Achieving Clinical Instructor Competence: A Phenomenological Study of Clinical Instructors' Perspectives

Abstract

Introduction. 

Defining best practice in clinical education is currently a primary focus of the American Physical Therapy Association and the American Council of Academic Physical Therapy. Although professional standards exist for physical therapist clinical instructors (CIs), there is little published research regarding the pathway to achieving competence as a CI. Moreover, there is currently no published definition for competence as a CI within the profession of physical therapy (PT). This study attempts to describe the meaning of competence and the experience of achieving competence as perceived by both credentialed and noncredentialed CIs.

Subjects. 

Twenty-nine physical therapist CIs who had independently supervised at least one full-time physical therapist student served as the subjects for this study.

Methods. 

A phenomenological methodology was used to understand and interpret the meaning of CI competence and the experience of achieving competence from the CI participants' perspectives. Data were collected through focus group interviews and written statements and then were analyzed using thematic analysis.

Results. 

The journey to competence, though unique to each CI, included commonalities. An overarching theme of “Empowerment” emerged from the data analysis and was supported by 6 subthemes: (1) the meaning of competence, (2) my first student, (3) finding the way, (4) barriers to achieving competence, (5) confidence, and (6) lifelong learning. Participants' descriptions of the meaning of competence included the roles of skilled clinician, teacher, mentor, reflective learning, collaborator, and effective communicator.

Discussion and Conclusion. 

Findings can inform CIs striving for effectiveness in clinical teaching by defining the meaning of competence, as well as revealing a variety of pathways used to achieve competence. These examples could be helpful for Site Coordinators of Clinical Education, Directors of Clinical Education and others who teach CI development. The physical therapy education community and its professional bodies can use these findings to define CI competence and to direct future efforts and programs designed to prepare clinicians to effectively educate students in the clinical setting.

INTRODUCTION

The American Physical Therapy Association (APTA) and the American Council of Academic Physical Therapy (ACAPT) have intensified their initiatives to improve and define best practices in physical therapist clinical education. Recently, the APTA Board of Directors passed recommendations 2 through six of the Best Practice in Physical Therapist Clinical Education Annual Report to the 2017 House of Delegates.¹ Recommendation three includes a directive for infrastructure and capacity to include mandatory clinical instructor (CI) training, certification, and recertification. Although training programs such as the APTA Credentialed CIs Program exist for CIs who wish to improve their clinical teaching skills, there is no standard definition of CI competence or a standard process for achieving competence. Recommendations for CI development have been identified in the literature,^2-6 but input from a primary stakeholder in clinical education, the CI, has been minimal. Understanding the meaning of competence from the CI's perspective and the process of achieving CI competence may provide clarity and direction for developing CIs, inform CI development curricula, and assist in the development of national standards of CI competence.

REVIEW OF LITERATURE

The APTA's Guidelines for Clinical Education⁴ and the Physical Therapist Clinical Education Principles³ provide direction and guidance in the development and enhancement of clinical education including CIs, and represent current practice and future ideals in physical therapy (PT) clinical education. At present, the accreditation standards that govern entry-level physical therapist academic programs do not include a specific description of CI competence.⁷ Clinical education experiences across all PT programs, including the quality of CIs, vary in quality and consistency.^5,8-14

The effectiveness of CIs in PT education and other health professions is a well-published topic. Findings from many studies provide consensus on traits that lead to success as an instructor, including interpersonal skills,^5,15-21 effective teaching behaviors,^5,22-24 professionalism,^5,19,21-26 and professional clinical skills.^5,7,27 A qualitative study by Buccieri et al¹⁸ analyzed interview data from 9 PT CIs to develop a model for the expert CI. The authors advocated for the use of this model to facilitate CIs clinical teaching skills, but did not outline the process of becoming an expert.¹⁸ In a recent study, DPT students on their final clinical education experience rated the interpersonal relations category as the most important trait, followed by communication, professional skills, and teaching behaviors.²⁸ This study also identified important CI traits but not the process of developing those traits. Differences have been reported between the views of academic program directors and CIs in relation to the importance of evaluative behaviors.²⁹ These findings suggest that it may be helpful to explore the CI's perspective in an effort to describe the pathway or pathways to achieving competence.

CIs are primary stakeholders in the clinical education experience. Evidence is needed that supports the meaning of competence and the experience of becoming a competent CI from the CI's perspective. This evidence can be used to support best practice in clinical education. The purpose of this study was to describe and interpret the meaning of CI competence and the experience of achieving competence as perceived by CIs.

METHODS

Study Design

The CI's perceptions, beliefs, values, and personal experiences, related to clinical teaching and the achievement of competence, are predictors of teaching proficiency.^17,23,30 Yet, the subjective nature of these inner constructs are not easily measured through quantitative research methods.

Van Manen³¹'s phenomenological methodology, a qualitative approach aimed at understanding and interpreting human experience, was used in this study.

