A Comparison of Productivity and Learning Outcome in Individual and Cooperative Physical Therapy Clinical Education Models.

Health care professional education programs attempt to produce competent practitioners. Learning in the clinical setting, therefore, should maximize the students' program of study. The purpose of this study was to conduct a program evaluation designed to evaluate productivity and learning outcomes in individual and cooperative clinical education experiences.

Attainment of optimal educational objectives may not always be feasible given the trend to rationalize spending for health care and higher education. Strategies that make wise use of resources are necessary to overcome fiscal challenges. Cooperative learning, where multiple students engage in collaborative practice as part of their professional development, has been suggested as a viable method of promoting learning.[1-7]

In individual learning experiences, students are encouraged to develop their competency individually, usually under the direct supervision of a single clinical instructor (CI). This is often viewed as a resource-intensive training experience, and it is has been argued that it also encourages students to rely on experts to have their questions answered.[3,6] We believe that this reliance on experts is incongruent with the collegial interdependence required in the professional work situation. Lynch[7] argued that the extensive use of expert-centered teaching interferes with the students' opportunities to develop their own resources. She further contended that students do not learn to interact effectively or to deal with the anxieties that disagreements produce. According to Johnson and Johnson[8] the most logical way to emphasize collegial interdependence among learners is to structure learning situations cooperatively.

In spite of these criticisms of the individual learning experience, we believe that there are benefits to this "apprenticeship" style of teaching and learning that cannot be ignored. For example, students are required to perform independently and to make individual decisions, which are requirements for autonomous professional practice. By combining opportunities for both cooperative and individual learning, however, an opportunity may exist to enhance the completeness of the professional development experience.

Cooperative Learning

"Cooperative learning," in many ways, is a "catch-all" phrase for group learning. For example, Topping noted that "CO- means together, in company, jointly, in common, equally, mutually, reciprocally, while OPERATE, means to work, act, influence, effect, accomplish, cause, or carry out. From these options, 49 definitions of cooperative may be generated."[9](p151) Johnson and colleagues[8,10,11] used the term "cooperative learning" to describe principles of group learning. Bruffee, in contrast, used the term "collaborative learning" and defined it as a "reacculturative process that helps students become members of a knowledge community."[12](p.3) "Peer learning" is another term used to describe group learning, and it has been described in great detail by Lincoln and McAllister.[6] They also referred to terms such as "peer tutoring," "peer teaching," "peer review," and "peer evaluation." For the purposes of our research, the term "cooperative learning" is used broadly, even though many of these definitions would be appropriate for describing multiple student learning experiences in the clinical setting. For example, in a cooperative learning experience, students would tutor and teach one another, review each other's work, and perhaps even be involved in evaluating each other's work. This cooperative or collaborative approach is encouraged by developing joint goals for the learning team and encouraging them to share each other's knowledge and experiences.

Bandura[13,14] provided a useful framework or theory for cooperative learning. He described 3 kinds of reinforcement that influence learning outcomes: (1) direct external reinforcement, (2) vicarious reinforcement, and (3) self-administered reinforcement. Under direct external reinforcement, people regulate their behavior on the basis of the consequences they experience directly. Vicarious reinforcement is the result of observing the experiences of other people. Self-administered reinforcement involves regulating a person's own behaviors according to standards. Bandura also stated that modeling is a large component of the teaching function. Modeling is the process by which a person observes the behaviors of other people, forms an idea of the performance, and uses the information to guide further behaviors.[13,14] Cooperative learning, therefore, provides rich opportunities for modeling and the 3 types of reinforcement described by Bandura.

