3 The Clinical Learning Environment

Students in health-care education programs at universities complete practicums in a clinical learning environment in addition to attending academic classes. Clinical practicums are considered essential to professional competence in most health-based professions. For example, clinical practicums are viewed as essential to the curriculum by programs in medicine (Ruesseler & Obertacke, 2011), nursing (Courtney-Pratt et al., 2011), pharmacy (Krueger, 2013), physical therapy (Buccieri et al., 2013; McCallum et al., 2013), occupational therapy (Rodger et al., 2011), dietetics (Dietitians of Canada, n.d.), radiation therapy (Leaver, 2012), paramedic training (McCall et al., 2009), and dental hygiene (Paulis, 2011). Internationally, clinical practicum placements for students in these and other health-care disciplines are in markedly short supply. Available placements might be in programs offering care only to seriously ill clients, might be inundated with learners from the health disciplines, and might be experiencing budget cuts and staff shortages (Brown et al., 2011; Roger et al., 2008).

The real-world learning environment in which students in the health professions complete their clinical practicums is an “interactive network of forces” (Dunn & Burnett, 1995) rich in opportunities for learners to transfer theory to practice. Sequences of learning activities in unpredictable clinical environments can be more difficult to plan and structure than in traditional classroom environments. Both planned and unplanned experiences must be taken into account.

Following direction from a curriculum is a widely used planned learning experience in the clinical learning environment of any professional health-care program. At the curricular level, clinical practicums are usually arranged before students are granted admission to their programs of study. A curriculum is the range of courses and experiences that a learner must complete successfully in order to graduate. Curricula are expected to include philosophical approaches, outcomes, designs, courses, and evaluation strategies. Clinical practicums can be structured as courses in the curriculum, either as part of a theoretical course or as a stand-alone course. Clinical practicums must be considered in relation to available health-care facilities that are able to accommodate students.

Curricula in programs that educate future practitioners in health fields are strongly affected by requirements of professional associations, regulatory agencies, and approval boards (Melrose et al., 2020). Curricula must address discipline-specific competencies. Throughout the process of curricular planning, program planners from educational institutions must negotiate with administrators of service agencies to find suitable clinical practicum sites.

Since the education of health-care professionals now occurs in universities rather than in the agencies providing services, designing, negotiating, and evaluating clinical practicums in relation to the overarching curriculum is seldom a linear process. One consideration is program structure or the duration and division of learning to be undertaken by students. Here modes of delivery matter: program structure could be framed within face-to-face settings in traditional classrooms, distance delivery, or a blend of them. Partnerships between institutions and consortiums or collaborations among institutions also matter. When programs are structured to be delivered at a distance, learners might have to travel and find accommodations in different geographical areas in order to attend their practicums. In both face-to-face and distance programs, international practicum experiences might be available and even required.

Another consideration is the program model or organization of required courses, elective courses, laboratory experiences, and clinical practicums within the curriculum. In clinical practicums, the program model guides the method of instruction to be used. For example, the program model might require that students are taught in small groups by a clinical instructor, in one-to-one interaction with a preceptor, or in a combination of these and other instructional methods.

In the health disciplines, coordinating instruction extends well beyond the actual institutions of learning and into clinical agencies. Schedules, faculty appointments, and budgets must all be addressed. The instructors and preceptors who teach students during their clinical practicums might have no other association with the university. Similarly, university faculty assigned to teach in a particular clinical area might have no current association with a particular agency.

Program design configures the program of studies, including the courses selected, practicum experiences, relationships among courses, and policies that communicate this information. Designs can include building with blocks of required study, building by spiralling back and adding to previous content at different points, and establishing opportunities for specific tasks such as an essential psychomotor skill. Clinical teachers seldom have input into how programs are structured, the type of model used to organize content, or the design influencing how and when information is presented. However, all those involved in educating students must seek a basic understanding of the “big picture” curriculum that students follow.

Traditionally, curricular organizing strategies often revolved around the medical model. The hospital areas of medicine, surgery, pediatrics, maternity, and psychiatry framed the focus of learning for health practitioners. This model is strongly aligned with hospital-based apprenticeship orientations to learning and is now considered somewhat outdated in today’s complex and ever-changing health-care system (Benner et al., 2010; Diekelmann, 2003; Tanner, 2006).

Today programs are more often organized within a conceptual framework generated in the discipline or around the outcomes expected of grad­uates. For example, with outcomes such as promoting health, thinking critically, and making decisions, curriculum planners would organize content related to each of these outcomes in different courses throughout the program. Methods of evaluation would be determined in relation to these outcomes, and they would include a wide range of educational measurements. Examples are multiple choice exams and scholarly papers in academic classes and skill mastery or client communication in clinical practicums.

Levelling is the process of linking program content, introduced at different times and in different courses, to the evaluated outcomes expected of graduates. Levelling requires planned opportunities for students to build on their previous knowledge and work incrementally toward achieving more complex outcomes. However, if a limited number of clinical placements are available, scheduling appropriate clinical opportunities for students at all levels is particularly challenging. Introductory-level students might find themselves in practicums in which they must care for acutely ill individuals. In many instances, practicum placements are more suited to advanced learners than to students in basic health-care programs.

Furthermore, instructors, staff members, and students can find it difficult to link the learning outcomes and evaluation methods that flow from a program’s unique conceptual framework with the day-to-day work of a clinical agency. This might be another consequence of the limited associations between universities and clinical agencies. Although links between learning outcomes and day-to-day practice are made during planning by representatives of universities and agencies, the links might not always be clearly communicated to staff actually working with learners.

Admission criteria are another important curricular element in appreciating the complexities of planned aspects of clinical learning environments. Some learners come to a health-related program of study with less than a high school education. Others come to postsecondary education with high school completion but are introduced to a college, technical institute, or university for the first time. Still others have at least one level of certification or an undergraduate or graduate degree. At any level, qualifications for admission might have been completed in another country and in another language. Learners might also have been awarded credit for prior learning or transfer programs.

Clinical agencies often host learners from a variety of different programs, and admission requirements will be different for each program even within the same discipline. For example, whereas one registered nurse program might require high school completion, another might accept adult learners who have completed bridging programs. Inconsistent admission criteria among programs can leave agency staff members unsure of what learners are expected to know when they arrive, particularly when coupled with learning outcomes and evaluation methods that might not seem to be straightforward. In turn, staff can feel confused about how learners should be progressing and the specific task-based competencies that they should be achieving.

