Educating clinical educators: using a model of the experience of being a clinical educator

Abstract

Background: Clinical educators are expected to prepare students to be competent beginning practitioners, ready to enter the workforce and meet the demands of competent practice. As part of ensuring the quality of clinical education, universities that provide these programs need to be involved in the education and support of clinical educators. In this paper we examine the preparation and professional development of clinical educators based on research into the experiences of being a clinical educator (McAllister 2001).

Methods: The research approach involved a blend of hermeneutic phenomenology and narrative inquiry. In-depth interviews were conducted with five speech pathologists in Australia. Data were analysed using a phenomenological analysis process.

Results: Recurrent themes in the research were represented by 12 themed stories to richly portray participants’ experiences of being clinical educators. An example is provided in this paper. The research produced a model of The Experience of Being a Clinical Educator. The six dimensions of this model are: a sense of self, of self-identity; a sense of relationship with others; a sense of being a clinical educator; a sense of agency or purposeful action; dynamic self-congruence; and the experience of growth and change.

Conclusion: Becoming and being a clinical educator is a developmental process, mirroring in some ways the developmental process clinical educators strive to facilitate for their students. This journey of growth and development as a clinical educator requires active learning approaches coupled with reflection on one's practice as a clinical educator. The model can be used to educate clinical educators in speech pathology and other professions, given the commonalities in clinical educators’ roles across professions. Interactive and reflective strategies are presented in the paper for the development and support of clinical educators across the continuum from novice to professional artist.

Introduction

Health professional education programs commonly include fieldwork or clinical education as a major component of their curricula. Clinical educators are expected to prepare students to be competent beginning practitioners, ready to enter the workforce and meet the demands of evidence-based practice. As part of ensuring the quality of clinical education, universities that provide these programs need to be involved in the education and support of clinical educators. In this paper we explore this topic, building on a model of clinical supervision derived from research into the experience of being a clinical educator McAllister (2001). The value of using models as the basis of educational programs is that participants and teachers can make sense of the goals, content and processes of teaching and learning through a central organising framework and set of ideas.

How are clinical educators prepared for their roles? Early clinical education literature and training emphasised the characteristics of clinical educators (e.g. approachability, role modelling, fostering student participation) (e.g. Stritter et al. 1975; Irby 1978; Rubeck & Anderson 1981). Later literature emphasised preparing clinical educators for the process of clinical education (e.g. Anderson's 1988 continuum of supervision involving the stages of evaluation—feedback, transition and self-supervision; and Romanini and Higgs's (1991) teacher-manager model of clinical supervision including preparatory, implementation and evaluation phases). Subsequently focus shifted Boud (1987; Higgs 1992; Knowles et al.1998; Harden & Crosby 2000) to the roles of clinical and workplace educators as facilitators of adult learning, emphasising respect for learners and their experience and the importance of commencing with the learner's present understanding.

Table

Practice points
•Clinical educators play a key role in the education of health professionals.
•The training and support of clinical educators need greater attention.
•Clinical educators need to be prepared for a complex and demanding role.
•A model of the lived experience of being a clinical educator provides a framework for clinical educator training.

Recent publications on clinical education (and workplace education) have again shifted in focus, to understanding and providing frameworks for education. These considerations are built on earlier models of adult learning (Knowles1984; Knowles et al.1998) and reflective practice Schön (1987), and include:

• learning in communities of practice, recognising that learning and practice are cultural processes occurring in communities (Wenger1998; Abrandt Dahlgren et al. 2004);

• work-based learning (Foster1996; Boud1998; Sangster et al.2000), where learning is student-centred, team-based, cooperative and interdisciplinary, and is concerned with performance enhancement and upgrading experience, is process-oriented, activity-based, performance-related, problem-based (focusing on complex work-based problems) and promoting of lifelong learning. Such learning deals with workplace expectations; it is contextualised and consequential rather than isolated from reality;