Johnson and Johnson[8] also emphasized the importance of congruent goal structures in cooperative learning. Goal congruency exists when students perceive that they can obtain their goals only if the other students with whom they are linked obtain their goals as well.[11,15] This cooperative learning incentive is quite distinct from the goal structure in the individual learning experience in which a student's achievement is unrelated to the goal achievement of other students.[8,11] Ensuring that these goal structures are in place is important because they influence the cognitive and affective outcomes of learning and determine the nature of student interaction.[16]

Studies of Cooperative Learning

Several reviews of cooperative learning have appeared in the literature.[8-11,15,17] These reviews, which focus on primary and secondary education, provide evidence supporting cooperative learning. The reviews illustrate that the successful mastery, retention, and transfer of concepts, rules, and principles is higher in cooperative learning situations than in individual or competitive learning situations. A meta-analysis conducted by Johnson et al[11] further suggests that cooperative learning appears to promote higher achievement than does competition or individual efforts for all age groups. Outcomes appear to be further enhanced when peer tutoring is encouraged.[9,17]

In peer tutoring, peers help their peers to learn. One peer plays the role of the teacher or leader while the other peer becomes the tutee or subordinate.[6] Traditional definitions of peer tutoring suggest that the more able students help the less able students in cooperative pairs carefully organized by their instructor.[9] More contemporary dyadic tutoring models, however, suggest that there is no need for an ability differential.[9] Both approaches appear to yield strong benefits for both the tutor and the tutee.[9] Students may also reciprocally coach one another throughout a conjoint learning experience. They both play the role of the tutor and tutee.[9]

Lynch[7] noted that cooperative learning strategies appear to be particularly effective for high-level cognitive outcomes such as identification of concepts, analysis of problems, judgment, and evaluation. Costello[18] also found that learning occurs among peers as part of a "hidden curriculum." This hidden curriculum consists of information and knowledge that are shared or constructed by others. Claims by students that they were taught more by other students than by instructors and ward personnel have been reported.[4,19]

With respect to professional practice, the achievement of specified objectives or outcomes among learners engaged in cooperative learning experiences has been reported.[1,4,20,21] Iwasiw and Goldenberg[4] studied peer learning among nursing students who were learning to change surgical dressings. They measured cognitive and psychomotor gains due to peer teaching versus gains due to teaching by instructors. Cognitive gains were higher for the peer group.

DeClute and Ladyshewsky[1] compared the clinical competency scores of physical therapist students in a cooperative learning placement with the scores of physical therapist students in an individual learning placement. Clinical competency scores of the cooperative learning group were higher for all performance dimensions (eg, patient evaluation, communication, treatment, professional behavior). The bulk of studies on cooperative learning in the health sciences, however, tend to be qualitative or descriptive in nature.[3,5,6,18,22-24] Their focus was on describing the social, affective, and learning benefits of cooperative clinical education learning experiences.

Clinical reasoning may also be facilitated through the use of cooperative learning.[25] Clinical instructors may not always be available to assist students in developing their clinical reasoning competencies. Time pressures and heavy workloads may make it difficult for the CI to explore clinical reasoning in action with the student.[26] Cooperative learning strategies can be used to relieve the CI of some of this responsibility as students can engage in these discussions themselves.

Not all studies or reviews of cooperative learning, however, have described its benefits, even though the negative results appear to be in a minority of the reports.[15,27-29] One argument is that many of the studies are laboratory based and lacking in external validity. Another perspective is that it is the sharing of answers, not any emergent property of group interaction, that explains the increased productivity of groups in problem-solving experiments.

Another component of cooperative learning that is of particular interest to health sciences educators and clinicians is that the use of multiple-student-single-instructor models has the potential to offer clinical facilities more in terms of patient care productivity.[2,30] This possibility is explored in the next section.

Student Productivity and Clinical Education

Ladyshewsky et al[31] have stated that calculating the costs and benefits of a clinical education program is complex and, more often than not, adequate analytical methods are lacking. Numerous methods, differing sample populations, and institutional practices make comparisons across studies difficult, if not impossible. For example, cost-benefit studies have used the following indices to evaluate the cost benefit of clinical education programs: amount of time staff spend on student supervision,[30-35] number of patients treated and number of treatments provided,[36-42] amount of actual time spent in patient care activities,[2,30-33,36,38,39] and revenue generation,[37,39] Ladyshewsky et al[31] argued that the most important indicator is net productivity. Focusing purely on the costs of staff time to supervise students[34,35] is inappropriate because it ignores the fact that patient assessment and treatment are often occurring concurrently.[43]

