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Teaching and Learning in the Clinical Setting

Striving for Excellence in Clinical Practice

Aaron B. Rindflesch, PT, PhD, NCS; Heidi J. Dunfee, PT, DScPT; and Margaret M. Plack, PT, DPT, EdD

CHAPTER OBJECTIVES

After reading this chapter, the reader will be prepared to:

• Summarize the roles and responsibilities of the stakeholders in clinical education.
  
• Communicate effectively with the other stakeholders in clinical education.
  
• Prepare for your full-time student clinical experiences.
  
• Use active learning strategies when participating in a clinical experience.
  
• Recognize the possible similarities and differences between your learning and your performance in the classroom and the clinic.
  
• Evaluate your own performance in the clinical setting.
  
• Prepare for an eventual role as a clinical instructor.

Clinical education is a significant component of entry-level physical therapy professional education programs. On average, students in entry-level physical therapist education programs spend 30% of the program weeks in full-time clinical education.¹ However, since students typically spend more hours/week during clinical experiences than during the academic experiences, full-time clinical experiences can make up nearly 50% of hours spent over the 3 academic years. There is no question that clinical education is an important component of an entry-level physical therapy education program!

Despite the prominence of clinical education in an entry-level program, students and clinical instructors (CIs) may not be sufficiently prepared for success in their clinical experiences. Our experience has been that students prepare much more for their academic success, such as in reading, studying, and assignments, than for their clinical success. Some students may look forward to their time in clinic primarily because they think that it provides a break from homework, papers, and examinations; some erroneously view it as a break from school. In truth, clinical experiences may be a break from academic learning, but they certainly are not a break from learning.

Participation in a full-time clinical experience requires much more than simply demonstrating competency in the skills of physical therapy. According to the Commission on Accreditation in Physical Therapy Education (CAPTE),² clinical education is the “aspect of the professional curriculum during which student learning occurs directly as a function of being immersed within physical therapy practice. These experiences comprise all of the formal and practical ‘real-life’ learning experiences provided for students to apply classroom knowledge, skills, and professional behaviors in the clinical environment.” To be successful, you will need to apply your knowledge, skills, and professional behaviors.

CIs have the daunting task of facilitating the development of full-time students working with patients. CIs are simultaneously obligated to your development as a student and to the care of the patient, the reputation of the clinic, and the reputation of the profession, let alone basic obligations, such as the financial bottom line of the clinic and protection of their own licenses!

Unlike health professions such as medicine, clinical education in entry-level physical therapy professional education generally takes place prior to graduation from the program. However, since most programs typically do not have enough in-house clinical facilities for students to complete their clinical experiences, you will likely participate in at least some—or all—of your experiences at clinical sites not directly part of your institution. The average physical therapy program claims nearly 500 clinical site affiliations, although usually only 100 or so are used each year.1,3

Including the physical therapy student, there are several stakeholders in clinical education. The Evaluative Criteria for Accreditation of Physical Therapy Programs offers definitions of clinical education and of each role.²

Clinical Education Coordinator

The clinical education coordinator (CEC) is also called the director of clinical education (DCE) in many programs.

In entry-level professional physical therapy programs, the CEC’s role (also referred to as the DCE) typically consists of approximately 35% administrative time and 40% teaching time.³ The remaining time is devoted to scholarship, service and/or clinical practice. As the doctor of physical therapy (DPT) is held by more physical therapy graduates, it will soon be the most common degree held among CECs/DCEs.

As most entry-level professional physical therapy programs send students to contracted clinical sites for at least some of their full-time clinical experiences, and considering the CAPTE definition of the role as the faculty of record for clinical education courses, the CEC/DCE typically manages students at numerous clinical sites simultaneously. The CEC/DCE schedules the clinical experiences, develops objectives for each experience to be met by the students, develops and maintains relationships with clinical faculty and clinical sites, and ensures that students meet the specific requirements for each clinical site, such as immunizations, background checks, training, or insurance requirements. While a student is at a clinical site, the CEC/DCE may also conduct a site visit or coordinate a phone conference to check in on a student’s performance or help the CI work with the student. At the conclusion of a student clinical experience, the CEC/DCE is typically the faculty evaluator to determine whether the student successfully completed the clinical experience. Because the CEC/DCE is the faculty member of record representing the academic program, he or she determines grading. CIs typically do not determine grading because they represent the clinical site, not the academic program.

