Speech-language pathology students’ experiences of viewing clinicians learning a new skill: A thematic analysis

doi:10.21203/rs.3.rs-5301505/v1

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Research Article

Speech-language pathology students’ experiences of viewing clinicians learning a new skill: A thematic analysis

https://doi.org/10.21203/rs.3.rs-5301505/v1

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Background

Gaining competency in a clinical practice such as speech-language pathology requires more than studying anatomy or learning about disorders: Students are often required to gain skills intersecting their self-perceptions, levels of confidence, trust in practice educators, and willingness to be vulnerable while learning. Yet, limited research has investigated students’ perceptions of error recovery processes in practice education, and demonstrations often focus on best-practice behaviours which may contribute to students’ perceptions or interpretations of deficits in their own skill.

Aims

This study aims to explore information, processes and behaviours speech-language pathology students attended to when observing clinicians learning a new skill.

Methods & Procedures:

This qualitative study used in-person and online workshops in which students discussed concepts, watched videos and reflected on video content. Fifteen speech-language pathology students aged 17–50 (m = 21, SD = 8.17) participated from a university in Australia. Workshop discussions were thematically analysed.

Outcomes & Results:

Three major themes were generated, including (1) Clinicians gradually learned how to use a new tool properly; (2) Clinicians were person-centered as skills were applied flexibly as every client is different; and (3) Workplace culture plays a role in skill acquisition.

Conclusions & Implications:

The themes are indicative of the importance of valuing flexibility in administering therapy, acceptance of mistakes, and the key role person-centeredness plays in practicing new skills. Practice educators may wish to use these insights in guiding their students’ attentional focus when undertaking clinical observation and practice, while also considering psychological and emotional strategies aiding student development.

student

practice education

speech-language pathology

person-centered care

video

What is already known on this subject? Practice education often involves the use of modelling or demonstrations, and most often includes demonstrations of successful therapy, either live or via videos, during which students are assumed to have attended to important or key behaviours and processes. The information to which students attend has not been studied, yet the focus of students’ attention determines their capacity to develop a mental model of appropriate clinical behaviours.

What does this study add? The present study shows students identifying the gradual process of skill acquisition and ways in which clinicians recovered from errors while learning new strategies, along with demonstrating their deeper understanding of clients’ individuality. Practice education would benefit from the use of videos showing clinicians developing a new skill, as students may benefit from modelling of appropriate error recovery processes.

What are the potential or actual clinical implications of this work? Practice educators can use these insights in understanding their students’ attentional focus when undertaking clinical observation and practice, aiding student development.

Practice education aims to develop competency in students for the provision of clinical services (Hosseini Beidokhti & Moradi, 2017), and developing autonomy and job readiness in trainee clinicians (Gribble et al., 2017). Beyond the dissemination of fact-based content, practice education also requires the demonstration and instruction of skills that might otherwise remain hidden, such as clinical reasoning, problem-solving, application of abstract concepts, and the development of the self as a professional (Delany & Molloy, 2009). The process of learning to become an allied health clinician is complex, comprising factors related to the educator (e.g., expertise, teaching skill), student (e.g., self-efficacy, effort, ability), discipline subject matter (e.g., intricate diagnostic criteria), and processes (e.g., case history taking, assessment, managing resistance and barriers). The interaction between these different variables may produce clinicians of vastly different capabilities (Jackson et al., 2020), with each factor providing an opportunity for refinement in quality practice education. In practice, the interaction of these factors means that practice educators are often required to consider all of these things simultaneously, without necessarily knowing the student’s attentional focus.

When acquiring new skills, social learning theory (Bandura, 1977) describes that by watching others performing a skill or activity, individuals can identify components of the behaviour to be performed, learn to mimic it, and apply it in new situations. The acquired behaviours are refined through practice and feedback, with success moderated by the quality of these along with emotions associated with performing the action: Behaviours that promote negative affect are less likely to be repeated than those producing positive affect (Bandura, 1986). Throughout the social learning process, observers not only develop their skills, but also their self-efficacy for using those skills (Bandura, 1977).

