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RESEARCH REPORT

A Novel Approach to Clinical Instructor Professional Development: A Multi-Session Workshop With Application of Skills in a Student Standardized Patient Exam

Recker-Hughes, Carol PT, PhD; Dungey, Jill PT, DPT, MS, GCS; Miller, Sue PT, DPT, MS; Walton, Amber Hansel CHSA; Lazarski, Janice PT, DPT

Author Information
Journal of Physical Therapy Education: Volume 29 - Issue 1 - p 49-59
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Abstract

BACKGROUND AND PURPOSE

Full-time clinical education experiences afford students the opportunity to integrate and apply essential knowledge, skills, and behaviors to develop entry-level competencies required for clinical practice. These integral authentic learning experiences account for up to 45% of a student physical therapist's (PT) professional curriculum.1 During clinical experiences, students are supervised by clinical instructors (CIs) whose primary duty is patient management, while also assuming the role of student educator. The Commission on Accreditation of Physical Therapist Education (CAPTE) criteria recommends that CIs have a 1-year minimum of clinical experience and “demonstrate the ability to be effective clinical teachers, including the ability to assess and document student performance, including deficits and unsafe practices.”2(pp32) However, one cannot assume that CIs are confident or competent in essential teaching skills.

Effective CIs must develop rapport with the student and possess strong communication and interpersonal skills.3–5 They must be able to engage in shared dialogue, ask questions to assess understanding, and engage in meaningful feedback sessions to promote learning.3,4,6,7 A study by Healy that explored factors promoting deep learning by student PTs noted the critical role the CI plays in this process through asking questions and providing ongoing feedback.6 Other studies by PT researchers have highlighted the importance of asking questions to prompt student clinical decision making (CDM) and self-assessment, which can also be accomplished by providing specific and constructive feedback to help students accurately assess their abilities while simultaneously identifying areas needing further development.3,4,7 While these competencies are identified as desirable attributes in the literature and in American Physical Therapy Association (APTA) documents,8,9 CIs may have limited formal training in the development of essential assessment and feedback skills.

One mechanism for CI training is APTA's Clinical Instructor Education Credentialing Program (CIECP),10 a comprehensive course that was developed for CIs to intentionally develop teaching and assessment skills. The course consists of 2 parts: a 12-hour didactic component and a 3-hour practical assessment. An exercise in which CIs simulate a student-CI interaction is embedded in the assessment portion of the course. While there is some evidence in the literature suggesting effectiveness of the CIECP on specific criteria related to CI performance,11,12 more research is needed to support these findings. The CIECP provides CIs an avenue for professional development as teachers. Other professions, however, have incorporated standardized patient methodology.

Standardized patient methodology has been widely used for teaching activities and for formative and summative assessments for students across medicine and health professions.13,14–21 Adult learning theory offers support for the current proliferation of standardized patient (SP) and other simulation experiences.22 Simply put, people learn new skills and behaviors most effectively when they are required to apply them in a situation which resembles a real scenario. Active engagement in tasks that learners perceive as relevant, which provide a reasonable challenge to an adult learner and creates a need for deliberate self-assessment, appears to foster deep learning.23,24

Faculty development activities that incorporate standardized patient methodology are more novel. An objective structured teaching encounter (OSTE) uses a standardized student (SS) with a scripted role in a teaching scenario. The teacher interacts with and teaches the SS, which is then followed by feedback on his/her teaching from the SS or another observer. In a recent study of clinical faculty MDs, participants engaged in 3 to 4 OSTE sessions.25 Feedback was provided by the SS and the faculty watched videos to self-assess. The results were then used by the faculty to create individual professional development plans. Although no teaching interventions were provided, faculty self-reported satisfaction with the experience and improvements in their teaching skills 6 months after the OSTE. Similarly, participants in a study by Gelula and Yudkowsky26 found OSTE workshops highly relevant to their teaching, reporting that the authentic nature of the interactions, coupled with the opportunity to review and discuss videotaped encounters, contributed greatly to their learning. A systematic review of OSTEs concluded that these encounters potentially provide valuable feedback on clinical teaching behaviors in a setting “that is protected from the pressures of clinical care and free from the hierarchical considerations that may influence student evaluations of their teachers.”27(pp901) Limitations to these studies27 include a lack of detailed description of the educational programming and course materials, an element of artificiality when other health care professionals portray the part of a medical student or resident, and little follow-up with faculty on transfer of learning.

