Assessing the need for change in clinical education practices. (Perspective).

Physical therapists work in a health care climate of increasing complexity and rapid change, of fiscal restraint and demands for accountability, of scrutiny from both internal and external sources. In such a climate, the ability to respond appropriately to these pressures is critical, not only for professional growth but also for professional survival. New generations of physical therapists emerging from professional programs require more than a solid foundation of clinical skills. In our view, they require an educational foundation that is reinforced with attitudes and skills that will enable them to build their profession as well as their own professional practice. These attitudes and skills are believed to include the desire to engage in lifelong learning and professional growth and an ability to identify and critically evaluate their own practice and the underlying theories and perceptions that inform the practice of physical therapy. (1)

We contend that clinical education, in which students engage in learning in the context of clinical practice, is the best area in which such skills and attitudes can be taught and refined. Through a consistent and effective approach to the clinical education process, we believe it is possible to influence the formation of these attitudes and skills and, by doing so, have an impact on the future of the profession. In this article, we explore several aspects of the clinical education process, including needs and proposed models of clinical education. The primary focus of the review will be the literature in physical therapy, but perspectives from occupational therapy, speech-language pathology, and adult education also will be addressed. Although critical analysis is not the focus of the discussion, reference will be made to the relative strength of the research studies cited. Critical appraisal is based on the checklist for primary research developed by Bury and Mead? Position statements and anecdotal information characterize much of the literature in this area. These publications do not lend themselves to such formal ratings, but they make important contributions to our collective understanding of the clinical education process. The discussion concludes with implications for future clinical education research and practices in physical therapy.

Needs

We believe that a consistent and effective approach to clinical education requires a guiding philosophy that is clearly communicated, understood, and embraced by all the groups and individuals involved in the clinical education process. Cranton and Kompf (3) addressed the dichotomy between adult education and health care professions training and recommended against developing educational philosophies for these disciplines in isolation. They contended that theory building for education in the health care professions requires an interdisciplinary and holistic approach in order to fully address the needs of students as adult learners. This approach would involve consideration and inclusion of interdisciplinary perspectives from the various health care professions, as well as adherence to foundational principles from cognitive psychology, developmental psychology, and adult education.

Opacich, (4) from the perspective of occupational therapy, asserted a need for a carefully worded, clearly understood vision for the profession and its process of clinical education. An historical review of clinical education in occupational therapy highlighted the need for a continuity of professional vision to serve as a framework and a source of accountability in clinical education, particularly as a profession changes and develops. She claimed that "the essential ingredient missing in the fieldwork solution is a well articulated educational philosophy that could link the tenets of occupational therapy with a viable, ideationally compatible fieldwork model." (4(p160)) This same need exists in physical therapy.

Two research groups have addressed the importance of cultivating nontechnical skills during the clinical education process. Higgs and colleagues (1) briefly described an exploratory study from which they developed a list of 14 goals of clinical education in the health care professions. The goals were derived first from their analysis of the literature, then they were revised through 2 consecutive surveys of clinical educators in Sydney, Australia, (90 participants) and Hong Kong (15 participants). The goals included the following: (1) an awareness of health, holistic health care (ie, health care that addresses the multidimensional needs of the client), and the health care system; (2) awareness of one's attitudes, values, and responses to health and illness; (3) a broad understanding of the roles of the health care team, (4) interpersonal skills and the ability to educate others effectively; (5) the ability to critically evaluate personal and professional practice; and (6) accountability and commitment to continued development of competence and lifelong learning. Also included were competencies such as clinical reasoning, psychomotor skills, examination, treatment and evaluation, integration of theory and practice, and an ability to articulate rationales for treatment. The list of goals revealed clinical educators' awareness of the complexities of clinical practice and a desire to foster reflective practice and critical thinking to effectively cope with these complexities. A well-designed qualitative study (5) further indicated the importance of cultivating nontechnical competencies during the clinical education process. Using the critical incident technique, the researchers explored some of the factors underlying inadequate clinical performance of students during their clinical experiences. Thirty-three clinical educators discussed specific incidents in which they had questioned the competence of students. Of the incidents described, more than half involved behaviors that the researchers believed reflected inadequate nontechnical skills such as poor communication and unprofessional behavior.

Schon, (6) writing about reflective practice, also discussed the need for developing nontechnical competence. Schon wrote of the tension between rigor, or technical rationality, and relevance, found in acting in the complex, uncertain world of practice. He argued that the most important areas of professional practice lie beyond the commonly understood areas of technical competence, and he stressed the need for artistry as well as technical excellence in practice. He articulated the need to challenge previous assumptions, to embrace uncertainty and ambiguity as opportunities to deepen and broaden learning, and to pursue a holistic grasp of the practice. In this approach, multiple perspectives and solutions to problems are valued. Schon's approach to practice has been incorporated in much of the literature on clinical education, (7-11) but that perspective is reportedly adopted less consistently by clinical educators and students. (7,10) An absence of common philosophy for clinical education may contribute to an inconsistency of approach to clinical supervision. Several researchers compared students' perceptions of physical therapy clinical education with those of clinical educators (12) and with academic faculty. (13,14) That research revealed that stakeholders differ in some of their perceptions of appropriate roles and power sharing in the supervisory relationship and of approaches to facilitating learning. Students, therefore, may fail to experience the continuity of approach in their practica that would optimize their acquisition of the attitudes and skills required for life-long learning.

