Teaching Students in Clinical Settings (Therapy in Practice

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FORTHCOMING TITLES

Research Methods for Therapists

Avril Drummond

Group Work in Occupational Therapy

Linda Finlay

Stroke: Recovery and Rehabilitation

Polly Laidler

Caring for the Neurologically Damaged Adult

Ruth Nieuwenhuis

HIV and Aids Care

S. Singh and L. Cusack

Speech and Language Disorders in Children

Dilys A. Treharne

Spinal Cord Rehabilitation

Karen Whalley-Hammell
THERAPY IN PRACTICE SERIES

Edited by Jo Campling

This series of books is aimed at 'therapists' concemed with rehabilitation in a very

broad sense. The intended audience particularly includes occupational therapists,
physiotherapists and speech and language therapists, but many titles will also be of
interest to nurses, psychologists, medical staff, social workers, teachers or volunteer
workers. Some volumes are interdisciplinary, others are aimed at one particular
profession. All titles will be comprehensive but concise, and practical but with due
reference to relevant theory and evidence. They are not research monographs but
focus on professional practice, and will be of value to both students and qualified
personnei.

1.Occupational Therapy for Children with Disabilities

Dorothy E. Penso
2. Living Skills for Mentally Handicapped People
Christine Peck and Chia Swee Hong
3. Rehabilitation of the Older Patient
Edited by Amanda J. Squires
4. Physiotherapy and the Elderly Patient
Paul WagstaJf and Davis Coakley
5. Rehabilitation of the Severely Brain-Injured Adult
Edited by Ian Fussey and Gordon Muir Giles
6. Communication Problems in Elderly People
Rosemary Gravell
7. Occupational Therapy Practice in Psychiatry
Linda Finlay
8. Working with Bilingual Language Disability
Edited by Deirdre M. Duncan
9. Counselling Skills for Health Professionals
Philip Burnard
10. Teaching Interpersonal Skills
A handbook of experiential leaming for health professionals
Philip Burnard
11. Occupational Therapy for Stroke Rehabilitation
Simon B.N. Thompson and Maryanne Morgan
12. Assessing Physically Disabled People at Home
Kathy Maczka
13. Acute Head Injury
Practical management in rehabilitation
Ruth Gamer
14. Practical Physiotherapy with Older People
Lucinda Smyth et al.
15. Keyboard, Graphie and Handwriting Skills
Helping people with motor disabilities
Dorothy E. Penso
16. Community Occupational Therapy with Mentally Handieapped Adults
Debbie Isaac
17. Autism
Professional perspectives and practice
Edited by Kathryn Ellis
18. Multiple Sclerosis
Approaches to management
Edited by Lorraine De Souza
19. Occupational Therapy in Rheumatology
An holistic approach
Lynne Sandles
20. Breakdown of Speech
Causes and remediation
Nancy R. Milloy
21. Coping with Stress in the Health Professions
A practical guide
Philip Burnard
22. Speech and Communication Problems in Psychiatry
Rosemary Gravell and Jenny France
23. Limb Amputation
From aetiology to rehabilitaiton
Rosalind Harn and Leonard Cotton
24. Management in Occupational Therapy
Zielja B. Maslin
25. Rehabilitation in Parkinson's Disease
Edited by Francis I. Caird
26. Exercise Physiology for Health Professionals
Stephen R. Bird
27. Therapy for the Bum Patient
Annette Leveridge
28. Effective Communication Skills for Health Professionals
Philip Burnard
29. Ageing, Healthy and in Control
An alternative approach to maintaining the health of older people
Steve Scrutton
30. The Early Identification of Language Impairment in Children
Edited by Jarnes Law
31. An Introduction to Communication Disorders
Diana Syder
32. Writing for Health Professionals
A manual for writers
Philip Burnard
33. Brain Injury Rehabilitation
A neuro-functional approach
Jo Clark-Wilson and Gordon Muir Giles
34. Living with Continuing Perceptuo-motor Difficulties
Theory and strategies to help children, adolescents and adults
Dorothy E. Penso
35. Psychology and Counselling for Health Professionals
Edited by Rowan Bayne and Paula Nicholson
36. Occupational Therapy for Orthopaedic Conditions
Dina Penrose
37. Teaching Students in Clinical Settings
Jackie Stengelhofen
Teaching Students in
Clinical Settings

Jackie Stengelhofen
Lecturer and Consultant in the education of health professionals and
in Speech and Language Pathology

Springer-Science+Business Media, B.V.

First edition 1993
© 1993 Jac1cie Stengelhofen
Originally published by Chapman & Hall in 1993.
Typeset in 10/12 Times by Mews Photosetting, Beckenham, Kent

ISBN 978-0-412-45250-5 ISBN 978-1-4899-2933-4 (eBook)

DOI 10.1007/978-1-4899-2933-4

Apart from any fair dea1ing for the purposes of research or private study, or
criticism or review, as permitted under the UK Copyright Designs and Patents
Act, 1988, this publication may not be reproduced, stored, or transmitted, in
any form or by any means, without the prior permission in writing of the
publishers, or in the case of reprographie reproduction only in accordance
with the terms of the Jicences issued by the Copyright Licensing Agency in
the UK, or in accordance with the terms of licences issued by the appropriate
Reproduction Rights Organization outside the UK. Enquiries concerning
reproduction outside the terms stated here should be sent to the publishers at
the London address printed on this page.
The publisher makes no representation, express or implied, with regard to
the accuracy of the information contained in this book and cannot accept any
legal responsibility or liability for any errors or omissions that may be made.
A catalogue record for this book is available from the British Library

8 Printed on permanent acid-free text paper, manufactured in accordance

with the proposed ANSI/NISO Z 39.48-199X and
ANSI Z 39.48-1984
For friends and colleagues in teaching, both in educational institutions
and clinical settings. In particular to Sandra Rowan for her wisdom and
support over many years, and to the students with whom we have had the
privilege to work.
 Contents

Contributors xi
Acknowledgements xiii
Preface xv

1 Issues in the preparation of health care professionals 1

2 Teaching and learning methods in the dassroom and dinic 22
3 The special job of teaching students in dinic 40
4 Preparing for working with students in dinic 62
5 Helping students to become independent 1earners and
professionals 90
6 Helping students develop insights arid skills in management 120
7 Feedback 153
8 The assessment of professional competence 180
9 Practical work experience: a review of the literature 198

Appendix A
A revised model of the elements of professional competence 219

Index 221
 Contributors

Jenny Eastwood, Principal Lecturer, School of Speech Pathology,

De Montfort University

Peter Richards, Head of School of Postgraduate Studies,

Faculty of Health and Social Sciences,
University of Central England, in Birmingham

Jane Whitehouse, Speech and Language Therapist, Nunnery Wood

Language Unit, Worcester and District Health Authority
 Acknowledgements

The material for this book has been developed mainly over the past 3 years,
in response to the needs of health professionals attending clinical teaching
courses. The efficacy of the teaching of students during periods of clinical
placements takes on particular importance in the context of quality assurance.
During this time it has been possible to share ideas with colleagues from many
fields. It has been arewarding experience to gather together the richness of
experience from clinicians attending these courses. Many gave their ideas
generously and encouraged me to continue with the preparation of this book.
Where possible the specific source of examples has been given in the text.
As this has not always been possible I would like to acknowledge the help
and support received from clinical teachers during courses in Dudley,
Hounslow and Spelthorne, Southampton and South East Hampshire, Swindon,
North and South Warwickshire, and Yorkshire Region as well as the clinical
teachers for the BSc Podiatry, and clinical colleages on the BSc Health Studies
courses at Birmingham Polytechnic.
During the preparation of the book colleagues have given of their help most
generously in commenting on a number of chapters; particular thanks are due
to Carolyn Leach, orthoptist; Celia Firmin, dietitian; Thelma Harvey, physio-
therapist; Linda Finlay, occupational therapist; and to Beryl Kellow, speech and
language therapist, for her comments on the chapter on management skills.
A special thanks to Cath McMaster who was the first district manager to
have the courage and vision to mount a multiprofessional course on clinical
teaching. It was a stimulating experience which encouraged me to mount further
courses and to prepare this book.
I want to thank especially the three contributors; Jenny Eastwood, Peter
Richards and Jane Whitehouse, for their support, encouragement and patience,
as well as for their excellent contributions.
Special thanks to Val Dinning who, in many ways, has helped me to the
end, and who painstakingly read the final stages of the manuscript.
 Preface

As part of the pre-registration education for students who intend to enter health
care work, periods of work experience are bullt into the curriculum. Students
are placed in work settings, generally termed clinical settings, for specified
periods, ranging from single days to extended periods of time. Ouring these
placements the students are 'supervised' by qualified staff whose first
responsibility is to the care of patients. It is therefore important that provi-
sion is made to support these clinicians in their role of teaching and super-
vising students.
Initiatives have therefore been taken to enhance clinicians' knowledge and
skills in the teaching process. The principles and procedures to be used in
the supervision and teaching of students are generic in nature and therefore
applicable to a number of fields. This book has been prepared for use by a
wide range of professionals in health fields. There is particular attention to
chiropody/podiatry, dietetics, occupational therapy, orthoptics, physiotherapy,
speech and language therapy and radiography, although the principles covered
are also applicable to a wider spectrum of professions. The content draws
on the experience of clinicians and teachers and will, it is hoped, help to
disseminate the good practice which already exists.
The aims of the book are: to examine the nature and value of supervised
work experience in a number of different fields; to familiarize the reader with
concepts related to the curriculum; to examine the roles and responsibilities
of the clinical teacher; to consider a range of teaching methods and examine
their appropriateness to teaching in clinical settings; to examine how receiv-
ing departments can prepare themselves for working with students; to consider
ways of helping students to become independent in their learning; to consider
ways of introducing management skills to students; to examine the nature
of and the ways of providing feedback to students; and to examine the methods
and difficulties of the assessment of practical work and its relationship to pro-
fessional competence.
xvi Preface

The value of a multiprofessional book on the topic of clinical teaching is

that it is, for the most part, free from the content of the particular fields for
which students are preparing. Thus, it allows the reader to concentrate on
the principles of teaching and leaming being discussed, rather than being con-
cemed about, for example, the nature of the condition being treated, the
appropriateness of treatment, etc., which are the paramount daily concems
of clinicians. At points in the text the reader is encouraged to apply the ideas
explored, to their own field, through specific examples, and then to generate
similar examples of their own. Such examples and other practical ideas are
'boxed' in the text, in order that they can be quickly retrieved. Furthermore,
in order to encourage this application, Chapters 1-8 include practical
suggestions for follow-up activities.
In the first chapter, a model of professional practice is considered. Courses
designed for students who are preparing for professional work are discussed
in relation to the consequences the design may have on both teachers and
leamers. Concepts oftheory and practice are considered; the model adopted
is one which views theory and practice as a continuum, with the thinking
nature of practice being viewed as of major importance. The teaching of theory
and practice cannot, therefore, be seen as separate; this has major implica-
tions for course design and student leaming. The second chapter examines
methods of teaching in general and, more specifically, the methods which
might be applicable to clinical teaching. Careful consideration is given to the
clinic as an environment for teaching and leaming. Chapter 3 explores the
role of the clinical teacher. At this point the reader is ready to consider in
detail ways of becoming prepared to receive a student into their department
or service, in Chapter 4. An awareness of student anxieties and expectations
is encouraged. As part of the preparation for working with students, teaching
and leaming styles and the interpersonal aspects of the teacher-student
interaction are considered.
Chapter 5 concentrates on procedures to be used while the student is on
placement. There is an examination of such aspects as, developing observa-
tion skills, teaching procedures and helping students to fit into the team. Chapter
6 concentrates on introducing students to management skills; this is seen as
an essential part of professional practice and it is therefore important for the
clinical teacher to heighten the student' s awareness of management procedures.
In Chapter 7 the important area of formative feedback is fully explored.
This is seen within the context of helping students to become independent
practitioners who are able to evaluate their own practice. The chapter also
includes an examination of the feedback which may take place when college
tutors visit students on placement. The nature, content and potential difficulties
of such visits are thoroughly considered. Following on from the chapter on
feedback, which is a formative process, the reader is taken on to summative
 Preface xvii

