Lindy McAllister, FSPAA, M.A.
Charles Stuart University
In considering where we are going with clinical education, this paper asks three major questions: (a) where we are now? (b) where might we want to be and why? and (c) what theoretical and philosophical frameworks might we use to guide us in new directions? I will consider each of these in turn.
Where are We Now with Clinical Education?
The specialization of clinical education is dealing with many issues that affect the structure, objectives, and content of clinical education programs. These issues include public expectations of graduates, rapidly changing workplaces, employer expectations of graduates, and diverse student cohorts. In addition, we need to critique currently held restricted views of supervision and constrained interactions between clinical educators and students.
Public expectations of health science graduates have changed considerably in recent years, concurrent with the shift from medical models of service to the new public health, client-centered services, and family-based practice. In making these shifts in service delivery models, speech-language pathologists (SLPs) and audiologists are taking on new roles of educating, promoting health, enabling, and client and service advocacy. To implement these roles effectively requires excellent interpersonal, team and communication skills, and professional artistry (Fish & Coles, 1998).
Our workplaces are changing at a rapid rate due to economic rationalism and managerialist approaches to the provision of health, welfare, and educational services. The globalization of health care, the application of information technology to tele-health, and changing clinical populations (Pickering & McAllister, 1997) have altered the nature, location, and manner of delivery of health care. We work in uncertain and complex environments and deal daily with ethical dilemmas and what Schon (1987) called the gray areas of practice.
Employer expectations have changed in line with changed workplaces. Carney and Goldsmith (1999) highlighted the gap in expectations between educators and CFY supervisors regarding educational outcomes for SLP graduates. An Australian study (Adamson, Harris, Hunt, & Heard, 1996) similarly highlighted discrepancies in expectations of generic skills. This study showed that employers now expect graduates to:
Diverse Student Cohorts
Meeting the educational expectations and needs of our increasingly diverse
student cohorts also poses significant challenges (Pickering & McAllister,
1997). According to the Chronicle of Higher Education Almanac (1995)
40% of the US student population is over age 25, 23% are minority Americans,
and there are significant numbers of part-time enrollments. There
was a 26.3% growth in Hispanic and Asian American enrollments between 1990
and 1995 (Carter & Wilson, 1995), and according to Henderson (1995),
there were some 800,000 students with disabilities in American universities
in 1992-1993. These trends have continued and their management requires
creative responses from clinical education programs.
Restricted Views of Clinical Education
In considering where we are with clinical education, we also need to critique what I suggest are restricted views of clinical education. Part of this narrow view is evident in the persistence of the term supervision. A quick look at the semantics reveals a supervisor to be "a person who exercises general direction or control over a business, a body of workmen etc.; one who inspects and directs the work of others" (Oxford English Dictionary, 1992). There are connotations of overseeing, and compliance with prescribed standards, not a scenario congruent with our rapidly changing workplaces. Further, such a term is more congruent with apprenticeship models of training rather than the education of professionals.
Constrained Interactions between Clinical Educators and Students
Such a restricted view of clinical education impacts on the achievement
of goals of clinical education. We aspire to "professional growth
and development of the supervisee and the supervisor, which it is assumed
will result ultimately in optimal service to clients" (Anderson, 1988,
p. 12) and "to prepare professionally competent individuals ... capable
of self-analyzing, self-evaluating, and independent problem-solving" (Casey,
Smith, & Ulrich, 1988, p.5). However, we often fall short of
these outcomes, as summarized by Anderson (1988):
The supervisor assumes a dominant role, doing most of the talking, initiating and structuring most of the discussion, thereby setting the tone for the entire conference. Supervisor style will be much the same from one conference to another, regardless of the supervisee's experience, expertise or expectations. Supervisees are usually passive participants, seldom ask questions, initiate a topic, or ask for justification of supervisory statements. Instead they react and respond to supervisors. Their
responses tend to be short, most likely agreeing with the supervisor. [Their] needs for indirect behavior from the supervisor and for their own participation are probably not met. As with supervisors, supervisees utilize simple utterances without justification or rationalization and they do not provide reinforcement for the supervisor. (pp. 28-29)
Australian clinical education research has revealed similar patterns (Joshi & McAllister, 1998; Kenny & McAllister, 1996).