Curricular structure, model, design, outcomes, evaluation methods, and admission requirements of a program are planned with great care. They offer big picture direction and open doors for learning in the clinical environment. Even so, unpredictable events are sure to emerge once clinical practicums are under way. In the following section, we discuss the heart of any clinical learning environment for many students, instructors, and staff, the unplanned aspects of clinical learning.

The clinical learning environment is equivalent to a classroom for students during their practicums (Chan, 2004), yet few clinical agencies resemble traditional classrooms. In their clinical classrooms, learners hope to integrate into agency routines and feel a sense of belonging (Levett-Jones et al., 2008). Learners want to feel welcome and accepted by staff, and they want staff to help teach them how to practise confidently and competently (Courtney-Pratt et al., 2011; Henderson et al., 2012). Students require and expect feedback on their performance, and they must have opportunities for non-evaluated student-teacher discussion time (Melrose & Shapiro, 1999) and critical reflection (Duffy, 2009; Forneris & Peden-McAlpine, 2009; Mohide & Matthew-Maich, 2007). Learners need time to progress from one level of proficiency to another (Benner, 2001). Just as learners in classroom environments need support to develop competence in their chosen professions, learners in clinical practicums need a supportive clinical learning environment.

Although supportive clinical classrooms are hoped for, clinical teachers must also be well prepared for unplanned experiences that raise barriers to learning. Research suggests that clinical learning environments might not be as supportive as learners would like. For example, Brown et al.’s (2011) work with undergraduate students from 10 different health disciplines reveals significant differences between learners’ descriptions of their ideal learning environments and what they experience during their actual clinical practicums. Although participants in Brown et al.’s study express satisfaction with their learning experiences, they describe a mismatch between what they hoped for and what actually occurred. Similarly, recently graduated nurses indicate significant differences between the kinds of practicums that they deem good preparation for practice and those that they actually attended (Hickey, 2010).

Investigations of the experiences of physical therapy students were unable to define conclusively a quality learning environment, in part because of the diverse instructional practices by different community agencies overseeing students’ practicums (McCallum et al., 2013). Over the past decade and in several different countries, student nurses rated their clinical experiences higher for their sense of achieving tasks but much lower for accommodating individual needs and views (Henderson et al., 2012). Although university students are encouraged to question existing practice and the status quo, they find that staff in their clinical placements are seldom open to innovation or challenges to routine practices (Henderson et al., 2012).

Staff shortages, and other issues with which clinical agencies struggle, can leave students feeling that they are not receiving the direction that they need and that they are a burden to staff (Robinson et al., 2007). Students might feel alienation rather than the sense of belonging that they hope for (Levett-Jones et al., 2009). Students might express fear and discomfort in their relationships with staff (Cederbaum & Klusaritz, 2009, p. 423). Clinical learners have felt rejected, ignored, devalued, and invisible (Curtis et al., 2007). These findings suggest that in some instances health-care students are not receiving the support that they need.

By acknowledging that both unplanned and planned aspects of learning will occur in all clinical learning environments, educators can plan fitting responses. Clinical agencies will always have a professional duty to prioritize safe patient care over providing learners with clinical classrooms that align with their curricular and individual needs. As a consequence, and in spite of careful planning by university and agency program representatives, students might perceive their learning environment as unsupportive.

However, international leaders in the health disciplines are calling on clinical agency staff to view clinical teaching as part of their own professional development. They ask clinical agency staff to aid the next generation of professionals by striving to provide quality clinical learning environments in which students do feel supported (Courtney-Pratt et al., 2011; Koontz et al., 2010). Programs are testing new models of instruction (Franklin, 2010). Individual clinical teachers are striving to implement innovative teaching approaches that can create mutually beneficial connections between learners and staff during clinical practicums. Recognizing when unplanned aspects of clinical learning environments distract from students’ learning is an important first step in triggering change. Evaluation surveys are one way to cast a spotlight on troublesome areas.

Clinical Learning Environment Inventory. Surveys to measure the quality of clinical learning environments are available. For example, the Clinical Learning Environment Inventory (CLEI) was developed in Australia by Chan (2001, 2002, 2003) to measure student nurses’ perceptions of psychosocial elements in clinical practicums. The CLEI consists of an “Actual” form that assesses the actual learning environment and a “Preferred” form that assesses what the student would like ideally in a learning environment. The CLEI is a self-report instrument with 42 items classified into six scales: personalization, student involvement, task orientation, innovation, satisfaction, and individualization. Students respond using a four-point Likert scale with the response options “Strongly agree, ” “Agree, ” “Disagree, ” and “Strongly disagree.” Inventory factors of the instrument have been modified to include student centredness (Newton et al., 2010).

The CLEI has also been abbreviated to a 19-item scale measuring students’ satisfaction with their actual learning environment in two aspects of their clinical experience: clinical facilitator support of learning and clinical learning environment. The Clinical Learning Environment Inventory-19 (CLEI-19; Salamonson et al., 2011) is shown in Table 2. The CLEI-19 can be used in formal processes of evaluation implemented by university program evaluators. It can also be used more informally by agency staff and clinical teachers interested in strengthening their clinical classroom environments.

Table 2—Abbreviated Clinical Learning Environment Inventory (CLEI-19)

Note. Clinical facilitator support of learning component: Items 1, 2R, 4, 6, 8R, 9, 10, 12R, 14R, 16, 17R, 18R. Satisfaction with clinical placement: Items 3, 5R, 7, 11R, 13R, 15, 19. Items are scored 5, 4, 2, or 1 respectively for responses SA, A, D, and SD. Items marked with R are scored in the reverse manner. Omitted or invalidly answered items are scored 3. Adapted with permission (Salamonson et al., 2011).

Incidental learning. Adult educators Marsick and Watkins (1990, 2001) name learning that occurs as a by-product of doing something else incidental learning. Incidental or unintentional learning differs from formal learning, in which learners register with educational institutions to complete a program of study. Incidental learning also differs from informal learning, in which learners intentionally seek further information, for example, by joining a study group.

Although incidental learning is unplanned, learners are aware after the experience that learning has occurred. Incidental learning occurs frequently while a person is completing a seemingly unrelated task, particularly in the workplace. It is situated, contextual, and social. It can happen when watching or interacting with others, from making mistakes, or from being forced to accept or adapt to situations (Kerka, 2000). Clinical practicums, both those that students find supportive and those that they do not find supportive, offer unprecedented opportunities for incidental learning. Tapping into these opportunities can turn potentially negative experiences into positive ones.

