10 Developing Community Partnerships

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Contents

Developing Community Partnerships

Patricia Solomon, Sue Baptiste 10

Description of Clinical Faculty Positions . . . 148

Why Establish a Unfunded Clinical Faculty Stream? . . . 149

Other Community–University Initiatives . . . 152

Joint Research and Evidence-based Practice Initiatives . . . 152

Emerging Roles Fieldwork Placements . . . 152

Development of Client Education Packages . . . 153

Challenges and Strategies . . . 153

Conclusion . . . 155

References . . . 155

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One of the greatest strengths of the Occupational Therapy (OT) and Physiotherapy (PT) Programs at McMaster University is the sustained commitment of the clinical community. Accreditors, visitors, and students are consistently impressed with the approximately 120 part-time unfunded clinical faculty each of whom contribute 50–100 hours to the programs every year. However, the relationship between the community and the university is not perceived as one-sided. The goal is for the university to be a part of the professional community and work in harmony with all stakeholders to improve research, practice, and education in the rehabilitation sciences.

The model for our community partnerships reflects the values of the School of Re- habilitation Science at McMaster University. These values are founded in a culture of respect and admiration for our community partners. We believe that clinical skills and expertise are equal in importance to those skills associated with scholarly activity, and that working together promotes mutually beneficial outcomes for all involved in the educational process. Commitment to self-directed, lifelong learning is another value which influences the relationships. The university provides opportunities for clinical faculty to engage in ongoing learning opportunities and mentoring relationships to help achieve career goals. This partnership is not easy to maintain in a health care system under ever-increasing fiscal restraints and an education system with growing research and educational demands. The university must provide effective infrastructure to recruit, reward, and evaluate clinical faculty. The clinical community must value the relationship with the community and perceive that there are benefits to involvement in the university’s educational and research initiatives. This chapter will describe our community–university model and the challenges and supports necessary to sustain an effective partnership.

Description of Clinical Faculty Positions

A description of the clinical faculty positions will place this chapter into context. At McMaster University, clinical faculty differ from “adjunct” faculty who are defined as instructors employed to teach a course or part of a course in a higher education program (Copolillo et al. 2001). The clinical faculty positions are unfunded positions in which the faculty member is employed by an institution outside of the university.

These are typically, but not exclusively, clinical facilities. There are two types of appointment:

1. Part-time clinical faculty appointment

A clinician who takes a part-time clinical faculty appointment contributes approximately 100 hours of his or her time to either the OT or PT Program each year. This is a more traditional model in which faculty members must meet specific criteria to both receive and maintain their faculty appointment. It is recognized that these faculty are primarily clinicians and they are eligible for promotion through the ranks of Clinical Lecturer, Assistant Clinical Professor, Associate Clinical Professor, and Clinical Professor. In a research-intensive university, scholarly activity is an expec- tation of all faculty, though in recognition of the fact that their primary responsibilities are in the clinical arena the expectations for clinical faculty are less than for tenured faculty. The performance and contributions of all clinical faculty are reviewed on a three-year basis at which time an internal committee makes decisions on reappointment and promotion to the Faculty Promotion and Tenure Commit- tee.

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2. Professional Associate Appointment

The Professional Associate appointment was developed to recognize the contributions of those who are not eligible for a “traditional” clinical faculty appointment.

The clinician may not meet the minimum criteria for eligibility for a clinical faculty appointment (e.g., a masters degree and regular scholarly contributions) or be unable to contribute 100 hours to the programs on an annual basis. Each Profes- sional Associate commits 50 hours per year to the educational programs. Profes- sional Associates undergo a review every three years; however, the review is solely by an internal committee of the School of Rehabilitation Science.

Why Establish a Unfunded Clinical Faculty Stream?

While from the academic institution’s perspective, the fact that a clinical faculty stream provides additional unfunded faculty would appear to be a powerful motivator, this is insufficient rationale for development. In the School of Rehabilitation Sci- ence the community–university partnerships are viewed as being important for the professions as a whole. The benefits are discussed below with a somewhat artificial distinction between those for the institution and those for the clinical faculty member.

It must be emphasized that this is a true partnership with the goal of building mutually supporting environments. Nonetheless, it is true that the contributions of clinical faculty have allowed us to maintain a more intimate learning environment. In the School of Rehabilitation Science, the cornerstone of learning is the small group problem- based tutorial. We have found the optimal size of a tutorial group to be between 6 and 8 students. In a group of this size students are able to participate regularly and the tutor is able to provide ongoing and extensive feedback to individual students on a regular basis. In a three semester per year program with 60 students, this translates to 8–10 tutors per semester or 48–60 tutors per class over a year of study. The involvement of clinical faculty allows for the maintenance of small groups in our programs.

Clinical faculty assume a wide variety of other roles including evaluator, clinical skills laboratory assistant and developer of resource materials. Table 10.1 outlines some of the typical roles and responsibilities.

Table 10.1. Examples of roles for clinical faculty

Role Description

Problem-based tutor Work with six or seven students twice a week for 2.5-hour session to develop and address learning issues from health care problems

Clinical skills tutor Teach and/or evaluate student assessment and treatment skills

Guest lecturer Provide a session on a topic in an area of clinical expertise Committee member Community involvement in a number of committees in-

cluding admissions, curriculum, and ad hoc

Education resource Act as a resource for a number of initiatives including development of health care problems and clinical learning experiences, assisting with student evaluation, or be avail- able to students for consultation

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The benefits to the academic institution extend far beyond enabling smaller student to faculty ratios. In a research-intensive institution it is often difficult for tenure stream faculty to maintain an active clinical caseload. Clinician involvement in all as- pects of the academic program helps to maintain a current clinical perspective. A high level of clinician involvement adds credibility to the curriculum, particularly when students are concerned that academic faculty are not seeing clients and patients and hence are not “in tune” with current practices. A visible partnership between academic and clinical faculty portrays an important message to the students and helps to close the “theory–practice gap” that is often perceived by the students.

Students enjoy exposure to a wide variety of clinical and academic faculty and to varying teaching styles. In fact the involvement of the clinical community in the educational programs is consistently ranked by the students as one of the major strengths of the programs. Given the diverse nature of practice today it is unlikely that a small pool of academic faculty could provide the spectrum of skills, knowledge, and expertise that is provided through the clinical faculty stream. This is the reason many PT and OT educational programs employ clinicians as adjunct faculty. The unique aspect of the programs at McMaster University is the sheer number of clinical faculty with whom the students interact in each semester of study.

In today’s ever changing and frantic health care environment one wonders why a busy clinician would be interested in assuming clinical faculty responsibilities. Trem- blay et al. (2001) surveyed clinical faculty who had tutored in the OT Program at McMaster University. Those motivated to tutor enjoyed the role of educator, received pleasure through the intimacy of a small group learning environment, and felt that they had a unique perspective to offer the students. Another motivator was related to professional development; tutors found that the tutoring experience helped keep their knowledge current. About 10 percent of the tutors in the study stated that they felt tutoring was a part of their “professional obligation.” Similarly, alumni of the OT and PT Programs at McMaster University often return to contribute to the educational programs.When asked informally why they want to participate, they mention the richness that the clinical faculty provided to their education and of wanting to “give something back” to the program in appreciation.

Copolillo et al. (2001) found that one of the benefits of being an adjunct OT faculty included informing and invigorating practice though the reading and reviewing of literature and following new developments in the field. Although the clinical faculty in our programs do not have the same responsibilities for curriculum development and coordination as would adjunct faculty, they also benefit from the exposure to current information. An example is related to the popular evidence-based practice (EBP) movement. The EBP movement started at McMaster University under the original name of evidence-based medicine (Evidence Based Medicine Working Group 1992) and has had a great impact on all health professional programs at the university. The expectations related to EBP for OT and PT students are high (see Chapter 5). At the be- ginning of the EBP movement, there were few clinical faculty who were familiar with EBP principles and their application to practice. This led to a potential problem; it could be very difficult for clinical faculty to reinforce EBP in tutorials and clinical skills laboratories if they were not confident with their knowledge. Supports have been developed to enable clinical faculty to improve their knowledge and skills with the as- sistance of academic faculty. For example, current and seminal articles come with supporting tutors’ guides which explain in detail the learning objectives, critical content, and key facilitation points. Ongoing tutor and clinical laboratory assistant meetings provide opportunities for clinical faculty to clarify concepts and highlight any difficul-

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ties their student group encountered. These sessions are in a variety of formats rang- ing from open discussions related to the learning scenarios being studied by the students, to more formal presentations of issues related to the evidence-based principles of critical appraisal of the literature. Academic faculty often provide “mini-workshops” on EBP to clinical faculty. Clinical faculty have also been invited to attend students’ large group or seminar sessions. Several clinical faculty to participated in a weekly interactive seminar course related to clinical measurement that occurred over an eight-week period. The ongoing development of EBP skills has benefits for all stakeholders. The clinical faculty member is able to participate in a professional development opportunity, the educational programs and the students benefit from the faculty member’s increased ability to facilitate and reinforce the students’ EBP skills, and the clinical facility has a clinician who is better able to implement EBP in the practice environment.