Contributing to what we believe is an inconsistency of approach is inadequate preparation of clinicians for the important and complex role of clinical educator. Expertise in clinical practice does not imply expertise in clinical education. Many authors (8,14-16) agree that specific preparation for becoming a clinical educator is necessary. Walker and Openshaw (17) surveyed one cohort of 22 physical therapy clinical educators and 43 students and described their responses. Because those clinical educators lacked formal education in this area, they often learned the role primarily by trial and error. (17) The need for instruction in clinical education is addressed in the United States through the American Physical Therapy Association (APTA) Clinical Instructor Education and Credentialing Program. In addition, APTA has developed Guidelines and Self-Assessments for Clinical Education to clarify roles, responsibilities, and expectations, allowing both sites and clinicians to determine readiness for involvement in clinical education. (18) These voluntary programs may also address clinical educators' expressed desire for improved communication with academic teaching programs and other clinical educators. (17)

Cross (15) wrote of the need for quality assurance in clinical education, recognizing the critical role of clinical education in the development of competent professionals who value lifelong learning. Cross explored various perspectives on quality, in which emphasis is placed either on the product of clinical education, as indicated by training outcomes, or on the process of clinical education, as it relates to students learning to be lifelong learners. A process of quality assurance would be optimally feasible with the adoption of a widely shared philosophy of clinical education and with implementation of formal educational practices around the preparation of clinicians for assuming the role of clinical educators. An important example of the profession's readiness to develop more uniform practices in the area of clinical education is the recent development of Clinical Performance Instruments (CPIs) by APTA for use in evaluation of physical therapist and physical therapist assistant students. (19)

A concern expressed in the literature is the belief that students and new practitioners often perceive an inconsistency between theory and practice, (10) According to Steward, (10) they fail to make connections between course work and fieldwork, between different areas of practice, and between different forms of knowledge used in academic and clinical practice. Such separation of theory and practice may result from inadequate development of skills in reflection and theory building within their placement settings. (10) This may reflect a limited awareness, on the part of both clinical educators and students, of the importance of reflection in identifying, analyzing, and reworking theories to improve practice.

A practical need that is identified repeatedly in the literature is that of finding adequate resources for clinical education. (20-23) We believe the current climate of health care, with growing fiscal and time constraints, creates a growing tension between provision of appropriate patient care and provision of clinical education experiences for students. There are some issues that may affect the willingness or ability of facilities or clinical educators to offer student placements. Funding cutbacks have resulted in site closures and staff layoffs. We believe that when there is excessive attention to cost reduction in clinical facilities that have a service-only mandate (ie, no educational mandate), providers may not accept the extra "burden" of student placements. There is mounting evidence to suggest that students are not a liability, at least not insofar as amount of patient service is concerned. (21,24-27) However, in our view, many administrators and clinicians still perceive students as detractors from the amount and quality of care. As education programs in the United States and Canada move toward graduate degree entry level, there may be some apprehension on the part of clinical educators with an undergraduate degree who are expected to provide supervision for graduate students. In addition, reimbursement for student services has become an issue. In the United States, it was decided by the Health Care Financing Administration that reimbursement would occur only under Medicare A and not under Medicare B or in private practice settings. (28) Limitations in the number of sites for clinical education, reductions in staffing, administrative policies, staff attitudes, and reimbursement practices, in our view, necessitate creative and innovative approaches to accommodate clinical education while maintaining acceptable levels of productivity and quality of care.

According to the literature, there are numerous philosophical and practical needs to be studied and addressed in the area of clinical education. There is a need for a common philosophy of clinical education, encompassing both the process and the product of the clinical education experience. (4) A second need is to develop a commitment to ongoing reflective practice and lifelong learning among professional (entry-level) therapists. (1,5-11) There is a need for greater consistency in the approach to establishing mutually beneficial supervisor-student relationships throughout the clinical education experience. (12-14) Additionally, many clinicians have expressed the need for formal preparation and training to more adequately fill the role of clinical educator. (8,14-17) A process of quality assurance in clinical education to assess and, if necessary, enhance the consistency and effectiveness of the clinical education process is needed. (15) A sixth need is for greater emphasis on facilitating the connection of theory and practice in the clinical education setting. (10) Finally, there is a need to effectively accommodate students in a health care environment with increasingly limited resources.

Models

The literature contains descriptions of models for clinical education and of more specific methods and tools to enhance implementation of an effective clinical education process. Collectively, the models address many of the needs we discussed above. Individually, they are limited in their ability to meet the diversity of needs. A comparative overview of these models is presented in the Table. The following discussion will explore 10 models and methods for clinical education as described in the literature and will address their potential for meeting the current needs of physical therapy clinical education. Discipline-specific models will be discussed first, followed by transdisciplinary and interdisciplinary models.