In sum, the clinical learning environment is one of the most important classrooms for pre-service students. This environment offers a range of planned and unplanned opportunities for learners to practise and achieve the competencies that they need. Clinical placements are in short supply for most disciplines and might not always be as supportive as learners hope. Clinical teachers can find foundational guidance for their own courses in curricular structure, model, design, outcomes, evaluation methods, admission requirements, and tactics for levelling student learning.

Both unplanned and planned aspects of learning must be expected. University training programs for health professionals are separate from most clinical agencies, so clinical staff responsible for guiding learners might not be fully aware of their programs. Instruments such as the CLEI -19can serve as a measure of how students perceive their clinical practicums. Ensuring that incidental or accidental learning is acknowledged and celebrated can begin to turn potentially negative clinical experiences into times of valuable learning.

Teaching in the health-care professions is a dynamic process. Practitioners can share their clinical expertise with novices beginning their careers or with more expert colleagues advancing their knowledge. One of the strongest motivators for becoming a clinical instructor is a desire to influence students’ success and shape the next generation of health-care professionals in your discipline, ultimately influencing the quality of care provided by future practitioners (Penn et al., 2008). Clinical teachers are influential role models who continuously demonstrate professional skills, knowledge, and attitudes (Davies, 1993; Hayajneh, 2011; Janssen et al., 2008; Mohammadi et al., 2020; Okoronkwo et al., 2013; Perry, 2009).

The influence of employment category. Employment categories exert an important influence on the clinical teaching role. Some clinical teachers are full- or part-time employees of universities or agencies hosting clinical practicums. Workloads for these teachers are negotiated with their employers, and they are given release time for preparation and attendance in their assigned clinical areas. Other clinical teachers might be employed only on a contract basis.

Over the past decade, contract faculty have become the new majority at universities (Charfauros & Tierney, 1999; Gappa, 2008; Meixner et al., 2010). Contracts can offer positions such as limited-term full-time faculty (Rajagopal, 2004), part-time faculty, sessional instructors, term instructors (Puplampu, 2004), and adjunct faculty (Meixner et al., 2010). These faculty “are paid per course taught and are seldom offered benefits such as health insurance or access to retirement plans” (Meixner et al., 2010, p. 141). Clinical teachers can be employed in different ways and at several different institutions.

Although contract employment offers employees flexibility and independence, workers who are employed on a contract basis might feel less secure in their jobs, and their sense of well-being can be negatively affected (Bernhard-Oettel et al., 2008). Contract employees can feel marginalized and disadvantaged (Guest, 2004).

In university health-care programs, PhD qualifications are usually required for permanent academic positions, leaving many highly skilled practitioners underqualified (Jackson et al., 2011). Often clinical teachers continue their own education through graduate studies at the master’s or doctoral level while they are instructing in clinical practicums. However, contract work might not accommodate the time that clinical teachers need to complete assignments for their own studies or to attend to family matters. Given the high demand for placements at clinical agencies, the times that students are scheduled to attend practicums cannot be altered, and substitute instruction is seldom available.

Uncertainty about whether their limited employment contracts will be continued can leave clinical teachers hesitant to risk implementing new ideas. Students’ evaluations of teachers can reflect issues that are beyond teachers’ control, yet these evaluations influence contract renewals. Student feedback is the main form of assessment of clinical teachers (Center for Research on Teaching and Learning, 2014; Fong & McCauley, 1993; Kelly, 2007). For some practitioners, contract employment with a university can seem to be less predictable than a clinical agency position.

In most instances, becoming a clinical teacher involves self-orientation to the practicum placement area. Instructors who are new to the particular clinical setting in which they will be teaching or who have not practised there recently often choose to “buddy” or partner with an experienced staff member. Teresa Evans shares the following suggestions.

1. Call and make an appointment for your buddy shifts (it is often good to do 2 days in a row).
2. Make an appointment to meet with the unit manager during that time. It is good to know that everyone is starting on the same page, and clear communication from the beginning is essential. Some things to discuss with the unit manager include the following.
   1. Determine when you will start, how long you will be there, and which days of the week you will be there (roughly). The placement coordinator will send out a letter containing the relevant infor-mation to the facility in advance of your clinical starting date.
   2. Give the unit manager a course outline and talk a bit about what you hope students will get out of this clinical experience.
   3. Briefly go over the assignments that the students are to do during the course.
   4. Ask the unit manager about their expectations of you and the students. (What worked well in the past? What would the manager like to change?)
   5. Discuss your expectations of the staff.
3. Go through policies and procedures that will be used during the course of the clinical experience (e.g., administering blood and blood products).
4. Ask the staff which typical skills, conditions, and interventions they see or perform on a regular basis. Ask questions about them. You might want to find some research on them for your clinical binder.
5. Understand how the normal routine of the day goes.
   1. When are meals?
   2. When are vital signs typically taken if they are routine?
   3. How often is bedding changed? Where does soiled linen go?
   4. Get help learning how to use the assist tub if necessary.
   5. Where is report taken? When does report occur?
   6. What are the physio/occupational therapy schedules?
6. Look through the charts and have someone run through typical charting for the day and expectations regarding times of completion.
7. Do an admission or have someone walk you through the admission process.
8. What needs to be done for discharges? Transfers?
9. Orientate yourself to where all the supplies are. Go through all storage areas so that you know where everything is.
10. How are medications given and by whom? Do students usually have a separate binder for their own patients? Who has keys to the medication carts, and how many are there?
11. Your primary role during your buddy shift is to get to know the staff and have them get to know you. Also discuss what you and the students will be doing on the floor.
    1. Clarify which year the students are in.
    2. Mention which skills they can do (it can be helpful to bring a year skills list and post it for the staff).
    3. Determine the role that you need the staff to fulfill.
    4. Clarify what the students will do on the floor (e.g., charting, vital signs, bed baths, etc.).
    5. State your expectations of the staff.
12. Do morning care, assessments, and vital signs, and then ask to chart and have a staff member look over the information to make sure that it is complete.
13. Talk with the unit clerk, the crucial gatekeeper of information. Ask the clerk what typically happens when orders are received, where to put charts, how orders are processed, what to do if supplies need to be ordered, and so on. Unit clerks sometimes have concerns about students, especially when they take charts and do not understand orders that need to be processed, so discuss this with them in advance.
14. Look through patient charts to get a feel for how they are set up and what types of patients the unit generally receives.
15. Are there clipboards on which vital signs are recorded? Where are they recorded in the charts?
16. Ask staff how they know if samples (urine, sputum, etc.) need to be collected?
17. Ask about which certifications are needed to work on the floor. It might be prudent to talk to the appropriate individual and see if you can set up a date and time to complete these certifications if necessary (e.g., IV starts and central lines).
18. Are there teaching tools that the unit uses for patients? Review them so that you are familiar enough with them to alert students to them when they need them.
19. If you are not familiar with any of the equipment, then arrange an in-service (e.g., IV pumps, vital machines, glucometers, lifts, etc.).

