Clinical Education Components

Original Editor - Stacy Schiurring based on the course by Larisa Hoffman

Top Contributors - Stacy Schiurring, Jess Bell and Rishika Babburu

Introduction

According to the American Physical Therapy Association, clinical education is "a formal supervised experiential learning, focused on development and application of patient/client-centered skills and professional behaviors. It is designed so that students gain substantial, relevant clinical experience and skills, engage in contemporary practice, and demonstrate competence before beginning entry level practice."

Clinical education is one of the most valuable opportunities for student learning in a programme. Experiential learning provides an opportunity for students to practise knowledge, skills, and attitudes in the workplace where they are ultimately expected to perform. Clinical education is also valuable for programmatic improvement. Student performance in the clinical setting provides useful feedback to the programme regarding student preparation to serve individuals in the community.

Clinical Educators

One of the most essential features of a successful clinical education programme is the quality of the clinical instructors (can also be called a clinical mentor, educator, or preceptor) or clinical faculty.

Clinical instructor: The rehabilitation professional responsible for the therapy student and for directly instructing, guiding, supervising, and formally assessing the student during the clinical education experience. Clinical education faculty: The individuals engaged in providing the clinical education components of the curriculum.

• Across health professional programmes, clinical instructors must have a professional license in the relevant profession.
• Some programmes require at least one year of clinical experience before clinical mentorship occurs. 
• Creating a requirement to participate in a clinical mentorship training programme improves the quality of clinical education programmes. Programmes have been developed to improve mentorship, and these have resulted in improvements in student experiences.  

The clinical instructor's supervisory style has been identified as an important element to evaluate. Characteristics of successful clinical instructors and environments have been described by Recker-Hughes et al. in 2014. The authors describe successful characteristics of instructors to include mentors who have (1) strong interpersonal and communication skills, (2) professional behaviours, (3) instructional and teaching skills, and (4) evaluation and performance skills. Notably, these characteristics are largely similar to characteristics of successful academic instructors.  

1. Interpersonal and communication skills that promote student learning include demonstrating a motivation to mentor students, creating a positive learning environment, and effective communication.
   • An example behaviour that suggests a preceptor is interested in mentoring includes simply making time to discuss, answer questions, and provide feedback to the student. 
   • Creating an individualised communication plan is helpful because it helps align the instructor and student expectations for appropriate opportunities to discuss a clinical case, as well as the timing and approach to providing constructive feedback.  
2. Skills in the domain of professionalism that promote success in the clinical environment include modelling principled behaviour, demonstrating evidence-based care, and collaborating with the team.
   • Modelling patient-centered care, evidence-based practice, and collaboration are essential behaviours in a mentor. 
   • In the clinical setting, teaching must shift from student-centred to patient-centred care. Both discussing the shift and modelling the behaviour can help the student shift towards patient-centred care. 
   • Modelling evidence-based practice includes asking clinical questions, providing interventions that are based on evidence, and comparing patient outcomes to the literature. Students often struggle with predicting outcomes and integrating prognostic indicators. Clinical instructors can guide this process by collecting patient outcomes and helping a student compare patient outcomes to published outcomes. This comparison can spark conversations on reasons for delayed recovery or faster recovery. The discussion itself can help students learn how to anticipate prognosis in patients. 
   • Modelling collaborative practice provides an opportunity for a novice practitioner to observe leadership skills in terms of offering expertise, understanding the perspectives of colleagues, and coming to a consensus when opposing ideas collide. Simply making time for meetings and discussions helps students observe behaviours around the value of interprofessional collaboration.      
3. Skills in teaching that promote student learning include (1) modifying the level of expectations based on student performance, (2) use of multiple types of instructional strategies, and an (3) emphasis on reflection.  
   • Mentors who have a variety of teaching strategies may be able to adjust their instruction based on the needs of the student. Instructional strategies that have the best evidence include (1) mastery learning, (2) goal setting and (3) small group learning. 
     • Mastery learning is a form of deliberate practice of a specific task with an expected level of proficiency defined.  Important elements of this type of instruction include goal setting, which can be defined in terms of levels of competence, practice opportunities, and the timeframe may be individually defined rather than set for all students.   This type of strategy can be modified based on the level of the student’s initial performance, which can vary from beginning, intermediate or entry level skilled performance. Huang  et al. suggests that skill based components of practice may be best suited for mastery learning. 
     • Small group learning is another instructional strategy that demonstrated a large effect size on student performance. Small group learning in this context included flipped classroom design where students prepared for the learning activities with a reading assignment, then participated in discussion on clinical cases with their peers and a content expert. Important elements of this type of instructional strategy include the active elements by the student. Rather than direct instruction, students have an opportunity to discuss and justify their decisions with their peers. Peer discussions are useful because the pace of the discussion can be slower, allowing students the opportunity to think methodically and slowly. Clinical experts often think quickly and come to the answer much faster than the novice. Small group discussions provide an opportunity to discuss clinical decisions at a slower pace.  
   • Other examples of effective teaching in clinical education include (1) providing worked examples, (2) concept mapping, and (3) meta-cognitive strategies.  
4. Skills in assessment of student performance include providing feedback that is timely, objective and specific; and applying the feedback to identify opportunities for success.  
   • Feedback that is provided in a manner that both promotes student learning and evaluates student performance is essential. 
     • When feedback is given frequently, it provides the opportunity for the student to modify and improve. 
     • Feedback that is too frequent does not provide the student with the opportunity to reflect on their own performance and modify before the instructor redirects. 
     • Providing vague comments is less effective than describing both specific behavioural observations and comparing it to expected behaviours.  
   • Student performance can be evaluated with clinical performance measures or rubrics. This helps both the student and the instructor anticipate expectations in clinical performance. 
     • Examples of clinical assessment tools in physical therapy include Clinical Performance Instrument, Canadian Physiotherapy Assessment of Clinical Performance, Assessment of Physical Therapy Practice.  
     • Occupational therapy programmes often use Fieldwork Performance Evaluation. 
     • Speech language pathology programmes use a variety of tools, two of which are the COMPASS:  Competency Assessment in Speech Pathology Assessment Resource Manual and the Clinical Performance Evaluation Criteria.  

Teaching Ratios

The ratio of students to clinical faculty varies across professions. Some professions have multiple students assigned to the same clinical supervisor. This often occurs in settings where there are multiple patients assigned to a single rehabilitation provider in an ongoing manner, such as medicine and nursing in a hospital setting. This is less common in therapy professions, where there is usually one clinical instructor assigned to supervise a single student or pair of students.

• The model where multiple students are supervised by the same instructor may have benefits, namely peer to peer teaching and collaborative decision making.  
• Some situations require a larger student to faculty ratio, where there may be 10-30 students assigned to a single instructor.   This type of ratio provides an opportunity for the instructor to model clinical performance. 
• Another option that may be more engaging is to divide the tasks of the clinical interaction amongst the group - such that each student has an opportunity to lead a component of the clinical interaction. To further improve student engagement, the remaining students could practise providing feedback to the leading student. Having varied supervision with group, one-to-one, peer led, and teacher led may have the biggest benefit.

Clinical Experiences

Timing of the clinical experience

Clinical education models vary across professions in terms of the timing of clinical experiences. Some professions emphasise terminal experiences that occur prior to graduation, whereas others such as medicine and speech therapy, take license exams prior to graduation, but in order to obtain certification of clinical competency, they must complete a clinical residency or fellowship. 

Fellowship: A post-professional learning experience comprised of a curriculum encompassing the essential knowledge, skills, and responsibilities of an advanced rehabilitation professional within a defined area of subspecialty practice. Residency: A post-professional learning experience comprised of a curriculum encompassing the essential knowledge, skills, and responsibilities of an advanced rehabilitation professional within a defined area of practice.

More recently, early clinical experiences have become more common. McCallum et al. provide a definition for a specific type of early experience, the integrated clinical experience. 

Integrated clinical experience is a model of clinical education where the internship occurs before completion of the didactic courses. Often, there are specific learning objectives that are achieved in the clinical environment.

For example, during a course on communication, where students learn elements of history taking and client interview skills, one of the objectives for the integrated clinical experience could be that the student would independently gather historical information from a client or caregiver. An alternative to emphasising psychomotor or knowledge skills is to use the integrated clinical experience to emphasise skills in the affective domain. The benefit of an integrated clinical experience is that the student’s competence can be measured in a clinical setting.  

Student competency assessment

Prior to sending a student to a clinical experience, it is helpful for the programme to identify a student’s readiness to learn in the clinical environment. Identifying competency before students begin learning in the clinical setting, protects the relationship between the programme and the community. If a student is unprepared for the experience, the trust between the clinical faculty in the community or stakeholders in the community can be lost. 

Patient simulation in the classroom or laboratory setting is one way to identify clinical readiness. Students who struggle with risk assessment and planning in the academic setting, also struggle with these skills in the clinical setting. However, early remediation of safe skill performance may lead to improvements in risk assessment in the clinical setting setting. 

Requiring students to pass a list of competency skills prior to beginning clinical experience, helps to assure the community of a student’s preparation for the experience.

Clinical setting

The clinical setting is an opportunity for students to be exposed to common health conditions that they will be expected to manage as rehabilitation professionals. Therefore, clinical experiences should match the local burden of disease.   

Further, identifying common levels of healthcare and creating requirements around levels of care such as primary, secondary and tertiary care, provides students with a diversity of clinical exposure. 

• Some programmes require students to have both inpatient and outpatient experiences; as well as rural and urban experiences. 
• One of the benefits of requiring an inpatient experience is to expose students to interprofessional collaboration. Inpatient settings are unique because they often employ multiple types of rehabilitation professionals which allows for more opportunities for interprofessional interaction. 
• One of the benefits of the outpatient experience is the emphasis on autonomous decision making. The rural clinical setting is different from the urban setting, in that there are less specialty clinics. 
• The rural setting often provides students with a greater opportunity to be exposed to a diversity of health conditions and age groups at a single clinical site than an urban setting. 
• Having a diversity of speciality areas is also beneficial. For example, requiring exposure to clinical settings that emphasise cardiopulmonary, orthopaedics, neurology, sports medicine, paediatrics, and public health. Naidoo et al. suggests that more than 6 areas is ideal, whereas 4-6 practice areas are fair and 3 or less is narrow.

Clinical length

Another feature that must be addressed in the development of a clinical education programme is the length of the clinical experience. 

• Across professions and globally, there is no consistent standard for length of a clinical internship. 
• In the United States, the minimum 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. 
• Some of the requirements are based on a full time work schedule, but many professions provide flexibility in the work schedule and some require part time hours to allow for didactic courses to be taught concurrently.

Programme monitoring and quality assurance

The final element of clinical education that will be reviewed is the programme monitoring and quality assurance. In 2022, Naidoo et al. published a tool to evaluate a clinical education programme.  The tool is organised according to (1) Governance, (2) Academic Process, (3) Learning Exposure, (4) Clinical Orientation, (5) Clinical Supervision, and (6) Monitoring and Quality Assurance.

• In the governance section, the authors suggest reviewing policies that guide clinical practice by students such as rules and regulations from department of health or licensing boards, as well as institutional policies to ensure policies are in alignment with the clinical programme activities. In addition, establishing an agreement, memorandum, or contract with a clinical site promotes common understanding and can help with building relationships. 
• The section on academic process, learning exposure, and clinical supervision guides the programme through a critical appraisal of clinical education requirements, teaching strategies, and relationship with didactic learning.  
• The clinical orientation section reviews the process in which students are oriented to the clinical site. 
• Finally the quality assurance section identifies clinical site specific attributes to reflect upon.  

This tool is beneficial in that it is a comprehensive, objective and standardised assessment of a clinical education programme. The authors have established the reliability and validity in different programmes across different regions. This tool is one way to measure the quality and rigor of a clinical education programme.

Resources

Clinical Assessment Tools:

• The American Physical Therapy Association (APTA) Clinical Performance Instrument for Physical Therapy Students
• APTA Clinical Performance Instrument for Physical Therapy Assistant Students
• Assessment of Physiotherapy Practice
• The Australian Orthotic Prosthetic Association (AOPA) Competency Standards, Wall Chart
• CALIPSO Clinical Competencies
• Canadian Physiotherapy Assessment of Clinical Performance (ACP)
• Clinical Fellowship Skills Inventory
• COMPASS® Competency Assessment in Speech Pathology Assessment Resource Manual
• Fieldwork Performance Evaluation (FWPE) for the Occupational Therapy Student

Optional Additional Recommended Reading:

• McCallum C, Bayliss J, Becker E, Nixon-Cave K, Colgrove Y, Kucharski-Howard J, Stern D, Evans K, Strunk V, Wetherbee E, Russell B. The Integrated Clinical Education Strategic Initiatives Project—Development of Parameters to Guide Harmonization in Clinical Education: A Scoping Review. Physical Therapy. 2019 Feb 1;99(2):147-72.
• Myers K, Davis A, Thomas S, Bilyeu C. Clinical instructor perceptions of the collaborative clinical education model: Providing solutions for success in physical therapy education. Internet Journal of Allied Health Sciences and Practice. 2019;17(4):4.
• Naidoo V, Stewart AV, Maleka ME. A tool to evaluate physiotherapy clinical education in South Africa. South African Journal of Physiotherapy. 2022 Aug 31;78(1):11.