Let's Talk about the Talk: Exploring the Experience of Discussing Student Performance at the Mid- and Final Points of the Clinical Internship

Abstract

Purpose: The purpose of this study was to explore the experiences of physiotherapy students and clinical instructors (CIs) when discussing student clinical performance at the mid- and final points of clinical internships. The objectives were to identify why performance assessment discussions are valuable, explore the role of each participant throughout the discussion, identify the challenges associated with these discussions, and explore the effect of the standardized assessment tool on the discussion. Methods: This study used a qualitative descriptive design, consisting of student and CI focus groups in the Greater Toronto Area from January to June 2016. Results: All participants (N=29) recognized the importance of having face-to-face performance assessment discussions in a quiet and private space. Students and CIs agreed that the Canadian Physiotherapy Assessment of Clinical Performance helped to structure and focus the discussions. Valuable discussions occurred when students were open minded and self-reflected on their performance and when CIs were honest and used their expertise to guide learning. Other key features included mutual preparedness, two-way feedback that was constructive and tangible, and a goal-setting process. Students described the emotional component of these discussions as being challenging, and CIs found it difficult when a student took a more passive role in the discussion. Conclusions: Our findings indicate that valuable discussions can provide meaningful feedback, strengthen the student–CI relationship, and engage the learner in an ongoing and cumulative learning process that contributes to professional development.

Clinical education is a vital component of preparing students to enter the physiotherapy (PT) profession.¹ Throughout their clinical education, students are assessed on their ability to perform the required clinical skills and behaviours necessary for competent PT practice. Summative performance assessments include a standardized assessment tool, completed by a clinical instructor (CI), which is then sent to the director of clinical education or academic coordinator of clinical education at a student's university. Formative performance assessments include the student's self-assessment, completed using the same standardized tool. Exchanging both completed assessment tools facilitates an important discussion of performance assessment between the CI and the student.

Performance assessment discussions between the student and the CI are used to structure the clinical experience, outline performance expectations, and evaluate instructional effects.^2,3 The CI's assessment identifies the student's strengths and areas for improvement, motivates the student, promotes learning, and assesses the transfer of knowledge.³ For students, these discussions serve to outline expectations and define goals. The importance of establishing these goals extends past the current internship into future placements and entry into clinical practice.

Background

Clinical internships give PT students opportunities to make connections among academic knowledge, coursework, and clinical practice. These experiences engage them in a real-life learning process that includes acquiring and improving specific skill sets.⁴ Internships are equally as important for providing an opportunity for professional socialization, a term used to describe the practice of gaining a better understanding of the culture of a profession, its values and attitudes, and its accepted behaviours.^5,6 Thus, clinical education experiences are foundational because they require students to go beyond applying classroom knowledge in a clinical setting and gain a practical and comprehensive understanding of the PT profession.⁴

In 2014, a standardized tool called the Canadian Physiotherapy Assessment of Clinical Performance (ACP) was developed, and it is now being implemented in PT programmes across Canada to replace the American-based Physical Therapist Clinical Performance Instrument (PT–CPI).^7–10 During all internships, a student and a CI are required to independently complete and then review an ACP on two occasions: at the internship's midpoint and at its end. The ACP is organized into seven roles, each of which includes one or more key competencies outlined by the Essential Competency Profile for Physiotherapists in Canada.⁹ Each role includes a brief description, one or many key competencies, and enabling competencies. A rating scale follows each key competency, and at the end of each role is a Comments section. The last page of the form has two Summative Comments sections in which the CI notes a student's overall strengths and areas needing improvement.

Feedback is a necessary and interactive process, and it can benefit both the CI and the student within and beyond the realm of teaching and learning. For students, receiving accurate and timely feedback helps them develop their clinical practice and directs their attention to certain skills and behaviours.⁴ It can also contribute to increased motivation and self-esteem.^10–12 Feedback aims to provide learners with insight into their performance, and it ideally occurs both informally and formally.⁴ Informal feedback includes on-the-spot comments and general conversation about performance, both of which are crucial to a student's clinical learning experience.⁴ Formal feedback is defined as a planned and intentional process.¹³ The ACP is a tool for exchanging formal feedback.

