Introduction

Health professional students reportedly experience fitness to practise (FTP) issues that may affect their performance while on clinical placement (Lo, Maloney et al. 2014). FTP issues comprise clinical competence, professionalism, mental or physical health, communication and the ability to recognise limits (Parker 2000; Parker 2006; Lo, Curtis et al. 2017). While FTP issues are common on clinical placements, clinical educators (clinicians who work in the clinical environment and have dual responsibility to support patients and student education) may not feel confident in supporting students presenting with issues that may affect their FTP (Lo, Curtis et al. 2017). This study builds on a previous study that investigated the effect of a brief education workshop on the perceptions and confidence of physiotherapy clinical educators. Demonstrably, that study identified that physiotherapy clinical educators were aware of, but lacked confidence in assisting students with, FTP issues (Lo, Curtis et al. 2017). Therefore, one way to potentially increase clinical educators' confidence and skill is to provide further education and training on addressing issues that may affect student FTP during clinical placement.

The use of brief continuing professional development workshops for health professionals is common in workplace settings and has been shown to improve professional practice (Forsetlund et al. 2009; Gerdtz et al. 2013). Additionally, facilitated debriefing and collaborative learning strategies have been shown to enhance workplace learning by recognising the educational effect of discussion and questioning in promoting reflection on practise (Mertens et al. 2018). Considering previous research, this study employed a brief educational intervention aimed at broadening the exploration of clinical educators' reflections on, and confidence to work with, students presenting with FTP issues outside physiotherapy. Additionally, this study sought to use a facilitated education workshop to identify the experiences and describe the recommendations of clinical educators from a diverse range of allied health professions, exploring the full range of potential FTP issues that may affect student performance during clinical placement.

The aims of this study were to 1) evaluate if a one-and-a-half-hour interprofessional education workshop changed the knowledge and confidence of allied health clinical educators to manage student FTP issues that may arise on clinical placement, 2) elucidate allied health clinical educators' experiences with student FTP issues in the clinical setting and 3) explore strategies that allied health clinical educators use or would recommend to support students on clinical placement.

Methods

A once-only clinical educators' professional development workshop was the source of data for this study. Monash University (#13824) and Monash Health (#RES-18-0000-073XL) Research Ethics committees approved this study.

Design

This study used a mixed-methods approach to investigate the perceptions of allied health clinical educators who participate in an education program regarding managing student FTP issues in the clinical setting. Clinical educators rated their confidence with and knowledge of supports for students with FTP issues in pre- and post-workshop questionnaires (see Supplement 1). The qualitative section of the questionnaire sought to elucidate clinical educators' views and experiences of supporting students with FTP issues during their clinical placement.

An interactive discussion during the education workshop was used to record strategies that clinical educators identified as appropriate in various scenarios involving students on clinical placement. Issues discussed in the workshop related to anxiety, a crying student, cultural and linguistic diversity (CALD), a disinterested student, a student involved in a clinical incident, a student who does not take on feedback, challenges transitioning to the clinical placement, an unaware and incompetent student and an unprofessional student. The participants had the opportunity to provide additional recommendations about managing these scenarios via an online survey following the workshop.

Participants

Clinical educators where invited to attend a one-and-a-half-hour FTP professional development workshop. The workshop was advertised to all allied health clinical educators across a large health network via email distribution lists managed by the Allied Health Student Coordinator team. Attending the workshop was the only inclusion criterion and all participants received an explanatory statement. Of the 77 allied health clinical educators who attended the workshop, 46 participated in the study. The workshop occurred at a tertiary health service in Melbourne, Australia.

