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Some Aspects of the Quality Debate in Clinical Education
REVlEW PAPER
Some Aspects of the Quality Debate in Clinical Education vine*
cmss
What is Qualityin Clinical Education?
Key Wonls Ctinii education,quality assurance, physiotherapy.
k m w Diering views on what counts as q u a l i in clinical education meke developmentof meaningfulqWi assurance mechanisms bffiarlt.This paper outlines some of the issues invokedand their possiMe effectson physiotherapyclinical education.
Introduction ‘Greater than the tread of marching armies is an idea whose time has come.’ So wrote Victor Hugo, and there is something about the inexorable march of quality assurance into the field of education that gives his view the ring of truth. During the past decade, discussion about quality in education has been transformed from a minefield through which only the reckless dared to venture, into a n avalanche of conflicting opinions. Its time has undoubtedly come.
There is considerable uncertainty in higher education about what quality actually is (Yorke, 1992).Barnett (1992)warns that ‘quality’ should be seen as no more than a metaphor for conflicting viewpoints about the aims of the educational system. In other words, a number of involved groups may express opinions about quality from M e r e n t starting points. The system must try to respond in some way to these differing views, which are o h n based upon who is deemed to be the consumer in the education process. In clinical education the consumer may be identified according to a ‘pmduct’or a ‘process’ model.
A Product Model
Mullet and Funnel) (1991)suggest the term ‘quality‘ may be used synonymouslywith effectiveness. They include efficiency and economy within the term. If this is so, then a first step in determining effectivenessof clinical education programmes might be to examine the quality of the practiTransfer to the higher education sector made it tioner they are designed to produce (Nicklin and inevitable that physiotherapy educators would be Lankshear, 1990).This product model of quality drawn into the education quality debate. This assurance focuses on managers, employers and debate centres on conflict between the legitimate concern of academic institutions that the courses patients as consumers; student assessment, employer satisfaction, cost effectiveness and level they offer are of high qudity, and the imposition patient care being significant performance indi- by external stakeholders - of structures and of cators. Implicit within this model is delivery of a mechanisms for demonstrating ‘quality assurpredetermined product - the quality practitioner ance’, with its attendant financial implications, at the end of the formal education period (HER, 1993).Thus there is pressure to replace (a student-as-product viewpoint). It reflects the what is seen as mere anecdote and professional in Working Paper 10 that clinirecommendation reassurance, with ‘hard data’ related to quality cal education contracts should include a stateof educational provision. This pressure has also ment of training outcomes which takes as its been brought to bear on the clinical component starting point the professional competencies of health service courses in the higher education eector. The arrival of the ‘age of the contract’ has statutorily required. Thus, employers might been largely responsible for these demands on be expected to see quality as a measure of the educators. The traditional relationship between education system’s ability to provide productive ‘scholar and pupil, maater and apprentice’i s being manpower which has ‘utility value’ in the workreplaced by one in which buyers and sellers are place. required to confront each other in an education market place. Working Paper 10 (DOH, 1989) A Process’ Model states that ’training should be the subject of con- A different view of quality accepts the notion tractual arrangements between purchasers and that students need to learn how to learn through providers’. In effect this places ownership of clin- their own clinical practice (rather than simply ical education in the hands of employers with learning to reproduce traditional procedures). schools of physiotherapy as ‘purchasers’and host They need to be able to reflect upon and refine units aa ’providers’of placements. their practice to adapt to evolving and novel
Phyrlo(h.crpy,
1095, volm, no 9
situations (Fish, 1991).Accepting responsibility for the longer-term impact of an educational programme in this way focuses on a studentas-consumer viewpoint with the educational programme as product. It requires that quality be defined in terms of the processes involved in learning and the extent to which etudents are enabled to contribute creatively to their own continuing education beyond the formal education period. This view leans more towards the higher education principle of education as a life-long and life-enhancing experience ‘not to be confused by performance at end points and outputs’ (Barnett, 1992).
spective. In ita ‘Guidelines for Good Practice for the Education of Clinical Educabd(CSP,19fU) the Society recommends a comprehensive list of skills which should be acquired by clinicians involved in clinical education (see table). They
What Factors May Influence Quality in Clinical Education? Two key factors currently influence the quality of clinical education programmes: first the existence of differing perceptions of those involved; and secondly the question of funding for clinical placements.
