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Exploring the experiences of novice clinical instructors in physical therapy clinical education: a phenomenological study
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Exploring the experiences of novice clinical instructors in physical therapy clinical education: a phenomenological study B.H. Greenfield ∗ , P.H. Bridges, T.A. Phillips, A.N. Drill, C.D. Gaydosik, A. Krishnan, H.J. Yandziak Division of Physical Therapy, Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, GA, USA
Abstract Objective To explore the perceptions of novice physical therapy clinical instructors (CIs) about their interactions and teaching behaviours with physical therapy students. Design A phenomenological approach using semi-structured interviews and a focus group. Participants Six novice physical therapy CIs (less than two years as a CI and supervised fewer than three students) were recruited purposefully from a large metropolitan area in the USA. All participants were credentialed by the American Physical Therapy Association as CIs. Main outcome measures Transcripts of interview data and focus group data were analysed using interpretative analysis for themes and subthemes. Results Participants viewed the transition of students from the classroom to the clinic as their primary role, using strategies of ‘providing a way in’, ‘fostering critical thinking’, ‘finding a balance’, ‘overcoming barriers’ and ‘letting go’. Conclusion While novice CIs showed skill in fostering student reflection and providing orientation, they struggled with student autonomy and balancing the competing obligations of patient care and clinical instruction. They expressed issues related to anxiety and lack of confidence. In the future, novice CIs could benefit from training and support in these areas. © 2014 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. Keywords: Education; Clinical education; Clinical instructor; Novice; Professions; Physical therapy
Introduction Clinical experiences are instrumental for physical therapy students to develop practical knowledge and critical thinking in the context of the uncertainty and unpredictability of clinical practice [1,2]. According to the Commission on Accreditation in Physical Therapy Education, over 20% of a professional physical therapy curriculum is comprised of clinical education; a trend that has been increasing over the last few years [3]. Fundamental to successful clinical learning are the relationship and interactions between the clinical instructor (CI) and physical therapy student [1]. An American Physical Therapy Association (APTA) task force surveyed ∗ Correspondence: Division of Physical Therapy, Department of Rehabilitation Medicine, Emory University School of Medicine, 1462 Clifton Road NE, Suite 312, Atlanta, GA 30322, USA. Tel.: +1 404 712 4139; fax: +1 404 712 4130. E-mail address: [email protected] (B.H. Greenfield).
members of the education community to identify knowledge and skills needed by CIs to demonstrate competency and foster behaviours and dispositions essential for clinical learning. The survey results were used to craft the ‘Guidelines for Clinical Instructors’ which became the foundation of the ‘Clinical Instructor Education and Credentialing Program’ (CIECP), developed in 1997 under the direction of Michael J. Emery, PT, EdD [4,5]. A standardised and formalised CI credentialling course, the re-named ‘Credentialed Clinical Instructor Program’ (CCIP) [4] was designed for rehabilitation therapists involved in clinical education. Content and learning objectives teach CIs to optimise clinical education experiences (Box 1). As of 2012, 37,000 physical therapists and physical therapy assistants have been awarded credentials. Studies exploring the effectiveness of credentialled vs non-credentialled CIs have reported mixed outcomes [6,7]. The centrality of the clinical teacher has resulted in studies and documents exploring and delineating characteristics,
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with three experienced clinicians in order to standardise processes. Questions were formulated in a previous study by Greenfield et al. [12] (Appendix 1, available on request from corresponding author). Pseudonyms were used to protect the participants’ identities.
Box 1: Overall objectives of the Credentialed Clinical Instructor Program [4]. The participant will be able to: Describe the parallel roles between clinician and clinical educator Plan and prepare for the clinical education experiences of students Identify the needs of the student learner and areas of competence Develop high-quality learning experiences Support ongoing adult learning through clinical teaching methods and supervisory techniques Demonstrate skills in effective formative and summative evaluation Identify legal implications for clinical educators Identify and manage the student who is demonstrating problem performance or exceptional performance
Participants
behaviours, dispositions, qualities, and the teaching and clinical skills of instructors across various practice settings [1,8–15]. Most studies have examined these factors in experienced and expert CIs, but not novice CIs. Research comparing novice and expert clinicians has helped academicians and clinicians understand practice pattern differences and similarities [16–18], thereby providing strategies for education and clinical training. Similar insights and innovative training strategies may be gained by exploring the characteristics, behaviours and dispositions of novice CIs. Therefore, the purpose of this study was to obtain a first-person account of how novice CIs perceive their roles and interactions with students.
Methods
Participants were recruited from a sample of 38 novice CIs who completed the CIECP sponsored by the Division of Physical Therapy, Emory University from 30 to 31 July 2010. Based on previous studies of experienced CIs, and experienced and novice clinicians [12,18,21], a novice CI was defined as having served as a CI for less than two years and having trained fewer than three physical therapy students. Ten individuals met the inclusion criteria and six agreed to participate, including five females and one male practising in a variety of clinical settings. Five participated in both the initial interview and a focus group. Each interview lasted for approximately 60 minutes, and the focus group lasted for approximately 2 to 3 hours. Demographic data are shown in Table 1. Pseudonyms were used to de-identify the participants. Data analysis Fig. A (see online supplementary material) outlines the chronology of data analysis, and Appendix 2 (available on request from corresponding author) describes specific methods of data analysis and reduction, including steps taken to establish trustworthiness [22].
Design An interpretative narrative phenomenological approach was used to explore the lived experiences of novice CIs based on their own perceptions. Phenomenology is a philosophy and methodology that discovers how individuals perceive and constitute personal experiences [19,20], consistent with this study’s purpose. The research team consisted of three faculty members with several years of experience in qualitative research design and analysis, as well as four physical therapy students. Throughout data collection and analysis, the faculty trained and mentored the students in the qualitative method and analysis. Individual practice interviews were conducted
Results Role of participants Novice CIs envision their roles as ‘guides’, ‘role models’ and ‘coaches’ to translate classroom learning into clinical application; an approach perceived as vastly different from academic teaching. Descriptions included the following: ‘I see my role as a CI as an important adjunct to classroom education. . .I can help to integrate those principles into realworld situations.’ [David]
Table 1 Demographic information. Participant
Sex
Age (years)
Setting
Degree
Experience (years)
Experience as a CI (years)
Number of students supervised
Andrea Hannah David Kelly Carolyn Susan
F F M F F F
28 29 28 28 29 35
Acute Outpatient Outpatient Inpatient rehabilitation Inpatient rehabilitation Acute/academic institution
DPT DPT DPT DPT PT DPT, MPH, CHES
2.5 2.0 2.5 2.0 2.0 7.0
1.0 0.5 1.0 1.0 1.0 6.0
1 1 2 2 2 1
CI, clinical instructor.
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‘I mean teaching [in the classroom] is more lecturing. But I see an educator in a clinical setting; it’s more of an interaction.’ [Andrea] Scully and Shepard [8] explained differences in the roles and teaching style between CIs and teachers in the classroom: ‘Because patient primacy may run counter to student educational goals, the teaching tools used in clinical teaching situations are uniquely shaped and often vastly different from teaching tools used in academic settings [p. 352].’ Scully and Shepard cited coaching, a supervision technique frequently used in clinical instruction, as a hallmark differentiating academic from clinical teaching. They noted that when demonstrating a skill, the CI may ask the student to look or ‘feel’. The opportunity to ‘feel’ real patient impairments distinguishes coaching from classroom laboratory demonstration in the eyes of many CIs. In this study, the phrase ‘transitioning a student from paper to person’ was used to capture the distinction that novice CIs made between their teaching role in the clinic and that in the classroom. Fig. 1 illustrates the relationship of these subthemes to the overarching theme of transitioning the student. Scully and Shepard [8], Irby [15] and Mostrom [1] commented that primacy of patient care affects all levels of clinical education, including assignment of CIs (and in the case of Irby, medical clinical teachers), patient selection and on-the-spot feedback. Not surprisingly, as indicated in the quotes below, novice CIs were challenged in ‘finding a balance’ between caring for their patients and teaching students:
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‘Of course, the underlying priority is the patient is going to get what he needs. Yes, the student learning is important, but my first priority as a physical therapist is the patient gets the proper treatment.’ [Andrea] ‘Also I think the other challenge is just time, even if you’re not spending a lot of extra time doing patient encounters, there is obviously a lot more documentation time involved because you’re having to double check everything.’ [David] Previous literature highlights the dual goal of excellent patient care with excellent clinical instruction. Mostrom [1], Scully and Shepard [8], and Irby [15] reported that more experienced CIs have learned to integrate patient care successfully into learning experiences with students. The results of this study indicate that efforts should be made to help novice CIs, who in many cases are novice clinicians, to manage patient loads until they become more skilled at integrating patient care into clinical teaching. Teaching strategies When asked specifically about teaching strategies, novice CIs discussed a process of incremental learning beginning with ‘providing students a way in’, and progressing them to greater responsibility (‘letting them go’) in caring for patients. One participant said: ‘I would have the student observe for a day or two first. . .then, I let them do pieces of an evaluation and treatment of a less complex patient first. I move them on to harder and harder stuff as they get more comfortable.’ [Kelly]
Fig. 1. Schematic interpretation of theme and subthemes.
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This incremental approach includes the use of critical thinking through a reflective process of questioning and discussion; a process used for both learning and assessing competence in patient care. ‘I try to get students to think of things, asking them questions, trying to get the answers themselves instead of just lecturing them.’ [Susan]
me taking a lesser case load, so I can spend more time educating the student with initial orientation and that kind of stuff.’ [Andrea] ‘When I was in acute care, [. . .] one thing my CI did was let me shadow the speech and occupational therapists, and spend a day in the ER. It was a good learning environment, and I try to do the same with my students.’ [David]
Another participant used role playing to facilitate reflection: ‘If the student was doing something completely wrong, I might step in and say ‘let me try something with the patient’ and then later role play the situation. I’d say, ‘OK this is what was going on during this patient interaction. What can be improved?’.’ [Hannah] To facilitate learning throughout the clinical education experience, participants spoke of the importance of providing a positive learning environment via empathy and compassion: ‘One hard and fast rule is I will never humiliate students in front of anyone. One of my main themes as a CI is respecting the student as an adult learner, not treating him like a child, being condescending, or embarrassing him in any way.’ [Susan] The ethical commitment to provide a learning environment that is ‘safe’ and caring is a hallmark of good clinical instruction. Other researchers [1,6,9–12,23] described the value that students placed on CIs who created a positive learning environment. Interestingly, the goal of providing a safe and humanistic learning environment is supported by recent research into the neuroscience of learning. Imaging techniques have illustrated the emotional salience of shortand long-term memory formation related to learning [24]. In this study, CIs drew upon their own experiences as recent students, attempting to emulate situations where they felt most comfortable and respected: ‘Even though it’s been longer than 3 and a half years since I was a student in clinic, I still remember the way certain CIs gave me feedback; ways I liked and ways that made me feel like a complete idiot. So that affected how I presented as a CI.’ [Andrea] ‘I think it allows us to possibly be more empathetic to students and what they’re going through if we’ve recently gone though it ourselves. [. . .] we’ve recently been there, being unsure of learning new subjects, new topics and new themes.’ [David]