Data Collection

If participants consented, they completed a 4-item pre-workshop and a 14-item post-workshop questionnaire related to the workshop content (see Supplement 1). Quantitative questions were scored on a 5-point Likert-type scale from 1 (not at all confident) to 5 (very confident). Five points was devised as the optimal number to give respondents the opportunity to express a range of views including a neutral stance, while minimising the cognitive effort required to complete each questionnaire (Chyung et al. 2017). Additionally, a member of the research team (MF) transcribed verbatim the facilitated discussion commentary live during the workshop. This transcription was visible during the workshop to all participants, who confirmed its accuracy in real time. Additionally, the participants had the opportunity after the workshop to provide additional written suggestions of how they would manage cases. This data was collected via an optional reflective survey that was available over a two-week period. The researchers provided this survey, along with the workshop content and documented discussion notes, to the participants.

Training Program Content

The content of the professional development workshop was based on a workshop previously conducted with a group of physiotherapy clinical educators (Lo, Curtis et al. 2017). The first 30 minutes of content included: the definition and contextualisation of FTP; an overview of regulatory frameworks and notifiable conduct pertaining to pre-qualification health professionals; university preparation of students for clinical learning; and options for university and clinical placement providers to manage FTP issues in the clinical setting. The remaining one hour comprised a facilitated discussion about the clinical educators' experiences of, and strategies used when, working with students presenting with various FTP issues. Learning objectives, facilitator and learner activities, and questions that guided the facilitated discussion are summarised in Supplement 2.

Data Analysis

Data were analysed to evaluate the effect of the interprofessional education workshop on clinical educators' knowledge of FTP supports and confidence in their ability to manage student FTP issues that arise on clinical placement. Pre- and post-workshop quantitative data were analysed by independent t-tests using GraphPad with a significance level of p < 0.05.

The transcript of the recommended strategies that incorporated not only the strategies identified during the workshop, but also additional reflections submitted online were analysed using content analysis (Graneheim & Lundman 2004). Two researchers (MF, KL) independently coded the data, which was then merged into a final matrix by consensus. The open-ended survey responses exploring the personal experiences of clinical educators working with students with FTP issues were inductively coded independently by two investigators (MF, KL) using thematic analysis (Braun and Clarke 2006; Miles et al. 2014). After independent coding, code tables were reviewed, and a consensus was reached on a merged final code table. This final table was reviewed by a third member of the research team (JT) to confirm and validate the codes and thematic structure.

Results

Quantitative Data Analysis

Forty-six clinical educators participated in the study, representing nine professions: allied health assistance, dietetics, exercise physiology, occupational therapy, physiotherapy, podiatry, psychology, speech pathology and social work. In summary, the participants had an average of 8 years ± 5.4 years (range 1-20 years) of clinical experience. Further, the participants had collectively supervised 212 students in the 12 months preceding the workshop and indicated that they had worked with 54 students presenting with issues that affected the students' FTP (24% of all students). The participants were asked to categorise the FTP issues that those students presented with. They reported that 36 students had issues with reaching competency on placement, 23 presented with professional behaviour issues and 15 presented with mental or physical health issues. In 39 cases (75%), the participants reported seeking support from the local health service student coordinator (an allied health educator employed by the health service with responsibility for supporting students and managing clinical placement allocation across the health service) or the university.

Unpaired t-testing showed that the change in confidence in ability to define FTP following the workshop increased significantly from a mean of 2.59 (SD 0.93) to a mean of 4.1 (SD 0.62), p < 0.001. Similarly, the change in participants' knowledge of support available to help manage FTP issues for students on clinical placement improved significantly from a mean of 2.57 (SD 1.11) to a mean of 4.0 (SD 0.81), p < 0.0001.

Qualitative Data Analysis

Two types of qualitative analyses were performed: a thematic analysis of participants' experiences of student FTP issues and a content analysis of clinical educators' recommendations to manage student FTP issues.

The thematic analysis of clinical educators' responses to questions about experiences of student FTP issues identified three major themes. These themes included a description of the types of student FTP issues that were experienced, the effect of student FTP issues on clinical educators and system factors that are important in managing student FTP issues that arise on clinical placement (see Figure 1). A summary of the key themes is presented here in student-, educator- and system-related clusters. The full code table is provided in Supplement 3.