Subjects

Twenty-nine physical therapist CIs practicing in the Midwest in a variety of clinical settings participated in this study. Inclusion criteria required experience as a CI with at least one full-time student. Additional demographic information is presented in Table 1. Upon receiving Institutional Review Board approval, participants were recruited through convenience and purposive sampling based on their positions as CIs, CI credentialed status, and affiliation with the University's entry-level Doctor of Physical Therapy (DPT) program at which the study was conducted. The primary researcher obtained informed consent from each participant before data collection.

Table 1.: Participant Demographics

Data Collection

A pilot focus group interview was conducted with a group of CIs who were not study participants to test the quality of the interview guide and the potential for researcher bias during the interview process.^32,33 The pilot interview resulted in minor changes to the guiding questions and interview technique to improve clarity and focus of the questions.

Data were collected by 2 methods, written statements and focus group interviews. Before all interviews, the primary researcher asked the participants to provide a written statement explaining their beliefs about the meaning of competence and achieving competence as a CI. These written statements were intended to triangulate and validate the interview data. The primary researcher emailed each participant 2 questions with instructions for the written statements once when they agreed to participate in the study, and again before the focus group interviews (Table 2). Participants brought their written statements to the focus group interview. The primary researcher reviewed the written statements after each focus group interview. Five focus group discussions were conducted using the interview guide, which consisted of predetermined, open-ended questions designed to guide the group discussion and elicit information about the participants' experiences achieving competence as a CI (Table 3). Consistent with the phenomenological methodology, the primary researcher asked clarifying, follow-up questions. Each focus group discussion, ranging from 33 to 54 minutes, contained five to seven participants and took place in private conference rooms, located in the facilities in which the participants worked. After the focus group discussions, the primary researcher followed up with participants through telephone and email to collect demographic information and to clarify data when necessary.

Table 2.: Written Statement

Table 3.: Focus Group Interview Guide

During the data collection process, the primary researcher maintained detailed fieldnotes with recorded observations, thoughts, and ideas for follow-up questions. Following each focus group discussion, the primary researcher reviewed the field notes and written statements, and further reflected on the discussions, ideas, and possible patterns or themes that emerged from the data. This process, known as precoding, enables the researcher to identify concepts that require further exploration through follow-up interviews and during subsequent focus group interviews, and sets the stage for data analysis.³⁴ The focus groups were audio-taped and the recordings transcribed verbatim by a transcriptionist. The primary researcher used 2 recording devices, a semistructured interview guide to assist in directing the conversation, and ensured all participants had the opportunity to speak. Data saturation was confirmed and achieved after five focus group discussions, when the interviews no longer revealed new information, were redundant to previous focus group discussions, and no new themes emerged from the data.

Data Analysis

Each participant received a copy of the interview transcript and was given the opportunity to make corrections, comments, or additional statements for member checking. Two participants submitted minor corrections to the primary researcher. NVivo10 qualitative data analysis software was used to assist with data management during the analysis process. Both the written statements and the interview transcriptions were entered into NVivo for the analysis. The primary researcher analyzed the data using thematic analysis, the process of discovering patterns or themes in the texts.^31,35-37 The primary researcher applied three approaches to uncovering themes: wholistic, selective, and detailed.³¹ In the wholistic approach, the primary researcher created phrases that represented emerging themes to capture the central meaning of the text. During the selective approach, the primary researcher highlighted phrases that stood out in the text and placed them under the emerging themes identified in the previous step. Finally, the primary researcher examined every sentence considering what it revealed about the experience being described and assigned that sentence or sentence cluster to an emerging theme or subtheme. Ultimately, an overarching theme and six subthemes emerged from the data. These results provided the framework necessary to interpret the findings.

Establishing Trustworthiness of Findings

Trustworthiness of findings refers to the extent to which the results are true, applicable, consistent, and neutral.³⁸ In qualitative research, trustworthiness of findings can be demonstrated by meeting 4 criteria: credibility, transferability, dependability, and confirmability. Credibility is establishing believable results through sound inquiry,³⁹ and in this study, it was partially established through peer-debriefing over multiple debriefing sessions with a peer knowledgeable in clinical instruction and qualitative research. Transferability is the ability to transfer the findings to the reader's own situation.⁴⁰ Dependability coincides with the quantitative term of reliability and confirmability corresponds to objectivity.³⁸ To achieve trustworthiness of findings in this study, the primary researcher implemented all strategies described in Table 4. The primary researcher was familiar with all participants in the study from her previous work as a Director of Clinical Education, which added credibility through prolonged engagement. The primary researcher maintained a reflexive journal to address potential biases and minimize the limitation this familiarity introduced. In addition, the primary researcher triangulated the data by including and analyzing from both interview transcriptions and written statements. These written statements provided an opportunity for each participant to share their perspective before participating in the focus group interviews. This guaranteed that their perspectives were not influenced by their participation in the focus group interviews. Another benefit of collecting participants' perspectives through written statements is that it provides each participant the opportunity to share their thoughts privately, as there is potential for some individuals to withhold information in a group setting.

