Teaching and Learning in the Clinical Setting: Striving for Excellence in Clinical Practice

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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!


This chapter is written for students who desire to excel in their full-time clinical experiences and perfect their skills as future CIs. Our basic assumption is, at minimum, all students want to pass their clinical experiences to graduate and obtain licensure. We also assume that all CIs want to see students succeed. This chapter includes practical strategies for you to excel in clinical education, going above and beyond average performance. We share strategies from multiple students and CIs with whom we have interacted over the years to enable both students and clinical educators to select the tools that best meet the needs of each individual student.


DEFINITIONS AND ROLES IN CLINICAL EDUCATION


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.



The core faculty member(s) responsible for the planning, coordination, facilitation, administration, and monitoring of the clinical education component of the curriculum. The clinical education coordinator(s) is/are the faculty member(s) of record for the clinical education courses. NOTE: the term is intentionally generic; programs are free to use any appropriate title.2


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



The individuals engaged in providing the clinical education components of the curriculum, generally referred to as either Center Coordinators of Clinical Education (CCCEs) or Clinical Instructors (CIs). While the educational institution/program does not usually employ these individuals, they do agree to certain standards of behavior through contractual arrangements for their services. The primary CI for physical therapist students must be a physical therapist; however, this does not preclude a physical therapist student from engaging in short-term specialized experiences (e.g., cardiac rehabilitation, sports medicine, wound care) under the secondary supervision of other professionals, where permitted by law.2


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


Integrated Clinical Experiences


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



Clinical education experiences that occur before the completion of the didactic component of the curriculum. Options include but are not limited to one day a week during a term, a short full-time experience at the end of a term, a longer full-time experience between two regular terms. Integrated experiences cannot be satisfied with patient simulations or the use of real patients in class; these types of experiences are too limited and do not provide the full range of experiences a student would encounter in an actual clinical setting.


Full-Time Terminal Clinical Experiences



Extended full-time experience that occurs at the end of the professional curriculum but may be followed by a short didactic activity, such as a seminar or a short licensure preparation course that does not require additional clinical experiences.2


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.



STOP AND REFLECT


How would clinical experiences be different if they all took place after graduation from an academic physical therapy education program (similar to a medical residency model)? In this scenario, who would be responsible for scheduling experiences? Evaluating experiences? Would the student pay for the experiences or would the student be paid? Would clinical sites need to be accredited? What do you see as the pros and cons of this type of scenario in physical therapist education?



KEY POINTS TO REMEMBER



  • Clinical education constitutes a significant portion of a DPT curriculum.
  • Accreditation standards from CAPTE influence the design of the clinical education portion of individual programs.
  • Programs and clinical sites typically use standard terminology when referring to key stakeholders in clinical education.
  • Clinical education programs vary significantly across the country.

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.


NEEDS ASSESSMENT



CRITICAL THINKING CLINICAL SCENARIO


Student:


You are a student who is getting ready to participate in your first full-time 10-week clinical internship. While you have participated in 2 short-term integrated clinical experiences, they were only 1 day/week and you had limited input into your experiences.


How would you prepare for this experience? What do you need to know to be able to plan properly? What questions would you ask? Who would you ask? How would you get the information you need? What would you do to ensure you make a good first impression for your CI?


CI:


You are getting ready to supervise your first full-time 10-week student intern. While you have had a few students in their brief integrated clinical experiences, this will be your first full-time student.


How would you prepare for this experience? What do you need to know to be able to plan properly? What questions would you ask? Who would you ask? How would you get the information you need? What would you do to ensure that you make a good first impression for your student?


As a student, your first opportunity for assessment should occur prior to selecting a physical therapy program to attend. You may select a program based, in part, on the number of clinical education experiences, how students are placed, or perhaps even the locations of affiliated clinical sites. The quality of the experiences, however, is difficult to judge for a pre–physical therapy student evaluating entry-level physical therapy programs. Quality has many variables (eg, outcome, cost, efficiency, opportunities). These variables are not often measured in ways that are accessible to pre–physical therapy students.


After matriculation into a physical therapy program, some programs will allow you to participate in the selection and scheduling process for full-time clinical experiences. Others use a random or lottery-type system to schedule experiences. Oftentimes, students want to know which sites offer the best clinical experiences. Unfortunately, this can be a difficult question to answer. Many variables go into establishing the quality of clinical experiences and clinical sites, including (but not limited to) the following:



  • Behaviors and characteristics of the individual student (eg, strengths, weaknesses, learning styles, motivations, self-directedness)
  • Characteristics and preparations of the individual CI
  • Relationship developed between the CI and the student
  • Resources available and the atmosphere of the clinical site
  • Timing of the experience in the curriculum (later students may be more equipped to succeed in complex or specialized clinical experiences.)

If your program’s CEC/DCE uses student input when scheduling clinical experiences (as opposed to a random or lottery-type system), take the initiative to research the list of clinical sites by meeting with your CEC/DCE and speak with students who have completed a clinical experience at your site(s) of interest. Your CEC/DCE may also allow you to read clinical site evaluations written by students who previously attended the clinical site. It may be tempting to think that a clinical site is great after simply talking to a student who tells you that he or she had the best experience there. However, as we stated above, there are many variables that exist in a successful clinical experience. Never assume your clinical experience at a given site will be identical to that of a student who was previously at the site. Rather, use the information you receive to realize what is possible at the clinical site. Prepare for the experience diligently and bring forward the positive student behaviors outlined in the implementation section of this chapter. Positive student behaviors typically contribute to a good clinical experience. Negative student behaviors can dramatically decrease the learning opportunities at a clinical site.


As a graduate student, you have spent many years in the classroom and have developed certain learning strategies that have been very effective for you. However, it is important to recognize that learning in the academic setting is somewhat different from learning in the clinical setting. The key to being successful in the clinical setting is to know yourself. Completing a thorough needs assessment that considers the learning variables that occur in the clinical setting along with your own personal learning needs, motivations, and locus of control will help you to identify your strengths and areas for improvement. In addition, providing your CI with just the right information will help him or her to refine his or her teaching strategies to best meet your needs in the context of patient care.


Learning Variables


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



STOP AND REFLECT


Think about a recent learning experience that you engaged in, such as an individual class session, in which the expected outcome was cognitive learning (ie, remembering or categorizing facts). Consider the following:



  • How did you approach your learning?
  • How was the information given to you?
  • When were you notified of the teaching plan?
  • Which strategies did you use to remember the information?
  • Did you use the new knowledge to solve a problem?

Now think about a recent learning experience that you engaged in, such as learning a skill, in which the expected outcome was psychomotor learning (ie, performing a movement or task). Consider the following:



  • How did you approach your learning?
  • How was the information given to you?
  • When were you notified of the teaching plan?
  • Which strategies did you use to remember the information?
  • Did you use the new knowledge to solve a problem?

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.1820


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.



CRITICAL THINKING CLINICAL SCENARIO


You have always been a successful student. You graduated from college with a major in biology, achieving a 3.94 grade point average (GPA). You scored well on the Graduate Record Examination (GRE), but not as high as you expected. You scored in the 60th percentile in your quantitative reasoning score and the 30th percentile in verbal reasoning. Your analytical writing score was in the 40th percentile.


In the didactic portion of your graduate physical therapy curriculum, you performed well, achieving a 3.9 overall GPA. You participate in your first full-time clinical experience in an inpatient rehabilitation setting. At midterm, your primary CI gives you feedback that you are not performing to the standards of the clinical site. You are told that you have struggled in forming a plan of care for your patients. Your CI gives you a very low score for clinical reasoning. In your conversations with your CI, you have not been able to consistently articulate reasons for what you are doing. He states that you have struggled in teaching your patients and their families. He calls your CEC/DCE, who informs you that you are in danger of failing the clinical experience.


Reflective Questions



  1. What could be the problem(s) for this student in the clinical setting? Establish a list of differential learning diagnoses.
  2. Which strategies could the student use to improve performance in clinical reasoning? Patient education?

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:



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.


