Basics of Clinical Education

Original Editor - Angela Patterson

Top Contributors - Ewa Jaraczewska, Vidya Acharya, Jess Bell and Kim Jackson  

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 and medical environments. Experiential learning allows 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 valuable feedback to the programme regarding student preparation to serve individuals in the community. This article describes the fundamentals of clinical education as a component of entry-level education programmes.

Definitions

Clinical Education

"A formal supervised experiential learning focused on developing and applying 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." -- American Physical Therapy Association

Clinical Instructors

Clinical instructors (CIs) can also be called clinical mentors, educators, preceptors 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

"The academic clinical education coordinator is an educator from the student's academic institution that serves as the coordinator for the student placement at the clinical healthcare site." -- Dr. Angela Patterson

General Guidelines for a Clinical Education Programme

One of the most essential features of a successful clinical education programme is the quality of the clinical instructors or 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." -- World Confederation for Physical Therapy (2011)

Some programmes require clinical instructors to have at least one year of clinical experience before they can become clinical mentors. 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 student experiences.

Characteristics of Successful Clinical Instructors

Being a clinical instructor is "an opportunity, honour and a challenge." Recker-Hughes et al. described the characteristics of successful clinical instructors and environments. According to their findings, successful instructors have a set of characteristics, including:

• strong interpersonal and communication skills
• professional behaviours
• instructional and teaching skills
• evaluation and performance skills

Notably, these characteristics are largely similar to the characteristics of successful academic instructors. The clinical instructor's supervisory style is also an important element to evaluate.

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 of 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's and student's expectations for appropriate opportunities to discuss a clinical case and 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 students 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 (3) emphasis on reflection.

• Mentors with various teaching strategies may be able to adjust their instruction based on the student's needs
• Instructional strategies with the best evidence include mastery learning and 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 the deliberate practice of a specific task with a defined expected level of proficiency. 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.

"Mastery learning enables students to move forward at their own pace as they master knowledge, skills, and dispositions."

Huang et al. suggest that skill-based practice components may best suit mastery learning. It should be applied in the competency-based curriculum where students focus their learning on job-related tasks. Mastery learning promotes learner-centredness and moves away from time-based training.

Important elements of this type of instruction include goal setting, which 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 has been shown to have a large effect size on student performance. Small group learning in this context included a flipped classroom design where students prepared for the learning activities with a reading assignment and then participated in a discussion on clinical cases with their peers and a content expert.

Important elements of this instructional strategy include the active engagement of the student. Rather than direct instruction, students can discuss and justify their decisions with their peers. Peer discussions are helpful 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 allow participants to discuss clinical decisions at a slower pace.

Evaluation and Performance Skills

Clinical practice relies heavily on clinical reasoning, which is highlighted in the competency frameworks across the health professions. Skills in the 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 performance and modify before the instructor redirects
• Providing vague comments is less effective than describing specific behavioural observations and comparing them 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 physiotherapy or 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 therapy (pathology) programmes include:

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

Responsibilities of the Clinical Instructor and the Student

The clinical instructor's responsibilities include the following:

• having a basic understanding of the foundation of learning provided to the student by the educational institution
• managing clinic responsibilities and the responsibilities of mentoring a student
• understanding the policies, procedures, and everyday tasks in the clinical areas where they teach students
• establishing collaborations among students and the health professionals they encounter in clinical placements
• being a professional role model who gains professional development and collaborates with an academic institution

The student's responsibilities when attending a clinical education programme include:

• arriving at the clinical education site ready to learn and attain entry-level competency skills
• passing competency skills taught in the classroom and lab

Characteristics of Successful Students in Clinical Education Programmes

Skills essential to the success of rehabilitation students in the clinical environment include generic abilities and the ability to form relationships. These general abilities are interdependent; they cannot guarantee success when only one or a few are present. Forming relationships includes relationships with patients, clinical instructors, and healthcare team members.

Generic abilities:

• critical thinking
  • essential when in various unfamiliar clinical situations
  • allows the student to assess the situation and decide on a course of action
• clinical reasoning
• commitment to learning
• stress management
• responsibility
• professionalism
• interpersonal skills
• communication skills
• time management
• use of constructive feedback
• problem-solving

Ability to form relationships with patients:

• engagement on an emotional level through touch, assuring safety and facilitating movement and activities
• developing empathy
• attending to a patient's emotional needs

Ability to form relationships with clinical instructors:

• mutual respect
• establishing boundaries
• choosing a mode of communication

Ability to form relationships with healthcare team members:

• understanding the team member's role and responsibilities

The Role of the Academic Clinical Education Coordinator

The academic clinical education coordinator (in the physiotherapy profession) or fieldwork coordinator (in the occupational therapy profession) is responsible for:

• building and maintaining relationships between the academic institution and the clinical education sites
• understanding the mission and vision, patient populations, and expectations of the site
• successfully matching students with clinical instructors
• serving as an education resource for the clinical instructor's professional development
  • coordinates the academic institution providing continuing education for clinical staff

Benefits and Challenges of Clinical Education

The presence of students at the clinical site has its benefits and challenges. However, clinical instructors perceive that limitations, such as increasing their workload and time spent at work, outweigh the benefits. Benefits for clinical instructors include:

• solidifying their knowledge base
• stimulating learning
• deepening their understanding of disease
• developing new therapies and research opportunities
• increasing productivity
• growing and developing clinical materials and programmes with the help of the students

The benefits for the clinical education healthcare site include:

• development of continuing education and professional growth for the staff
• understanding the clinic's areas of clinical strengths and areas for improvement based on the student's evaluation

Students benefit from clinical education by:

• experiencing various practice settings and patient populations to determine their best fit for employment
• having the opportunity to apply their knowledge and skills from the classroom to the clinical context
• practising in an environment that allows them to grow their professional abilities outside of patient care by providing presentations

Challenges with clinical placement involve both clinical educators and clinical sites and include:

• setting up expectations and goals for the student
• finding space for the student to practice
• setting aside time to meet and discuss progress and goals with the student
• maintaining additional paperwork
• preparing patients for interactions with students

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.