Figure 1 . Schematic representation of themes grouped in student, educator and system related clusters.

THEME 1: STUDENT FTP ISSUES

In their responses, clinical educators identified several themes of student FTP issues that have been described previously by Parker (2000, 2006) and Lo et al.(2017). These themes included: clinical competence; professional behaviour; communication; recognition of limits; and mental, physical and financial health. Further, the challenges that clinical educators described included working with students who did not adequately translate feedback into practise, students who were affected by external issues such as homelessness and students who were not necessarily aware of the issues affecting their FTP, which at times led to failing the placement.

[T]he student was late, unprofessional, did not take on [or] change professional behaviour following feedback, did not seem to care about the placement or profession. (Professionalism)

A person who was so impacted by anxiety that they didn't have the insight into how this was impacting their performance. (Clinical competence)

[The student was] falling asleep in meetings, [had a] lack of eye contact during feedback, [and was] eye rolling. (Communication)

[The s]tudent becoming homeless during placement secondary to family breakdown. (Mental, physical and financial health)

THEME 2: AFFECTS ON CLINICAL EDUCATORS

Clinical educators described the effect of student FTP issues on themselves personally and emotionally, and gave insights into their support options and coping mechanisms. There were mixed accounts of experiences when students did and did not reach competency and how that affected clinical educators.

[I felt f]rustrated as I put … a lot of effort into trying to support the student but was unable to 'succeed'. (Emotional response)

[I felt f]ailure, guilt, frustration, sadness for [the students'] struggle [and] anger over 'wasted' time and effort. In the end relief that [the] student identified their own struggle and found their own path. (Emotional response)

[I] required more support from uni to further assist [the] student with the process following failing a placement. (Support)

[I m]ade expectations [of the student] clear, [provided] regular supervision [and] feedback … involved university, put more responsibility for the student's learning on them [the student], [used] reflection strategies and more direct expectations. [I used] FTP definition [and] support available from uni. (Coping strategies)

The clinical educators also identified the attributes and skills they bring to their role, and the teaching and learning strategies they use in the clinical setting to support learners with FTP issues. Some clinical educators expressed uncertainty of or a lack of confidence in the teaching strategies they have used in the past or would like to try in the future. This was due to either their own breadth of experience or from their concern of treating a student with FTP issues inappropriately or insensitively.

[I f]elt awkward repeating myself when we both knew I had gone over [the feedback point] a number of times before. [I a]lso found it hard to problem-solve different ways of giving feedback. (Clinical educator attributes and skills)

[I] felt ill-equipped to assist with significant mental health issues. (Clinical educator attributes and skills)

I felt I was going out of my way to change my methods to … assist the student but not getting the same effort in return from the student. Hence feeling lost with what to do. (Teaching and learning strategies)

[I]ncreased feedback (formal [and] informal), student coordinator involvement, tutorials, learning needs, step-by-step breakdown of problem lists [and] clinical reasoning, planning with both educators and student, unsupervised interactions with clients when it was deemed safe and appropriate. (Teaching and learning strategies)

THEME 3: SYSTEM FACTORS IN MANAGING STUDENT FTP ISSUES

The third theme centred on the roles and responsibilities of the university, the health service student coordinator and the clinical educator in identifying and managing student FTP issues that arise while on clinical placement. This theme includes the importance of communication, frustration when a university is unable to disclose information about a student prior to placement, and the practical realities of navigating these situations and who is ultimately responsible for what.