• professional socialisation (Du Toit1995; Cant & Higgs1999), where learning occurs in a framework of acculturation into a profession—a complex process of acquiring the knowledge, skills and sense of occupational identity of a profession within changing contexts and cultures;

• situated learning (Vygotsky1978; Brown et al.1989; Lave & Wenger1991; Billet1996; McLellan1996), where learning is a function of the activity, context and culture in which it is situated;

• peer learning (Cohen & Sampson1999; Ladyshewsky et al.2000), which involves interdependence, accountability, group work, and feedback;

• flexible learning (Laurillard1993; Roberts1997; Mahony2004), where ‘flexible’ refers to flexibility in mode, time, place, etc.;

• learning for capability (Stephenson1998; Fraser & Greenhalgh2001), where ‘capability’ implies being able to look ahead and act accordingly in a changing world.

Research into the experience of being a clinical educator

In this paper we build on these prior trends and step inside the context of clinical education, inside its roles, tasks and characteristics, and focus on the lived experience of being a clinical educator. We present a report of research that investigated these experiences and reflect on the implications for the education of clinical educators.

Methods

The research approach was hermeneutic phenomenology (building on the work of van Manen 1990) and narrative inquiry (building on the work of Clandinin & Connelly1986, 1991). The research strategy involved the observation and in-depth interviewing of five female speech pathologists working in Australia. Their assigned pseudonyms were Ann, Annette, Robin, Emma and Jenny. From 7 to 14 interviews were conducted with each participant over a period of 3 to 13 weeks, coinciding with the length and intensity of clinical education (number of days offered to students per week). Figure 1 illustrates the data collection and analysis process.

Figure 1. Data collection, analysis and presentation process.

Participants were selected by purposive sampling (see Patton 1990) to reflect (a) the variety of settings in which clinical education was conducted with speech pathology students (a university clinic, a community health centre, a hospital, a school, and a community-based service for people with intellectual impairment) and (b) the variety in the levels of experience of the participants as clinical educators. Strategies to ensure trustworthiness and rigour in the research, based on recommendations of Guba & Lincoln (1994), Koch(1994), Leininger (1994) and Doyle (1997), were the use of multiple data sources, data saturation, use of thick description, repeated observations, in-depth interviewing, use of an audit trail and analytical log, and participant critique and verification of stories.

Data were analysed using a six-stage data analysis process based on a phenomenological analysis approach developed by Titchen & McIntyre (1993) combined with narrative inquiry approaches as described by Clandinin & Connelly (1991):

1. Identifying first-order (participant) constructs (i.e. the way the participants understood and portrayed their experiences of being clinical educators).

2. Identifying themes in the data.

3. Writing themed stories.

4. Validating stories with participants.

5. Elaborating themes and their relationships.

6. Developing a theoretical model.

Review of the emerging themes and the model was conducted via presentation of the research findings at conferences and in workshops with clinical educators. Clinical educators in speech pathology and other disciplines (e.g. physiotherapy) commented on the high level of applicability to their situations. The educators heard their experiences in the stories being told and saw the themes as giving good insight into their roles and experiences as well as a foundation for professional development.

Results: themed stories

Recurrent themes in the research were represented by 12 themed stories utilising narrative inquiry strategies (Clandinin & Connelly1986, 1991; Beattie 1995). The participants’ oral stories from a variety of data sources and episodes were collated and re-presented to highlight the key themes. These were subjected to participant validation. These themed stories enabled large quantities of data to be synthesised into meaningful wholes to richly illustrate the themes, as evident in the following extract. We have selected one of these stories and present an extract of this story to illustrate the lived experiences of these participants through this rich portrayal.

Extracts from a themed story

Plotting and planning: Managing dilemmas; scaffolding learning

In this story the researcher (L. McAllister) talks with Ann, a clinical educator, about Ann's experiences of clinical education. These experiences have been constructed into one of Ann's themed stories. (FN = field note, followed by date of observation or interview); words in italics come from interview transcripts (followed by transcript then page numbers).