Assuming the role of facilitator in a student-centered curriculum provides an opportunity to develop new skills, many of which are transferable to the clinical setting.

Senior PT students who participated in a peer tutoring program (see Chapter 9) identified skills which would be relevant to clinical practice developed during their tutoring experience (Solomon and Crowe 1999). Analyses of the reflective journals kept throughout their experience found that the students learned to ask more appropriate, well-structured questions that they felt would assist in communicating with their clients. These students also reflected on the usefulness of the tutoring skills in assisting in a number of educational roles they would be assuming in practice. Students recognized the value of developing group process skills and the usefulness of these skills when interacting with health care teams and in staff meetings, when chairing a meeting, or when working on a research team. The skills identified by the peer tutors would be of value to all health care practitioners and is another benefit of the clinical faculty appointment identified by the clinical community.

Other tangible benefits include access to continuing education workshops and to the library facilities. Clinical faculty have complimentary access to faculty development workshops related to educational roles and to special educational initiatives developed by the School of Rehabilitation Science. In the early to mid 1990s, access to an email address and account was perceived as a major benefit by the clinical faculty. Cur- rently, personal email is widely subscribed to and this is no longer viewed as a major benefit. However, with the advent of electronic journals, faculty privileges allowing access to these are highly valued. Clinical faculty are also eligible for travel awards to support presentations at conferences and for internal research competitions. Through their part-time appointments, clinical faculty have links with the School of Rehabilita- tion Science research groups and projects and are invited to attend monthly meetings and rounds.

There are other, less overt benefits. The concept of mentoring is incorporated in the notion of community partnerships. Academic faculty often recognize the potential of a clinician and encourage him or her to pursue opportunities that will enrich their career; this may be through approaching individuals to apply for a clinical faculty appointment, inviting a clinical faculty member to participate in a specific educational or scholarly opportunity, or to enroll in an advanced degree.

And finally there are benefits to employees that go beyond providing staff with access to new information and skill development. In the tutoring survey, Tremblay et al.

(2001) found that many clinicians had negotiated time to participate in the educational programs when they commenced their employment. Employers have found that allowing therapists to participate in the educational programs assists in recruitment.

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With the advent of innovative organizational structures, many clinicians have been placed in circumstances where their involvement in educational endeavors has been curtailed. As these organizational models become more mature, the hierarchical relationships within them are becoming clearer and the need for structures to support health professionals in remaining current in their practice and engaged with new learners has become evident. The clinical faculty appointments are a source for continuing professional development of the clinicians. Through ensuring an informed, involved, and energetic body of clinicians, employers can also ensure a happier, more productive workplace thus investing in retention as well as recruitment.

Other Community–University Initiatives

There are a number of other initiatives which have been of mutual benefit. These opportunities link areas of interest and focus on research, EBP, fieldwork placements, and the development of patient education materials.

Joint Research and Evidence-based Practice Initiatives

In an entry-level masters program, there is a delicate balance involved in the level of knowledge and skill that is transmitted concerning research skills and understanding.

While we are not preparing students for research careers, we want to ensure they are skilled in the interpretation of evidence and familiar with research and program evaluation methods (see Chapter 5). Through the development of independent evidence- practice projects, the students work in partnership with clinicians to engage in a research process that links with the real world of practice. These clinician–student relationships come in a variety of forms. During the independent projects, clinicians are approached to define practice questions that are intriguing or of concern, and are of- fered the chance to participate with students in developing and undertaking a project that will be of value to their practice setting. Similarly, during the evidence-based small group seminars within the OT Program, clinicians are invited to pose a practice dilemma for the students to consider (see Chapter 5 for additional detail). The students search the literature to determine the “best practice” response to the dilemma, develop a mini-monograph, present it to their small group as an evaluated assignment and then provide the results to the clinician who posed the question. This particular initiative has produced excellent results in terms of reinforcing existing relationships and forging new ones. Throughout the evidence-based process within the curricula, the importance of relationships between faculty and clinician is highlighted. Faculty provide input to practice environments to enhance understanding of research principles and methods and engage in their own research on site. This last example serves to inculcate even closer relationships between these two professional spheres.

