Clinical Education Components

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

Top Contributors - Stacy Schiurring, Jess Bell and Rishika Babburu

Introduction

Clinical education is one of the most valuable opportunities for student learning in a program.  Experiential learning provides an opportunity for students to practice knowledge, skills, and attitudes in the workplace where they are ultimately expected to perform (Timmburg, 2022).   Clinical education is also valuable for programmatic improvement.  Student performance in the clinical setting provides useful feedback to the program regarding student preparation to serve individuals in the community.

Clinical Educators

One of the most essential features of a successful clinical education program are the quality of the clinical preceptors or clinical faculty (Recker-Hughes, 2014) . Across health professional programs, the criteria for clinical mentors who supervise students are often individuals who have a professional license in the relevant profession (Jette, 2014). Some programs require at least 1 year of clinical experience before clinical mentorship occurs.  Creating a requirement to participate in a clinical mentorship training program improves the quality of clinical education programs.  Programs have been developed to improve mentorship, which have resulted in improvements in student experiences (Steinert, 2006).  

The clinical educator’s supervisory style has been identified as an important element to evaluate (Naidoo, 2022).   Characteristics of successful clinical instructors and environments have been described by Recker-Hughes et al.    The authors describe successful characteristics of instructors to  include mentors who have strong interpersonal and communication skills, professional behaviors, instructional and teaching skills, and evaluation and performance skills (Recker-Hughes, 2014).  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 (Recker-Hughes, 2014). An example behavior that suggests a preceptor is interested in mentoring includes simply making time to discuss, answer questions, and provide feedback to the student.  Creating an individualized communication plan is helpful such that both the instructor and student have similar expectations for appropriate opportunities to discuss a clinical case, as well as timing and approach to providing constructive feedback.  
2. Skills in the domain of professionalism that promote success in the clinical environment include modeling principled behavior, demonstrating evidence-based care, and collaborating with the team (Recker-Hughes, 2014). Modeling patient centered care, evidence based practice, and collaboration are essential behaviors in a mentor (Naidoo, 2022).  In the clinical setting, teaching must shift from student centered to patient centered care.  Both discussing the shift and modeling the behavior can help the student shift towards patient centered care.  Modeling 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.  Finally, modeling 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 consensus when opposing ideas collide. Simply making time for meetings and discussions, helps students observe behaviors around the value of interprofessional collaboration.      
3. Skills in teaching that promote student learning include modifying the level of expectations based on student performance, use of multiple types of instructional strategies, and an emphasis on reflection (Naidoo, 2022) (Recker-Hughes, 2014).   Mentors who have a variety of teaching strategies may be able to adjust their instruction based on the needs of the student (Naidoo, 2022).  Instructional strategies that have the best evidence include mastery learning, goal setting and small group learning (Huang, 2019).  Other examples of effective teaching in clinical education include providing worked examples, concept mapping, and meta-cognitive strategies (Huang, 2019).   Mastery learning is a form of deliberate practice of a specific task with an expected level of proficiency defined (McGaghie et al. 2011).  Important elements of this type of instruction include goal setting, which can be defined in terms of levels of competence, practice opportunities, and timeframe may be individually defined rather than set for all students.   This type of strategy has the benefit of modifying based on the level of the student’s performance from the start, which can vary from beginning, intermediate or entry level skilled performanced.  Huang  et al. suggests that skill based components of practice may be best suited for mastery learning (Huang, 2019).  Small group learning was 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 (Chavda, 2016).  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.  Clinician 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.  
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 (Recker-Hughes, 2014).   Feedback that is provided in a manner that both promotes student learning and evaluates student performance is essential.  When feedback is provided 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 behavioral observations and comparing it to expected behaviors.   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 programs often use Fieldwork Performance Evaluation.  Speech language pathology programs 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 (Lekkas, 2007).  The model where multiple students are supervised by the same instructor may have benefits, namely peer to peer teaching and collaborative decision making (Myers, 2019) (Ezenwankwo, 2019).  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 practice providing feedback to the leading student.  Having varied supervision with group, one-to-one, peer led, and teacher led may have the biggest benefit (Naidoo, 2022).

Clinical Experiences

Timing of clinical experience

Clinical education models vary across professions in terms of the timing of clinical experiences.  Some professions emphasize terminal experiences that occur prior to graduation (Jette, 2014), 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 (Erickson, 2018).  More recently early clinical experiences have become more common (McCallum, 2019).    McCallum et al. provides 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 (McCallum, 2019).  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 emphasizing psychomotor or knowledge skills is to use the integrated clinical experience to emphasize skills in the affective domain (Timmberburg, 2019).   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 program 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 program 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 (Judd, 2018), however early remediation of safe skill performance may lead to improvements in risk assessment in the clinical setting setting (Irwin, 2018).  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 exposure

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 (Nadioo, 2022).    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 (Nadioo, 2022).  Some programs require students to have a clinical experience in both inpatient and outpatient experiences; as well as rural and urban experiences (Jette, 2014).  One of the benefits of requiring an inpatient experience is to expose students to a greater emphasis of interprofessional collaboration, because inpatient settings often employ multiple types of rehabilitation professionals, there are often more opportunities for interprofessional practice.  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 emphasize cardiopulmonary, orthopedics, neurology, sports medicine, pediatrics, and public health.  Naidoo et al, suggests that more than 6 is ideal (Nadioo, 2022), 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 program 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 (Jette, 2014).  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 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 program monitoring and quality assurance.  In 2022, Nadoo published a tool to evaluate a clinical education program.  The tool is organized according to Governance, Academic Process, Learning Exposure, Clinical Orientation, Clinical Supervision, and 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 program 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 program 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 standardized assessment of a clinical education program.  The authors have established the reliability and validity in different programs across different regions.   This tool is one way to measure the quality and rigor of a clinical education program.  

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