E d u c a t i o n a l P e r s p e c t i v e P h y s io t h e r a p y C l in ic a l E d u c a t o r ’ s N e e d s A B S T R A C T : P h ysio th era p y clin icia n s ha ve been in vo lved in stu d en t clin ica l educa- tion sin ce the ea rly d a ys o f p h y sio th e ra p y training. A s the p h ysio th e ra p y p ra c tic e a n d MBAMBO NP, M Phys T stu d e n t learning has c h a n g e d o ve r the la st three decades, so have the role o f the clini- Department of Physiotherapy, m e d u n s a cal educators. L ittle has been done though, to p rep a re o r su p p o rt the clinical ed u c a ­ tors in this new role w hich is m ore com plex. The n eed s o f the clinical ed u ca to rs in term s o f th eir invo lve m en t in clin ica l education a n d their training f o r this role are esta b lish ed a n d recom m endations are m ade to m e e t these needs. INTRODUCTION Clinical education form s a m ajor part o f the teaching program m e for physiothe­ rapy education and should provide a stim ulating foundation for integrating and internalizing the theoretical know ­ ledge learnt in lectures and during self study. Clinical activities and experiences that are planned as part of physiotherapy education should provide this stim ulat­ ing foundation and the provision thereof depends on effective collaboration and com m unication between the universities and providers o f clinical education. The experiences that the students are supposed to gain during clinical educa­ tion include treating o f patients with various m edical conditions, w orking with other health care team members, and decision m aking concerning other aspects o f the patients’ wellbeing, and problem solving around the patients’ ill­ ness or disability. The clinicians who are charged with the task o f clinical educa­ tion of students, plan and conduct clini­ cal activities and experiences that will fit in with the day to day running of a cli­ nical department. The clinical educators therefore play a pivotal role in the training o f the stu­ dents because: CORRESPONDENCE: N P M bam bo D epartm ent o f Physiotherapy M edical University of Southern A frica P.O. Box 1637 M edunsa 204 South Africa • they are the ones who have close and frequent contact with the students dur­ ing their practical time in the clinical settings • the students treat the c lin ic ia n s’ patients, and • they are the mem bers o f the health care team to whom the students must be introduced and into whose depart­ ments they need to be incorporated. Coates (1991) defined the role o f the clinical educators by suggesting that: Clinicians are the members o f our profession who are spending the major­ ity o f their time treating patients, achiev­ ing the mastery level o f their clinical skills and becoming fam iliar with mo­ dern equipment. It is these members o f our profession who have so much to offer students and should therefore be at the forefront o f the clinical education process. CHANGES IN THE PHYSIOTHERAPY PROFESSION Over the last* three decades the phy­ siotherapy profession has evolved in clinical practice, student learning and clinicians’ involvement in students learn­ ing. Physiotherapy practice has devel­ oped from the dependency o f the 1960s w here the clin ician s w orked under the direction o f medical practitioners, to full autonom y (Cross, 1994). As these changes were taking place in clinical practice, the role o f the clinicians in­ volved in student training changed from a clinical instructor who was drilling learners to produce traditional proce­ dures (Wastaff, 1988) to that o f a clinical educator who is required to facilitate students to cope with change, to make judgem ents and take responsibility for those judgem ents, and to deal with the com plexities o f real-w orld clinical prac­ tice (Higgs, 1992). The need to improve professional status and the credibility o f professional decisions saw a change from d ip lo m a-b ased program m es to degree-based program m es. This change in training also co n trib u ted to the change in the clinical supervisor’s role, which was from a supervisor to an edu­ cator. W hat is the differen ce then betw een edu catio n and supervision? Daloz (1986) defined education as: Something we neither give nor do to students, it is the process o f nourishing or rearing towards a competent profes­ sional; development o f power and fo r ­ mation o f character o f the learners. Supervision on the other hand was defined by Onions (1973) as “directing or inspecting; exercising control.” This difference in the definition means that student