Emerging Roles Fieldwork Placements

The development of creative fieldwork placements in which students are placed in emergent areas of practice also has benefits for all stakeholders. The university is provided with new clinical fieldwork opportunities, which are often in short supply. Stu- dents develop consultation, marketing, and advocacy skills. Clinical facilities are pro-

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vided with an opportunity to engage in program development and have a source of clinical consultation. Chapter 4 provides detailed examples of role-emerging placements.

Development of Client Education Packages

Another successful initiative involves the students’ development of patient/client education materials. In a popular assignment, student teams design patient/client education packages which incorporate principles of patient education and behavior change.

These take on a variety of forms, for example, pamphlets, videos, and web sites. While some student teams work on their projects independently, others partner with an institution to target the materials to a specific community need (e.g., The Arthritis Soci- ety). The result has been the production of high caliber patient/client education materials that are actively utilized in the clinical setting rather than collecting dust on a faculty member’s shelf. The community partners are delighted to have this “free” consultation, whereas the students find the fact that the materials will be valued and used to be rewarding.

Challenges and Strategies

The clinical faculty positions are not without their challenges. Particularly in hospital settings, the clinician may find that an employer may support their part-time faculty role in principle, but be unable to provide coverage for patient care when he or she is fulfilling their faculty responsibilities. This can lead to a stressful work environment in which the clinician must work overtime to complete their clinical caseload. This has been most problematic for tutor roles, which require two meetings per week. Some creative scheduling has served to minimize this problem. For example, rather than the tutor spending time traveling to the university to meet with student groups, the students travel to the clinical facility for their sessions. As there is flexibility in the students’ timetables, some clinicians schedule their tutorial sessions early in the morning or later in the day to minimize scheduling disruptions. In private practice, there is often a concern related to lost income while the clinician is fulfilling his or her faculty obligations. In some instances the clinician has negotiated with their employer to have one tutorial session during working hours and has organized the other session for “after hours.” Inevitably, for a variety of reasons, some clinicians are unable to receive support from their administration or feel that they cannot participate for finan- cial reasons and resign from their faculty position.

For therapists who are giving generously of their time, the receipt of poor student evaluations can be a disheartening experience and lead them to question their commitment. It is important that student evaluations be received within the context of constructive feedback for ongoing improvement of teaching and facilitation skills. In our experience, it is rare for a clinical faculty member to receive consistently poor student evaluations; students genuinely value their expertise and contributions. In addition, faculty development activities are structured to provide basic skills and mentoring for inexperienced faculty, both academic and clinical. However, some faculty members do struggle with their roles, and strategies must be put into place to assist in fur- ther skill development. While this is a struggle, it is also a rich opportunity to invest in our collaborative community and build mentoring relationships as they naturally

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emerge (Baptiste 2001; Carruthers 1993). For example, encouraging faculty to work together in peer-mentoring groups is a strategy of choice. The regulatory college for occupational therapists in the province of Ontario has a program in which educational, self-assessment modules that address key practice issues are distributed to members.

After completing their independent work, groups of clinicians and academic faculty meet to respond to these modules. This then transfers into a much clearer understanding and appreciation of the practice issue as a faculty collective, and allows the faculty to impart these ideas and understandings to the students in a consistent and articulate manner.

An integrated semester of study that involves many academic and clinical faculty requires considerable organization and communication amongst the players. In student-centered curricula which allow the students greater choice in the learning that they pursue, students worry that they are not obtaining all the “essential” information and that there is variation between groups in their learning (Solomon and Finch 1998). Although these concerns tend to fade as students progress through the curriculum and gain more confidence in themselves and the curricular philosophy, there is still a need for all faculty involved, both academic and clinical, to be familiar with the core objectives of the unit of study particularly in curricula that have extensive verti- cal integration of the courses. Ongoing tutors’ meetings assist in facilitating dialogue between the course coordinators and the clinical faculty. Tutor guides and other resource materials are provided to all faculty. Debriefing and feedback sessions at the end of a unit of study are particularly helpful as the clinical faculty provide their unique perspective on the students’ strengths and weaknesses and work with the academic faculty to evaluate the curriculum. In addition, there is close communication between the course coordinators and the clinical faculty. Ongoing meetings provide an opportunity for clinical faculty to relay their concerns and receive advice and training about a range of issues related to both the process of learning and new content that is being introduced.