assessment of clinical competence. The final chapter consists of a literature

review on supervised work experience, thus placing the book within a firm
theoretical and research background as weH as providing an introduction to
the research literature for those readers who wish to explore the topic further.
It also enables all readers to see the subject of clinical teaching in a wider
academic and educational context.

Jackie Stengelhofen
 1

Issues in the preparation of health

care professionals

INTRODUCTION

This introductory chapter aims to set the scene for the rest of the volume.
General points are made about the nature of courses for health professionals
and the role of work experience within these courses. Patterns of placements
are outlined. There is a discussion on the nature oftheory and practice, which
is viewed as an essential starting point before clinical teaching is considered
further. The development of a model of professional practice is explored as
a basis for the consideration of those aspects of professionalisation which need
to be addressed in the context of students becoming professionals. There is
reference to the design of pre-registration courses and how these affect student
learning and dinical teaching.

THE SCOPE OF THE BOOK

Students enrolled on courses which have an outlet into work in health

care follow a curriculum which contains not only dassroom-based but
also 'dinic'-based learning experiences. The term 'dinic' in this book
will be used to indude all the settings in which health professionals work,
from community dinics to hospitals and schools. The literature on teaching
methods suitable for dassroom use is vast and covers teaching methods
such as lectures, seminars, tutorials, workshops and practicals. Although
the principles of some of these methods can be used when teaching and
learning takes place in the dinic, nevertheless clinical teaching needs are
somewhat different. There has been very little attention to the more specific
methods targetted at learning during periods of work experience undertaken
by students.
2 Issues in the preparation of health care professionals

The purpose of this book is to provide an introductory text for health care
professionals who are involved in teaching students, during the clinic-based
parts oftheir courses. The ideas explored will be relevant to the work ofthose
working with students in practical settings in the following fields:
• Chiropody
• Dietetics
• Occupational therapy
• Orthoptics
• Physiotherapy
• Radiography
• Speech and language therapists/pathologists
Examples will be given from the above disciplines, although it is hoped that
clinical psychologists, doctors, nurses and others rnay fmd that the principles
explored are relevant to their own fields. Indeed it is possible to apply the
principles across health and education, as Fish et al. (1989, 1991) have shown
in their comparison of methods used by supervisors of students in education
(teacher training) and health visiting.

COURSES ON CLINICAL TEACHING

Most of the health care groups, listed above, offer courses on clinical teaching
for their own practitioners who receive students for work experience. An
examination of the courses offered reveals some interesting features. Firstly
there has been a gradual shift away from the use of the term clinical super-
visor to clinical teacher, although such terms as clinical educator, clinical
instructor, clinical practice teacher, field work teacher/supervisor and clinical
tutor are also in use. Some of these terms are used to designate those staff
appointed by the educational institution to set up and monitor the work
experience; they are not the full-time clinicians who also teach students. The
other shift in terminology is from training to education. Secondly, the content
of courses, although containing a good deal on teaching methods, also allocates
considerable time to topics which are specific to the discipline or even to a
specific course within that discipline. Thirdly, the professions involved appear
to be at different stages in the development of these courses. Fourthly, the
principles of teaching and learning methods covered could be applied to clinical
teaching in all health care groups.
It would be unfortunate if the valuable experiences and forward thinking
of some professions were not disseminated to the other fields. The Health
Care Professions Education Forum established in the UK may help in this.
All professions offer support to clinicians who take responsibility for
students' clinical education and training. However, the provision is variable
 Courses on clinical teaching 3

in nature, length and status. In the UK, the College ofOccupational Therapists
has a well-developed sequential programme (Box 1.1). While in Dietetics,
where students spend 31 weeks in placement, a range of opportunities are
planned for clinicians (Box. 1.2).

Box 1.1 A sequential approach to clinical education. Adapted from information

from the Post-registration Studies Committee, College of Occupational Therapists
UK (1989)

1. Role of clinical education; appreciation of basic education theory.

Awareness of sources of information available to students. Under-
standing the learning objectives at each stage of training and the need
to identify the specific requirements of individual students.
2. Planning and implementing clinical education; planning and organiz-
ing field work within the supervisor's own clinical environment.
Recognizing and responding to needs and changes. Teaching and
assessment techniques. Evaluation and non-performance.

3. Management of learning; recognizing different ways in which attitudes,

cognitive and practical skills can be acquired. Applying selected tech-
niques to improve this understanding and performance of students and
staff. Assessment of students' performance.

4. Professional development; developing and evaluating opportunities for

learning. Observing self and others' progress and relating strategies and
outcomes to theories of learning and education. Planning programmes
for individual student's using a variety of settings and resources.
5. Curriculum design; being sufficiently familiar with professional
knowledge and skill, with education theory and the needs of students,
so that the supervisors can design curricula for professional educa-
tion at different levels.
6. Research and evaluation; skilled, continuing observation of learning
ta king place in a variety of settings. Analysis of strategies and out-
co me leading to structures of controlled innovation.

There is clearly a need for constant dialogue between the college course
placing students and the receiving agency. Indeed, clinicians often feel that
there is not sufficient contact. Perhaps the interface between college tutors
and clinicians should focus on the particular course needs and the students,
and the principles of teaching and leaming should be left for another forum.
The author has found considerable value in offering clinical teaching courses
4 Issues in the preparation of health care professionals

Box 1.2 Model for clinical supervisors' education in dietetics. British Oietetics
Association UK (1990)

Ongoing education Formal clinical Work input

inputs 'supervisors' courses

BOA trainers/tutors' Pre-registration Newly qualified;

meetings/study / Education relevant clinical areas
workshops to clinical related to
supervision supervision
'BOA Education With student
Group' study dieticians
days/workshops developing clinical
supervisor role

BOA study BOA clinical

conferences supervisors course
'Tier I'

BOA specialist groups Increased student

study days involvement,
workshops, courses assessment,
planning

Non-BOA-relevant BOA clinical

courses, e.g. supervisors course
counselling skills. 'Tier 11'
training,
communication Increased need for
training, wider approach:
counselling BOA Certificate research and
certificate, for clinical evaluation
teaching certificate tutors
management
courses

on a multiprofessional basis (Stengelhofen, 1990a). This kind of provision

has the advantage of bringing health professionals together to share an area
of common concern, and it discourages practitioners from focusing too much
on their own field instead ofthe principles ofteaching and learning. Further-
more, the opportunity to examine clinical teaching practices in other spheres
illuminates and enhances our own often rather blinkered approaches. Having
to explain to another professional what we really do in our jobs covertly
improves our skills as teachers, as wen as adding to our skills as team members.
 Literature on clinical teaching 5

It is hoped that this book will demonstrate further that the knowledge and
skills to be used in clinical teaching have relevance to all fields. A rational
way forward might be not to bring all the professions together for courses
on clinical teaching, but to divide the professions into two groups (Stengelhofen,
1990b). Although there are common needs for students in all fields, there
are some differences according to the way the groups carry out their clinical
activity (EHis, 1980, 1988). All health professionals care about and cater
for the needs of others, but some groups do this more by technical means
and others do it primarily through the interpersonal medium. EHis avoids the
terms 'helping and caring' because they are loaded, and adopts the term
'interpersonal professions' as value free. It is for each field to decide where
they lie on the technical-interpersonal continuum; clearly, all fields contain
both aspects. All the fields are included in this book, but some ideas presented
may be more relevant to teaching students in some fields than others. Dickson
and Maxwell (1985) explored this in the context of the training of
physiotherapists, stressing that everything is channelled through the inter-
personal medium in physiotherapy practice. It is possible that the way we
work may have a major influence on the way we teach students, both in the
classroom and in the clinic.

THE LITERATURE AVAILABLE ON CLINICAL TEACHING

Some professional groups, such as medics and social workers, show that they
have paid considerable attention to the needs of students learning in the work
place; this is indicated in the literature. Some professions publish journals
solely related to education in their own fields. Readers may find the follow-
ing journals of interest:
• Medical Education
• Medical Teacher
• Education in Social Work
• Journal of the Association of Chiropody Teachers in the UK
The Clinical Supervisor includes articles on all fields in health care.
Articles in education journals such as:
• Journal of Further and Higher Education
• Journal of the Society of Research into Higher Education
• Programmed Learning and Educational Technology
will be found of value in the examination of educational principles which can
be applied to teaching and learning in clinical settings.
The final chapter of this book looks more widely at some of the research
literature on the value of 'supervised work experience' in the preparation of
6 Issues in the preparation of health care professionals

professionals. It is hoped that it will serve as a starting point for those clinieal
teachers who wish to extend their interests further on the topie. Some readers
may fmd that they prefer to read Chapter 9 first, in order to set the topic
of clinical teaching in its broadest context, as weIl as within a firm research
background. Others may prefer to get on more quickly with the ideas on work-
ing with students in clinie, explored in the earlier chapters.

THE NATURE OF THEORY AND PRACTICE

Placing appropriate importance on the role of the clinician receiving the student
for work experience should stern from the course team's views about the status
of practice in the student's learning experience as a whole. This view needs
to be upheld by validating bodies, bOth professional and academic. The design
of some courses unfortunately suggests that 'practice' is viewed as an added
extra and possibly of lower status than that which is studied in college and
termed 'theory'. An alternative view is to see practiee as central and the
pinnacle of academic achievement, as it requires the highest level of intellec-
tual functioning namely:
• Synthesis
• Application
• Evaluation
Bloom, 1954
Colleagues sometimes say 'she's not very bright, but she's a very good
therapist' . I am always puzzled as to what exactly this can mean. The converse
has been found in research in medical education which suggests that good
academic performance does not necessarily imply good practice. Nevertheless
adequate academic performance must be aprerequisite for competent clincal
practiee. Academic achievement and clinieal competence must be closely
related, because the large part of what clinicians do is academic, the jobs
require thought, not just the carrying out of techniques and procedures. Yes,
we all have high level skills whieh we use frequently, but much of what others
can observe us doing, on the surface, appears comparatively simple. For
example, counselling in dieteties, eliciting a language sampie in speech and
language therapy, teaching a hemiplegie to walk in physiotherapy, helping
someone to dress in occupational therapy, strapping in chiropody, or taking
a chest X-ray in radiography do not appear too difficult to the onlooker.
The activity itself is not the most difficult part, although we know that
there are in fact many difficulties in carrying out these tasks. Students know
all too weIl that some tasks which look incredibly easy when carried out by
the experienced clinician, are a minefield for the learner. Nonetheless
what is the most difficult for the practitioner is what goes on in the head;
 The nature of theory anti practice 7

observing and analysing the patient's problem, deciding what has to be done
and evaluating the effectiveness of what has been done. The thinking part
of the job is essential in the identification of the patient' s needs and the provision
of appropriate care. These points about what we do on the surface and what
we think about while we're doing it leads us to the central issue of the rela-
tionship between the knowledge base of competence and what we actually
do on the job or the nature of 'theory and practice'.
In considering the nature of theory and practice I have found it helpful
to look at the literature in other professional spheres. The definitions by Schwab
(1969, 1971) from education are particularly illuminating. He defines prac-
tice as:
'The discipline concemed with choice and action, in contrast with theoretic
which is concemed with knowledge'.
and
'Thepractica1 is always marked by particularity thetheoretica1 by generality'.
I especially like this second defmition because of the alliteration which resonates
in the health care context:
• Practical
• Particular
• Patients
So, in Schwab's terms, the theoretic is about that which is generally true,
while the practical is about particular examples of the general. Schwab also
talks about the 'arts of the eclectic', that is, what can be chosen from the
generality of theory of a subject or discipline or even schools within these
disciplines. For example, professional groups which make considerable use
of psychology, will be aware of the different schools of thought and conse-
quently the choices which have to be made from the knowledge base and the
consequent differing approaches. Choices and decision-making are a central
part of professional practice; experienced clinicians will be aware how
frequently choice has to be made.
The first follow-up activity at the end ofthis chapter is on making choices.
It is the major activity of health care professional to decide both the nature
of a problem and the appropriate management. This discussion therefore
suggests that theory and practice should not be viewed as separate but should
be seen as a continuum. At one end theory attempting to solve problems or
explain by seeking knowledge, at the other end practice, trying to bring about
change through action. In this view theory and practice become complemen-
tary parts of the same process. This is surely what is involved in the work
of all health care professionals.
8 Issues in the preparation of health care professionals

Argyris and Schon (1974) take these ideas further in their work Theory
in Practice: increasing professional effectiveness. They propose a model of
practice under the title 'theories-of-action'. This has two components; (i)
espoused theory ~ that is what we say we do, the values and strategies we
proclaim publicly; (ii) 'theories-in-use', that is, what we actua1ly do in reali-
ty. These two components may or may not be compatible. This model is helpful
as it includes the possibility of the individual talking about theory, as though
it will be used in practice, but not applying it. In the context of professional
education this concept is particularly useful. I am sure we can all remember
students who have been able to tell us all about it!
Argyris and Schon stress that learning to become competent in professional
practice 'does not consist of learning to recite a theory; the theory-of-action
has not been learned in the most important sense unless it ean be put
into practiee'. Furthermore they stress that theory-in-use needs to be
individually created by each practitioner through his own experience. This
underlines the importance of every student having enough first hand work
experience, during their pre-registration course, to develop their individual
theory-in-use. This view that 'theory-in-use' has to be individually created
in professional preparation means that work experience, Le. that which is
usually termed the practical and is largely leamt through clinical practice,
must be placed centrally in the curriculum.
Curriculum developers presumably believe that the overall design of a course
and the syllabus content have a direct bearing on the preparation of students
for practice. At the centre of this is the need to enable students not only to
acquire knowledge and skills and appropriate attitudes, but to be able to apply
these competently in the exercise of their profession. There are therefore two
major questions for professionals to ask:
1. What is the rea1ity of professional practice?
2. How does the course of study prepare the student for this reality?

TEACHERS' RESPONsmILITIES
The term 'espoused theory' used by Argyris and Schon, is areminder that
college-based teachers need to be constantly vigilant, in that although they
have a responsiblity to introduce students to the latest research findings, these
should not be so far removed from the rea1ity of the working situation
that it is impossible for students to apply them in their clinical practice. Con-
versely, teachers have a responsiblity to include in their classroom teaching
current clinical practices which, in fact, may be ahead in the field, for indeed
it is often practice which informs theory. There is a need to guard against
approaches which will deepen the often observed split between what students
leam in the classroom and what they experience in the clinic. Teachers
 Pre-registration course design 9

in college have a responsibility to try to bridge this gap through the use of
teaching methods which inc1ude real clinical examples; 'the particular problems
of patients'. So also do clinical teachers have a responsibility to encourage
students to refer back to what has been found to be generally true, by having
discussions about the knowledge base, by looking at the literature, at lecture
notes, professional journals, etc.
In their study of supervisors of student teachers and health visitors Fish
et al. (1991) found that there was very little attention to the knowledge base
in the debriefing sessions with students. This shared responsibility for
teachers of encouraging theory and practice to overlap, fosters what Jarvis
(1983) describes as a 'community of learning'. These approaches guard
against placing students in impossible situations where they find that they
are unable to apply what they learnt in college, during their work experi-
ence.
Gaiptman and Anthony (1989), in discussing the development of self-
directed learning in occupational therapy students, suggest that there is a conflict
between the philosophies of the institutions running courses and those providing
placements and running a service. The main aim of the institution being to
expand and evaluate the body of knowledge, whereas the main aim of the
placement agency is to provide a service to those who need it. This they say
creates a dynamic tension, which can be productive, but can be difficult for
students to reconcile. These ideas are explored further in the next chapter.

PRE-REGISTRATION COURSE DESIGN

A central aim of the curriculum in any sphere of professional education is

to prepare the student to become a competent practitioner. Presumably
curriculum developers believe that the overall design of the course and the
syllabus content have a direct bearing on the preparation of students for the
world of work. Those who have been involved in course design and develop-
ment will be aware that although the main aim is straightforward the path
to it is usually very complex. In health care courses, many different designs
will be found; all inc1ude work experience which is supervised in some way.
Various patterns of work experience can be found:

1. clinical practice taking place in college;

2. clinical practice arranged outside college but 'supervised' by a tutor
appointed by college;
3. students going to a c1inic outside college, supervised by practitioners;
4. students going to a c1inic once or twice a week;
5. students going to a placement for a block of time as part of the term-time
timetable.
10 Issues in the preparation of health care professionals

In addition to these different patterns of work experience in the education

programme, there are also variations in the way that placements are selected
and monitored, or approved/accredited. In some fields the professional body
takes the responsibility for approving the placement, while for other profes-
sions it is up to the individual course to select and monitor the placement.
In some instances the pressure to find placements is such that there may be
little choice.
A range of patterns is presumably fine because there are many and the
courses are recognized, by the relevant professional and validating body, as
being appropriate to get students to the starting line of competence on qualifica-
tion. Nonetheless competence is unfortunately not an absolute, as we weil
know when we try to assess it. Therefore it is likely that some students enter
their first job better prepared than others. Providing they are encouraged in
their first post and maintain their motivation, they will grow to be practi-
tioners who work to the maximum of their potential to provide a good quality
service. It is inevitable that course designs vary, possibly the more they vary
the richer will be the mix of practitioners entering the professional resource.
Those courses which have externally set and/or examined curricula will
find that there are many frustrating restrlctions with which they have to comply.
What seems most important therefore is that college tutors and dinical teachers
recognize the strengths and limitations of each individual course and thus ensure
that measures are taken to balance up weak areas. For example, when students'
main exposure to clinical work is in dinics on the site of the institution, do
students also have the opportunity to work in the community and settings such
as hospitals and schools, to identify and evaluate the differences. This is an
area that has been addressed by a number of chiropodylpodiatry degree
programmes in the UK, which now indude community placements in the
students' work experience. Most fields have always induded a range of place-
ment experiences for students. Other issues to be addressed might be:

1. If students go into dinic mainly on a weekly basis do they also have the
opportunity to see what it is like to be in dinic all the week?
2. Do students have the opportunity to work with cases on an intensive as
weil as an occasional basis?
3. If clinical experience is mainly patient-focused, does the curriculum also
prepare them for the wider work context, such as the social and
psychological factors which affect both dients and professionals?
4. Does the dinical practice attend only to the core of practice and not
embrace the preparation of students to carry out administrative and
managerial duties, as part of their work role? (see also Chapter 6).
5. Is the course design organized into tight subjet packages, which do not
encourage students to integrate knowledge across subject boundaries?