CIs believe that verbal feedback exchanged between the CI and student can enhance their own communication and interpersonal skills while also fostering a sense of personal satisfaction.^10,14 In addition, a study exploring the perceptions of CIs using the PT–CPI found that the comments were considered the most useful part of the assessment because they initiated a conversation between the CIs and their students.² This demonstrates that there are multiple methods of feedback delivery—such as verbal, written, formal, and informal—that can be valuable to furthering student and CI learning. For the purpose of this study, we defined a valuable performance assessment discussion as one that motivates the student and promotes learning by identifying areas of strength and areas needing improvement, outlines performance expectations, and assesses the transfer of knowledge from classroom to practice.

Clynes and Raftery⁴ examined the performance assessment discussions that took place between nursing students and their preceptors, and they identified the effective delivery of feedback as a multi-factorial process. First, it was helpful for a CI to have an understanding of how a student was likely to respond to feedback. This required the CI to assess the nature of the relationship between him or her and the student. Second, setting up a conducive physical environment was a significant part of the process. The authors concluded that feedback “should be given in a quiet, private environment [and that] an informal room layout will promote a two-way discussion of the student's performances and should foster openness and honesty.”^4(p.408) The exchange should be structured in a way that required the student to share his or her self-assessment first because this would give the CI an opportunity to assess the student's ability to evaluate his or her own performance.¹⁵ Finally, the CI should allocate sufficient time for discussion and clarification.

Purpose

The PT literature has limited research examining the essential features, challenges, and benefits of a performance assessment discussion from the perspectives of students and CIs. The purpose of this study was to explore students' and CIs' experiences discussing clinical performance at the mid- and final points of a clinical internship. The objectives were to (1) identify why performance assessment discussions are valuable, (2) explore the role of each participant throughout the discussion, (3) identify the challenges associated with these discussions, and (4) explore the effect of the standardized assessment tool on the discussion. After our analysis of the data, we propose recommendations that could help to promote a valuable performance assessment discussion.

Methods

Study design

This study used a qualitative descriptive design, consisting of student and CI focus groups (FGs) in the Greater Toronto Area from January to June 2016. This study was approved by the Research Ethics Board of the University of Toronto, and informed consent was obtained from all participants.

Participants

All students (excluding the student investigators) enrolled in the Master of Science in Physical Therapy (MScPT) programme at the University of Toronto who had completed three of five caseload-carrying internships were eligible to participate. A minimum of three internships was a selection requirement because students would be familiar with these discussions and would have different experiences to draw from. CIs were considered eligible if they were registered physiotherapists in the University of Toronto catchment area and had supervised MScPT students between January 2015 and January 2016, when the ACP was used. To achieve diversity in the sample, four different practice settings were selected for the CI FGs: a hospital serving a pediatric population; an acute care hospital and a rehabilitation hospital, both serving an adult population; and a private practice clinic.

Data collection

We chose to conduct face-to-face, semi-structured FGs to explore the students' and CIs' experiences of the mid- and final clinical performance discussions. Face-to-face FGs would provide an opportunity to draw out multiple viewpoints in a single session, and using open-ended questions would allow unprompted exchanges between the participants to occur. The goal was to create an open environment in which participants felt comfortable expressing their ideas.¹⁶

Two investigators facilitated the student FGs, and two other investigators facilitated the CI FGs. A standard discussion guide was developed for each type of FG using the four objectives of the study; it consisted of nine open-ended questions with appropriate probes to encourage exchange among the participants. Each FG was audio recorded and then transcribed verbatim by one investigator in the research group.

Data analysis

We used an inductive thematic analysis to analyze the FG data; this type of approach is suitable for topics lacking extensive literature and therefore applied to this study.^17,18 Five investigators (JY, RW, JL, GA, SSG) participated in a step-wise paper-and-pencil coding process that consisted of identifying the emerging ideas, assigning codes, and discussing the overarching themes (see Table 1). The coding spreadsheet and themes were then used to determine patterns, agreements, and contradictions in the data.

Table 1.

Example of CI Coding Spreadsheet

Quote from participant	FG	Interpretation/code(s)
“I think the summative comments in the end are the gist of it; that's the stuff in my opinion that makes everything come together 'cause that's where you can point out all the specific issues. You can write it out in your own words, instead of it being guided. The guide reminds you of the things you need to focus on, but the end gives you the time to focus in with your own words.”	CI-FG4	Summative comments are a beneficial, important part of the discussion. A summary of the assessment in the CI's own words A section not bound by the language or format of the tool The tool serves as a reminder.