[S]uspected issues with anxiety [or] depression. Student did not disclose. Spoke to [university] clinical support [team] about this issue but still felt that we were searching in the dark about what was going on. (Logistics and process)

[B]eing very proactive in seeking support from the uni and student coordinator as [there are] many resources out there. (Logistics and process)

I am comfortable that I tried everything that I could including discussion with colleagues and the university and providing appropriate strategies to [s]upport the student. (Logistics and process)

[I]t was important to bring to their [university] attention but also [to] gain information re[garding] what checks are in place at uni for clinical competence as well as supports available for financial and mental health issues. (Responsibility)

[My actions included communicating] clear expectations of placement. Developed understanding of how best to provide feedback. Liaised with student coordinator regularly. Clear communication with co-supervisor. (Responsibility)

[R]aise issue[s] early, notify student coordinator early, use professional development forms early. Document all discussions for future reference. (Responsibility)

Finally, the clinical educators identified several ways that they were intending to change their practise after attending the workshop. These changes indicated an intention to increase their environmental scanning and level of collaboration with the student and education providers.

[G]ive students more opportunities to discuss FTP issues and ask about it. (Process)

[E]scalate to uni earlier and be more assertive when requesting support through using evidence relating to FTP. (Responsibility)

[M]ake the time to check in with students about their wellbeing. (Process)

The clinical educators' recommendations for managing FTP issues that may arise on clinical placement were examined by content analysis to create a matrix of strategies that indicated the frequency of recommendations for each FTP issue (see Table 1). Three strategies were recommended for use in the majority of potential scenarios. The first strategy included facilitating open discussion, providing feedback without judgement and gaining rapport (>4 recommendations for all but one FTP issue category, with 1-3 recommendations). The second strategy was seeking support from others outside the clinical educator-student pairing (>4 recommendations for all but three FTP issue categories, with 1-3 recommendations). The third strategy, which was recommended to a lesser extent, was providing feedback to facilitate learning, including written and verbal feedback and feedback books (>4 recommendations for 1 FTP issue category). Additionally, giving a student space and providing opportunities for observation were each recommended for only two FTP issue categories. Finally, following protocols was recommended for only one type of FTP issue category-a clinical incident involving a student.

Table 1. Content analysis of clinical educator recommendations to assist students with various FTP issues on clinical placement

	Category of Issues Affecting FTP
Recommended Strategies to Manage Issues Affecting FTP	Anxiety	Crying	Cultural and Linguistic Diversity	Disinterest	Clinical Incident	Not Taking Feedback	Transition Challenges	Unaware and Incompetent	Unprofessional
Scaffold tasks and time to match skill level	✓	✓✓	✓	✓	✓	✕	✓	✕	✕
Identify learning needs	✓	✓	✓	✓	✕	✓	✓	✕	✓
Allow mistakes, use risk management strategies	✓	✕	✓	✕	✓	✓	✕	✓	✕
Use templates and structure	✓	✕	✓	✕	✓	✕	✕	✓	✓
Clarify expectations and the roles of student and clinical educator	✓	✕	✓✓	✓	✓	✕	✓	✓	✓✓
Have open discussions, give feedback without judgement, gain rapport	✓✓	✓✓✓	✓✓	✓✓	✓✓✓	✓✓	✓	✓✓	✓✓
Plan and practise (write things down, role-play, use peer-assisted learning techniques)	✓	✓	✓✓✓	✕	✕	✕	✓	✓	✕
Facilitate independent learning and coaching	✓	✕	✓	✕	✕	✓	✕	✕	✕
Think critically, ask questions, problem-solve	✕	✕	✓	✓	✕	✓	✕	✓	✓
Provide student with opportunities for observation	✓	✕	✕	✓	✕	✕	✕	✕	✕
Record video, practise self-reflection, write in a diary	✓	✕	✓	✓	✕	✕	✕	✓	✓
Seek support from others outside the clinical educator-student pairing	✓	✓✓	✓	✓	✓✓	✓✓✓	✓✓✓	✓✓✓	✓✓
Give feedback to facilitate learning (written and verbal feedback, feedback books)	✓	✓	✓	✓	✓	✓	✓	✓✓	✓
Give student space, ensure appropriate environment	✕	✓✓	✕	✕	✕	✕	✕	✓	✕
Follow protocols	✕	✕	✕	✕	✓✓	✕	✕	✕	✕

Key: ✓ = 1-3 responses, ✓✓ = 4-5 responses, ✓✓✓ = >5 responses, ✕ = 0 responses.

