Clinical Education the Objective of This Study

¶ … Clinical Education

The objective of this study is to conduct a critical analysis of issues in clinical education. Toward this end, this study will conduct a review of literature in this area of inquiry.

The work of Strohschein, Hagler and May (2002) entitled 'Assessing the Need for Changes in Clinical Education Practice' reports a study that identifies areas of need within clinical education and well as describing "…various models and tools that are proposed and utilized in clinical education, as well as the exploration of the extent to which these models and tools might meet the identified needs of the clinical education process in physical therapy." (p.1) Physical therapists are reported as working in a health care climate "of increasing complexity and rapid change, of fiscal restraint and demands for accountability, of scrutiny from both internal and external sources. In such a climate, the ability to respond appropriately to these pressures is critical, not only for professional growth but also for professional survival." (Strohschein, Hagler and May, 2002, p.1) It is reported that new generations of physical therapists completing professional programs make a requirement of more than just clinical skills on a solid foundation but in addition must receive an education that is founded and reinforced "with skills and attitudes that will enable them to build their profession as well as their own professional practice." (Strohschein, Hagler and May, 2002, p.1)

I. Attitudes and Skills

Included in these attitudes and skills is the "desire to engage in lifelong learning and professional growth and an ability to identify and critically evaluate their own practice and the underlying theories and perceptions" formulating the clinical practice." (Strohschein, Hagler and May, 2002, p.1) It is the contention of Strohschein, Hagler, and May (2002) that clinical education "is the best area in which such skills and attitudes can be taught and refined. Through a consistent and effective approach to the clinical education process, we believe it is possible to influence the formation of these attitudes and skills and, by doing so, have an impact on the future of the profession." (Strohschein, Hagler and May, 2002, p.1)

It is the belief of Strohschein, Hagler, and May (2002) that a consistent approach to clinical education that is additionally is effective is a view that is "clearly communicated, understood, and embraced by all the groups and individuals involved in the clinical education process." (p.1) Strohschein, Hagler, and May (2002) report that the "dichotomy between adult education and health care professionals training" was addressed by Cranton and Kompf who stated recommended, "against developing educational philosophies for these disciplines in isolation. They contended that theory building for education in the health care professions requires an interdisciplinary and holistic approach in order to fully address the needs of students as adult learners. This approach would involve consideration and inclusion of interdisciplinary perspectives from the various health care professions, as well as adherence to foundational principles from cognitive psychology, developmental psychology, and adult education." (p.1)

It was asserted by Opacich that there is a need for "carefully worded, clearly understood vision for the profession and its process of clinical education." (Strohschein, Hagler and May, 2002, p.1) Opacich held that missing in the fieldwork solution "is a well articulated educational philosophy that could link the tenets of occupational therapy with a viable, ideationally compatible field work model." (Strohschein, Hagler and May, 2002, p.1) This same need is existent in physical therapy and other clinical professions.

II. Clinical Education Goals

The clinical education process has been noted to be important in the cultivation of nontechnical skills by two separate groups. Firstly, Higgs and Colleagues -- developed 14 clinical education goals in the health care professions which included the following: (1) an awareness of health, holistic health care (ie, health care that addresses the multidimensional needs of the client), and the health care system; (2) awareness of one's attitudes, values, and responses to health and illness; (3) a broad understanding of the roles of the health care team, (4) interpersonal skills and the ability to educate others effectively; (5) the ability to critically evaluate personal and professional practice; and (6) accountability and commitment to continued development of competence and lifelong learning. Also included were competencies such as clinical reasoning, psychomotor skills, examination, treatment and evaluation, integration of theory and practice, and an ability to articulate rationales for treatment." (Strohschein, Hagler and May, 2002, p.1)

Strohschein, Hagler and May (2002) report that the list of goals revealed the awareness of clinical educators of the "…complexities of clinical practice and a desire to foster reflective practice and critical thinking to effectively cope with these complexities. Secondly, it is reported that it was indicated in a well-designed qualitative study that cultivation of nontechnical competencies during the clinical education process is extremely important. Stated is that through use of the critical incident technique that the researchers conducted an exploration of "…the factors underlying inadequate clinical performance of students during their clinical experiences. Thirty-three clinical educators discussed specific incidents in which they had questioned the competence of students. Of the incidents described, more than half involved behaviors that the researchers believed reflected inadequate nontechnical skills such as poor communication and unprofessional behavior." (Strohschein, Hagler and May, 2002, p.1)

III. Nontechnical Competence Needed

The work of Schon in the area of reflective practice is reported to have "…discussed the need for developing nontechnical competence. Schon wrote of the tension between rigor, or technical rationality, and relevance, found in acting in the complex, uncertain world of practice. He argued that the most important areas of professional practice lie beyond the commonly understood areas of technical competence, and he stressed the need for artistry as well as technical excellence in practice. He articulated the need to challenge previous assumptions, to embrace uncertainty and ambiguity as opportunities to deepen and broaden learning, and to pursue a holistic grasp of the practice. In this approach, multiple perspectives and solutions to problems are valued." (Strohschein, Hagler and May, 2002, p.1)