Collaborative Model

Several researchers explored the process and outcomes of collaborative placements in physical therapy clinical education. DeClute and Ladyshewsky (20) provided a thorough overview of collaborative placements, with the term "collaboration" referring to 2 or more students being supervised concurrently by a single clinician. The clinician delegates most or all of his or her caseload to the students and devotes time to facilitation of learning among the students. (20) The rationale for such placements is multifaceted. The limited availability of placements for clinical education can make this option appealing, as more students can be accommodated. In theory, skills of teamwork and collaboration can be developed, and effective learning can be enhanced in collaborative placements. (20) In DeClute and Ladyshewsky's retrospective study, (20) 38 matched pairs of students in traditional and collaborative placements were compared. Higher outcome scores on standardized clinical competence evaluations were found among students who had collaborative placements. The authors suggested that reasons for this difference included the benefits of peer learning, in which the emotional safety and stimulation of consistent interaction with peers allowed for improved problem solving, enhanced self-esteem, and a positive attitude toward learning.

In another retrospective study, (21) the researchers compared workload productivity among clinicians with no students, one student, and more than one student. They also compared learning outcomes between students in traditional and collaborative placements. Productivity, as defined by time spent in patient care, student supervision, and other activities, during the clinical placements was higher than when no students were present. No differences in productivity were apparent between the 1-student and 2-student models. The researchers also reported higher learning outcomes for students involved in collaborative placements as opposed to traditional placements. Students in the collaborative placements rated their opportunities to discuss theory and practice and the adequacy of their learning experiences more positively than did the students in traditional placements. By contrast, clinical educators' evaluations of the learning and teaching process were lower for the collaborative placements than for the individual placements. The authors suggested that these findings may reflect clinician preference for a more traditional approach, in part because of their lack of familiarity with the collaborative process. There has been some discussion (29) of situations in which more than 2 students are supervised concurrently by a single clinician; however, the efficacy of those situations has not been thoroughly studied.

In a qualitative study of 3 collaborative placements, (30) factors that enhanced or interfered with collaborative placements were identified through limited observation, one-time interviews, and student journals. Positive aspects of these placements included enhanced communication and learning as peers interacted and collaborated. The observations indicated that the clinical educators experienced less stress than they did with traditional placements and believed they developed their clinical knowledge and management skills. Disadvantages perceived by participants included decreased time and attention for individual students, the potential for negative interpersonal dynamics among the students, and difficulty with differing skill and knowledge levels. The authors made several suggestions as a result of their study. They argued that caseloads should be gradually increased and should combine collaboration among students and independent treatment. They also contended that, if possible, students should be paired according to similarity in experience and that other staff should be prepared to assist with managing the caseload shared by the clinical educator and student at the beginning of the placement and upon its completion when students leave.

A collaborative model of clinical education, therefore, may address the following needs. More students can be accommodated in clinical sites, and there may be increases in productivity at these sites. The process and product of clinical education may be enhanced through increased dialogue and the reflection made possible by the presence of peers. Connection of theory and practice may be facilitated through this communication and reflection. The collaborative model of clinical education seems particularly promising in its potential to address a number of the needs identified in the literature.

Mastery Pathway Framework

The development and implementation of a framework for guiding, monitoring, and evaluating clinical competence in clinical education was described by Old-meadow. (31) The rationale for development of the framework was twofold: to assist clinicians with organization of the clinical education process and to improve consistency and reliability of supervisory assessment of the students. The framework employed principles of progressive mastery, individual pacing, and part-to-whole sequencing. It was established on the basis of guidelines that had been developed by several national bodies of physical therapy in Australia (ie, the Australian Physiotherapy Association, the Physiotherapists Registration Board of Victoria, and the Australian Council for Overseas Physiotherapists). These guidelines were designed to define standards of competency in new graduates.

Progress from dependent to independent practice is monitored and evaluated in 5 areas of the SOAPE system, which, when adapted for this purpose, involve the following: Subjective, Objective, Analysis, Action, Plan, and Education. These components, with the exception of analysis, are further divided into cognitive, manual, and affective components, each of which is defined. A grid pathway is used to depict areas of progress and of weakness. Evaluation of competence is done on a weekly basis after the midpoint of the 4- to 6-week placement, with scores in each category allocated from a range of 0 for maximum supervision to 5 for proficient independence. The stages of progressive mastery are defined, beginning at novice and progressing through the stages of advanced beginner, competent practice, proficient, and expert. Progression involves not only increasing independence in practice but also improved flexibility, ability to analyze and problem solve through reflection and discussion, an increasingly holistic view of the clinical picture, and development of a proactive rather than a reactive stance to practice.

This method of work-based assessment addresses a number of needs and was developed around a guiding philosophy and defined goals. Work-based assessment is intended to allow increased consistency in approach and evaluation of clinical education. The framework should help streamline the formal and informal evaluation process and to guide discussions and goal setting, thus addressing limitations of time. This may help students to better bridge the theory/practice gap, through delineating and connecting the different aspects of clinical reasoning and practice. In addition, the framework should enhance students' ability to self-evaluate and reflect, which in turn should strengthen their skills and attitudes for lifelong learning. The thorough evaluation form also could be utilized for quality assurance.