This chapter focuses primarily on the following 2 stakeholders in clinical education: the student and—because all students could eventually be teachers—the CI. For a detailed overview of the role of the CEC/DCE, see the Model Position Description from the American Physical Therapy Association (APTA).⁴

Clinical Education Faculty

In some cases, the person who fills the role of CCCE may also directly work with students as a CI. For an overview of the CCCE role, see the reference manual for CCCEs from the APTA.⁵

According to CAPTE, integrated clinical experiences are defined as follows:2

Full-Time Terminal Clinical Experiences

Full-time clinical experiences vary widely across entry-level professional physical therapy programs, even though nearly all of the programs in the United States offer the same degree: the DPT. As of this writing, the typical program offers approximately 36 full-time weeks in clinic, but the range is 21 to 58 weeks.¹ There is not consistency regarding the types of experiences offered in each program, and CAPTE dictates only a minimum of 30 full-time weeks,² although in 2010 the APTA made the following recommendations regarding what clinical education should include⁶:

• Full-time experiences at the end of the didactic program that are 10 to 12 weeks in length.
  
• An experience working with the acutely ill.
  
• An experience in rehabilitation focusing on neuromuscular and cardiovascular/pulmonary systems.
  
• An outpatient/ambulatory care/community experience with a focus on cardiovascular/pulmonary, musculoskeletal, and neurologic systems.
  
• Specific pediatric and geriatric experiences are not necessarily required, but experience across the lifespan is recommended.

As a student in an entry-level professional physical therapy education program, your full-time clinical experiences are likely to include inpatient (eg, acute care, inpatient rehabilitation, transitional care, skilled nursing) and outpatient (eg, orthopedic clinic, sports medicine, work rehabilitation) settings. Although length of experience and expected outcomes differ across programs, this chapter focuses on students and CIs participating in full-time clinical experiences with the assumption that they are 10 to 12 weeks in length and with the expectation that the student will achieve an entry-level performance rating. (Note: entry-level performance is described in the evaluation section of this chapter.) We include general recommendations for any type of experience.

Applying concepts from Chapter 5, there are several essential phases to the design of any well-planned learning experience. In full-time clinical education, the phases are as follows:

• Needs assessment
  
• Pre-experience preparation/planning, including motivational hooks, characteristics of the adult learner, and learning objectives
  
• Implementation (teaching and learning), including content, content boosters, and active learning strategies
  
• Evaluation, including both formative and summative assessment.

The content of this chapter is organized using this framework, and we address each component from perspective of the student and, because current students are our future CIs, occasionally from the perspective of the CI.

Many student-related variables can affect the outcome of a full-time clinical experience. For example, your personality type may influence how you prefer to learn or conduct yourself in the clinic. A personality or temperament self-assessment would allow you to discover your preferences. As you may recall from Chapter 1 in this text, the Myers-Briggs Type Indicator is an example of a self-assessment tool that can be used to help you determine your personality preferences.⁷ It is based on the theory of psychological types first developed by Jung. There are 16 distinctive personality types that result from the interactions among the following 4 basic preferences: extraversion or introversion; sensing or intuition; thinking or feeling; and judging or perceiving. You could use the results of this tool to determine your preferences for taking in information, evaluating information, or making decisions for action. Real Colors (NCTI, Inc.) is another personality or temperament tool that can help you to understand your behavioral preferences, especially how to work well within a group.8

It may be helpful for you to understand your own learning style or preference as well. However, as noted in Chapter 1, it is important to remember that knowing your own preference is only a starting point for understanding differences; remember also that the most effective learners may have a preference but use a variety of strategies for learning and interacting. In addition, as noted previously, it is important to recognize the significant differences that may exist between learning in an academic setting and learning in a clinical setting. In the academic setting, you may take in information via lecture or textbook. This information is usually well planned and presented sequentially and logically. You are allowed time for processing the information. Learning objectives are usually clearly articulated in a course syllabus. Multiple-choice tests or laboratory practical examinations are frequently used to determine if you have sufficient mastery of the content. Classic academic learning has structure; information is presented or given, students have time to process, and testing is conducted. In the academic setting, a student may be able to more frequently use a surface learning approach, defined as a function of both learning characteristics and teaching factors,⁹ and could still achieve satisfactory grades.

