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From Clinical Supervisor to Clinical Educator: Too Much to Ask?
609
REVIEW PAPER
From Clinical Supervisor to Clinical Educator: Too Much to Ask? Vinette Cross
Education
+
of a professional service through negotiation and
Key Words Clinical education, professional development, educational relationships.
I I
I 1
I
Summary Clinicians involved in clinical education have been required to adopt a variety of roles In relation to physiotherapy students. These roles are defined and some of the reasons for the changes which have taken place are considered. The paper goes on to question the feasibility of further developments in the face of current pressures within the health service.
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1980s
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1
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‘profession’with
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Introduction
Skilled operatives
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+p..”
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under the direction of Much has been written about the changes which have taken place in physiotherapy practice and education medical practitioners during the past three decades (Kaiser, 1968; CSP, Training 1979; Pagliarulo, 1986; Jensen, 1988; Walker, 1991; Richardson, 1992;Thornton, 1994).These changes have been necessary and important developments in the growth of the profession. The word ‘development’ is Clinical appropriate, implying not only change but direction. practice Human development has been described as’occurring not in a gradual linear manner, but in a series of spiralling The development of physiotherapy practice and clinicians’ roles in clinical education plateaux, each a qualitative improvement on its predecessor (Daloz, 1986).The left side of the figure shows view that the profession had developed an autonomy this concept applied to physiotherapy practice, from the which had gone ahead of professional training. There dependency of the 1960s to the autonomy of the 1980s. was a need for ‘professional training to be . . . liberalised There is a purpose and direction to this movement which and deepened to catch up with the tasks expected of may or may not continue into the uncertainties of the the physiotherapist’. One might postulate that this 1990s,uncertainties which are explored in more detail asynchrony in development fostered an occasional lack below. of empathy between practitioners and educationists in relation to their needs and expectations of each other. Set alongside the developmental spiral of practice in the figure are the roles which clinical practitioners have been required to adopt in relation to students’ learning Some Effects of Professional in the clinical setting. The word ‘required’ is deliberDevelopment on Clinical Education ately chosen. While the world of clinical practice has apparently developed in the sense of qualitative The instructor of the 1960s was quite adequate in drilling improvements building one on another, the world of the learners to reproduce traditional procedures and enough clinician involved in student learning seems to have of the ethos of the ‘enthusiastic amateur’ (Wagstaff, 1988) stumbled through a variety of roles each teetering only still remained to make this no great burden to the precariously on the one before. Why should this be so? clinicians involved. The 1970s saw increasing numbers In 1979 the CSP Education Committee expressed the of students and a broadening curriculum. This demanded
-
Physiotherapy,September 1994, vol80, no9
610
more in the way of organisational skills from clinicians who might be required to supervise the :,ctivities of .several students. Important in this supervision, from the clinicians’ viewpoint, was minimising disruption to the normal running of departments in which greater clinical responsibilities and increasing external pressures were becoming the norm.
As the notion of professional autonomy took firm hold throughout the 1980s, the need to improve status and credibility drove educational establishments towards degree-based programmes grounded in a core curriculum; ‘training’ was transformed into ‘education’. Clinicians were expected to take on the role of teachers of students in the field. Drilling and role-modelling - the established way of doing things - were no longer appropriate. Active teaching in a widening variety of clinical locations, giving and receiving feedback, encouraging initiative and a greater focus on individuals were now the way to foster professional practitioners of the future. Unfortunately, increasing student numbers, coupled with the need for clinicians to acquire more secure teaching skills to meet the challenge of changed student expectations, did not always sit comfortably with a concomitant increase in clinical workloads (Nosworthy, 1990). What of the 199Os? Some would argue that the notion of development through qualitative improvement fails to stand up against an avalanche of NHS management upheaval, a market-place mentality and a private sector onslaught. Perhaps ‘survival’ is the word of choice here? Richardson (1992) suggests that physiotherapy as a profession has reached a watershed in its development; that it will be exposed to searching scrutiny from other disciplines. It will be called upon to respond to conflicting ideologies while trying to maintain a clear sense of its own. Certainly a situation has been created in which clinical expertise alone may not be enough to justify survival. In order to ‘fight the corner’ for a physiotherapy service in which practitioners can take honest pride, staff must develop expertise in a range of interpersonal communication and management skills. In the future it is the exercise of these skills in fora well beyond the professional reference group of physiotherapy which could determine the profile and credibility of clinical expertise. While many existing physiotherapy managers have been forced by circumstance to acquire management skills under fire, training opportunities in stress management, time management, communication skills, facilitation and evaluation of learning, collaborative skills, etc, are now de rigeur for even the most junior staff. Physiotherapy educators within the schools have a responsibility to equip students fully to take up the cause of quality physiotherapy in the future. Making them aware of the need to develop basic management expertise is a n increasingly important part of this responsibility. That being so, educational strategies and resources must be devised and evaluated which will enable students to explore the nature of the skills involved and practise them in protected circumstances, in precisely the same way as they do in relation to clinical skills. Such a change of emphasis, involving as it does experimentation with new educational models, creates a yet more challenging role for clinicians involved in student learning.