For the most part, studies in physical therapy provide evidence that clinical education programs lead 10 net productivity benefits for the institution,[32,33,36,37,39-42] Graham et al[39] have pointed out, however, that length of placement is a critical factor in determining whether a net positive benefit will accrue. Furthermore, Graham et al illustrated how other variables such as year level of the students, waiting lists, staff shortages, and case mix can also influence productivity. In most of the studies on the costs and benefits of clinical education programs, individual learning experiences were used.[30] Only a few studies have investigated the productivity dimension of cooperative learning or group placements.[2,30,38] The results of these 3 studies[2,30,38] indicate the net productivity benefits of having multiple students, which exceed the normal productivity levels of the supervising CIs (without students). Exploring the cooperative learning experience in more detail, from the dimensions of both quality of learning and productivity, was the focus of our study.

Method

In order to explore these 2 dimensions further, the Clinical Education Quality Audit (CEQA) tool was used.[44] This tool is designed to measure student and CI time in patient care, administration, and teaching activities and closely parallels the principles underlying the Canadian workload measurement system for physical therapy.[45] Similar methods have been used by other investigators[30-32,36,38] to study the impact of clinical education programs on institutional productivity in physical therapy.

The CEQA tool was developed in 1995 and 1996 by Ladyshewsky and Barrie at Curtin University of Technology, Perth, Western Australia, Australia, to evaluate the quality of clinical learning experiences. This process involved conceptualization; pilot testing on 2 occasions with physical therapists and students in acute care, aged care, and community-based facilities; developing CEQA software to analyze the results of the audits; and testing the CEQA software. The first pilot test sought the participants' perspectives on layout of the forms, instructions, definitions, and time required to complete the tool. Where necessary, the appropriate revisions were made to the tool. The second pilot test used the revised format and was implemented with 23 physical therapy supervisors and their 20 students in 18 different clinical agencies. An individual learning experience was used in this pilot test. Data were subsequently analyzed using the CEQA software.

The CEQA tool consists of 2 parts. Part A is a time sheet that is designed to capture data on workload productivity. Clinical instructors record information on the following activities: time spent in patient care, time spent in student supervision, time spent in other activities, and total paid work time per day. Students record information on time spent in direct patient care and time worked per day. Time is recorded to the nearest 5 minutes. Students and CIs were responsible for recording the amount of time spent in each of these categories, per day, for the duration of the placement. Data were then summarized using the computer application that supports the CEQA tool. The mean amount of time spent in each category per hour worked is the format in which the data are reported.

Part B of the CEQA tool deals with student and supervisor perceptions of the teaching and learning experience. Twelve learning process statements, derived largely from the literature on best practice in clinical teaching,[46-55] were designed to assess the quality of the teaching and learning experience. These statements are anchored on a 9-point Likert scale, with 1 being a negative outcome (disagree) and 9 being a positive outcome (agree). The learning process statements survey the following themes in clinical education: orientation, discussion of roles and expectations, goal setting, support from university and clinical facility, nature and quality of feedback, supervision, and learning opportunities. The following is an example of the statements in part B of the CEQA: "The roles of the student(s) and the supervisor were negotiated so that both parties had a clear understanding of their needs and expectations." In our study, the students and CIs completed part B at the end of the placement. The mean and standard deviation for each learning process statement were reported by the CEQA software.

All CIs volunteered to participate in the study. Students were assigned to their placements by the Academic Coordinator of Clinical Education according to the guidelines of the academic program. No specific matching strategies were undertaken. There was no requirement to complete parts A and B of the CEQA, and subjects and CIs were free to abstain from submitting this information to the investigators. Participants were ensured of anonymity in any reports or publications that emanated from the study.