Table 4.: Establishing Trustworthiness

RESULTS

An overarching theme of “Empowerment” emerged from the data analysis of the transcriptions and fieldnotes. This overarching theme is supported by six subthemes which resonated across the five focus groups. The first subtheme focused on the meaning of competence, and the remaining five subthemes describe the journey to competence.

Overarching Theme: Empowerment

After detailed review and reflection of the themes that emerged from the data, the overarching theme of empowerment became clear. As all five focus groups reflected on and discussed the meaning of CI competence, their ideas, examples, and stories pointed to their ability to empower themselves through intrinsic motivation, self-efficacy, and the capacity to facilitate positive outcomes in themselves and in their students. As mentors, role models, and providers of experiential learning, the CIs empowered students to succeed and become excellent physical therapists. Participants also indicated that the journey to competence enabled them to make a difference in the profession and helped them empower their students to do the same. The concept is illustrated in Figure 1, by empowerment surrounding the subthemes. The 2 components of empowerment, psychological and structural, are defined and described in the discussion.

Figure 1.: Illustrates the meaning of competence as a central point influenced by the surrounding subthemes and the overarching theme of empowerment. The new CI enters the circle and is affected by structural and psychological empowerment as they make their way through the subthemes and ultimately leave as a competent CI with lifelong learning and empowerment continuing to be a part of competence.

Subtheme 1: The Meaning of Competence

To capture the meaning of the journey to CI competence from the participants' perspectives, the primary researcher asked, “What is the meaning of competence as a CI?” and probed deeper with prompts such as “Describe an experience where you recognized yourself as a competent CI.” Participants' descriptions revealed 6 roles of the competent CI and the skills and characteristics within each role. The 6 roles included being a skilled clinician, teacher, mentor, reflective learner, collaborator, and effective communicator (Figure 2).

Figure 2.: Theme 1, the meaning of competence as perceived by clinical instructors in this study comprised of 6 roles including the skills and characteristics within each role, of the competent clinical instructor.

Skilled Clinician

Many participants discussed the importance of first becoming a confident skilled clinician, before one could be considered a competent CI. At a minimum, the skilled clinician must have competence in examination, evaluation, diagnosis, prognosis, interventions, outcomes, documentation, and billing.

[The CI would] Have to have understanding of anatomy, physiology, neuro, ortho etc. to teach and help students grow. … to have a good understanding of current position, documentation, billing, to a level that can be taught to others. (P20)

A few participants, however, felt that being a competent clinician did not necessarily imply the person would be a competent CI.

I think it's important for the CI to be competent as a clinician although that doesn't always translate into being a good CI but you have to be competent as a clinician to be a good CI. (P18)

Teacher

According to all participants, being a skilled teacher was also essential to be a competent CI. Competent CIs have a desire to teach, despite the challenges they face.

Additionally, a competent CI will be looking to take on students regularly to expand their ability to learn different learning styles. (P18)

They are knowledgeable about academic programs and their evaluation tools.

…self-directed learning using the [Clinical Performance Instrument] and appendices as guidelines. Knowing what is expected by the university and knowing the students' class/clinical background are also crucial to being a competent CI (P25)

Competent CIs are proactive in their approach to teaching and planning learning experiences and fostering critical thinking skills; and teaching reflection while fostering a safe and structured learning environment that permits questions and mistakes within the boundaries of patient safety.

I really like what [P8] does with his first day with a new student. He tells them everything he expects from them. He gives them an overview of the clinical, everything from expecting the in-service and so on and it's very good. (P10)

I always let them observe first, gather questions if they have and you sit down together and then answer those questions. That way they are prepared in knowing what to expect from certain kinds of diagnoses. If there's something totally more complex then you're always there to guide them or to help them out with their thought process with providing treatment techniques, and what can be altered. But providing a very good observation situation is very very important I feel without which they wouldn’t be able to grasp as to how much to proceed or what can be done. (P9)

In this safe learning environment, the teacher also challenges the student to grow professionally and improve their skills.

…to provide learning opportunities and experiences that challenge those strengths and weaknesses as well. To recognize them but to also structure a learning environment that allows them to improve their weaknesses but then also challenge their strengths. (P26)

Teachers identify their students' learning styles, personality differences, and needs, establish individualized plans, and adjust those plans as the need arises.

We all have preferred learning styles, too, but we have to assess and figure out with our student what their best learning styles are … then they need to also be able to interpret that for their patients, and how am I going to teach them? How are they going to learn best? So there is definitely a trifecta there! (P13)

I think understanding different personalities, … there may be something you see as different or not the way that you would do, that doesn't necessarily mean that it's wrong … try to understand that and adjust accordingly. (P28)

Mentor

Numerous participants described the competent CI as a mentor, leading by example in advocating for the profession, conducting themselves professionally, and modeling teamwork. They act as a coach, inspire students, and are dedicated to maintaining the quality of future professionals, despite the investment of time required.

