As the authors of several chapters in this handbook have clearly indicated, clinical education is a critical component of professional preparation and education for physical therapists at both the entry-level and postprofessional level (see Chapters 8, 9, 11, and 16). In the United States, the clinical education portion of the curriculum currently comprises more than 20% of the professional preparation program on average, and the trend has been toward increasing the length and amount of clinical education experience over the past few years.³ Central to learning in clinical environments are the relationship and interaction between the student physical therapist or physical therapist assistant and the clinical instructor (CI) (or instructors) who provide supervision and guidance during clinical experiences. Although many studies⁴^–¹³ and several documents¹⁴^–¹⁶ have suggested desirable characteristics, attributes, professional behaviors, and teaching and clinical skills of physical therapy clinical instructors, only a handful have sought to describe expert or exemplary clinic instruction using qualitative approaches to inquiry¹⁷^–²⁵ and exploring the perspectives and contextualized stories of both CIs and students.

In my own experience as a Director of Clinical Education for decades, there has been ample evidence of a wide variation in student experiences with clinical instructors; many students report tremendously positive experiences with CIs who facilitated their learning and development as future therapists, whereas others report experiences with CIs that were detrimental to their learning. Of greatest interest to me for the study I share in this chapter was the profound and positive impact on learning and development that students who have worked with exceptional CIs report. The landmark work of Jensen and colleagues ²⁶^–²⁸ on expertise in physical therapy practice and some of my own inquiry into clinical mastery^29,³⁰ spurred my interest in further exploring expertise in clinical instruction through the perspectives and voices of outstanding clinical instructors and physical therapist students with whom they have worked.

The broad purposes of the investigation were to undertake the following:

• Explore the professional learning and development of physical therapists who have been recognized as outstanding clinical teachers.

• Elucidate the nature and sources of their beliefs about teaching and learning in clinical settings.

• Describe the characteristics, attributes, and instructional practices of exceptional CIs from the perspective of those instructors and their students.

• Generate rich narrative descriptions of clinical teaching and learning to guide development of preliminary theory about expertise in clinical teaching and student learning in physical therapy clinical settings.

Some guiding questions for this investigation are shown in Box 10-1.

Box 10-1 Guiding Questions for the Investigation of Good Clinical Teaching Practices

Clinical Instructors	Students
What makes a good clinical teacher in physical therapy? What can we learn from CIs who have been identified as excellent teachers? How can we best understand their own learning and development as a CI? What are their beliefs about clinical teaching and student learning? What is their teaching philosophy? What teaching strategies or techniques do they employ?	What makes a good clinical teacher in the view of physical therapy students? What can we learn from students who have worked with exceptional CIs? How do they describe the characteristics, attributes, and behaviors of those CIs? How did their experience with the CI shape their learning and development as a student and future therapist? What lessons were learned? How were they learned?

Findings: the voice of outstanding clinical instructors

The findings from phase 1 of the study (Figure 10-1) are discussed in the following section through the words and stories of these exemplary clinical teachers. (Please refer to Appendices 10–A to 10–C and Tables A2–1 and A2–2 for further detail about the study design, methods and participants.³¹^–³⁸ The results have been broken down into two broad categories according to the type of data collection method involved:

1. Resume Sort

2. Clinical Instructor Interviews

Figure 10-1 Study design and sequence.

Resume sort

Before the interviews, participants were asked to sort activities listed on their resumes and placed on note cards into piles of those activities they felt were “most,” “somewhat,” or “least” influential in their learning and development as a CI. There were six main categories of activities that appeared on resumes:

1. Formal educational preparation

2. Professional memberships and activities

3. Work experiences

4. Continuing education

5. Honors and awards

6. Community service

During the interview, participants could then elaborate on the nature of the activities they felt were influential and how they contributed to their development as a clinician and clinical teacher. Not surprisingly, most saw their development as a clinician as tightly interwoven with their development as an instructor.