On my last visit you were talking with the students about their work during the day (FN 26/7), the word ‘dilemma’ came up a few times from the students. You had also talked about dilemmas in a couple of prior interviews. The concept of a dilemma obviously has some significance for you …. You first identified something as a dilemma during a discussion with the students on my first visit (FN 15/7). Louise felt the children that she was working with weren’t getting much out of the reader used in the classroom by the teacher. You responded that this was a dilemma, and asked the students how this could be dealt with. You were affirming and valuing of the insights they offered about teachers’ skills and respecting teachers’ competence. You were pleased that they came to recognise the dilemma of understanding her point of view whilst also making a contribution about working with children with communication disorders. You ended by suggesting that in the afternoon perhaps they could role-play how to manage this dilemma, developing strategies to tactfully confront the teacher and offer alternatives.

We talked about this particular dilemma in our interview later in the day and you elaborated on what could be seen as an extra dimension to the dilemma. While the students were excited that they had been able to recognise a dilemma in the classroom, you said: they don’t understand the educational context and they haven’t been in a lot of classrooms, they still have got unreal expectations of what teachers can achieve … and what they [as student speech pathologists] can give [the teachers] to get around [the problems] (2:7). The students’ goals for therapy might be different from the goals and expectations of the school. This creates a dilemma for you in that you feel you have to find a way to take up what [the students] are saying and twist it and encourage them to think they’ve come up with the idea that [you] wanted them to come up with (2:8), which was a way of working with the teacher that would not alienate the teacher. You feel it's important to ‘prepare not repair’ interactions between students and teachers.

In our second interview you also identified what you said was the major dilemma for you in your work in the student unit, that of trying to balance the needs of the students, the school and the children (2:9). You said that to manage this dilemma, to balance the needs of the teachers, the school community, the students and the children … [you] have become more directional (2:14). You told me that you have changed the way you approach giving the students experience in the unit. You felt initially you’d been expecting too much of [the students] … [you’d] missed a step along the way and made it a lot more difficult for them (1:4). When you first started you would just send them off to do a task, such as assessing children. You realised that the students didn’t have the knowledge of testing in general and assessment in the school context in particular. As a result, you now introduce them slowly to the concept of assessment, have them do some pre-reading, sharing what they’ve learned and discussing different approaches in the group.

When you described this to me and I later saw you doing similar things with the students in a group discussion, the image that came to my mind was one of scaffolding. You felt this metaphor described very well what you did. You described the plan that you now have for the placements and how you develop the different skills they will need as collaborators in different stages of the placement. You feel that by preparing and enabling them in this way that they can in turn meet the teachers’ and children's needs, avoid dilemmas, and that delicate balance will have been achieved.

Although you have through experience developed a scaffold, a way of what you referred to as plotting and planning the placement, I sense that this still leaves you with dilemmas about how to balance teaching versus collaborative roles, and how to enact the values you care deeply about in dealing with people. Quite a lot of time is spent at the start of the placement getting the students up to speed, to give them some handle quickly on what they’re doing and why they’re doing it and how to go about doing it (2:14). The students at this stage are not feeling confident in their ability to work in the school setting and you say that in this context you become more ‘directive’ (2:14; 4:11). Being more directive in the context of orienting students and helping them to become what you call ‘functional’ in the school setting fits with what I have observed you doing in individual discussions with students as well as in group discussions where you are more in control of the agenda (FN 15/7 19/7). You described your group discussions towards the end of the placement in this way: We just kind of sit around and just discuss and whatever comes up … [I sit] with an ear listening, rather than confronting them and telling them to do things, suggesting, drawing their attention to points … (2:1–2).