Two audits were undertaken using fourth-year physical therapist students at Curtin University of Technology. The physical therapy program is a 4-year undergraduate program leading to the Bachelor of Science degree. Placements were for 4 weeks' duration, with students engaged in clinical practice for 30 hours per week. In the first part of the study, we used the pilot test data obtained from the individual learning placements for 23 physical therapy CIs and 20 fourth-year students. This audit took place during the first semester of the students' final year of undergraduate study. All data for these subjects were included in the data analysis. In the following year, the cooperative learning experience was evaluated. The physical therapy audit involved 9 CIs and 18 students. This audit also took place during the first semester of the students' final year of study. In one facility, 2 students did not fill out the CEQA forms, so data for this cooperative learning team are not reported. In 2 other cooperative learning teams, only 1 of the 2 students completed the CEQA forms. In these cases, the data for the student who did respond were entered twice as the next best measure. In the end, 8 CI data sets and 16 student data sets were used to calculate the cooperative learning productivity data. A description of the facilities that participated in both audits, with the specific specialty areas and numbers of students assigned to that area, is presented in Table 1.

Table 1. Facilities Involved in Program Evaluation(a)

Type of Experience                            Number

Individual learning
  Teaching hospitals: adult > 500 beds        3
    Cardiopulmonary (3)
    Neurology (3)
    Neurology outpatients (1)
    Outpatient orthopedics (2)
    Inpatient orthopedics (1)
    Burn unit (1)

  Tertiary hospital: pediatric                1
    Pediatrics-general (1)

  General hospital: < 500 beds                3
    Outpatient  orthopedics (2)
    Gerontology (1)

  Community-based agency                      5
    School-based therapy service (1)
    Home therapy service: pediatrics (1)
    Pediatric treatment center (1)
    Extended care facility: gerontology (1)
    Outpatient orthopedics center (1)

Cooperative learning
  Teaching hospital: adult > 500 beds         3
    General surgery (2)
    Cardiothoracic surgery (2)
    Neurology (2)
    Intensive care unit (2)
    Spinal cord rehabilitation (2)

  General hospital: < 500 beds                2
    Women's health (2)
    Gerontology (2)
    Outpatient orthopedics (2)

(a) Numbers in parentheses indicate actual numbers of students assigned to that clinical rotation.

At the end of each experience, the CIs completed another audit of their workload productivity when there were no students present. This baseline period occurred anywhere from 1 week to 2 months after the initial student placement audit, depending on when the environment was free of students. These audits provided us with a measure of the productivity at these facilities when no students were present. The data obtained in these audits served as a baseline for comparing the impact of individual and cooperative learning practices on normal operational practice. These baseline audits were conducted for 1 week. The data were then multiplied by 4 to create an equivalent comparison period for the student placement periods.

The CIs' paid work hours were standardized to 7 1/2 hours, as were the work hours of the students. On the 2 days when the students spent only a half day in the clinic, work hours were standardized to 4 hours. All data from parts A and B of the CEQA was subsequently entered into the CEQA software program by a research assistant. This software program was specifically developed for this audit system using Excel 5.0 for Macintosh.(*)

Results

The productivity results from part A of the CEQA are reported in 5 categories: mean CI time spent in patient care, mean CI time spent in supervision, mean CI time spent in other activities, mean facility patient care productivity, and mean overall facility productivity. The Appendix provides a more detailed description of these categories. Time is also reported as a fraction of an hour; for example, a value of 0.25 is equivalent to 15 minutes, a value of 0.5 is equivalent to 30 minutes, and so on.

Table 2 provides a summary of the productivity changes in the individual learning experience. The "baseline" column reports the CIs' mean productivity during the baseline period in both the "patient care" and "other activities" categories. Two separate student periods are reported. The "student period 100%" column combines the actual CI and student data. The "student period 60%" column combines the actual CI data and modified student data. Fourth-year students, in the first semester, are expected to be able to manage a 60% caseload by the end of their placement. The student data in this column, therefore, are reduced by a factor of 40% to account for the students' inefficiency. This reduction factor was selected by the investigators. It has been used in 2 other studies[30,33] and parallels the university's clinical education program guidelines on caseload expectations.