Across all professions, studies are scarce where, after targeted training workshops, a clinical educator has the opportunity to apply strategies and skills in an authentic student encounter, receive feedback from the student, review a recording, and complete a selfassessment. The purpose of developing this multisession professional development workshop was to promote CI confidence and competence in assessing student performance, sharing feedback, and asking questions to prompt student reflection and clinical decision making (CDM). The workshop allowed CIs to receive instruction in these skills, apply them in a second-year DPT student comprehensive standardized patient examination (SPE), and self-assess and reflect on their performance individually and in group discussions. At the same time, we hoped to enhance the student learning experience by including CIs in the SPE.

METHOD/MODEL DESCRIPTION AND EVALUATION

The SUNY Upstate ISPE

The physical therapist education program at SUNY Upstate Medical University administers an integrated standardized patient examination (ISPE) to all students at the end of the spring semesters in the first and second year of the program. Students collect patient history information, collect pertinent data from a systems review, and answer 3 patient questions during a 45-minute patient interaction in a format that is similar to that described by Panzarella and Manyon.28,29 Prior to implementation of the CI workshop, students completed a written examination following the SP interaction to prompt reflection and assess decision making skills. Expected performance competencies on the ISPE are linked to core skills, behaviors, and knowledge taught across the curriculum, and are deemed necessary for safe and appropriate performance during full-time clinical experiences. To promote coherence of the ISPE assessment with curriculum content and to ensure that anticipated student performance is at an appropriate level of skill and competence, the cases and accompanying rubric for the ISPE are developed by all faculty who teach related coursework.

The ISPEs were implemented to promote assurance of student readiness for early and intermediate full-time clinical experiences and to provide the students with feedback from faculty and SPs on their skills and behaviors. Students need to successfully pass the ISPE prior to full-time clinical experiences. Those who do not perform at an accepted level on the ISPE must meet individually with academic faculty to identify strategies of remediation, such as participating in shortterm/part-time clinical experiences. They are then given another opportunity to retake the ISPE.

The ISPE is administered in the Upstate Medical University Clinical Skills Center, equipped with resources routinely used for standardized patient encounters (treatment rooms, cameras, recording devices, and a monitor room). Following the ISPE, students review the recording of the student-patient encounter and complete a self-assessment. They subsequently receive individualized feedback on their communication and interpersonal skills from the SPs, along with written feedback on all components of the interaction from academic faculty.

Impetus for Development and Implementation

Feedback from the students and from academic faculty indicated that the patientstudent interaction portion of the ISPE was realistic, valuable, and valued. However, the usefulness of a follow-up written examination to assess student clinical reasoning was questionable and did not simulate what happened in the clinic following a patient encounter. Students also shared (via course evaluations and informal feedback to faculty) that the use of a written examination limited their ability to engage in CDM and prevented them from receiving immediate feedback and expert input (as during a clinical experience). Likewise, academic faculty were not convinced that the work required to grade the written, CDM portion of the exam was the optimal mechanism to assess and promote student learning.

Concurrently, the directors of clinical education (DCEs) determined, using input from CIs during site visits, calls, and debriefing sessions with students following clinical experiences, that CIs were often reluctant to provide constructive feedback to students, especially if it required delivery of bad news linked to student performance. At times, there was also a perceived disconnect between CIs and program expectations of student performance linked to core entry-level competencies. Consideration of this input from students, faculty, and CIs led to the development of this workshop. Hence, the 4-part workshop that incorporated CI participation in the SPE was implemented to promote development of essential teaching skills of CIs and to enhance the student learning.

Development and Format of the Workshop

A 5-person team from Upstate Medical University comprised of 2 DCEs, the department chair, the coordinator of the Clinical Education Center, and the assistant director of the Clinical Skills Center, was convened to determine content and format for delivery of the workshop. The content was guided by a review of the literature regarding essential CI assessment and feedback skills.3,4,6–9 Course objectives were developed as follows:

  • Following participation in a workshop, observation of a student's performance on a standardized patient examination, and one-on-one interaction to facilitate student learning, you will be able to:
    • Assess student competence, including knowledge, skills, and behaviors.
    • Use professional documents and resources to assist in assessment of student competency.
    • Ask questions to facilitate student reflection and clinical decision making.
    • Engage in a student feedback session to promote learning.
    • Reflect on this experience to identify areas of strength and areas for personal improvement to help you develop from a novice to an expert clinical instructor.

