The Learning Triad: Optimizing Supports and Minimizing Barriers to Learning in the Clinical Setting

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The Learning Triad


Optimizing Supports and Minimizing Barriers to Learning in the Clinical Setting


Margaret M. Plack, PT, DPT, EdD and Maryanne Driscoll, PhD


CHAPTER OBJECTIVES


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



  • Compare and contrast learning in the classroom and clinic settings.
  • Apply the concept of the learning triad that emerges in the clinical setting to developing effective teaching and learning strategies.
  • Analyze the potential barriers and supports to learning in the clinical setting.
  • Apply the concept of mentorship within a community of practice to engage in and design effective teaching and learning experiences in the clinical setting.
  • Use a comprehensive and systematic approach to optimize learning in the clinical setting.

As we discovered in Chapter 10, learning in physical therapy requires total immersion in the physical therapy community of practice in the clinical setting.1 This is true not just in physical therapy, but in other health professions as well.2 While classroom learning is critical to our success, for many of us, the abstract concepts learned in the classroom do not begin to make sense until we apply them in practice. Gaining access to, and engaging in, practice with professionals enables us to begin to develop a shared understanding of our role as practitioners.3,4 However, as we learned in the previous chapter, simply gaining access to observe practice is not enough.1,2 Observation is important in the learning process, but in the health professions, of equal—if not greater—importance is gaining personal experience and being actively engaged in all aspects of practice. Through active participation, we learn how experienced practitioners act and interact, and, ultimately, what it truly takes to become a fully participating member of a profession.3,4 Active participation allows for dialogue, which enables us to negotiate meaning and develop a shared understanding of the values, beliefs, behaviors, and expectations of professional practice.1 Dialogue and engagement are social processes, essential to learning and professional development in the health professions, and begin with the sponsorship of a mentor. In physical therapy, that mentor is the clinical instructor (CI).



STOP AND REFLECT


You are at the end of your first year in physical therapy school, and next week you will be starting your first full-time clinical experience. You are excited and nervous!


Reflective Questions



  1. What are you excited about? What are you nervous about?
  2. Who do you anticipate learning the most from in the clinical setting?
  3. Where will you turn if you run into a problem or situation that you cannot seem to solve?
  4. What if that situation involves your CI?

In this chapter, we present the concept of a learning triad, which includes the learner, the instructor, and the clinical community. We examine the role of mentorship within the physical therapy community of practice and how mentorship in physical therapy moves beyond the one-to-one relationship of the student and CI to include the entire learning triad. We also examine the role of the student, the CI, and rest of the clinical community in supporting learning. Of course, the director of clinical education (DCE) and all faculty members within the academic program are essential in supporting student learning, whether it be in the classroom or in the clinic; however, this chapter focuses on the clinical environment specifically. We also explore how the same components that support learning in the clinical environment can potentially hinder learning as well. Finally, we present a framework for learning that optimizes the supports and minimizes the potential barriers to learning in the clinical setting.


As in Chapter 10, you will see direct quotes from students and clinicians that illustrate, reinforce, and provide additional opportunities to apply the concepts discussed. These quotes provide evidence of how learning in the physical therapy clinical environment is similar to, yet different from, a more traditional mentorship or apprenticeship model of learning.


MENTORSHIP: THE MASTER AND THE APPRENTICE


Wenger3 and Lave and Wenger4 discuss apprenticeship learning within a community of practice. They examine apprenticeship learning in a variety of professions; however, little mention is made of the actual relationship between the “master” and the “apprentice” or the teacher and the learner. They describe this relationship as ranging from almost nonexistent to a well-defined and explicit relationship, without which the apprentice would not have had access to the community. Spouse2,57 specifically studied nursing students and notes that support from clinicians in the mentorship role significantly increased the students’ adjustment to the clinical environment and, ultimately, enhanced learning. Similarly, in physical therapy, the CI becomes a significant teacher and mentor in the life of students and novice clinicians.2,8,9



STOP AND REFLECT


Think about someone who has been a mentor to you in your life. Perhaps you have had more than one mentor, or perhaps you have been a mentor someone else.


