Margaret M. Plack, PT, DPT, EdD and Maryanne Driscoll, PhD
After reading this chapter, the reader will be prepared to:
- Differentiate between learning in the classroom and learning in the clinical setting.
- Recognize the complexity of teaching and learning in the clinical setting.
- Relate the concepts of apprenticeship learning and communities of practice to learning in physical therapy practice.
- Recognize the challenges that students face while learning in the clinical setting.
- Differentiate between personal meaning making and shared meaning making.
- Appreciate the importance of dialogue in the negotiation of shared meaning.
- Apply the concepts of communities of practice to designing effective teaching and learning experiences in the clinical setting.
STOP AND REFLECT
- In what ways does learning in the clinic differ from learning in the classroom?
- In what ways does teaching in the clinic differ from teaching in the classroom?
As we know from previous chapters, teaching and learning in the classroom is much more complex than simply standing up in front of an audience lecturing and hoping that the audience will absorb the content. Similarly, teaching and learning in the clinic is also much more complex than simply matching a student and clinical instructor (CI) and having them work together with patients. One of the reasons why teaching and learning are so complex in the clinical setting is because one expectation of clinical education is that the learner will develop a unique professional identity, which is much more than just accumulating knowledge and skills, assimilating core values, or even simply applying their knowledge and skills to patient care. As we have tried to do throughout this text, in this chapter we provide you with a framework to help you recognize the complexity of the clinical teaching environment so that you can both engage in and design effective teaching and learning situations within the clinical setting.
This chapter emphasizes the development of professional behaviors and the affective domain as these behaviors become even more critical as students begin to interact with patients and other professionals. Professional behaviors, including communication and interpersonal skills, are emphasized because these are often the most challenging to teach and, for some, the most challenging to learn. Learning how to communicate as a professional is further complicated because some assume that communication is innate; yet, as you learned in Chapter 3, communication can be taught and is something that must be continually refined. While the focus is on communication and interpersonal skills, the concepts we present can be generalized to all aspects of learning (psychomotor and cognitive) in the clinical environment. Much of the information in this chapter is a synthesis of research and personal interviews with more than 50 students and clinicians, as well as written critical incidents from nearly another 350 students.1,2 Throughout the chapter, you will see direct quotes from students and clinicians that illustrate and reinforce the concepts being discussed. The quotes provide student and CI perspectives on how they developed their own professional identity, which is so integral to becoming a competent health care professional.
STOP AND REFLECT
Consider the following multiple-choice question:
In 1999, Hayes et al3 completed a study titled “Behaviors That Cause Clinical Instructors to Question the Clinical Competence of Physical Therapist Students.” Issues related to which of the following domain of learning do you think most often caused CIs to initially question the safety, efficacy, and overall abilities of physical therapy students?
- Cognitive skills
- Psychomotor skills
- Affective skills
PROFESSIONALISM IN HEALTH CARE
While we know that it is critical for professionals to develop a level of expertise in their cognitive and psychomotor skills, we also know this is not enough. If you think back to Chapter 5, you will remember that learning occurs in 3 domains (cognitive, psychomotor, and affective). You will also remember that Dettmer4 advocates the addition of a fourth domain: the social domain. To develop high-quality, competent, caring practitioners who have assimilated the core values of the profession, we need to facilitate development in all domains of learning.
In the Stop and Reflect above, if you selected “affective skills,” you would be correct. It is truly our affective behaviors and social skills that enable us to interact effectively with patients.5 In any health care profession, the patient must be at the heart of all that we do. Without developing the values, attitudes, and beliefs that enable us to communicate and interact professionally and effectively with our patients, clients, and other health care providers, our own professional competence may be called into question. This is particularly true when we are interacting with laypeople who may have limited knowledge of health care in general or physical therapy specifically.3,6–8
STOP AND REFLECT
Laypeople place a great deal of trust in their health care provider and often assume that, because a provider holds a license, he or she is prepared to practice.7
- What are your thoughts on the statement above?
- How do patients with limited knowledge of health care judge whether their providers are “good” or not?