As a CI we have the important role of preparing the future professional of our profession to ensure we are building our profession up and assisting in providing competent Physical Therapists for the future. (P4)

It is very personal, it takes increased work outside of the clinic………. My first third year student, so they were here for a longer period of time, we could really establish short and long term goals. She wasn't very confident in orthopedic physical therapy so we spent time at the end of each week practicing different techniques with her and then by the final she had met those goals that we had established along the way for very specific orthopedic techniques and skills. I thought that was good. [The] feedback to me [from the student]: taking the extra time goes a long way and practicing with her made a big difference and she felt a lot better about orthopedic physical therapy after that. (P24)

They also foster autonomy by allowing students to develop their own style and way of practice, not expecting them to “be like me.”

I think something is you're teaching them how to be a physical therapist, not you [several “yes” affirmations from the group], you're not teaching them how to do everything how you would do it—which is hard to let that go but I think that's what makes somebody a little bit more competent is realizing that you're teaching them thinking skills, thinking strategies, clinical decision-making in a clinical setting, not well, what would my CI do? (…) how would my instructor do this? (P12)

I don't think you would be a competent CI if your student was saying, “Well you know these are the exercises that my CI would have you do.” You know I think it's good with every student that we have, we end up learning a little bit, something like a new activity to do with a patient that I hadn't thought of because you don't want your student just to mimic you [several ”yeah” affirmations from the group] you want them to—you want to give them the tools to think for themselves. (P14)

Reflective Learner

Participants described the competent CI as a reflective learner, one who seeks to learn from experiences, students, colleagues, and professional development courses by reflecting on those experiences and using that reflection as a process of improvement. They are teachable themselves and they recognize their limitations.

The students were giving me feedback either at the mid-term or sometimes the final, and I kept trying to adjust accordingly. And granted, (…) obviously they're not all the same. But if I started hearing something repeatedly, then I realized ok, this is an area of weakness for me, and I need to alter this to be helpful to future students. Some of it you recognize is just an individual style, but a lot of times there is a pattern. So I kept having to adjust as I went along thinking ok, I know I'm not very organized but it's important to students. So that helped. (P3)

Collaborator

The participants in this study described the competent CI as a collaborator, someone who builds relationships with colleagues, students, and academic institutions in an effort to ensure student success. They work together as teams, sharing the responsibility of mentoring students, allowing them, as instructors, to learn from one another, and model collaboration to the student. With academic programs, they work with the programs to meet the students' needs, especially when they face challenges. In addition, they intentionally include the student in developing a plan for the students' success.

…neither of us is able to take on a fulltime CI role and so we always share and that's been a great learning experience, like you were saying just talk things through together about how we're going to do it and learn from each other. (P1)

I think the [Academic Coordinator of Clinical Education] have good resources too and are helpful (…) whether it's just (…) a phone call or other resources that they can sometimes provide. I think they're a good partner (…). (P27)

Goal-setting is important. We have to set goals, teach the student how to set goals for their patients, but especially teach to students themselves. And that's a collaborative thing. (P1)

Effective Communicator

Competent CIs, according to the participants, are also effective communicators who communicate their expectations to the student, keep open lines of communication with the student, and provide feedback on performance, whether positive or negative.

As the student follows the instructor's example, the CI must give the student adequate feedback and constructive criticism and maintain a constant and open dialogue with the student to keep them on track. (P8)

I think competence as a clinical instructor (…) you have to be ok with saying the hard stuff to guide somebody, you can't sugarcoat it and you can't really be their friend, you have to be willing to let them know your clinical decision. You have to be able to separate yourself from that to (…) be objective. (…) you can't just sugar-coat it for them to build them up and hold their hand. You're not there to tear them down either. Competence is knowing the difference between the two and then finding the balance. (P12)

While the first subtheme focused on the meaning of competence, the remaining subthemes, 2–6, reveal the journey to competence as perceived by the CIs.

Subtheme 2: “My First Student”

When the primary researcher asked, “Tell me about your journey to becoming a competent CI,” participants reflected and each recounted how their journey started. This start was meaningful to them, because they all shared about their experience with the first student. Although each story was unique, there were similarities. Many of them described a positive start, one in which they were able to develop competence as a physical therapist or make a gradual entry into clinical teaching before becoming a CI. Some CIs started their journey by sharing students with another CI. Others began their CI experience by progressing from beginner to final clinical experiences, Physical Therapist Assistant (PTA) to PT students, or by filling in for the primary CI for a few days. Participants felt this progression contributed to their competence.

