The Learning Alliance Between Clinical Instructors and Students at a Campus Occupational Therapy Teaching Clinic: Support for the Development of Clinical Reasoning

In order to practice as an occupational therapist, students must complete clinical educational experience as part of their graduation requirements. During this experience, a supervising clinical instructor (CI) provides feedback and guidance that builds the foundation for clinical reasoning skills of the student. The CI-student learning alliance represents the relationship that supports this educational experience. This study used qualitative methodology based in grounded theory to examine the role of the CI-student learning alliance in facilitating students’ development of clinical reasoning by studying the relationship between CIs and fourth semester graduate occupational therapy students during a level I fieldwork experience at a university on-campus teaching clinic. Five themes emerged from the data including: 1) Clinical Instructors Assessed How a Student Learns Best; 2) Clinical Instructors Used Different Ways to Facilitate the Clinical Reasoning Process and the Learning Alliance; 3) The Nature of Feedback was Important; 4) Students Took a Positive, Active Approach to Learning; and 5) Student Autonomy was Preserved. The themes that emerged appeared to simultaneously support the learning alliance and the development of clinical reasoning. This information may provide CIs and occupational therapy students with a better understanding of strategies used in fieldwork settings that contribute to the development of an effective CI-student learning alliance and the development of students’ clinical reasoning. LEARNING ALLIANCE AND CLINICAL REASONING 4 The Learning Alliance Between Clinical Instructors and Students at a Campus Occupational Therapy Teaching Clinic: Support for the Development of Clinical Reasoning Clinical education plays a critical role in the development of an occupational therapist. Although the clinical education experience may vary based on the academic institution, in the U.S., the American Occupational Therapy Association (AOTA) Accreditation Council for Occupational Therapy Education (ACOTE) requires that graduate occupational therapy students in an accredited occupational therapy program complete a minimum of 24 weeks of full-time practice based fieldwork as part of the academic program (AOTA, 2010). It is through this clinical experience that students are challenged to apply their knowledge and skills acquired as part of their theoretical academic background to develop treatment approaches within the context of a clinical practice setting (AOTA, 2009). The appropriate application of the student’s academic knowledge to the practice setting requires clinical reasoning skills. Clinical reasoning, also referred to as professional reasoning, is defined as “the process that practitioners use to plan, direct, perform, and reflect on client care” (Schell, 2009, p. 314). The metacognition involved in clinical reasoning has been widely described as a skill best acquired through experience (Cohn, 1989; Fleming, 1991b; Gibson et al., 2000; Mattingly, 1991; Schell, 2009; Schell & Cervero, 1993). Gibson et al. (2000) used an ethnographic study to investigate how the clinical reasoning process differed between an experienced and novice therapist at the same setting. The authors noted that the novice therapist discussed the concept of clinical reasoning readily, whereas the experienced therapist struggled to define the concept. LEARNING ALLIANCE AND CLINICAL REASONING 5 However, the actual application of the concepts of clinical reasoning was more apparent during the interviews with the experienced therapist (Gibson et al., 2000). This study illustrated how the development of clinical reasoning skills evolves as a therapist gains experience. Fieldwork plays a significant role in establishing a foundation for a student’s clinical reasoning skills (Cohn, 1989; Farber & Koenig, 2008). In the fieldwork setting, the occupational therapy student is supervised by a fieldwork educator, or clinical instructor (CI), a licensed occupational therapist who is responsible for the student’s clinical learning experience. The CI plays a considerable role in the student’s development of competence to practice (Housel, Gandy, & Edmondson, 2010). Throughout the fieldwork experience, the student receives guidance and feedback from the CI on evaluation and intervention as the student begins to build clinical reasoning skills. This feedback process serves to support the success of the student within the context of the clinical setting as the two strive towards the common educational goal of developing the student’s clinical reasoning skills. The relationship between the CI and the student may impact the student’s professional development during fieldwork, and a successful relationship becomes important for facilitating effective communication in the clinical setting. James (2005) proposed a model of self-regulated fieldwork learning that students and CIs might use as a guide in understanding successful learning strategies utilized during fieldwork education. One component of the model, the learning alliance, supports the translation of knowledge between the student and CI. “A learning alliance is defined as the relationship between the student and clinical supervisor, which consists of mutually agreed upon LEARNING ALLIANCE AND CLINICAL REASONING 6 learning goals and tasks, a shared understanding of the learning process, and a positive relationship” (James, 2005, p. 137). Currently, it is not known which aspects of the learning alliance contribute to the development of clinical reasoning. Additional research would enhance understanding about this aspect of fieldwork education and support the occupational therapy profession’s commitment to developing and graduating competent future practitioners. The University of Puget Sound in Tacoma, Washington operates a free on-campus clinic for the local community in which fourth semester graduate occupational therapy students, under the supervision of faculty and CIs, plan and implement treatment for both adult and pediatric clients. The on-campus clinic provides a fieldwork level I education experience for students, prior to beginning their fieldwork level II experiences. For students, this unique clinical setting located at the university serves as the beginning of the transition from the classroom to applied clinical practice. In addition, the on-campus clinic with the support of the department faculty provides a more controlled setting in which the relationship between the student and CI might be explored.