- Have you ever worked with a health care provider who had a poor bedside manner? What did that make you think about the overall competence and skill of your health care provider? Did it make you feel confident in your choice of providers? If you had a choice, would you return to that provider for follow-up care?
Beliefs, attitudes, values, norms, and standards are the noncognitive behaviors that comprise the affective domain. In the eyes of some patients, these skills may be even more important than some of the more technical skills. Laypeople assume that, because you have a license, you must be a competent practitioner. So, how do they really judge whether you are good or not? How do they determine whether you are providing quality care or not? They may very well make this judgment based solely on how you interact with them (ie, on your bedside manner).7 We also live in a society of consumerism, and patients are much savvier, much more informed, and more consumer-oriented than individuals from previous generations. They know that there are plenty of very smart and very skilled clinicians available, so why work with someone who does not appear to respect them or value them as individuals? Very often, it is the behaviors in the affective or social domains (your interpersonal skills) that will set you apart from other clinicians and will place you a notch above. So, professional practice is not complete without the ability to demonstrate the attitudes, values, and beliefs established by our profession.
The Code of Ethics for the Physical Therapist, the Standards of Practice, and the Core Values9,10 of the physical therapy profession provide us with a set of expectations of professional abilities and behaviors. For some of us, these behaviors come easily; they are intuitive. Altruism, care and compassion, accountability, social responsibility, etc, are values that perhaps we grew up with and, therefore, we simply take them for granted. For others of us, these behaviors are not so simple and straightforward; they do not come so naturally. In fact, research has shown that these behaviors, while critical, have been problematic not only in physical therapy, but also throughout the medical community.11-17 It has also been shown that problems with these behaviors raise red flags for CIs. When a CI observes students having difficulty with professional behaviors, he or she often begins to question the safety and efficacy of his or her overall performance.3,15
STOP AND REFLECT
Pause for a minute and think about the following Core Values of the Physical Therapy Professiona:
- Care and compassion
- Professional duty
- Social responsibility
- What does each value mean to you?
- How would you define each value?
- How might your definitions differ from someone from another generation? From another culture?
- How might you reconcile those differences?
- How would you assess your abilities with each value?
aIf you are not familiar with the Core Values of the Physical Therapy Profession, they can be found, along with a Core Values self-assessment instrument, on the American Physical Therapy Association (APTA) website at www.apta.org/CoreValuesSelfAssessment/CaringCompassion/.
So, why has the development of professional behaviors been such a challenge in medicine and the health professions? Attitudes, values, and beliefs are abstract and complex concepts. They are more complex than what is written in the APTA Code of Ethics for the Physical Therapist, Standards of Practice, or Core Values documents. These behaviors are not technical skills, so they cannot necessarily be taught or measured objectively. Addressing issues of unprofessional behaviors or poor interpersonal skills can also feel very personal and uncomfortable at times. Finally, while we do have a set of standards and expectations in the profession, these standards are reinterpreted with subtle differences in each setting. For example, as a young physical therapist, I (MP)worked in 2 very different organizations. One organization was a very well-known rehabilitation setting, while the other was a well-known pediatric school setting. Expectations in each facility were quite different; behaviors and activities acceptable in the less-formal setting would likely not be acceptable in the more-formal setting. In addition, as noted in Chapter 1, we recognize that these attitudes, beliefs, and values are quite interconnected with our own histories, cultures, and generational experiences, making them ingrained and, at times, unconscious. Each clinical setting or community also has its own history and culture, which adds to the expectations of professionalism.
CRITICAL THINKING CLINICAL SCENARIOS
- A student routinely arrives late to clinic (ie, anywhere from 5 minutes before his first patient is to be seen to 10 after the session has begun). He always has an excuse, but he never seems to have a strategy to improve his performance.
- A student is observed reviewing a chart on a patient that was not on his caseload. When asked about it, he comments that he had overheard another therapist speaking about this patient’s illness and he was just curious and wanted to learn more. He does not recognize that his behavior violates the rules of confidentiality.
- A CI comes to her student to tell her that they need to see a patient immediately because the patient is scheduled for a procedure later in the afternoon. The student responds that she will see the patient, but this is the only break that she has so she really wants to finish her lunch first.