Reflective Questions



  1. What was your relationship like with this/these person(s)?
  2. How did this/these relationship(s) develop?
  3. How long did this/these mentorship relationship(s) last?
  4. What role did your mentor(s) play in your life? Or, if you were a mentor, what role did you play in the life of your protégé?

The term mentor comes from Homer’s The Odyssey in which Mentor was a trusted friend of Odysseus to whom he entrusted his son Telemachus. Mentor was a teacher, guide, friend, adviser, protector, and even surrogate father to Telemachus at times.1013 This mythological story depicts the essence of a traditional mentorship (ie, an older, wiser, more experienced person influencing and guiding a younger, less experienced individual or protégé through life’s transitions). Has this been your experience, either as a mentor or as a protégé? Terms such as sponsor, role model, coach, supervisor, preceptor, advisor, gatekeeper, guide, counselor, and friend have been used synonymously with the term mentor.2,10,1214



STOP AND REFLECT



  • Of the terms used in the text above (eg, counselor, guide, friend), which term(s) best describe(s) your mentor(s)? If none, what term would you use to describe your mentor’s role in your life?
  • If you had more than one mentor, did they come at different times in your life? Did they have different functions in your life?
  • In what ways did your mentor(s) help you develop? Or, if you were a mentor, in what ways did you help your protégé grow and develop?

Just as the term mentor is a complex one that means different things to different people, the role of the mentor is also quite complex. If you take even a few minutes to compare your mentorship experiences with those of some of your peers, you are likely to find that your experiences may have some similarities, but they may have quite a few differences as well. Mentors can play many different roles and provide many different functions in the life of a protégé. In his text titled Mentor: Guiding the Journey of Adult Learners, Daloz10 describes 3 distinct functions of a mentor: support, challenge, and vision.


Daloz10 defines support as the affirmation and validation of the protégé’s experiences. Kram14 more explicitly delineates the mentor’s role as having 2 distinct support functions (career and psychosocial functions), although certainly there is overlap between the 2. These functions are defined as follows:



  1. Career functions are those functions that help orient a protégé and advance the protégé’s career, such as providing sponsorship, visibility, exposure to challenging assignments, and coaching. Career functions also include protecting protégés from situations for which they are not yet prepared.
  2. Psychosocial functions are “those aspects of the relationship that enhance a [protégé’s] sense of competence, identity, and effectiveness in a professional role,” such as providing acceptance, confirmation, counseling, friendship, and being a role model.14

Kram14 notes that career functions are generally the result of the longevity, position, and influence of the mentor within the organization, whereas the psychosocial functions are the result of the interpersonal relationship or bond that forms between the mentor and the protégé.



STOP AND REFLECT


Think back on your mentors, and consider the following:



  • In what ways were their roles consistent with what Kram14 and Daloz10 describe?
  • In what ways were their roles inconsistent with what Kram14 and Daloz10 describe?

In physical therapy, both career and psychosocial functions are critical for newcomers to any clinical practice. When we first enter the clinical environment as students, we look to our CI (mentor) for emotional support and for guidance in the areas of career and psychosocial functioning. For example, in an acute care setting, physical therapy students may be working directly with seriously ill patients for the first time. They may even experience the death of a patient whom they have come to know and value. The CI becomes a role model for how to experience strong emotional reactions, even sadness and a sense of loss, while continuing to provide care and treatment for other patients on that day’s schedule. Whether it is during lunch or an interdepartmental meeting, the function of the mentor is to facilitate learning in the protégé through social engagement in the community of practice.2 It is often through this mentorship relationship that clinicians share their professional values, beliefs, and behaviors, often tacitly, in the midst of being actively engaged in everyday activities.15


