We believe it expedient to discuss the principles of adult learning, one of the factors that can influence the atmosphere of trust. Supervisors knowledgeable about these principles have a better grasp of the things that affect learning. They adopt helping attitudes and take steps to create a climate conducive to learning. The relationship of trust is improved in the process.

Bossers, Polatajko, Connor-Schisler and Gage (1997) propose these six principles of adult learning:

1. Adults learn better when the training atmosphere fosters self-esteem and interdependence.

It is important to:

• See that each student feels respected, accepted and valued by the placement supervisor and staff.
• Encourage all participants to be open and honest about themselves and their experiences.
• Explain that differences of all kinds are regarded as good and desirable.
• Explain to students that mistakes are a normal part of the learning process.
• It helps for the placement supervisor to support students rather than judge them and to collaborate rather than compete.
• Recognize and build up students’ attitudes and knowledge based on their experience.
• Create an atmosphere in which open discussion builds esteem and is seen as a learning method.

2. Adults learn better when they expect the learning outcomes to be significant for them and their life to come.

Specific strategies:

• Begin the learning process by determining the students’ knowledge and strengths. Next, identify needs, weaknesses and deficits in order to choose the right approaches.
• Establish goals and directions in light of what students want to know and what they feel and are able to do.
• Allow goals and directions to emerge and address them through the learning experience, as opposed to identifying them from the outset.

3. Adults learn better when they have an active role in making decisions and planning their learning experience and when authority is shared.

Specific strategies:

• Identify and make use of students’ skills, enabling them to make choices regarding their future.
• Promote participative decision making during the learning experience.
• Give students frequent opportunities to discuss their experiences with their supervisor and other field/clinical staff and to make any necessary changes.

4. Adults learn better when knowledge and learning are working in synergy.

Specific strategies:

• See that learning focuses on a task, problem or further development, not on the student.
• Use learning activities that help students discover the personal impact of their ideas.
• Encourage students to trust themselves and outside resources.
• Encourage students to incorporate outside learning of personal significance.
• Supervisor and student embark on an experience of mutual exploration and discovery.
• Be confident that interaction between supervisor, field/clinical staff and student can generate more knowledge and understanding than the individuals could acquire on their own.
• Tolerate ambiguity and help others do the same.

5. Adults learn better when they have the opportunity to work with ideas and experiences acquired in learning situations.

Specific strategies:

• Allow students to ask questions and find answers to them.
• Allow students to generate, formulate and clarify ideas.
• Give students the opportunity to practise newly learned behaviours in a safe, helping environment.
• Recognize and deal with students’ feelings about their ideas and experiences.
• See that students have the time and tools needed to think over their learning, ideas and experiences.

6. Adults learn better when they assess their learning outcomes and abilities and their needs.

Specific strategies:

• Evaluate students through a cooperative method that emphasizes self-assessment.
• End each training period with a comeback on what students hope to achieve next through the training program.
• Help students examine the learning process and discover how to be more skillful, accountable learners.

The supervisor plays a number of roles vis-a-vis students. Hagler & McFarlane (1991) name and describe the following five “training roles”:

• Educator
• Coach
• Mentor
• Counsellor
• Confronter

They write that “A trainer’s ability to recognize which role is appropriate at any given moment guides the coach during interaction with learners at all levels of development. Training is a process of developing excellence while recognizing that not all students are excellent and that even excellent students can have specific performance deficits. Although the five roles are distinct, the goal of each role and the training process as an overarching endeavour is an independent, creative, self-supervising learner” (1991, p. 6).

You will learn to integrate each of these roles into your supervisory duties by asking yourself the following questions:

• What is the right time to use each role?
• What supervisory activities will solidify these roles?
• What effects are these roles expected to have?
• What skills are needed to properly fill these roles?

Paul Hagler and Lu-Anne McFarlane

We stand at a crossroads in clinical education. Behind us are decades of doing the best we could with little more to guide us than our own, sometimes painfully acquired, preferences about supervision. Around us lie fragments of new information about this complex process. This information tells us that quality supervision requires special training, that supervisors tend not to change their behaviour in response to differing student needs, and that much of what we do while interacting with students is at odds with sound theory. Ahead of us at this crossroads lie choices. We can choose to pursue supervisory training. We can decide what should go into that training. We can equip ourselves to be responsive to individual students’ needs by learning about our conference interactions and what governs them. We can begin to implement sound theory in clinical education and examine the effects on our students and their clients.