CI=clinical instructor; FG=focus group.

Results

We conducted four student FGs consisting of 4 students each for a total sample of 16 students. We also facilitated four CI FGs at four diverse practice sites: three FGs consisted of 3 CIs, and one FG consisted of 4 CIs for a total sample of 13 CIs. All students had used the ACP three times before participating in the FG. Six CIs had supervised between 1 and 5 students, and 5 CIs had supervised more than 15 students. All CIs had used the ACP at least once. The results of the data analysis are presented below, organized into the four main objectives of the study.

Why are performance assessment discussions valuable?

Students

Students in all FGs agreed that performance assessment discussions gave them more specific feedback about and clarification of the comments written by the CIs. “[CIs] don't always have time to sit down and write out the examples, so the discussion is always much more in-depth than the comments” (student [S]-FG1). Students recognized that constructive criticism from their CIs was more helpful; however, they also appreciated positive feedback because it provided encouragement. One student stated, “For me it goes a long way when my CI includes some positive feedback; it goes a long way for the student's confidence” (S-FG3). Students expressed the value of receiving constructive and tangible feedback, as described by this participant. “The CI came prepared with a lot of thoughtful comments and constructive [feedback] and came up with things that I didn't even think of, strengths and areas for improvement.… I took a lot more away from that discussion” (S-FG3).

Students in all FGs stressed that the value of performance assessment discussions depended on factors that had occurred before a discussion took place, such as adequate preparation and ongoing communication and feedback. For example, “I think it [the discussion] goes much better when you have had small bits of communication throughout and you get feedback prior to those two dates” (S-FG3).

Clinical instructors

All CIs agreed that performance assessment discussions facilitated the students' learning and increased their confidence. “Conversations are always valuable for students; they seem to really appreciate the feedback they're given as long as it's constructive” (CI-FG2). Two CIs also mentioned that these discussions were valuable because they prompted them to reflect on their roles as instructors and experts. The CIs spoke about valuable discussions being a dynamic two-way exchange that enhanced the student–CI relationship. A discussion was also considered valuable if a student came away with a clear understanding of expectations and had engaged in a process of goal setting.

These discussions provide them with direction and guidance. They should have a really good idea of what their areas of improvement are.… You want to add to their confidence in their areas of strengths but also give them a plan or direction for moving forward regarding their weaknesses, whether it's at midterm or final. (CI-FG2)

Some CIs explained that the mid-term and final discussions had different benefits, while others said the conversations were very similar. We found that the CIs used the mid-term discussion to provide “guidance on where to go next and the things that have been lacking” (CI-FG4), “reaffirm the student is on the right track” (CI-FG1), “make a plan moving forward” (CI-FG2), and “set the expectations for the second half of the internship” (CI-FG3). The discussion at the end of the internship was used to “give them suggestions when they're moving on to their next placements” (CI-FG2), comment on whether the student was able to apply the feedback, and caution students that “they are not going to walk away from the placement knowing everything” (CI-FG2). Two CIs stated that the discussions at mid-term and final were very similar.

Importance of the environment

All FGs discussed the importance of having face-to-face performance assessment discussions in a quiet and private space. The students and CIs believed that meeting face-to-face provided an opportunity to clarify issues and allowed the participants to interpret body language and tone. These face-to-face conversations helped to build a more personal relationship and prepare students for professional practice. “Our whole job is face-to-face; why would that be any different with our student?” (CI-FG1)

What are the roles of the student and the clinical instructor?

Students' perspective

Six participants in the student FGs reported that their role was to remain open minded to feedback and to honestly reflect on their performance. They believed it was important for them to advocate for their performance if there was a discrepancy between their ratings and those of the CI. They also thought it was their role to come up with tangible methods to improve on identified weaknesses. “I think that, as a student, it is our role to reflect on our performance and try to be specific on things we think we did well and things we think we need to improve on” (S-FG2).