Sessions were all conducted in the evening at the Clinical Skills Center with mandatory attendance. Continuing education hours were provided.

Sessions 1 and 2. The first 2-hour session focused on entry-level DPT skills and behaviors and included an introduction to the content and format of the ISPE linked to key student performance competencies. Core professional documents, including the patient/client management model and disablement models from the Guide to PT Practice,30 the generic abilities,31 and APTA's Minimum Entry-Level Skills,32 were shared and discussed. A qualitative study by Jette et al33 on CI perceptions of entry-level behaviors of student PTs was used to springboard discussion with CIs on their expectations for student behaviors. This session was designed to stimulate CI engagement and interest by providing relevant information to be applied in upcoming sessions. Prior to concluding the first session, CIs were asked to share their individual reasons for participating in the course.

The second session focused on strategies for engaging in effective feedback sessions with students. The use of open-ended questions to elicit student clinical decision making, prompt reflection, and student selfassessment was stressed.34,35 Video clips of previous ISPE student-patient interactions prompted CIs to assess the performance of students who demonstrated problematic behaviors and/or unsafe or inappropriate performance. After viewing the videos, CIs took turns role-playing the part of the student or the CI using a feedback form for guidance (Appendix 1). Group discussion followed each scenario to highlight key points.

Session 3: Participation in the ISPE. On the evening of the ISPE, each CI was partnered with an academic faculty member in the monitor room of the Clinical Skills Center. While the student reviewed the patient referral and prepared for the subsequent patient encounter (15 minutes), the CI and academic faculty member prepared to observe the upcoming patient-student encounter.

The CI was instructed to watch the 45-minute student-patient interaction as if this were a typical initial clinical encounter and to jot down overall impressions of the student's performance using a form to guide their observations (Appendix 2). Simultaneously, the academic faculty member completed a detailed rubric on all aspects of the student's performance. Following the student-patient interaction, the student had 10 minutes to review information collected from the SP and to prepare for the CI interaction. Concurrently, the CI exchanged notes on the student's performance with the academic faculty member and prepared to meet with the student.

Thirty minutes was allotted for the CI and student interaction. During this time, the CI used open-ended questions to prompt the student's self-assessment and reflections on the SP encounter. Also used by the CI was a semistructured script to elicit the student's clinical decision making based on data collected during the SP interaction. The CI then shared feedback and teaching tips with the students in a dialogue intended to mirror a discussion in the clinic. Following the CI interaction, the student completed a brief online self-assessment of his/her performance. Subsequently, the student provided the CI with narrative feedback regarding his/her teaching skills by answering the following questions: (1) What was helpful about the CI interactions? (2) What suggestions do you have for the CI? (3) Additional Comments? Simultaneously, the CIs completed a rubric on the student's receptiveness to feedback, ability to perform an accurate self-assessment, and ability to engage in clinical decision making (Appendix 3). CIs participated in 1 to 3 of these student interaction(s) during the ISPE.

Session 4: Post ISPE and Debriefing Session. The CIs were provided with narrative feedback from each of the students and with a DVD of their performance during the student-CI interaction. They were asked to view the recording on their own time and to self-assess their own performance in a narrative response to the following questions: (1) What do you think went well? (2) What did you do to facilitate the student's clinical decision making and reflections on the patient encounter? (3) What didn't go so well? (4) Is there anything you would do differently?

One week following the ISPE, clinical faculty returned to the Clinical Skills Center for a final debriefing session. The CIs were divided into small focus groups and questions were posed to elicit their reflections on the workshop sessions and to gather perspectives on take-home lessons they planned to use in the clinic. A comprehensive course evaluation was also completed (Appendix 3).

Participants

Clinical instructors from affiliated acute care or rehabilitation settings were invited to participate in the workshop for 2 reasons: The case scenario was in the inpatient setting for the second-year ISPE, and the DCEs identified that there was a need for CIs in these settings for professional development of teaching skills.