This guest editorial is an attempt to apply leadership theory from business management to supervisory theory in a rehabilitation discipline. The intent is to help rehabilitation professionals respond to individual student needs by providing a practical framework for their interaction with student clinicians. The goals of business and rehabilitation are obvious. The goal of business is to make money and the goal of rehabilitation is to provide quality health care. Not so obvious, at first glance, is that the leadership and educational skills that help business leaders guide their employees to be successful money-makers look amazingly like desirable clinical educator skills, as they are described in our literature.

To be a good supervisor, in the clinic or in the business environment, is to be many things to those one supervises. Supervisors are teachers, skill builders, advocates, confidants, and critics. In fact, “coach” may be a better term than “supervisor”. The term “supervisor” connotes a person who ensures minimally acceptable performance from supervisees. The term “coach” means to facilitate. “Coaching does not mean to make less demanding, less interesting or less intense. It means to make less discouraging, less bound up with unnecessary controls and complications” (Peters & Austin, 1985, p. 326). Coaching recognizes the many different roles we fill as clinical educators. Peters and Austin (1985) outline five coaching roles: educator, coach, sponsor, counsellor, and confronter. A coach’s ability to recognize which role is appropriate at any given moment guides the coach during interaction with learners at all levels of development. Coaching is a process of developing excellence while recognizing that not all students are excellent and that even excellent students can have specific performance deficits. Although the five roles are distinct, the goal of each role and the coaching process as an overarching endeavour is an independent, creative, self-supervising learner. Following are examples of the five coaching roles, along with brief discussions of the distinguishing characteristics, applications, and outcome of each role.

Educating

When the Occupational Therapy Department at the Foothills Hospital in Calgary wanted to structure its orientation process for students, it created a video tape on writing individualized student learning objectives to teach self-directed learning (Foothills Hospitals, 1990). The video tape follows the supervisor/clinician from her first meeting with the student through the early portion of the placement. It is a colourful and realistic portrayal of a good working relationship between the two principal parties. They are depicted as partners, one more knowing, the other less knowing, who share a common goal. The student nervously tackles clinical tasks with a healthy measure of enthusiasm. There is evidence of the student’s potential to contribute as an active member of the professional staff. The video presents the student as a partner in the decision making process about the direction to be taken by her newest learning experience. The role and implementation of learning objectives in the structured clinical education process are emphasized.

What the video tape illustrates, and what Peters and Austin (1985) maintain, is that educating is not just giving information. It is a demonstration of the belief that, with a little bit of information and guidance, even the new learner can contribute creatively to clinical services. It provides clear, manageable expectations, and it demands more attention to progress and reinforcement of the student than other coaching roles. Education “. . . means giving people a chance to experiment a little but from the start and to learn the difference between mistakes and disasters, between satisfactory and exceptional” (Peters &Austin, 1985, p. 341).

Educating is best suited to new learners who may be first practicum students or experienced students with new clinical responsibilities. It is especially useful during orientation. Essentially, educating is the role of choice when the educator or supervisor wants to assist the student in the acquisition of new skills. The supervisor creates an atmosphere that is positive and supportive, emphasizing the learning process and the application of academic knowledge to the clinical setting. The “educated” student will feel “talked with” rather than “talked at”. With the availability of practical new information, students will acquire a broader perspective on the practicum site, its staff, clients, and mission. A critical skill for the supervisor is an ability to clearly convey performance criteria early in the placement and at later times when there is evidence of the student’s failure to remember or achieve these criteria. Good supervisors have a knack for using critical incidents as teaching opportunities but always do so with respect for the students’ often fragile self-perception. Educating lays the foundation for later development of professional self-confidence.

Coaching

A university speech clinic initiated use of a supervisory conference outline to encourage student clinicians to begin assessing their own clinical practices. In the past, student clinicians had been observed to be passive during supervisory conferences and resistive to any structured attempts to encourage a more active role. The outline listed topics known to be discussed in conferences, such as assessment of client progress, analysis of the student’s clinical techniques, and report writing. It also listed topics not typically covered in conferences, such as participants’ interest and enjoyment of the session and discussion of student/supervisor interaction. In preparation for their regularly scheduled conferences, students selected discussion topics from the outline and, in the process, developed their own ideas about why they wanted to deal with each topic. Analysis of conference interactions revealed that students initiated more during dialogue with their supervisors and engaged in more complex discussion of retrospective and prospective clinical activities.