Hint: Instructors set an example for students to follow. Ensure you are as prepared as possible.

Nursing is a team profession. Encourage your students to embrace interdisciplinary team work where appropriate.

TERESA EVANS, MN, NURSING INSTRUCTOR, GRANDE PRAIRIE REGIONAL COLLEGE

Transitioning from practitioner to educator. As with any career change, the transition from practitioner to educator can cause feelings of anxiety, isolation, and uncertainty (Anderson, 2008; Dempsey, 2007; Heathcote & Green, 2021; Jetha et al., 2016; Little & Milliken, 2007; McDermid et al., 2013; Penn et al., 2008; Rodger, 2019). Although specific tasks required of clinical teachers can be learned, the language, culture, and practices of a university can be unfamiliar and difficult to grasp (Penn et al., 2008). For many practitioners, discussing specific expectations of the faculty role both formally with program leaders and informally with other teachers can help.

Competencies expected of clinical teachers (Robinson, 2009) include

• being both a skilled practitioner and a skilled educator;
• having excellent interpersonal and professional communication skills;
• implementing a range of assessment and evaluation methods;
• possessing leadership and administrative skills; and
• maintaining professional development and scholarship activities.

Juggling the roles of practitioner and educator and feeling as though they must be near perfect in both, can leave clinical teachers feeling threatened (Griscti et al., 2005). The professional development activities required to gain and retain competence in each role are different. Practitioners must continue to provide client care in new and different ways and attend in-service workshops on new skills, products, and equipment being used in their clinical agencies. Educators must integrate knowledge from the discipline of education, understand student-centred approaches to learning, and initiate a scholarly program of research and publication. Common to both roles are keeping up to date with research findings, attending conferences or other educational events, and undertaking self-directed study projects.

Moving beyond simply maintaining competence and toward excellence in the two roles takes time. At different points in their careers, clinical teachers might commit more time and effort to one role than the other. New clinical teachers who are experienced practitioners might focus initially on understanding the educator competency of assessing and evaluating learners.

Once novice clinical teachers gain expertise and confidence as university faculty members, they can collaborate with experienced researchers and authors to complete scholarly activities. At other times, clinical teachers might find it helpful to return to practice and strengthen their clinical expertise. Mentorship from more experienced faculty can help clinical teachers to establish and work toward achieving realistic career goals (Billings & Kowalski, 2008).

Practice can help to ease the transition from practitioner to educator. Facilitating engaging post-conferences is a skill that many new clinical teachers in the health professions must learn. Yet how does one learn to facilitate a clinical post-conference? Is it possible to learn this from trial and error? Does it help to discuss the role during a clinical instructor orientation session? Might it be helpful to be mentored and watch an experienced teacher facilitate a post-conference?

These are questions that Mary Ann Fegan at the University of Toronto thought about as she prepared new and returning instructors to facilitate clinical post-conferences. Many identified this aspect of their role to be challenging, and they wondered how to do the role better. Some asked, “How do I ensure that every student has a voice and feels comfortable participating in the discussion?”

Mary Ann and her colleague used the following active learning strategy to help prepare instructors for their facilitator role during clinical post-conferences. They find it to be an effective and fun way to address some of the challenges of the role and a great way to facilitate active discussion among both new and returning instructors. This activity uses role playing to simulate a post-conference.

Participants (instructors) are divided into small groups of six or seven people. One person volunteers to be the facilitator, and everyone else is handed a nursing student “role card.” The role card provides a brief description of the student, and participants are invited to take on that role as they think it would play out in a real situation. Among the student roles are the following: a quiet student who only speaks when spoken to; a bored or unengaged student; a very chatty student who has an answer or comment for almost everything; an English language learner student who provides very short answers to questions; a dominant student who has had a great clinical day and wants to talk about everything that she or he did; and an anxious student who arrives a few minutes late and is very distraught about something that happened earlier that day. The simulation typically runs for about 15–20 minutes.

This activity is followed by small group debriefing (about 20 minutes) led by a faculty member who observed the small group discussion and took some notes. As with any simulated activity, the debriefing opens with a general question to help the group decompress, something like “How did that feel?” The discussions are rich and provide some interesting and insightful perspectives and observations from participants. Many questions are raised, and many are answered, among both new and returning instructors. This opportunity for peer-to-peer feedback helps to reveal some of the challenges in facilitating a group and offers some specific strategies to enhance this role. After the small group debriefings, everyone comes together for a larger group discussion and shares some of the things that went well, some that could have been done differently (in the spirit of wondering), and finally one key learning about the facilitator role.

MARY ANN FEGAN, MN, SENIOR LECTURER, CLINICAL EDUCATION COORDINATOR, LAWRENCE S. BLOOMBERG FACULTY OF NURSING, UNIVERSITY OF TORONTO

The identity of clinical teachers as individuals, practitioners, and educators has a significant impact on their effectiveness in the clinical learning environment. How instructors understand the process of learning will ultimately guide how they go about teaching (Hand, 2006). Rather than simply teaching as they were taught, clinical teachers are now actively seeking ways to strengthen the scholarship of educating learners in clinical learning environments (Buccieri et al., 2013; Sabog et al., 2015; Schmutz et al., 2013).

If we view the clinical environment through the eyes of students, then it is not unexpected that learners perceive effective teachers as individuals who demonstrate caring behaviours (Jahangiri et al., 2013), who have high emotional intelligence (Mosca, 2019), who are calm during stressful experiences (Smith et al., 2011), who exercise patience (Cook, 2005; Parsh, 2010), and who demonstrate enthusiasm for their profession and for teaching (Gaberson & Oermann, 2010). Teachers who are approachable can help students to feel less anxious and more confident (Chitsabesan et al., 2006; Sieh & Bell, 1994). Students appreciate teachers who make themselves available outside of clinical time, who take the time to answer questions without seeming to be annoyed, and who provide students with time to debrief and discuss issues (Berg & Lindseth, 2004). Students find it helpful when teachers are not controlling or overly cautious and allow students to learn the practice skills that they need by actually doing them (Masunaga & Hitchcock, 2011). In short, students value respectful collegial relationships with their teachers (Kelly, 2007).