Barriers and challenges Letting go Part of incremental learning is allowing students to take greater responsibility in patient care. This decision may involve a set of external performance criteria, but also involves judgement and prior experience [23,25]. Novice CIs expressed uncertainty about when to transfer greater patient care responsibility to students: ‘[My biggest challenge is] when to know to let the student take the reins and really direct everything and not be under my wing. It’s kind of multifactorial, you want the student to be confident so the patient is comfortable, and assuming they know how to do everything sufficiently, just know when to merge them into a more independent treatment.’ [Hannah] One participant talked about letting the student be more independent during interactions with hospital staff, while fighting the urge to jump in: ‘Knowing when to hold back can be a fairly big challenge, and I think for me, [. . .], it’s again interpersonal communication with other staff. Everyone’s busy, the nurses and the attending MDs are busy, and you want to just jump in there and say what the student means to say or is asking. But then you realise even though they are busy, this is a teaching hospital, and it is important to have the student be able to figure out on their own how to be concise and succinct with what they have to say. I know that has been a challenge for me, knowing when to hold back, even if it means letting them squirm and be uncomfortable, in order to get a sense of how much time they really have for talking with people.’ [Susan]
Lack of confidence A significant challenge for novice CIs was dealing with their own fears and anxiety when it came to lack of experience and confidence:
Similar to findings in previous research that explored how clinical learning involves a community of practice [23,25], novice CIs also found that the attitude and contribution of their organisations and their colleagues were important to create a caring and supportive environment for the students and the novice CIs:
‘[My biggest concern is] my own knowledge base. You know, just not having seen everything out there. So I worry if the students ask me a question, I may not know the answer, hopefully I do. There’s always a fear.’ [Hannah]
‘The whole staff is supportive. It’s pretty easy to balance things at the beginning because everyone’s so supportive of
A participant expressed concerns about his knowledge base and experience as a novice clinician:
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‘I would just say lack of confidence due to lack of experience and just not being confident in what you told that person.’ [Kelly] ‘I would probably say the main thing about being a new CI is, it’s scary at first, but it turns out you learn a lot from the student. I think that is an important thing. . . not only is the student learning, but the instructor gets to learn a lot too by teaching.’ [Kelly] ‘Since I’ve only been out for 3 years, there’s still stuff that I’m figuring out. I would like to think I know everything, but I don’t and so I was kind of nervous. . .I want to look professional. . .have the students see me as an educator, have the student have a good experience. I wanted to be the best I could for them because I saw it as a big learning experience for them. And I don’t want to say ‘I don’t know a lot or look it up a lot’.’ [Andrea] Interestingly, when Mostrom [1] asked exemplary CIs for advice for novice CIs, it mirrored concerns expressed by the novices in this study: ‘Don’t try to know it all! You don’t need to know everything. If you don’t know something, admit that to the student and learn with them [p. 168].’ Time and organisational constraints In addition to lack of confidence and experience, many of the novice CIs struggled with multiple clinical responsibilities as a clinician and a CI. One participant described time restrictions as one of her biggest challenges: ‘For me [my biggest challenge is] time, although initially we’re given a little bit of time for orienting the student to our facility. We have several meetings during lunch, and it’s just difficult to be able to have one-on-one time with the student, when your time at the beginning of the day, the middle of the day, and the end of the day are all taken up with other things. So that’s a barrier.’ [Carla] Another participant explained how productivity expectations can be harmful to student learning: ‘I think these days in managed care there is a huge focus for therapists on units, how many units you get per day, and are you meeting your unit goal? So I think that, alongside of all those things, that’s a huge barrier for CIs, feeling like they have to keep up with their unit expectations, which are still at x number when they have a student, and so it seems like it would be good for facilities to really take that into account. If a therapist has students, lower their productivity expectations, at least at the beginning.’ [Susan] The difficult student Another challenge for some novice CIs was working with a difficult student: ‘A student who was a little over-confident came in, and just couldn’t understand some of the ways I was doing things. She
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would say, ‘why aren’t you measuring this way, why aren’t you. . .’ but she went to a school that taught a certain belief of thought in manual therapy that is different from the school I came from.’ [David] Working with difficult students is an ongoing challenge for CIs [1], similar to the patient–clinician interaction [21,26]. Recent literature has attempted to reframe the problem more equitably as a difficult patient and provider relationship [27]. In a study of experienced CIs, Mostrom [1] reported that many embraced the challenge of working with difficult students, and found it a good learning experience. Similarly, in clinical practice, Greenfield [28] found that experienced physical therapists are better able to navigate difficult patient encounters than their novice counterparts. Novices often struggle in their dealings with patients perceived as difficult, often blaming the patient for breakdowns in communication.
Physical therapist students This study suggests that additional strategies are needed for the novice CI in order to find a balance between patient care and clinical responsibilities, deal with difficult students, develop confidence as a CI, and learn when to let the student go. Developing these behaviours is critical for improving the quality of the clinical education experience for physical therapy students. The study raises the question of CI preparedness, and whether a 2-day course in CI training is sufficient to create the necessary disposition for action, reflective of higher-level and long-term learning. Historically, most experienced and exemplary CIs and teachers learn on the job [1,8,15]. Novice CIs have little or no experience from which to draw. Although novice CIs in this study indicated that the CIECP helped to organise learning experiences with their students (see Box 1), they pointed to their own experiences as students as their primary method for clinical instruction and student interaction. Experienced CIs use multiple knowledge sources including their own student experiences and those with their patients [1]. As these novice CIs reflected on their own student experiences to create teaching strategies that they felt were most effective, there may be a need to encourage CIs to use a formal process of critical reflection as part of their personal development as CIs. In his seminal book, ‘Democracy in Education’, Dewey [29] advocated reflective practice to create dispositions or habits of mind to develop intellectual and emotional dispositions for action. Both Mostrom [1] and Irby [15] reported that experienced CIs and exemplary medical clinical teachers used ongoing reflection to improve teaching skills with students. The CIECP encourages CIs to use reflection on – and for – action to improve students’ critical thinking, and might want to consider encouraging CIs to use narratives (as an example) to reflect on their own roles and behaviours with students.