Discussion

This study has identified several experience-informed insights and recommendations made by a multidisciplinary group of clinical educators during a one-and-a-half-hour interprofessional workshop on student FTP. The workshop had an immediate effect on the clinical educators' confidence in defining FTP and their knowledge of available supports, which was particularly reflected in the quantitative data. This is important because the participants in this workshop identified that more than one in four of their students in the preceding 12 months had presented with an FTP issue. Considering this experience, this study provides not only an interprofessional perspective on how working with students presenting FTP issues affects clinical educators, but also suggestions and recommendations on how to deal with FTP issues during a clinical placement.

Several similarities arose when comparing the findings of this study (that engaged a multidisciplinary group of clinical educators) with those from a similar study (that engaged a group of physiotherapy clinical educators and academics). Both groups discussed clinical competency issues, but the participants in the previous study raised their lack of confidence in supporting students with mental health issues more often than the clinical educators in the current study. This could be due to the current study including clinical educators from professions such as social work, occupational therapy and psychology, which all necessitate core skills based on working with people with mental health conditions.

Participants in both studies preferred early disclosure (prior to placement) of mental health issues, such as anxiety, and using feed forward mechanisms, and valued receiving early support. While only the participants in this study discussed the importance of students' insight into difficulties, participants in both studies identified that they were 'going out of their way' to support students who presented with FTP issues, and were unsure how to proceed and where to draw boundaries. Additionally, both groups found that their relationships with education providers were helpful regarding support, particularly when student performance was unsatisfactory. Further, both groups identified the importance of preparation as a key education strategy and felt there was inadequate training for clinical educators in managing FTP issues in the clinical setting.

Although the participants in this study stressed the importance of putting the onus of learning on the student, they also listed numerous strategies they would use to support students with additional learning needs. Notably, the participants in both studies identified not only a lack of confidence in their role as clinical educators, but also a pressure to 'bring students up to standard'. This tendency to contribute more effort and time when a student is struggling is consistent with the key findings of Bearman et al. (2013) regarding the usual actions of clinical educators while working with an underperforming student. Interestingly, in both studies some of the clinical educators' lack of confidence was related to a fear of not treating students who present with FTP issues in a sensitive and appropriate way.

Conversely, the facilitated discussion in this study's workshop included more prompts than in the previous study, meaning the participants in the former were invited to address a broader variety of student FTP issues. Specifically, the participants in this study were asked to discuss their past experiences of students with FTP issues. These included safety and professionalism, mental and financial health, problems of sleep deprivation and becoming homeless during placement.

Additionally, this study's workshop content included information regarding how written and verbal communication issues present as an FTP issue. This was specifically related to mature aged students and students from CALD backgrounds. Further, effective communication was considered a critical skill when managing student FTP issues, especially regarding the clinical educators increasing their environmental scan of the issues that can affect students on clinical placement.

The participants in this study raised concerns regarding students self-identifying their scope of practise. In response, other participants recommended setting expectations early in the clinical placement and developing an understanding of how to best provide feedback. Another key strategy raised was clinical educators communicating with support persons other than university staff (e.g. managers), particularly where multiple clinical educators were involved with the same student. The group also discussed the benefits of clearly defining FTP issues and escalation processes.

In both studies, the participants discussed the skills that they possessed and the coping skills they utilised in the learning environment. After further prompting, this study's participants disclosed their emotional responses to educating students with FTP issues. They also discussed the range of supports they used, including other supervisors, student coordinators and university staff. The clinical educators' perspectives in this study have further elucidated factors important in supporting students with FTP issues. However, investigating more comprehensive education regarding student FTP issues for clinical educators and a longer-term assessment of the effect of this type of education may be beneficial to better understand how to support students and educators in a workplace learning environment.