learning in the clinical setting has developed from training o f skills to facilitation o f the developm ent o f a stu­ dent into a professional physiotherapist. Higgs (1992) described the primary role o f clinical educators as that o f providing com petent clinical role models, facilitat­ ing and m anaging students’ learning and em pow ering students to learn and to take control of, and responsibility for, their learning. T he role that the clinical educators m ust take is not w ithout constraints and concerns. In 1988 Best described con­ straints that clinical educators have in their involvem ent with students as: 16 SA J o u r n a l o f Ph y sio t h e r a p y 1999 V o l 55 No 4 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) • P h y s io th e r a p is ts ’ p rim a ry e th ic a l responsibility for patient treatment. • P h y siotherapists’ m otivation in ac­ cepting the role o f clinical educator. • Inadequate preparation by informal training for the task o f clinical educa­ tion. • The fact that clinical education is regarded as a time consum ing and non-reim bursable input o f tim e for the physiotherapist. • The fact that few clinical educators have the luxury o f reduced case loads in order to allocate more time to stu­ dent activities, and therefore see time as a constraint to clinical education. C oncerns o f clinical educators regard­ ing th eir in v o lv e m e n t w ith stu d en t train in g w ere id entified in a one-day w orkshop organized by the M edical University o f Southern Africa for clinical educators and lecturers: ■ Clinical educators are confused about expectations regarding their evaluation o f the students’ clinical performance. ■ Clinical educators would like guidance w ith evaluation o f clinical p erfo r­ mance. ■ Em phasis on certain aspects of clinical practice differs between lecturers and clinical educators. ■ Students are not well prepared for the clinical blocks. ■ Students lack self-confidence, asser­ tiveness and initiative. ■ M o st stu d e n ts lack re sp o n sib ility towards their patients. In a m ore extensive study o f 39 clini­ cal educators other concerns were raised (M bam bo, 1998). Some o f the clinical educators raised concerns about the evaluation form at used by the various universities. They felt that the evalua­ tion tool was not objective and did not really evaluate the clinical com petence o f the students. O ther clinical educators fe lt th at co m m u n icatio n reg ard in g the curricula was not effective. They suggested that the universities should include clinical educators in the devel­ opm ent o f curricula and the revision thereof. PREPARATION OF CLINICAL EDUCATORS Since the early days o f the profession, p h y sio th e ra p y c lin ic ia n s have been involved in the clinical education o f phy­ siotherapy students. However, although health care professions value clinical education, little attention has been given to preparing therapists for their teaching role (Christ-Hickerson, 1986). It appears that the problem o f preparation o f cli­ nical educators is not unique to physio­ therapy as other health professions have sim ilar problems. In a study by Christie et al (1985) among occupational therapy clinical educators, it was found that the majority o f the clinical educators were dissatisfied w ith the p reparation they received for their clinical teaching role. M any o f them indicated that different aspects o f training were required for adequate p rep aratio n for the clinical education role. T he objectiv es o f the training should be: • To im prove supervisory skills by developing com petency in assessing the needs o f the students, establishing perform ance objectives and expecta­ tions, evaluating student perform ance, structuring the students’ clinical expe­ rience and adapting their clin ical teaching approach to meet specific stu­ dents’ needs that have been identified. • To im prove teaching skills by provid­ ing theo retical k n ow ledge o f the teaching-learning process and assis­ tance in im proving clinical teaching techniques. • To enable clinical educators to handle students’ clinical and personal pro­ blem s that hinder their effective learn­ ing by providing information regard­ ing curriculum changes and how to counsel students. The sentim ents expressed by these clinical educators indicate that they have insight into their training and therefore preparatory needs. The study o f student health visitors and teachers conducted by Fish et al (1989) revealed evidence that many clinical educators were not aw are o f the skills