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Research Reports |
Director of Clinical Education
Associate Professor
Program in Physical Therapy
Central Michigan University
134 Pearce Hall
Mt Pleasant, MI 48859
(elizabeth.mostrom{at}cmich.edu)
 | Introduction |
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Drawing on literature from several health care professions and their own experience with physical therapist clinical education, the authors developed an initial conceptual framework to guide their investigation. Their framework proposed that inadequacies in student knowledge and psychomotor skill (what they called "cognitive factors") and other unknown "noncognitive" factors could be contributors to unsafe and ineffective practice as determined by CIs. Although classic descriptions of learning domains distinguish between cognitive and psychomotor domains,1,2 these authors clustered knowledge and psychomotor dimensions of performance to reflect their linkage in physical therapy practice.
The authors used a retrospective, descriptive, and qualitative approach to inquiry. They examined the frequency and nature of student behavior descriptions by CIs to ascertain the extent to which their findings fit or altered their initial conceptual framework. The volunteer, purposive, and convenience sample for this study consisted of CIs who had worked with or observed physical therapist students who had "problems functioning effectively in the clinic." The sample was composed primarily of female therapists working in inpatient rehabilitation and acute care settings. The authors acknowledge the implications the sample demographics may have for interpretation of their findings. Student behavior descriptions provided by the predominantly female CI sample, working in inpatient settings, included a disproportionate number of descriptions of behaviors observed in male students. This finding raises some interesting questions regarding the possibility of clinical setting or gender bias, or other unexplored interactional issues related to CI-student characteristics or attributes. Although the sample size and design of this study were inadequate to address these questions, they certainly warrant further investigation.
The critical incident technique and individual or small-group semistructured interviews were the methods used by the investigators to gather detailed descriptions of student behaviors of concern to the participating CIs. Flanagan's3 initial formulation of the critical incident technique suggested that the search for specific detail in descriptions of events enhances concreteness and accuracy of reports. Beyond this idiographic function of the critical incident technique lies another valuable function pertinent to this study—particular and contextualized descriptions of events can reveal important assumptions and values of the reporters.3,4 In this study, examining CI choices of critical incidents provided insight into their assumptions and values with respect to competent versus incompetent or effective versus ineffective clinical practice.
The majority of student behaviors described in this study occurred within 1 to 3 years of the interviews, although some CIs reported on incidents that occurred more than 20 years previously. Because the length of time that has elapsed since an incident might reasonably be expected to influence accuracy of recall, future studies of this nature could be enhanced by the use of a prospective design, with the gathering of critical incident data closer to the actual time of events.
Although many findings of this study are worthy of note, I would like to focus on a few key findings that I believe have important implications for physical therapist practice and education. The first of these findings is the prevalence of noncognitive behaviors identified by CIs as contributors to ineffective and unsafe delivery of services (57% of identified behaviors). Based on the investigators' analysis, these noncognitive behaviors were categorized as either unprofessional behaviors or poor communication and then further subcategorized. Some practitioners may argue that there is overlap between these 2 categories and that both categories of behavior have the capacity to interfere with the delivery of services. Regardless of this distinction, behaviors that fell into these 2 categories collectively were clearly the majority of behaviors identified as markers of ineffective or unsafe practice by CIs.
The frequency of these student behaviors in critical incident descriptions suggests the extent to which CIs value professional behavior and good communication skills in clinical practice. This finding encourages early and explicit attention to these elements of student behavior throughout the professional socialization process in academic and clinical settings. Physical therapist education programs and clinicians should clearly specify expectations with respect to professional behavior and communication skills in their earliest encounters with prospective therapists. In physical therapist education, the work of May and colleagues5 on generic abilities assessment, in my opinion, resulted in a mechanism for articulating expectations and proposing developmental trajectories for students and practitioners (in the areas of professional behavior and communication skills). Although clinical education may provide more frequent opportunities for ongoing assessment of these student behaviors, there may also be many ways that the academic component of curricula can serve this purpose. In my opinion, such opportunities should be actively developed and emphasized in physical therapist professional preparation programs.
The relative reticence of CIs in this sample to give "feedback" to students on noncognitive factors as opposed to cognitive factors (inadequate knowledge and skill) is also noteworthy. In this study, the absence of feedback to students about a behavior apparently led to a decreased likelihood of change in behavior. If an essential stimulus to behavioral change is the recognition of a need to change, how will students initiate such change without feedback that helps them recognize and value the need to change?
Expectations for behavior and performance in cognitive and noncognitive (professional behaviors and communication) areas, in my opinion, need to be specified across all aspects of professional curricula. For those students who can self-monitor and accurately assess their performance, change and growth may come without much extrinsic feedback. For those students without such abilities, I contend that regular feedback and assessment will be essential to their professional development. Certainly, it is a more uncomfortable task for any faculty member (academic or clinical) to present students with feedback about professional behaviors and communication skills (which seem more personal in nature than other aspects of performance). Even so, I believe it must be done and can be done. Tools such as the Generic Abilities Assessment5 and the Clinical Performance Instrument6 can be used in an attempt to describe desired behaviors in the areas of interpersonal and communication skills, professional behaviors, responsibility, and critical thinking and problem solving and can be invaluable in this process. Finally, academic faculty and center coordinators of clinical education (CCCEs) can empower CIs to give feedback to students on professional behaviors and communication in a variety of ways, not the least of which is leading by example.
The findings of this study illustrate how important behavioral change is to CIs. Without exception, students who were perceived as having changed their behaviors in both cognitive and noncognitive areas (even in the absence of feedback) were identified as having "positive outcomes" in clinical education. Furthermore, all students identified as having "negative outcomes" (failing) did not show change in behaviors. Finally, students who did not show change in knowledge and skills (often perceived to be more easily addressed and remediated) were more likely to have negative outcomes. Of note is the fact that the cognitive category of behavior described by the authors had several subcategories that could be directly linked to safety.
If CIs value and expect change, we need to also ask how they, in cooperation with students, can become facilitators of such change. One area left relatively unexplored in this study was the nature of feedback (or responses) provided to students about the problem behaviors identified by CIs. Several authors7–10 have described various types and forms of feedback that might or should be provided to learners in educational or clinical settings. Furthermore, they distinguished types of feedback from various types of evaluation based on the degree to which the communication with the student conveys a judgment (positive or negative) about the performance.7–10 Studies aimed at determining what forms of input to physical therapist students seem to encourage positive behavioral change and conversely what types of input seem to constrain or inhibit behavioral change would be desirable. Qualitative investigations in this area might also reveal important contextual information about clinical education experiences and the relational aspects of CI-student exchanges that may or may not facilitate behavioral change and professional development.
Based on their analysis of behaviors and demographics for students identified with negative outcomes, the authors raise the question of whether covert or overt bias might have been reflected in CI critical incident descriptions. As the authors point out, their sample size and the design and focus of this study are inadequate to permit further conjecture about this question—but it is an important question nonetheless and one that merits further investigation.
I applaud the authors for undertaking this important study. As with most inquiry in relatively uncharted territory, it leaves us with much "food for thought" and many questions ripe for further investigation using a variety of approaches. Moreover, it contributes to the dialogue in physical therapy about what constitutes clinical competence and effective delivery of services; at the same time, it encourages us to carefully examine the aims of professional education in our field.
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