Learning Environment	Primary Learning Activity
Classroom	Acquisition of knowledge • Definition of muscle performance • Characteristics of performance • Mediators of performance • Reasons for examination • Selection of specific tests and measures • Expected examination outcomes
Laboratory	Acquisition of skill • Tests and measures for conducting a muscle performance examination, including generation of data
Clinic	Use of knowledge and skill for clinical decision making and patient management in • Evaluation • Diagnosis • Prognosis • Determination of appropriate intervention

Adapted from American Physical Therapy Association. Guide to Physical Therapist Practice, 2nd ed. Phys Ther 2001;81:9.

Academic and clinical teaching: two different realities

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, ultimately, the patient. This fundamental difference underlies all aspects of developing a clinical education program, and it must be recognized and accommodated in clinical education programs. The academic setting has been organized for the efficiency and convenience of the system, its administration and faculty, and technologies, whereas the clinical system is generally organized for the convenience of delivering health care to the patient. Most educational issues flow from this basic difference, including those of appropriate and attainable educational objectives, effective instruction and evaluation methods, effect of clinical education on the patient and patient care, and costs of teaching.

Prevailing conditions in the clinical environment

The clinical setting 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. The learning situation within the clinic is framed by several factors or ground rules.

Scully ² suggests that there are three generic sources for the ground rules that frame the clinical learning environment: (1) those originating external to the clinical education facility, (2) those originating internal to the clinical education facility, and (3) those originating from within the clinical teacher. Table 9–2 gives examples of each. Although these delineations are helpful in understanding the origin of factors influencing the context of the clinical experience, examples may not fit exclusively in one category.

Table 9–2 Ground Rules Framing the Context of the Clinical Education Experience

Sources	Examples
External	University mission and program objectives Assignment of students Time and length of assignment
Internal	Department policies and procedures Assignment of the clinical instructor Health requirements
Clinical teacher	Preparation and experience • Value judgments (i.e., patient primacy, professionalism)

Adapted from Scully RM. Clinical Teaching of Physical Therapy Students in Clinical Education. Ph.D. dissertation. New York: Columbia University, 1974.

Consider the examples of Natasha and Anne. Both are physical therapy students assigned to a pediatric clinical setting by their respective academic programs. Student assignment or placement is an academic prerogative, and the method used varies from program to program. The following descriptions of the placement procedures that affect Natasha and Anne provide an example of external factors that affect the clinical education experience.

NATASHA: A pediatrics rotation is important to me. I don’t have much experience with children. But, I volunteered over the summer at a camp for kids with AIDS [acquired immunodeficiency syndrome], and I took the pediatric elective. It was tough, but I’m really excited about learning to do all we talked about. The student who was here last year said this was a great place!

ANNE: I’m not planning to get a job in pediatrics or anything. I just sort of got sent here—I was at the end of the lottery. I mean, I want to be well rounded and everything, but I don’t want to work with kids. I just want to get the basics. You know, so if kids ever come into my office I’ll know what to do with them.

On closer examination, however, the effect of this external factor, the placement procedures, may not be so clear cut. Consider values held by two physical therapists who could be assigned as Anne’s CI:

CLINICAL INSTRUCTOR A: It’s going to be a long 8 weeks. Anne doesn’t want to be here. You can’t just learn the basics and expect to be a good physical therapist. Where do I even begin with her?

CLINICAL INSTRUCTOR B: I appreciate Anne’s honesty, and I hope I can work with her to become more diplomatic. I think there are many aspects of pediatric practice that apply to all patients. I think we can work together to create an excellent experience. I want to start by learning more about her interests.

The attitudes held by each of these therapists would greatly influence Anne’s clinical education experience. Think of other external and internal constraints imposed on the clinical education process. In almost every case, the CI’s knowledge, skill, values, and attitudes could reframe the learning context in a way that would dramatically change the outcome of the clinical experience.

Consider the demands imposed by the changing health care delivery system. Although addressed by academic programs in the curriculum, students often express the reality as follows:

ROBERTO: This hospital isn’t a very good place right now. There’s a lot of change going on. The patients are all seen in their rooms or in little satellite departments on the floors. It seems like all we do is get them out of bed. I don’t have time for a complete examination before they’re discharged. The biggest job the therapists have is deciding where to refer the patients when they’re discharged from the hospital. I want to do real physical therapy.

The CI, Mariah, has the ability to reframe this response and challenge Roberto to make the most of his learning experience by expressing something like the following:

MARIAH: You’re absolutely right. I think we sometimes get the notion that physical therapy means using our hands all the time. Sometimes, though, the emphasis is on using our heads to think and plan. We can learn about the patient’s functional status before admission, we know what’s happened here, and then it’s our job to make the best possible guess about the future and make recommendations based on that. What a challenge! Discharge planning is a focus from the beginning, and even our treatments need to take that into consideration. What do you think about Mr. Baird, whom we saw this morning?

After the context of the clinical education experience is understood, physical therapists can develop ways to mold it as Clinical Instructor B and Mariah did. 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.

Prevailing conditions in the clinical environment provide additional opportunities and challenges for both the clinical teacher and the learner. The political climate of a given health care facility, reimbursement, interprofessional roles, productivity demands, and patient demographics represent just a few.³ Given these prevailing conditions, it is important to ask the following: How do students learn in the clinic? What is helpful for clinical teachers to know and understand about the clinical learning process?

Clinical learning

The purpose of this section is neither to review the work of learning theorists ⁴^–⁹ nor to examine the literature related to student physical therapists’ learning.¹⁰^–¹⁵ Rather, this section provides a contextual basis of clinical learning to use in the upcoming section, Roles of the Clinical Teacher: Diagnosing Readiness, Planning, Teaching, and Evaluating. John Dewey provided key descriptors of the clinical learning process when he stated, “education is not an affair of ‘telling’ and being told, but an active and constructive process.”¹⁶ Successful clinical learning requires the student to make meaning of knowledge in a clinical sense and then to enact that meaning when providing physical therapy services.

Clinical learning occurs in the context of the “whole” as opposed to isolated parts of physical therapy care. As students learn to practice and practice learning, they acknowledge that there are no simple patients. Holistic activities with concentrated work on the “hard parts” promote the acquisition of needed knowledge and skill with the opportunity to learn how to learn.¹⁷

Student ownership and responsibility

The clinical education experience belongs to the student, despite the fact that it occurs in the CI’s clinic. It involves patients to whom the CI has legal and ethical responsibilities. It requires the CI’s time, energy, and creativity. It is imperative, however, that the student accepts ownership and responsibility for the experience. Clinical education is not only an opportunity for a student to learn the knowledge, skills, values, and attitudes of the profession, but also is the first experience in a lifelong pattern of learning and continual development as a physical therapist. Table 9–3 summarizes principles that enhance competence and encourage self-determination in actions. It is important that students assume responsibility for learning what they need to know and how to go about learning it.

Table 9–3 Principles that Dampen or Motivate Students to Enhance Competence and Encourage Self-Determination in Actions

	Dampeners	Motivators
Focus of goal orientation	Judgment	Development and learning
Performance expectations	Low	High
Learning opportunities	Governed by rules and regulations Prescriptive, mandatory experiences	Self-directed Multiple opportunities with recommendations
Instructional strategies	Routine Extrinsic rewards and incentives	Challenging Encourage deep and rich thinking processes
Feedback/evaluation	Dominate and control behavior	Available but infrequent from external sources
Institutional/personal premiums	Emphasize conformity	Emphasize creativity, innovation, and alternative perspectives

Adapted from Lewthwaite R, Burnfield JM, Tompson L, et al. Education and development principles. Presented at: Seventh National Physical Therapy Clinical Education Conference; April, 1995; Buffalo, NY.

There are several learning experiences that can be used to encourage student ownership for clinical learning. The student should prepare for each experience by becoming familiar with the clinical site information form and any orientation materials sent before the student’s arrival. Based on this information, the CI may wish to ask students to prepare specific personal goals and learning objectives they would like to meet during their time at the facility. This student-specific information provides an excellent basis for discussion during orientation, at which time the CI can affirm or revise student goals and plan relevant learning experiences. It is important to revisit these goals and objectives periodically. The CI can use them in weekly planning or as a part of the midterm evaluation by asking what the student has accomplished, what activities still need to be undertaken, or if further revisions or additions need to be made. Having the student develop objectives within the context of practice enables the student to further develop professional identity and mission as a physical therapist or physical therapist assistant. In doing so, the student acquires a framework for establishing lifelong learning habits.