IV. Legal Clinical Education Examined

Condlin (nd) writes that clinical legal education "is defined typically as instruction in interpersonal skills" including such as interviewing, counseling, and negotiation as well as professional ethics which is described as the "moral principles that regulate the behavior of lawyers in role…" (p.316) This is stated to be discussed in the context of student fieldwork or the "representation of actual clients with live cases in law offices created by law schools for this purpose under the supervision of a lawyer" or teacher or law. (Condlin,, p.318) Clinical education is stated to differ in two ways from apprenticeship training, the form of lawyer education replaced at the end of the nineteenth century by the university law school. It looks for content more to the interpersonal dimension of law practice -- its psychology and ethics- than to its administrative tasks and gives critical self-analysis of student work priority over the absolute quality of that work." (Condlin, nd, p.31( The emphasis is on psychological and ethical subject matter and critical self-analysis which is stated to have "important practical consequences." (Condlin, nd, p.318) Clinical education is additionally reported by Condlin to be described commonly as a "new teaching methodology" with the following components:

(1) student assumption and performance of recognized roles within the legal system;

(2) teacher reliance on this experience as a focal point for intellectual inquiry and speculation; and (3) motivational tensions, which arise out of ordering the teaching-learning process in this way. (Condlin, nd, p.318)

It was believed that Clinical education would serve to confront ethical problems in two ways and firstly in a substantive way and secondly in a methodological way. Condlin states "Substantively, clinical education would analyze the interpersonal skills of law practice. This substantive focus was supposed to make explicit the student's moral stance towards clients and third parties, and in the words of one commentator 'compel the examination of personal ethics, morality, and individual conceptions of professional role." (Condlin, nd, p.320) From this view, ethical issues were viewed as "inescapably embedded in issues of interpersonal technique. It was not though possible to consider questions of what would work, without simultaneously considering question of what was right." (Condlin, nd, p.320)

V. Links Between Ethics and Technique

According to Condlin the link existing between ethics and technique "also appear in the ostensibly psychological literature in which clinical study is grounded. " (nd, p. 320) Condlin states that even more important that the substantive approach to ethics is that clinical education "confronts ethical issues methodologically as well: clinical students actually practice law. Moral issues are thus raised in ways that differ from those of traditional instruction in three crucial respects: (1) the issues are confronted in the first person, in the lawyer's role, with ready-made motivational tensions -- instead of Pi and Delta and their lawyers, the parties are real and their lawyer is I; (2) the problems appear in the full richness of real-life factual situation; and (3) all student work is done as part of a bilateral partnership with a skilled practitioner/teacher who models appropriate behavior at the same time that he or she criticizes student performance. (Condlin, nd, p.321) According to Condlin, the central feature of this process and it conscious use "both in theory and practice, of the dynamics of role adjustment." (nd, p.321) This process is reported to generate "a number of epistemological and motivational consequences of enormous importance" and as well, the process of role adjustment additionally "triggers a need to know and justify." (Condlin, nd, p.321)

The New York State Judicial Institute Partners in Justice in their "Colloquium on Developing Collaborations Among Courts, Law School Clinical Programs and the Practicing Bar reports that the earliest forms of clinical legal education was such that "…embraced the dual goals of hands-on training in lawyering skills and provision of access to justice for traditionally unrepresented clients." (Condlin, nd, p.321) In the beginning, the legal realism movement of the 1920s and 1930s made provision for the goal of instruction of lawyering skills and professional values in Law school legal aid dispensaries." (Condlin, nd, p.321 ) Legal realists such as Llewellyn and Frank are reported to have advanced the views that students 'must learn about law as a means to an end rather than as an end in itself." (Condlin, nd, p.321 ) Both Llewellyn and Frank advocated legal education. During the 1960s, there was a great deal of support for voluntary advocating of clients in the clinical setting in assisting poor individuals with their legal issues and was accomplished in the form of "legal aid dispensaries" in the 1960s and 1970s and were clinical programs that "provided representation to indigent clients with a myriad of legal problems." (Condlin, nd, p.321) The earlier legal programs were expanded upon through clinics that served to "…demystify law for students and to represent client communities with claims that thrust clinical programs into the civil rights, consumer rights, environmental rights, and poverty rights movements. During this same period, the Critical Legal Studies (CLS) movement grew out of the earlier legal realism movement." (Condlin, nd, p.321) Clinical teachers worked with law students and utilized the law as an instrument for social justice and change while proponents of CLS utilized the classroom for the purpose of demystifying the law and teaching students that political conviction is primary in adjudication and that the "shape of the law at any time reflects ideology and power as well as what is wrongly called logic." (Condlin, nd, p.321)

V. Clinical Education in Physical Therapy Field Examined

Clinical education in the field of physical therapy is reported in the Conference and Regional Forum Summaries: A Consensus Conference on Standards in Clinical Education (2007) to include performance standards in specific categories including those stated as follows:

(1) Autonomous practice and direct access;

(2) Documentation

(3) Billing and coding;

(4) Cost-effectiveness;

(5) Practice Management;

(6) Evidence-based practice;

(7) Screening (includes review of systems);

(8) Patient/client management examination;

(9) Evaluation

(10) Diagnosis;

(11) Prognosis;

(12) Safe and Skilled Interventions;

(13) Outcomes assessment;

(14) Health policy;

(15) cultural competence;

(16) Direction, supervision, and delegation;

(17) Interpersonal skills;

(18) Communication

(19) teaching and learning;

(20) interprofessional collaboration

(21) emerging skills

(22) Prevention, wellness, and health promotion

(23) Quality improvement/assurance; and (24) Consultation;

(25) Professionalism;

(26) Accountability for Ethical and Legal Expectations;

(27) Professional development;

(28) Involvement in Professional Organizations

(29) technology and informatics. (Conference and Regional Forum Summaries: A Consensus Conference on Standards in Clinical Education, 2007)

Clinical instruction performance standards were identified in 17 categories including those of:

(1) Teaching/instruction;

(2) learning/expectations

(3) performance assessment/evaluation

(4) self-assessment;