Coaching is the bread and butter of clinical education. Students need information. Coaching is a supervisory role best suited for students who already have basic clinical skills and academic preparation. Such students do not require extensive education. General guidance or minor corrections are all that is required. Coaches are encouraging, enthusiastic, and open-minded with regard to the student’s ability to contribute. Good coaches have the ability to listen, even to ideas that do not match their own. They are able to foster a sense of independence and accomplishment in the learner. Coaching refines skills, and skill improvements enhance confidence.

Sponsoring

A physical therapist at a children’s hospital described having arranged observation of a dorsal rhizotomy for her student. This new surgical procedure is performed to reduce spasticity in individuals with cerebral palsy. The procedure was new to the hospital, and physical therapy staff were anxious to learn more about its clinical implications. The student who was extremely competent in the clinic had written a term paper on the procedure. Realizing that this student’s knowledge in this area went beyond her own, the supervisor accessed outside resources. The student observed neurosurgery and subsequently presented the substance of her paper and described her observation experience to the physio staff.

Sponsoring is the ultimate expression of maximizing student potential. It goes beyond coaching by arranging for students to take charge of their own learning and to perform autonomously. It trusts them to solicit help as necessary, reinforcing the notion that recognition of the need for help is at the heart of independence. Autonomy is not a lack of attention. Sponsors take a personal interest in their students’ development, providing feedback on yesterday’s effort and opportunity for tomorrow’s achievement. A special responsibility of sponsors is to help promising learners come to grips with the subtleties of clinical practice. For example, sponsors guide learners on the best way to approach certain clients and coworkers or on how to wind their way through institutional politics. Sponsoring is not mentoring. Mentoring emphasizes “be like me”; sponsoring emphasizes “be yourself”. If supervisors teach their students to be like them, the result is learners limited by their own shortcomings as well as those of their supervisors. If supervisors encourage their students to go beyond the supervisor’s abilities, their students are restricted only by their own limitations. Sponsoring requires a lot of a supervisor, because it means not being threatened by an exceptional student’s skills and abilities. It is difficult to remember that, when a supervisor lets a student shine, the students does so for both of them.

Sponsoring begins when the student’s skill speaks for itself. It sets the stage for the student to make a unique contribution. Sponsoring broadens the student’s professional development by providing special learning opportunities. Sponsors are positive and enthusiastic. They emphasize career development by providing opportunities to showcase each learner’s outstanding skills and contributions. The sponsor attempts, at every turn, to remove barriers to performance. The sponsor relates to the student as a colleague and facilitates access to new people and experiences.

Not all students are excellent, and not all excellent students are so in every respect. Coaching has two roles that recognize this and guide clinical educators in their dealing with students who have gone off track.

Counselling

A speech-language pathology student experienced sleep loss while in her first full-time practicum assignment during the latter part of her program. Her inability to sleep at night was leaving her fatigued during the day which, in turn, adversely affected her practicum performance. The student focussed on her lack of sleep as the problem, and devised her own solution. She reasoned that, if she increased her fatigue at the end of the day, she would be so tired, she would have to sleep. Each evening after studying, she began running at the university’s outdoor track. This failed. Not knowing what else to do she decided to confide in her supervisor. At the close of a regularly scheduled supervisory conference during which the student’s shortcomings had been fairly well covered, the student described herself as having a sleep disorder which might explain some of the trouble she was experiencing. This provided the supervisor with a focus for the concerns she was having about the student’s work. The supervisor asked the student if it was possible that lack of sleep was merely a symptom of something else. The ensuing discussion revealed that this student was probably experiencing anxiety-induced loss of sleep. She was concerned not only about her ability to work with the patients she has been assigned but about her ability to cope with the placement demands in general. Such doubts so late in her academic training had given rise to fears that she was not well suited to a career in speech-language pathology. The supervisor and the student settled on a plan of action. More time would be spent in observation of the supervisor and other speech-language pathologists doing therapy. The student would do some supplementary reading in manageable chunks and discuss these at regular intervals with her supervisor. There would be a gradual, more comfortable return to a full case load later in the placement. They agreed that the running has a certain logical appeal but that doing so, late at night, might actually exacerbate the problem. Vigorous exercise was probably leaving her “pumped up” at a time of day when she should be winding down. They agreed that the running should continue but only in the morning. There was an understanding that expert medical advice was readily available, if their plan proved unsuccessful. Finally they agreed that thoughts about a career change were counterproductive at this stage. The student would require too great an attribution effort, attribution being the tendency for supervisors to respond to students’ behaviours on the basis of their attribution or belief about the causes of those behaviours (Roberts & Naremore, 1983). For example, if the above supervisor had attributed the student’s poor clinical performance to apathy, the story would have ended much differently. Obviously there is a converse relationship at play as well; students respond to supervisors in terms of their beliefs about what causes the supervisors’ behaviours. Recognition of the reality of the phenomenon combined with some basic communication skills such as active listening, paraphrasing, perception checks, and open-ended questions will minimize inappropriate responses to the behaviour of others. Counselling cultivates a closer working relationship between the supervisor and supervisee.