and strategies required in clinical education and they did not acknowledge the com plexities o f enabling students to learn from experience. This situation was seen to be aggravated by the fact that som e o f the clinicians who were required to offer clinical education to students did not have sufficient clinical experience themselves. The findings by Fish et al (1984) are supported by an earlier study by Orton (1981) which was done on clinical education in nursing. This study suggested that the models and skills o f clinical education were not fully recognized or understood by many qualified staff undertaking clinical edu­ cation, even though many nursing sisters had attended a course in teaching and assessing o f students. This indicates per­ haps either a lack o f a conceptual fram e­ w ork for clinical education in the educa­ tors’ courses or that the courses alone are not adequate. THE SOUTH AFRICAN SCENARIO The clinical facilities used for physio­ therapy stu d en ts’ clinical experience have changed in South Africa. The shift tow ards Prim ary Health Care and the lack o f sufficient financial and therefore hum an resources in the tertiary health in stitu tio n s have b ro u g h t ab o u t this change. The clinical facilities used there­ fore are no longer in the vicinity o f the academic institutions; some are more than five hundred kilom eters away. It is important therefore to em pow er the cli­ nical educators to deal with all aspects o f clinical education because som e of them do not have the luxury o f nearby academic staff for consultation. At the m om ent the follow ing are the different systems used by the universities to either prepare or support their clinical educators: • An ‘outline’ on clinical education is given to clinical educators to give them guidelines on what is required from the students in each clinical set­ ting and how to allocate marks. • Clinical educators are given a 20-hour course and workshops to prepare them for their role and they attend regular m eetings where any problem s they may encounter, are discussed. • Clinical educators i.e. clinicians and lecturers m eet at the beginning o f the year to discuss objectives for clinical education and to revise the assessm ent form and procedural fo rm at for assessm ent o f students’ clinical per­ formance. SA J o u r n a l o f Ph y sio t h e r a p y 1999 V o l 55 No 4 17 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) • M eetings are held once every term to discuss progress, problem s and addi­ tional specific guidance structures for those who have specific problems. • Clinical educators are given objec­ tives and evaluation forms for specific clinical settings. A few o f the universities create the opportunity for the lecturers and clinical educators to discuss clinical education objectives and the problem s encoun­ tered during clinical education. There seems to be a lack o f em pathy though between the lecturers and the clinical educators in relation to their needs and expectations o f each other. Central to this concern or lack of em pathy is its im pact on learning outcomes and the overall quality o f clinical education. NEEDS OF THE CLINICAL EDUCATORS - SOUTH AFRICAN CONTEXT Physiotherapists have varying percep­ tions o f the task o f clinical educators, which are influenced by their own expe­ riences, work situations and recent stu­ dent contact, professional developm ent and interpersonal needs. With the phy­ siotherapy training transform ed from “drillin g ” students to education and learning, active teaching takes place in a widening variety o f clinical areas. The giving and receiving o f feedback and encouraging initiatives are also now the way to groom p ro fessio n als o f the future. This means that the role o f the clinical educators and expectations are changing and hence their needs. The present systems used by the uni­ versities therefore may not be sufficient to achieve the objective they are meant for. In a study done by M bam bo in 1998 to establish the needs o f clinical educa­ tors, the clinical educators identified the following. Aspects of p lan n in g that clinical e d u ­ cators need to be involved in: • Tim e-table and student placem ent The clinical educators perceive planning o f timetables and placing students in the clinical settings as part o f active involve­ ment. Their involvem ent in planning tim etables will ensure that the clinical educational program m e can more or less fit in with the daily routine o f the clini­ cal setting with minim um disruption. Their participation will also give them the opportunity to plan the learning experiences o f students in accordance with the university regulations, the types o f patients available, duration o f treat­ m ent and hospitalization. • Clinical objectives and pre-clinical preparation o f students Discussion o f clinical objectives and pre-clinical preparation o f students were the areas which the clinical educators felt would minimize if not eradicate, the dichotom y betw een the lecturing staff and the clinical supervisor. This dicho­ tomy tends to confuse students and may cause anxiety when they have to treat patients. N ee ds o f the supervisors re g a rd in g training courses for themselves M ost of the clinical educators feel that there is a need for preparation for the role o f being a clinical educator. Some o f the clinical educators who share this sentim ent have been trained for their role and therefore had experienced the benefits o f being trained for clinical education. With regard to the areas o f training that need to be included in a training course, most clinical educators indicated the following: • Teaching methods • A ssessm ent o f students • Awarding o f marks • Interpersonal skills • Setting o f objectives The foregoing findings indicate that the clinical educators have insight into their needs and that they acknowledge that they need to improve and broaden their educational skills. They therefore appreciate that their role has changed and has becom e more complex. RECOMMENDATIONS ■ S taff from un iv ersity departm ents need to show appreciation for the w ork done by the clinical educators so that their morale and m otivation can be boosted. This can be done using the follow ing strategies: • Paying an honorarium to the clinical departm ent for the clinical education that they offer to students. • The universities that train physiothe­ rapists should give clinical educators a sum m ative clinical exam iner’s status so that they can act as external exam i­ ners. Clinical educators should be invited as sessional lecturers in their areas o f expertise. • Clinical educators should pay reduced fees for continuing education courses run by the universities. ■ S taff from u n iversity departm ents should offer academic support for the clinical educators • Their training needs should be esta­ blished and courses designed to meet these needs. • They should be given access to uni­ versity libraries or if the clinical set­ tings are situated far from the libra­ ries, they should get recent articles from journals to which the universities subscribe. • They should be supported in their research endeavours and should be encouraged and assisted to present papers or posters at congresses ■ Clinical educators should be included in clinical education planning so that they can be equal partners in profes­ sional education • They should be invited to planning sessions o f the clinical program m es. • They should be involved in decision making on which clinical setting is to be utilized for which clinical block, and the num ber o f students to be accommodated. • They should get involved in setting of the clinical objectives and advise the universities on the activities and expe­ riences available to achieve these objectives In 1987 Barnett et al outlined prere­ quisites fo r equal partnership in clinical education: the academic sta ff must be conversant with realities and contextual variables o f contem porary practice, even though they are not necessarily fu lly involved with them AND the clini­ cal sta ff taking part in clinical education must also have a measure o f awareness 18 SA J o u r n a l o f Ph y sio t h e r a p y 1999 V o l 55 No 4 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) TABLE 1: CATEGORIES OF EXPECTATIONS . CATEGORY EXPECTATIONS Communication Open discussion of issues with students Prompt provision of feedback on clinical performance Clear answers to questions Supervision activities Allow the students progressive and appropriate independence Accurate documentation of student evaluation Make the formal evaluation a constructive process Make effective learning experience out of situations as they arise Make the relationship between academic knowledge and clinical practice Assist the students to define specific objectives for the clinical education experience Professional skills Demonstrate professional behaviour as a member of the health care teamDemonstrate basic theoretical knowledge and teaching skills Interpersonal relations Establish an environment in which the students feel comfortable Demonstrate positive regard