The Roles and Attributes of the Clinical Teacher that Contribute to Favourable Learning Environments: A Case Study from Physiotherapy

Corresponding Author: Mrs DV Ernstzen, Division Physiotherapy, Faculty of Health Sciences, Stellenbosch University, South Africa. E­mail: dd2@sun.ac.za AbSTrAcT: The quality of clinical education is dependent on learning experiences. The clinical teacher plays a key role in successful clinical education. The aims of the study were to determine which roles and attributes of physiotherapy clinical teachers contribute to a supportive clinical learning environment according to physiotherapy students and their clinical teachers. The study protocol was approved by the Committee for Human Research at Stellenbosch University. A qualitative research design was used. An interview schedule was developed based on existing literature. data was analyzed using content analysis. data was coded, categorized and conceptualized into key themes and patterns. All third year (n=40) and fourth year (n=40) undergraduate physiotherapy students and their clinical teachers (n=37) were eligible to participate. Semi-structured individual interviews were conducted with a purposive sample consisting of six third-year students, six fourth-year students and six clinical teachers (n=18). Written informed consent was obtained from all participants prior to the interviews. The teacher as role model and facilitator of learning was emphasised. The attributes of the clinical teacher that created a supportive learning environment were approachability, recognising student abilities and good communication skills. The value of active involvement and individualism in learning was highlighted. The study confirmed that the clinical teacher is pivotal in the success of a physiotherapy clinical education program. The findings agree with the large body of international literature about supportive clinical learning environments.

cal education employed (Higgs 1993, Strohschein et al 2002), student assess ment (Higgs, 1993) and the health care setting (Higgs, 1993) also plays a role in creating a learning environment.
The interaction between clinical teachers and students is the strongest element in developing expertise and forming professional identity in clinical education (LaitinenVaananen, 2007).Furthermore, the students' relation ship with the clinical teacher plays an important part in the students' clinical learning experience (Chan, 2001).The relationship between the clinical teacher and the student has been found to be a better predictor of client outcome than skill or helpfulness of the clinical teacher (Kilminster and Jolly, 2000).Higgs (1993) supports this notion by comment ing that clinical teachers play a major role in ensuring entrylevel competence.The clinical teacher is thus pivotal in the

INTRODUCTION
Clinical education forms a core part of physiotherapy training and is essential to develop clinical skills (Lekkas et al, 2007, Mbambo, 1999, Strohschein et al 2002).Kilminster et al (2007) defines the clinical educational process as the provision of guidance and feedback on personal, professional and educational development in the trainee's experience of providing appropriate patient care.The quality of the clinical learning expe rience is influenced by several factors.These factors influence the learning environment and have been identified as the roles and attributes of the clini cal teacher (Bennet 2003, Cross 1995, Harden and Crosby 2000, Kilminster and Jolly 2000, Onuoha 1994), and the clinical instructional model used (Babyar et al 2003, Stalmeijer et al 2009, Walker and Openshaw 1994, Williams and Webb 1994).The model of clini achievement of learning outcomes by physiotherapy students (Cross, 1995).
Several changes have taken place in the aim and delivery of physiotherapy clinical education (Mbambo 2005).The changed role of the physiotherapy clinical teacher extends beyond super vision to include being a facilitator and manager of learning (Hewson 2000, Higgs 1993).For example, Stalmeijer et al (2009) advocates a cognitive appren ticeship model for instruction, consist ing of modelling, coaching, scaffolding, articulation, reflection and explora tion.Thus cognitive and noncognitive attributes of the clinical teacher plays a role in creating a supportive learning environment (Bannister et al, 2010).
There is a need to determine which factors affect the delivery of good clini cal education in contemporary practice.In particular, the roles and attributes of clinical teachers need to be explored in order to inform clinical teachers and to guide clinical educator training pro grams.No previous studies on the roles and attributes of physiotherapy clinical teachers in the South African context were found.Studies focussed mainly on the needs of clinical educators (Mbambo 1999, Mothabeng 2006).Furthermore, Delany and Bragge (2009) found incongruence between the expectations that students and clinical teachers have about learning.They found that teachers described their role relating to imparting knowledge, and students required a pro cess of facilitating learning.Hayajneh (2011) performed a critical incident study amongst nursing students in Jordania and found that the beha viours of clini cal instructors identified as enhancing their learning in the clinical setting were mainly those already identified in the literature as good teaching in nursing practice.It is important to highlight that this possibility also exist in physio therapy clinical education.
The purpose of this study was to determine undergraduate physiotherapy students and their clinical teacher per ceptions of the roles and attributes of the physiotherapy clinical teacher that contributes to a supportive clinical learn ing environment.

Research design
A qualitative research approach was used.Golafshani (2003) emphasizes that the qualitative research approach seeks to come to an understanding of a context specific, real world setting without manipulating the setting.The study reported on in this paper, formed part of a larger mixed method study that employed quantitative and qualita tive methods.This article focuses on the second phase of the study where qualitative methodology were employed to explore the roles and attributes of transcriber.Participants were invited to view and comment on transcripts to assist with validation (Creswell 2003, Mays andPope 1995).

