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Techniques for Teaching

in Clinical Settings

by:
Dr. Maria Simplicia E. Flores
Clinicaleducation has long been recognized
as a necessary part of PT education.
The purpose of clinical education (Callahan
et al., 1968) was
1. To assist the student to correlate clinical
practices with basic sciences.
2. To acquire new knowledge, attitudes and
skill to develop ability to observe, to
evaluate, to develop realistic goals and plan
effective treatment programs.
3. To accept professional responsibility.
4. To maintain a spirit of inquiry and to
develop a pattern for continuing education.
The importance of clinical education is
expressed by students when they remind
instructors that “real learning” in PT
occurs in the clinic.
At the end of the lesson, the student
should be able to:
1. Describe the dynamic environment in
which clinical education occurs.
2. Describe the clinical learning process
and identify expected outcomes.
3. Discuss and give examples of the four
roles of a clinical teacher.
4. Identify practical strategies for
enhancing clinical teaching methods.

OBJECTIVES
Clinicallearning is situated in the context
of physical therapy practice.
It occurs in real practice settings, with
real patients, and with real physical
therapists as clinical teachers.

Context of Clinical Education


Explicitlydefining the desired outcome for
each clinical experience will dictate the
appropriate timing in the curriculum,
the duration of the experience, the
type of setting, and the qualifications
of the clinical teachers.
Students must be ready to enter the clinic
setting and interact with patients. They
must know where to start, and must come
with the expectation that they will learn
by thinking and doing with a patient.
Questions to Asked - Intern
What does a student need to know on
day 1 of a clinical learning experience?
What is best taught in the classroom or
the laboratory?
What is best learned during a clinical
education experience?
Basic knowledge and skills -prerequisites
to clinical learning.
The primary difference between
academic and clinical teaching is that
control of academic teaching lies with
the educational system and control of
clinical teaching lies with the health
care system and the patient.

Academic and Clinical Teaching:


TWO DIFFERENT REALITIES
Academic setting has been organized for
the efficiency and convenience of the
system, its administration and faculty,
and technologies.

Clinical
system is generally organized for
the convenience of delivering health
care to the patient.
Clinicalsetting is a unique and complex
learning environment. Student
performance is based on knowing and
doing in a real situation with a real
patient or client.

Learningsituation within the clinic is


framed by several factors or ground rules.

Prevailing Conditions in the


Clinical Environment
Three generic sources for the ground
rules that frame the clinical learning
environment (Scully):
1. Those originating external to the
clinical education facility
2. Those originating internal to the
clinical education facility
3. Those originating from within the
clinical teacher.
CIs can often reframe the circumstances if
they view the ground rules as defining
opportunities and challenges that allow
them to better enable student clinical
learning.

Questions to Asked - CI
How do students learn in the clinic?
What is helpful for clinical teachers to
know and understand about the clinical
learning process?
Student Ownership and Responsibility
It will involve patients for whom the CI has
legal and ethical responsibilities. It is
imperative that the student accept ownership
and responsibility for the experience.
Clinical education is an opportunity for a
student to learn not only the knowledge,
skills, values, and attitudes of the profession,
but also the first experience in a lifelong
pattern of learning and continual
development as a physical therapist.

CLINICAL LEARNING
It is important that students assume the
responsibility for learning what they need
to know and how to go about learning
it.
Process of Clinical Learning
Clinical learning is a process of mutual
inquiry conducted by the student and CI
during the provision of patient care
services.
Itis a situated learning experience in
which teaching and learning occur
around the patient in a series of
complex interactions.
Bridging Theory with Practice
Primary goal of clinical teaching: to
enable the student to build bridges
between theory and practice.
Theoretical knowledge and fundamental
skills taught in the physical therapy
classroom and laboratory may be couched
in a patient problem orientation, but
students rarely learn in the clinical context
until their first clinical education
experience.
Ability to Perform Effective Actions
Knowing is not enough. Students must
learn to put their knowledge to work, in
doing so, practice and perform
fundamental skills to enhance movement.
Physical therapists examine, assess,
evaluate, plan, and treat. They palpate,
stabilize, mobilize, facilitate, and inhibit.
They teach, motivate, simplify, and
modify.
Skilled performance of these actions
comes only with practice, development,
and refinement.
Acculturation
Is the process by which a student is
socialized into the profession of
physical therapy.
The socialization process is an account
of how a new person is added to the
group and becomes a member capable of
meeting the traditional expectations of the
profession.
PhysicalTherapy is a service-oriented
profession.
Clinical education occurs in settings
where patients come to receive care.
Patients are not exhibits who give time
and money to come to a clinic to provide
an example of a diagnosis for a student.
They are real people with movement
dysfunctions that limit their ability to live
their lives the way they would choose.
Students must learn what it means to
provide service.
Majority of students use their own lives as
the primary example for the way others
live and may assume that their own
beliefs, values, and socioeconomic status
are those of the people whom they will
serve.
Critical Analysis of Clinical Competence
Accurate self-assessment is a critical
ability for professional practice.
Students acquire expectations about their
own abilities from several sources.
Successful experiences are a primary
foundation on which to add from
observing role models or receiving verbal
feedback provided by a clinical teacher or
a patient.
The expected outcome for any clinical
education experience is formally defined
by the academic program.
The goal of clinical learning is for the
student to progress from other-assisted
to self-assisted learning while
developing patterns of learning that form
the basis for a lifelong, reflective
practice.

OUTCOMES OF THE CLINICAL


LEARNING PROCESS
Good clinical teachers enable student
learning. They begin by inviting students
to participate in the community of PT
practice, then they plan, model, coach
question, encourage, instruct, supervise,
and evaluate to optimize the learning
experience.

ROLES OF THE CLINICAL TEACHER:


Diagnosing Readiness, Planning,
Teaching, and Evaluating
Scully describes the role of the clinical
teacher as “pacing the student to
professional competency”, which involves
diagnosis of readiness, selection of clinical
problems, supervision, and evaluation.
Clinicalteacher has limited knowledge of
a specific student’s background before the
student’s arrival.

Clinicalteacher needs to gain an


understanding of the school’s mission and
the goals and objectives of the academic
program because these frame the context
in which the curriculum is presented.

Diagnosis of Student Readiness


A list of completed classes and course
descriptions provide the content to which
a student has been exposed and suggest
curricular themes around which the
academic faculty have chosen to instruct.
Preparation for the clinical education
experience is a key component that
begins after a student is assigned to a CI.

CI should introduce himself or herself and


begin to exchange information as soon as
possible.

Pre-Experience Planning for the


Clinical Education Experience
CI should also communicate directly with
the student.

Important key elements to any types of


initial contact:
◦ Welcoming the student
◦ Introduces the clinical teacher and faculty
◦ Demonstrate truth telling in a candid,
forthright, honest, frank, and open
manner
◦ Conveys expectations
◦ Encourages student’s active participation
A well-planned orientation session can
handle administrative details, introduce
the student to key members of the health
care delivery team, and provide pragmatic
information the student needs.

Orientation is the time for the CI to begin


assessing the student by verbal exchange.
It is also the time to begin joint planning

Student Orientation to the Clinical


Setting and the Clinical Education
Program
Verbal exchange and planning during
orientation sets the tone for conversations
and learning activities that will continue
throughout the learning experience.

Three questions that may guide the


planning:
1. What does the student need to know
before beginning to learn in the context
of patient care?
2. What can wait until later?
3. What is best learned along the way?
Self-insight and the ability to self-assess
are skills based on knowledge and values.

Student’s self-assessment and the


accuracy of that assessment are important
components of the diagnosis of readiness.

Itis critical to evaluate whether a


student’s self-assessment matches the
student’s demonstrated abilities.

Student Self-Assessment versus


Demonstrated Abilities
Performance testing is an ongoing piece of
clinical teaching that must be done in a
manner that allows the student to focus
on learning and development rather than
the adequacy of performance.