The mechanism by which social learning is thought to influence observers’ ability to perform new tasks relates to the development of a cognitive representation, which can increase the quality of behaviour performance even once models are no longer available (Carroll & Bandura, 1987). Providing a sample stimulus (e.g., a clinician administering therapy) allows the observer to create a mental reference point for their own later implementation of the skill or strategy being learned (Carroll & Bandura, 1987). As the learner makes their own attempts at the behaviour, mental comparisons are made between their own execution and their memory of what they observed, with adjustments made accordingly. This means their competence in completing that behaviour successfully is in part determined by the features they notice and remember from the example. Understanding what information students attend to when learning skills and processes may inform practice education by ensuring students are attending to the most relevant features of a behaviour.

The process of viewing training videos and reflecting on the content is a common means for students to gain familiarity with not only their profession’s settings, but also with required skills, clinical procedures and client needs (Moro et al., 2020). Benefits to video use in clinical training can include the extensive range of clinical presentations available for students, covering infinite variations in patient demographics, presentation, complexity of health needs and many other considerations. Video technologies hold considerable appeal for training institutions given their scalability and cost effectiveness for large student cohorts, lack of risk to clinical patients, and relevance over long periods of time (Moro et al., 2020), and were especially useful during the COVID-19 pandemic (Dzara et al., 2022). Use of video reflexivity methods further provides opportunities for students to practice clinical decision-making and learn from others’ mistakes in a low-risk environment (Iedema et al., 2013). However, the success of video technologies as a tool for practice education depends on the information students notice and to which they attend. To date, limited research has documented students’ attention to information in videos for practice education purposes.

This study was part of a larger study conducted by the research team, in which we aimed to determine whether video observation of learning new skills could be an effective means for students to improve confidence and reduce anxiety, and how video observation can be refined to enhance learning. The present study aimed to determine the kinds of information, processes, and behaviours students noticed and attended to when observing experienced clinicians learning a new skill.

Ethical approval

The University of Queensland Human Research Ethics Committee granted ethical approval for this study (approval #2019001593). Written informed consent was received from all participants prior to participation.

Design

This qualitative study was conducted using a workshop format in which students discussed concepts, watched videos, and reflected on their clinical learnings.

Researcher positionality

The research team are experienced qualitative researchers with track records of using thematic analysis from critical realist and social constructivist perspectives; in this paper, we adopt a critical realist perspective. In doing so, we anticipate that the students’ observations of the videos will inform the reality of their own experience, within the constraints of their experiences of clinical education. Within our team, author KT holds a PhD in psychology, and is an experienced tertiary educator of qualitative methods including thematic analysis and interpretative phenomenological analysis. Author MN has extensive clinical experience and holds a PhD in audiology and has with experience in qualitative analysis. Author NS an experienced pragmatic thematic analysis researcher with a PhD and clinical qualifications in speech-language pathology.

Participants

Fifteen students enrolled in a Bachelor of Speech Pathology at a metropolitan university in Queensland, Australia participated in this study. Participants were recruited by email invitation from the program director at the university. Initially 19 participants were recruited but only 15 could be scheduled to participate in workshops. All participants were female, and were aged 17-50 (m = 21.00, sd = 8.17). Students were eligible to participate if they i) were aged over 16 years; ii) were enrolled in their first semester of a Bachelor of Speech Pathology (Honours) program, and iii) were not clinically trained in any discipline.

Measures

In addition to demographic details as above, participants responded to questions during the workshop that are outlined in Appendix A. These were constructed to gain an understanding of student perception of and attention to clinician behaviours and experiences

Procedure

Following disruption due to the COVID-19 pandemic, original plans to hold workshops in person and in small groups were no longer feasible. Accordingly, there were nine workshops of varying sizes conducted using a variety of in-person and online formats. Online sessions were conducted using Zoom videoconferencing software (Zoom Video Communications, 2020). Seven workshops had only one participant (five online, three in-person). The remaining two workshops had three participants (online) and four participants (in-person). All workshops were audio-recorded and professionally transcribed.