There wasn't a ton of clinical instructing that I had done prior to that other than just helping on off-days of other therapists. But I feel like overall two years of experience I'm not saying I had all the preparedness I needed and I obviously was nervous but I think you always will be until you do it but, I think I was at a good point and I am learning. Obviously I can learn more but with two years of experience I was feeling more and more confident as a clinician. So I think I was at a good point to help me, too. (P19)

When I was comfortable and I thought I'm ok I can guide, I just wanted to start to have students, I started to share students with [one CI or another CI] Then I started to learn (…) but again I had shared [with another CI] so I had some experience from them, I learned from them. (P22)

I started taking PT Assistant students first. And then I would take the short two or three-week PT students – their first couple years. And then I progressed up to taking final year PT students. So that was over like three or four or five years. (P10)

Other clinicians, who had been CIs for more than 15 years, shared their journeys' start as a “sink-or-swim” type of experience in which they were thrown into being a CI, often because there was no one else willing to do the job. They also recounted the fact that they did not have 1 year of experience as a physical therapist or any training before instructing their first student.

I had trial by fire. I was out of school for six months when I had my first student. And there was no orientation; there was nothing. “Here's a student, they're here for eight weeks.” (P2)

My initial experience being a CI was not good because I hadn't even been out of school for I think six months when I was given my first student. … I needed to be confident as a clinician first before I felt I could be confident as an instructor, cause you don't really feel like you've got your feet under you. My first couple students were probably not the best students they could have possibly presented to me. I should have failed them, but I didn't know that at the time. (P21)

Subtheme 3: Finding the Way

Just as the start of the journey was unique yet comparable, so was the continued pathway to competence. Regardless of the journey, all participants in this study shared that the pathway they traveled was filled with many teaching and learning experiences, which contributed to their competence in multiple ways.

Participants who experienced a “sink-or-swim” start to their CI journey reflected on building their competence upon their own experience as a student and what little clinical experience they had at that time.

I had my first students when I had just been out of school so I was able to draw on my own clinical experiences right off the bat. What worked, what didn't; I was able to glean from that and apply it….(P2)

Participants across the spectrum spoke of opportunities they had to learn from their experiences with students and described how they would apply this new insight to the next experience.

I may be confident in a lot of different ways but if it doesn't translate for the student then I feel I have been lacking in some aspect and those are the things I would certainly like to improve upon for the next student … (P9)

Most participants expressed a desire and need for good feedback from students so that they, as CIs, could understand where they needed improvement.

I guess I would echo too that you learn a lot from your students. …Especially I think earlier when I was a CI I learned a lot like at the final eval where it was like, ok, some of these things are making sense but it's too late now! But then it helps to apply those earlier…(P27)

Participants also conveyed that the support and lessons learned from colleagues and Site Coordinators of Clinical Education (SCCEs) were very influential in their journey.

Being able to ask … and even observe what they do with their students I think that's where I've learned a lot you know like oh, that's what [P27] does, that's what I want to do [laughter from the group] (P28)

A part of “finding the way” included the decision for or against CI credentialing. Some participants chose credentialing before taking their first student, others instructed a few students before becoming credentialed, and others who were not yet credentialed expressed their plan to become credentialed in the near future. Most of the participants with more than 10 years of experience as a CI became credentialed after being a CI for many students. Neither of the 2 noncredentialed CIs, with more than 20 years of CI experience, mentioned their plans of becoming credentialed. Follow-up with both of these CIs revealed that although they see the value of the course, they found benefit in other types of training, including in-services and continuing education courses focused on clinical education, and believed that their time and money were better spent on a clinically related continuing education course.

There are several reasons why I haven't gone to a CI credentialing course. I can totally appreciate the effort by APTA to try to standardize CI requirements. And, of course, I am all for training, that is important for growth……. There have been restrictions in educational allowance. I think we get $500 right now. At times, we haven't been allotted anything. So, I would rather use it for a course that is clinically based. I take one student a year so although I enjoy doing that, it is a relatively small part of my practice. (P3)

All but one of the participants felt that the Credentialed Clinical Instructor Program (CCIP) course was helpful in their journey and that it gave them tools they could use immediately and reference in the future.

I think after I did that class [CCIP] it helped me think of this whole experience as more objective and less emotional, before that it would be a lot of emotions, … it was just more clarity of like what should be the communication … system and … expectations, both from the student and from my side. What they are expecting what I am expecting. So things became a little bit more objective and that helped me bring my own emotions down a little bit. So that helped me. And I think honestly that was my biggest gain from that class; I was able to think the whole process out a little bit better. And I'm not the most organized person so for me to get that was kind of big. (P23)

While “finding the way”, clinical instructors began to build “confidence” even when faced with “barriers to achieving competence.” These experiences further shaped the meaning of competence.

Subtheme 4: Barriers to Achieving Competence

All participants in this study identified obstacles that interfered with or prohibited their ability to perform as a competent CI or at a level they desired, and these barriers are symbolized in Figure 1 by the word barrier between several themes. Some examples include limited knowledge of the academic program's expectations, curricular changes, availability of resources, academic preparation of students, length of clinical experiences, lack of warning before being assigned to “problem” students, and limited communication from programs on students' personalities and learning styles.