Learning in the clinical setting, on the other hand, may be much less structured and more emergent. Clinical sites may not have formal learning objectives or teaching plans. Information is gathered from patients who may not present it in a logical fashion, nor may the student request it in a logical fashion. Students and clinicians have to make decisions with limited time and often limited information. Academic tests are not typically used in the clinic. Your patient is your test. Success is the creation and implementation of a physical therapy plan of care that facilitates your patient to realize that his or her movement potential. Often, there is not one right answer, as an effective plan of care can be approached from a variety of angles based on your patient, the available evidence, and your own knowledge and skills. Learning in the clinical setting may lack the structure of the academic setting. Students who rely on an orderly and structured approach for successful learning will need to develop new and different learning strategies to be successful in the clinical setting. A student may be more likely to use a deep learning approach where he or she actively seeks to understand meaning and critically analyzes the evidence prior to making decisions.⁹

Because your successful learning strategies may vary depending upon setting or expected outcome, you may want to complete a learning style self-assessment to establish your baseline. As noted in Chapter 1, there are many different ways to look at learning styles. An awareness of even the most basic learning style preferences, such as a preference for taking in information visually, aurally, via reading, or kinesthetically,¹⁰ may help you to develop strategies for success in clinical education. As you remember, Kolb Learning Style Inventory is a widely used tool to assess a learner’s preferred learning style.¹¹ One study found the preferred learning styles of physical therapy students to be equally spread across the converging, assimilating, and accommodating learning styles, with the least-preferred method being the diverging style.¹² (See Chapter 1 for a review of learning styles.) However, do not assume that using your preferred learning style will make you a successful learner. Regardless of setting, active learning strategies, such as retrieval practice through testing and spacing of practice, are more useful than meeting one’s preferred learning style.¹³

Research supports the assertion that learning in the academic and clinical settings may be different. A physical therapy student who performs well in the academic setting is not guaranteed to perform well in the clinical setting. One study found no significant relationship between scores obtained by students on the Physical Therapist Manual for the Assessment of Clinical Skills (PT MACS; ie, clinical performance) and performance on the National Physical Therapist Exam (NPTE), although it did find a small but significant relationship between student performance in the evaluation, diagnosis, and outcomes sections of the PT MACS and the corresponding sections of the NPTE.14 Two studies found no significant relationship between clinical performance as measured by the Clinical Performance Instrument (CPI) and performance on the NPTE.^15,16 Yet, another study found no statistically significant relationship between preprofessional or professional academic achievement and clinical performance.¹⁷ In addition, learning and performance in the clinical setting likely involves the application of professional and ethical behaviors to a greater extent than learning in the academic setting, and these behaviors are frequently the subject of the clinical education literature.^18–20

However, it is important to avoid putting too much emphasis on matching the student’s preferred learning style with the CI’s instructional method. Although adapting instructional design to a student’s knowledge level has been shown to be beneficial,²¹ adapting instructional design to a student’s learning style has not.^13,22 You will remember from Chapter 1 that, by the time you reach graduate school, while you may have a learning preference or style, using a variety of learning styles is what will make you most effective in your learning. CIs often have a variety of teaching and learning tools on hand to not only match specific learning styles and engage their learners, but also to challenge them by moving away from their preferred learning style to promote a higher level of skill that will match patients and family members as the student’s professional career evolves. Recognizing preferences may help to minimize conflicts in the clinical setting, and being flexible in your approach to learning in the clinical setting will optimize your learning experience.

Learning Needs

As a student, you would benefit from conducting a self-assessment of your learning needs prior to any full-time clinical experience as well. Learning needs are the gaps in knowledge between your desired level of performance and your actual level of performance. As part of your needs assessment, in addition to your own learning style, it is critical for you to reflect on your strengths and weaknesses and on any gaps in your knowledge and skills before walking into the clinical setting. The more specific you can be in identifying your own learning needs, the better equipped you will be to work in partnership with your CI to design a clinical experience that best meets all of your needs.

To assess your learning needs prior to a specific full-time clinical experience you could do the following:

• Review the CPI categories and assess your proximity to entry-level performance in that clinical setting (especially important if you have already completed a clinical experience in a similar clinical setting).
  