Problem-Solving Model

A method to improve the problem-solving abilities of physical therapist students was developed from the literature and from clinical educator input, and its effectiveness was evaluated with a small (N=31) pretest-posttest control group design. (32) The method consisted of an analytic questioning sequence for problem solving that addressed patient examination, problem identification, and treatment planning. The Watson-Glaser Critical Thinking Appraisal (CTA) was used to determine the effectiveness of the problem-solving model with 16 first-year physical therapist students during their first formal clinical practicum experience. In the authors judgment, the CTA was deemed to be a suitable instrument for assessment of a problem-solving model. (32) Students were required to apply the questioning sequence to 5 prepared case studies and to a case with which they were actually involved during their clinical experience. The cases were discussed first with their clinical educator and later with peers. The clinical educators had been provided with strategies to assist students with effective use of the questioning sequence through facilitative questioning and discussion. Members of the control group only wrote individual case studies.

Quantitative analysis, which omitted 3 low outliers from the experimental group, failed to reveal a difference in CTA scores between the groups. Several factors may have contributed to this, including the fact that these were beginning students with limited clinical exposure, there was inadequate time to complete the follow-up CTA, and the CTA may not have been an appropriate instrument for this study. Feedback, however, from students and clinical educators who used the analytical questioning model was positive. They also believed the model was beneficial in promoting effective, logical problem solving. Increased discussion with the clinical educators was also identified as a positive aspect of the model.

This method facilitates the application of theory to practice through use of a structured framework. It helps students follow a sequence of data collection and hypothesis formation. The structure contributes to consistency of vision and approach. The focus is purely anticipatory, however, as the model fails to address how well the students reflected on their chosen interventions and outcomes. These aspects would also need to be addressed in the context of the clinical setting, possibly with other tools such as interactive journals, which are used to develop, record, and encourage dialogue about students' reflections. (11) Such tools promote an enhanced understanding of learning processes such as reflection and critical thinking, and they help students and clinical educators identify learning needs.

Integrative Model

Some authors (10,33) have described what they believe are the processes and benefits of interactions between educational programs and clinics in the context of clinical education. Three models for intervention between educational programs and clinics were outlined in which the gap between theory and practice was perceived to be bridged by occupational therapy students' applied research in the context of a clinical setting. (33) One model, developed at Dalhousie University, involved senior students. Clinicians generated research questions and submitted them to the research practicum coordinator at the university. Students were provided with theoretical training in research and were then able to choose a research question that interested them. Their final clinical placements were held at the facility from which that particular question originated. Prior to this placement, the students developed a proposal that was submitted for ethics review at the university. Implementation of the study and collection of the data were done during the placement. Students were instructed to spend only 20% of the time in their placement conducting the study. Following completion of the placement, students analyzed and wrote up the results of their study. The project culminated in a formal presentation of their research in conference format. The authors did not report whether publications followed. Although the descriptions of this model were thorough and informative, evaluation of the effectiveness of this model in achieving the projected outcomes was not reported.

We believe the implications of this model are substantial. As established and new practitioners engage together in a form of what we would consider scientific inquiry, we believe a changed approach to practice and research is facilitated, but data are lacking to support that contention. Through the process of research, students, in theory, could act as a bridge between theory and practice and between academic educators and clinicians. It seems unreasonable to expect that through this process students would gain a deeper appreciation of the importance of research, the continuity of theory and practice, and a process for lifelong learning. A generation of students adequately equipped to be researching, critically reflecting practitioners and lifelong learners could have a strong impact on the culture and future of the profession.

Multiple Mentoring Model

Nolinske (23) proposed a theoretical model of supervision that involved several clinicians in the course of a student's placement at a particular site. This model expanded on the collaborative model previously described in that 2 or more students were supervised by 2 or more clinicians. The rationale for such a model lies in what are perceived as the diverse needs of students as they develop clinical skills and professional attitudes and identities during their clinical education experience. According to Nolinske, these needs are primarily met through the development of meaningful relationships. Nolinske defined a mentoring relationship as an interactive relationship between mentor and protege in order to provide information, role-modeling, wisdom, and emotional support. The process of developing a mentoring relationship was described as complex, requiring emotional commitment by both participants and considerable time and effort. The author also identified a continuum of peer relationships developed by students in their professional education. According to the author, there are information peers, who are primary sources of information, collegial peers, who provide encouragement and support in both personal and professional areas, and special peers, with whom rapport and emotional connections are established.

These relationships may be developed with clinical educators and other clinicians at the site, as well as with academic faculty and peers. Because we believe one individual cannot effectively fill all of these roles, several individuals share the responsibility of mentoring several students. In this structure, clinicians assume a mentoring role in which they are particularly strong, either coordinating the overall process or sharing expertise in an area of practice or theory. No single clinician has sole responsibility for the students' development. Students also are encouraged to establish meaningful peer relationships and to use each other as resources.