Some authors suggest that mentors also have a “political function” and “power perspective.”16,17 This may be particularly critical in a physical therapy setting where, as newcomers, we are expected to quickly recognize and adapt to the expectations of the community. We know that first impressions are important, so we must quickly figure out what we can and cannot do, how we should and should not act, and with whom we should and should not interact (ie, we must learn to navigate the subtleties of each community of practice). For example, in a hospital setting, the physical therapist is part of a multidisciplinary team. Students must very quickly learn who is in charge at the nursing station or what questions to pose to the social worker vs the nurse or the physician. In an outpatient setting, it can be equally important to recognize who has the power to influence even basic aspects of practice management, such as scheduling and patient assignment. It is often the mentor that helps the newcomer to learn to effectively negotiate through the community’s political and social structures as he or she moves toward becoming an active participant in that community.1619 Spouse2 believes that it is this early mentoring relationship that allows students to feel comfortable in an unfamiliar environment and enables them to move beyond the one-to-one mentorship relationship to engage with others in the community of practice besides the CI.



STOP AND REFLECT


Think back to a time when you were a newcomer to a particular environment and consider your first day of physical therapy school. Consider the following:



  • How did you figure out what was expected of you?
  • Who helped you figure that out?
  • What did that person(s) do to help you?
  • How does that compare with our previous discussion of the role of the mentor?

Think back also on some of the challenges you faced during your first semester of physical therapy school or your first clinical internship. Consider the following:



  • How did you overcome each of those challenges?
  • What did you learn by overcoming those challenges?

As noted, the role of the mentor is not only to support the protégé, but also to challenge the protégé, because it is through those challenges that we learn. Mentors challenge us by providing experiences that result in a tension or a gap between what we know and what we do not know. To resolve this tension or bridge this gap, we must learn.5,10 In Chapter 6, we discussed the importance of scaffolding in the learning process; mentors help scaffold learning for their protégés.


From Chapter 10, you know that challenges, like supports, can take many forms. You also know that CIs use different strategies to challenge students, such as providing novel tasks, facilitating reflection, discussing problems, questioning hypotheses and solutions, exploring new ideas and alternative perspectives, experimenting with new approaches, and setting high standards.1,20 However, we also know that students are faced with many more challenges in the clinical setting than those explicitly designed by the CI. Being exposed to novel situations and having to manage the different personal attributes of the student, CI, and community (including the patient and environment) can be quite a challenge.1 Although challenging, these strategies and activities are critical to our learning in the clinical setting, and our CI can help us to master these challenges through coaching,21 role modeling,19,22 scaffolding our learning,5 and/or facilitating our engagement in practice.24,23


Finally, Daloz10 and Zachary11 note that the third role of the mentor is to provide vision for the protégé. Mentors bring a great deal of experience to any given situation, and, as a result, can provide us with not only a sense of what our own careers might look like some day, but also with information on how they achieved success, giving us a sense of how we might work to reach that vision. Effective mentors are our role models and are role models for the profession. In his theory on social learning, Bandura22 discusses the importance of role models and how true mentors embody the role of a professional and help us to understand what it takes to achieve competence and expertise in our profession. Wenger,3 on the other hand, argues that it is more important for newcomers to be exposed to a wide variety of career paths so that we can each begin to negotiate our own way in developing a professional identity. As students, we have many mentors, and each may have taken a different path to success. By being exposed to a variety of clinicians with varying levels and types of success, we can begin to define who it is we want to be and how we want to be viewed as professionals. In Chapter 10, this was described as providing the learner with access to history.



KEY POINTS TO REMEMBER


The role of the mentor is to provide the following:



  • Support
  • Challenge
  • Vision

A mentor helps the protégé to navigate the sociopolitical landscape of a new environment and provides both career and psychosocial functions.


MENTORSHIP IN PHYSICAL THERAPY EDUCATION



STOP AND REFLECT



  • In what ways do you think the role of a CI is similar to that of a mentor as described previously? What functions are the same?
  • In what ways do you think the role of a CI is different from that of a mentor as described previously? What functions are different?