Physiotherapy, September 1994, vol80, no 9
Role Definitions As much as anything else, the prevailing vocabulary embodies the changes taking place. ‘Conflict’, ‘collaboration’, ‘facilitation’, ‘ideology’,negotiation, etc, are a long way from the formal classwork and traditional therapeutic measures of yesteryear. ‘Clinical educator’ is the term now being used to describe those clinicians responsible for leading students towards this new millenium (CSP, 1991). It is these clinical educators who are ‘ideally situated to enable students to learn to cope with change, to deal with the complexities of real-world clinical practice’ (Higgs, 1992). The change from ‘supervisor’ to ‘educator’ defines the greater complexity of this new role. Education is very different from supervision; ‘Learning is very different from being taught’ (Thomas, 1985). Daloz’s (1986) view that ‘Education is something we neither “give” nor “do” to our students. It is a way we stand in relation to them’, prompts speculation on the way in which terminology might define role in clinical education. Reference to dictionary definitions can often lead to oversimplification of complex situations, but by the same token they can be of help in clarifying apparently overlapping concepts. ‘Supervision’ is defined as ‘directing or inspecting; exercising control’ (Onions, 19731, and as such could be seen as something ‘done to’ students. Thus control over what is done lies in the hands of the supervisor. The extent to which individual student needs or demands are allowed to disrupt the established pattern of what is done can be fairly easily controlled within the role definition. ‘Teaching’, on the other hand, is defined as ‘imparting or conveying knowledge or skill’ (Onions, 1973). Thus clinical teachers have a more ‘giving’ role in so far as they impart their own knowledge and skill to students, using a variety of techniques designed to help their transmission. Both supervision and teaching in these definitions appear confined in terms of the clinicians’ input and passive in terms of the students’ response (interestingly, ‘teachable’ is defined as docile). Their relationship seems limited and one-sided. In contrast, among the definitions of ‘education’is found ‘the process of nourishing or rearing; development of powers; formation of character’ (Onions, 1973). The clinical ‘educator’ enters into a relationship which embodies these definitions; an active one based on the provision of care as well as the transmission of knowledge or skill. More significantly, it involves a different balance of power.
Power Sharing in a Clinical Education Relationship Brown (1993) focuses on three key elements in a power sharing educational relationship: approachability, selfdisclosure and respect. Approachability involves clinical educators in negotiating, acting as mentors and supporting students in their own efforts to achieve educational outcomes. In this relationship it is implicit that on-going mutual respect cannot be taken for granted, it must be earned. The reciprocity of the relationship makes it legitimate and desirable for clinical educators to share their own concerns, weaknesses and limitations with students, through appropriate self-
61 1
disclosure. The linkage between these three elements holds the potential to empower the cliniciadstudent relationship in a way which supports students in their early attempts to develop basic management skills. As qualified practitioners they will be required to use these skills in facilitating power sharing relationships with patients, negotiating with and on behalf of patients, as well as in determining the quality of the physiotherapy service which is ultimately available to those patients. Logical and desirable though this change of emphasis seems to be, it nonetheless involves a return to uncertainty for clinicians who may only just be coming to terms with the role of ‘clinical teacher’.