The students believed it was the role of CIs to lead the discussion, communicate their expectations, and give feedback with concrete examples. Six students considered CIs to be the experts and expected the CIs to be honest and to give them guidance on how to implement the feedback delivered by the CI. “I feel like the CI is in the driver's seat for most of the discussion because they are the expert; they have a better idea, I feel, of where I should be in my progress rather than myself” (S-FG2). Four students mentioned that they found it valuable when their CI made an effort to discuss performance every day.

So I think the role of the CI is to talk daily and weekly with the student. It feels good for the student to know where they are at because it is hard to make improvements when weeks have gone by, but if you are told in the first or second week, then that [informal discussions] becomes a good tool. (S-FG2)

Clinical instructors' perspective

The CIs stated that their role was to guide the discussion and provide students with direction for learning. Five CIs indicated that an important role of the student was to maintain an open dialogue and to ask for clarification throughout the conversation, if needed. They also mentioned that reviewing both ACP forms at the same time helped ensure a dynamic two-way conversation and often instilled a sense of confidence in the student. CIs should use this opportunity to reflect on their own performance as educators.

It's nice to be able to go over [a student's evaluation] and self-reflect; it almost happens simultaneously. I find that as I'm talking to the student, I'm like, “You did really well, and I would have liked to have given you more opportunities.” (CI-FG2)

What are the challenging aspects of these discussions?

Both the students and the CIs identified several factors that made these discussions challenging. Three students reported feeling anxious and nervous beforehand, and four other students thought that these discussions had an awkward and emotional component throughout and “especially at the mid-term.” Likewise, two CIs stated that they often found it challenging to give their students negative feedback. The power differential between students and CIs was mentioned by two students and perceived as a challenge to the discussion. As one student described, “There is a power differential a bit and I don't think it's specific to the ACP, more the discussion” (S-FG1).

Four students indicated that the CI's role as the clinical expert and leader of the discussion made it difficult for them to give their CI feedback and advocate for themselves. One student stated, “It's really hard to speak up for myself, at mid-term, telling them that they are wrong about something if you disagree” (S-FG1). Two students admitted to ranking themselves lower to avoid appearing overconfident and having to justify their ranking; another student said, “I tailor my comments to what my CI will say” (S-FG3). Five CIs commented on some students taking “a very passive role” (CI-FG4) in these feedback conversations. The students' feelings of awkwardness were also reflected in the story told by one CI in FG1. “I did mine [ACP evaluation] first, and we went to do hers, and she was more like, ‘Oh, I don't care about mine'; she didn't want to self-evaluate as much because she had given herself such a low score.”

For some students, the rating scale presented a challenge when there was a discrepancy between their own score and that of the CI or, as one student put it, “showing up to your evaluation on a completely different page as your CI” (S-FG4). Students in FG2 said that this challenge related more to the mid-term discussion than to the final. “The discussion is awkward at the mid-term if you see yourself one way and your CI sees you differently; it's a little bit awkward if there is inconsistency.” One student mentioned that it affected the content of the discussion as well. “If I saw that I was higher or lower, it kind of altered how I talked about my own scoring, so for me sometimes the conversation wasn't as fluid” (S-FG1). This challenge was mitigated, however, by consistent feedback before the discussion, according to one student. “[The discussion can be] challenging if you're not getting feedback day to day; the experience for me has been, like, constant feedback from the CI, so the mid-term or final isn't as big of a surprise” (S-FG3).

Both the students and the CIs agreed that conversations were challenging if there was a difference in the amount of preparedness. As described by a student in FG1, “If they [my CI] wrote a lot and I didn't write a lot, it would make it pretty awkward in that they were doing most of the talking.” One CI in each FG reported that the timeline for these discussions was in itself a challenge: When an internship lasted only 5 weeks, the brief time frame leading up to the mid-term (2.5 weeks) made it difficult for them to comprehensively assess and discuss each aspect of the students' performance outlined in the ACP.

How does the assessment tool affect the discussion?

The ACP was considered to be a useful instrument for prompting CIs to discuss all aspects of professional competency, whether or not they were directly related to the clinical setting. Ten CIs frequently spoke about how the ACP had helped focus a discussion, provided flow, and developed a conversation with good structure. “It [ACP] helps focus our discussion on the various components of the ACP and gives you a nice breakdown of different areas” (CI-FG2). Five students reported that the enabling competencies under each key competency directed and added to the conversation.