Most Influential Activities

Somewhat Influential Activities

Continuing Education

The activities identified as “somewhat influential” were a variety of continuing education activities that most CIs saw as essential to keeping current for their practice but not as most influential in their learning and development as a CI. Thus, these CIs suggested that their knowledge of practice, what in the literature on knowledge in teaching might be called “subject matter or content knowledge,”⁴² was important, but it was only one of several dimensions or domains of knowledge that contributed to good teaching.

Community Service and Honors and Awards

This “somewhat influential” category most often included the category of engagement in community service, viewed as important to their personal development and commitments; and honors or recognitions the CIs had received, most notably the recognition as a recipient of the Michigan Physical Therapy Association (MPTA) Outstanding Clinical Instructor Award. They described the award variously as an “honor,” a “reinforcement,” an “encouragement,” and a “validation,” although several pointed out that it did not or would not really change what they do as a CI:

• You try to do the best job you can, but then when you get something like this, it’s like WOW! I’ve been recognized for something you really like to do and that makes you strive to do even better.⁴³^{(p 2)}

• It’s the recognition…. I take away some sense of giving back and helping people through their education (by being a CI.) But … it was nice to be recognized for my efforts being that I do care about these future PTs and the profession.⁴¹^{(p 3)}

Clinical instructor interviews

Exemplars

Description of exemplars as an interview strategy has been used in several studies of expertise.^26,^28,³¹^–³³ The CIs in this study were asked to share one or two exemplars; they were urged to “tell me the story” or to “replay the video” of that event (see Appendix 10-B.). As forecast earlier, by far the most frequently shared exemplars were descriptions of experiences as physical therapy students working with CIs. In roughly half of the cases, the experiences were positive, and the CIs purposely sought to emulate the characteristics, commitments, and behaviors of that CI in their own clinical teaching. The negative experiences, which made up the other half of the experiences reported, defined what the CIs did not want to be (or become) for their students.

One example of both the positive and negative experiences of one of the CIs is provided in the narrative at the beginning of this chapter, but others had similar good and bad experiences:

I had a situation when I was a student where this CI, I think, was on a mission to flunk me. It was strange I don’t know where it was coming from…. She just wasn’t open. If she had a concern it was all top secret you know. She wasn’t really telling me what she was looking for or what the problems were. It was sort of like a CIA kind of thing. I never knew. I was always walking on eggshells and when you’re a student your confidence is kind of flighty and she was harming that for sure. Maybe that was just her method, but I wasn’t responding well to it. So I never forgot it.⁴⁴^{(p 9)}

This CI, however, also never forgot how another staff therapist and instructor saw the situation and stepped in:

Luckily one of the other therapists there saved me. She saw what was happening and took me over and I never forgot that. She realized that what was happening was not kosher. So that experience has stayed with me.⁴⁴^{(p 9)}

These experiences have been translated into the CI’s current teaching style. This instructor felt it was important “to have it [expectations] all on the table. My goal is to be an advocate and to create a great experience but also to meet expectations that are there from the school and from our facility … but to be helpful and to gently pull people to a higher level.⁴⁴^{(p 9)}

A more positive experience with a CI was described by another participant:

It was my first rotation in my final year. My CI believed very heavily in education; [she] would take me aside and we would go through a lab in a sense—a practice lab—of what was coming up with the next patient. She was very, very energetic, a lot of fun, and I enjoyed [the labs] because it took the pressure off…. She was never condescending to me; it was always ‘well, yeah, that will work [the way the student suggested], but maybe try this.’ [She was] letting me choose and letting me make my mistakes without jumping on me.⁴⁵^{(p 5)}

The CI speaking here has purposefully attempted to emulate the enthusiasm for teaching, the respect for students, and the scaffolding for learning that was demonstrated by his memorable CI many years prior.

The other most frequent exemplars offered by CIs were stories of their learning through doing: learning through their own teaching experiences with students, through feedback from students, and, importantly, through reflection on those experiences. They asked themselves, What went well? What didn’t go well? and Why? Often, such critical reflection was prompted by their work with difficult students, in some cases even those who didn’t succeed. It is noteworthy that these CIs took seriously their responsibility to help students succeed and examined not only the performance of the learner but also their performance as a teacher in such cases.

