Clinical Education Models

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Introduction

The clinical education of the healthcare professionals prepare them to work effectively in healthcare environment. The development process of the clinical education program can be a complex task and requires good assessment of the resources available to conduct and support these programs. Clinical education models may focus on students' early exposure to clinical context, when others wait until the students complete their full academic curriculum. There are clinical eduction models that emphasis the individual learner knowledge and abilities or "collective competence" where individual's competence depends on share knowledge and teamwork. This article provides an overview of various clinical education models and the stakeholders’ responsibilities in maintain and conducting these models.

Key Stakeholders of Clinical Education

All the stakeholders play a key role in a successful clinical education experience. The academic institution and the clinical healthcare education healthcare site provide the foundation for the academic clinical education coordinator, clinical instructor, and student to unite and provide a clinical experience that meets the required competencies for the student to progress towards completing academic requirements and progressing into clinical practice. When in the student’s progression the clinical experience occurs varies across professions and degree programs.

Academic Institution

The role of the academic institution in clinical education include the following:

• establishes the curriculum for the 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
• provides program member that serves as the academic clinical education coordinator.

Clinical Education Healthcare Site

identifies and provides the academic institution placement opportunities for the students to complete their clinical education training. The site sets the standards for placement requirements such as trainings the students must have prior to their clinical education training. These may include CPR, first aid, immunizations, and other regulated requirements to practice in a healthcare facility. The site provides the clinical instructor and ensures that they meet the criteria to clinically educate students in their area of expertise. Finally, the site needs an established plan to welcome and orient the students as well as a program to ensure that the objectives of the experience are met. The establishment of a clinical education plan and manual will be discussed in other courses.

The clinical education healthcare site and the academic institution must collaborate on shared responsibilities. These shared responsibilities include an affiliation agreement, orientation procedures, and procedures for accident/injury that may occur during the experience. The affiliation agreement is a legal document that includes the scope of the clinical education experience and liability protections.

The Academic Clinical Education Coordinator (ACEC)

that is assigned by the academic institution is responsible for ensuring these shared responsibilities are complete. This person is the link between the academic institution and the clinical education healthcare site. Thus, bridging the student together with the clinical instructor. They communicate with the clinical instructor via phone call or email to make sure they are informed of the placement details and have the required resources for a successful student placement. They may also visit the healthcare site to confirm the site is an appropriate learning environment. The academic clinical education coordinator verifies that the student has completed required courses and orientation to meet the objectives of the placement and the requirements to pass the clinical education placement.

Site Coordinator of Clinical Education

This person is responsible for the administration and management of the clinical instructors at the site and provides additional oversight of learning activities for students during their clinical experiences. The site coordinator selects clinical instructors and ensures they are ready to educate students. They work with the clinical instructor and student through a supervisory role and participate in communication with the academic institutions. In the absence of a site coordinator of clinical education, the complete responsibilities of the clinical training fall on the clinical instructor with assistance from site administration.

Clinical Instructor

chosen by the clinical education healthcare site to teach and mentor the student during their clinical education experience. The clinical instructor or CI is responsible for supporting the student’s success by creating a learning environment that meets the objectives of the experience. The CI provides patient interactions in the placement specialty, assigns the student responsibilities, and provides constructive feedback. The CI is responsible for completing the student’s evaluation and a final recommendation for pass/fail based on the placement objectives. Beyond the responsibility for the student, the CI is also accountable for any risks that may arise with a student placement including patient safety. If any concerns arise during a student’s clinical education experience, the CI will be supported by the healthcare facility. The concerns will be communicated back to the academic clinical education coordinator. The CI and coordinator will collaborate to address the issues with the student performance or ability to meet objectives.

Student

Clinical education experiences are established for the student. The student qualifies for the experience by meeting the academic course objectives and requirements to begin learning in the healthcare facility. It is the responsibility of the student to complete all required orientation materials tasked to them by the healthcare facility. When it comes time to begin the experience the student should demonstrate professional skills by arriving on time, engaging in communication, following the facility requirements, and taking initiative for their learning. Clinical education experiences may be challenging and a new style of learning for the student. The student must take care of themselves to ensure they stay healthy physically and mentally.

Clinical Education Models

A one size fits all clinical education model is not feasible across all rehabilitation professions. Factors on the use of a clinical education model depends on the profession, location of the clinical education, accessibility of clinical instructors, regulation of clinical education, and/or level of clinical education experience. Commonly, no matter the model, the objective is to develop the student into a competent clinician that is confident in their knowledge and skills.

The length of a clinical placement varies across professions and globally. There is no consistent standard for length of a clinical education training. As an example, in the United States, the minimum requirements for medicine is 2 years, physical therapy is 30 weeks, speech language pathology requires 400 supervised hours, and occupational therapy has a minimum of 24 weeks. Learners can complete clinical education on a full time or part time basis depending on the timing of the training.