The Role of the Clinical Instructor in Mentoring Students


When we enter the clinical setting as physical therapy students, typically we are assigned to a CI for the purpose of orientation and socialization, and to help us make sense of, and apply, our theoretical knowledge. The role of the CI in physical therapy education is similar to, yet somewhat different from, that described by Daloz10 and Kram.14 Responsibilities of the CI include planning for and orienting the student, developing objectives, designing and implementing learning experiences, identifying problems, providing feedback, and completing formative and summative evaluations.24 The role of the CI as assessor, grader, and evaluator is not traditionally viewed as a function of a mentor; however, assessment is critical to the mentor’s ability to provide appropriate challenges and supports and to identify potential barriers to learning. Given that the clinical internship is a component of the professional curriculum, while CIs may not award grades, they do provide input on student performance, which ultimately impacts the grade awarded. Assessment for the purpose of grading raises an issue of power in physical therapy education that may, in some cases, change the dynamics of a traditional mentorship relationship. On the other hand, the CI-student relationship may lay a foundation for future mentoring experiences.


The Learning Triad: Moving Beyond the Clinical Instructor


Physical therapy clinical education today is most often provided in a one-to-one mentoring model consisting of a student-CI dyad. Some would describe this as a formal mentoring relationship, even though it is relatively short lived and focused primarily on career functions and on-the-job training.12,14,12,25 In physical therapy clinical education, this mentoring relationship takes place within a community of practice. So, while Daloz10 suggests that it is the mentor who provides the vision, challenges, and supports, more recent research shows that vision, challenges, supports, and barriers can emerge from many aspects of the clinical setting.1,20,26 Our learning and professional development in the clinical setting are really the result of our interactions with many different individuals. These interactions result in a complex learning triad consisting of the student, the CI, and the entire health care community (eg, patients, families, other therapists, doctors, nurses, other health care workers, other students; Figure 11-1).



art


Figure 11-1. The learning triad.


POTENTIAL BARRIERS AND SUPPORTS TO LEARNING IN THE CLINICAL SETTING


We already described the importance of having access to different challenges in the learning environment, and we defined challenges as those activities, experiences, or ordeals that we are faced with while in the clinical setting that we need to overcome or master as we learn. In contrast, barriers or impediments are factors that hinder our learning, that make it more difficult for us as to overcome or master these challenges, or that constrain or restrict us from fully participating in the community of practice. My (MP) research also highlighted how we each bring our own personal histories and experiences with us to any learning situation, as do the members of the already established community of practice. Interactions that occur within the learning triad have the potential to facilitate and hinder our learning, as both supports and barriers can emanate from each component of this triad (Figure 11-2). Each member of the learning triad presents with his or her own unique set of attributes, knowledge, and skills, so each learning situation is a unique confluence of factors that can support and, at times, impede learning.



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Figure 11-2. Barriers to and supports for the learning process.


Barriers


Boud and Walker27 note that personal assumptions; negative past experiences, expectations, inadequate preparation, lack of time, a hostile, unreceptive, or threatening environment, and the like can present barriers to learning. Many of the students and practicing clinicians I spoke with agreed and shared examples from their own experiences. They discussed how their own past experiences and attributes sometimes negatively influenced the learning situation and described how their own lack of confidence, fear, shyness, language limitations, or cultural differences also hindered their learning at times (Table 11-1).


You may remember from the last chapter, Vera shared a prime example of how her presuppositions and negative past experiences became barriers to her own learning. She described how she tried to avoid conflict with her father at all costs because of his explosive nature. Stories she shared about her interactions with her CI showed that she continued to avoid conflict in a similar manner in the clinical setting as well. As a result, Vera avoided asking questions of her CI and limited the dialogue that occurred. Without dialogue, assumptions were made, both by the student and her CI, which further limited learning. As we have discussed earlier, shared meaning is central to the learning process, and, without dialogue, shared meaning cannot be developed.1,3