Clear communication and consistency among students and mentors, in our view, are critical in such a model. Theoretically, a learner-centered approach helps unify the diverse perspectives and approaches of different clinicians by focusing on the goals and learning needs of the students. Expectations for goals and processes in the placement, in our opinion, must be clearly understood by both mentors and students. Regular meetings are believed to be necessary to facilitate such communication. One mentor can assume the major responsibility of overseeing the process. Learning contracts (34) and journals (7,11) could also contribute to the development of communication skills and consistency.

There are potential benefits to this model for both the students and the mentors. Through involvement with more clinicians and students during fieldwork, students could develop a diversity of relationships, experience a range of perspectives and approaches, identify appropriate role models, and benefit from the unique strengths and interests of a number of individuals. Of course more role models will not necessarily be better role models. It seems safe to assume that students, for the most part, can distinguish good role models from bad role models. In theory, they would be equipped to assume responsibility for their learning and seek out appropriate resources to meet their individual needs. This process could enhance skills and attitudes of lifelong learning. A learner-centered approach by the mentors also could lead to greater consistency in implementation of the clinical education process, but, in our opinion, this would require adequate clinical educator training and support. Mentors might experience less stress from responsibility and time pressures and would be able to share their particular strengths and interests in the context of the mentoring relationship. This model could help make efficient use of potentially scarce resources of staffing and time through the flexibility and creativity inherent in the structure, but again data to support these assertions are lacking.

Continuum of Supervision

A model of "dynamic" supervision for speech-language pathologists, in which change takes place in the roles of students and clinicians, was proposed by Anderson. (35) She suggested that the supervisory relationship ideally should progress through 3 stages, moving from the evaluation-feedback stage, through the transitional stage, to the self-supervision stage. The roles of supervisor and student, in her view, should gradually change in identifiable and predictable ways with progression through these stages. At the evaluation-feedback stage, when the student has little competence in a particular area, the educator assumes an active role of teaching, guiding, and modeling, and the student takes on a more passive role while seeking to meet the educator's expectations. The goal at this stage is to move on as quickly as possible in order to encourage the student to become more actively involved in learning. The transitional stage involves a collaborative process between educator and student as responsibility for decision making is supposed to be increasingly shared. Gradually, the supervisory relationship can begin to approximate colleagueship. At the self-supervision stage, the student, in theory, has become sufficiently independent to rely on the educator primarily for consultation. At this stage, the student is supposed to effectively self-analyze and seek assistance and resources when appropriate. For the most part, educator and student are meant to interact as peers at this time.

Although we believe most clinical educators affirm the need for changes in the supervisory relationship, Anderson (35) contended that the supervisory interactions that most consistently characterize clinical educators in speech-language pathology are the ones that typify supervisory behavior with students in the evaluation-feedback stage. Some students may contribute to this phenomenon with their tendency to remain passive in the learning process. We argue that it is important to encourage students in their professional growth by encouraging them to assume increasing responsibility for their clinical experience. If clinical educators were aware of the need for such a dynamic process of supervision and were able to recognize their tendency to remain at the evaluation-feedback level, greater consistency and effectiveness in facilitating student learning could be possible. Students who are encouraged to engage in such a process of increasingly self-directed learning could develop skills for critical self-evaluation and lifelong learning.

Reflective Model

Mandy (9) proposed a model of clinical education in speech-language pathology that is supposed to emphasize the importance of reflection in learning from experience. A structure was outlined in which the interaction between the student and clinical educator focuses on facilitating reflection to encourage learning. The intent of the process was to encourage students to connect theory and practice and to engage in consistent and intentional self-evaluation and professional growth.

Two conceptual models were merged to form this reflective model: the "Goldhammer cycle" of supervision (36) and a reflective learning model. (37) Phases of the supervision cycle were described. Prior to observation of the student by the supervisor, a conference is held in which the intent is to establish an understanding of the supervisory model and of both participants' roles and expectations, to identify and discuss the student's previous experiences, to discuss plans for client management, and to discuss the need for the development of a relationship of mutual respect and trust. Observation of student-client interaction, in which the supervisor collects descriptive data, is the next phase. Analysis and strategy follow. Student and supervisor independently make notes on the examination or intervention session with the patient or client in preparation for later discussion of issues that arose from the session. The supervisor attempts to construct questions that will help the student reflect on the experience. Student and supervisor then meet for the supervision conference, in which the student revisits the experience and recalls not only events but also emotional reactions to these events. In turn, the events and emotions of the session are analyzed in terms of their impact. Negative emotions can inhibit effective learning and thus need to be recognized and dealt with; positive emotions can enhance learning and thus need to be recognized and used to confirm sound clinical decisions.

Re-evaluation of the experience follows. This re-evaluation involves the following progression: (1) associating new knowledge and feelings with previously acquired knowledge and observations, (2) integrating relationships between old and new knowledge to form hypotheses, (3) attempting to validate these hypotheses by anticipating their practical application, and (4) appropriating this new information into the student's working knowledge base. Boud and colleagues (37) stated that this appropriation may not occur in every learning cycle but is likely to occur when the new learning is perceived by the learner as meaningful. It likely would not occur during the conference but would be more likely to occur by testing this new knowledge in the context of practice. Post-conference analysis is the last phase of the supervisory cycle. At this time, student and supervisor reflect on the cycle to determine whether the goals of process and learning were met.