A total of 25 CIs participated in the course (Table 1) in 2010 and 2011. The majority had fewer than 10 years of work experience, had been a CI for 5 years or fewer, and had worked with a total of 5 or fewer students. Ten of the 25 participants were APTA-credentialed clinical instructors. Eleven of the CIs held a clinical doctorate in physical therapy, with the majority of these obtained at a post-professional level, and 2 of the participants were currently enrolled in a DPT program in the transition format.

Table 1
Table 1:
Demographics of Workshop Participants (n = 25)

Data Collection and Analysis

All 25 CIs participated in small group discussions during a final debriefing session. Guided questions (Table 2) were used to elicit participant perceptions in focus groups consisting of 5 to 7 participants. The focus group sessions were recorded and transcribed. Twenty-three of the 25 CIs completed a course evaluation. One year after the workshop, 19 CIs responded to a brief questionnaire that asked them to reflect on how lessons learned were used in the clinic. Using qualitative research methodology for identification of recurrent themes, 3 of the researchers analyzed the transcripts from the focus group sessions, data from the course evaluations, and brief questionnaires completed 1 year later. Recurrent themes emerged across all data regarding CI perceptions of the workshop. Participation in the workshop resulted in clarifying expectations of student performance, facilitating student CDM, and in sharing student feedback and promoting reflection. The CIs consistently described the workshop as a valuable learning experience. Written feedback from the students to the CIs regarding strengths and suggestions for improving the CI-student session was also reviewed and incorporated in the thematic analysis, where appropriate

Table 2
Table 2:
Small Group Debriefing Questions

OUTCOMES

Clarifying Expectations of Student Performance

For many CIs, the workshop provided enhanced awareness of academic expectations for student performance, as exemplified in the following quotes:

It helps me to understand where the students are coming from in terms of educational background and everything like that. I mean it really, you know, you really get a feel for how they are taught to do things and how thorough it (the academic program) really is.

This course has helped me to understand the behaviors expected at different levels in the clinical experience and to be able to ask questions that better facilitate them.

The workshop served as a reminder to some of the CIs that what comes automatically to a PT may be challenging to students with limited clinical experience, as noted in these statements:

We're making decisions and judgments based on our experience, which they don't have, so they really need to rely on the evidence and the models to get them through…it's a good reminder to get back to that method.

I can't believe I had to take a course to learn this! Because it is so second nature that I can't believe I had to be tested on this and it was so challenging back then.

Facilitating Student Clinical Decision Making

All of the workshop participants agreed or strongly agreed with the statement (Table 3), “I feel better prepared to ask questions which will facilitate clinical decision making.”

Table 3
Table 3:
Selected Items From Course Evaluation (n = 23)

CIs shared specific examples of how they utilized questions, nonverbal behaviors, and other strategies to facilitate the student clinical decision making (CDM) during the ISPE in the final debriefing session. In the following quote, a CI reflected on strategies she used during the student-CI encounters:

I encouraged the students to think for themselves, to try and work through the problems. I tried to provide them with time to think about the answer and then time to answer. I used open-ended questions and tried to make them think about their (patient) interaction by using examples from it.

Across all sources of data, several CIs discussed the importance of giving students an opportunity to engage in CDM and to guide (instead of control) this process. When asked about take home lessons from the workshop, 1 CI provided the following response during the debriefing session.

to make sure that you ask questions that encourage critical thinking and not encourage the answer that I'm looking for so that we can move on. It seems like they've answered it correctly, but really you just did all the thinking.

Student comments in written feedback to the CIs after the ISPE often conveyed their perspectives on how the CIs facilitated their clinical decision making, as expressed by 1 student:

I felt that talking out what I wanted to do helped to crystallize my thought process and helped me to take the next steps in decision making. In addition, talking through the reasoning behind performing some tests and not others was a great help…

One year after the ISPE, the vast majority of CIs (Table 4) responding to the questionnaire reported that the workshop prompted a significant change in the way that they asked questions to facilitate student CDM. Many comments, including those noted below, reflected how they changed their approach:

Table 4
Table 4:
Questionnaire: 1 Year Post-Workshop (n = 19)

I let the student think about questions more than I used to. I try to let them figure it out on their own and come back to me with the answers, no matter how much later it is. I think students appreciate this and gave them confidence in their decision making. I also allowed them to go into greater detail with explanations as opposed to stepping in too early.

I feel more comfortable with my own skills/knowledge base and have noticed that instead of giving away the answer to the student, I am able to present the problem in a way that facilitates problem solving on their end.