[The school sends] an email that tells you everything that the person has learned but it's been now ten years since you graduated and trying to remember what all those courses mean, sometimes … I wish they would just come and give us a brief overview of what they are presenting in some of the classes. I guess there's times when you have a difficult student and then you do contact the facility and they know but they didn't bother to tell you and that's kind of frustrating because they actually might know good ways to [communicate] and I'm sure part of it is they don't want to bias you. But if they could help you figure out better ways to communicate or what some of those strengths and weaknesses are before they came then you could cater to those instead of figuring out at mid-term …. (P5).

One less experienced, noncredentialed participant seemed to see credentialing as a necessary part of becoming a competent CI. She implied that the availability and timing of the course was a barrier to becoming credentialed and therefore a barrier to being a competent CI.

For me … I feel like there are very few CI credentialing courses and the ones that … I found … were very far away and there was no way I was going to fly out to take a CI course especially when you are not reimbursed for it, so it's for your own personal gain and I feel a little renegade having a student without having that right now because I feel like maybe I'm supposed to have had that… (P12)

Some participants indicated that the volume of patients and limited variety of diagnoses can negatively impact their ability to provide students with good learning experiences.

I've definitely apologized to my students because 80% of my caseload is geriatrics so that's something that's out of my control. … it's not a very diverse orthopedic clinical. It's definitely one of my barriers. (P25)

Most participants also expressed limited time was an obstacle to achieving competence. They discussed the continuous burden of productivity demands leaves them with inadequate time to teach effectively. Many also shared frustrations about the time it takes to complete the Clinical Performance Instrument.

I had weekly worksheets that I had to complete and we'd meet for at least an hour every week and I feel like I have gone away from that because of productivity and I think that is very sad [sounds of agreement- “mmm” and “yeah” from group]…. (P14)

[CPI] would be a barrier. I mean, we don't have any choice and I love having students. So I go for it but I would certainly like it to be a lot more concise to be able to focus on specific points rather than so much more in detail and then be able to focus more on treatment aspect that would certainly be very very helpful. (P9)

Subtheme 5: Confidence

When the primary researcher asked, “When did you first acknowledge yourself as competent?” participants in each focus group responded similarly: with laughs that sounded insecure or comments such as “I never have.” The less experienced CIs were not the only ones who seemed to question their competence. Even participants with more than 15 years of experience made comments that revealed their own struggles with the question of competence.

I tend to think everything I know is just common sense and everybody should know it but when a student shows up and they know so little, I'm like “wow I do have things that I can teach them” [laughter from all]… We know we're competent when [Interviewer] comes to interview us [laughter from all] (P10)

I don't think I've ever felt that way! I've been doing it for a long time. (P3)

Even though many expressed concerns about competence, they still shared their “ah-ha” moments, which were moments when they realized they were moving toward competence. As the interviewer probed deeper into the idea of being competent, she asked participants to describe an experience where they acknowledged that they were competent as a CI. Nearly all participants shared experiences in which their competence was confirmed, most often by students, peers, and Directors of Clinical Education (DCE), as well as through self-reflection. Confidence stemmed from their experiences including the continued desire to learn.

my “ah-ha moment” was, … that I got a call and [DCE] asked me to take a student that was failing other places and I thought to myself, well number one, they're either really desperate and they're just taking anything they can get or they think I'm ok at this so maybe I'm ok at this (laughs). I'm going to stick with that story. (P21)

I guess positive feedback from a DCE with a student I had last year, … she said, oh, I just wanted to really thank you for giving the student a great experience, she's really had an awesome time and you know just saying nothing but good things of how I did. And I was like, oh, I guess I did a good job then …(P20)

Subtheme 6: Lifelong Learning

No matter how participants' journeys began, the training they had, the obstacles they overcame, or their current level of perceived competence, a common thread across focus groups was the understanding that the road to competence as a CI was a lifelong journey. They felt that there was always more to learn, in part, due to the ever-changing knowledge base and uniqueness of each student, which fueled their desire to continue to learn and pursue growth as CIs.

… the more you learn the more you realize you don't know because there is always just so much to learn about..(P1)

… Will I ever get to the point that I'll say yeah, I'm a good competent CI—I don't think so cause I agree with [P3], it's always a challenge what the next student will bring to you. And I think that's just part of the learning in education cause if you get complacent….I don't think it's beneficial to your student. (P4)

You know you start with a clean slate with every new student so it's almost like you're re-establishing your competency with every student that comes…(P27)

Conceptual Framework

Figure 1 is a visual representation of the results. The new CI enters the journey to competence surrounded by structural and psychological empowerment in each phase of the journey. Structural empowerment included positive and/or negative circumstances with proper or limited access to resources, information, and opportunities. Psychological empowerment included the individual's self-efficacy and intrinsic motivation. The meaning of competence is at the center of the experience and is impacted by the 4 surrounding subthemes and the overarching theme of empowerment. Between each of the subthemes are the word barriers which symbolize the “barriers to achieving competence.” This represents the participant's perception that barriers to competence were present throughout the journey. The CI exits the experience as a competent CI with lifelong learning, continuing to influence CI competence.