Data analysis
The data was analyzed by the primary researcher using content analysis.The transcripts were interpreted using spe cific analysis strategies (Creswell 2003, Krippendorf 2004) including familia risation with the data, interpreting the data by coding, categorizing and con textualizing texts.An external auditor, supervising the research process checked the initial coding to aid validation.The codes were then revised into final codes which were grouped into categories by the researcher in conjunction with the external auditor.Categories lead to the development of patterns and themes within the data to explore their possible relationships.

Ethical considerations
The protocol for the study was approved by the Committee for Human Research at the FHS, SU, SA.Permission to under take the study was obtained from the Division Physiotherapy chair person.Written informed consent was obtained from participants prior to the interviews.

RESULTS
A profile of the population and interview participants is included as Table 1.

Key findings
The key roles and attributes of the clini cal teacher that influences the learning environment were identified as: The teacher as role model

Participants
All enrolled undergraduate physio therapy students at SU who had clini cal experience, and all physiotherapists involved in the clinical education of these students during 2005 were eligible to participate.Purposive sampling was used (Creswell 2003).To ensure rich data, six participants from each of the three groups (third year students, fourth year students and clinical teachers) were chosen via random number gen eration and were invited to participate.
Table 1 provides a profile of the popula tion and sample.

Instrumentation
Data was generated using onetoone, semistructured individual interviews.These interviews were conducted dur ing the students' final clinical rotations.Topics discussed in the interviews are included in the main interview sched ule given in Box 1. Probing questions were used to develop a deeper under standing of participants' accounts of learning.Interviews were conducted by the primary researcher in English or Afrikaans according to the choice of the parti cipant.The interviews were recorded using a digital voice recorder and was down loaded and stored on compact discs (CD) after the interviews.Each inter view, lasting an average of 20 minutes, took place at the Division Physio therapy, SU.Unique serial numbers were given to each CD data set.Interview data was transcribed by an independent  These key roles and attributes, together with its components and substantiating verbatim quotes from the participants are represented in Table 2.
The teacher as role model for profes sional conduct was one of the strongest themes.The teacher was confirmed to model personal and professional skills such as interpersonal, technical and cognitive skills.
The teacher's role dual role as facilita tor of learning and assessor of learning influenced the learning process.Student participants particularly focused on what the teacher requires (or would like) during the assessment of clinical competence.This aspect of wanting to please the clinical teacher could influ ence the students own learning goals and the goals of the clinical rotation.The teacher as assessor may hinder the openness of the learning atmosphere as students noted that they become anxious at the thought of the teacher as assessor.Students highlighted this dichotomy more than teachers did, which could indicate that clinical teachers might be unaware of the influence of this dual role on learning.The influence that these two aspects have on each other thus needs further assessment.
Approachability of the clinical teacher was the strongest attribute of the clini cal teacher to create a supportive learn ing environment.Participants were able to determine if the clinical teacher is approachable through verbal and non verbal communication.
Another strong theme that emerged from the interviews is the clinical teacher's personal interaction with the students.A teacher with good interper sonal skills, who is able to connect with the students, was seen as a good clinical teacher.A good clinical teacher was also thought to be responsive to what to the students have to say.Communication and teaching on the level of the students, and respect for the difference of power in the relationship were also strong com ponents of personal interaction.The role of the teacher in ascertaining the learn ing needs of each student according to that student's specific level of develop ment and experience was emphasised.

DISCUSSION
This qualitative study provides informa tion on students' and teachers' perspec tives of the teachers' role in learning production in a clinical setting, and adds to the body of knowledge on effective clinical teaching processes and practices for physiotherapy.The findings indicate that the clinical teachers' role in clinical education surpasses the role of provision of teaching and learning activities, and extends to personal and professional fac tors.Clinical teachers thus have a multi dimensional purpose in the academic, personal and professional development of a student.The results thus confirm the findings of Chan (2001) and Hewson (2000) that the clinical teacher plays an important role in establishing an environ ment and atmosphere that is conducive to learning.This study may contribute to knowledge base about aligning expec tations on learning and teaching between students and clinical teachers to enhance the effectiveness of clinical education, as advocated by Delany and Bragge (2009).The findings of the study is aligned with the cognitive apprenticeship model (Stalmeijer et al 2009), which advocates a clinical instructional model involving modelling, coaching, scaffolding, arti culation and exploration.However, one aspect of this model, namely reflection did not feature strongly in the study and needs further exploration.
The teacher as role model was a strong theme in this study.The litera ture is clear on the powerful effect the teacher as a role model has on learning

• Clarification of expectations
The first two days is important in the clinical block.A step for step approach on how to go about managing the clients is useful.
A good orientation program, where expectations are clarified, and administrative aspects are dealt with, helps the students to focus on learning.