Effective and student-centred clinical teachers empower their students. Empowering teaching behaviours include enhancing students’ confidence, involving students in making decisions and setting goals, making learning meaningful for them, and helping them to become more autonomous professionals in their discipline (Babenko-Mould et al., 2012). Empowering teachers care about, commit to, and create with their students toward a shared vision that anything is possible (Chally, 1992).

Empowering strategies that foster a shared vision between clinical teachers and students include inviting students to identify the kinds of approaches that best support their learning styles (Melrose, 2004). Effective teachers support students in identifying their personal strengths and working with their teachers to build on these strengths (Cederbaum & Klusaritz, 2009). Empowering educators affirm students’ efforts, share positive messages, and create supportive dynamics within the learning group (Chally, 1992). Note that empowering strategies also redirect students when their work is unsatisfactory or off track.

In higher education settings, educators must assess and evaluate students’ work, thus affording educators power over whether students can continue in a course or program. The inherent tension in holding power over students while seeking to empower them or share power with them is not easily resolved. Ultimately, clinical teachers must determine students’ grades, whether students are capable of practising safely in their discipline, and whether students can progress in their chosen field.

Once you identify the learning needs of students in clinical settings, you might have difficulty knowing the best strategy to support their learning and provide the safest care to patients. To address students’ and clinical instructors’ learning needs for clinical issues, instructors at Lakehead University conduct a general orientation at the beginning of each clinical session.

Clinical instructors from all year levels are asked to attend. The instructors range from those who have many years of experience in the clinical area to those who are just starting. We begin the session by asking the experienced instructors to describe how they orient students to the clinical area. This usually stimulates questions from the new instructors.

We then ask the instructors to give examples of challenges that they have faced in the clinical area. This again stimulates questions about formal documentation and how the clinical instructor can seek guidance from faculty and other instructors.

Feedback from the clinical instructors has been very positive. They get a chance to hear what the challenges are in each year level, to know who else is teaching in the program, and to learn who can contribute to the conversation with their own experiences. The instructors have developed a greater sense of connection. We would like to make this an even more interactive experience by having the clinical instructors role-play a situation in a clinical setting and then have feedback from the entire group.

CATHY SCHOALES, MN, FACULTY OF NURSING, LAKEHEAD UNIVERSITY

In sum, clinical teachers are role models who serve their profession by nurturing and supporting the next generation of practitioners. Clinical teachers affiliated with university programs can be employed in different ways. They can be part-time or full-time continuing faculty, or they can be employed on time-limited contracts for each course taught. They can work for several different learning institutions and clinical agencies. Given that finding substitutes to cover clinical teaching commitments is difficult, instructors should establish contingency plans such as student phone lists for when they are ill.

In most instances, full-time faculty are qualified at the PhD level. Often clinical teachers undertake graduate studies at the same time as they instruct in clinical practicums. Planning time to complete your own study assignments while teaching is essential.

The process of transitioning from practitioner to educator can seem to be overwhelming. Expectations of university faculty members might not always be clear. Seeking mentors and collaborating with experienced faculty involved in research and publication activities can help new clinical teachers to develop their own programs of scholarship. As both educators and practitioners, clinical teachers must gain and maintain competence in both areas. At different times in their careers, clinical teachers might focus more on one set of these competencies.

In addition to demonstrating competence and expertise in their discipline, effective clinical teachers project a calm, patient, approachable, and enthusiastic attitude during their interactions with students. Effective clinical teachers go beyond what is required of them and find ways to empower and inspire students with the idea that anything is possible. Whether students are progressing well, need redirecting, or are failing, effective clinical teachers work from a student-centred approach based on student strengths to affirm and support students.

Like snowflakes, no two students are alike. Learners who come to clinical areas of health care can be young adults beginning their higher education at a local college or university, they can be adult learners just launching their university learning, or they might have already completed undergraduate or graduate degrees. Students might be living at home with their families or far away in new locations. Some might have been awarded advanced credits. Others might have been educated in different countries and have cultural orientations that are unfamiliar to teachers, peers, or agency staff. In addition to their studies, many university students are employed either part time or full time. Many students have extensive family responsibilities.

Despite this student diversity, teachers can expect that students in the health-care professions will find the clinical learning environment stressful, at least initially. Although all learners will experience and project emotions in unique ways, research suggests that commonalities exist. Students are likely to fear that they will harm patients, they want to help people, they need to integrate theory and clinical practice, and they desire to master psychomotor skills (O’Connor, 2006). Mastering those skills can seem to dominate what students view as most important during clinical practicums. After graduating, however, learners report that having time and opportunity to practise their communication, time management, and organizational skills is actually more important (Hartigan-Rogers et al., 2007).

The high cost of tuition is a concern for most university students. Coupled with living costs that can include travel to and additional accommodation at out-of-town clinical practicum sites, students face significant debt loads. Given the sacrifices that students make to earn credentials in their chosen health-care professions, understandably they usually expect to be awarded top marks and feel devastated when their efforts are graded as poor or failing.

Students, teachers, clinical agency staff, and patients come from different backgrounds and have different perspectives and ways of interacting. These diverse perspectives become apparent in clinical practicums as students are required to communicate with individuals with whom they have little in common. One way of understanding these perspectives is to consider learners, teachers, patients/clients, and health-care team members with whom they must interact in relation to cultural, intergenerational, and emotional diversity.

The term “culture, ” which broadly refers to people’s way of life, can have many meanings. The term includes the standards, morals, principles, and experiences that influence how people think and behave (Sonn & Vermeulen, 2018). Age, gender, ethnicity, race, language, religion, spiritual tradition, and sexual orientation all contribute to the diverse cultural identities that individuals and groups affiliate with or are influenced by (Garneau & Pepin, 2015; Melrose et al., 2020). Each affiliation can influence what people value, how they express themselves, and how they carry out their activities of daily living.

Although health professionals are expected to demonstrate knowledge and understanding of and sensitivity to the expressions of cultural diversity that they encounter when caring for patients or clients, some people still receive unequal treatment (Jongen et al., 2018; Smedley et al., 2003). Similarly, in educational settings, some students in the health professions continue unfairly to receive unequal treatment (Guerra & Kurtz, 2016; Kruse et al., 2018; Smith, 2018).