DISCUSSION

The understanding gained from this study supports current literature, while informing practice, education, and future research from the perspectives of the CIs who participated in this study. The results fill the gap in the literature by informing CIs striving for effectiveness in teaching through revealing the meaning of competence and a variety of pathways to achieve competence. Those who train CIs can tailor their training to include descriptions of the journey to and the meaning of competence to broaden the trainees' understanding of competence as a CI. These examples may be helpful for those who select CIs by bringing a deeper awareness of the value of providing support for CIs and an enriched understanding of the meaning of competence, which can assist in selecting competent CIs. These findings may assist the professional bodies, such as the APTA, ACAPT, and the Academy of Physical Therapy Education, to define CI competence and determine CI development best practice.

Encircled by Empowerment

Encircling CIs with experiences that are supported by positive structural and psychological empowerment may be a key to success. Findings in this study revealed 2 elements of empowerment: structural empowerment and psychological empowerment.^41-43 Structural empowerment relates to employees' access to opportunity, resources, information, and support in the work environment. The level of structural empowerment has been found to either optimize or constrain employees' job performance.^41,44,45 A lower risk of burnout among nurses has been found in those who scored higher in both structural and psychological empowerment scales.⁴⁶ In this study, CIs reported the impact of structural empowerment in their descriptions of employment settings, which included either positive structural empowerment or a lack thereof. Within the subthemes of my first student subtheme, in the positive empowerment situations, CIs were allowed to develop competence as a clinician before becoming a CI. Comparatively, in situations with a lack of structural empowerment, others felt thrown into the situation without support. Within my first student, finding the way and lifelong learning subthemes, colleagues and SCCEs also contributed to participants' CI competence by acting as resources and providing structural empowerment. Other components of positive structural empowerment were continuing professional development, including the APTA CCIP. Conversely, lack of support from academic programs and employers negatively affected structural empowerment and were therefore barriers to competence.

Psychological empowerment relates to the individual's self-efficacy, or intrinsic belief in one's ability to complete a task, as well as the capacity and motivation to take action.^47,48 In this study, psychological empowerment was threaded throughout all subthemes. Clinical instructors demonstrated intrinsic motivation by empowering students through providing opportunities for them to learn, grow, and build confidence in their own skills. Clinical instructors embodied empowerment through behaviors, such as sharing information, creating a safe learning environment, and fostering autonomy and critical thinking through teaching strategies leading to confidence. These practices are supported by Clouder and Adefila,⁴⁹ who recently discovered an empowerment cycle in which physiotherapist clinical educators empowered students through increasing responsibility, giving feedback, and establishing trust. Future research should include a deeper exploration of the role the construct of empowerment plays in CI development.

Clinical Instructor Competence

Findings in this study support the current evidence that effective characteristics of CIs include qualities, not necessarily credentials,^{5,16,19,20,23,50-62} and these qualities are akin to the APTA CI guidelines.⁴ In this study, participants described a competent CI as a skilled clinician, teacher, mentor, reflective learner, collaborator, and communicator (Figure 2). Participants indicated that competence in clinical skills is a prerequisite to competence as a CI. This finding concurs with other authors who assert the importance of CIs demonstrating skilled clinical practice by providing patient-focused care that is outcomes-oriented and evidence-based. This use of an evidence-based practice demonstrates a commitment to lifelong learning, which helps their students develop a clinical rationale for treatment while integrating current research.⁶³

Pedagogical skills combined with clinical competence have been found to positively influence students.⁶⁴ Not surprisingly, participants stated that being a teacher is the primary role of a CI. This finding echoes many other studies on effective teaching behaviors, including the need to have a sincere desire to teach and knowledge of the content, as well as the ability to establish a safe and caring learning environment, foster critical thinking skills, teach reflection and self-assessment, and evaluate and assess students' performance.^{5,16,19,20,23,50-61,65} Participants in this study indicated that customizing the teaching approach according to student needs and personality differences is essential. This need for flexibility in teaching style, according to student learning style and situational needs, was exhibited by the exemplary CI²³ and supported by other authors.^22,50,66,67 Data analysis revealed that, consistent with other published findings, competent teachers adapt the level of questioning to keep students engaged.^{5,16,23,58,68}

Finally, in teaching practices, just as Buccieri et al¹⁸ found in their study of the expert CI, participants in this study approached problem solving with a strategy analogous to the APTA Patient Client Management Model found in the Guide to PT Practice.⁶⁹ This analogy was evidenced by participants' description of performing examination and evaluation of the students' learning styles and performance, developing a diagnosis for the learning needs including strengths and weaknesses, establishing a prognosis by setting goals with the student and evaluating their teaching technique, applying teaching interventions, adjusting instructional methodology as needed, and finally, reviewing the outcomes of the entire clinical education experience.