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Future revisions of the CIECP, now the CCIP, should include these approaches. Directors of clinical facilities and centre coordinators of clinical education will find these results helpful in understanding the needs of CIs. Facility support to smooth the transition, including decreased patient load, scheduled education time, mentoring and other resources, will help CIs to focus on their students’ needs. Finally, academicians responsible for clinical education programmes would benefit from understanding the experience of the novice CI. It appears that although novice CIs struggle with some issues, they have considerable insight into the critical components of being a good educator, and should participate in clinical education programmes.
Limitations
Based on these findings, it is recommended that novice CIs who are also novice clinicians should be mentored in developing better skills to integrate patient care demands with student care demands, including strategies that experienced CIs use to integrate their patients as active participants in teaching students. This could be accomplished by simply asking if patients would like to provide feedback to students. Novice CIs should be taught to use reflection on – and for – action, perhaps through narrative and journals to learn from their experiences. Reflective narrative could provide invaluable insights for novice CIs to improve their judgement about dealing with difficult students, or learning the proper timing to provide students more responsibility in patient care. Ethical approval: Exemption from Emory University Institutional Review Board. Conflicts of interest: None declared.
Although consistent with other phenomenological studies, this study had a small sample size of six participants, all of whom were from the Atlanta area. Additionally, only five of the six individuals were able to participate in the focus group, so further clarification of themes was not possible with one person. When this project began, Emory’s programmatic curriculum embedded 36 weeks of clinical internships between project inception and completion. Therefore, a significant amount of time elapsed between the initial interviews and the focus group, which may have affected the responses. The possibility exists that a CI may have had additional students and experience since the first interview. Inherent to any focus group or group-think activity is a tendency for participants to agree with each other, rather than develop individual answers or thoughts. It is important to note that while most participants were novice CIs and clinicians, one participant was a more experienced clinician. This leads one to question if differences exist among novice CIs related to their years of experience as a clinician. Finally, it would be interesting to explore if distinctions are present between APTAcredentialled novice CIs and uncredentialled novice CIs.
Conclusion The exploration of lived experiences provided a deeper understanding of the novice CI. Emergent themes were similar to those exhibited by their more experienced colleagues, such as reflective practice, reciprocal and incremental learning, and creating a positive learning environment. Furthermore, there was agreement that the main purpose of a clinical experience is to transition the student from ‘paper to person’. However, some of these concepts are taught in the CIECP, so it remains unclear if these behaviours are inherent dispositions for action. Novice CIs struggle with confidence in their abilities to instruct, striking a balance, and deciding when to allow a student more independence. These conflicts may be linked to the fact that the novice CI is often a novice clinician as well.
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/ j.physio.2013.10.005.
References [1] Mostrom E. What makes a good clinical teacher? In: Jensen GM, Mostrom E, editors. Handbook of teaching and learning for physical therapists. 3rd ed. St. Louis: Elsevier; 2013. [2] Schon D. The reflective practitioner: how professionals think in action. London: Ashgate; 1991. [3] Commission on Accreditation of Physical Therapy Education. Physical therapist education programs 2010–2011. Fact sheet. Alexandria, VA: American Physical Therapy Association; 2011. [4] American Physical Therapy Association. Credentialed Clinical Instructor Program. Alexandra, VA: American Physical Therapy Association; 1997. Revised 2005. [5] Wojciechowski M. Clinical instructor education and credentialing program: a decade later. PT Magazine 2007;February:70–4. [6] Wetherbee E, Nordum J, Giles S. Effective teaching behavior of APTA credentialed vs. non-credentialed clinical instructors. J Phys Ther Educ 2008;22:65–74. [7] Giles S, Wetherbee E, Johnson S. Qualifications and credentials of clinical instructors supervising physical therapist students. J Phys Ther Educ 2003;17:50–5. [8] Scully M, Shepard K. Clinical teaching in physical therapy education: an ethnographic approach. Phys Ther 1983;63:349–58. [9] Buccieri KM, Pivko SE, Olzenak DL. How does a physical therapist acquire the skills of an expert clinical instructor? J Phys Ther Educ 2011;25:17–23. [10] Emery M. Effectiveness of the clinical instructor: students’ perspective. Phys Ther 1984;64:1079–83. [11] Jarski RW, Kulig K, Olson RE. Clinical teaching in physical therapy: student and teacher perceptions. Phys Ther 1990;70:173–8. [12] Greenfield B, Bridges PH, Hoy S, Metzger R, Obuaya Resutek L. Exploring experienced clinical instructors’ experiences in physical therapist clinical education: a phenomenological study. J Phys Ther Educ 2012;26:40–7.
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[13] American Physical Therapy Department of Education. APTA clinical education principles. Alexandria, VA: American Physical Therapy Association; 2010. Available at: http://www.apta. orgPTClinicalEducationPrinciples/ (accessed 01.10.13). [14] Page CG, Ross IA. Instructional strategies utilized by physical therapist clinical instructors: an explanatory study. J Phys Ther Educ 2004;18:43–9. [15] Irby D. What clinical teachers in medicine need to know? Acad Med 1994;69:333–42. [16] Jensen G, Resnik L, Haddad A. Expertise and clinical reasoning. In: Higgs J, Jones M, Loftus S, Christensen N, editors. Clinical reasoning in the health professions. 3rd ed. Boston, MA: Elsevier; 2008. p. 123–36. [17] Benner P, Chesla C. Expertise in nursing practice: caring, clinical judgment, and ethics. New York: Springer Publishing Company; 1996. [18] Jensen GM, Shepard KF, Hack LM. The novice versus the experienced clinician: insights into the work of the physical therapist. Phys Ther 1990;70:314–32. [19] Giorgi A. The phenomenological movement and research in the human sciences. Nurs Sci Quart 2005;18:75–82. [20] Creswell J, Plano V. Designing and conducting mixed methods research. Thousand Oaks, CA: Sage; 2007.
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[21] Greenfield BH, Anderson A, Cox B, Tanner MC. Meaning of caring to 7 novice physical therapists during their first year of clinical practice. Phys Ther 2008;88:1154–66. [22] Patton M. Qualitative research and evaluation methods. 3rd ed. Thousand Oaks, CA: Sage; 2002. [23] Plack M, Driscoll M. Teaching and learning in physical therapy: from classroom to clinic. Thorofare, NJ: Slack; 2011. [24] Dubinsky JA, Roehrig G, Varma S. Infusing neuroscience into teacher professional development. Educ Res 2013;42:317–29. [25] Lave J, Wenger E. Situated learning: legitimate peripheral participation. New York: Cambridge University Press; 1991. [26] Potter M, Gordon S, Hamer P. The difficult patient in private practice physiotherapy: a qualitative study. Aust J Physiother 2003;49: 54–61. [27] Blackall GF, Green MJ. ‘Difficult’ patients or difficult relationships? Am J Bioeth 2012;12:8–9. [28] Greenfield BH. The meaning of caring in five experienced physical therapists. Physiother Ther Pract 2006;22:175–87. [29] Dewey J. Democracy in education: an introduction to the philosophy of education. New York: Free Press; 1916.
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Exploring the experiences of novice clinical instructors in physical therapy clinical education: a phenomenological study B.H. Greenfield ∗ , P.H. Bridges, T.A. Phillips, A.N. Drill, C.D. Gaydosik, A. Krishnan, H.J. Yandziak Division of Physical Therapy, Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, GA, USA
Abstract Objective To explore the perceptions of novice physical therapy clinical instructors (CIs) about their interactions and teaching behaviours with physical therapy students. Design A phenomenological approach using semi-structured interviews and a focus group. Participants Six novice physical therapy CIs (less than two years as a CI and supervised fewer than three students) were recruited purposefully from a large metropolitan area in the USA. All participants were credentialed by the American Physical Therapy Association as CIs. Main outcome measures Transcripts of interview data and focus group data were analysed using interpretative analysis for themes and subthemes. Results Participants viewed the transition of students from the classroom to the clinic as their primary role, using strategies of ‘providing a way in’, ‘fostering critical thinking’, ‘finding a balance’, ‘overcoming barriers’ and ‘letting go’. Conclusion While novice CIs showed skill in fostering student reflection and providing orientation, they struggled with student autonomy and balancing the competing obligations of patient care and clinical instruction. They expressed issues related to anxiety and lack of confidence. In the future, novice CIs could benefit from training and support in these areas. © 2014 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. Keywords: Education; Clinical education; Clinical instructor; Novice; Professions; Physical therapy
Introduction Clinical experiences are instrumental for physical therapy students to develop practical knowledge and critical thinking in the context of the uncertainty and unpredictability of clinical practice [1,2]. According to the Commission on Accreditation in Physical Therapy Education, over 20% of a professional physical therapy curriculum is comprised of clinical education; a trend that has been increasing over the last few years [3]. Fundamental to successful clinical learning are the relationship and interactions between the clinical instructor (CI) and physical therapy student [1]. An American Physical Therapy Association (APTA) task force surveyed ∗ Correspondence: Division of Physical Therapy, Department of Rehabilitation Medicine, Emory University School of Medicine, 1462 Clifton Road NE, Suite 312, Atlanta, GA 30322, USA. Tel.: +1 404 712 4139; fax: +1 404 712 4130. E-mail address: [email protected] (B.H. Greenfield).
members of the education community to identify knowledge and skills needed by CIs to demonstrate competency and foster behaviours and dispositions essential for clinical learning. The survey results were used to craft the ‘Guidelines for Clinical Instructors’ which became the foundation of the ‘Clinical Instructor Education and Credentialing Program’ (CIECP), developed in 1997 under the direction of Michael J. Emery, PT, EdD [4,5]. A standardised and formalised CI credentialling course, the re-named ‘Credentialed Clinical Instructor Program’ (CCIP) [4] was designed for rehabilitation therapists involved in clinical education. Content and learning objectives teach CIs to optimise clinical education experiences (Box 1). As of 2012, 37,000 physical therapists and physical therapy assistants have been awarded credentials. Studies exploring the effectiveness of credentialled vs non-credentialled CIs have reported mixed outcomes [6,7]. The centrality of the clinical teacher has resulted in studies and documents exploring and delineating characteristics,
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with three experienced clinicians in order to standardise processes. Questions were formulated in a previous study by Greenfield et al. [12] (Appendix 1, available on request from corresponding author). Pseudonyms were used to protect the participants’ identities.
Box 1: Overall objectives of the Credentialed Clinical Instructor Program [4]. The participant will be able to: Describe the parallel roles between clinician and clinical educator Plan and prepare for the clinical education experiences of students Identify the needs of the student learner and areas of competence Develop high-quality learning experiences Support ongoing adult learning through clinical teaching methods and supervisory techniques Demonstrate skills in effective formative and summative evaluation Identify legal implications for clinical educators Identify and manage the student who is demonstrating problem performance or exceptional performance
Participants
behaviours, dispositions, qualities, and the teaching and clinical skills of instructors across various practice settings [1,8–15]. Most studies have examined these factors in experienced and expert CIs, but not novice CIs. Research comparing novice and expert clinicians has helped academicians and clinicians understand practice pattern differences and similarities [16–18], thereby providing strategies for education and clinical training. Similar insights and innovative training strategies may be gained by exploring the characteristics, behaviours and dispositions of novice CIs. Therefore, the purpose of this study was to obtain a first-person account of how novice CIs perceive their roles and interactions with students.
Methods
Participants were recruited from a sample of 38 novice CIs who completed the CIECP sponsored by the Division of Physical Therapy, Emory University from 30 to 31 July 2010. Based on previous studies of experienced CIs, and experienced and novice clinicians [12,18,21], a novice CI was defined as having served as a CI for less than two years and having trained fewer than three physical therapy students. Ten individuals met the inclusion criteria and six agreed to participate, including five females and one male practising in a variety of clinical settings. Five participated in both the initial interview and a focus group. Each interview lasted for approximately 60 minutes, and the focus group lasted for approximately 2 to 3 hours. Demographic data are shown in Table 1. Pseudonyms were used to de-identify the participants. Data analysis Fig. A (see online supplementary material) outlines the chronology of data analysis, and Appendix 2 (available on request from corresponding author) describes specific methods of data analysis and reduction, including steps taken to establish trustworthiness [22].
Design An interpretative narrative phenomenological approach was used to explore the lived experiences of novice CIs based on their own perceptions. Phenomenology is a philosophy and methodology that discovers how individuals perceive and constitute personal experiences [19,20], consistent with this study’s purpose. The research team consisted of three faculty members with several years of experience in qualitative research design and analysis, as well as four physical therapy students. Throughout data collection and analysis, the faculty trained and mentored the students in the qualitative method and analysis. Individual practice interviews were conducted
Results Role of participants Novice CIs envision their roles as ‘guides’, ‘role models’ and ‘coaches’ to translate classroom learning into clinical application; an approach perceived as vastly different from academic teaching. Descriptions included the following: ‘I see my role as a CI as an important adjunct to classroom education. . .I can help to integrate those principles into realworld situations.’ [David]
Table 1 Demographic information. Participant
Sex
Age (years)
Setting
Degree
Experience (years)
Experience as a CI (years)
Number of students supervised
Andrea Hannah David Kelly Carolyn Susan
F F M F F F
28 29 28 28 29 35
Acute Outpatient Outpatient Inpatient rehabilitation Inpatient rehabilitation Acute/academic institution
DPT DPT DPT DPT PT DPT, MPH, CHES
2.5 2.0 2.5 2.0 2.0 7.0
1.0 0.5 1.0 1.0 1.0 6.0
1 1 2 2 2 1
CI, clinical instructor.
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‘I mean teaching [in the classroom] is more lecturing. But I see an educator in a clinical setting; it’s more of an interaction.’ [Andrea] Scully and Shepard [8] explained differences in the roles and teaching style between CIs and teachers in the classroom: ‘Because patient primacy may run counter to student educational goals, the teaching tools used in clinical teaching situations are uniquely shaped and often vastly different from teaching tools used in academic settings [p. 352].’ Scully and Shepard cited coaching, a supervision technique frequently used in clinical instruction, as a hallmark differentiating academic from clinical teaching. They noted that when demonstrating a skill, the CI may ask the student to look or ‘feel’. The opportunity to ‘feel’ real patient impairments distinguishes coaching from classroom laboratory demonstration in the eyes of many CIs. In this study, the phrase ‘transitioning a student from paper to person’ was used to capture the distinction that novice CIs made between their teaching role in the clinic and that in the classroom. Fig. 1 illustrates the relationship of these subthemes to the overarching theme of transitioning the student. Scully and Shepard [8], Irby [15] and Mostrom [1] commented that primacy of patient care affects all levels of clinical education, including assignment of CIs (and in the case of Irby, medical clinical teachers), patient selection and on-the-spot feedback. Not surprisingly, as indicated in the quotes below, novice CIs were challenged in ‘finding a balance’ between caring for their patients and teaching students:
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‘Of course, the underlying priority is the patient is going to get what he needs. Yes, the student learning is important, but my first priority as a physical therapist is the patient gets the proper treatment.’ [Andrea] ‘Also I think the other challenge is just time, even if you’re not spending a lot of extra time doing patient encounters, there is obviously a lot more documentation time involved because you’re having to double check everything.’ [David] Previous literature highlights the dual goal of excellent patient care with excellent clinical instruction. Mostrom [1], Scully and Shepard [8], and Irby [15] reported that more experienced CIs have learned to integrate patient care successfully into learning experiences with students. The results of this study indicate that efforts should be made to help novice CIs, who in many cases are novice clinicians, to manage patient loads until they become more skilled at integrating patient care into clinical teaching. Teaching strategies When asked specifically about teaching strategies, novice CIs discussed a process of incremental learning beginning with ‘providing students a way in’, and progressing them to greater responsibility (‘letting them go’) in caring for patients. One participant said: ‘I would have the student observe for a day or two first. . .then, I let them do pieces of an evaluation and treatment of a less complex patient first. I move them on to harder and harder stuff as they get more comfortable.’ [Kelly]
Fig. 1. Schematic interpretation of theme and subthemes.
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This incremental approach includes the use of critical thinking through a reflective process of questioning and discussion; a process used for both learning and assessing competence in patient care. ‘I try to get students to think of things, asking them questions, trying to get the answers themselves instead of just lecturing them.’ [Susan]
me taking a lesser case load, so I can spend more time educating the student with initial orientation and that kind of stuff.’ [Andrea] ‘When I was in acute care, [. . .] one thing my CI did was let me shadow the speech and occupational therapists, and spend a day in the ER. It was a good learning environment, and I try to do the same with my students.’ [David]
Another participant used role playing to facilitate reflection: ‘If the student was doing something completely wrong, I might step in and say ‘let me try something with the patient’ and then later role play the situation. I’d say, ‘OK this is what was going on during this patient interaction. What can be improved?’.’ [Hannah] To facilitate learning throughout the clinical education experience, participants spoke of the importance of providing a positive learning environment via empathy and compassion: ‘One hard and fast rule is I will never humiliate students in front of anyone. One of my main themes as a CI is respecting the student as an adult learner, not treating him like a child, being condescending, or embarrassing him in any way.’ [Susan] The ethical commitment to provide a learning environment that is ‘safe’ and caring is a hallmark of good clinical instruction. Other researchers [1,6,9–12,23] described the value that students placed on CIs who created a positive learning environment. Interestingly, the goal of providing a safe and humanistic learning environment is supported by recent research into the neuroscience of learning. Imaging techniques have illustrated the emotional salience of shortand long-term memory formation related to learning [24]. In this study, CIs drew upon their own experiences as recent students, attempting to emulate situations where they felt most comfortable and respected: ‘Even though it’s been longer than 3 and a half years since I was a student in clinic, I still remember the way certain CIs gave me feedback; ways I liked and ways that made me feel like a complete idiot. So that affected how I presented as a CI.’ [Andrea] ‘I think it allows us to possibly be more empathetic to students and what they’re going through if we’ve recently gone though it ourselves. [. . .] we’ve recently been there, being unsure of learning new subjects, new topics and new themes.’ [David]
Barriers and challenges Letting go Part of incremental learning is allowing students to take greater responsibility in patient care. This decision may involve a set of external performance criteria, but also involves judgement and prior experience [23,25]. Novice CIs expressed uncertainty about when to transfer greater patient care responsibility to students: ‘[My biggest challenge is] when to know to let the student take the reins and really direct everything and not be under my wing. It’s kind of multifactorial, you want the student to be confident so the patient is comfortable, and assuming they know how to do everything sufficiently, just know when to merge them into a more independent treatment.’ [Hannah] One participant talked about letting the student be more independent during interactions with hospital staff, while fighting the urge to jump in: ‘Knowing when to hold back can be a fairly big challenge, and I think for me, [. . .], it’s again interpersonal communication with other staff. Everyone’s busy, the nurses and the attending MDs are busy, and you want to just jump in there and say what the student means to say or is asking. But then you realise even though they are busy, this is a teaching hospital, and it is important to have the student be able to figure out on their own how to be concise and succinct with what they have to say. I know that has been a challenge for me, knowing when to hold back, even if it means letting them squirm and be uncomfortable, in order to get a sense of how much time they really have for talking with people.’ [Susan]
Lack of confidence A significant challenge for novice CIs was dealing with their own fears and anxiety when it came to lack of experience and confidence:
Similar to findings in previous research that explored how clinical learning involves a community of practice [23,25], novice CIs also found that the attitude and contribution of their organisations and their colleagues were important to create a caring and supportive environment for the students and the novice CIs:
‘[My biggest concern is] my own knowledge base. You know, just not having seen everything out there. So I worry if the students ask me a question, I may not know the answer, hopefully I do. There’s always a fear.’ [Hannah]
‘The whole staff is supportive. It’s pretty easy to balance things at the beginning because everyone’s so supportive of
A participant expressed concerns about his knowledge base and experience as a novice clinician:
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‘I would just say lack of confidence due to lack of experience and just not being confident in what you told that person.’ [Kelly] ‘I would probably say the main thing about being a new CI is, it’s scary at first, but it turns out you learn a lot from the student. I think that is an important thing. . . not only is the student learning, but the instructor gets to learn a lot too by teaching.’ [Kelly] ‘Since I’ve only been out for 3 years, there’s still stuff that I’m figuring out. I would like to think I know everything, but I don’t and so I was kind of nervous. . .I want to look professional. . .have the students see me as an educator, have the student have a good experience. I wanted to be the best I could for them because I saw it as a big learning experience for them. And I don’t want to say ‘I don’t know a lot or look it up a lot’.’ [Andrea] Interestingly, when Mostrom [1] asked exemplary CIs for advice for novice CIs, it mirrored concerns expressed by the novices in this study: ‘Don’t try to know it all! You don’t need to know everything. If you don’t know something, admit that to the student and learn with them [p. 168].’ Time and organisational constraints In addition to lack of confidence and experience, many of the novice CIs struggled with multiple clinical responsibilities as a clinician and a CI. One participant described time restrictions as one of her biggest challenges: ‘For me [my biggest challenge is] time, although initially we’re given a little bit of time for orienting the student to our facility. We have several meetings during lunch, and it’s just difficult to be able to have one-on-one time with the student, when your time at the beginning of the day, the middle of the day, and the end of the day are all taken up with other things. So that’s a barrier.’ [Carla] Another participant explained how productivity expectations can be harmful to student learning: ‘I think these days in managed care there is a huge focus for therapists on units, how many units you get per day, and are you meeting your unit goal? So I think that, alongside of all those things, that’s a huge barrier for CIs, feeling like they have to keep up with their unit expectations, which are still at x number when they have a student, and so it seems like it would be good for facilities to really take that into account. If a therapist has students, lower their productivity expectations, at least at the beginning.’ [Susan] The difficult student Another challenge for some novice CIs was working with a difficult student: ‘A student who was a little over-confident came in, and just couldn’t understand some of the ways I was doing things. She
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would say, ‘why aren’t you measuring this way, why aren’t you. . .’ but she went to a school that taught a certain belief of thought in manual therapy that is different from the school I came from.’ [David] Working with difficult students is an ongoing challenge for CIs [1], similar to the patient–clinician interaction [21,26]. Recent literature has attempted to reframe the problem more equitably as a difficult patient and provider relationship [27]. In a study of experienced CIs, Mostrom [1] reported that many embraced the challenge of working with difficult students, and found it a good learning experience. Similarly, in clinical practice, Greenfield [28] found that experienced physical therapists are better able to navigate difficult patient encounters than their novice counterparts. Novices often struggle in their dealings with patients perceived as difficult, often blaming the patient for breakdowns in communication.
Physical therapist students This study suggests that additional strategies are needed for the novice CI in order to find a balance between patient care and clinical responsibilities, deal with difficult students, develop confidence as a CI, and learn when to let the student go. Developing these behaviours is critical for improving the quality of the clinical education experience for physical therapy students. The study raises the question of CI preparedness, and whether a 2-day course in CI training is sufficient to create the necessary disposition for action, reflective of higher-level and long-term learning. Historically, most experienced and exemplary CIs and teachers learn on the job [1,8,15]. Novice CIs have little or no experience from which to draw. Although novice CIs in this study indicated that the CIECP helped to organise learning experiences with their students (see Box 1), they pointed to their own experiences as students as their primary method for clinical instruction and student interaction. Experienced CIs use multiple knowledge sources including their own student experiences and those with their patients [1]. As these novice CIs reflected on their own student experiences to create teaching strategies that they felt were most effective, there may be a need to encourage CIs to use a formal process of critical reflection as part of their personal development as CIs. In his seminal book, ‘Democracy in Education’, Dewey [29] advocated reflective practice to create dispositions or habits of mind to develop intellectual and emotional dispositions for action. Both Mostrom [1] and Irby [15] reported that experienced CIs and exemplary medical clinical teachers used ongoing reflection to improve teaching skills with students. The CIECP encourages CIs to use reflection on – and for – action to improve students’ critical thinking, and might want to consider encouraging CIs to use narratives (as an example) to reflect on their own roles and behaviours with students.
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Future revisions of the CIECP, now the CCIP, should include these approaches. Directors of clinical facilities and centre coordinators of clinical education will find these results helpful in understanding the needs of CIs. Facility support to smooth the transition, including decreased patient load, scheduled education time, mentoring and other resources, will help CIs to focus on their students’ needs. Finally, academicians responsible for clinical education programmes would benefit from understanding the experience of the novice CI. It appears that although novice CIs struggle with some issues, they have considerable insight into the critical components of being a good educator, and should participate in clinical education programmes.
Limitations
Based on these findings, it is recommended that novice CIs who are also novice clinicians should be mentored in developing better skills to integrate patient care demands with student care demands, including strategies that experienced CIs use to integrate their patients as active participants in teaching students. This could be accomplished by simply asking if patients would like to provide feedback to students. Novice CIs should be taught to use reflection on – and for – action, perhaps through narrative and journals to learn from their experiences. Reflective narrative could provide invaluable insights for novice CIs to improve their judgement about dealing with difficult students, or learning the proper timing to provide students more responsibility in patient care. Ethical approval: Exemption from Emory University Institutional Review Board. Conflicts of interest: None declared.
Although consistent with other phenomenological studies, this study had a small sample size of six participants, all of whom were from the Atlanta area. Additionally, only five of the six individuals were able to participate in the focus group, so further clarification of themes was not possible with one person. When this project began, Emory’s programmatic curriculum embedded 36 weeks of clinical internships between project inception and completion. Therefore, a significant amount of time elapsed between the initial interviews and the focus group, which may have affected the responses. The possibility exists that a CI may have had additional students and experience since the first interview. Inherent to any focus group or group-think activity is a tendency for participants to agree with each other, rather than develop individual answers or thoughts. It is important to note that while most participants were novice CIs and clinicians, one participant was a more experienced clinician. This leads one to question if differences exist among novice CIs related to their years of experience as a clinician. Finally, it would be interesting to explore if distinctions are present between APTAcredentialled novice CIs and uncredentialled novice CIs.
Conclusion The exploration of lived experiences provided a deeper understanding of the novice CI. Emergent themes were similar to those exhibited by their more experienced colleagues, such as reflective practice, reciprocal and incremental learning, and creating a positive learning environment. Furthermore, there was agreement that the main purpose of a clinical experience is to transition the student from ‘paper to person’. However, some of these concepts are taught in the CIECP, so it remains unclear if these behaviours are inherent dispositions for action. Novice CIs struggle with confidence in their abilities to instruct, striking a balance, and deciding when to allow a student more independence. These conflicts may be linked to the fact that the novice CI is often a novice clinician as well.
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/ j.physio.2013.10.005.
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Please cite this article in press as: Greenfield BH, et al. Exploring the experiences of novice clinical instructors in physical therapy clinical education: a phenomenological study. Physiotherapy (2014), http://dx.doi.org/10.1016/j.physio.2013.10.005