In one instance, a CI described an experience with her most difficult student:

When I think about my whole career being a CI and having students, there’s one student that comes to mind … it was the most difficult student I had and one in which the student did not succeed. It was a real challenge for me…. But I was determined to make this work. As a CI I thought, I can do this. I have a challenging student and that’s okay. And what do I need to do to make this work. And so for me it was a good experience.⁴⁶^{(p 5)}

For this CI, working with this student who didn’t succeed was a “good experience” because she was forced to re-examine approaches to teaching and strategies that had previously worked for her with other students. She explored the student’s learning needs and tried to adapt her teaching to best meet those needs. And, despite the fact that the student was not successful in the end, she felt the kind of deliberate reflection she engaged in about the student’s learning and her teaching had transformed her as a teacher. She felt she had expanded the repertoire of approaches that she could employ for the variety of students she might encounter in her continued work as a CI.

The exemplars described by this sample of CIs are consistent with the findings of David Irby years ago in his studies of distinguished medical educators.^47,⁴⁸ As Irby writes of his excellent clinical teachers: “They acquired their knowledge of teaching primarily from the experience of being a learner (the apprenticeship of observation of good and bad examples) and a teacher (reflecting on what worked and did not work).”^{49(p 339)} In a later study of clinical teachers in medicine, Pinsky and Irby⁴⁹ found that good teachers used the experience of failure to improve their teaching. They did so by using failure as a catalyst for several forms of reflection:

• Reflection on action involved assessing their teaching after a perceived failure.

• Reflection for action (anticipatory reflection) involved planning for future teaching in light of past experience.

• Reflection in action involved assessing and trying to adapt teaching in the moment in the context of a teaching/learning activity that did not seem to be going well.

Similar forms of reflection were also reported by Buccieri and associates ¹⁸ based on a study with a small sample of expert physical therapist clinical instructors. These findings also resonate with a large body of research on teacher thinking summarized by Clark and Peterson⁵⁰ and Clark.⁵¹ The experienced teachers those authors describe engage in intentional, interactive, improvisational and reflective thinking about their teaching: “They reflect on and analyze the apparent effects of their own teaching and apply the results of these reflections to their future plans and actions. In short, they have become researchers on their own teaching effectiveness.”⁵⁰^{(p 292)}

Influential People

In a follow-up question to the resume sort activity and the description of exemplars, CIs were asked to identify people (vs. events or activities) who influenced their learning and development as a CI and to describe how these individuals influenced them. Some of the findings presented elsewhere in the chapter overlap with responses to this question. In fact, it’s worth noting how many of the descriptions of events or activities were infused with vivid memories of the people who were characters in those narrative accounts of events. Responses to this question were categorized as the following influential people:

• Teachers or professional colleagues

• Students

• Patients

Teachers and Professional Colleagues

In the category of teachers, 11 participants identified academic faculty members who served as professional role models for them as both clinicians and clinical educators. These academic faculty members were almost universally described, as shown in Box 10-2.

Box 10-2 Characteristics, Attributes, and Behaviors of Individuals with Positive Influence

Academic Faculty Role Models and Mentors	Clinical Instructors	Professional Colleagues and Mentors
• Very involved in professional organizations, physical therapy education, and clinical practice • Dedicated to the field and to their students • Knowledgeable and up to date • Encouraged students to think critically, to ask why • Modeled evidence-based practice • Positive and respectful interactions with students; made students feel recognized and unique as a person in their encounters	• Very involved in professional organizations and activities • Respectful and supportive of students and professional colleagues • Dedicated to their patients; being a patient advocate • Open, clear, and honest in their communication; made expectations clear and provided regular feedback • Patient; made student feel comfortable and welcome • Treated student as a member of the team • Committed to assisting student learning and development; let me “try my wings” • Well-rounded	• Very involved in professional organizations and activities; encouraged professional engagement • Knowledgeable and current in their areas of practice • Creative; “think outside of the box” • Supportive of the CI as a clinician and clinical teacher; “took me under their wing” • Modeled professional behaviors; respectful of patients and colleagues • Collaborator; team player • Dedicated to their work and patients