• Articulate
A good clinical teacher is an enthusiastic person who can be assertive towards the student and can take leadership.
It is good to be enthusiastic and show that you enjoy the profession.
*Some quotes have been translated form Afrikaans to English for the purpose of this manuscript.(Bandura, 1986in Schunk, 2004, Harden and Crosby 2000).Role modelling is a powerful means of teaching values, attitudes and patterns of thought and behaviour in the social cognitive theory of Bandura, (1986in Schunk, 2004).
The clinical teacher is perceived as a role model of health care provider in the sphere of communication with the patient, caring for the patient and know ledge dissemination.Students particu larly observed the teacher's attitude and skills toward teaching, and the way the teacher manages the patient.
The teacher as assessor of learning is an integral and important role of the clinical teacher (Harden and Crosby, 2000).However, the findings of the study indicate that the dual role of the clinical teacher as facilitator of learn ing and assessor of learning could have detrimental effect on the atmosphere of learning, the learning process and the learning goals of the student and pro gramme.The findings above empha sises the need for clinical teachers to cre ate an open atmosphere of trust, where students can learn from their mistakes.The influence that assessment has on learning in this context needs to be further explored.
Student and teacher participants valued facilitation of learning and individualism as an important part of creating a sup portive learning environment.In view of the participants, facilitating learning signify assisting the student at his or her point of need.This finding concurs with that of Delany and Bragge (2009), who found that the clinical teachers in their study responded to the levels of knowl edge and skill of the student and adapted their guidance to be in line with the stu dent needs.This notion also concurs with the concept of task maturity (con fronting the student with a task that is on his competency level) (Higgs (1992) and scaffolding (providing appropriate building blocks for learning for an indi vidual) (Bandura, 1986in Schunk, 2004, Stalmeijer et al 2009).
The participants in this study suggested that facilitation of learning be utilised as gentle guiding towards an outcome, where the student is given sufficient opportunity to be involved.This need for active participation in learning and thus articulation was expressed by students in this study as well as by participants in studies by LaitinenVaananen (2007) andStalmeijer et al (2009).Students want to be recognised for their abilities and contribution to patient care (Hayajneh 2011).In the current study, recognition of abilities is manifested when teach ers do not dominate learning sessions, but facilitates learning sessions, giving the student the opportunity to explore.A dominant clinical teacher who takes over procedures inhibits initiative and decreases motivation (also supported by Williams and Webb, 1994).This study found that clinical teachers' recognition of students' abilities, expressed through giving positive feedback, had a power ful effect on the motivation of students.
Students valued the personal attention they received from the teacher.Nursing students, in a study by Chan (2001) also found this aspect valuable in enhanc ing the learning process.Furthermore, Williams and Webb (1994) found that a personal relationship with the clini cal teacher who demonstrates empa thy, encouragement and care, assisted learning better than any other attribute.Clinical teachers who recognise students as team members and display the quali ties of encouragement and support were perceived as providing a supportive learning atmosphere.The consequence of such a learning environment might be rich personal growth as the student and teacher function as a team to achieve learning and personal goals.
The attributes that formed the strong est themes in this study was approach ability, interpersonal skills and recognis ing student abilities.These three factors, together with individualism could be interdependent on each other.Cross (1995) identified approachability as the most important attribute of the clinical teacher.The participants in the study understood approachability to mean the creation of a learning atmosphere where students are free to ask questions with out feeling threatened.Approachability contributes to a learning atmosphere that is risk free (Hewson, 2000).

Implications for practice
The findings of this study may guide clinical education training programmes for clinical teachers.It may contribute to the alignment of student and clinical teacher expectations, therefore enhanc ing the clinical education process.The findings of the study highlight the notion that the teacher's approach to the stu dent and the learning situation plays an important part in facilitating learning.Clinical teachers should be aware of the powerful role they play in student learning.This role includes the provi sion of teaching and learning activities, as well as personal and professional development.

Limitations
A number of limitations need to be con sidered which could impact the inter pretation and generalisability of the study.It should be acknowledged that, at the time of the study, the researcher was a lecturer in the Division Physiotherapy and this aspect could have played a role in the responses of the interview ees.However, due to the similarity of findings of this study with international literature, this aspect seemed to have had a limited effect.Participants in the study could only reflect on learn ing experiences and clinical teachers to which they were exposed to.Thus the study findings can only be general ized to similar contexts.A more diverse exposure to teachers and activities may provide other findings.Most of the par ticipants were female, and a gender bias could thus exist.Furthermore, the study focussed on the clinical teachers' influ ence on learning, but a more holistic study which includes the students own personal and professional factors that affects development is advisable.

CONCLUSION
The study confirmed that the clinical teacher is pivotal in the success of a physiotherapy clinical education pro gram.A good physiotherapy under graduate clinical teacher is thus a person who models professionalism, expertise and holistic care to both the patient and the student, and assist the student as an individual to develop academically and professionally.The finding of this study agrees with the large body of international literature about support ive clini cal learning environments.
Describe your best clinical learning/teaching session (story or incident) OR Describe your ideal clinical learning/teaching session (story or incident) Specific probing questions What influence does the clinical teacher have on your learning?-Probe for positive experiences -Probe for negative experiences How and why does it influence you?What, in your view, are the characteristics of a good clinical teacher?-Motivate your choices

Table 1 : Profile of the case population and participants 3 rd year students 4 th year students clinical teachers POPulATiON
*23 clinical lecturers and 14 clinicians in this category.