- What might be going on in each of these situations? Consider the perspectives of the student, the CI, and the patient.
- Limitations in which of the core values are demonstrated by each of the scenarios above?
- To address these limitations, what goals might the CI develop for the student to make the expectations more explicit?
So, how are appropriate professional behaviors learned, and how do we teach them? Very often, it is simply assumed that, by the time you come to a professional program, you should already have the attitudes, values, and beliefs needed to be a professional or that you will learn them when you get to the clinic.3,11,18,19 However, as with any other skill, these abstract attitudes and behaviors must be practiced; to perfect them, an openness and willingness to both provide and accept feedback is essential. We know, and research has shown, that academic faculty and CIs hesitate to provide adequate feedback on affective behaviors because, as noted earlier, they often consider it too personal.3,11,14,20 As instructors, be it in the classroom or the clinic, we often emphasize the cognitive and psychomotor domains of learning and minimize the importance of learning in the affective domain. Again, this may be because cognitive and psychomotor domains can be evaluated more easily and more objectively, while the affective domain requires substantially more subjectivity in evaluation. If you think back to Chapter 2, this is exactly what Schön referred to when he suggested that professional programs focused too much on technical rationalism almost to the exclusion of professional development. This is why it is so critical to develop the skill of creating objectives that incorporate all domains of learning.
As we noted, professional behaviors in the affective domain are not so easily defined, taught, or evaluated. We also know that, although passing the licensing examination gives us a certain degree of credibility, it does not guarantee that we have acquired the professional behaviors needed to become a fully functioning and competent therapist.21 We first learn about these behaviors in the abstract setting of the classroom and then we apply and continually refine them in our day-to-day experiences during our clinical internships and in clinical practice. However, as you remember, Dewey suggests that just because we have had these lived experiences does not guarantee that we will learn from them. This is particularly true now in our rapidly changing, fast-paced health care environments, where students are expected to arrive in the clinic well prepared to work collaboratively, not be a burden on their CIs, and perhaps even add to the productivity of the department. We typically expect that the students will hit the ground running as they enter the clinical setting.
THEORETICAL PERSPECTIVES ON LEARNING IN THE CLINICAL SETTING
As you will remember from previous chapters, learning is grounded in experience, and it is only through the application and interpretation of knowledge that education occurs.22,23 Kolb23 believes that learning is a cyclic “process whereby concepts are derived from and continuously modified by experience.” Remember from Chapter 1 that the cycle of learning starts with our concrete experiences and moves through reflection and observation, abstract conceptualization, active experimentation, and, finally, back to concrete experiences. It is this cycle that helps us to transform abstract academic theories into practical clinical application.24 This is particularly relevant in physical therapy and other health care professions because we not only need to develop the knowledge, skills, and behaviors essential for practice, but we must also be able to apply them in the practice setting. Clinical internships and other clinical education experiences are what provide the real-life or contextual, social, and interactive experiences that help us to translate some of the abstract theories learned in the classroom to actual clinical practice.
STOP AND REFLECT
- How do you learn what the appropriate personal space is when interacting with others? How does it feel when someone stands too close to you when conversing?
- How did you learn how you were supposed to act in the classroom in first grade?
- How did you learn about your parents’ value system regarding work, service, and education?
In thinking about some of the questions raised above, chances are that you may have indicated that you learned through observation or by listening to, and engaging in, conversation with your parents and others. Some theorists suggest that our goals, values, interests are developed tacitly—that is, we learn them essentially through osmosis! Because professional behaviors are so complex, they cannot simply be taught through explicit instruction in an academic setting; rather, they must be experienced and learned on the job, through demonstration, practice, and indirect instruction.25 In addition, as discussed earlier in this text, we know that theorists such as Schön26 and Mezirow27 believe that through the use of the reflective process we can make what we have learned tacitly more explicit and therefore more fully recognized and understood. Not only do students need to learn and assimilate the core values of the profession, but they also must learn the sociocultural expectations of each new setting.28 While Bandura29 proposes that much of this acculturation process occurs through observation within the social context, Lave and Wenger21 and Wenger30 suggest that it takes much more than simply observation and imitation; rather, to make sense of the sociocultural expectations of each new clinical environment, active engagement in practice is critical.
This is a real paradigm shift in our thinking about how we learn. We now recognize that learning, particularly in physical therapy practice, is not simply an accumulation of facts or the processing of information, but, more importantly, it is how we apply what we have learned in a given context.21,30,31 Problem-based learning, patient simulations, and the use of cases to simulate real-world problems are examples of classroom strategies that we use to create real-life situations from which we learn to think critically, reason clinically, and solve real-world problems. In contrast, clinical practice requires us to actually function within a much more complex clinical environment. So, as authentic, or high fidelity, as we can try to make a classroom scenario, it is still quite different from what occurs in real-world situations. In simulations, we often are given the problem and asked to come up with a solution; in real-world practice, we often do not even know what problem to address. In simulations, it is the instructor’s responsibility to create the problem; as students, our role is simply to solve it. In real-world practice, we own the problem, not the instructor. It is our patient who presents with a problem and it is our responsibility to first define problem and then to develop the strategies that we might use to address that problem within the context of the unique clinical scenario.
STOP AND REFLECT
- How does “learning about physical therapy” differ from “learning to become a physical therapist”?
- How does the quote “Learning to talk not learning from talk” relate to physical therapy education?
- What are the implications of both of these statements to teaching and learning in physical therapy practice?
While the differences noted earlier are substantial, perhaps the most significant difference in learning in the clinical setting vs the classroom setting is that learning takes place in a professional community of practice. Learning is no longer solely focused on gaining knowledge and skills or problem solving; rather, of equal importance is how we function effectively within the community of professionals, patients, and families. When you are in the clinical setting, you are no longer learning about physical therapy. You are learning to become a physical therapist.
If you just take a second to think about physical therapy, you will quickly realize that it is inherently a social practice and, therefore, learning must be a social process. Learning in physical therapy, or in any community of practice, is not simply the acquisition of knowledge and skills, but, rather, the development of an identity, the ability to engage, and the development of a sense of belonging within that community. Wenger30 suggests that, within a community, this process is both reciprocal and evolutionary (ie, not only does the newcomer learn from those already in practice, but those in practice also learn from the newcomer). Newcomers often add different perspectives that may actually result in changes within the community (ie, an evolution). A student learns from and adds to the community as much as the community learns from and adds to the development of the student. For example, because students are required to frequently search the literature and utilize current evidence to support their work in the classroom, they bring these skills to the clinic; simultaneously, clinicians bring years of experience to bear on how that evidence is used in a given context.
COMMUNITIES OF PRACTICE
Unlike the classroom, learning in the clinical setting is improvisational or extemporaneous. It is driven by the unpredictable real-life problems that we encounter on a day-to-day basis. These problems are embedded in the complex social and physical environment within which we practice. Perspectives on how this impacts teaching and learning have evolved over time. As noted earlier, numerous educational theorists have explored the importance of different factors in the teaching-learning situation, and, because of their efforts, effective instructional strategies in professional education today include social interactions, context, and active participation in practice.21–23,26,30,32,33
Active participation in practice is what helps students and novice clinicians learn how experienced practitioners act and interact throughout the day and how they interact as professionals and communicate with patients and other health care providers.30 It helps to shape how they think, what they do, how they communicate and interact, and how they make sense of their experiences. Actively engaging in practice involves negotiating ways of being and interacting with one another within the community. It is through this negotiation process that students ultimately learn what it truly takes to belong and to become a fully participating member of a profession.30 Each new experience reshapes how we understand practice. This continuous renegotiation of the meaning of our day-to-day experiences, which is facilitated by our own ongoing self-monitoring and reflection on what is and is not working, results in our professional identity development. Shepard and Jensen34 describe this transmission of shared meanings as an acculturation process and suggest that it is the means by which students become socialized into the physical therapy profession. This renegotiation process holds true for newcomers and for those who have been in practice for some time, and forms the basis for lifelong learning in the profession. Continuous self-monitoring and self-assessment undergird this negotiation/renegotiation process.
KEY POINTS TO REMEMBER
Active participation in the community of practice of the clinical setting enables students to do the following:
- Develop their own identity as professionals.
- Turn theoretical knowledge into practical knowledge.
- Further validate their understanding of the norms, standards, and ethics of the profession at large.
- Learn how experienced practitioners act and interact throughout the day and how they communicate both within the community of practice and outside of the community.
- Learn what it truly takes to belong to and become a fully participating member of a profession.
CRITICAL THINKING CLINICAL SCENARIO
As a physical therapist, my first job was at a very large prestigious metropolitan rehabilitation center. This was a very traditional hospital environment, which included formal meetings, presentations, and formal rounds with families, physicians, and other health care providers. We wore uniforms with blue pants, white tops, and name tags. Patients and supervisors were identified by surnames. Appointment times were very structured, and patients waited for you in the waiting room. We worked with patients one on one in a quiet setting with minimal distraction. My second job was at a school for children with developmental disabilities. It was a much less-formal environment, with drawings on the walls and frequent impromptu meetings. We wore pants (some even wore jeans) and colorful shirts. We treated all together in a large gym. Families were in the gym at all times, working with some therapists and waiting for others. There was always a lot of chatter and a lot of activity, including laughing, joking, and playing.
- How did the expectations of professional behavior differ in each setting?
- How do you think I reacted on my first day of my second job? How do you think my colleagues in the pediatric facility reacted to me on that day?
- How do you think I learned what was expected of me in each setting?
- What kind of influence do you think my colleagues and these environments had on my development as a young clinician and vice versa?
- How might my acculturation process have been different had I first started at the pediatric facility and then moved to the rehabilitation facility?
LEGITIMATE PERIPHERAL PARTICIPATION: MAKING YOUR WAY INTO THE COMMUNITY
Based on the scenario presented above, you can begin to recognize the complexity of becoming a physical therapist in a specific clinical setting. Even experienced clinicians need to learn what the expectations of the community are and adjust accordingly. So, how can we help newcomers make that transition more easily, be it from classroom to clinic or clinic to clinic?
In physical therapy, we learn from experienced practitioners much like an apprentice learns from a master craftsman. Lave and Wenger21 studied apprenticeship learning in a variety of settings. They broadened the traditional concept of apprenticeships to include communities in which increasing levels of participation lead to identity formation, much like in physical therapy and most other health care professions.30 The goal of their work was to find the common threads that facilitated and inhibited learning in social practice. Common to all of these apprenticeships, as with physical therapy internships, is the concept of legitimate peripheral participation, which is a framework for understanding how newcomers learn by engaging with members of the community in progressively more complex and inclusive ways. For example, in physical therapy practice, students start by simply observing, asking questions, and, perhaps, performing a discrete component of patient management under close supervision. As they demonstrate increased competence, they gain credibility in the eyes of their CIs, who then begins to allow them to perform more and more complex skills with greater and greater independence. Over time and with additional experiences, the now novice clinician gains full membership in the community as a practicing clinician with responsibility for a total patient caseload. Throughout this transition from student to novice clinician, the learner is interacting with many individuals throughout the community of practice in the clinical setting. It is this progressively more complex engagement with other members of the community of practice that allows us, as newcomers, to continually enhance and modify our skills and interactions. Even for me, as an experienced clinician, yet as a new member of the pediatric community, I (MP) had to go through a similar process of learning about the culture of this new environment, and it reshaped the way I practiced and interacted with all members of the community, including my patients.
STOP AND REFLECT
Think back over a time when you started a new job, joined a new club or social group, or experienced your first clinical immersion or internship. Perhaps consider your first day of physical therapy school.
- How did you figure out what was expected of you? What were the written rules? What were the unwritten rules? How did you learn about the unwritten rules?
- How did you figure out the social norms of the community where you were (eg, how you were expected to act, dress, communicate)? How were these norms similar to or different from the norms of groups with whom you were previously engaged?
- What helped your learning/transition to this new community?
- Did you ever feel like you really belonged? If so, at what point did you really feel like you belonged? How did that happen? If not, why not?
- What most helped you to develop a sense of belonging? Or what hindered you from developing a sense of belonging?
- In what ways did you influence how things were done within your new community?