Invited Commentary.

In this study, the authors addressed a very timely and important issue in physical therapy education. This is also a topic about which there is very little literature. If we, as a profession, want to maintain viable clinical education programs, we should be responsive to the changes in the health care environment and the pressures on clinical instructors (CIs) without sacrificing the quality of the patient care rendered and the educational experience. Ladyshewsky and colleagues used an innovative approach to clinical education, a 2:1 model, to look at 2 pieces of the clinical education equation, which includes the patient, the facility (including the CI), the student, and the academic institution. They used the data that they collected to examine (1) productivity, a dimension that is increasingly important to the facility, and (2) learning processes that have an impact on the student and the CI.

In this article, the authors have chosen to use the terms "cooperative learning" and "collaborative learning" interchangeably. Although the literature[1-3] describes these terms slightly differently, the emphasis throughout all of the descriptions is on the outcomes that can be achieved when the students are given opportunities and responsibilities to work together to achieve common goals. This is an important issue to remember when designing collaborative learning experiences. According to Gandy, "Merely placing two or more students together during a clinical experience does not connote cooperative or collaborative learning experiences. Specific components must be present for small group learning to be cooperative and collaborative."[4] Some of these components might include an atmosphere where the CI serves as a facilitator, not a teacher. The CI may also have a diminished caseload so that his or her energies can be directed toward the clinical experience. The students should be encouraged to use each other to brainstorm, share ideas, and solve problems and should be responsible for both individual and common goals. The excellent literature review in this article carefully reviews the benefits of these models of education.

To determine the effect of the 2:1 model of collaborative clinical education on quality of learning and productivity, Ladyshewsky and colleagues used the Clinical Education Quality Audit tool (CEQA). This tool, not commonly used in the United States, attempts to quantify dimensions of clinical education and offer us some perspectives on the important dynamics of a high-quality clinical education program.

The outcomes of a well-designed cooperative learning educational experience that may be sought include increased productivity, increased student self-confidence in decision making, improved ability to work with colleagues to solve clinical problems, and a tangible product that can enhance the quality of services available at the facility. In the study by Ladyshewsky and colleagues, there was an increase in both the individual and cooperative learning experiences. The overall mean facility productivity increased, based on the combined efforts of the student(s) and the CI. These data should interest those individuals who fear that clinical education will have a negative impact on their productivity and, therefore, their overall profits. This is apparently a reward for those individuals who plan a well-designed clinical education experience. In my opinion, however, increasing productivity should not be used as the sole reason to develop a clinical education program.

In the individual learning experience, it took 2 people--the CI and the student--15 person-hours per day to manage the caseload. In the cooperative learning experience, it took 23 person-hours to manage the same caseload. Based on the data collected by the CEQA, we can determine how much time the student(s) spent providing direct patient care. The data also allow us to examine how the CI divided his or her time. The one additional piece of information that is not provided is how much time the student spent in joint meetings or working with the other student and the CI. From these numbers, one could infer that the 3-person team of the CI and 2 students spent an additional 8 hours per day (approximately 2.6 hours per person) collaborating on activities that either directly included the patient or revolved around other facility-related activities. I believe that the role of the CI in the collaborative learning model is to facilitate learning, not to teach. I believe that it is this additional time that allows the emphasis to be placed on creating an environment conducive to collaboration. The students should be able to use the additional time to reap the benefits that the authors previously described, not focus on how many more patients they can see in a day.

Another dimension of collaborative learning that is often addressed[5,6] is the need for the group to have an identifiable, measurable goal. The authors did not mention whether the students were asked to generate a product (eg, in-services, patient education materials). These activities can provide another opportunity for collaboration while offering the facility a useful product and enhancing overall productivity of the unit.

The data on the perceived benefits of the collaborative learning model, that the students rated the experience higher than the CI did, did riot surprise me. The research that Ladyshewsky and colleagues cite suggests that student outcomes are improved when compared with a more traditional approach. We should consider these findings regardless of the health care climate. For the CI, however, surrendering his or her caseload to assume the role of "facilitator of learning" can, in my experience, be a difficult transition. I contend that the CI must use new strategies of student supervision, and this can be uncomfortable and initially time consuming. Ladyshewsky and colleagues did not mention whether the CIs involved in this study had been students in a 2:1 collaborative model or had received training in using a collaborative learning model in clinical education. These factors could have affected the CIs' perceptions. Although there are clinicians who have begun to explore new ways of providing clinical education, these innovative models are not yet in widespread use. The current American Physical Therapy Association Clinical Instructor Education and Credentialing Course includes information on alternative models of clinical education (Department of Education, American Physical Therapy Association, 1998). This training should provide the credentialed CI with the groundwork to create a learning environment that fosters the important elements of cooperative learning.

Clinical education is at a crossroad. The demands that the health care environment is placing on our delivery system, coupled with the increased need for high-quality clinical education sites, should encourage all of us to be creative in meeting the challenges that are ahead of us. We can no longer continue with the status quo. Ladyshewsky and colleagues have done an excellent job of enlightening us on the benefits of an alternative model of clinical education, from the theoretical support that the literature provides to cooperative learning to the data to show that there can be a positive outcome for the facility and the student.

References

[1] Brufee KA. Sharing our toys: cooperative learning versus collaborative learning. Change. 1995;27:12-18.

[2] Matthews RS, Cooper J, Davidson N. Building bridges between cooperative and collaborative learning. Change. 1995;27:35.

[3] Web site maintained by Cooperative Learning Center, University of Minnesota. Available at: http://www.clcrc.com.

[4] Gandy J. Preparation for teaching in clinical settings. In: Shepard KF, Jensen GM, eds. Handbook of Teaching for Physical Therapists. Newton, Mass: Butterworth-Heinemann; 1997.

[5] Cusea J. Cooperative learning versus small-group discussions and group projects: the critical differences. Cooperative Learning and College Teaching. 1992;2(3):5-10.

[6] Instructional Innovation Network. Available at: http://www.eminfo.emc.maricopa.edu/innovation.

Babette S Sanders, PT Instructor Program in Physical Therapy Northwestern University Medical School Chicago, IL 60611