Perceptions of Clinical Education Clearly, much potential exists for widely Mering perceptions of quality in clinical education. It might be expected, for example, that employers would adopt a ‘student-as-product’ viewpoint. Academic staff, on the other hand, might look for quality in the character of clinical education experiences and the ‘value added’ as a result of these. Such potentially conflicting aims and viewpoints may contribute to difficulties in implementing effective clinical education programmes and in attaching meaning to quality measurements. Information about students’ views on quality derives largely from studies of their perceptions of clinical educators. The majority of these studies are based on a student-as-consumer or process approach (Emery, 1984;Flagler et ul, 1988,Hewson and Jensen, 1990;Neville and French, 1991). They are directed mainly towards creating inventories of teacher behaviours considered important by the students themselves. However, if clinical educators perceive their primary role to be upholding the interests of the workplace, then compliance with these desired behaviours will happen only if this can be made congruent with that role. Thus clinical educators may have a difficult choice to make regarding the quality of what they can offer students. Professional bodies - in this case the Chartered Society of Physiotherapy (CSP)- also have a view on quality of professional education, which may need to reflect both a product and a process per-
are the result of consultation between senior managers and course leaders. The Society see8 adoption of these guidelines as benefiting first employers through a general improvement in workplace education; secondly,clinical educators who will be better prepared to tea&, and fmally studente, who will benefit from improvements in quality of learning experiences. However, they remain indicative rather than mandatory because ‘the Society recognises the difficulty of implementing the guidelines in terms of clinicians’ heavy workload and the source of funding of the programmes’. Herein lies the dilemma facing clinicaleducattm. On one hand they have a commitment to patient care at a time of increasing workload8 and decreasing resources. (It should not be forgotten that the march of quality assurance has penetrated the senice as well as the educationeector.) On the other hand clinicians have a vital role to play in student education. The pivotal nature of this role is d e h e d by Coates (1991)who asserts that ‘the clinicians are the members of the profession who are spending the majority of their time treating patients, achieving the mastery level of their clinical skills and becoming familiar with modern equipment. It is these members of our profession who have so much to offer students and who should be at the forefront of the clinical education process.’
This suggesta clinical educators are the key level of quality control to ensure standards of clinical practice are maintained in the profession as a whole. If so, then the need for congruent viewpoints among academic staff, students, clinical educators and managers is apparent.
Funding and Quality Characteristic of ‘the age of the contract’ are attention to cost-benefit and opportunity costs, to performance indicators, explicit standards, compliance, conformity controls and accountability. Clinical education is being shaped by this new age. Reviewing upheavals in funding of physiotherapy clinical education in New Zealand, Lamont (1992) argues that the principles underlying funding should emulate those related to other situations requiring ‘on-the-job experience’, for example, the in-service education of student teachers. Among the important principles to which he points are (1)the recognition that there are costs and benefits for both the service and the education facilities, and (2) that there are obligations for both parties which can be defined in a contract. In relation to (11, providers have to decide how best to identify and quantify such factors as clinical stafftime spent on student education, the effects of clinical placements on patient throughput, additional consumables used during placements, and the value of the service contribution made by students. In the changing economic climate it is clear that physiotherapy schools can no longer expect to rely on the goodwill which has underpinned these costs in the past. Earlier it was suggested that Working Paper 10 cast employers as the owners of clinical education (the clinical locations acting as providers)and the physiotherapy schools in the role of purchasers of clinical education. Erosion of the NHS employer monopoly means that self-governing trusts, local authorities, district health authorities, the private sector, general practitioners, industry, etc, have become potential areas of clinical education experience. On the negative side, this could render schools vulnerable to a much wider range of local anomalies and variables in the quality of clinical education provided for their students. More positively, in this expanded education market-place another view of quality could be considered; that is, quality as a measure of customer Satisfaction. ‘Quality’ is therefore owned by the customer or purchaser - the school of physiotherapy - preferably through a system of accreditation. The most optimistic interpretation of this scenario is that given a potentially wider choice of clinical education providers, if the schools purchase one product (clinical education experience) for their students, but find it unsatisfactory, they will buy someone else’s product in the future. However, even the most confirmed optimist could not ignore the dampening effect of funding on such joyful expectations. The issue of funding for clinical education has yet to be resolved and it remains to be seen
whether it will be financial constraints, rather than the quality of the education programmes offered, which will dictate schools’ choice of clinical placements.