Thad’s CI did it in the following way:


The context of patient care provides a
unique environment in which the CI can
evaluate student performance and
teach, monitor and reinforce, and
question and answer almost
simultaneously.
Ongoing re-evaluation is critical to ensure
that selection of clinical learning
experiences matches the student’s
readiness.

Ongoing Re-evaluation of
Student Performance
Clinical
learning experiences or problems
need to be selected based on the
potential they provide for useful
learning.

General guidelines for the selection of


clinical learning experiences must
acknowledge that students need to learn
routines and standards BEFORE they
develop creative alternatives.

SELECTION of CLINICAL PROBLEMS


Once confidence develops, students can
discern when routine evaluation and
treatment approaches fit and when they do
not.

Routines are rare when comparing


patients, but there may be many
similarities when considering “pieces” of
physical therapy interventions.
Example: have the student work with
patients with similar diagnoses to establish
confidence in procedural reasoning and
technical skills.
Repeated actions over time will
enable students to look for patterns,
develop hypotheses, and learn to
respond to the unexpected.
Once the pattern of learning is established,
challenge the known and dare the student
to stretch beyond his or her comfort zone.
The selection of clinical problems and
learning experiences progresses
throughout the clinical experience with
consideration of the student’s readiness,
types of patients, numbers of patients,
and level of student responsibility.
Students should progress from self-
centered to patient-centered learning in
preparation for real-world practice.
There is no evidence that variety makes a
better practitioner.
Supervision includes monitoring a
student’s performances, providing
supportive guidance, and directing
instruction.
At a more advanced level, ongoing,
direct observation may be less frequent
with information derived from written
documentation or even patient outcomes.
While providing supportive guidance to
students, a clinical teacher must also
provide targeted instruction.

SUPERVISION of STUDENT PERFORMANCE


It is important to move beyond the book
knowledge and laboratory skills a student
brings to the clinic, but it is essential to
listen to the student and teach in
response to the student’s questions.

Itis important to teach over the patient


and enable the student to build the bridge
between theory and practice.
Make your reasoning process explicit
while providing a safe environment for
the student to develop an understanding of
his or her own reasoning process while
working with you.
Students should be encouraged to
question their own practice, and they
should be given permission to question
the instructor’s. The instructor should
teach students to take effective actions.
Good clinical teachers DO NOT have to
know everything.
The instructor should model and teach the
student to use the resources available
by looking it up in a reference, asking
another therapist, asking the patient, or
asking other health care practitioners.
Experienced clinical teachers admit that
the most difficult part of working with
students is giving up their own
patients.
Physical Therapists value the relationship
they develop with their patients and take
pride in their ability to help them. Likewise,
it is difficult to give up control of the
student as the student moves from other-
assisted to self-assisted learning.
Purpose of Evaluation:
1. Measure performance
2. Enhance attainment of goals
3. Minimize risk to patients

 Summative evaluation – incorporates


multiple sources of information which is
used to decide about the student’s
readiness to practice by assessing the
students’ cognitive, psychomotor, and
affective behaviors.

EVALUATION of STUDENT PERFORMANCE


Summative evaluations are necessary
to minimize risk to the consumer and
determine entry-level competence.
Formative evaluations occurs
throughout the learning experience as
a continuous part of clinical teaching.
They assess where the student is and
where they are going.
Evaluation – is used by the academic
institution to determine the success or
failure of the student’s clinical
performance.
Clinical problems are selected to provide
opportunities for teaching and learning to
enable the student to progress to
competent professional practice.

A student lacking confidence may feel


uncertain and judge his or her
competencies to be lower than those
observed by the clinical teacher. Another
student, feeling satisfied with a
patient’s progress, may fail to consider
aspects of his or her intervention where
improvement is needed.
Modeling is an effective teaching
technique to encourage students to
develop skill in accurate self-assessment.

Ifthe instructor has concerns or suspects


difficulty among students, it should be
addressed immediately with the student.
Questions or concerns are best addressed
before they become problems.
Itis important for students to learn that
professional development includes
ongoing self-assessment and re-
evaluation followed by defining new
goals targeted at enhancing knowledge
and skills.