Cultural competence requires health professionals to ensure that, at both individual and systemic levels, the agencies where they practise demonstrate “a set of congruent behaviours, attitudes, and policies that come together [to] . . . enable [people] . . . to work effectively in cross-cultural situations” (Cross et al., p. 28). Cultural competence in health professions education requires teachers to “adapt teaching and learning techniques in a way that values, empowers, and accommodates . . . student diversity. Cultural competence begins with an assessment of the learner’s needs and includes student interactions, curricula and policy development, in-class and online considerations, culturally competent policies and procedures, and . . . educators committed to lifelong learning” (Smith, 2018, p. 20). Achieving needed cultural competence is an ongoing process by which teachers learn with (and from) students, patients, clients, agency practitioners, and fellow faculty members.

Cultural safety extends the concept of cultural competence beyond efforts to understand the kinds of behaviours in which people from different cultures engage. Cultural safety directly acknowledges that patients/clients or students receive unequal treatment and learning opportunities because an inherent power imbalance exists between them and their health-care providers or teachers. “This concept rejects the notion that health providers should focus on learning cultural customs of different ethnic groups. Instead, cultural safety seeks to achieve better care through being aware of difference, decolonising, considering power relationships, implementing reflective practice, and by allowing the patient [or student] to determine whether a clinical encounter is safe” (Curtis et al., 2019, p. 3).

Strengthening cultural competence and creating culturally safe learning environments for students centre on teachers becoming more self-aware through self-reflection. Acknowledging that teachers hold power and privilege in their relationships with their students is an important first step. Furthermore, Melrose et al. (2020) urged teachers to reflect deeply on their own cultures, beliefs, and imprinted stereotypes. In turn, when teachers question how their personal views affect their teaching, they are better equipped to help their students feel safe and to meet their needs, expectations, and rights respectfully. Ultimately, teachers who are committed to demonstrating cultural safety participate in practices that challenge stereotypes, structural racism, and systemic inequities in health care and in the education of health-care professionals.

Although the term “diversity” is often used in relation to the cultural affiliations mentioned above, diversification can also occur when multiple generations work or study together (Fry, 2011; Johnson & Romanello, 2005; Weston, 2006). Each generation grows up with different life experiences, which influence how members of a generational cohort view the world, how they communicate, and how they approach teaching and learning (Billings, 2004; Notarianni et al., 2009).

A generation is a group of people or cohort who progresses through time together, holding or sharing a common place in history. Each group shares social and political events that usually span from 15 to 20 years. As a result, members of that group view the world in a way different from generations born before and after them. However, we must not make assumptions that all individuals of a particular age will demonstrate characteristics associated with their cohort. In some instances, though, linking an individual’s way of being in the world with characteristics expected of the generational group can be useful. Viewing learners and those with whom they interact through a generational lens can promote awareness of today’s students, their expectations, and how teachers can respond to their needs (Earle & Myrick, 2009).

Currently, four active generations are interacting in schools, work-places, homes, families, and communities (Gibson, 2009; Weston, 2006). These four generations are known as the Traditionalists or Veterans or Silent Generation, born between 1900 and 1945; Baby Boomers or Sandwich Generation, born between 1946 and 1964; Generation X or Nexers, born between 1965 and 1980; and Millennials or Generation Y or Net Generation, born between 1981 and 2002. A fifth generation, Generation Z, learners born after 1995, is now entering universities.

Students are most likely to meet Traditionalists as clients or patients during clinical practicums. Having lived through world wars and the Great Depression, those born during this period commonly experienced hardship. As a result, they worked hard, were loyal, and believed that the sacrifices they made would be rewarded (Tilka Miller, 2007). The world of this generation was very different from that of today. News came from newspapers and radios; shopping was done locally. Members of this generation were willing to conform to their parents’ beliefs rather than rebel against them, and they have been able to adapt to changes in the world (Johnson & Romanello, 2005). Their early work environments had clearly defined hierarchies, with plainly outlined rules, roles, policies, and procedures that employees were required to implement (Weston, 2006).

In health-care environments, uniforms offered immediate explanations to this generation of who the health-care providers were and what could be expected of them. In today’s fast-paced and technology-rich health-care environments, Traditionalists might be unsure of students’ roles and find their explanations difficult to understand.

Baby Boomers, now in their 50s, 60s, and 70s, are the largest cohort working in health care (Fry, 2011). Students will meet members of this generation primarily as the clinical leaders and practitioners in their practicums. Many Boomers grew up in a healthy, flourishing economy in which hospitals and schools thrived. Positive social influences on this generation encouraged Baby Boomers to think as individuals from a young age, to express themselves creatively, and to speak out when not in agreement with others.

Many women of this generation were socialized into the primarily female professions of nursing or teaching since these educational opportunities were widely available (Hill, 2004). Women of the Boomer generation were the first to work outside the home. This resulted in appreciably different home lives for the next generations.

In response to growing up in an era of prosperity, Boomers were willing to work long hours to pursue their goals, often in a relentless manner that might have negatively affected their personal lives (Stewart & Torges, 2006). Boomers are now often sandwiched between caring for their aging parents and their adult children. They are also investing considerable time, effort, and money into health maintenance and retirement (Johnson & Romanello, 2005). Given their leadership roles and experiences in health care, Baby Boomers might be seen as intimidating by students.

Generation Xers, now in their 30s and 40s, are a much smaller group and have been referred to as a bridge between the generations born before and after the introduction of the internet (Wortsman & Crupi, 2009). They grew up with computers, video games, and microwaves, and they are comfortable and skilled using new technologies. They expect instant access to information.

Members of this cohort were raised by two working parents or by single mothers and thus became known as the “latchkey” generation. They learned to manage on their own, became resourceful, and increasingly relied on friends (Walker et al., 2006; Weston, 2006). Generation Xers have been described as having little regard for corporate life, are intent on challenging authority, and expect to have their opinions considered (Earle & Myrick, 2009; Walker et al., 2006; Weston, 2006).

In health-care environments, Generation Xers entered the workforce during the turbulent 1990s period of downsizing and restructuring. Many were unable to find full-time or continuous employment (Fry, 2011). As a result, they do not view employment as security (Hill, 2004). Opportunities for promotion can seem to be eclipsed by the Baby Boomers who remain in the workforce. Students will encounter Generation Xers among their peers, teachers, and clinical agency staff. Until relationships are forged, students can find Generation Xers to be impatient and somewhat unwilling to offer in-depth explanations.