Table 2. Productivity Data for Individual Learning Experience: Students and Clinical instructors (CIs)

                        Baseline

                        % of    Actual
                        Work    Minutes per
Data Set                Hour    Work Hour

CI patient care time    0.78    47
CI other activities     0.25    15
CI supervision time     NA(b)   NA
Student direct care     NA      NA
Facility patient care
  productivity          0.78    47
Overall facility
  productivity          1.03    62

                         Student Period 100%

                         % of    Actual
                         Work    Minutes per   % of
Data Set                 Hour    Work Hour     Change(a)

CI patient care time     0.63   38            -19.1
CI other activities      0.23   14             -6.7
CI supervision time      0.16   10            NA
Student direct care      0.57   34            NA
Facility patient care
  productivity           1.20   72            +53.2
Overall facility
  productivity           1.43   86            +38.7

                        Student Period 60%

                        % of    Actual
                        Work    Minutes per   % of
Data Set                Hour    Work Hour     Change(a)

CI patient care time    0.63    38            -19.1
CI other activities     0.23    14             -6.7
CI supervision time     0.16    10            NA
Student direct care     0.34    20.5          NA
Facility patient care
  productivity          0.97    58            +23.4
Overall facility
  productivity          1.2     72            +16.1

(a) % of change=percentage of change from baseline to student period: actual minutes.

(b) NA = not an applicable measurement.

As shown in Table 2, there was a reduction in the CIs' mean time spent in patient care (19.1%) and in the CIs' mean time spent in other activities (6.7%) during the student placements. The additional patient care time provided by the students, however, resulted in an overall mean patient care productivity increase of 53.2% for the facilities (23.4% if the prorated factor is considered).

Table 3 provides a summary of the productivity changes in the cooperative learning experience. The "baseline" column reports the CIs' productivity during the baseline period in both the "patient care" and "other activities" categories. There was a drop in the CIs' mean time spent in patient care (47.7%) and an increase in the CIs' mean time spent in other activities (31.3%) during the student placements. The additional patient care time provided by the students resulted in an overall mean patient care time increase of 27.3% for the facilities (there was a reduction of 1.0% in overall patient care productivity if the prorated factor is considered).

Table 3. Productivity Data for Cooperative Learning Experience: Students and Clinical Instructors (CIs)

                        Baseline

                        % of    Actual
                        Work    Minutes per
Data Set                Hour    Work Hour

CI patient care time    0.73    44
CI other activities     0.27    16
CI supervision time     NA(b)   NA
Student direct care     NA      NA
Facility patient care
  productivity          0.73    44
Overall facility
  productivity          1.00    60

                        Student Period 100%

                        % of   Actual
                        Work   Minutes per   % of
Data Set                Hour   Work Hour     Change(a)

CI patient care time    0.39   23            -47.7
CI other activities     0.35   21            +31.3
CI supervision time     0.31   19            NA
Student direct care     0.55   33            NA
Facility patient care
  productivity          0.94   56            +27.3
Overall facility
  productivity          1.29   77            +28.3

                        Student Period 60%

                        % of   Actual
                        Work   Minutes per   % of
Data Set                Hour   Work Hour     Change(a)

CI patient care time    0.39   23            -47.7
CI other activities     0.35   21            +31.3
CI supervision time     0.31   19            NA
Student direct care     0.33   20            NA
Facility patient care
  productivity          0.72   43             -1.0
Overall facility
  productivity          1.07   64             +6.7

(a) % of change=percentage of change from baseline to student period: actual minutes.

(b) NA = not an applicable measurement.

The Figure summarizes the results of Tables 2 and 3 graphically. Each column represents the mean proportion of time spent in the various activities that make up a work day. Each column is expressed in minutes per work hour and illustrates the differences in how time was spent in the individual and cooperative learning experiences. In both experiences, the students generally provided the same mean level of patient care. What differed between the 2 experiences from the perspective of the CIs was the time spent in student supervision and other activities. In the cooperative learning experience, the CIs spent more time in supervision and other activities. Both learning experiences illustrate, however, that the total amount of time spent in patient care during the student period exceeded the time spent in patient care during the baseline period.

[Figure ILLUSTRATION OMITTED]

Table 4 shows the students' and CIs' responses with respect to teaching and learning processes. These are descriptive summaries. In the individual learning experience, only minor differences between the 2 groups were reported. The students' ratings showed more variation than did the CIs' ratings. For the most part, however, both the CIs and the students were in relative agreement about the learning processes that they believed occurred in the individual learning experience.

