Introduction. The characteristics of effective and of exemplary clinical instructors (CIs) have been described in physical therapy clinical education literature. However, little is known about how CIs acquire expert skills as clinical teachers or how expert CIs interact with students. The primary purpose at the start of this investigation was to answer the question: "How do physical therapist CIs attain expertise as clinical teachers?" To do so, first "expert CI" had to be defined. Next, a subset of 3 participants were interviewed and data were analyzed as a pilot study. Then, in this phase, 6 additional participants were interviewed to confirm, refute, and expand on the initial findings. A secondary phenomenon, the expert CIs' approach to teaching students, was identified and examined.
Methods. A qualitative study using thematic analysis was developed to investigate CI expertise. Three investigators conducted semi-structured interviews with a purposive sample of 9 participants. Based on literature, the investigators defined the phrase "expert CI" and developed an interview guide. Constant comparative technique refined the interview guide, codes, and emerging concepts. Theoretical models depicting our findings were developed and member checked.
Results. The participants acquired expert CI teaching skills by applying a reflective process of identifying needs and integrating relevant teaching strategies from the themes of professional development, teaching and learning, and relationships. Furthermore, the expert CIs applied a problem-solving approach to the episode of teaching; analyzing and facilitating teacher and learner needs in 6 areas: examination, evaluation, diagnosis, prognosis, intervention, and outcome.
Discussion and Conclusion. The CI Expertise in Action Model presented is an interpretation of the data that reveals a complex and multifaceted approach to clinical instruction that may be used to facilitate clinical teaching skills.
Key Words: Expertise, Clinical education, Professional development, Clinical teaching.
The current model of physical therapist (PT) clinical education has become a controversial model, with some authors raising concerns regarding its effectiveness.1"8 In existing approaches to clinical education, physical therapists have volunteered to serve as clinical instructors (CI) with no required training in clinical teaching.9 Anecdotally, clinical educators are aware that some PTs are talented as CIs and that others lack teaching effectiveness. To address the need to train PTs to be CIs, the American Physical Therapy Association (APTA) developed the Clinical Instructor Education and Credentialing Program (CIECP).10 However, outcome studies seeking a positive association between the completion of the CIECP and improved CI teaching have been inconclusive.11"14 Among the unanswered questions in determining how to effectively provide clinical education to students are 3 that frame our study: (1) How does the physical therapy profession identify "expert CIs"? (2) How do expert CIs acquire skills as clinical teachers? (3) What are the expert CIs' approach(es) to student learning? We theorized that answers to these questions might inform clinical educators in meaningful ways to enhance the effectiveness of clinical teaching and ultimately improve students' preparation to enter a doctoring profession.
Review of the Literature
While the existing needs within the structure of PT clinical education have inspired alternative models,5,6,8 it is likely that any model of PT clinical education will continue to rely on clinicians to facilitate student acquisition of clinical competence.5 The literature on clinical instruction, in PT and in other health professions,6,1526 articulates important facets of an effective CIs approach to clinical teaching. These include instructional,6,16,17,22,24,25 interpersonal,6,14"16,18"20,22,24,25,27 professional,6,18,22,26,28 and evaluative6,14"16,20,25,26 skills. …