Counselling is needed when problems interfere with students’ clinical performance. When supervisors’ best attempts at educating have failed, counselling is indicated. It is a proactive response to setbacks and disappointments. Counselling puts client service first but treats the student clinician with compassion and respect. When successful, it speeds the student toward improved performance. It can turn a critical situation around quickly. The counsellor shows a willingness to listen and is able to give clear, useful feedback. Later payoffs include an increased sense of belonging and importance on the part of the student who will enjoy a renewed commitment to learning and client care.

Confronting

A physical therapy student has a history of attendance problems in two previous clinical practicum placements. Although illness was always the reported reason for these absences, the student admitted that she was not “really sick” but felt physically unable to cope. Educating and counselling made no difference in either placement. Educating was tried first. The student was shown her own record of days off for illness in contrast to those of the other staff, told how important it was to her patients’ progress that she attend daily, and directed to seek medical advice. When attendance did not improve, involvement of the clinical placements coordinator was invited. The coordinator educated again, this time with respect to the impact of unsatisfactory performance on the student’s academic program. Again she was urged to see a doctor. Her clinical work, when she was there to do it, was minimally satisfactory. Continued attendance problems in her next placement caused the new supervisor and the coordinator to counsel the student. A meeting was arranged, concerns were succinctly stated, and discussion ensued. The plan of action called for the student to acquire time management counselling and to request a full physical examination through student health services. Unfortunately there was only a temporary improvement in attendance, and neither outside source of assistance was sought. Each of these placements ended with low evaluation and hesitant recommendations for passing grades. The coordinator decided that confronting was appropriate, because the student had been given every chance to succeed through timely feedback and guidance. She understood what was expected of her, and what was expected was reasonable. Because of the coordinator’s past involvement, confrontation did not come as a surprise to the student. It was clear that the coordinator intended to do what was best for the student, the training program, the next practicum facility and its patients. The coordinator and student entered into a written agreement which stated that a medical examination would precede the placement, a special attendance record would be maintained, and any unacceptable absences would result in immediate withdrawal from the placement with a failing grade.

A confrontation is a showdown. It puts all the cards on the table with the intent of deciding the outcome of the hand being played. It is done in the best interests of everyone involved. The confronter has in mind specific, measurable standards of a behavioural nature below which the student may not go. Confronting removes any remaining questions about performance-based criteria for the student’s continuation with the responsibilities in question.

Confronting is needed when performance problems persist despite educating and counselling. Confronting focuses clearly on the need for some decisive action and a deadline by which such action will take place. The confronter must try to deal with the facts in an unemotional manner, being as positive and supportive as possible. Like counsellors, confronters provide direct, useful feedback, and listen attentively. Results of confronting may range from success with current responsibilities (or success with new less demanding responsibilities) to failure.

So, is the practice of coaching anything more than common sense? Peters and Austin (1985) described their work as a “blinding flash of the obvious”. If we view it as such, perhaps we pay them the highest possible praise, because common sense applied to human relationships is not really common at all. Furthermore, “obvious” does not translate to “easy”. Being a supervisor coach takes planning, enthusiasm, consistency, dedication to teaching, and an ability to see the unique potential in every student. “The best coaches set in motion a continuing learning process – one that . . . helps people develop a tolerance for their own struggles and accelerate the unfolding of skill and contributions that would not have been possible without the “magic” attention of a dedicated coach. Coaching . . . done well is the best a leader can give” (Peters & Austin, 1985, p. 377).

Recall, from the introduction, that we are at a crossroads. Perhaps this overview of one perspective on the clinical education process will function as a catalyst for action. If only a few of us are motivated to attend workshops or courses in supervision, study human behaviour (our own as well as others), influence professional training programs to include supervision course content, and practise what we know makes sense, then future generations of rehabilitation professionals will enter the clinical teaching/learning process with more confidence, know how, and enthusiasm.

Paul Hagler and Lu-Anne McFarlane
Centre for Studies in Clinical Education
Faculty of Rehabilitation Medicine
University of Alberta