Several students and novice clinicians described how their own lack of confidence, fear of being wrong or of making a mistake, prevented them from asking questions or sharing their thoughts. More often than not, they shared how they decided not to disagree with or ask their CI questions because they were afraid to look bad in front of their CIs. This not only limited the dialogue that took place, but also the potential for learning. On the contrary, one student commented on how he much preferred to let his CI see his weaknesses. He found that, by doing so, the CI could help him correct his thinking, and this often resulted in rich discussions that enhanced his learning. However, the reverse, excessive confidence, could be a barrier to a student’s learning as well. Overly confident individuals tend not to ask for confirmation or clarification, making the assumption that they are correct, again limiting the potential for open dialogue and the development of shared meaning.20 By making assumptions and not using your CI for validation and constructive feedback, learners miss the valuable opportunity to hone their own self-assessment skills


However, it is not only the attributes of the students that can pose potential barriers to learning, as certain attributes of the CIs and supervisors can be equally problematic. Of course, just as it can be challenging to work with a CI who has a limited knowledge or skill base, the same can also be said for students who lack knowledge or skill (see Table 11-1). However, what students found to be more of a hindrance to their learning was working with CIs who were inconsistent, overly demanding, condescending, uncaring, or disrespectful. Some students found themselves in clinical settings where the community itself was not receptive or responsive to their needs. They also expressed how working with CIs who lacked skill in providing clear expectations, feedback, and supervision was problematic at times. Even the pace and evaluative nature of the environment can be potential barriers to learning for some in the clinical setting. Table 11-1 also provides some quotes that exemplify potential barriers to learning, resulting from the characteristics of the CI.


Several students and novice clinicians described their experiences with disrespectful clinicians. They described the sense of embarrassment they felt after being reprimanded in front of others and how these reprimands often came without any attempt to actively listen or understand their thinking. The resultant embarrassment closed down communication and made it very difficult for them to face other professionals with any sense of credibility. This fear of embarrassment at times followed them to their next internship and is an example of how negative past experiences can influence future actions and interactions. Once communication was closed down, the negotiation process could not progress and shared meaning was never developed, resulting in a missed learning opportunity. Furthermore, having lost credibility, access to additional challenges and activities may very well be limited, further impeding the entire learning process.1


A number of students described a power differential and how they chose not to risk disagreement or share differences of opinion because they were afraid of receiving a lower grade. This power differential significantly limited their freedom to ask questions and ultimately engage in effective dialogue. To truly engage in dialogue, it is important that each person has the ability to contribute by asking questions, agreeing, disagreeing, or challenging what is being said; and it is important that both participants in any dialogue are open to truly hearing what the other is saying.28 A power differential, where one participant feels more empowered than the other, can limit effective communication. Learners described that, at times, this power differential was exacerbated by CIs who were overly judgmental, authoritative, condescending, or overly demanding. All of this led to limited communication. Without this communication, both access and negotiation of shared meaning were impeded.1


Communication is integral to effective teaching and learning. Communication is a collaborative process that requires openness on the part of both the student and the CI. You remember from Chapter 3 that communication is also a skill that needs to be developed and refined. Just as students have the responsibility to seek and receive feedback on their communication skills, it is equally important that CIs share this responsibility in providing feedback and in seeking feedback on their own skills.



CRITICAL THINKING CLINICAL SCENARIO


You just started your second full-time internship and are preparing for orientation with your new CI. In your last setting, you never really had a good sense of how you were performing and were often afraid to speak up. Your CI had the following 2 strategies for giving you feedback: (1) she would not give you any feedback until the end of the week, so you never knew if you were really on target or not; or (2) she would comment directly in front of patients. Both strategies made you very uncomfortable.


Reflective Questions



  1. What strategies would you discuss with your new CI to help minimize the chances of being faced with some of the issues described above?
  2. What suggestions would you give your CI about how and when you would find feedback most effective?

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May 30, 2017 | Posted by in NURSING | Comments Off on The Learning Triad: Optimizing Supports and Minimizing Barriers to Learning in the Clinical Setting
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