Clinical education can occur as the following:

• a clinical internship at the end of the education program.
  • The student completes all didactic coursework for their degree program 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.

• a clinical education is integrated throughout the curriculum.
  • The student has smaller chunks of time in a clinical setting as they are 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 complete longer periods of clinical education when they have successfully completed their courses.

Clinical Education Models With a Theoretical Foundation

Provide consistent and reliable student assessment using goal setting, reflection on clinical experiences, and debriefing. These models have been investigated and have produced outcome data. The following four theoretical models have been utilised in rehabilitation: 

• The coaching model
  • The clinical instructor (CI) takes on the role of a coach versus a supervisor
  • The CI encourages the student to gain their maximum potential
  • This model supports the students in becoming independent, creative, and self-supervising
  • This model is most effective for clinical education that is near the end of the rehabilitation program with a student that has established clinical skills and knowledge as well as professional skills in communication
• The educator-manager to self-directed learner model
  • Dynamic and individualized model depending on the student’s readiness for clinical tasks.
  • It incorporates the entire process of clinical education (planning, implementation, and evaluation).
  • It requires input from the academic clinical education coordinator, the clinical instructor, the student, and professional associations competency requirements.
  • It allows to match student’s level of knowledge and skills with the requirements to achieve entry level practice competency.
• The Mandy model or reflective model
  • It supports the student in attaining a deep understanding of knowledge and skills through a five-step process during clinical education:
    • pre-observation and observation
    • analysis and strategy
    • reflection on action
    • reflection for future action
  • The students connect to current and relevant knowledge from the classroom
  • The students use their skills to apply them outside of the classroom.
  • The students utilise their skills to support application of their learning to future clinical practice
• The mastery pathway framework
  • It bridges the gap between theory and practice,
  • It allows the student to improve their self-evaluation skills,
  • It provides quality assurance for student evaluations.
  • It monitors student progress from dependent to independent via a practice known as SOAPE system:
    • subjective, objective, analysis, action, plan, and education
  • Students take ownership of their learning

Clinical Education Practice Models (CEPM)

Based on the Timing of Clinical Education Experiences

This model follows the academic institution's curriculum model.

The Integrated Clinical Experiences (ICE) Model

• Clinical exposures that occur throughout the curriculum.
• Student may be supervised by a clinical instructor from their own profession or a clinical instructor from another profession.
• Meet specific course learning objectives in the clinical environment.
  • Example: The objective may be for the student to complete a standardised assessment with a paediatric patient. The clinical instructor can supervise the student completing the assessment and coach the student on their performance.

• It allows the student the opportunity to practice their communication and interpersonal skills prior to the end of the curriculum.
• It provides opportunity to improve on student's professionalism prior to the next clinical education experience.
• It allows for the student’s competence in course content to be measured in a clinical setting.

Based On the Supervisory Structure of the Clinical Experience

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

The structure:

• One CI is responsible for the student’s learning and progression for the entire clinical placement.
• The CI is responsible for all activities with the student including creating schedules, setting expectations, assessing progression, and determining final grades.
• The CI is the teacher, guide, and mentor during clinical education through direct interaction and modeling 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 get exposure to the interprofessional team members and ability to work with another CI when the primary CI is out of the facility.

The challenges:

• Not enough CIs for the number of students studying in rehabilitation programs.
• 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.

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

The structure:

• 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.
• It 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 or when a limited number of clinical settings exist.
• The goals to increase the autonomy of students and decrease their dependency on the clinical instructor.
  • The students are expected to learn from and with each other.

• Students collaborate with the peers to move from lower-level learning to higher levels of learning.
• The students rely on the CI to complete more complex levels of learning such as analysis and synthesis of cases, creating plans of care, and completing self-assessment.
• The CI does provide the direct supervision for student interventions and ensures learning and interventions are safe.

The challenges:

• The CI must teach to each style during the same experience avoiding comparing the students to each other.
• The CI must consider students' different experience levels
• Decreases hands-on care for CI
• The CI may need to be intentional about how, when and where feedback is provided to the students to avoid comparison of their performance.
• Increases paperwork and feedback for the CI to complete on student performance.
• Not enough patients for each of the students to see the patients one on one. The students may have to work with the same patient together.

The benefits:

• Promotes teamwork and collaboration
• Facilitates active learning
• Offers a shared experience for students with peer support
• Simulates of real-world collaboration
• Increases productivity at the clinical education healthcare site
• Increase recruitment of the students to become future clinicians

Based on Timing and Resources

• The self-contained model:
  • the academic institution’s faculty serve as the clinical instructors for all clinical experiences
  • the academic institution’s faculty go to the health care institution to work with the students in the clinical environment
  • the academic faculty also have clinical appointments within the clinical healthcare site
• The hybrid models:
  • students across professions learning together
    • WHO defines inter-professional education (IPE) as "two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes.”
    • IPE supports a collaborative practice by the learners and responds to health service needs.
  • in-person clinical education experiences with online learning
    • The 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