Clinical Education Models

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Introduction

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

This optional short video explains the importance of the clinical education:

Key Stakeholders of Clinical Education

There are a number of stakeholders who play a key role in a successful clinical education experience. They include the academic institution and the clinical healthcare education site which provide the foundation for the academic clinical education coordinator, clinical instructor, and student. All of them 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.

Academic Institution

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

• it 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
• 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
• it provides the program member who serves as the academic clinical education coordinator

Clinical Education Healthcare Site

The role of the clinical education healthcare site is a complex one and it includes several responsibilities which define the success of the clinical education program.

The expectations from the clinical education healthcare site include the following:

• To identify and provide academic institution placement opportunities for the students to complete their clinical education training.
• To set the standards for placement requirements such as training the students must have prior to their clinical education training (CPR, first aid, immunisations, etc.).
• To provide the clinical instructors.
• To ensure that the clinical instructors meet the criteria to educate students in their area of expertise clinically.
• To establish a plan to welcome and orient the students.
• To ensure that the objectives of the students' experience are met.

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

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 are complete as they become a link between the academic institution and the clinical education healthcare site. The ACEC's additional responsibilities may include the following:

• Communicating with the clinical instructor via phone call or email to ensure they are informed of the placement details and have the required resources for a successful student placement.
• Visiting the healthcare site to confirm the site is an appropriate learning environment.
• Verification 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

The responsibilities of the site coordinator of clinical education 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
• participating in communication with the 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's) role is to advance healthcare professionals to achieve the clinical program's objectives. Students rely on the clinical instructor's communication and teaching skills, internal motivation, and professional appearance to create a learning environment that meets the objectives of the experience.

The responsibilities of the CI include (1) providing patient interactions in the placement speciality, (2) assigning the student responsibilities, (3) providing constructive feedback, (4) completing the student’s evaluation and a final recommendation for pass/fail based on the placement objectives, (5) responding to risks that may arise with a student placement including patient safety, (6) collaborating with the coordinator to address the issues with the student performance or ability to meet objectives.

Student

Clinical education experiences are established for the student, and the student must demonstrate readiness to meet the expectations established by the clinical education program.

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 stay healthy physically and mentally

Clinical Education Models

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

The goal of the clinical education models is to develop the student into a competent clinician who is confident in their knowledge and skills.

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.

• 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.

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

Clinical Education Models With Theoretical Foundation

Clinical education models with theoretical foundations provide consistent and reliable student assessment using goal setting, reflection on clinical experiences, and debriefing. 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 clinical education process (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 the 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 the SOAPE system:
    • subjective, objective, analysis, action, plan, and education
  • Students take ownership of their learning

Clinical Education Practice Models (CEPM)

The primary objective of the 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. The 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

This model follows the academic institution's curriculum model:

The Integrated Clinical Experiences (ICE) Model

• 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.
• 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 students to practice their communication and interpersonal skills before the end of the curriculum.
• It provides an opportunity to improve 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.

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 throughout the 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 modelling behaviour.
• The CI maintains its 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 interprofessional team members and the 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 their peers to move from lower-level learning to higher levels.
• The students rely on the CI to complete more complex learning tasks, such as analyzing and synthesizing cases, creating plans of care, and completing self-assessments.
• The CI does provide the direct supervision for student interventions and ensures learning and interventions are safe.

The challenges:

• The CI must teach 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 comparing their performance.
• Increases paperwork and feedback for the CI to complete on student performance.
• There are not enough patients for each student to see 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

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 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
• 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