Data analysis suggests that the CIs roles of mentor, reflective learner, collaborator, and effective communicator parallel APTA core values.⁷⁰ As mentor, participants shared examples of characteristics synonymous with the core values of Altruism, Integrity, and Professional Duty. The core values of Accountability and Excellence correlate with competent CIs who assumed responsibility for their own learning and who recognized and understood their personal limitations. Excellence was also exemplified in the competency of the collaborator through collaborative practices to promote high quality outcomes. Finally, as an effective communicator, CIs demonstrated elements of accountability, as well as compassion and caring core values, by effectively communicating with stakeholders and creating a caring environment through thoughtful communication. Social responsibility was the only core value not directly supported by the data in this study. The importance of modeling APTA Core Values as a demonstration of professionalism is also promoted in a position paper on the essential characteristics of quality clinical education.⁵ Overall, the qualities shared by participants in this study imply that competent CIs embody the APTA core values and exhibit specific characteristics and skills in their role as a clinician and teacher.

Strategies for a Successful Journey to Competence

While participants achieved competence using a variety of different pathways, all benefited from a supportive environment at some point in their journey. Clinical instructors sought and received support from colleagues, SCCEs, and DCEs, as well as training resources; however, none of them mentioned the APTA open-access Internet CI development resources. Other studies have indicated consortia and DCEs are essential sources of support for CI development^5,71 and their role also includes raising awareness amongst CIs of the development resources.^5,71 CIs have benefited from access to a supportive academic faculty in the form of instruction and feedback during student teaching experiences.^72,73 This connection at the onset of a CIs experience would contribute to a supportive start and possibly prevent “trial-by-fire” experiences. Assigning a peer coach to new CIs may also be beneficial. Peer coaching experiences have been found to be effective with students, resulting in a broader range of hypotheses, thoughts, more confidence, and less anxiety.⁷⁴ Findings in this study indicate the CI must possess a willingness to learn by receiving feedback, accepting support, and using available resources for these components of support to be successful. The literature does support the move toward preparing students to be future CIs, so they have a foundation and knowledge of resources when they enter the workforce.⁶ Future research should consider exploring education models that include fostering mentorship experiences for students, both receiving and directing, with the intention of laying the groundwork for becoming CIs in the future.

The findings in this study also support the inconclusive nature of the effect of APTA CI credentialing found in a systematic review of quality in clinical education.⁷⁵ Most CIs in this study believed credentialing was beneficial, but did not indicate when or whether there was an optimal time to become credentialed. Two of the very experienced CIs chose not to become credentialed as they preferred to use their limited continuing education funds for clinical courses and only one CI stated credentialing should be required. Yet, Best Practice in Physical Therapist Clinical Education Task Force addressed a perceived need to provide an infrastructure that mandates CI training, certification, and recertification.¹ Perhaps an individualized development plan similar to the Milestone Development Pathway⁷⁶ should be considered. This pathway⁷⁶ was developed for the purpose of customizing professional development with nurses while taking into account the unique nature of the setting and CI. Future research with individualized pathway plans is warranted, particularly because there was not one specific pathway found in this study.

Limitations

All participants were practicing in the Midwest region of the United States at the time of this study, which limits generalizability to other regions in the country. The primary researcher's familiarity with the participants may have caused the CIs to refrain from full disclosure due to potential judgment on her part. She made attempts to minimize this possibility with opening remarks indicating she was there to learn from them. Each participant understood his or her right to withdraw from the study at any time, without prejudice. The wording used in the interview question “When did you acknowledge to yourself that you were a competent CI?” made the assumption that all participants were already competent, which may not have been accurate considering 17% of the participants had 0–2 years of experience and 17% of participants had 0–2 students in their career. Competence was not an inclusion criteria. Although this assumption may have influenced participants' replies, the primary researcher dually noted participants' hesitation to call themselves competent. Finally, the primary researcher performed all the data collection and analysis making attempts to minimize this limitation through triangulation of data, peer debriefing, and reflexive journaling (Table 4).

CONCLUSION

The competent CI personifies a skilled clinician, teacher, mentor, reflective learner, collaborator, and effective communicator. The CI's journey to competence includes a variety of methods for achieving competence, including self-directed learning, reflection, formal training, informal training, and mentorship from colleagues. All CIs in this study were faced with challenges and barriers in their journey including the lingering question of competence. The concept of empowerment played a role in their experiences and perception of the meaning of competence. Clinical instructors can use these findings to broaden their understanding of CI competence and, thus, inform their own pathway to competence. Continuing to include these primary stakeholders, both credentialed and noncredentialed CIs, in the discussion on best practice in clinical education is justified, especially since some may not be active APTA members and have limited knowledge of available resources, limited time and funds to attend conferences like the Education Leadership Conference, and have limited access to journals containing the current evidence in clinical education. Thus, it is imperative that professional bodies and educational programs, inform, educate, and solicit feedback from CIs by formal and informal methods so their collective voice may be part of shaping the ideals of best practice in clinical education. Testing these findings of CI competence in future research against a broader audience of CIs is vital to ensure their perspective is broadly represented in the quest for best practice.