This story was written to illustrate the skills used by Ann to avoid dilemmas arising in the complex fieldwork setting of a school. In school settings, there is the potential for considerable tension between meeting the needs of pupils and teachers and those of speech pathology students. Self-esteem needs to be preserved in both teacher and student groups, and both groups need to feel empowered in the delivery of speech pathology services. The story enabled Ann to reflect on her use of several skills, including indirect facilitation of students’ learning and careful support (or scaffolding) of their learning. Ann sees these skills as having developed over time.

Findings: the model

The model of the experience of being a clinical educator McAllister (2001) presents this experience as consisting of six interactive and dynamic dimensions:

• a sense of self, of self-identity;

• a sense of relationship with others;

• a sense of being a clinical educator;

• a sense of agency, or purposeful action;

• seeking dynamic self-congruence;

• the experience of growth and change.

The first four dimensions are interconnected aspects of being a clinical educator. The final two dimensions are overarching dimensions that transcend the other four: they depict the ultimate goal of achieving congruence between the first four dimensions and the development of all the dimensions over time. Each dimension is composed of a number of elements that form its character and agency (see Table 1).

Table 1.  Dimensions and elements of the experience of being a clinical educator

Dimension 1: A Sense of Self	Dimension 2: A Sense of Relationship with Others
Elements:	Elements:
1. Having self-awareness and self-knowledge	1. Being people-oriented
2. Having self-acceptance	2. Perceiving others
3. Having a self-identity	3. Values in relating to others
4. Choosing a level of control	4. Seeking to implement values and perceptions in relating to others
5. Being a lifelong learner
Dimension 3: A Sense of Being a Clinical Educator	Dimension 4: A Sense of Agency as a Clinical Educator
Elements:	Elements:
1. Understanding of role	1. Perceptions of competence and capacity to act as a clinical educator
2. Motivations for becoming a clinical educator	2. Creating and maintaining facilitative learning environments
3. Desired approaches to clinical supervision	3. Designing, managing and evaluating students’ learning programs
4. Affective aspects of being a clinical educator	4. Managing self
	5. Managing others
Dimension 5: Seeking Dynamic Self-Congruence	Dimension 6: Growth and Development—Possible Stages and Pathways
Elements	Elements:
1. Bringing a higher level of attention to the role	1. Embarking on the journey of becoming a clinical educator
2. Drawing the selves together	2. Moving from novice to advanced beginner
3. Striving for plan-action congruence	3. Developing competence in the role
	4. Pursuing professional artistry
	5. Suffering burnout

Source: McAllister(2001).

Using the model and research findings to train clinical educators

The model and research findings McAllister (2001) can be used as the basis for helping clinical educators to reflect on what it means to be a clinical educator, how to juggle the various dimensions of the roles and experiences of being a clinical educator, and how to both survive and grow in this demanding job. For example, the vision of the role and its challenges could be presented in a workshop for clinical educators, who could be invited to share their experiences, dilemmas and strategies for success in implementing the role.

Fostering a sense of self and a sense of relationship with others

Targeted professional development could be used to promote personal awareness and growth. For example, in exploring their ‘sense of self’ and its impact on relationships with others and on implementation of clinical educator roles, participants in a clinical educators’ workshop could identify areas for desired change in themselves as people as well as educators. Given the intense ‘people-focus’ of the work of clinicians and educators, and the humanistic orientation of this work, such professional development could be personally as well as professionally empowering for novice clinical educators. We suggest that interactions with students and learning from those interactions are powerful professional development opportunities for clinical educators. Participating in personal development courses, seeking professional supervision external to the workplace, and participating in formal mentoring programs are other useful strategies for developing a sense of self and strategies for effectively relating to others.

Opportunities in professional development workshops for clinical educators to discuss the demands and challenges of their clinical education relationships would be valuable. It would be useful to talk about how these relationship skills develop beyond the ‘people orientation’ that probably attracts many people to careers in the health professions. Keeping a professional journal and auditing video- or audio-tapes of interactions with students are useful strategies for reflecting on whether intent matches action and outcomes in our relationships and interactions.

Fostering a sense of being a clinical educator

In the study, the importance of the first two dimensions of self and relationships was integral to the sense of being a clinical educator. At workshops for clinical educators, the interlinking of these ‘senses’ as well as the characteristics and skills of educators would be important topics to explore through talks, discussions and activities such as role-plays and demonstrations. For example, clinical educators could explore the challenge they experience in balancing the roles of support person and assessor.

Fostering a sense of agency

In relation to the sense of agency, clinical educators in workshops could be invited to share their successes and difficulties in performing their roles, and thus learn from the experiences of others. They could discuss the meaning of professional artistry, its relationship to high levels of agency and its place in practice and education. Discussing the concept and experience of agency would also help educators to recognise this dimension in their own work and to reinforce actions that bring them a sense of agency. Participation in mentoring, external professional supervision and working with a critical friend or critical companion (see e.g. Titchen 2001; McAllister 2002) have also proved to be useful strategies for reflecting on and developing a sense of agency and overall performance.

Helping clinical educators achieve dynamic self-congruence

Dynamic self-congruence requires insight, self-awareness and self-monitoring (or metacognition), to observe, maintain and modify behaviour in the performance of tasks, roles and interactions in clinical education. Role playing, taking on and arguing viewpoints opposite to one's own, and discussing the consequences of pursuing particular goals, ideals and strategies could be used in clinical educators’ workshops to examine this fifth dimension. Reflecting on critical incidents experienced in practice as a clinical educator—‘How can I make all the pieces fit?’— McAllister (2003) is also useful in the quest for dynamic self-congruence.

Facilitating growth and development as a clinical educator

The sixth dimension in the model is growth and development as a clinical educator. Several strategies can be recommended to clinical educators to examine and facilitate this development and to support them through the challenges, self-doubts and crises they often face in their role. These strategies include (a) writing reflective diaries, (b) preparing teaching portfolios for discussion with mentors, (c) drawing timelines of professional experiences or careers illustrating changes in agency, confidence and satisfaction, and discussing them with peers, and (d) presenting mini-talks to peers in workshops. Further, engaging in, presenting and publishing research into clinical education is a powerful professional development tool for experienced clinical educators.

Conclusion

Becoming and being a clinical educator is a developmental process, mirroring in some ways the developmental process clinical educators strive to facilitate for their students. This journey of growth and development as a clinical educator requires active learning approaches coupled with reflection on one's practice as a clinical educator. Peer support and mentoring can assist but clinical educators must commit to personal and professional growth in the role. Interactive and reflective strategies have been identified for the development and support of clinical educators across the continuum from novice to professional artist in clinical education. The value and power of sharing stories and exploring experiences of practice as clinical educators have been highlighted.

The model presented in this paper has relevance to clinical education in speech pathology and could well benefit other disciplines. There are commonalities in roles (teacher, supervisor, mentor), in challenges (e.g. balancing patient care and education activities) and professional journeys (from clinician to educator) for clinical educators in many health professions. Using the model as the starting point or basis for the education of clinical educators could be valuable for other disciplines including medicine, nursing, physiotherapy etc.

Additional information

Notes on contributors

Joy Higgs

JOY HIGGS, PhD, is a Strategic Research Professor in Professional Practice at the Centre for Research into Professional Practice, Learning and Education (RIPPLE), Charles Sturt University, Australia. Her academic interests are in the areas of multidisciplinary health sciences education, higher education, clinical reasoning, professional practice knowledge and qualitative research methods.

Lindy McAllister

LINDY MCALLISTER, PhD, is Associate Professor in the Faculty of Health Studies and Course Coordinator for the Bachelor of Speech and Hearing Sciences at Charles Sturt University, Albury, New South Wales, Australia. Her academic interests include clinical education, ethics, service delivery issues, rural health and inter-cultural practice.