Sharing Feedback and Promoting Reflection

All participants in the course agreed or strongly agreed with the statement (Table 3), “I feel better prepared to provide feedback to students in the clinic.”

Several CIs noted that time constraints in the clinic impacted their ability to deliver feedback, and that this resulted in a tendency to spend more time critiquing than sharing with the student what he/she does reasonably well. One CI reflected on his experience during the ISPE and the tendency for feedback to dwell on the negative:

You know you start off with, “What do you think went well?” And on both of them (student interactions in the ISPEs), they might have said 1 or maybe 2 things and then jumped right to what didn't go well and I had to redirect them back to “Well, you did some other things nicely. Try to think of some other things…so I felt just how quickly things can go negative and especially in the clinic and how you really have to try and go back to that positive.

Several students reported that the questions from CIs prompted them to reflect on the patient encounter, as noted here:

I liked that the CI offered some insight and suggestions on things I wouldn't have thought of in my own reflection.

You asked me great open-ended questions that prompted me to reflect on things…you were encouraging and inspired me to improve myself.

Many of the students also commented on the manner that the feedback was shared and that the relaxed atmosphere created by CIs contributed to their learning.

While some students reported that the CI interaction mirrored what happens in the clinic, other students reported that this was a novel experience for them, as noted by these student statements:

This makes me realize that I need to set up a specific time to sit and really discuss my performance with my CI.

She built off my critical comments and addressed my concerns as well as her own without being judgmental. She was detailed in her advice and discussed with me possible ideas of how to correct next time. In past experiences, CIs haven't been willing to discuss.

All respondents to the survey administered 1 year after the workshop responded to the open-ended question asking them about take home messages from the course and how they translated to future practice. Responses consistently reflected CI feedback strategies and use of questions to prompt reflection and CDM, as captured in the following statements:

This course allowed me to be more comfortable in training students, especially since I haven't had one in a while. It taught me what to expect from students and gave me different ideas on how to provide feedback to meet the students’ and my needs. It taught me how to handle difficult situations to maximize my students’ learning experience.

Trying to ask more thought provoking questions and I have had success formatting facilitating feedback and the clinical decision making process by how I ask questions and interact. The way to increase the students’ learning experience is to make them think and have it be more of an active learning experience than passive. I was spoon-feeding the students more before this experience.

Several of the CIs noted a change in their behaviors and confidence when sharing feedback, as conveyed here:

It helped me to give feedback (by adjusting my tone and my wording) to the students in a non-threatening manner.

I've been more at ease discussing various issues with the students, both good and bad. I felt better at bringing up those issues, as I was able to justify what I was telling them rather than it appearing that I was pulling things out of thin air.

A Valuable Learning Experience

A few of the CIs noted the format of the sessions as a general strength of the course, with shorter meetings, flexible times, and time between to review handouts. One CI noted the contrast to other professional development courses taken in the following statement:

This is different…because of the big academic piece before, with the lectures really having it broken down like this. You tend to get further and further away from the way you did it in school the longer you've been out and it's nice to come back and think about you're really supposed to be doing things, how to do things professionally…because it's easy to drift away in the clinic week after week.

Many of the CIs referred to the live interactions with the students during the ISPE and to the authentic feel of these encounters, sharing statements such as, “The whole set up and organization of the ISPE was very realistic (not just role-playing).” The opportunity to interact with other CIs and with academic faculty members was also frequently mentioned, as exemplified in comments like, “Great CI/Faculty sharing,” “Networking opportunity with fellow CIs and PTs,” and “Hearing how other CIs interact with students.”

All of the CIs who completed the course evaluation strongly agreed with the statement, “I would recommend this experience to other CIs,” while all of the participants agreed or strongly agreed with the following statements (Table 3): “My participation in the ISPE was a valuable learning experience for me, the course objectives as stated were met, and the course met my personal learning objectives.”

Likewise, students were universally positive about the interaction with CIs, with several echoing the sentiments of 1 student who stated, “The immediate feedback from a practicing therapist was a great learning experience.”

DISCUSSION

Many of the CIs reported that the workshop provided them with a clearer and more realistic understanding of expected student competencies. Although several of the participants had a DPT degree (in either the standard or the transitional format), most held entry-level baccalaureate or master's degrees. A recent study demonstrated that CIs without a DPT were more likely to perceive that their teaching skills were “less than adequate” in core content areas, noting a lack of familiarity with foundational concepts such as the patient-client management, disablement, and International Classification of Function models.36 The sharing of professional documents and other resources on expected behaviors and skills for entry-level DPT students, coupled with group discussions and participation in a comprehensive ISPE, may have enhanced CI understanding of critical competencies, as well as their ability to challenge students at an appropriate level.

All participating CIs reported that they felt better prepared to ask questions and provide feedback. Similarly, student narratives consistently described how the CIs asked questions that prompted them to work through problems and engage in reflection. These findings warrant attention, as many CIs do not routinely use questions to effectively facilitate reflection and CDM.34 They often lack skill in the delivery of feedback, especially related to student professional behaviors or delivery of bad news.37 Comparable to the experiences of PT students interacting with standardized patients versus classmates,21 the opportunity to directly apply the skills introduced and practiced in the workshops prior to the authentic student encounter may have been perceived as more relevant and useful to the CIs than engagement in role-playing activities with colleagues.22 Consistent with factors associated with deep learning in DPT students,24,35 reflection and self-assessment of the videotaped interactions with the students, followed by group dialogue with other CIs and the course facilitators, may have supported the positive outcomes described by the CIs.

Partnering with academic faculty may also have impacted the CI experience. Academic and clinical faculty reported that they appreciated the unique opportunity to meet and dialogue with each other before and after the joint observation of the student-patient interaction. Networking and sharing with other CIs working in similar practice settings likely enhanced the learning experience. It is possible that these interactions created a supportive and non-threatening atmosphere that supported the CI learning experience.22

The students consistently shared their appreciation for the inclusion of the CIs in the ISPE. The immediacy of the CI feedback provided in a supportive manner, coupled with the opportunity to reflect on their decision making with a CI, mirrors what students have described as effective learning experiences in the clinic.6 Interestingly, some students reported that the interactions that they experienced with the CIs in the ISPE provided them with a model for CI-student interactions, which they may not have experienced in previous clinical experiences.

While the workshop appears to have met the stated objectives, it has had other unintended outcomes. Since its inception 4 years ago, many of the CIs who completed the workshop continue to participate in the ISPE or have sought out additional short-term teaching opportunities across the academic curriculum. The positive response to the inclusion of the CIs in the second-year ISPE has resulted in the expansion of the workshop to include CIs in the first-year ISPE (an outpatient case scenario). Relationships between CIs and academic faculty have been strengthened and the DCEs have noted an increased ease in placing students with these CIs for remediation, short-term integrated clinical experiences, and full-time experiences in the event of cancellations.

This workshop could be readily replicated by other academic programs that use standardized patient experiences for formative or summative assessments. While faculty time to develop workshop materials was substantial, it was not unlike time required to produce any quality professional development course. The inclusion of the ISPE required administrative time to schedule students, academic faculty, and CIs. Financial costs incurred from providing light dinners for the workshops and the use of the Clinical Skills Center for the student-CI recorded sessions.

The researchers acknowledge that the outcomes reported here are limited to the experiences of a convenience sample of CIs who participated in this workshop in 2010 and 2011. The other limitation is potential bias by the researchers who developed this model. We tried to minimize bias by looking across data points to confirm our findings and by including multiple researchers in the coding process to look at the data individually first, then comparing findings. This study relied on the self-reporting of CIs and of students who participated in CI encounters during a standardized patient examination. Future studies should explore how this professional development workshop model impacts CI teaching skills and/or student learning in the clinic.

CONCLUSION

A 4-part workshop, including participation in a comprehensive standardized patient examination, was successfully developed and implemented to provide an opportunity for CIs to develop competence and confidence in key assessment and feedback skills to promote student learning. The novel inclusion of an authentic student interaction following a patient encounter simulated a typical CI-student interaction in the clinical setting. Data collected from CIs during, immediately after, and 1 year following the workshop indicated that the workshop supported CI professional development, and that they carried these lessons into the clinic.

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Appendix 1: Rubric for Role-Playing, CI-Student Interaction, and Guide for CI Mentor-CI Session

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Figure

Appendix 2. Overall Encounter Quality

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Figure

Appendix 3: CI Checklist

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Keywords:

Clinical education; Professional development; Clinical instructors; Simulation

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