• Consult the Minimum Required Skills of Physical Therapist Graduates at Entry-Level²³ and develop a checklist of skills that you think you have achieved and those remaining to be achieved prior to graduation.
  
• Review your program’s list of objectives for performance in full-time clinical experiences and formulate ways to achieve them in your upcoming clinical experience(s).
  
• Have a discussion with your program’s CEC/DCE to develop strategies in achieving entry-level performance in your clinical experiences.
  
• Consult students ahead of you in the program or recent graduates of your program to ask them how they conducted themselves in their full-time clinical experiences.24

Locus of Control

As a student, you are engaged in a learning triad (CI, student, patient) in the clinical setting, and the process is complicated by the volume of knowledge that you are expected to know and integrate, anxiety and nervousness around patient encounters, CI/student interactions, and overall effort and preparation as guided by the CI but are truly your responsibility. Pashler et al²⁵ note that students present to their clinical sites with variable levels of accountability and self-directedness. This variability can be related to number of factors, such as type of setting, interest in setting, early vs terminal clinical experiences, life events, CI/staff/student relations, interaction with other students, teaching-learning style differences, or unclear expectations. Students demonstrating an internal locus of control recognize and believe that they are responsible for their own actions, will work to control and manage their own life events, and will take charge of their learning, regardless of the setting. Students demonstrating an external locus of control often blame external factors for their lower performance rather than taking responsibility for their learning.²⁵ To be effective in your clinical experiences, you will need to foster an internal locus of control on a day-to-day basis. You will need to take responsibility as a professional to demonstrate to your CI the Core Values of the APTA. These strategies are particularly important if you are in an experience where you did not choose your placement (ie, lottery-type scheduling). Recognizing that, as an emerging professional, you have a great deal to learn about your profession regardless of the setting you are in will help you to foster that internal locus of control.

Clinical Instructor Information

While we noted earlier in this text how learning in the classroom is a partnership between you and your instructor, this becomes even more important in the clinic where the clinician-to-student ratio or the clinician-to-resident ratio is much smaller, often 1:1. So, the more information you can provide your CI and your CI can provide you about him- or herself, the easier it is to develop this partnership. Your answers to the following questions may provide information your CI will find helpful:

• Where are you in your academic preparation? What classes have you completed?
  
• What is your background prior to entering your physical therapy program?
  
• What clinical experiences have you completed prior to coming to our clinic?
  
• What are your strengths?
  
• What areas have you identified where you need improvement?
  
• What general goals do you have for the experience? (Review your initial self-assessment to guide your development of goals.)

Although there are restrictions on the type of information a program CEC/DCE or CCCE can share with the CI (ie, Family Educational Rights and Privacy Act of 1974),²⁶ a student may freely share any information with a CI. The more CIs who know about you (eg, strengths, weaknesses, preferences), the more prepared they will be to design experiences that will most effectively meet your needs.

Other information that may be helpful in forming the student/CI partnership include the following:

• What are your program’s expectations for performance in this clinical experience?
  
• What is your program’s absence policy?

The first question above will help the CI to determine the level and types of interaction that you should have with patients at the clinical site. The second question will help the CI to determine a plan for any make-up time that you may need to complete if you are absent during the experience. Should you be absent and need to make up time, the CI will want to make sure that the clinic can accommodate (eg, additional days the student is assigned to the site) or make arrangements with other staff at the clinical site (eg, a backup CI should the primary CI be away or occupied). If a student is performing below standard, the CI would want to make sure to be present for any required makeup days. If the student is performing well, it may actually be beneficial for him or her to be paired with a backup CI to make up time in an effort to allow the student to see other perspectives on patient care.

The relationship built with the academic program is critical to your success. Understanding and valuing expectations will only enhance the clinical experience and overall outcomes of communication between you, your CI, and your program. Since there is no national standard, academic programs vary significantly in their style of communication with clinical sites (paper, electronic, email) and in the types of information sent to the clinical sites. Ideally, the information is passed along to your CI, and your CI has time to review all of the information provided in preparation for your arrival. However, as a student, you must always remember that most clinicians are incredibly busy, and you should be prepared to provide your CI with any information (eg, program of study, expectations, timelines) needed to help you be successful.