The issue of time constraints in the clinical education setting was acknowledged by Mandy, (9) and she emphasized the importance of the quality of learning experiences rather than their quantity. She suggested flexible use of the model, contending that the level of the learner's experience and the learner's individualized goals would guide application of the model. Through the structure of this model, effective learning is not left to chance but is intentionally facilitated and enhanced. Theoretically, students who have engaged in this process will have begun to learn the skills of reflection that will equip them to pursue professional careers of lifelong learning. The reflective process should facilitate the connection between theory and practice. The clear framework for the supervisory conference is designed to increase the consistency of philosophy and approach to the learning process by clinical educators, but again data are lacking as to whether this is achieved.

Educator-Manager/Self-Directed Learner

A conceptual, transdisciplinary model that encompasses the entire process of clinical education planning, implementation, and evaluation was proposed by Higgs. (8,38) Higgs (8) first described the roles of the clinical educator as manager and of the student as self-directed learner. Based on principles of adult learning and self-directed learning, she viewed the clinical educator's role as facilitator and manager of learning rather than as teacher. This facilitation is dynamic and individualized, depending on the student's "learner task maturity" or readiness for a particular task. She contended that, when maturity is low, more structure for facilitation of learning is provided. As the learner demonstrates greater maturity and ability to be self-directed, there can be increased opportunities for co-management, which could encourage students to take greater responsibility for their learning. Interdependence rather than independence is supposed to be facilitated by effective interaction among participants. She suggested that a collaborative model of clinical education could create opportunities for such group collaboration.

Higgs presented a framework for the broader management of clinical education programs, (38) based on the context, input, process, product (CIPP) model of management proposed by Stufflebeam. (39) In this model, the author attempts to address: (1) context, or the identified needs of the program, (2) input, or the intended means of implementation of the program, (3) process, or the actual means of implementation, and (4) product, or the outcomes of the program. Through comprehensive goal setting, monitoring, and evaluation of clinical education, it could be possible to address the obstacles to developing a common philosophy among clinical educators. Such an understanding might enhance the consistency of approach by clinical educators and provide data from quality assurance measures to inform ongoing improvement of the process. Students could develop skills and attitudes for lifelong, self-directed learning. Contributions from academic educators, clinical educators, students, and professional bodies at all stages, in theory, would be needed to ensure consideration of the various perspectives.

Coaching Model

An interdisciplinary model of clinical supervision derived from ideas used in business was proposed by Hagler and McFarlane. (40) Use of the term "coach" rather than "supervisor" is meant to emphasize the role of the clinical educator as facilitator of a process rather than monitor of minimal performance standards. Throughout the dynamic process of clinical education, the coach is supposed to assume various roles to appropriately assist the learner in becoming an "independent, creative, self-supervising learner." (40(p6)) The 5 coaching roles are: educator, coach, sponsor, counselor, and confronter. The first 3 roles, in our view, are appropriate for clinical educators working with learners who are progressing normally toward professional competence. We believe the latter 2 roles are appropriate for clinical educators working with learners who are offtrack and with whom the other 3 roles have failed.

In this approach, education is the first role assumed by the clinical educator when interacting with learners who are new to a particular learning situation. An environment of affirmation and support is supposed to be developed, an effort is made to identify the students' existing strengths and knowledge, and performance criteria for the placement are determined and communicated. Emphasis at this stage is on the acquisition of new skills. The second role is coaching. Students are expected to begin taking more control of their learning once basic knowledge and skills are developed. Questioning is designed to provide students with "a pathway to information" (40(p8)) that strengthens their skills and develops attitudes that promote eventual autonomy in learning. Students are challenged to take risks; mistakes are allowed and are meant to be used as sources of deeper learning. As students begin to reveal strengths and skills and to demonstrate appropriate autonomy, the coach is supposed to assume the third role, sponsoring. Opportunities for further growth are sought out, perceived barriers for performance are identified and removed, and the unique contributions of the student within the setting are recognized.

To deal effectively with problems that may arise during the course of a clinical education experience, the coach may need to assume 2 additional roles. Counseling is thought to be required when problems begin to interfere with the student's performance and education has not alleviated these problems. The coach facilitates a meeting in which the issues and concerns are identified and explored, goals and means for improvement are established, and a subsequent meeting is arranged to monitor progress. Communication skills and a positive, supportive environment are crucial for this process. Confronting is the second additional role that is supposed to be necessary when both education and counseling have failed. Decisive actions and deadlines for addressing specific problems are established and consequences for failure to follow through are determined in an effort to remove any uncertainty about expectations for performance and responsibility.

We believe that with this model the roles of the clinical educator, through the dynamic process of clinical education, are defined. It has the potential to contribute to improved consistency in philosophy and effectiveness of supervisory interactions through all stages of a student's clinical development and growth. The model is designed to develop self-directedness and to encourage students to develop skills in self-evaluation and professional growth. Additionally, in this model, the possibility of problems developing during the course of a placement is considered, and strategies to deal with these problems are offered. This focused approach to dealing with problems may help develop a sense of professional accountability in students who lack this, but again research to document our belief about the model is lacking.