Conclusions The relationship between schools of physiotherapy and providers of clinical education has changed from one based on tacit assumptions and general goodwill to one of rigorous negotiation within a market economy. This means that clearer answers to questions about quality are required by a wider range of interested parties. It could be argued that resorting to such tools as performance indicators is simply to avoid making difficult decisions about the quality of educational processes. But, it is possible that they could stimulate inqujry which could lead to indirect insights into processes. Nevertheless many see the respective principles of quality assurance and higher education as unhappy bedfellows, part of the problem being that process and product in education are often inextricably entwined. However, the nettle remains to be grasped and if nothing else the continuing debate has served to dispel apathy, by raising questions about existing practice, and causing those with seemingly conflicting viewpoints t o look for common ground on which to meet the common challenge of developing appropriate and meaningful quality assurance mechanisms for clinical education. Author and Addmss for Correspondenn, Vinefte Cross MMedEd MCSP CertEd is a lecturer in physiot h e w with responsibility for course evaluation at the University of Birmingham Department of Physiotherapy, Morris House, Edgbaston, Birmingham B15 2lT. This artide was received on January 19,1995. and accepted on January 24.1995.
R-8 Bamett. R (1992). ’The idea of quality: Voicing the educational‘, Higher EducetionalQuartedy, &,I, 3-19. Chartered Society of Physiotherapy(1994). ‘Guidelines for good practice for the education of clinical educators’, Physiotherapy, 80,5,299-m. Coates. M, cited in Neville, S and French, S (1991). ‘Clinical education: Students’ and clinical tutors’ views’, Physiotherapy, 77,5,351-356. Department of Health (1989). Working for Patients: Working Paper 10 - Education and Training, HMSO.
Higher Education Review (1993). ‘Quaiiand judgement‘, Higher Education Review, 25,2,3-5. Emery, M J (1964). ‘Effectiveness of the clinical instructor: Students’ perspective’, Pbysical Tberapy, 64,7,1079-83. Fish, D (1991). ‘But can you prove it? Quality assurance and the refiective practilbner‘, Assessment and Evaluation in Higher Education. 1 6 , l . 22-36.
Flagler, S,Loper-Powers, Sand Spitzer, A (1988). 'Clinical teaching is more than evaluation alone!' Journal of NursingEducation, 27,0,342-348. Hewson, M G A'B and Jensen, N M (1990). 'An inventory to improve clinical teaching in the general internal medicine clinic', Medical Education, 24. 518-527. Hugo, V (1852). L'ffistoife d'un Crime. Lamont, M K (1992). 'The funding of clinical education -The options', New Zealand Journal of Physiotherapy, August, 11-16.
4\4 % b\
Print personal client handouts on your PC with
c
4e
for Wmdows
Muller, D and Funnell, P (eds) (1991). Delivery Qualityin V w fional Education, K q a n Page, London. Neville, S and French, S (1991). 'Clinical education: Students' and clinical tulors' views', Pbysiotherapy, 77, 5, 351-354. Nicklin. P and Lankshear, A (1990). 'Quality control', Nursing Times, 86. 3 6 , 6 1 4 2 . Yorke. M (1992). 'Quality in higher education: A conceptualisation and some observations on the implementationof a sectoral quality system', Journal of Further and Higher Education, 16.2, 90-1 04.
+ Hundreds of new exercises & advice + Build your own treatment programs + Add your own graphics & exercises + Intelligent on-screen search & select
+ Customisable texts Complete Windows program with over 700 General physiotherapy exercises €249.00. Upgrade to Windows from DOS version (also includa over 300 new items) fSO.00. Hydrotherapy exercises M9.00. All p n a q u d ex VAT and d c l i v q
For further infonnatioddemo disc contact: UK Enquiries: TelO1869 .%M44 Fax 01869 320040 International Enquiries: TelO14817OO602Fax 01481 700616
Some Aspects of the Quality Debate in Clinical Education vine*
cmss
What is Qualityin Clinical Education?
Key Wonls Ctinii education,quality assurance, physiotherapy.
k m w Diering views on what counts as q u a l i in clinical education meke developmentof meaningfulqWi assurance mechanisms bffiarlt.This paper outlines some of the issues invokedand their possiMe effectson physiotherapyclinical education.
Introduction ‘Greater than the tread of marching armies is an idea whose time has come.’ So wrote Victor Hugo, and there is something about the inexorable march of quality assurance into the field of education that gives his view the ring of truth. During the past decade, discussion about quality in education has been transformed from a minefield through which only the reckless dared to venture, into a n avalanche of conflicting opinions. Its time has undoubtedly come.
There is considerable uncertainty in higher education about what quality actually is (Yorke, 1992).Barnett (1992)warns that ‘quality’ should be seen as no more than a metaphor for conflicting viewpoints about the aims of the educational system. In other words, a number of involved groups may express opinions about quality from M e r e n t starting points. The system must try to respond in some way to these differing views, which are o h n based upon who is deemed to be the consumer in the education process. In clinical education the consumer may be identified according to a ‘pmduct’or a ‘process’ model.
A Product Model
Mullet and Funnel) (1991)suggest the term ‘quality‘ may be used synonymouslywith effectiveness. They include efficiency and economy within the term. If this is so, then a first step in determining effectivenessof clinical education programmes might be to examine the quality of the practiTransfer to the higher education sector made it tioner they are designed to produce (Nicklin and inevitable that physiotherapy educators would be Lankshear, 1990).This product model of quality drawn into the education quality debate. This assurance focuses on managers, employers and debate centres on conflict between the legitimate concern of academic institutions that the courses patients as consumers; student assessment, employer satisfaction, cost effectiveness and level they offer are of high qudity, and the imposition patient care being significant performance indi- by external stakeholders - of structures and of cators. Implicit within this model is delivery of a mechanisms for demonstrating ‘quality assurpredetermined product - the quality practitioner ance’, with its attendant financial implications, at the end of the formal education period (HER, 1993).Thus there is pressure to replace (a student-as-product viewpoint). It reflects the what is seen as mere anecdote and professional in Working Paper 10 that clinirecommendation reassurance, with ‘hard data’ related to quality cal education contracts should include a stateof educational provision. This pressure has also ment of training outcomes which takes as its been brought to bear on the clinical component starting point the professional competencies of health service courses in the higher education eector. The arrival of the ‘age of the contract’ has statutorily required. Thus, employers might been largely responsible for these demands on be expected to see quality as a measure of the educators. The traditional relationship between education system’s ability to provide productive ‘scholar and pupil, maater and apprentice’i s being manpower which has ‘utility value’ in the workreplaced by one in which buyers and sellers are place. required to confront each other in an education market place. Working Paper 10 (DOH, 1989) A Process’ Model states that ’training should be the subject of con- A different view of quality accepts the notion tractual arrangements between purchasers and that students need to learn how to learn through providers’. In effect this places ownership of clin- their own clinical practice (rather than simply ical education in the hands of employers with learning to reproduce traditional procedures). schools of physiotherapy as ‘purchasers’and host They need to be able to reflect upon and refine units aa ’providers’of placements. their practice to adapt to evolving and novel
Phyrlo(h.crpy,
1095, volm, no 9
situations (Fish, 1991).Accepting responsibility for the longer-term impact of an educational programme in this way focuses on a studentas-consumer viewpoint with the educational programme as product. It requires that quality be defined in terms of the processes involved in learning and the extent to which etudents are enabled to contribute creatively to their own continuing education beyond the formal education period. This view leans more towards the higher education principle of education as a life-long and life-enhancing experience ‘not to be confused by performance at end points and outputs’ (Barnett, 1992).
spective. In ita ‘Guidelines for Good Practice for the Education of Clinical Educabd(CSP,19fU) the Society recommends a comprehensive list of skills which should be acquired by clinicians involved in clinical education (see table). They
What Factors May Influence Quality in Clinical Education? Two key factors currently influence the quality of clinical education programmes: first the existence of differing perceptions of those involved; and secondly the question of funding for clinical placements.
Perceptions of Clinical Education Clearly, much potential exists for widely Mering perceptions of quality in clinical education. It might be expected, for example, that employers would adopt a ‘student-as-product’ viewpoint. Academic staff, on the other hand, might look for quality in the character of clinical education experiences and the ‘value added’ as a result of these. Such potentially conflicting aims and viewpoints may contribute to difficulties in implementing effective clinical education programmes and in attaching meaning to quality measurements. Information about students’ views on quality derives largely from studies of their perceptions of clinical educators. The majority of these studies are based on a student-as-consumer or process approach (Emery, 1984;Flagler et ul, 1988,Hewson and Jensen, 1990;Neville and French, 1991). They are directed mainly towards creating inventories of teacher behaviours considered important by the students themselves. However, if clinical educators perceive their primary role to be upholding the interests of the workplace, then compliance with these desired behaviours will happen only if this can be made congruent with that role. Thus clinical educators may have a difficult choice to make regarding the quality of what they can offer students. Professional bodies - in this case the Chartered Society of Physiotherapy (CSP)- also have a view on quality of professional education, which may need to reflect both a product and a process per-
are the result of consultation between senior managers and course leaders. The Society see8 adoption of these guidelines as benefiting first employers through a general improvement in workplace education; secondly,clinical educators who will be better prepared to tea&, and fmally studente, who will benefit from improvements in quality of learning experiences. However, they remain indicative rather than mandatory because ‘the Society recognises the difficulty of implementing the guidelines in terms of clinicians’ heavy workload and the source of funding of the programmes’. Herein lies the dilemma facing clinicaleducattm. On one hand they have a commitment to patient care at a time of increasing workload8 and decreasing resources. (It should not be forgotten that the march of quality assurance has penetrated the senice as well as the educationeector.) On the other hand clinicians have a vital role to play in student education. The pivotal nature of this role is d e h e d by Coates (1991)who asserts that ‘the clinicians are the members of the profession who are spending the majority of their time treating patients, achieving the mastery level of their clinical skills and becoming familiar with modern equipment. It is these members of our profession who have so much to offer students and who should be at the forefront of the clinical education process.’
This suggesta clinical educators are the key level of quality control to ensure standards of clinical practice are maintained in the profession as a whole. If so, then the need for congruent viewpoints among academic staff, students, clinical educators and managers is apparent.
Funding and Quality Characteristic of ‘the age of the contract’ are attention to cost-benefit and opportunity costs, to performance indicators, explicit standards, compliance, conformity controls and accountability. Clinical education is being shaped by this new age. Reviewing upheavals in funding of physiotherapy clinical education in New Zealand, Lamont (1992) argues that the principles underlying funding should emulate those related to other situations requiring ‘on-the-job experience’, for example, the in-service education of student teachers. Among the important principles to which he points are (1)the recognition that there are costs and benefits for both the service and the education facilities, and (2) that there are obligations for both parties which can be defined in a contract. In relation to (11, providers have to decide how best to identify and quantify such factors as clinical stafftime spent on student education, the effects of clinical placements on patient throughput, additional consumables used during placements, and the value of the service contribution made by students. In the changing economic climate it is clear that physiotherapy schools can no longer expect to rely on the goodwill which has underpinned these costs in the past. Earlier it was suggested that Working Paper 10 cast employers as the owners of clinical education (the clinical locations acting as providers)and the physiotherapy schools in the role of purchasers of clinical education. Erosion of the NHS employer monopoly means that self-governing trusts, local authorities, district health authorities, the private sector, general practitioners, industry, etc, have become potential areas of clinical education experience. On the negative side, this could render schools vulnerable to a much wider range of local anomalies and variables in the quality of clinical education provided for their students. More positively, in this expanded education market-place another view of quality could be considered; that is, quality as a measure of customer Satisfaction. ‘Quality’ is therefore owned by the customer or purchaser - the school of physiotherapy - preferably through a system of accreditation. The most optimistic interpretation of this scenario is that given a potentially wider choice of clinical education providers, if the schools purchase one product (clinical education experience) for their students, but find it unsatisfactory, they will buy someone else’s product in the future. However, even the most confirmed optimist could not ignore the dampening effect of funding on such joyful expectations. The issue of funding for clinical education has yet to be resolved and it remains to be seen
whether it will be financial constraints, rather than the quality of the education programmes offered, which will dictate schools’ choice of clinical placements.
Conclusions The relationship between schools of physiotherapy and providers of clinical education has changed from one based on tacit assumptions and general goodwill to one of rigorous negotiation within a market economy. This means that clearer answers to questions about quality are required by a wider range of interested parties. It could be argued that resorting to such tools as performance indicators is simply to avoid making difficult decisions about the quality of educational processes. But, it is possible that they could stimulate inqujry which could lead to indirect insights into processes. Nevertheless many see the respective principles of quality assurance and higher education as unhappy bedfellows, part of the problem being that process and product in education are often inextricably entwined. However, the nettle remains to be grasped and if nothing else the continuing debate has served to dispel apathy, by raising questions about existing practice, and causing those with seemingly conflicting viewpoints t o look for common ground on which to meet the common challenge of developing appropriate and meaningful quality assurance mechanisms for clinical education. Author and Addmss for Correspondenn, Vinefte Cross MMedEd MCSP CertEd is a lecturer in physiot h e w with responsibility for course evaluation at the University of Birmingham Department of Physiotherapy, Morris House, Edgbaston, Birmingham B15 2lT. This artide was received on January 19,1995. and accepted on January 24.1995.
R-8 Bamett. R (1992). ’The idea of quality: Voicing the educational‘, Higher EducetionalQuartedy, &,I, 3-19. Chartered Society of Physiotherapy(1994). ‘Guidelines for good practice for the education of clinical educators’, Physiotherapy, 80,5,299-m. Coates. M, cited in Neville, S and French, S (1991). ‘Clinical education: Students’ and clinical tutors’ views’, Physiotherapy, 77,5,351-356. Department of Health (1989). Working for Patients: Working Paper 10 - Education and Training, HMSO.
Higher Education Review (1993). ‘Quaiiand judgement‘, Higher Education Review, 25,2,3-5. Emery, M J (1964). ‘Effectiveness of the clinical instructor: Students’ perspective’, Pbysical Tberapy, 64,7,1079-83. Fish, D (1991). ‘But can you prove it? Quality assurance and the refiective practilbner‘, Assessment and Evaluation in Higher Education. 1 6 , l . 22-36.
Flagler, S,Loper-Powers, Sand Spitzer, A (1988). 'Clinical teaching is more than evaluation alone!' Journal of NursingEducation, 27,0,342-348. Hewson, M G A'B and Jensen, N M (1990). 'An inventory to improve clinical teaching in the general internal medicine clinic', Medical Education, 24. 518-527. Hugo, V (1852). L'ffistoife d'un Crime. Lamont, M K (1992). 'The funding of clinical education -The options', New Zealand Journal of Physiotherapy, August, 11-16.
4\4 % b\
Print personal client handouts on your PC with
c
4e
for Wmdows
Muller, D and Funnell, P (eds) (1991). Delivery Qualityin V w fional Education, K q a n Page, London. Neville, S and French, S (1991). 'Clinical education: Students' and clinical tulors' views', Pbysiotherapy, 77, 5, 351-354. Nicklin. P and Lankshear, A (1990). 'Quality control', Nursing Times, 86. 3 6 , 6 1 4 2 . Yorke. M (1992). 'Quality in higher education: A conceptualisation and some observations on the implementationof a sectoral quality system', Journal of Further and Higher Education, 16.2, 90-1 04.
+ Hundreds of new exercises & advice + Build your own treatment programs + Add your own graphics & exercises + Intelligent on-screen search & select
+ Customisable texts Complete Windows program with over 700 General physiotherapy exercises €249.00. Upgrade to Windows from DOS version (also includa over 300 new items) fSO.00. Hydrotherapy exercises M9.00. All p n a q u d ex VAT and d c l i v q
For further infonnatioddemo disc contact: UK Enquiries: TelO1869 .%M44 Fax 01869 320040 International Enquiries: TelO14817OO602Fax 01481 700616