Conclusions In this Centenary year Brook (1994) warns that emerging issues in physiotherapy education could give rise to ‘a sharp intake of breath!’ ‘New policies in health care will inevitably influence both the syllabus and the educational process so as to attempt continually to meet the demands of newly qualified physiotherapists’ (Brook, 1994). These demands will always include the highest standards of clinical expertise grounded in a sound and credible theoretical base. However, new policies are creating additional demands, as those currently practising are being made relentlessly aware. Justifiable concern has been voiced that the need to introduce students to management skills through their clinical education could be at the expense of hands-on experience. Nevertheless, graduates emerging without such skills are more likely to see themselves as ‘threatened . . . misrepresented . . . and hamstrung by fate’ (Lane, 1992) than as selfgoverning practitioners with the power to orchestrate a quality future for the students who follow in their footsteps. It is ironic that the very political and economic situation which provides such a convincing rationale for the advances in clinical education strategies discussed above, is also a major factor in obstructing their implementation. Lack of time, lack of staff, business plans which make only reluctant provision for clinical education, all conspire to hold back the liberalisation of physiotherapy education urged by the CSP a decade ago. The question: ‘Is it too much to ask clinicians to accept and fulfil the role of clinical educator at this time?’ is one which should be a t the top of the agenda in any discussions between practitioners and educational institutions. The answer could determine the future direction of the profession.
Author and Address for Correspondence Vinette Cross MMedEd MCSP DipTP is a senior teacher with responsibility for course evaluation at the School of Physiotherapy, Queen Elizabeth Medical Centre, Edgbaston, Birmingham 815 2TH.
References Brook, N (1994). ‘A sharp intake of breath: Inspiration in education - Some of the issues’, Physiotherapy, 80 A, 20A-23A. Brown, G D (1993). ‘Accounting for power: Nurse teachers’ and students’ perceptions of power in their relationship’, Nurse Education Today, 13, 111-120.
Chartered Society of Physiotherapy (1979). ‘The CSP’s policy on degree courses’, Physiotherapy, 65, 11, 353-354. Chartered Society of Physiotherapy (1991). Standards for Clinical Education Placements, CSP, London. Daloz, L A (1986). Effective Teachingand Mentoring,Jossey-Bass, London. Higgs, J (1992). ‘Managing clinical education: The educatormanager and the self-directed learner’, Physiotherapy, 78, 11, 822-828.
Jensen, G M (1988). The work of accreditation on-site evaluators. Enhancing the development of a profession’, Physical Therapy, 68, 10, 1517-25.
Kaiser, H L (1968). ‘Today’stomorrow’, Fifth Mary McMillan Lecture presented at 45th Annual Conference of American Physical Therapy Association, Physical Therapy,71,5, May 1991,407-414. Lane, R (1992). ‘Management - The enabling function’. Physiotherapy, 78, 12, 885-890.
Nosworthy, J (1990). ‘Physiotherapy education: The fight for the future’, Australian Journal of Physiotherapy, 36, 1, 4. Onions, C T (ed) (1973). Shorter Oxford English Dictionary, On Historical Principles, Oxford University Press. Pagliarulo, M A (1986). ‘Accreditation. Its nature, process and effective implementation’, Physical Therapy, 66, 7, 1114-18. Richardson, B (1992). ‘Professional education and professional practice today - Do they match? Physiotherapy. 78, 1, 23-26. Thomas, L F (1985). ‘Nothingmore theoretical than good practice: Teaching for self-organised learning’ in: Bannister, D (ed) lssues and Approaches in Personal Construct Theory, Academic Press, London, chapter 13. Thornton, E (1994). ‘100 years of physiotherapy education’, Physiotherapy, 80, A, 11A-19A.
Wagstaff, P (1988). ‘The great debate’,Proceedings of Association of Teachers of Chartered Society of Physiotherapy, Spring Conference, pages 16-18.
Walker, A (1991). ‘Clinical education - Funding and standards’, Physiotherapy, 77, 11, 742-743.