However, a number of major reasons for these restricted interactions between clinical educators and students can be postulated. Firstly, there still appears to be a focus on the transmission of what Cranton (1998) has called instrumental knowledge, meaning propositional or textbook knowledge. There is not enough emphasis on the facilitation of what Cranton (1998) refers to as communicative knowledge (i.e., jointly constructed practical knowledge) and, I would suggest, virtually no attempt to foster emancipatory learning (Cranton, 1998) or critical knowledge interests (Habermas, 1971). To advance the profession in our workplaces of constant change and uncertainty requires graduates who can critique and be proactive with change rather than merely comply.
I would suggest further that our restricted approaches to clinical education apply because of the increasing shift to managerialism in supervision (for example, see the 13 tasks of supervision described by ASHA, 1985) and the shift away from humanistic orientations to our work. Clinical education in the earlier days of our profession was intensely humanistic in focus (for example, see the writings of Caracciolo, Rigrodsky & Morrison, 1978a, 1978b; Ward & Webster, 1965a, 1965b). One of the most commonly used models of clinical supervision in SLP, Anderson's (1988) Supervisory Continuum, was based on the work of scholars and educators such as Blumberg (1980), Cogan (1973), Goldhammer (1969), Goldhammer, Anderson and Krajewski (1980) who focused on the interpersonal domain of education and supervision. Early speech-language pathologists also recognized this profoundly interpersonal nature of clinical education. Erickson and Van Riper (1967) believed that "in training clinicians we not only teach; we also nurture" (p. 33).
Clinical education is, or should be, an essentially person-focused process. Knowing oneself as a clinical educator, and in turn helping students to know themselves are key aspects of our work as clinical educators. Ward and Webster (1965b) insisted that supervisors clarify their views of themselves as teachers, supervisors, and members of the profession. Further, clinical educators must help students to "merge who they are personally with whom they are becoming professionally" (Pickering, 1987b, pp. 108-109). However, in contemporary policies and literature regarding clinical education, few emphasize the human encounter. Rather, they are more likely to emphasize counting hours and other aspects of the management of clinical placements and clinical services. I believe that in the current climate of accountability, the dialogue of the interpersonal has been silenced.
This section has reviewed some factors shaping where we now are with clinical education, noting changed workplaces and expectations, and restricted views and practices in clinical education. The next section considers where we might want to go with clinical education.
Where Do We Want to Be?
In order to meet changing workplace and student expectations and to become more effective, I propose that we need to take some big steps forward in how we view ourselves and how we act. In this section I outline two directions for change: new goals for clinical education, and a new name for ourselves which better reflects the nature of our endeavors with students.
New Goals for Clinical Education
The interactional professional. Higgs and Hunt (1999) have proposed that a goal of clinical education might be the development of what they term the interactional professional. The interactional professional demonstrates technical competence (generic and discipline specific), interpersonal competence, an ability to interact with and change the context of practice, and professional responsibility in serving and enhancing society. These last two attributes extend the traditional view of competence in new graduates and are congruent with contemporary workplace demands for the ability to survive and respond to constant change. However, an interactional professional would also have a critical view (as per Habermas, 1971 and Cranton, 1998) of the workplace and professional practice and strive not just to respond to change but to direct it for the good of clients, professionals and society. An interactional professional would also have the ability to work in changing and uncertain contexts called for by Schon (1987).
Professional artistry. Fish and Coles (1998) have written extensively about the need to develop professional artistry in health professionals. Professional artistry "takes a view of practice as complex, holistic and creative, with an interpretive attention to details and complexities of practice. Frameworks and rules of thumb, rather than rules are utilized. Both means and ends of practice are valued. Moral and professional judgment and accountability for judgements are highlighted" (McAllister, in progress). Professional artistry requires reflective practice (Schon, 1987) and uses professional craft knowledge, personal practical knowledge as well as propositional knowledge (Higgs & Titchen, 2000). Clinical reasoning (McAllister & Rose, 2000) can be seen as a part of professional artistry. The development and exercise of professional artistry enables work in uncertain work contexts and in the gray areas of practice (Schon, 1987), now a regular feature of our workplaces.
The life-long learner. Another goal for clinical education programs might be to facilitate the development of life-long learners. Candy, Crebert and O'Leary (1994) profiled life-long learners as having:
It is important to note that Candy et al. call for the development of personal agency. This is congruent with my call for a return to humanistic approaches in our clinical education interactions. Personal agency is developed in relationship with others, and clinical educators are a powerful other in students' development. A sense of personal agency can also be promoted through encouraging students to develop and use their personal practical knowledge and professional craft knowledge, in addition to propositional knowledge.
A New Name
The semantics of our work do matter (McAllister, 1997). In an earlier section of this paper, I critiqued the use of the term supervisor as limiting both our vision and our actions. In contrast to supervision, education can be defined as the systematic instruction in preparation for the work of life; the process of nourishing or rearing; the process of bringing up; and culture or development of powers, formation of [intellectual or moral] character (OED, 1992). Further, "education frees a professional to operate appropriately in context, where training only expects the application of what has been learned" (Fish & Twinn, 1997, p. 15). A new name - clinical educator - would be more congruent with workplace expectations, and the new goals and humanistic approaches to clinical education outlined earlier. If we change the semantics we can begin to change our practices as clinical educators.
In this section I have outlined where we might go with clinical education and why I believe it is important to head in these directions. However, change of this order needs to be guided by some theoretical and philosophical frameworks. Some theoretical and philosophical frameworks that can serve as guideposts to new directions in clinical education are discussed in the next section.
Some Theoretical and Philosophical Guideposts to New Directions
An appreciation of systems theory is important in changing directions for clinical education, as is an understanding of how contemporary conceptual developments of systems theory can be helpful to us as clinical educators. I will also outline these as well as how adult learning theory can be applied in clinical education, and finally how these can be integrated with my call for a rediscovery of humanism in our work as clinical educators.
Farmer and Farmer (1989) suggested an understanding of systems theory
as important to the understanding and study of clinical education.
There are several extant systems theories but I find the CIPP model of
a system proposed by Stufflebeam (1983) to be useful in understanding the
flux and unpredictability of the clinical education system. In Stufflebeam's
C = context (in our case the clinical education context),
I = inputs,
P = processes and
P = products.
The inputs are the clients, students, clinical educators, educational experiences and client encounters, policies and so on. The processes are the encounters between students and clients, students and clinical educators, and students and peers, together with the learning processes such as experiential learning, reflection and self-evaluation that occur in the clinical context. The products in the clinical context are changes in clients, students and clinical educators in the form of enhanced competence, self-image and self-knowledge, as well as products such as reports and programs.
Clinical education programs are examples of open systems (von Bertalanffy, 1969) in that they are unpredictable and uncontrollable due to the human elements involved. Clinical education programs also are examples of soft systems in that the goals and outcomes are sometimes ambiguous and difficult to recognize (Checkland, 1981). Because of the open and soft nature of the clinical education system, inputs do not equal outputs. No matter how much we prescribe what should occur, in what quantities and in what time frames, we cannot ensure that the outputs we desire will be achieved. Rather than focus on inputs, we would be more likely to achieve the goals of clinical education if we focussed on processes, particularly the humanistic processes involved in our work as clinical educators.
While systems work most efficiently when there is congruence between all elements, in the clinical education context there always will be some degree of incongruity between inputs and outputs. Congruence, therefore, is probably not an achievable goal of clinical education systems, but rather something to be striven for. According to Torbert (1978), two behaviors -- acting authentically and paying attention - are important in striving for congruence. He suggests that we need a higher quality of attention that we usually use in our daily activities, and that through paying attention we can uncover incongruence, in our case between elements of a clinical education system. This notion of paying attention in action to uncover incongruence is resonant of the notion of Argyris and Schon (1976) of recognizing discrepancies between our espoused theory and our theory-in-action. When we pay attention to our theories of education revealed in our actions, we have a better chance of remedying incongruence and hence improving efficiencies and achieving enhanced learning outputs in the clinical education system.
Liberating Program Systems and Learner Task Maturity
Another way of striving for congruence can be to adopt what Torbert calls liberating program structure: "an ironic kind of leadership and organizational structure, which is simultaneously educative and productive, simultaneously controlling and freeing" (1978, p. 113). While this might work well in some learning systems, in clinical education programs, clinical educators have legal and moral responsibilities to clients, students and other stakeholders. There is a need to balance freedom and control. One way of doing this is to work with Higgs's (1993) concept of learner task maturity. This involves matching clinical educator support to students' maturity or competence for the task at hand. This means that with some students where maturity for the task is low, supervision (in the restricted sense of the word) will be appropriate. For other students where learner task maturity is high, education (as conceptualized earlier in this paper) is the more appropriate strategy to apply.
The application of this concept of learner task maturity in clinical education programs leads to the development of liberating program systems (Higgs, 1989). The concept of liberating program systems in clinical education provides means of conceptualizing and understanding professional socialization, the balancing of freedom versus control (i.e., education versus supervision), the dynamic state of flux of variables in the learning program and unpredictable outputs. These can then be planned for and monitored, with the increased likelihood that congruence will be achieved.
Adult Learning Theory
Another theoretical framework that can provide guideposts for changes in clinical education programs is adult learning theory. Adult learning theory as described by Knowles (1980) suggests that adult learners have certain characteristics, notably that they:
While clinical education programs can be structured around adult learning principles, there are particular provisos inherent in clinical education programs, needed to ensure client care. Adult clinical learners cannot be fully autonomous and self-directed in environments where mistakes might be dangerous to client well-being. This is where the concepts outlined above of liberating program systems, with the balancing of freedom and control, offer a way of adopting adult learning theory in the clinical context. A further useful concept in seeking to balance freedom and control is to think of the clinical educator as manager and co-manager with students of adult clinical learning programs (Higgs, 1993). For students with low task maturity, the clinical educator manages the clinical learning program tailored to meet individual student's needs and ensure client care. With more mature students, the clinical educator takes on a co-manager role with the students taking a larger role in self-directing their learning activities and independently pursuing tasks within their task maturity or competence level. (For a full description of roles, approaches and strategies within The Teacher-as-Manager Model see McLeod, Romanini, Cohn and Higgs, 1997.)
Lastly, I would like to suggest that we make a return to our humanistic origins. Humanism and person-focused approaches (Caracciolo, Rigrodsky & Morrison, 1978a, 1978b; Pickering, 1987a; Rogers, 1962; Ward & Webster, 1965a, 1965b) provide a philosophical framework highly congruent with new goals of clinical education (e.g., to facilitate the development of the interactional professional). Being sensitive to the person is important in adult learning approaches as adult clinical learners work best when tasks are congruent with self-concept (Brookfield, 1986). Such an approach requires a knowing of self and a knowing of others that moves beyond the superficial. Working as humanistic educators rather than supervisors we might be able to achieve Anderson's (1988) clinical education goal of personal and professional growth for student and clinical educator. Additionally, having self-knowledge should help offset the anxiety, loss of identity and self-confidence experienced in the transition from clinician to educator (Brammer, 1996; Ferguson, 1996; Lawler, 1985).
Self-knowledge is also important for understanding what drives the decisions and actions that clinical educators take. A sense of self was identified as the core concept in a phenomenological study of the experience of being a clinical educator in speech-language pathology (McAllister, in progress). In this study, I found that this sense of self determines our values as clinical educators, affects our relationships with our students and drives our decisions and actions. Our sense of self also impacts what I have called the meta-functions of education and supervision (McAllister, ibid.). Having self-knowledge and insights helps us as clinical educators to close the gap between our espoused theories of education and human development and our theories-in-action (Argyris & Schon, 1976), improving the efficiency of our educational endeavors in achieving the goals, outputs or competencies we desire for our students.
I believe it is time for reflection and critique of where we are with clinical education and why we seem stuck there, and where we want to be and why that presents a more desirable option. I have outlined the changed workplace expectations our graduates face, and restricted views and approaches to supervision. I have critiqued the managerialist approaches to our educational endeavors. I have suggested new goals for clinical education to meet changed expectations, and a new name for us, clinical educator, as I believe that education rather than supervision will help us meet new goals and expectations. Lastly, I have outlined how an expanded view of systems theory, incorporating the concept of liberating learning systems, together with the adoption of adult learning theory and a return to humanistic and person-focused approaches could provide the guideposts for new directions in clinical education.
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