Workshop

Full workshop procedures are described in Appendix A. Relevant steps to the current project were that participants discussed their knowledge of person-centred care, then viewed the video Managing Change – Realities and Roadblocks (34:00 minutes; Ida Institute, 2011). Discussion ensued of participants’ observations of person-centred care and their perceptions of the clinicians’ experiences of learning new skills. They then watched a second video, Initial Thoughts on Diagnosis (3:20 minutes; Ida Institute, n.d.), and answered questions about their perceptions of person-centred care in the second video and how the skills learned by experienced clinicians in the first video could have been applied to the situations discussed in the second video. Although it was not by design, the clinicians in the videos modelling learning a new clinical strategy bore similarities to the research participants in age and gender; this has been shown to improve relatability for learners (Bandura, 1977). The questions developed for use in the workshops were developed using recommendations by Plack et al. (2005).

Data analysis strategy

Procedures outlined by (Braun & Clarke, 2021) were followed: Author MN and KT reviewed all transcripts for accuracy and data familiarisation, then cross-coded two transcripts to establish confirmability. Author MN then coded the remaining transcripts, producing 210 codes. After further refinement for clarity and overlap, 200 codes remained. With satisfactory similarity in coding, codes were arranged into categories, then categories into themes using iterative processes whereby codes and categories were consistently reviewed for their fit with other items in their grouping. Following creation of themes, a consensus approach was taken between authors KT, MN, and NS. In this consensus approach, themes and categories were reviewed and refined based on discussion, and with reflexive consideration of our own biases. Original transcripts have been retained.

Three major themes were generated from the analysis of qualitative data, including (1) students noticed that clinicians gradually learned how to use a new tool properly, (2) the tools allowed clinicians to practice person-centred care, and (3) workplace culture plays a role in skill acquisition. The themes and categories along with some illustrative participant quotes are presented in Table 1.

Theme 1: Students Noticed that Clinicians Gradually Learned How to Use a New Tool Properly

“Awkward” and “Uncoordinated” at Start; Strong, Confident, and Capable in the Following Sessions

Students in this study noticed that clinicians were “uncoordinated,” slow, “stiff,” and “awkward” when using the person-centred tool for the first time, and they mostly focused on the tool during the appointments. A student reported that seeing clinicians using the tools awkward at the start was “hard to watch” and made the student “cringe.” However, students reported clinicians, in the following sessions, learned how to use the new tool without it being the centre of the attention; and had more eye contact in the second appointment instead of looking at the tool several times. It was also reported that clinicians became strong, confident, capable, and less nervous in the following sessions:

“I think it's really interesting how at the start pretty hesitant and had some issues, but then just the next day they were just so much more confident, and they saw how beneficial it was and how much it had changed their patient relationship.”

Students also noticed that the second sessions were more conversational and followed the client's lead. A student also found it interesting that clinicians were hesitant first, but the next day they saw the benefits of the tool and changes in the client-clinician relationship and were motivated to use the new tool. Students reported that clinicians gradually got more fluent with the new tool and became “smoother” not “necessarily quicker.”

Clinicians’ Confidence, Flexibility, and Acceptance of Mistakes

Students in this study reported they learned that clinicians’ confidence helped with their success in using a new tool. Students thought clinicians accepted their mistakes and were happy to do “trial and error” with the new tools instead of getting “too upset” if it did not work well at first. Clinicians were also willing to be flexible with the tool:

“They understood the purpose of it … They were more willing to put the time in that if needed, but also be flexible with it and just follow their patients.”

Role of Experience in Using New Tools

Students interviewed in this study believed in the role of experience in using new tools. They acknowledged that doing anything for the first time with clients makes clinicians worried about clients' responses and how they perceive the treatment. Students thought as clinicians get more comfortable and skills with the tool, they get less focused on asking questions and had more cognitive capacity to store what clients say to have an “open discussion” instead of “filling in a form.” A student also noticed that when a clinician did not receive the response that she was expecting, the clinician became more confident in how to respond to similar clients using the tools in the future:

“Well, I think that in one of the earlier [examples], the client hadn't responded in the way that she was expecting. From that, I think that she felt more confident in how to respond if the next client also didn't respond in that way. So, I think she was confident if this client does X, whatever, I can now respond to that, because I've had that experience. Again, in the video that I think I'll refer into, obviously, the client responses. I could see that she saw that they were contradicting and contradictory.”

Students also shared their beliefs that clinicians would prefer the new tools if they get used to it as “you just got to fake it until you make it.”