One CI described how an academic faculty member influenced his approaches to clinical teaching:

He influenced … how I think, how I critically analyze. If I go to a course, I’m not going to believe it just because they tell me [it is correct]. Same thing with a research article … just because it’s there, I’m going to look for the flaws in it and how that might influence whether I can use that [information] clinically or not. He modeled evidence-based practice long before it became cliché.⁵²^{(p 7)}

Thus, the CI today reports a commitment to assisting his students to incorporate this type of critical analysis into their learning experience with him: “I want them to know why they are doing a particular technique, not just [do it] because it was shown to them.”⁵²^{(p 8)}

As discussed earlier, other teachers who were very influential in the learning and development of these CIs were clinical faculty members: their CIs when they were students. The characteristics, attributes, and behaviors of CIs that were viewed as positive influences for the CIs who participated in the study are shown in Box 10-2. Most of the CIs indicated that they seek to emulate many of these attributes and behaviors in their work with students.

Alternatively, negative characteristics and behaviors by their previous CIs usually revolved around these factors:

• CIs not sharing or making expectations clear

• Supervision at the shoulder during the entire experience

• A lack of regular feedback

• A disrespectful or condescending attitude toward the student

• Public humiliation of the student (in front of patients caregivers or colleagues)

• Outright unethical behavior

Some of these negative experiences were described earlier in this chapter. The following describes the experience of one of the CIs with a clinical supervisor who taught her how she did not want to be with her own students:

I had an instructor who would not leave me ever, ever, to the point where they would sit right next to me and write things down as I was doing things. I even had to say once, ‘Do you have to be right there?’ ‘Well, yeah.’ And so I said I would never make my students that uncomfortable…. I said that I would never, ever be that way with my students.⁴³^{(p 4)}

Eleven of the 17 CIs also identified professional colleagues as powerful role models and mentors for them as both clinicians and CIs in their respective communities of practice.^20,^53,⁵⁴ As you might expect, and as has been borne out by these findings, the professional identities of “clinician” and “clinical educator” are interwoven in the view of the CIs in this sample. The most frequently described characteristics, attributes, and behaviors of these professional colleagues and mentors are listed in Box 10-2 and mimic those in the previous two categories of clinicians.

One CI describing two colleagues who had been mentors to her put it this way: “They showed me that you didn’t have to be an 8 to 5 PT. There was much more to it than managing your caseload. There is that personal side. That’s how I practice. I don’t practice by the numbers and things like that; I practice by the people.”⁴³^{(p 5)}

Students

The students themselves were influential for the CIs involved in the study. All of the CIs reported that they learned something from every student they had worked with, from excellent students to very challenging students. The common refrain was “the experience works both ways” or “it’s just a great two way street.”⁵⁵^{(p 8)} Here is one description from a CI who has worked with numerous students for more than 12 years: “Every student is a teacher. I learn something from every student that I have. It sort of all molds together … the more students I have, the more I learn about them and teaching.⁴⁰^{(p 8)} This same CI went on to report that the students he learns most from are those that provide him with honest feedback on his performance as a CI, which he genuinely appreciated. He also remarked on how the wide spectrum and diversity of students he has worked with require him to constantly “reconfigure my (his) approach” according to the student’s learning needs.

In all cases, these CIs viewed the student-CI relationship as one of reciprocal teaching and learning, and they valued lessons learned from students about learners, learning, and their own teaching. Often these CIs made their beliefs about this reciprocal relationship explicit to the students early in their experience with them. This is the way one CI put it:

I think a lot of my students bring as much to the clinical as what I can give back to them … and I always make it a point to say that to them. ‘Don’t be afraid to express or inform us of those things that you’ve learned along the way because I feel the clinical education experience works both ways. You don’t come here and I just give you all this knowledge and then you leave. I like to see the interaction back and forth because there are always things that you can teach me. I’m not the all-knowing wise one here. I know what I know, but you also know what you know, so it works both ways.⁵⁶^{(p 8)}

Sharing this viewpoint early in the experience with the student goes a long way in diminishing the socially conferred status differential between teacher and learner by explicitly valuing their knowledge and respecting what they can uniquely bring to the learning experience.

Patients

Finally, influential people for these CIs included the patients they have worked with throughout their careers. They saw their relationship with patients as similar to that with students in some ways; that is, the relationship is one that involves reciprocal teaching and learning, partnering, mutual respect, and mutual responsibility. As one CI stated: “As therapists we are teachers … and healing and learning are joint efforts.”⁴⁵^{(p 8)} The CIs reported that they translate the lessons learned from their patients over the years into their encounters and teaching with students. Such lessons included the importance of respectful interaction, using people first language, treating the patient as a person as a whole versus a body part, obtaining informed consent, being an active listener, and being patient: “I want the student to be respectful to every patient they see and know that they are not a body part or a problem; they’re a person. I want them to evaluate the whole body, the whole person, not just a knee.”⁵²^{(p 9)}

One CI learned about using patient-first language from one of his patients; it is a lesson he passes on to his students:

I treated an English professor years ago. He kept overhearing PTs refer to their patients as the ‘shoulder lady’ or the ‘guy with the knee.’ He was recovering from a tibial fracture and wanted to be referred to as the ‘guy who will ski again’ rather than a ‘tibial fracture.’ What this taught me is that how we label patients could have a substantial effect on their view of themselves, how we treat them, and perhaps their outcomes.⁵⁷^(p11)

Beliefs about Student Learning and Clinical Teaching

When asked about how they felt students learn best, the CI’s responses merged with another question about the type of environment that enhances learning. The recurring themes in response to these questions are shown in Box 10-3.

Box 10-3 Facilitators and Impediments to Student Learning from Clinical Instructors’ Perspective

Facilitators of Student Learning	Impediments to Student Learning
• An environment and CI that make the student feel welcome, comfortable, supported, not threatened • CI who is accessible and approachable • CI who wants to teach and cares about student learning • CI who provides honest and constructive feedback • CI who is not “all-knowing” • CI who uses questioning as a tool for fostering insight and learning versus as a practical examination • CI who invites the student to be a partner in the design and decisions about the experience and providing multiple opportunities for learning • CI who provides hands-on experience at the right time and place—sequencing and pacing the learning activities and experiences according to student readiness and needs • CI who grades the level and amount of supervision according to where students are at the moment with attention to where they need to go	• Today’s health care environment—productivity demands and restrictions on what students can and cannot do in clinical settings • CI not available, approachable • Lack of clinical instructor feedback; constructive criticism (or destructive criticism) not balanced with positive feedback, affirmation • Not sharing expectations openly with students— “cards under the table”; not being honest and up front with students • Public questioning of students or questioning in ways that could be embarrassing or humiliating • Too much to do, too fast for student; not sequencing and pacing activities • Too little or too much supervision or guidance (in some cases trying to create a “clone” of the CI) • Student perfectionism • Student passivity; not actively engaging and taking responsibility for one’s own learning

Facilitators of Student Learning

Impediments to Student Learning

• An environment and CI that make the student feel welcome, comfortable, supported, not threatened

• CI who is accessible and approachable

• CI who wants to teach and cares about student learning

• CI who provides honest and constructive feedback

• CI who is not “all-knowing”

• CI who uses questioning as a tool for fostering insight and learning versus as a practical examination

• CI who invites the student to be a partner in the design and decisions about the experience and providing multiple opportunities for learning

• CI who provides hands-on experience at the right time and place—sequencing and pacing the learning activities and experiences according to student readiness and needs

• CI who grades the level and amount of supervision according to where students are at the moment with attention to where they need to go

• Today’s health care environment—productivity demands and restrictions on what students can and cannot do in clinical settings