I found it very helpful to focus on different things. So for “A,” whatever the subheading was, she [the CI] would make a remark about a patient or an example. That was valuable because we went through each subheading instead of one overarching comment. (S-FG2)

In contrast, two CIs reported that the ACP could restrict the conversation because they perceived it to be too theoretical and detailed. “I am just better at giving the student feedback on a day-to-day basis, [instead of] sitting there trying to mould this tool to what I want to say” (CI-FG3).

The ACP incorporates many opportunities for comments to be written throughout it. Students emphasized how important it was for CIs to provide specific examples for reflection and give thorough comments to guide a discussion. One student explained, “When the CI uses examples in the comments, the discussion has more depth” (S-FG1). Four CIs stated that the Comments section contributed to the conversation by triggering memories and providing clarification. As one CI put it, “The comments throughout [the ACP] help facilitate the discussion so that we don't just sit together and say, ‘You're good at this, not good at that.' We build a discussion around it” (CI-FG2).

We found mixed opinions regarding the importance of the Summative Comments section, which is the last page of the ACP form. Although this section is meant to be used for emphasizing or entering comments that have not already been mentioned, we found that it was often used to summarize the feedback and to give general comments to a student or CI. Eight students stated that the summative comments served to end the conversation on a positive note and provide “a better picture of you as an overall clinician” (S-FG1). Both the students and the CIs reported that the summative comments weighed more heavily during the mid-term conversation because they led to setting goals for the remainder of the internship. However, five students and two CIs thought that this part of the assessment tool was a repetition of previous comments and added no value to the discussion.

Discussion

Our results suggest that a valuable discussion occurred when both parties came prepared to exchange constructive and positive feedback, engaged in an ongoing process of self-reflection, and built rapport through their interactions. Performance assessment discussions provide an opportunity for formal feedback. Formal feedback discussions are a component of the clinical education experience and, as such, are shaped by the interaction among the learner, the educator, and the clinical setting.¹⁹ When this interaction creates a positive learning climate, it promotes both awareness and discovery, thus enhancing the clinical experience.²⁰ It is also in this environment that optimal performance discussions can take place. These conversations can provide meaningful feedback, strengthen the student–CI relationship, and engage a learner in an ongoing and cumulative learning process that contributes to professional development.

Feedback is powerful

Our findings support those in the feedback literature in which some educators have reported a level of unease with the process of giving their students constructive feedback and that students were somewhat apprehensive about these conversations.^4,21,22 We found that both parties were aware that this exchange of feedback was highly beneficial and were thus willing to persevere through the unease.⁴ Intentionally avoiding sensitive issues, such as areas in which a student needs to improve, not only hinders the student's learning experience but also puts the educational relationship at risk of remaining superficial and unable to address important issues.²³ This phenomenon is known as vanishing feedback, and it is important to highlight its implications.²⁴ When their CI avoided addressing sensitive issues throughout the placement and during the feedback discussion, the students described the feedback as less valuable. In addition, although the students appreciated praise, they recognized that it could go only so far to increase confidence and build rapport.^4,25,26 Furthermore, the literature on feedback has suggested that uncritical, positive feedback directed at performance rather than effort does not serve to inspire further achievement.^4,27

Throughout our analysis, we found that the students and educators engaged in distinct behaviours that could hinder or facilitate the exchange of feedback during these discussions.¹⁹ On one hand, students perceived the CIs who had written limited or broad comments as being unprepared and stated that it made the discussion “robotic” and awkward. On the other hand, students perceived the CIs who had booked a private space for the discussion and prepared comments that were honest, specific, tangible, and directly related to clinical practice as being invested in the discussion and the students' learning experience. For their part, the CIs recognized that performance assessment discussions were difficult for the students. They stated that a conversation was negatively affected when students did not come prepared with comments or questions. It was also a challenge when students did not accurately evaluate their own performance or did not contribute to the conversation by sharing their concerns or expectations. The literature has explained that these behaviours may be attributed to a student's focusing on the educator's summative assessment rather than on the learning process.¹⁹

Given that the ACP includes several rating scales, disparities between the student and CI assessments were visually apparent, and this could lead to a conversation that predominantly focused on the rating scales. Ongoing informal dialogue between a student and a CI decreased the likelihood of significant discrepancies in the assessment forms. On the basis of the data, it appears that a valuable and motivating discussion was more likely to occur when both parties presented comparable ACP assessments of a student's performance. The students and CIs consistently emphasized how important ongoing communication was for preparing students and reducing their anxiety about formal feedback. Drawing on our findings, we propose that it is important to recognize that the nature of the relationship throughout the internship can promote or hinder the exchange of feedback at the mid-term and final evaluations.