As stated in Chapter 1, faculty development initiatives are important for the success of innovative student-centered curricula. Given the extensive contributions of part- time clinical faculty it is essential to have faculty development opportunities that are not exclusively for academic or adjunct faculty. Workshops related to problem-based learning and tutor skill development are mandatory for all new faculty. While not all faculty will assume a tutor role, the workshops provide the background knowledge and skills which are important for facilitation in a student-centered curriculum re- gardless of the role. In addition, new tutors are paired with experienced faculty members and are considered a “tutor-in-training” for a semester. This model allows the experienced faculty member to mentor the new faculty member and to model desirable tutor behaviors. At the conclusion of the tutor-in-training experience, the experienced faculty member makes a recommendation on whether the tutor in training should go

“solo.”

Throughout the existence of our rehabilitation science programs, there has been a commitment to the ongoing support of our tutors. More recently, as the demands have changed to a graduate entry level, faculty have declared a sense of discomfort and concern that they would be unable to provide the same level of support and facilitation to students. As one way to address these concerns, the role of tutor mentor has been developed to allow those faculty with a strong track record of success in the tutor role to provide support to clinical faculty. This support can take the shape of meeting together to address specific tutorial situations or to role play and strategize about potential responses. The tutor mentor may also be asked to attend group sessions as an observ-

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er to provide direct input to the tutor as a professional growth strategy. Finally, the tutor mentor can be asked to attend a tutorial session and provide role modeling for the tutor colleague, when group problems have become entrenched or destructive to the learning taking place.

Negotiating and tracking the educational contributions of 120 clinical faculty requires resources. The School of Rehabilitation Science has a faculty member, the De- partment Education Coordinator, who devotes approximately 25 percent of her time to recruiting and orienting new clinical faculty and ensuring the electronic database that documents educational contributions is current. In addition, the Department Ed- ucation Coordinator meets formally with each clinical faculty member to review their contributions, discuss their career goals in relation to their faculty appointment, and negotiate future contributions based on their goals and the needs of the programs. The faculty member’s contributions and evaluations are reviewed every three years by a Personnel Committee, chaired by the Department Education Coordinator. This committee makes recommendations for re-appointment and promotion.

In recent years, the increased fiscal pressures on health care institutions have creat- ed challenges to the retention of clinical faculty. In our efforts to respond to clinical faculty feedback we have developed alternate models which may be of interest to those who do not have access to the same rich resources. In instances where it is not possible for the clinician to commit to an extended period of tutoring, two or more tutors may be responsible for a tutorial group. This can take several forms. With two tutors, each may be responsible for one tutorial session per week. This requires a system for the tutors to communicate and share concerns and can be disruptive to the group process so is more desirable for experienced groups. An alternative is having one tutor facilitate for the first half of the semester and another tutor facilitate the second half with a week of overlap in the middle. Some clinical faculty members who are unable to travel or participate on a weekly or biweekly basis, assume responsibilities related to curriculum development (e.g., development of specific resource materials or modules) or evaluation (e.g., evaluate specific assignments). In the OT Program some tutorial groups meet only once weekly in the more advanced terms, thus decreasing the time commitment of the tutors.

Conclusion

The contributions of clinical faculty to the OT and PT Programs at McMaster Univer- sity may be unique in that the relationship with the clinical community has developed over many years and the clinical faculty contribute to the programs without remuner- ation. It is a model which requires ongoing “maintenance,” organizational infrastructure, and explicit and implicit reward systems to be successful. There are many benefits to all involved in the partnership. The end result is a stimulating and rich environment for student learning and a rewarding environment for professional development of the clinicians.

References

Baptiste S (2001) Mentoring and supervision: creating relationships for fostering professional development. CAOT Publications ACE, Ottawa

Carruthers J (1993) The principles and practices of mentoring. In: Caldwell BJ, Carter EMA (eds) The return of the mentor: strategies for workplace learning. Falmer, London

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Copolillo A, Walker E, Helfrich C (2001) Combining roles as an academic instructor and a clinical practitioner in occupational therapy: benefits, challenges and strategies for success.

Occup Ther Health Care 15 : 127–143

Evidence Based Medicine Working Group (1992) Evidence based medicine: a new approach to teaching the practice of medicine. JAMA 268 : 2420–2425

Solomon P, Crowe J (1999) Evaluation of a model of student peer tutoring. In: Conway J, Williams A (eds) Themes and variations in PB. University of Newcastle, New South Wales, Australia, pp 196–205

Solomon P, Finch E (1998) A qualitative study identifying stressors associated with adapting to problem-based learning. Teach Learn Med 10 : 58–64

Tremblay M, Tryssenaar J, Jung B (2001) Problem-based learning in occupational therapy: why do health professionals choose to tutor? Med Teach 23 : 561–566

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