Physiotherapy,September 1994, vol80, no 9
REVIEW PAPER
From Clinical Supervisor to Clinical Educator: Too Much to Ask? Vinette Cross
Education
+
of a professional service through negotiation and
Key Words Clinical education, professional development, educational relationships.
I I
I 1
I
Summary Clinicians involved in clinical education have been required to adopt a variety of roles In relation to physiotherapy students. These roles are defined and some of the reasons for the changes which have taken place are considered. The paper goes on to question the feasibility of further developments in the face of current pressures within the health service.
I I
[
practitioners with management responsibility
1980s
/
1
4
w G + ’ I I I
‘profession’with
?%
I I
FbQ
I I I
lh
Q
%
9 *
: I
I
Introduction
Skilled operatives
I
+p..”
i
under the direction of Much has been written about the changes which have taken place in physiotherapy practice and education medical practitioners during the past three decades (Kaiser, 1968; CSP, Training 1979; Pagliarulo, 1986; Jensen, 1988; Walker, 1991; Richardson, 1992;Thornton, 1994).These changes have been necessary and important developments in the growth of the profession. The word ‘development’ is Clinical appropriate, implying not only change but direction. practice Human development has been described as’occurring not in a gradual linear manner, but in a series of spiralling The development of physiotherapy practice and clinicians’ roles in clinical education plateaux, each a qualitative improvement on its predecessor (Daloz, 1986).The left side of the figure shows view that the profession had developed an autonomy this concept applied to physiotherapy practice, from the which had gone ahead of professional training. There dependency of the 1960s to the autonomy of the 1980s. was a need for ‘professional training to be . . . liberalised There is a purpose and direction to this movement which and deepened to catch up with the tasks expected of may or may not continue into the uncertainties of the the physiotherapist’. One might postulate that this 1990s,uncertainties which are explored in more detail asynchrony in development fostered an occasional lack below. of empathy between practitioners and educationists in relation to their needs and expectations of each other. Set alongside the developmental spiral of practice in the figure are the roles which clinical practitioners have been required to adopt in relation to students’ learning Some Effects of Professional in the clinical setting. The word ‘required’ is deliberDevelopment on Clinical Education ately chosen. While the world of clinical practice has apparently developed in the sense of qualitative The instructor of the 1960s was quite adequate in drilling improvements building one on another, the world of the learners to reproduce traditional procedures and enough clinician involved in student learning seems to have of the ethos of the ‘enthusiastic amateur’ (Wagstaff, 1988) stumbled through a variety of roles each teetering only still remained to make this no great burden to the precariously on the one before. Why should this be so? clinicians involved. The 1970s saw increasing numbers In 1979 the CSP Education Committee expressed the of students and a broadening curriculum. This demanded
-
Physiotherapy,September 1994, vol80, no9
610
more in the way of organisational skills from clinicians who might be required to supervise the :,ctivities of .several students. Important in this supervision, from the clinicians’ viewpoint, was minimising disruption to the normal running of departments in which greater clinical responsibilities and increasing external pressures were becoming the norm.
As the notion of professional autonomy took firm hold throughout the 1980s, the need to improve status and credibility drove educational establishments towards degree-based programmes grounded in a core curriculum; ‘training’ was transformed into ‘education’. Clinicians were expected to take on the role of teachers of students in the field. Drilling and role-modelling - the established way of doing things - were no longer appropriate. Active teaching in a widening variety of clinical locations, giving and receiving feedback, encouraging initiative and a greater focus on individuals were now the way to foster professional practitioners of the future. Unfortunately, increasing student numbers, coupled with the need for clinicians to acquire more secure teaching skills to meet the challenge of changed student expectations, did not always sit comfortably with a concomitant increase in clinical workloads (Nosworthy, 1990). What of the 199Os? Some would argue that the notion of development through qualitative improvement fails to stand up against an avalanche of NHS management upheaval, a market-place mentality and a private sector onslaught. Perhaps ‘survival’ is the word of choice here? Richardson (1992) suggests that physiotherapy as a profession has reached a watershed in its development; that it will be exposed to searching scrutiny from other disciplines. It will be called upon to respond to conflicting ideologies while trying to maintain a clear sense of its own. Certainly a situation has been created in which clinical expertise alone may not be enough to justify survival. In order to ‘fight the corner’ for a physiotherapy service in which practitioners can take honest pride, staff must develop expertise in a range of interpersonal communication and management skills. In the future it is the exercise of these skills in fora well beyond the professional reference group of physiotherapy which could determine the profile and credibility of clinical expertise. While many existing physiotherapy managers have been forced by circumstance to acquire management skills under fire, training opportunities in stress management, time management, communication skills, facilitation and evaluation of learning, collaborative skills, etc, are now de rigeur for even the most junior staff. Physiotherapy educators within the schools have a responsibility to equip students fully to take up the cause of quality physiotherapy in the future. Making them aware of the need to develop basic management expertise is a n increasingly important part of this responsibility. That being so, educational strategies and resources must be devised and evaluated which will enable students to explore the nature of the skills involved and practise them in protected circumstances, in precisely the same way as they do in relation to clinical skills. Such a change of emphasis, involving as it does experimentation with new educational models, creates a yet more challenging role for clinicians involved in student learning.
Physiotherapy, September 1994, vol80, no 9
Role Definitions As much as anything else, the prevailing vocabulary embodies the changes taking place. ‘Conflict’, ‘collaboration’, ‘facilitation’, ‘ideology’,negotiation, etc, are a long way from the formal classwork and traditional therapeutic measures of yesteryear. ‘Clinical educator’ is the term now being used to describe those clinicians responsible for leading students towards this new millenium (CSP, 1991). It is these clinical educators who are ‘ideally situated to enable students to learn to cope with change, to deal with the complexities of real-world clinical practice’ (Higgs, 1992). The change from ‘supervisor’ to ‘educator’ defines the greater complexity of this new role. Education is very different from supervision; ‘Learning is very different from being taught’ (Thomas, 1985). Daloz’s (1986) view that ‘Education is something we neither “give” nor “do” to our students. It is a way we stand in relation to them’, prompts speculation on the way in which terminology might define role in clinical education. Reference to dictionary definitions can often lead to oversimplification of complex situations, but by the same token they can be of help in clarifying apparently overlapping concepts. ‘Supervision’ is defined as ‘directing or inspecting; exercising control’ (Onions, 19731, and as such could be seen as something ‘done to’ students. Thus control over what is done lies in the hands of the supervisor. The extent to which individual student needs or demands are allowed to disrupt the established pattern of what is done can be fairly easily controlled within the role definition. ‘Teaching’, on the other hand, is defined as ‘imparting or conveying knowledge or skill’ (Onions, 1973). Thus clinical teachers have a more ‘giving’ role in so far as they impart their own knowledge and skill to students, using a variety of techniques designed to help their transmission. Both supervision and teaching in these definitions appear confined in terms of the clinicians’ input and passive in terms of the students’ response (interestingly, ‘teachable’ is defined as docile). Their relationship seems limited and one-sided. In contrast, among the definitions of ‘education’is found ‘the process of nourishing or rearing; development of powers; formation of character’ (Onions, 1973). The clinical ‘educator’ enters into a relationship which embodies these definitions; an active one based on the provision of care as well as the transmission of knowledge or skill. More significantly, it involves a different balance of power.
Power Sharing in a Clinical Education Relationship Brown (1993) focuses on three key elements in a power sharing educational relationship: approachability, selfdisclosure and respect. Approachability involves clinical educators in negotiating, acting as mentors and supporting students in their own efforts to achieve educational outcomes. In this relationship it is implicit that on-going mutual respect cannot be taken for granted, it must be earned. The reciprocity of the relationship makes it legitimate and desirable for clinical educators to share their own concerns, weaknesses and limitations with students, through appropriate self-
61 1
disclosure. The linkage between these three elements holds the potential to empower the cliniciadstudent relationship in a way which supports students in their early attempts to develop basic management skills. As qualified practitioners they will be required to use these skills in facilitating power sharing relationships with patients, negotiating with and on behalf of patients, as well as in determining the quality of the physiotherapy service which is ultimately available to those patients. Logical and desirable though this change of emphasis seems to be, it nonetheless involves a return to uncertainty for clinicians who may only just be coming to terms with the role of ‘clinical teacher’.
Conclusions In this Centenary year Brook (1994) warns that emerging issues in physiotherapy education could give rise to ‘a sharp intake of breath!’ ‘New policies in health care will inevitably influence both the syllabus and the educational process so as to attempt continually to meet the demands of newly qualified physiotherapists’ (Brook, 1994). These demands will always include the highest standards of clinical expertise grounded in a sound and credible theoretical base. However, new policies are creating additional demands, as those currently practising are being made relentlessly aware. Justifiable concern has been voiced that the need to introduce students to management skills through their clinical education could be at the expense of hands-on experience. Nevertheless, graduates emerging without such skills are more likely to see themselves as ‘threatened . . . misrepresented . . . and hamstrung by fate’ (Lane, 1992) than as selfgoverning practitioners with the power to orchestrate a quality future for the students who follow in their footsteps. It is ironic that the very political and economic situation which provides such a convincing rationale for the advances in clinical education strategies discussed above, is also a major factor in obstructing their implementation. Lack of time, lack of staff, business plans which make only reluctant provision for clinical education, all conspire to hold back the liberalisation of physiotherapy education urged by the CSP a decade ago. The question: ‘Is it too much to ask clinicians to accept and fulfil the role of clinical educator at this time?’ is one which should be a t the top of the agenda in any discussions between practitioners and educational institutions. The answer could determine the future direction of the profession.
Author and Address for Correspondence Vinette Cross MMedEd MCSP DipTP is a senior teacher with responsibility for course evaluation at the School of Physiotherapy, Queen Elizabeth Medical Centre, Edgbaston, Birmingham 815 2TH.
References Brook, N (1994). ‘A sharp intake of breath: Inspiration in education - Some of the issues’, Physiotherapy, 80 A, 20A-23A. Brown, G D (1993). ‘Accounting for power: Nurse teachers’ and students’ perceptions of power in their relationship’, Nurse Education Today, 13, 111-120.
Chartered Society of Physiotherapy (1979). ‘The CSP’s policy on degree courses’, Physiotherapy, 65, 11, 353-354. Chartered Society of Physiotherapy (1991). Standards for Clinical Education Placements, CSP, London. Daloz, L A (1986). Effective Teachingand Mentoring,Jossey-Bass, London. Higgs, J (1992). ‘Managing clinical education: The educatormanager and the self-directed learner’, Physiotherapy, 78, 11, 822-828.
Jensen, G M (1988). The work of accreditation on-site evaluators. Enhancing the development of a profession’, Physical Therapy, 68, 10, 1517-25.
Kaiser, H L (1968). ‘Today’stomorrow’, Fifth Mary McMillan Lecture presented at 45th Annual Conference of American Physical Therapy Association, Physical Therapy,71,5, May 1991,407-414. Lane, R (1992). ‘Management - The enabling function’. Physiotherapy, 78, 12, 885-890.
Nosworthy, J (1990). ‘Physiotherapy education: The fight for the future’, Australian Journal of Physiotherapy, 36, 1, 4. Onions, C T (ed) (1973). Shorter Oxford English Dictionary, On Historical Principles, Oxford University Press. Pagliarulo, M A (1986). ‘Accreditation. Its nature, process and effective implementation’, Physical Therapy, 66, 7, 1114-18. Richardson, B (1992). ‘Professional education and professional practice today - Do they match? Physiotherapy. 78, 1, 23-26. Thomas, L F (1985). ‘Nothingmore theoretical than good practice: Teaching for self-organised learning’ in: Bannister, D (ed) lssues and Approaches in Personal Construct Theory, Academic Press, London, chapter 13. Thornton, E (1994). ‘100 years of physiotherapy education’, Physiotherapy, 80, A, 11A-19A.
Wagstaff, P (1988). ‘The great debate’,Proceedings of Association of Teachers of Chartered Society of Physiotherapy, Spring Conference, pages 16-18.
Walker, A (1991). ‘Clinical education - Funding and standards’, Physiotherapy, 77, 11, 742-743.
Physiotherapy,September 1994, vol80, no 9