Interdisciplinary Model

The need to develop competence in interdisciplinary teamwork and reflective practice was addressed in an interdisciplinary model developed, implemented, and studied by Cox and colleagues. (41) The authors developed and implemented an interdisciplinary clinical education project based on what they perceived as an emerging need for a client-centered, interdisciplinary team approach and on literature regarding interdisciplinary clinical education. Nine students, from physical therapy, occupational therapy, and speech-language pathology engaged in this interdisciplinary clinical education experience. The students were supervised by a member of their own discipline, but they also participated in interdisciplinary interactive modules. These modules were designed to increase the students' awareness of team roles and functions and to develop professional skills common to all of the disciplines. Following a member of another professional discipline during his or her clinical practice was an additional component of the experience. To assist in developing the students' reflective skills and to provide data for a qualitative study of the project, each student was required to keep a structured journal.

Qualitative analysis of data from pre-placement questionnaires, midterm and post-placement interviews, focus groups, and the journals revealed a number of themes. It was perceived that clients benefited from a more comprehensive, client-centered approach to treatment that resulted from students' improved interdisciplinary insights and understanding. Students reported that their professional development and communication skills were enhanced in the context of this placement. One disadvantage identified by the students was a loss of direct treatment time. Physical therapist students and supervisors in particular found this problematic. More time for development of clinical skills was thought by the students and supervisors to be important. Writing journals was perceived as tiresome and time-consuming by both students and supervisors. According to students, the discipline-specific assessments of clinical competence did not adequately address the important interdisciplinary and teamwork skills that were developed in this placement.

The clinical education experience provided by this model could help to develop skills in connecting theory and practice, in reflection and dialogue, and in collaboration with other members of the health care team, but whether it does must await further research. Cox et al (41) emphasized the importance of developing skills in reflection to assist with self-evaluation and to promote learning from experience. Some of the students' and supervisors' more negative responses to this model indicated a resistance to setting aside the time necessary for such reflection. We argue that a strong emphasis on technical skills in professional education should not overshadow the development of the nontechnical skills. Some authors (6,42) contend that such an imbalance would provide an inadequate foundation for practice in the current health care climate. According to Cox et al (41) and Shepard and Jensen, (42) the development of attitudes and skills for reflection should begin in an academic setting and then be further developed in the clinical setting. We contend that such consistency in philosophy between academic and clinical education settings is important for the development of openness to reflective practice. The model of interdisciplinary placements provides a structure that could enhance development of reflective professionals with attitudes and skills that will enable them to pursue learning throughout their professional careers.

Emerging Themes

From these diverse models and methods, a number of themes arise. The theme of process within the clinical education experience is emphasized in the models of mastery pathway, the continuum of supervision, reflective practicum, and coaching. A focus on the development of nontechnical competencies such as communication, collaboration, and reflection is evident in the collaborative, reflective practicum, educator-manager/ self-directed learner, and interdisciplinary models. The theme of collaboration within the clinical education process arises frequently; this may involve multiple students, clinical educators, disciplines, and clinics/universities. The collaborative, integrative, multiple mentor, educator-manager/self-directed learner, and interdisciplinary models reflect this theme. The importance of the roles established and relationships developed between clinical educators and students is acknowledged in the multiple mentor, continuum of supervision, educator-manager/self-directed learner, and coaching models. The problem-solving model alone is supposed to emphasize the development of a cognitive process. The developers of the models thus attempted to address a wide range of important areas of need within the clinical education process.

Implications

The literature demonstrates that, although there are numerous needs to be addressed in the area of clinical education, a wide range of possibilities for meeting these needs exists, but there are few data to show what does and does not achieve goals. In fact, the choices could be overwhelming. How is one to choose the most effective approach to meet the challenges of clinical education? This choice might be made easier through the development of clear goals for clinical education and for the process to be followed in achieving these goals. Given clear objectives for the clinical education process and appropriate frameworks to guide progress, clinicians should be able to choose the models and tools that will allow them to achieve these goals within the unique context of their setting. It probably is desirable to have a number of models to test and evaluate until we can determine which one is best suited to the user's own situation and to gather data about the effectiveness of each.

It is our belief that the choices relevant to an effective approach for clinical education should be considered within the context of professional education curriculum design. Professional programs can use the information presented to guide the development of activities that integrate the academic and clinical education experiences. It is possible that more than one model may inform the curriculum development choices, thereby ensuring institutional autonomy. For example, aspects of the integrative, problem-solving, and reflective models may help to define specific activities within the curriculum such as identifying the "best evidence" in support of interventions applied during the clinical placement or the involvement of clinicians as tutorial leaders, but only research can confirm our contention. This type of curriculum integration also may serve to strengthen the partnership between professional programs and the Clinical Instructor Education and Credentialing Program. It is also possible that information from the self-assessments included in the APTA Guidelines for Clinical Education could inform curriculum development that would further enhance quality academic and clinical learning experiences, although the guidelines have never been studied as to whether they have a benefit.