The role of the CI can be complex, requiring a great deal of thought and preparation. For example, the CI needs to do the following:



  • Be aware of expected outcomes of the upcoming clinical experience, including the expected level of student performance (eg, entry level or advanced intermediate).
  • Know the program’s clinical education policies, including the standards of attendance.
  • Be familiar with their own clinical setting and the types of patient experiences available for students.
  • Know how to balance the student’s need for mastery—assuming that students who need to achieve entry-level performance will need sufficient time and opportunity to do so—and the student’s desire for novel exposure or variety.

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.



CRITICAL THINKING CLINICAL SCENARIO


You are the CCCE at a clinic that typically accepts 4 students/year at varying times of the year. For the past 5 years, you have accepted 2 students/year from 2 different programs. The students have all been in their final clinical experience prior to graduation. You have had successful outcomes with these students. This year, a new academic program has requested to send you a student for his first full-time experience. In the past, you have been hesitant to commit to a first-time clinical experience because of the complexity of your clinical environment. You have also heard from CCCE colleagues in your geographic area that their clinical sites struggle with early clinical experiences because students typically do not have sufficient knowledge, experience, or confidence. Clinician productivity and staffing are big issues in your department. You are concerned that taking a first-year student will significantly decrease your productivity and will result in other staff needing to see more patients. However, you would like to accommodate this request.


Reflective Questions


If you are the CI:



  1. How would you adjust your clinical experience to support this early clinical experience request?
  2. How might you modify your typical methods of involving students in the care of your patients?
  3. How would you alter your expectations for student performance to ensure that this student would have a good clinical experience?

If you are the student:



  1. How would you prepare for this clinical experience?
  2. What questions would you ask the CI to help you prepare?
  3. What information would you want to be sure to provide the CI?


KEY POINTS TO REMEMBER



  • Prior to beginning your clinical experiences, you should take the time to know yourself as well as possible, including your learning needs.
  • Learning in the clinic may be different from learning in the classroom.
  • Do not assume that your preferred learning style will be met in the clinical experience. It may not be possible or even beneficial to your long-term retention.
  • Your prior experiences are important. Take the time to reflect upon these as you prepare for your upcoming clinical experiences.

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:



  • Preparing for a clinical site application or interview.
  • Completing a student profile form.
  • Writing learning objectives.
  • Preparing to actively engage as an adult learner.
  • Familiarizing yourself with how you will be assessed so that you can begin with the end in mind.
  • Familiarizing yourself with and completing essential legal and regulatory documentation.

In this section, we also discuss some of the strategies that your CI may use in preparing for your arrival on site.


Preclinical Experience Application and/or Interview


Because full-time clinical experiences in entry-level physical therapy education programs occur prior to graduation, and clinical experiences are largely completed at contracted clinical sites where clinicians primarily interact with patients not students, clinical sites do not have an opportunity to select which students should enter the field of physical therapy. In a way, entry-level physical therapy education programs are the gate keepers for the physical therapy profession. Clinical sites, then, depend upon academic programs to admit students who will be good clinicians.


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.


Since the judgment of professionalism lies with the perceiver, get feedback from your peers (ie, classmates, academic faculty) to see if any of your previous or current actions could be judged as being unprofessional. Can you provide examples to your interviewers and/or future CIs of times when you accepted responsibility for your learning? Examples of when you displayed empathy? Examples of when you demonstrated effective communication? Examples of how you acted in a self-directed manner, consistent with being an adult learner?



STOP AND REFLECT


Consider the characteristics that CIs find both effective and ineffective in students. Consider the following:



  • Reflect on how you might respond to questions during an interview for a clinical experience, such as questions asking you to demonstrate good communication, being professional, or being responsible.
  • Think of specific examples of times when you may have displayed the positive characteristics that CIs expect.
  • Think of a time when your behaviors were not what they should have been and consider the following:

    • How did you come to realize what you had done?
    • What did you do about it?
    • What did you learn from that experience?

May 30, 2017 | Posted by in NURSING | Comments Off on Teaching and Learning in the Clinical Setting: Striving for Excellence in Clinical Practice
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