Basics of Clinical Education

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Introduction

Clinical education is one of the most valuable opportunities for student learning in a programme. It is a complex process that connects the educational environment to the medical environment. 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 appreciated for programmatic improvement. Student performance in the clinical setting provides useful feedback to the programme regarding student preparation to serve individuals in the community.

Definitions

Clinical Education

"A formal supervised experiential learning, focused on development and application of patient/client-centred skills and professional behaviours. 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."--American Physical Therapy Association

Clinical Educator

The clinical instructors can also be called a clinical mentor, educator, or preceptor or clinical faculty.

"The rehabilitation professional responsible for the therapy student and for directly instructing, guiding, supervising, and formally assessing the student during the clinical education experience."--American Physical Therapy Association

Clinical Education Faculty

"The individuals engaged in providing the clinical education components of the curriculum."--American Physical Therapy Association

General Guidelines for Clinical Education Programme

• One of the most essential features of a successful clinical education programme is the quality of the clinical instructors or clinical faculty.
• Clinical instructors must have a professional license in the relevant profession.

"The clinical education director/coordinator and clinical education site instructors involved in the physical therapist professional entry level education programme should be licensed/registered physical therapists if such a process exists in the country/state or if no licensure/registration exists, then clinical faculty must be a member of the professional organisation."--WCPT (2011)

• 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.

Characteristics of Successful Clinical Instructors

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 the successful characteristics of instructors to include mentors who have:

1. Strong interpersonal and communication skills
2. Professional behaviours
3. Instructional and teaching skills
4. Evaluation and performance skills

Notably, these characteristics are largely similar to characteristics of successful academic instructors.

Interpersonal and Communication Skills

• 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.

Professional Behaviours

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-centred 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 inter-professional collaboration.

Instructional and Teaching Skills

• 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.
• Other examples of effective teaching in clinical education include (1) providing worked examples, (2) concept mapping, and (3) meta-cognitive strategies.

Mastery Learning

Mastery learning is a form of deliberate practice of a specific task with an expected level of proficiency defined. 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.

Goal Setting

Goal setting can be defined in terms of :

• levels of competence
• practice opportunities
• individually defined timeframe

Small Group 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.

Evaluation and Performance skills

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

• Feedback that is provided in a manner that both promotes student learning and evaluates student performance is essential.
• Frequent feedback provides the opportunity for the student to modify and improve.
• Too frequent feedback 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.

Performance Measures or Rubrics

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 programmes include:

• Clinical Performance Instrument
• Canadian Physiotherapy Assessment of Clinical Performance
• Assessment of Physical Therapy Practice

Examples of clinical assessment tools in occupational therapy programmes include:

• Fieldwork Performance Evaluation (FWPE)-USA
• Competency-Based Fieldwork Evaluation (CBFE)-Canada
• Modified Fieldwork Performance Report (MFPR)-Australia
• Assessment of Professional Competencies in Occupational Therapy (CPTO)-Spain

Examples of clinical assessment tools in speech language pathology programmes include:

• COMPASS: Competency Assessment in Speech Pathology Assessment Resource Manual
• Clinical Performance Evaluation Criteria

Resources

• 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 MED. A tool to evaluate physiotherapy clinical education in South Africa. S Afr J Physiother. 2022 Aug 31;78(1):1759.