for students as a person o f the thinking underlying educational change, while not allowing undue con­ cern fo r educational theory to impede their ability to deal with practical prob­ lems in the clinic. m The roles o f the clinical educating per­ sonnel, that is, lecturers and clinical educators, should be clearly defined. A supervision policy needs to be developed which will spell out all the different aspects o f clinical education. This policy should include: • The roles o f the lecturers and clinical educators in clinical education and how education will be shared. • How clinical education will be conduc­ ted, that is, activities to be executed. • W hen, during the block, these activi­ ties are to be executed. • W hen the students are to be evaluated during the block and by whom. • W hat the expectations o f all the stake­ holders in clinical education are. ■ The clinical educators should be made aware o f the students’ expectations so that they can ensure that their interac­ tion with the students fulfills the stu­ d en ts’ expectations. In a study done by Kekana and Hlwathi (1998) among students from M EDUNSA and univer­ sities o f Pretoria and W itwatersrand four categories o f expectations were identified by the students: (Table 1) The same study recom m ended w ork­ shops between students and clinical edu­ cators where expectations and needs would be discussed. These workshops should be organized by the lecturers and funded by the universities. CONCLUSION The literature reviewed and the em piri­ cal investigation that was done reveal that the clinical educators have a need for support and guidance in clinical edu­ cation. They need moral support’, recog­ nition o f the role they play in clinical education, inclusion in planning and decision making on clinical education issues and preparation for their role as clinical educators. They perceive them ­ selves to be com petent in their role but realize the changes that have taken place in their role and know their educational needs to fulfill this changed role. Work­ shops therefore, with the lecturers and clinical educators, should be run to con­ tinually engage in discussions about the clinical educators’ needs, the problems encountered during clinical education and other matters o f mutual interest including sharing o f ideas. REFERENCES Barnett R A , B e ch er RA and Cork N M 1987 M o d e ls o f p r o fe ssio n a l preparation: Phar­ m acy, nursing and teacher e d u ca tio n . S tu d ie s in H ig h e r E d u c a tio n , 12, (1 ),-5 1 - 63 B est D 1988 P hysioth erapy C lin ical Su p er­ vision : E ffe c tiv e n e ss and U s e o f M o d e ls. The A u s tra lia n J o u rn a l o f P h y sio th e ra p y , 3 4 , (4 ), 2 0 9 - 2 1 4 C hrist H ick erso n PA, 1 9 8 6 C ontem p orary issu es in clin ica l ed u cation. 1, (3 ), S la ck Incor­ porated, N e w Jersey. C h ristie B A , J o y c e PC and M o e lle r PL 1985 F ie ld w o r k e x p e r ie n c e , Part II: T h e su p erv i­ so r s’ d ilem m a . A m e r ic a n J o u rn a l o f O c c u ­ p a tio n a l T h e ra p y , 3 9 , (1 0 ), 6 7 5 - 681 C o a tes M 1991 C lin ica l ed u cation: S tu d e n ts ’ a n d c lin ic a l t u t o r s ’ view s. P h y s io th e r a p y , 7 7 , (5 ), 351 - 3 5 4 C ross V 1 994 From C lin ica l S u p erv iso r to C lin ica l Educator: Too m uch to a sk ? P h y s io ­ th e r a p y , 8 0 , (9 ), 6 0 9 - 6 11 D a lo z L A 1986 E ffe c tiv e tea ch in g and m en ­ toring. J o s s e y -B a s s, L ondon. F ish D , twin S and Purr B 1989 H o w to en ab le learning through clin ica l p ractice. P ilo t study report N o . 1. W est L ondon Institute o f H igh er E d u cation , London H ig g s J 1 9 9 2 M a n a g in g C lin ical E ducation. P h y s io th e r a p y , 7 8 , (1 1 ), 8 2 2 - 827 K ekana EM and H lw athi T M 1998 C om p eten t c lin ic a l supervisor: P hysioth erapy stu d en ts’ p ersp e ctiv e. U n p u b lish ed undergraduate re­ search project. M b a m b o N P 1998 T h e n eed s in physioth erap y c lin ic a l ed u cation: C lin ica l ed u c a to r s’ per­ sp e c tiv e . U n p u b lish ed postgraduate research project. O n io n s C T (e d ) 1973 Shorter O xford E n glish D iction ary. O n H istorical P rin c ip les, O xford U n iv ersity P ress Orton H D 199 4 Ward learning c lim a te. R o y a l C o lle g e o f nursing, L ondon W astaff P 1988 T he great debate. P ro ceed in g s o f A s s o c ia tio n o f teachers o f C SP, Spring C o n feren ce, 1 6 - 1 8 SA J o u r n a l o f Ph y sio t h e r a p y 1999 V o l 55 No 4 19 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )