BACKGROUND AND PURPOSE
Clinical education (CE) is a significant component of professional health education programs. It comprises up to 36% of the combined didactic/clinical curricula within professional physical therapy education programs.1,2 Immersion in physical therapy practice helps students learn to integrate theory, critical reasoning abilities, hands-on skills, and professional behaviors into actual clinical situations.2,3 Given that such a vast amount of time is dedicated to CE, and because it is viewed as a significant component of the educational process, it is imperative that quality CE experiences are designed to enhance student learning. It is thought that one of the most influential components of CE is the clinical instructor (CI).4,5 Clinical instructors are often viewed as role models who help to shape the student physical therapist (PT) into the clinician he or she will become.6,7
The CI's responsibilities are multidimensional as they are providers of care to patients in their service, as well as clinical teachers. CIs are held accountable, through an affiliation agreement between the university and CE site, for designing, implementing, and assessing the learning experiences and outcomes of a student PT's CE experience, although most likely not employed through the physical therapy education program.3,8 The CI is responsible for overseeing and promoting the student's progression through CE and for the development of critical thinking skills.4,5 Clinical instructors reinforce didactic knowledge, provide opportunity for skill development through applied learning, and bring to life the patient management model.6 In addition, they help shape a student PT's professional behaviors through modeling within a supervised clinical environment.6 Effective CIs enhance a student's experience,7 while ineffective CIs may challenge the student PT and inhibit student learning.9
The minimum requirements for serving as a physical therapist CI are few. The Commission on Accreditation in Physical Therapy Education (CAPTE) evaluative criteria state a CI should be a competent, licensed PT with a minimum of 1 year clinical experience.3,8 Recker-Hughes et al further suggest CIs should practice legally and ethically, demonstrate the desire to educate students, and exhibit evidence of teaching skills.10 APTA offers the Credentialed Clinical Instructor Program, a 16-hour continuing education course intended to develop teaching abilities; however, the program is voluntary, not mandatory.11 Clinical instructors volunteer their time to educate students; therefore, their age, acquired degrees, overall years of experience, practice setting, and further specialization of practice, such as clinical specialties or CIcredentialing, can vary significantly. While variations may exist in who serves as a CI, a standard of essential individual level characteristics of clinical instructors to guide effective learning experiences for student PTs is needed.
Health professions education literature highlights the need for CIs to display leadership skills, act as a professional role model, use effective communication strategies, and exhibit a positive attitude toward CE to influence their effectiveness as a clinical teacher.4,6 Development of expert CI teaching skills is a dynamic process that requires a balance of reflective teaching and learning, development of relationships, and participation in professional advancement opportunities.12 No systematic review synthesizes current evidence about physical therapist CIs and their impact on clinical teaching outcomes. While a literature review about clinical instruction exists within the health professions literature,7 it should not be assumed that what works for a particular health profession will work for all. Therefore, the purpose of this systematic review was to identify physical therapist CI characteristics that impact a CE experience.
Data Sources and Eligibility Criteria. A comprehensive computer search was conducted up to and including October 2015 in PubMed, PEDro, ProQuest, Google Scholar, ERIC, and CINAHL. Terms searched on the electronic databases included: physical therapy, CE, clinical instructor, teaching methods, and clinical competence. Detailed terminology for the computer search is listed in Table 1. Hand searches were also completed from bibliographies of included full text articles.
Study Selection. Articles were considered appropriate for selection if they met the following inclusion criteria: found in peer reviewed journals, written in English during or after 2000, pertained to professional physical therapy CE, broad spectrum of characteristics of clinical instructors such as CI demographics, APTA credentialing status, and personal characteristics. Excluded documents included doctoral dissertations, position papers, articles whose subject focused on the process of becoming a CI, and articles whose subject matter involved health professions other than physical therapy. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement13 guided the selection of the search-identified studies (Figure 1).
A 3-step review process was followed. Two reviewers (LM and RR) independently read each title, abstract, and full text article for inclusion. If a discrepancy for inclusion was noted, a joint discussion between the 2 reviewers (LM and RR) occurred. A third reviewer (CM) served as a tiebreaker when needed. The agreed upon full texts were filtered a final time to accept only those articles pertaining to physical therapist CIs.
Data Extraction and Quality Assessment. Two authors (SB and RR) completed data extraction. Information drawn from each article included: purpose statement, study size, demographics, characteristics of the clinical instructors identified as having a positive effect on student outcomes, and student performance outcomes.
Studies were classified according to research design and methodological rigor. First, a hierarchical research design level of evidence classification was assigned for quantitative studies according to the Oxford Centre for Evidence-based Medicine Levels of Evidence.14 This scaling system assigns a level based upon the degree of design quality, with the highest degree receiving a “1a” and the lowest level of evidence receiving a “5.”14 This standard approach clearly delineates the design quality of the articles included in this review (Table 2). Qualitative study designs were classified according to the categories of the McMaster University Occupational Therapy Evidence-Based Practice Research Group,15 However, a hierarchical classification was not attempted.
Second, the methodological quality of each article was critically appraised using the binary system developed by Lekkas et al16 based on the McMaster appraisal tools.15 The Lekkas et al16 scoring system provides a means to critically appraise the summative methodological quality of both quantitative and qualitative studies. Each of the 14 possible critical appraisal criterion was assigned a score of either “0 - not present” or “1 - present” for a total possible score of 14. Items taken into consideration when scoring included relevancy of literature reviewed, sample size and justification, reliable and valid outcome measures utilized, contamination avoidance, educational importance reported, and appropriate conclusions. The validity and reliability to appraise studies using the McMaster tool has been established with 75%-86% agreement.15 Both classification systems have been used in previous systematic reviews.16,17 Two authors (CM and RR) independently reviewed the included articles and scored for quality following the guidelines of these instruments. The authors then shared their scores with each other to ensure agreement on the quality of each study. A tertile scale was used to analyze the studies according to risk of bias.17 Scores of 13–14 indicate “high quality, low risk of bias,” scores of 11–12 indicate “moderate quality, moderate risk of bias,” and a score of 10 and under indicates “low quality, high risk of bias.”17
Data Synthesis and Analysis
Quantitative Analysis. A mixed-method approach was used for data synthesis and analysis. First, CI demographics were measured by mean and frequency of data within each included article (Table 3). Statistical tests (such as P values) within each article were assessed to determine if statistical significance was present on measures of CI effectiveness. Specific characteristics that lead to a more positive student outcome were also measured assessing P values as well as frequency of responses. Statistically significant P values were accepted if P < .05 was discovered in the examined studies. Meta-analysis was not completed due to heterogeneity in study methodology, outcome measures used, and variation in statistical tests.
Qualitative Thematic Analysis. Second, a descriptive, thematic analysis was used to identify, examine, and recognize patterns of significant key characteristics and trends in effective behaviors data.18 One author (RR) coded characteristics identified as having a positive effect on student outcomes in CE within the studies. A second author (CM) verified the accuracy of the data. The emergent data was then categorized into 4 distinct characteristics (Table 4): personal characteristics (aspects relating to the CI's style of practice, such as participating in continuing education, valuing time spent with the student, and being self-reflective), teaching characteristics (including traits such as adapting to the student's style of learning, the use of modeling, and encouraging students to question methods of practice), communication characteristics (including activities such as setting clear objectives, encouraging an open relationship with the student, and providing constructive feedback), and environmental characteristics (relating to the site and its level of support for the student PT).
Finally, the thematic characteristics identified in the qualitative analysis were examined to assess whether the studied CIs were credentialed and whether credentialing was reported as having an impact on the quality of the CE instruction.
Study Selection. Using our identified search strategy and other sources, a total of 511 items were identified. After title reviews, 401 were discarded because they did not meet the inclusion criteria and 1 duplicate was removed. Upon reviewing the 109 remaining abstracts, 57 were removed because they did not clearly address the research question. One abstract was not found. Fifty-one full text articles were read, resulting in the elimination of 1 duplicate, 41 articles because they did not meet the inclusion criteria, and 1 article because it was not accessible in print or electronic form. In total, 8 published articles were included in the systematic review (Figure 1). Seven of the 8 articles were published in the same journal (Journal of Physical Therapy Education).19–25 All 8 articles were published between 2003 and 2013.
Methodological Quality Scoring and Research Design.19–26 The possible range of methodological quality score was between 0–14. In the aggregate, all reviewed studies achieved a moderate to high quality methodological quality score of 11 or higher (Table 2).
Six of the 8 studies were quantitative research designs, and 2 were qualitative studies.
Thematic Analysis. Three distinct elements emerged from the thematic analysis of the literature: (1) Demographic characteristics of the physical therapist CI, (2) the impact of clinical instructor APTA-credentialing on student outcomes, and (3) fundamental characteristics of the CI (Appendix 1).
Element 1: Demographics. Six of the 8 studies provided a summary of CI demographics.19–24 The studies were published between 2003 and 2010 (Table 3).21–24 The average CI was a female, worked 8.71–13.28 years as a PT, had 6.2–9.13 years of CI experience, held a bachelor's degree, was not an APTA-credentialed CI, nor an APTA member, and was not a clinical specialist.
Four studies investigated the connection between demographic data and CI effectiveness.19,20,22,23 The Nursing Clinical Teacher Effectiveness Inventory (NCTEI) (P < .05) reports the greater number of years a PT had been a CI increased their clinical instruction effectiveness.23 Buccieri et al23 asked CI respondents to rate themselves on 3 questions, including if they felt adequately prepared to be a CI, with which type of student PT they felt most effective, and their overall competence as a CI. The results indicated statistically significant (P < .05) positive correlations between select CI demographics and self-report CI effectiveness for the following demographics: years as a CI, total years of practice, credentialed CI status, professional degree earned, and specialty certification.23 Housel et al reported an inverse relationship between years of experience and effectiveness as a CI using the Student's Evaluation of a Clinical Education Experience from the New England Consortium of Academic Coordinators of Clinical Education (NEC-ACCE), but it was not found to be statistically significant (P =.079, -.203).19 Similarly, Morren et al found no significant association between years of experience and CI effectiveness, as rated by the student PT (P = .581).20
Element 2: Credentialing Status. The impact of APTA credentialing on the effectiveness of a CI was reported in 4 studies.19,21,22,25 A positive correlation between CI effectiveness and holding APTA credentialing was present in 2 articles.19,21 These articles used the same data set collected between 2001–2002. The difference between the studies was the outcomes tool used to measure CI effectiveness. Housel and Gandy's article (2008)21 reported the differences between APTA-credentialed CIs and noncredentialed CIs based upon the results of the APTA Physical Therapist Clinical Performance Instrument (PT CPI), while the later article (2010)19 focused on the students’ assessment of CI teaching effectiveness using the NEC-ACCE Student's Evaluation of a Clinical Education Experience as the outcome tool. Housel and Gandy (2008) found that students who worked with an APTA-credentialed CI displayed increased improvement (P < .001) from midterm to final evaluation on the PT CPI compared to matched students who were paired with noncredentialed CIs.21 This improvement was measured by comparing the mean scores of all 24 CPI performance criteria of both student groups, rather than examining each CPI behavior independently. When the mean aggregate scores of the 5 red-flag foundational CPI performance criteria were compared to each red-flag item independently, students paired with APTAcredentialed CIs scored statistically higher than those with noncredentialed CIs (P < .001).21
Kelly's qualitative study on an exemplary CI revealed holding APTA-credentialed CI certification potentially had a positive influence on CI instructional effectiveness; however, the small sample size (n = 1) limited any generalizability of the results.25 Finally, the Wetherbee, Nordrum, and Giles22 study, which measured credentialing status effectiveness, found no difference between APTAcredentialed and noncredentialed CIs and the effect on CI instructional effectiveness when using scores from the Nursing Clinical Teacher Effectiveness Inventory (NCTEI). This tool is a valid and reliable outcome measure to evaluate effective clinical teaching behaviors and characteristics as adapted to physical therapy.18 The only statistical difference reported was related to years of CI experience and its positive correlation to effective teaching behaviors.22
Element 3: Modifiable Clinical Instructor Characteristics. Six studies investigated essential communication and teaching characteristics of CIs (Table 4).19–21,24–26 Kelly25 discovered that a CI's ability to adapt the CE experience to the student and the use of questioning and modeling as a teaching style were effective in creating a successful outcome for the student's CE. Rindflesch et al26 went on to state that customizing the learning experience to that particular student creates a learning environment that facilitates open communication. The authors added that taking time to meet with students and reflect on particular CE experiences is highly beneficial to student learning.26 Both Kelly25 and Rindflesch et al26 summarized that a CI who supported facilitation of clinical reasoning and emphasized the creation and maintenance of an open, collegial relationship leads to better student experiences. Positive communication characteristics noted included providing direct feedback and clear expectations, encouraging open communication, and seeking student input.25,26 It was suggested that the transition of a student from novice to an entry-level clinician could be accomplished more effectively by utilizing these favorable teaching and communication behaviors.2 Similar positive communication behaviors were also reflected in other included studies with larger sample sizes.19,21Housel and Gandy (2008) identified both integration of student learning styles and providing constructive formal evaluation as having a positive impact on student learning during a CE experience.21 These favorable teaching characteristics were found more frequently in APTA-credentialed CIs when compared to noncredentialed CIs (P < .001).21 Morren, Gordon, and Sawyer (2008) reported the following characteristics more frequently in APTA-credentialed CIs compared to noncredentialed CIs: giving timely feedback (P = .007), clear and concise communication (P = .022), and clear exploration of student responsibilities (P = .009).20
Utilizing the same data from the same population, but working with a different outcome measure (NEC-ACCE), Housel et al (2010) again supported that timely and thorough orientation and instructors having a clear set of objectives impacted CE.19 Those CIs with APTA credentialing were rated higher in both of these categories than those without APTA credentialing (P = .039 and P = .028, respectively).19 Though the authors found these characteristics to occur more frequently in CIs with APTA credentialing, those CIs without credentialing still incorporated these styles.19
Rindflesch et al's study26 included CI insight as a characteristic that may positively impact a student PT's CE experience. The authors found that being able to observe a student and adjust feedback based upon the student's knowledge base, comfort level, and progression through the CE experience assisted in the student achieving a level of independence by the end of the rotation.26 Clinical instructor personal and environmental factors were also reported to impact a students’ CE.26
Receiving environmental support from the clinical site personnel, such as expressing the value of CE experiences, was shown to positively impact the students’ learning,25 as was understanding and using evidence-based practice.26 A CI was seen as more effective if he or she made time for the student, was selfreflective, and participated in professional activities outside of the typical employment duties.25 Feeling welcomed as part of the team, not only by the CI but by the other professionals in the department, was reported as assisting in the development of a safe learning environment.26 Students reported feeling reassured when the CI was able to not only explain the clinical reasoning behind certain practices, but could cite current research on the techniques as well.26
The purpose of this systematic review was to identify physical therapist CI characteristics that impact a CE experience. We identified 3 common elements, which were CI demographics, APTA credentialing status, and fundamental characteristics. This study is important to the future of physical therapy CE in light of the shared vision in the delivery of effective CE practices among academic programs and CE practice sites.27
Results of this systematic review highlight that the role of a physical therapist CI on student outcomes of CE experiences is inconclusive. The study designs included both quantitative (n = 6) and qualitative studies (n = 2). However, most were of low-level design without any randomized controlled trials. The critical appraisal scores for methodological quality equated to low to moderate risk of bias, with the majority of the studies lacking the use of a reliable outcome measure. This may indicate there is the potential for inconsistency with the ability of these instruments to produce the same result at a different point in time. Despite the variability of study design and the heterogeneity of outcome measures, the authors used the best available evidence29 to systematically assess results, produce baseline characteristics of the CIs studied, and identify effective personal, environmental, teaching, and communication characteristics of PTs who serve as CIs.
The overall impact of APTA credentialing on the effectiveness of a CI is inconclusive. The same authors using the same population of subjects and demographic data set19,21 wrote 2 of the 4 studies that investigated the effect of APTA credentialing on effectiveness. Housel et al's 2 studies found differences between APTA-credentialed CIs when compared to noncredentialed CIs in the assessment of clinical competence and in effectiveness of clinical instruction.19,21 Students of APTA-credentialed CIs were found to have more improvement (P < .01) from the midterm to final evaluation on the PT CPI when compared to students under noncredentialed CIs, even though the 2 student groups had no difference in final assessment scores.21 It is uncertain whether student clinical competence improvement was due to CI teaching behaviors or if the APTA-credentialed CIs rated their students lower at midterm to show greater overall improvement from midterm to final. Credentialed CIs may have a better understanding of how to score the CPI when compared to noncredentialed CIs; however, this is uncertain.
Housel et al's 2010 study found students using the NEC-ACCE tool rated APTA-credentialed CIs higher on clinical instruction behaviors as compared to noncredentialed CIs.19 While statistical significance was found in only 2 of the 27 specific behaviors (timely and thorough orientation and a CI with clear objectives), trends of more effectiveness were noted in organizational behaviors related to the CE experience, CI feedback, CI teaching styles, and CI evaluation of the student. Alternatively, when the results of the 27 components of the tool were summated, statistical significance was found which indicated APTA-credentialed CIs were more effective than noncredentialed CIs, as assessed by their students (P < .01).19 What could not be determined, however, was if the NEC-ACCE is designed to be summated and compared across groups.19 When exploring the relationship between APTA-credentialing and years of CI experience, the authors found no solid conclusion that indicated improved effectiveness in clinical instruction resulted from specific CI training or the number of years practicing.
The results of this systematic review reveal the majority of CIs studied were early to midcareer clinicians (Table 3). This data is similar to published data from CAPTE2 and also congruent with findings from a previous systematic review.17 The authors were unable to determine conclusively if time teaching in the clinical environment impacts effectiveness as a CI. Results did reveal several fundamental characteristics that positively impacted students’ CE experiences, including teaching and communication behaviors, as well as personal and environment characteristics (Table 4).
The effective physical therapist CI teaching and communication characteristics identified in this review are similar to other studies from other allied health programs.29–32 Recker-Hughes et al also recently summarized essential characteristics of a CI, which corresponded well to the key characteristics found in this systematic review.10 The CI credentialing program of APTA includes modules in communication and principles of teaching and learning.11 Therefore, it would be interesting to know if standalone advanced training in these 2 elements could benefit the ongoing development of CIs. The CI is often regarded by students as a primary factor that impacts a CE experience; therefore, it would be beneficial to explore specific characteristics of the CI that are most effective, rather than the entire components of the credentialing program, such as interpersonal skills, communication, and specific instructional teaching style.
Additionally, results indicated the culture of the clinical practice environment10 impacts a student's CE experience. The expressed values of the members of the practice and the overall support provided by the practice environment made a difference in a student's CE experience.25,26 The type of practice setting (ie, acute, outpatient, long-term care) often impacts a student,33 and while not a result in this study, may relate to the values expressed by its clinicians. To date, the clinical practice environment itself has not been studied extensively in regard to its impact on CE.10 Because a CI often is not alone in the delivery of physical therapy services in his or her point of service, the overall practice environment should garner more attention in future studies. The culture of a clinical practice environment and the values expressed by its members are elements that can be modified through practice and instruction.
It would be unrealistic to expect all CIs to inherently possess the knowledge, skills, and behaviors needed to be an effective instructor;10 therefore, some training is needed to guide PT clinicians into becoming physical therapist CIs. Based on the results of this systematic review, the authors are unsure if all the components of the APTA credentialing CI program are needed or are contemporary to meet the needs of today's CI. More research is needed to investigate the impact of student learning outcomes within CE, coupled with CI demographics, communication and teaching characteristics, and other factors that impact a CE experience. It would be interesting to examine CIs with earned doctoral degrees in more quantity, as the studies reviewed had minimal participants holding this degree. Since 2006, CAPTE has required professional physical therapy education programs to prepare graduates for CE;3 therefore, long-term impact should be explored.
Some limitations are present in this systematic review. First, because of the exclusiveness of the search, a small sample size was realized. This was necessary to limit the focus to the profession of physical therapy. The primary purpose of this systematic review was to identify physical therapist CI characteristics that impact a CE experience; therefore, no other health profession studies were reviewed. We do recognize that a prior systematic review17 reported aggregate CI demographics; however, it was not coupled with essential characteristics of a CI.
Second, a risk of publication bias existed, as all but 1 of the articles were published in the same journal. Regional bias must also be considered because of the lack of variety in where the studies originated: 3 of the articles’ participant samples were from the New England region,19,21,22 4 sampled participants from select universities across the United States,20,22–24 and 1 was a single case study from Indiana.25 More research needs to be systematically conducted across the United States to ensure increased data generalizability.
Finally, a concern may exist about the lowlevel designs of the included studies; however, the selected studies offer the best available evidence about the topic at this time. As Jette et al stated, “the physical therapy profession must decide if there is compelling reason to make changes using the existing sparse and flawed evidence.”29(p6) The authors believe that it is noteworthy to provide a systematic analysis of physical therapist CIs and characteristics that impact student learning to help guide future CE practices.
As the physical therapy profession progresses toward a shared vision for CE, it is imperative that evidence guides key decisions along the way. This study examined published peer reviewed research that studied CI characteristics and its impact on CE experiences. While no significant conclusive relationships were identified, we were able to systematically determine key demographic characteristics of CIs and identify the common CI characteristics that impacted student outcomes. Despite no statistically significant relationship between the APTA credentialing program and student outcomes, it is noteworthy to recognize that this training program trended towards positive results. Future research is needed to focus on the process of acquiring fundamental CI characteristics, whether through CI training courses, years of CI experience, or other means. More research is also needed to determine whether APTA credentialing, as it is offered today, has any impact on CI effectiveness since no consensus could be determined in the current literature.
Deusinger et al34 responded to recent changes in health care policy and guidelines by suggesting solutions for new expectations of the physical therapy profession, and in particular, for the CE component in professional physical therapy education. The future of CE must include interprofessional educational opportunities that not only treat current conditions seen in the clinic, but also promote health and wellness in an evolving health care system.34 The profession may need to transition its training of CIs to prepare today's students to meet these needs. By acknowledging the key CI demographics and characteristics of the CIs that have a positive impact on a PT student's CE experience, innovative and novel approaches to postprofessional training could be designed.
Furthermore, the results of this study could be utilized to impact practice and policy guidelines surrounding CE for PTs. The 1 year minimum of required clinical practice for the CI is supported in the demographic data gathered, but a wide range of years of experience among CIs exists. Future research, using common outcome measure metrics, should be conducted to identify any other demographic factors that impact student outcomes in CE experiences. It should be determined if CI demographic data and/or characteristics truly impact qualifications of an effective CI.
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Appendix 1. Study Summary of Findings