The relationship is important

The best educational relationships promote co-learning and occur in an environment that encourages open dialogue.^20,28,29 Students and CIs must recognize their shared responsibility and assume their individual roles in the educational relationship because this fosters a sense of partnership. According to Vågstøl and Skøien,²⁰ PT students acknowledged that mutual respect and trust were the essence of the student–educator relationship. This was a feeling echoed by the students in the current study when they described the CI as someone “you can have these [difficult] conversations with.”

In our analysis, the CIs were aware of the significant role they played in shaping students' attitudes about themselves, and they stated that conveying a sense of reassurance and recognition to their students was an important objective of performance discussions. According to Gillespie,²⁸ an effective educator appreciated his or her students' current level of knowledge and contributions to patient care and framed their areas requiring improvement as potential for learning. This in turn allowed the students to feel safe and supported as they took risks and solved problems in new learning situations.²⁸ Hutchinson³⁰ argued that providing a sense of belonging and demonstrating behaviours that build students' self-esteem instills a sense of self-actualization, allowing learners to reach their full potential. Vågstøl and Skøien³⁰ also suggested that students who feel respected and recognized express a greater level of confidence and control over the challenges they encounter in clinical work. One student in our study summarized this idea well.

I think that providing gentle constructive criticism is the CI's role, when they provide you with room for improvement, but they do so in a non-judgmental way. They should understand that, as students, we are here to learn; we want to do better. (S-FG2)

The CIs appreciated it when students made a genuine effort to actively listen to their feedback, asked questions to clarify it, and collaborated with them to come up with strategies to apply it. These efforts showed that the students were invested in the learning process. Being invested could also include giving the CIs feedback on their teaching because CIs are also continuing to learn and self-reflect. The CIs thought that formal discussions with their students helped them build a better relationship with them.

Consistent with previous literature, our results indicated that some students thought that formal feedback conversations with their CI were emotional experiences.¹⁹ “I think either way it is an emotional experience, whether it be good or bad, because you are invested in it” (S-FG3). This emotional component was described as awkward when there were significant discrepancies in the students' and CIs' performance assessments or expectations. When this happened, students were more likely to assume the role of attentive listener and view the CI as the expert diagnostician.¹⁹ In the case of performance assessment discussions, students who take on the role of passive listener contribute to the conversation less frequently, less meaningfully, or both. We found two examples of this. One student stated, “If I saw that I was higher or lower [on the rating scale], it kind of altered how I talked about my own scoring” (S-FG 1). Another student explained, “I hear them say a comment, and I feel like I need to change [my response]. I feel like I don't get to say, ‘No, I think I am good at that'” (S-FG1).

The inherent emotional complexity of performance assessment discussions was not overlooked by the CIs, and they commented on their role in setting the tone of these discussions. For example,

I try to still go back to that “You will get there,” that overall ending message is, “We're here to support you and not just tell you what you're doing wrong” and giving them the chance to address anything. Just being open. (CI-FG4)

Another CI expressed a similar sentiment. “I think a key conversation that I always have with students is letting them know that they are not going to walk away from the placement knowing everything” (CI-FG2). In both these cases, the CI used his or her position as the expert to mitigate the students' stress or disappointment and reassure them of the bigger picture—that clinical internships are learning opportunities and that CIs are experts who use their skills to support and guide that learning.

Ongoing learning and professional socialization

In our study, the CIs consistently stressed the importance of the student learning process remaining ongoing and cumulative. They stated that conversations at the mid- and final points of an internship were good opportunities to remind students that clinical education extended beyond acquiring technical skills. One CI referred to it this way: “It's based on putting different pieces together; it's not about how to range, how to percuss, that's not what we are as professionals. It's putting all that together” (CI-FG2). This example reflects the attitude that achieving independent professional practice is not only about performing skills correctly but also about gaining important skills such as critical thinking, self-reflection, and understanding the PT profession as a whole. The structure of the ACP outlines the key competencies, which CIs use as a prompt to address each role and its relevance to the current clinical setting.⁹ When students reflect on each role, it allows them to better understand that entry-level practice encompasses both a clinical and a professional knowledge base.⁶ Part of the transition from student to clinician is a process of socialization and integration into the profession, during which students gain an understanding of its values, attitudes, and culture.^5,6

In a study by Molloy,¹⁹ used feedback sessions to disclose aspects of their own clinical practice and to teach students about the community of knowledge they were entering. CIs who shared their knowledge and provided feedback by linking clinical performance with professional competency encouraged students to develop expectations of themselves as members of the profession.^19,28 We found evidence that students considered their identity during a placement not only as students but also as members of the profession. For example, one student stated, “[These discussions] help facilitate our growth as practitioners, to kind of help us not only in our clinical skills but in that reflective piece, [our] growth and ways to improve” (S-FG4).

According to Molloy,¹⁹ to encourage students to take on the role of junior colleague rather than only that of student or learner, it was helpful if educators disclosed the difficulties they themselves had experienced. The author reported that self-disclosure had a positive impact on the learning climate because it conveyed empathy and encouragement and normalized the students' difficulties.¹⁹ One student in our study commented on how she appreciated a sense of empathy from her CI. “Just making them aware that it [the discussion] can be stressful for students, so [they should] keep that in mind” (S-FG4).

Our study had a few limitations. First, although we acquired rich data from 29 participants from a variety of practice settings, our sampling pool included only students from the University of Toronto programme and CIs from facilities in the Greater Toronto Area. Second, the participating students and investigators were all enrolled in the MScPT class of 2016. To mitigate this important limitation, the students and CIs were given the option of anonymously recording any additional thoughts not verbalized during the FG on a separate sheet of paper distributed to all participants beforehand. Investigators did not call on any participant who chose not to answer a question or probe. Participants were also reminded that they could withdraw from the study at any point without penalty.

Finally, convenience sampling for both the student and CI FGs may have introduced a bias: Students may have chosen to participate because they had constructive feedback to offer during an FG, and CIs may have chosen to participate because they were invested in clinical education, and their opinions may not represent the views of all CIs.

Conclusion

This study aimed to explore the experiences of students and CIs while discussing the assessment of the students' clinical performance at the mid- and final points of their clinical internship using the ACP. On the basis of our study's results, we provide four key recommendations as a framework for promoting a valuable performance assessment discussion.

1. The discussion should occur in a conducive environment (e.g., a quiet and private space) to enhance open, two-way dialogue.

2. Both the student and the CI should invest in the discussion by being prepared, honest, and open minded.

3. There should be ongoing communication during the internship, before the discussion, to mitigate any feelings of apprehension and anxiety about these formal feedback sessions.

4. Both reinforcing and corrective feedback should be tangible, specific, encouraging, and supported by examples. It should provide learners with a clear understanding of their strengths and areas needing improvement.

Used together, these recommendations should promote a valuable, dynamic exchange that shares meaningful feedback and encourages co-learning and a sense of partnership between students and clinical educators. Moreover, these recommendations should contribute to the socialization of students into the PT profession.

Key Messages

What is already known on this topic

Clinical internships are important opportunities for students to practice and apply classroom knowledge and improve their clinical skill sets in a real-life environment. Giving feedback on a student's performance is a necessary and interactive process that occurs both formally and informally throughout the student's clinical internship. Effective feedback can increase motivation and self-esteem and enhance communication skills for both a student and a clinical instructor (CI). The performance assessment discussions that occur at the mid- and final points of clinical internships are instances of formal feedback, and they help structure the clinical experience, outline performance expectations, and assess instructional effects.

What this study adds

This article explores the unique challenges and benefits of formal face-to-face performance assessment discussions. Valuable discussions take place in a quiet, private space; require preparation; and include meaningful feedback. The emotional component of these discussions continues to be a challenge because these conversations involve a process of self-evaluation and the exchange of constructive feedback. However, when performance assessment discussions occur in a positive learning climate, they strengthen the student–CI relationship and prepare students for ongoing learning and entry into physiotherapy practice.