Higgs' description of the CIPP model (38) provides one framework for analyzing clinical education needs, which could inform the selection of appropriate models. The context evaluation of intended outcomes involves a process including all of the stakeholders in clinical education: local and federal professional associations, clinicians, faculty members, and students. The input or program design is identified from the context evaluation and could include the provision of a formal education process for clinical educators. The goals of clinical education could then be clearly communicated, and potential models and tools for accomplishing these goals could be provided. This theoretically not only would allow for greater consistency in approach, but also could bring clinical educators together to allow for collaboration and mutual support. Process involves the monitoring of the actual implementation of the clinical education process. This could be done both externally, through a formal evaluation of the process, and internally, through intentional reflection by the clinical educators and students. Product is assessed through a retrospective evaluation of the outcomes of clinical education to determine whether the goals of process and product were achieved. Through such a focused approach to clinical education, the possibilities for excellence in clinical education and, subsequently in professional practice, would not be left to chance but would be nurtured and developed.

Needs for Research

There is a need to determine and clearly articulate specific goals to guide the development and evaluation of the clinical education process in physical therapy. Qualitative research to determine these goals and quantitative research to establish their generalizability and to test their efficacy are needed.

The literature provides many theoretical frameworks and suggestions to improve the clinical education process. To utilize these frameworks and suggestions appropriately, however, we believe it is necessary to clearly understand both the goals and the existing process of clinical education. Although there are a number of articles that report perceptions of the current process according to clinical educators, students, and faculty members in physical therapy, (12-14) there is a paucity of research to identify and understand the processes occurring in clinical education or the potential effects of using new models.

A qualitative approach, such as grounded theory or focused ethnography, could be used to identify the most salient features of the current clinical education process. Research may focus on developing an understanding of issues such as the roles assumed and relationships developed by clinical educators and students, the degree to which the clinical education process is variable, the presence and effects of reflection within the clinical education setting, and components of the learning process and learning outcomes. We believe that once there is a clearer understanding of the present status of clinical education, strategies for improving the process can be suggested, implemented, and evaluated. For example, it should be feasible to develop tools with which to measure the important aspects of clinical education such as the supervisory relationship; amount, type, and style of student learning; and their impact on quality of service. Once we have developed measurement tools, it will be possible to assess the effects of experimental intervention. Research will enable us to study the impact of supervisory relationships and models on student learning and quality of care.

Summary

Collectively, the 10 clinical education models described may offer many valuable guiding principles and potential ways of structuring the clinical education process in physical therapy. Unfortunately, none of them alone addresses all the needs of clinical education. Without a clear understanding of the current status of clinical education, the needs of the profession remain uncertain, and there are few or no data to support the use of any model. We argue that there are many excellent clinical educators and positive clinical education experiences, but at present this may be due more to clinicians' intuition and natural abilities as educators than to their effective, consistent approach to the clinical education process. We propose that a combination of qualitative, descriptive, and experimental research can illuminate the multidimensional nature of the process. Findings could then guide development of one or more models that satisfy the potentially unique needs of physical therapy clinical education while accommodating the diversities associated with factors such as personal and environmental contexts.

Table.
Comparative Overview of Needs Met by Each Model (a)

                          Need

                                                  Consistency
                          Common       Lifelong   of Learning
Model                     Philosophy   Learning   Relationship

Collaborative                          [check]
Mastery pathway           [check]      [check]    [check]
Problem solving           [check]      [check]
Integrative                            [check]
Multiple mentoring                     [check]
Continuum                 [check]      [check]    [check]
Reflective                [check]      [check]    [check]
Educator-manager/
  self-directed learner   [check]      [check]    [check]
Coaching                  [check]      [check]    [check]
Interdisciplinary         [check]      [check]

                            Clinical
                            Educator      Quality     Theory to
Model                       Preparation   Assurance   Practice

Collaborative                                         [check]
Mastery pathway             [check]       [check]
Problem solving             [check]                   [check]
Integrative                 [check]                   [check]
Multiple mentoring
Continuum
Reflective
Educator-manager/                                     [check]
  self-directed learner                   [check]
Coaching
Interdisciplinary           [check]                   [check]

                              Maximize
Model                         Resources

Collaborative                 [check]
Mastery pathway               [check]
Problem solving
Integrative
Multiple mentoring            [check]
Continuum
Reflective
Educator-manager/
  self-directed learner
Coaching
Interdisciplinary

(a) This comparative overview reflects the authors' analysis only.

All authors provided concept/project design, writing, and consultation (including review of manuscript before submission).

This article was submitted May 8, 2000, and was accepted June 14, 2001.

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J Strohschein, PT, BSc, is a second-year graduate student in the Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Alberta, Canada.

P Hagler, PhD, SLP, CCC, is Associate Dean, Graduate Studies and Research, Faculty of Rehabilitation Medicine, 3-48 Corbett Hall, University of Alberta, Edmonton, Alberta, Canada T6G 2G4 ([e-mail]). Address all correspondence to Dr Hagler.

L May, PT, PhD, is Assistant Professor, Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta.