What Are Clinical Supervisors Looking for in Residents?

Characteristics of Effective Clinical Learners

When evaluating candidates for residency positions, employers and clinical supervisors presumably look for certain skills and characteristics that will contribute to residents' success as novice clinicians. Since formal O&P education began in the United States in the 1950s, educational and credentialing requirements have evolved to prepare graduates to meet the changing demands of clinical practice. 1 Currently, the American Board for Certification in Orthotics, Prosthetics & Pedorthics (ABC) periodically completes a practice analysis to determine areas of focus in contemporary clinical practice and define the requirements for entry-level clinical competency. 2 The National Commission of Orthotics and Prosthetics Education (NCOPE) establishes minimum competencies for O&P students completing education and residency programs. However, there is no peer-reviewed literature describing what O&P residency directors or clinical supervisors expect from O&P students entering residency. Knowing what skills and characteristics supervisors value can guide education and credentialing standards, curriculum development, and the professional and personal goals of clinical learners.

In lieu of O&P literature on this topic, which is lacking, the expectations of clinical instructors in allied health fields closely related to O&P can provide valuable insight. Despite the fact that PT and OT clinical education differs from O&P education and residency in content, structure, length, and specific expectations, the accrediting bodies for these professions—NCOPE, the Commission on Accreditation in Physical Therapy Education (CAPTE), and the Accreditation Council for Occupational Therapy (ACOT)—have established many similar expectations regarding entry-level competencies. For example, along with sufficient knowledge of pathologies and diseases, current research, and common treatment interventions, all three accrediting bodies require that students communicate effectively, have adequate psychomotor skills, provide care in a safe and ethical manner, collaborate effectively with other medical professionals, demonstrate critical thinking, and provide patient-centered practice. 2-4 These general similarities enhance the applicability of the expectations of PT and OT clinical supervisors to the O&P profession.

Literature Review of PT and OT Studies

Peer-reviewed articles have reported the perspectives of PT and OT clinical instructors and educational faculty regarding the characteristics of effective clinical learners. These characteristics can reasonably be interpreted to represent expectations that these professionals have of clinical learners. Clinical instructors have historically placed emphasis on student demeanor, professional behavior, communication skills, and willingness to learn, in addition to basic clinical skills. A 2018 review of 14 studies from the previous decade examined what PT and OT employers, clinical educators, and educational faculty define as the characteristics of effective clinical learners. The participants in the studies were clinicians, clinical instructors, education faculty, and other stakeholders in the PT and OT professions. Study designs included surveys, interviews, Delphi processes, and group discussions.

The specific characteristics identified by participants in each study were ranked by how often they were mentioned in the reviewed articles. Each characteristic that was not explicitly defined in the article was given a definition the reviewer believed best fit the context of the article. Some characteristics were combined under one label to ensure that all the characteristics mentioned in the articles were represented in the review, including those that were only mentioned one time. For example, if recognizing limits was identified in one study, it was combined by the reviewer with related concepts from other articles (e.g., articulating one's strengths and weaknesses) to create the characteristic of self-awareness/self-assessment. Thirty-one characteristics were extracted from the articles, and the eight that were identified in at least 50 percent of the articles are listed in Table 1. The top four characteristics (communication/interpersonal skills, critical thinking/clinical reasoning, psychomotor skills, and initiative/commitment to learning) were mentioned in over 70 percent of the articles. To facilitate a more robust understanding of their significance, characteristics with similar definitions were grouped into categories (Table 2). The categorization of the characteristics was refined for this article and differs slightly from the original review. Four of the five categories (communication/interpersonal skills; knowledge, skills, and abilities; professional attributes; and character traits) were represented in 70 percent or more of the articles reviewed.

The literature indicates that the expectations of clinical instructors have remained fairly stable over the last decade. For example, communication/interpersonal skills have been considered an important characteristic in articles from 2007 5,8,12 and from 2017. 13 Key characteristics within each of the five categories will be considered to gain insight into O&P education and clinical training.