Millennials, in their teens to their 30s, were raised by Boomers who were actively involved in their learning. They have high levels of self-confidence and close relationships with their parents and members of their parents’ generation (Hill, 2004). Millennials are the second largest generational cohort in the general population (Buruss & Popkess, 2012; Wortsman & Crupi, 2009). They are fully comfortable with technology and with living in a diverse world. Millennials are considered the most culturally diverse generation of all time (Earle & Myrick, 2009; Walker et al., 2006).

This group of learners has a strong capacity to multitask, but their multitasking can erode their capacity to sustain focus and attention (Sherman, 2009). Their education has equipped them with the ability to work well collaboratively and on teams and to extend respect to each member of a group (Wortsman & Crupi, 2009). This cohort is accustomed to and requires immediate feedback (Bednarz, et al., 2010) and positive reinforcement (McCurry & Martins, 2010).

Millennials will be present in student, teaching, and staff groups. Students might find that individuals from this group are fun-loving, friendly, and approachable, particularly if students themselves are Millennials. Some members of this cohort might have had limited exposure to failure or even to negative feedback.

Generation Zers are people born after 1995 and comprise one-quarter of the North American population (Kingston, 2014). They lived through the terrorist bombings of 9/11 and the 2008 recession. Known as screenagers or digital natives, members of this cohort have grown up with the internet, social media, and smartphones, and they are considered the most connected generation in history (McCrindle & Wolfinger, 2014; Sparks & Honey, n.d.; Williams, 2019). Raised in inclusive classrooms, Generation Zers are collaborative, and over half will be university educated (Sparks & Honey, n.d.). They work quickly, can have short attention spans, communicate with symbols, and might not be precise or put effort into their writing (Sparks & Honey, n.d.). Assigned reading was identified as one of their least preferred methods of learning (Hampton, Welsh, & Wiggins, 2020).

Clinical teachers can use information about generational diversity as an introduction to who their students are and to create individualized instruction that will help them to succeed. The wisdom gleaned from Traditionalists, the drive modelled by Baby Boomers, the resourcefulness demonstrated by Generation Xers, the team spirit so ready to be tapped in Millennials, and the connectivity of Generation Zers can all be integrated into innovative teaching strategies.

Another way to understand the diverse perspectives that students bring to their clinical learning environment is to examine the diverse range of emotional issues that many face. Just as members of the general population deal with learning disabilities, substance abuse, poor mental health, or many other emotionally taxing problems, so too students who enrol in health-care programs deal with similar issues. Increased numbers of students with learning disabilities (Child & Langford, 2011; L’Ecuyer, 2019 a, 2019 b; McPheat, 2014; Meloy & Gambescia, 2014; Ridley, 2011; Sanderson-Mann et al., 2012), substance abuse problems (Monroe & Kenaga, 2010; Murphy-Parker, 2013), and poor mental health (Arieli, 2013; Megivern et al., 2003; Storrie et al., 2012) are successfully completing their programs. Although help and accommodation for these students are more readily available, the stigma associated with their issues makes students reluctant to share the challenges through which they are working.

Clinical teachers are not, and should not be, learning disability specialists or addiction and mental health counsellors. They must know, however, which program resources are available to students. All clinical teachers, whether they are full-time continuing faculty or teaching only one clinical course, should visit their university counselling centre and become fully informed about the services offered.

Most accommodations for learning disabilities are geared to academic class activities. For example, students with dyslexia benefit from supplemental study skills modules (Wray et al., 2013). If these kinds of modules are available, then clinical teachers should familiarize themselves with the content and highlight its clinical applicability during clinical conference discussions. Doing so would normalize the use of such resources. Non-dyslexic students might also find the supplemental activities a useful way to transfer theory to practice.

Research is beginning to reveal more about the nature of the difficulties experienced by learning disabled students in clinical placements. For example, dyslexic nursing students have more trouble writing notes about patients and using care plans than non-dyslexic students (Morris & Turnbull, 2006). Dyslexic students struggle with clinical documentation, drug calculations, and handovers of patients (Sanderson-Mann et al., 2012). They experience the most stress when the clinical environment is busy (Crouch, 2019).

Supports established in the academic setting might not be communicated to those instructing and precepting students in the clinical setting (Howlin et al., 2014). Staff nurses responsible for the clinical education of students and new nurses receive little preparation for that role and might not feel supported to meet the needs of those with learning difficulties (L’Ecuyer, 2019a). Preceptors can feel unprepared and lack confidence in their ability to instruct students who have learning disabilities (L’Ecuyer, 2019b).

Learning disabled students state that they would benefit from time spent with a clinical placement mentor who understands their specific learning issues (Child & Langford, 2011). Early referral and testing of students experiencing difficulties associated with dyslexia should be encouraged so that they can receive support as soon as possible (Ridley, 2011).

Focusing on abilities offers important balance in any discussion of disabilities. Individuals with learning disabilities have been characterized as focused, resilient, empathetic, compassionate, and intuitive, and they are known to have excellent interpersonal and problem-solving skills (Wray et al., 2013). These attributes are highly valued in health-care practitioners. Many clinicians with learning disabilities have found suitable strategies to overcome their learning difficulties and are thriving in their field.

The incidence of substance abuse among health-care professionals and students is both under-researched and under-reported, but from 10% to 15% of health-care professionals are estimated to be afflicted with alcohol or drug addiction (Monroe & Kenaga, 2010). In most jurisdictions, reporting is mandatory when any professional or student is impaired. When a clinical teacher encounters an impaired student, that student must be sent off the clinical area immediately, and the incident must be reported to the teacher’s supervisor. With this action, safety must be considered in areas such as finding alternative transportation if the student drove to the clinical site. Instructor and student should agree to discuss the incident when the student is no longer impaired.

Neither students nor practitioners should ever practise when impaired. Unfortunately, individuals with substance abuse issues might not believe that they have a problem and thus be reluctant to seek help. When clinical teachers identify substance abuse or the potential for substance abuse in their students and initiate referrals to university counselling services, they provide a critical lifeline. Throughout the world, programs are becoming available that offer confidential, non-punitive assistance for health-care professionals and students suffering from addictions (Monroe & Kenaga, 2010). Ignoring issues related to substance abuse is not an option.

