensure they can remain healthy (physically and mentally)

Clinical Education Models

"Clinical education is defined as the acquisition of professional clinical education skills under the supervision of a trainer or acquisition of clinical education through a clinical-educational model."

Clinical education models aim to enable students to become competent clinicians who are confident in their knowledge and skills.

Clinical education can occur at different stages of an education programme, including:

• a clinical internship at the end of the education programme
  • the student completes all didactic coursework for their degree programme and then completes clinical education prior to graduation

• a residency or fellowship in which the learner completes their required coursework and sits for a licensure exam prior to engaging in focused clinical education
  • the learner gains certification in clinical competency prior to completing clinical learning

• clinical education is integrated throughout the curriculum
  • the student has smaller chunks of time in a clinical setting while completing their didactic coursework

• a combination of timing for clinical placements
  • students may have an opportunity in the middle of a semester to spend a week in a clinical setting to observe and apply concepts being learned in their courses
  • students also complete longer periods of clinical education when they have successfully completed their courses

This optional article provides additional information on Clinical Education Components, including key characteristics of successful academic instructors, teaching ratios, and clinical experiences.

Clinical Education Models With a Theoretical Foundation

Clinical education models with a theoretical foundation provide consistent and reliable student assessment using goal setting, reflection on clinical experiences, and debriefing. There are many different theoretical models, but the following four models have been utilised in rehabilitation.

• Coaching Model:
  • the clinical instructor (CI) takes on the role of a coach versus a supervisor
  • the CI encourages the student to reach their maximum potential
  • supports students to become independent, creative, and self-supervising
  • can work well for clinical education that occurs near the end of a rehabilitation programme for students who have established clinical skills, knowledge, and professional communication skills
• Educator-manager to Self-directed Learner Model:
  • dynamic, individualised model that depends on the student’s readiness for clinical tasks
  • incorporates the entire clinical education process (planning, implementation, and evaluation) and requires input from the academic clinical education coordinator, the clinical instructor, the student, and the professional association's competency requirements
  • allows a student's knowledge and skills to be matched with the requirements to achieve entry-level practice competency
• Mandy Model or Reflective Model:
  • supports students in attaining a deep understanding of knowledge and skills through a five-step process during clinical education:
    • pre-observation
    • observation
    • analysis and strategy
    • reflection on action
    • reflection for future action
  • students connect to current and relevant knowledge from the classroom and apply their skills outside of the classroom
  • reflecting on the utilisation of skills helps support the application of learning to future clinical practice
• Mastery Pathway Framework:
  • bridges the gap between theory and practice
  • allows students to improve their self-evaluation skills
  • provides quality assurance for student evaluations
  • monitors student progress from dependent to independent via a practice known as the SOAPE system (i.e. subjective, objective, analysis, action, plan, and education)
  • students take ownership of their learning

Clinical Education Practice Models (CEPM)

The primary objective of clinical education practice models is to ensure that students have enough clinical practice experiences to develop particular knowledge and skills, put the basics together and manage the work of practice. Clinical education practice models can be grouped based on the following criteria:

• timing of clinical education experiences
• supervisory structure of the clinical experience
• timing and resources

Timing of Clinical Education Experiences

Integrated Clinical Experiences (ICE) Model: Integrated clinical experiences are clinical exposures that occur throughout the curriculum:

• students may be supervised by a clinical instructor from their own profession or a clinical instructor from another profession
• these clinical exposures are designed to meet specific course learning objectives in the clinical environment
  • example: the objective is for a student to complete a standardised assessment with a paediatric patient. The clinical instructor can supervise the student assessing the patient and coach the student on their performance

• allows students to practise their communication and interpersonal skills before the end of the curriculum
• provides an opportunity to improve a student's professionalism before the next clinical education experience
• a student’s competence in course content can be measured in a clinical setting

Examples of integrated clinical experiences in community and healthcare settings:

• a one-day or partial-day experience in a community or healthcare setting, giving students the chance to observe and / or try hands-on interventions; this experience can be repeated multiple times during the semester
• short-term full-time experience observing or completing hands-on interventions in a community or healthcare setting
• using a collaborative model for faculty to supervise multiple students in a community or healthcare setting at one time

Supervisory Structure of the Clinical Experience

One-To-One (1:1) Model:

• one CI is responsible for the student’s learning and progression throughout the clinical placement
• this CI is responsible for all activities with the student, including creating schedules, setting expectations, assessing progression, and determining final grades
• the CI is a teacher, guide, and mentor during clinical education through direct interaction and modelling behaviour
• the CI maintains their workload and productivity standards
• the CI communicates with the academic clinical education coordinator and the site coordinator of clinical education when available
• the student experience may be supplemented with opportunities to interact with other interprofessional team members and they may be able to work with another CI if the primary CI is unavailable

Challenges of the 1:1 model include:

• not enough CIs for the number of students
• students may have to travel to clinical sites outside of their region
• local sites may feel a burden placed on their clinicians that can distract from patient care

Two-to-One (2:1) Model (Collaborative Model):

• two students to one clinical instructor ratio (other options include more than two students to one CI or two or more students to two or more CIs)

• students can be at different levels of learning
• this model provides accessibility to students by increasing the number of students a site can take during a period of time
• it allows students access to clinical settings and patient populations that are difficult to place students in or where a limited number of clinical settings exist
• this model aims to increase students' autonomy and decrease their dependency on the clinical instructor
  • students are expected to learn from and with each other

• students collaborate with their peers to move from lower-level learning to higher-level learning
• students rely on the CI to complete more complex learning tasks, such as analysing and synthesising cases, creating care plans, and completing self-assessments
• the CI provides direct supervision for student interventions and ensures learning and interventions are safe

Benefits associated with the 2:1 model:

• promotes teamwork and collaboration
• facilitates active learning
• offers a shared experience for students with peer support
• simulates real-world collaboration
• increases productivity at the clinical education healthcare site
• increased recruitment of students to become future clinicians

Challenges associated with the 2:1 model:

• students may have different learning styles, so the CI must teach to each style, and avoid comparing the students to each other
• the CI must consider the students' different experience levels
• the CI is less involved in hands-on care as students provide the hands-on patient interventions
• the CI may need to be intentional about how, when, and where feedback is provided to students to avoid comparing their performance
• increased paperwork for the CI - the CI also has to give feedback to each student on their performance
• there may not be enough patients for each student to see one-on-one, so students may have to work with the same patient together

Timing and Resources

Self-contained Model: the academic institution’s faculty serve as the clinical instructors for all clinical experiences:

• the academic institution’s faculty goes to the healthcare institution to work with the students in the clinical environment
• the academic faculty also have clinical appointments within the clinical healthcare site

Hybrid Model: a combination of one or more clinical education models:

• can be used for students across professions to learn together
  • inter-professional education (IPE) is when "two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes.”
  • IPE supports collaborative practice by learners and responds to health service needs
• can also refer to a combination of in-person clinical education experiences with online learning
  • example: students may see a patient in the clinic and then join a virtual discussion forum to discuss the case and resources to support the patient

Resources

• WCPT guideline for the clinical education component of the physical therapist professional entry-level programme.
• Preceptor Education Program
• Guidelines To Promote Excellence in Clinical Education Partnerships