Knowledge/Skills/Abilities

This category most likely includes the characteristics that clinical learners and supervisors think of when they consider the core clinical responsibilities in O&P practice. Psychomotor skills include "physical skills such as movement, coordination, manipulation, dexterity, grace, strength, speed—actions which demonstrate the fine or gross motor skills, such as use of precision instruments or tools…." 6 These include the foundational skills and abilities required for the practice, including examination, measurement, taking impressions, fitting, and adjustment. It is not surprising that this characteristic and knowledge/ understanding were the second most common characteristics identified in the PT and OT articles, and it is likely that they would be ranked similarly high by O&P practitioners. Without a base of knowledge and skills in key content areas, an individual would not be considered ready to begin practice, even under direct supervision. The quality of care experienced practitioners provide is likely to be evaluated using these same characteristics, even as their performance improves over time.

Critical thinking/clinical reasoning can be defined as "applying knowledge and clinical reasoning to choose the proper assessment techniques and treatments, comprehending problems, and making clinical decisions using problem-solving skills. This requires being aware of and adapting to changes in patient care, and being flexible in thinking and considering options and consequences." The ability to apply knowledge and skill to specific clinical challenges using appropriate thinking and reasoning skills is more abstract and can be difficult to describe and observe. A combination of psychomotor and reasoning skills is required to provide quality care. Clinical reasoning is difficult to teach, particularly within the constraints of an academic program, and learning this skill requires repetition over an extended time within a clinical environment.

Professional Attributes

This category includes a wide range of characteristics that relate to encounters with patients and interactions with colleagues. Expectations regarding professionalism can be difficult to define and assess objectively, and perceptions can vary based on interpersonal and contextual factors. Regardless of the specifics in each context, clinicians at every level of experience who adhere to ethical standards and facility policies and conform to expectations for behavior, dress, and timeliness are likely to be considered more effective than those who do not.

Communication/Interpersonal Skills

This category includes the characteristic mentioned most often in studies that report on characteristics of effective clinical learners. A clinical learner who demonstrates these skills is effective at communicating verbally and nonverbally and relating to all stakeholders involved in clinical care, including medical professionals, patients, families, and third-party payers. This skill involves building professional relationships by optimizing interactions and communication with a diverse group of individuals and requires proficiency in active listening and engaging with challenging patients.

Character Traits

Several of the characteristics in this category may be challenging to demonstrate and assess since their presentation may vary based on personality, temperament, and other personal factors. Discussion of these characteristics requires a high degree of trust between clinical supervisors and learners. The characteristic initiative/commitment to learning was the third most common characteristic mentioned in the reviewed studies. This can be defined as "a willingness to self-teach and a desire to learn new information to provide better care for patients and to share with colleagues. It involves asking appropriate questions and being quick to get involved at clinical encounters." This characteristic is often readily apparent at every stage of learning and includes specific behaviors that learners can exhibit that demonstrate their active involvement in the learning process.

Leadership Skills

This category includes characteristics that were not identified frequently in the reviewed studies. Resource/fiscal management was identified in five studies, and the ability to educate and administrative/leadership skills were identified only three times each, suggesting that PT and OT clinical educators do not consider leadership skills as important as those in the other four categories. While CAPTE and ACOTE require leadership skills to be taught in educational programs, 3,4 it is likely that clinical instructors do not expect students to be placed in formal leadership roles early in their careers. 7,9,14 However, observing leadership traits and skills may be an important part of employers' assessments of clinical learners' ability to take on more responsibility and eligibility for promotion.

Preparing for Clinical Independence

The purpose of the literature review was to identify the characteristics of effective clinical learners within PT and OT to glean insight relevant to O&P. It is notable that many of the characteristics mentioned most frequently in the reviewed studies extend beyond the specific knowledge and skills that define the professions. Students and residents recognize correctly that obtaining a solid foundation in core areas is one of the primary purposes of their education and training. It may be more difficult to recognize the significance of professional skills such as communication, timeliness, initiative, and self-awareness that are not related as closely to specific clinical interventions. As challenging as it is to teach these skills, a variety of educational strategies can help learners recognize their importance and promote development of competencies in these areas. Clinical learners who recognize the breadth of skills required to function independently as a clinician can be more purposeful about growing in those areas. By coaching learners to higher levels of performance in these areas, clinical supervisors and mentors can help novice clinicians develop competence and independence more quickly. Increased independence will result in a greater capacity to contribute positively to patients' welfare and to employers.

Clinical strategies and technologies change over time, but many of the characteristics identified in these studies as determining clinical effectiveness are relevant across a wide range of time and clinical contexts. For example, one study involving PTs from two different generations (baby boomers and Generation X), found no significant differences in opinions between the two generations regarding generic abilities required of PTs. 12

Students can become frustrated with aspects of their education that they do not see as directly relevant to clinical practice. However, these professional skills and character traits may contribute as much or more to their clinical success than clinical knowledge and psychomotor skills, and part of residents' professional responsibilities are to continue to grow in every area. Clinical supervisors should not expect that these skills are fully formed or well developed in all graduates entering residency and should expect to devote time and energy to teaching them. Expectations of professionalism and clinical performance must be communicated clearly and reinforced through ongoing discussion and coaching.

Conclusion

Given the differences between O&P and PT/OT, similar surveys of O&P educators, employers, residency directors, and clinical supervisors would provide more meaningful insight into how to best prepare O&P students for clinical practice. As O&P clinical practice changes and standards for clinical practice evolve, it is important to consider the characteristics that these stakeholders consider most important when assessing competence. This research may reveal differences between the expectations of students, educators, and clinical supervisors, and inform the development of academic and residency standards.

Christopher Surface, MPO, CO, graduated from West Liberty University with a bachelor's degree in human biology and earned his MPO from Northwestern University Prosthetics-Orthotics Center (NUPOC). He is a certified orthotist and prosthetic resident at Hanger Clinic, Wheeling, West Virginia.

John T. Brinkmann, MA, CPO/L, FAAOP(D), is an assistant professor at NUPOC. He has over 25 years of experience in patient care and education.

REFERENCES

1. Hovorka, C. F., G. Donald, D. S. Bozik. 2002. The Concept of an Entry-Level Interdisciplinary Graduate Degree Preparing Orthotists for the New Millennium Part 1: History of Orthotic and Prosthetic Education. Journal of Prosthetics and Orthotics 14(2):51-8.

2. NCOPE. Standards of Accreditation for The Orthotic/Prosthetic Residency Training Program. 2017:1-18.

3. AOTA. ACOTE 2027 Mandate and FAQs 2017 [updated October 17, 2017]. www.aota.org/Education-Careers/Accreditation/acote-doctoral-mandate-2027.aspx .

4. CAPTE. Standards and required elements for accreditation of physical therapist education programs 2017. www.capteonline.org/uploadedFiles/CAPTEorg/Portal/CAPTEPortal_PTStandardsEvidence.doc .

5. Wetherbee E, S. Giles. 2007. Physical therapist education programs' performance expectations of students on clinical experiences. Journal of Physical Therapy Education 21(1):48-55.

6. https://en.wikipedia.org/wiki/Psychomotor_learning

7. Cross, V. 1998. Begging to differ? Clinicians' and academics' views on desirable attributes for physiotherapy students on clinical placement. Assessment & Evaluation in Higher Education 295-311.

8. Jette, D. U., A. Bertoni, R. Coots, H. Johnson. 2007. Clinical instructors' perceptions of behaviors that comprise entry-level clinical performance in physical therapist students: a qualitative study. Physical Therapy 87(7):833.

9. Sass, K, L. Frank L, A. Thiele, A. D. Newton, B. Bork, S. Hartung, et al. 2011. Physical therapy clinical educators' perspectives on students achieving entry-level clinical performance. Journal of Physical Therapy Education 25(3):46-59.

10. Chipchase, L. S., P. J. Buttrum, R. Dunwoodie, A. E. Hill, A. Mandrusiak, M. Moran. 2012. Characteristics of student preparedness for clinical learning: clinical educator perspectives using the Delphi approach. BMC Medical Education 12:112.

11. Hayes, K. W., G. Huber, J. Rogers, B. Sanders. 1999. Behaviors that cause clinical instructors to question the clinical competence of physical therapist students. Physical Therapy 79(7) 653-67.

12. Stumbo T., A. Thiele, A. M. York. 2007. Generic abilities as rank ordered by Baby Boomer and Generation X physical therapists. Journal of Physical Therapy Education 21(2):48.

13. Lo K., H. Curtis, J. L. Keating, M. Bearman. 2017. Physiotherapy clinical educators' perceptions of student fitness to practise. BMC Medical Education 17(1):16.

14. Kenyon L. K., R. L. Dole, S. P. Kelly. 2013. Perspectives of academic faculty and clinical instructors on entry-level DPT preparation for pediatric physical therapist practice. Physical Therapy 93(12):1661.

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