Combined, all of these pieces will help the CI set the stage for your arrival, allowing him or her to establish a learning diagnosis. A learning diagnosis is the result of the CI’s assessment of your learning needs, learning barriers, level of expertise within the content area, and expectations for learning performance. For a further description of levels of expertise, revisit Chapter 5.

As a student, knowing how your CI prepares for your arrival can give you additional insight into the types of questions that he or she may have and the types of information you may want to provide him or her. Your role as a student is to provide your CI with as much information as possible to help the design of a learning experience that is unique to you and your specific needs.

PRE-EXPERIENCE PREPARATION/PLANNING

Student Preparation

After you have taken some time to complete a thorough needs assessment to identify both your needs and the needs of your CI, it is important to think about planning ahead for your clinical experience. In this section, we discuss strategies for you to prepare for your full-time clinical experiences, including developing effective learning objectives. Taking time to prepare for full-time clinical experiences may be one of the most important actions that you can take as a student. As Benjamin Franklin once said, “Failing to prepare is preparing to fail.” Just as in giving a presentation, you have 3 to 5 seconds to grab your audience’s attention, in preparing for your clinical experience you have one opportunity to make a good first impression. Consider your first impression as the motivational hook for your CI! Effective preparation includes the following:

However, it is difficult to predict who will be a successful student, let alone a successful clinician. If you have made it into an entry-level DPT program, congratulations! Making it into a program, however, does not guarantee that you will be an outstanding clinician. Is it possible to predict who will be a good clinician? Some studies have correlated pre- or postadmission factors with performance on the NPTE, although, since the NPTE is a written examination, it cannot measure student variables that are important in the clinic, such as personality or locus of control. A number of studies have found correlations between preadmission factors such as verbal GRE27,28 and behavioral interview²⁷ and successful outcomes on the NPTE. Once enrolled, your first-year GPA²⁹ may be predictive of success. In fact, one study noted that the most powerful predictor of failure on the NPTE was academic difficulty during a student’s professional training.³⁰ At this point, what appears to be most critical is maintaining a high GPA during your program’s didactic curriculum.

Some clinical sites do not want to fully rely on GPAs or on academic programs to be the gate keepers. Some sites want more input regarding who they accept for a full-time clinical experience at their site, understandably so since a student may be working with them for 10 to 12 weeks or more, and, as you know, clinical performance requires more than a good GPA. An increasing phenomenon in physical therapy clinical education is the application and/or interview of students prior to being accepted for a full-time clinical experience. The CIs at these sites want to be sure that the student is a good fit for their clinic. They want to know that they can meet your needs and that you are prepared to perform at the level expected at the site. They may not only be looking for a match of knowledge and skills, but also specific professional behaviors, personality traits, or motivation. This section gives you tips for success as an applicant and/or interviewee. Always remember, the more the site knows about you (and vice versa), the better the learning partnership.

To be the best applicant for a full-time clinical experience at a clinical site, it is helpful to know what CIs are looking for in a student. Cross and Hicks³¹ interviewed 20 clinical educators to determine how they differentiated between good and bad clinical performance by undergraduate physiotherapy students in Ireland. In this study, the CIs were asked to think of 3 students, past or present, who they would describe as “good” in terms of clinical performance and 3 who they would describe as “bad.” They found that the CIs used 10 common dimensions to differentiate good from bad. As is common when analyzing affective behaviors, the most influential dimensions were the least measurable. Some of the dimensions that these CIs described as important are communication, insightfulness, organization, caring, sense of humor, academic ability, and approach to learning.

CIs also want students to demonstrate the characteristics of adult learners³² including the following:

• Being self-directed in solving clinical problems.
  
• Taking appropriate risks in providing patient care.
  
• Continually reassessing situations and actions to ensure that the best decisions were made.
  
• Reflecting on their experiences so that they can learn from them.

Being prepared to share situations from your past where you demonstrated these characteristics will certainly help in an interview.

Another way to prepare for your upcoming clinical experiences is to think about what not to do. Wolff-Burke¹⁸ interviewed 11 physical therapy CIs who had worked with 24 students who, at some point, demonstrated inappropriate behaviors in the clinical setting. Some of the inappropriate behaviors as described by these CIs included having an attitude, lacking interest, demonstrating poor communication and being unprofessional. Conversely, they described appropriate behaviors as accepting responsibility for learning, having good communication skills, showing empathy, and being professional.

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