Table 4. Teaching and Learning Process Scores(a) for Individual Learning (IND) and Cooperative Learning (CL) Placements

                                   CI(b)            Students
                                   (IND Model)      (IND Model)

Summary of Question                [bar] x    SD    [bar] x    SD

 1. Orientation to facility and
    staff                          7.91      1.38   7.35      1.76
 2. Roles and expectations of
    all parties negotiated         6.83      1.47   6.00      2.13
 3. Discussion of student
    learning goals                 6.52      1.68   6.10      2.20
 4. All parties aware of
    university requirements        7.43      1.56   6.35      2.03
 5. Support available to
    student(s) from CI,
    university, and staff          7.57      1.67   7.25      1.45
 6. Balanced feedback provided
    to student(s)                  7.43      1.50   6.55      2.35
 7. Feedback based on data
    collected through
    observation                    7.09      1.53   7.10      2.15
 8. Collegial and nonthreatening
    relationship between all
    parties                        7.87      1.39   7.45      1.93
 9. Students were encouraged to
    discuss theory and practice
    of physical therapy            7.70      1.29   6.95      2.48
10. Self-evaluation by the
    student(s) was encouraged      6.78      1.78   7.05      1.76
11. Balance of supervision
    provided independence and
    support                        7.22      1.41   6.60      2.30
12. Adequate clinical learning
    opportunities available        6.83      1.56   6.95      2.14
Total                              7.27      1.52   6.8       2.06

                                                    Students
                                   CI (CL model)    (CL Model)

Summary of Question                [bar] x    SD    [bar] x    SD

 1. Orientation to facility and
    staff                          7.11      1.69   7.81      1.17
 2. Roles and expectations of
    all parties negotiated         5.89      1.69   6.06      2.49
 3. Discussion of student
    learning goals                 6.11      1.36   5.94      2.29
 4. All parties aware of
    university requirements        6.44      2.01   5.88      2.68
 5. Support available to
    student(s) from CI,
    university, and staff          7.22      1.72   7.38      1.59
 6. Balanced feedback provided
    to student(s)                  6.89      1.45   6.44      3.03
 7. Feedback based on data
    collected through
    observation                    7.11      1.69   7.31      1.82
 8. Collegial and nonthreatening
    relationship between all
    parties                        6.78      1.48   7.94      1.69
 9. Students were encouraged to
    discuss theory and practice
    of physical therapy            6.78      1.56   8.13      0.89
10. Self-evaluation by the
    student(s) was encouraged      6.67      1.32   6.94      1.69
11. Balance of supervision
    provided independence and
    support                        7.11      1.83   7.31      2.24
12. Adequate clinical learning
    opportunities available        6.44      2.35   7.81      1.38
Total                              6.71      1.68   7.08      1.91

(a) Scores anchored from 1 = disagree (negative outcome) to 9 = agree (positive outcome).

(b) CI = clinical instructor.

Discussion

In the cooperative learning experience, there appears to have been more of a contrast between the CIs' views and the students' views in 3 categories. Students found the collegial relationship provided by the other students and the nonthreatening atmosphere to be much more positive features of the cooperative learning experience. Opportunities for discussion about the theory and practice of physical therapy were rated more positively by the students in the cooperative learning experience. Lastly, there appeared to be more learning opportunities in the cooperative learning experience. All 12 learning process statements taken as a whole, however, suggest that students and CIs are in relative agreement about the cooperative learning experience.

In both the individual and cooperative learning experiences, there is a cost to facilities in terms of staff productivity. This cost is the time spent in student supervision. In the cooperative learning experience, the cost is greatest because more of the CI's caseload is delegated to the 2 students and more time is spent in student supervision. These costs, however, can be offset if overall patient care, rather than time spent in student supervision, is used as the criterion for productivity. In both the individual and cooperative learning experiences, the unadjusted overall mean facility productivity increased. This finding is in keeping with other data on productivity and clinical education programs.[2,30,32,33,36-42] A greater increase (expressed as a percentage of change) in mean overall patient care productivity occurred in the individual learning experience, whereas a greater mean increase in the percentage of time spent in other activities occurred in the cooperative learning experience.

The productivity changes that occurred in our study may be somewhat unique to our particular sample of students, CIs, facilities, and country. The extent and nature of the productivity changes that occur emanate from the actual teaching and learning practices that are used. For example, in the individual learning experience, 2 people (instructor and student) provide approximately 15 person-hours per day to manage the caseload. In the cooperative learning experience, approximately 23 person-hours per day is needed to manage the caseload, which means that at least the same caseload can be managed by a larger number of people over the course of the day. The availability of more person-hours per day should result in more time for supervision and other activities, which is what occurred in the cooperative learning experience.

Although the individual learning experience produced a greater percentage of gain in patient care productivity, we believe that this type of experience will not always result in greater time spent in patient care than during the cooperative learning experience. The majority of facilities in this study were hospitals. Inpatient services were the source of most of the data. Most hospitals have finite inpatient caseloads, in part because the number of beds in the facility is generally fixed. During the cooperative learning experience, there may be time to manage this patient load as well as other teaching, learning, and administrative activities. In the cooperative learning experience, the CI-student team may not necessarily be able to become more productive because the patient complement is fixed, unless students pick up patients from other areas of the hospital outside of their specific assignment. If our study had examined outpatient departments with large waiting lists, we might have seen a greater increase in patient care productivity. Such large productivity gains using the cooperative learning experience in outpatient facilities have been reported.[2]

The teaching and learning process evaluation suggests that CIs view the cooperative learning experience perhaps slightly less favorably than they do the individual learning experience, with mean overall ratings of 6.71 and 7.27, respectively. This lower rating may be based on a traditional conception of teaching and learning by CIs. The lower rating for the cooperative learning experience may also be related to the therapists' uncertainty in managing students within this different supervisory, experience. Further training and development in multiple-student supervision may be necessary to improve the CIs' feelings toward cooperative learning. Some authors[8,11,15] have argued that, for a successful cooperative learning experience to occur, appropriate task and goal structures need to be put into place by the educator. Understanding these concepts, therefore, may help CIs to become more confident in their role.

The trend toward lower ratings in the cooperative learning experience by CIs may also emanate from a role conversion that may occur. Clinicians may not like being removed from their "hands-on" duties. In the cooperative learning experience, CIs gave up, on average, 46% of their caseload to the students. This caseload delegation was much higher than what occurred in the individual learning experience. This higher caseload delegation put clinicians into a greater supervisory role, which may have been uncomfortable. Ash and Quarry[56] have stated that new supervisors often are uncomfortable with their new supervisory responsibilities, particularly if they are accustomed to functioning in an operating mode. In our study, however, we did not collect data that would allow us to determine whether this outcome actually occurred. In-depth qualitative investigations that examine CIs' feelings about multiple-student supervision would overcome this limitation of our study.

The fact that CIs held on to more than half of their caseload, even though they had 2 students present to assist them, may have led to difficulties in managing the cooperative learning experience. Had they delegated more of their caseload to the students, they might have been able to spend more of their time supporting the students. Greater caseload delegation may have improved their attitudes toward the cooperative learning experience, but again we lack data to prove that this was true. The extent of caseload delegation has been shown to be a variable that influences the outcome of the cooperative learning placement.[5,30]

In contrast to the CI perspectives, students rated the overall cooperative learning experience just slightly higher than the individual learning experience, with mean overall ratings of 7.08 and 6.8, respectively. Opportunities to engage in joint problem solving, case discussions, and collegial support appear to be particularly positive features of the cooperative learning experience for students. These outcomes are not surprising and are described in great detail in reports of studies of cooperative learning in clinical education.[3-6,18,22,23,30,57,58]

The results of our study also suggest that students have a positive impact on patient care productivity regardless of whether it is an individual or cooperative learning experience. This finding is in keeping with previous research.[2,30,32,33,36-42] The argument that students are a cost to the facility at which they are trained, therefore, should be tempered because this outcome does not necessarily appear to be the case in all circumstances. Both types of learning experience appear to be suitable from a productivity standpoint, provided the students have the adequate skills at the time to manage the patients and the placement is of adequate length.[39] The cooperative learning experience appeared to provide some additional learning benefits that were not as prominent in the individual learning experience (ie, joint problem-solving activities, opportunities for clinical reasoning discussions on the theory and practice of physical therapy, and a more collegial and nonthreatening learning atmosphere).

There are limitations to our study, and further research is needed. In this study, we measured only productivity and teaching and learning processes. Further studies are needed to determine how individual learning experiences versus cooperative learning experiences influence the students' level of clinical competency. We did not attempt to measure the quality of patient care that was provided by the students. An increase in the amount of patient care does not necessarily mean that there is an increase in quality. The mix of time spent in patient care activities also was not evaluated. For example, the number of patients seen per hour or per day and the amount of time spent in assessment versus treatment across the individual and cooperative experiences would be worthy of further investigation. More complex computer and data analysis systems are also needed for this type of analysis and reporting. Although this level of data would be useful, it also requires more recording time and would stress CIs and students, who often feel under pressure in the clinical environment.

Our study, because it was a program evaluation study, also had several methodological limitations, in particular, the collection of data. The use of different clinical environments introduces variables that cannot be controlled. Two different sets of students and CIs across 2 years also influences the integrity of the data. Ideally, the same set of students and CIs provides for better control but is unrealistic in actual practice. The numbers of participants in the cooperative learning experience was also small and influenced the generalizability and statistical feasibility of conducting intensive analyses of these results. Furthermore, the student data had to be adjusted in the cooperative learning experience to compensate for the 2 students who did not complete part A of the CEQA. Lastly, the data in this program evaluation are reported on a collective basis using mean results. What occurs at a specific level in a specific clinical specialty is lost in the analysis. It is possible, for example, that some areas experience a loss in productivity regardless of which experience is utilized.

Conclusion

This program evaluation has examined the productivity and learning benefits of the individual and cooperative learning experiences. Although both types of learning experience appear to offer a variety of benefits, it would seem that the cooperative learning experience offers some additional benefits from the perspective of students. Further CI training in multiple-student supervision and shifts in attitudes toward clinical education may also be needed to encourage more widespread use of the cooperative learning experience, which appears to offer greater productivity and teaching and learning benefits.

(*) Microsoft Corp, 1 Microsoft Way, Redmond, WA 98052.

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Appendix.

Description of Categories

Mean CI(a) patient care time is the total amount of time spent in patient care. Patient care is defined as the amount of time spent in direct patient care and indirect patient care activities (eg, things that support the direct care of the patient such as charting, team meetings). Time spent observing a student providing patient care is not recorded in this category.

Mean CI time spent in other activities is the total amount of time spent in all other work-related activities.

Mean CI supervision time is the total amount of time spent in student-related activities such as orientation, observation of students, discussion, evaluation, reviewing documentation, giving feedback, and writing and presenting evaluation reports.

Mean facility patient care productivity is the sum of mean CI patient care time and mean student direct patient care time. This latter category is defined as evaluative or therapeutic activities administered by the student in the presence of a patient. This evaluative or therapeutic activity can occur in situations where the student is working independently or under the direct supervision of a CI.

Mean overall facility productivity is the combination of mean CI patient care time, mean CI time spent in other activities, and mean student direct patient care time.

(a) CI = clinical instructor.

RK Ladyshewsky, MHSc, BMR (PT), is Lecturer and Clinical Coordinator-Development, School of Physiotheraphy, Curtin University of Technology, Selby Street, Shenton Park, Western Australia ([e-mail]), and Honorary Research Associate, Faculty of Health Sciences, University of Sydney, Sydney, New South Wales, Australia. Address all correspondence to Mr Ladyshwesky at the first address.

SC Barrie, BSc(Hons), is Lecturer, Centre for Teaching and Learning, University of Sydney.

VM Drake, MSc, is Lecturer and Clinical Coordinator, School of Occupational Therapy, Curtin University of Technology.

This study was approved by the Ethics Committee of Curtin University of Technology.

This article was submitted April 25, 1997, and was accepted August 27, 1998.