Limitations to this study include the relatively small number of participants from a single metropolitan health network and the self-reported pre- and post-workshop measures of knowledge and confidence. Considering these limitations, the results of this study may not represent allied health clinical educators in general. However, the participants had been involved in the education of a large number of health professional students in the preceding year, and a high proportion of those students had experienced some form of FTP issue while on clinical placement. Therefore, the combined experience of the participants is highly relevant to the findings. Additionally, the findings of this study are aligned with and build on the results of the previous study discussed above.

Conclusion

A multidisciplinary group of clinical educators who have worked with students with FTP issues reported higher levels of confidence and greater knowledge of appropriate supports after a brief workshop on managing student FTP issues. The clinical educators not only identified increased confidence levels, but also identified and recommended a range of appropriate strategies drawing on their practical, personal and emotional experiences of supporting students with FTP issues. In addition to the clinical educators' experiences, academics' perspectives should also influence future professional development for clinical educators to reinforce their confidence and skills in supporting students with FTP issues while on clinical placement.

Acknowledgements

Nil

Conflict of Interest

Nil to declare

Funding

Nil

References

Bearman, M, Molloy, E, Ajjawi, R & Keating, J 2013, ' "Is there a Plan B?": clinical educators supporting underperforming students in practice settings', Teaching in Higher Education, vol. 18, no. 5, pp. 531-544.

Braun, V & Clarke, V 2006, 'Using thematic analysis in psychology', Qualitative Research in Psychology, vol. 3, no. 2, pp. 77-101.

Chyung, SY, Roberts, K, Swanson, I & Hankinson, A 2017, 'Evidence-based survey design: the use of a midpoint on the Likert Scale', Performance Improvement, vol. 56, no. 10, pp. 15-23.

Forsetlund, L, Bjørndal, A, Rashidian, A, Jamtvedt, G, O'Brien, MA, Wolf, F, Davis, D, Odgaard-Jensen, J & Oxman, AD 2009, 'Continuing education meetings and workshops: effects on professional practice and health care outcomes', Cochrane Database Systematic Review, vol. 2, no. 2.

Gerdtz, M, Daniel, C, Dearie, V, Prematunga, R, Bamert, M & Duxbury, J 2013, 'The outcome of a rapid training program on nurses' attitudes regarding the prevention of aggression in emergency departments: a multi-site evaluation', International Journal of Nursing Studies, vol. 50, no. 11, pp. 1434-1445.

Graneheim, UH & Lundman, B 2004, 'Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness', Nurse Education Today, vol. 24, no. 2, pp. 105-112.

Lo, K, Curtis, H & Cracknell, AF 2017, 'Exploring student fitness to practise in physiotherapy-strategies from the coalface', New Zealand Journal of Physiotherapy, vol. 45, no. 2, pp. 59-66.

Lo, K, Curtis, H, Keating, JL & Bearman, M 2017, 'Physiotherapy clinical educators' perceptions of student fitness to practise', BMC Medical Education, vol. 17, p. 16.

Lo, K, Maloney, S, Bearman, M & Morgan, P 2014, 'Proactive student engagement with fitness to practise', Journal of Biomedical Education, vol. 2014, pp. 1-8.

Mertens, F, de Groot, E, Meijer, L, Wens, J, Gemma Cherry, M, Deveugele, M, Damoiseaux, R, Stes, A & Pype, P 2018, 'Workplace learning through collaboration in primary healthcare: a BEME realist review of what works, for whom and in what circumstances: BEME Guide No. 46', Medical Teacher, vol. 40, no. 2, pp. 117-134.

Miles, MB, Huberman, AM & Saldaña, J 2014, Qualitative data analysis: a methods sourcebook, Sage, Los Angeles.

Parker, M 2000, 'Assessing medical students' professional development and behaviours: a theoretical foundation', Focus on Health Professional Education: A Multi-disciplinary Journal , vol. 2, no. 2, pp. 28-38.

Parker, M 2006, 'Assessing professionalism: theory and practice', Medical Teacher, vol. 28, no. 5, pp. 399-403.

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