Students with emotional problems are also present across health-care disciplines and in clinical placements. Learners with mental health issues can demonstrate inappropriate behaviours, including anger, neediness, and inability to complete tasks (Storrie et al., 2012). They can display poor motivation, negativity, overconfidence, or inability to work as a member of the health-care team. They might not accept responsibility for their actions or change their behaviour in response to feedback.

In response, clinical teachers can feel anxious, distressed, intimidated, or unsure about what to do (Storrie et al., 2012). When students present with a psychiatric or mental health crisis, they must be accompanied to an emergency treatment facility. In non-emergency situations, the best course of action is less clear. University counselling services are not immediately available to students when they are in practice areas. Other members of the student group, as well as agency clients and staff, will be affected by any inappropriate student behaviour.

Storrie et al. (2012, p. 101) suggest the following four strategies that clinical teachers can consider when responding to students with poor mental health.

1. Communicate with colleagues in advance about high-risk students who might have special needs in a clinical placement.
2. Maintain a consistent approach by following university procedures. If students have a complaint, then they are to address it first at a local level with clinical teachers. If the complaint is not resolved, then students must formalize it via a letter to a university supervisor.
3. Keep a clear audit trail by documenting any encounter with the student and regularly briefing your immediate supervisor.
4. Determine if the problem can be managed by rearranging the design of the student’s study plan. A revised plan will consider the student’s needs and strengths but still maintain academic expectations.

Throughout the course of a clinical day, have students note when they feel good about something that they have done. Encourage them to experience the feelings and then jot down the experiences. In the post-conference, have them share those experiences and discuss how they felt proud of what they did.

Mary Ellen Bond (2009) has examined the detrimental effects that negative emotions such as shame can have on students’ ability to learn in clinical nursing education. Keeping a pride journal introduces an opportunity for students to articulate and celebrate positive emotions, those times when they felt proud.

MARY ELLEN BOND, RN, MSN, COLLEGE OF THE ROCKIES

Health-care students can be culturally, generationally, or emotionally diverse, but they share the common goal of needing to develop professional independence during their clinical practicums. Through a stepwise process of gradually decreasing direction and guidance from teachers and agency staff, learners must work toward practising independently. University-educated professionals in health-care fields are required to think and act on their own, with limited or no direction from professional colleagues. A crisis is an everyday occurrence. Once learners graduate, they will be expected to implement client care independently.

The processes and strategies that learners use to develop independence as practitioners are inherently difficult to understand. Seminal literature from the field of adult education indicates that a key element of developing independence in any educational activity is for students to take responsibility for their learning above and beyond responding to instructions (Boud, 1988; Knowles, 1975). Becoming independent requires students to choose suitable learning activities, reflect on their effectiveness, and initiate any needed changes (Holec, 1981; Little, 1991).

In chaotic clinical learning environments, in which maintaining patient safety is critical, students can feel unsure about how they could or should go beyond what they have been instructed to do. There is an inherent tension between providing safe patient care and initiating new or perhaps unfamiliar activities in clinical practicums. Ameliorating that tension is different from trying new ideas in academic classroom settings. Students might not feel that they have developed the independence they need to function in a complex professional role until nearly a year after they graduate (Melrose & Wishart, 2013).

In sum, students in the health-care professions are a diverse group. Some will be new to university, and others will be experienced adult learners. Despite differences in their backgrounds, they can all be expected to be highly invested in their education, and they will have made sacrifices to complete clinical practicums. Most will feel anxious initially, particularly in their desire to provide safe care to patients and to pass course requirements.

Student groups will include learners from different cultures. Clinical teachers can support and celebrate their diversity by intentionally developing cultural competence and striving to create culturally safe learning environments. They can best do so by acknowledging the power that they hold in teacher-student relationships and engaging in ongoing self-reflection on how their own beliefs influence their teaching.

The groups will also include students from different generations. Clinical teachers can find it helpful to come to know their students as members of a generational cohort. Students will meet Traditionalists or older adults as clients/patients and Baby Boomers or middle-aged adults as clinical leaders and practitioners. They will meet Generation Xers in their 30s and 40s and Millennials in their 20s and 30s in peer, instructor, and agency staff groups. They will meet Generation Zers in their 20s in peer groups. Traditionalists are known for their wisdom and experience, Baby Boomers for their leadership and drive, Generation Xers for their resourcefulness and willingness to challenge, Millennials for their confidence and team spirit, and Generation Zers for their ability to work collaboratively.

Student groups will also include learners with emotionally diverse needs related to learning disabilities, substance abuse, or poor mental health. To accommodate these learners and ensure public safety, clinical teachers must have a clear understanding of any program resources and policies relevant to students with special needs. Key strategies for supporting troubled students include documenting both students’ behaviours and teachers’ responses implemented to help and consistently keeping supervisors informed.

Students and teachers in clinical learning environments share the goal of developing independent practitioners. Becoming independent is work in progress for students, teachers, and clinicians alike. By grounding instruction in the premise that students will soon be on their own and responsible for their practice, the importance of supporting students toward initiating and managing their own learning becomes clear.

Clinical environments are “classrooms” rich with planned, unplanned, and incidental opportunities for creative teaching and meaningful learning. Some clinical placements might not be as supportive as learners would like, and clinical agency staff might not be fully aware of students’ programs. Still, more practitioners are embracing the view that supporting students is a valuable part of their own professional development.

Clinical teachers, whether they are continuing faculty members or employed only on a course-by-course basis, are impactful role models who can make a critical difference in their students’ lives. Students view effective clinical teachers as individuals who are calm, patient, enthusiastic, and approachable. Excellent teachers seek to empower and inspire their students. Clinical teachers are often continuing their own graduate studies and juggling career plans that require expertise in both their practice discipline and the field of education.

The students whom clinical teachers meet in clinical practicums come from diverse cultural and generational backgrounds. Some will need unique instructional and institutional support as they deal with issues such as learning disabilities, substance abuse, or poor mental health. Clinical teachers must familiarize themselves with policies related to students with special needs and with counselling resources that are available to students. The stakes are high in university health-care programs, and all students have made sacrifices. They want to succeed, to earn top marks, and to practise independently once they graduate.

In this chapter, we examined the clinical learning environment and clarified the teachers and students in that environment. We hope that the creative strategies mentioned will provide practical ideas to help clinical teachers with the complex problems that they face daily. Perhaps the process of questioning and seeking to understand how our learners see the clinical environment is as important as the answers themselves.

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