Theme 2: The Tools Allowed Clinicians to Practice Person-Centred Care

Individualised Care

Students interviewed in this study noticed that clinicians were person-centred in many ways. For example, they deliberately asked relevant and individualised rather than generic questions and provided individualised care to address clients' needs with a solution that made clients feel they got a high standard of care. A student also liked that clinicians explicitly noted that they remembered information from the previous meeting instead of starting from scratch. It was also reported that clinicians could switch and adjust quickly to meet the individual needs of each client, and clients’ feedback was very important to clinicians because every client's need is different:

“So even though the second clinician tried to fix her mistake from the previous day, she felt as if this was an entirely different person, so you just have to go into the session with an open mind and be able to adapt.”

Students also spoke of clinicians’ behaviour that was calm, allowed clients to direct the session, focused on clients' concerns, and did not talk over clients that made clients feel important. Clinicians found out about clients’ difficulties in daily activities by asking “Why do you think you need one [hearing aid]” and “What others are feeling.” It helped clinicians with understanding family or social communication difficulties and how people's feedback affected clients. Then clinicians repeated/rephrased clients' statements for confirmation and accepted what clients wanted: “I noticed that they often repeated or rephrased what the client said, or the patient said, to make sure that they were getting the right message.”

Students reported that, in the video, clinicians seemed open toward clients not awkward or embarrassed, and their person-centred approach helped clients to be engaged and to feel they are treated as individuals:

“… it's just basically, they're not a number and they're an individual because otherwise, you don't get that relaxed kind of... You don't get the information out of people because they don't feel like it's... I don't know. They just don't... If you don't feel like you're very wanted in a space if that makes sense... If they're just treating you to get the money out of you, then you're not going to be very engaged in the follow-ups, in the processes of getting that done because you're not going to be adjusted to the hearing aid in one day.”

Informed Decisions

Helping clients with making informed decisions was also reported in this study. Students thought clinicians explained and clarified things to their clients to help with making an informed decision. Students liked that clinicians were not rushed in the session and focused on getting patients “mentally prepared before they could have the device fitted.” Students reported that clinicians also talked about the connections between hearing loss and clients' personal life (meetings, communication with family) that helped clients in decision making: “They bring out the connections between the hearing problems and their personal lives, so they feel like it's important and that it's really about them and not about the medical... What they think we need.” A student also reported that offering a 6-week hearing aid trial to client was good to remove pressure from the client who was uncertain about getting hearing aids.

Building Relationship with Clients

Participants in the study noticed that building relationship was important to clinicians, and that clinicians tried to build a relationship with clients so that clients felt comfortable and free. For instance, when the clinicians restated what their clients said, it made the clients think clinicians were really listening to them. A student thought repeating the statement the client puts an emphasis on, has a lot of feelings. Another student also noticed that one of the clinicians who had a client who contradicted himself kept a friendly and understanding approach. The student thought that client could sort through his emotions and felt freer/not afraid when the clinician did not change her tone because of his resistance to hearing aids:

“I think there was one guy that was quite resistant; and he just didn't want any part of it, so she [clinician] did have to use a lot of kind of closed-ended questions because she obviously kind of noticed that he was contradicting himself, so she had to change that. But she did really well with obviously keeping a friendly tone and trying to be understanding … she remained firm. She stayed facing him, she stayed with the same tone, the same body language. Nothing changed, which I think was really good, because sometimes some people, when someone starts to resist them, they kind of close off and they turn away or change their tone of voice. But because she stayed really well, I think that that really helped him as well to actually sort through his emotions and figure that out, because he... I can't obviously speak for him, but I feel like he might have felt more free, I suppose and not as afraid, because she wasn't attacking him, she wasn't doing anything to him. So, I think he responded really well to that in that sense.”

A student also thought the clinicians had appropriate professional physical distance with clients like a therapist—not “too far away or too close.”

Engaging and Collaborative

Clinicians being engaging and collaborative with clients was another important person-centred skill that was recognised by the participants in this study. Clinicians using the tool in partnership with clients stood out to students. For example, a student noticed clinicians used the pronoun “we” when talking about improving clients' hearing to build a relationship (e.g., how we can work together). Sometimes, clinicians also paused conversations so clients could talk. Another student thought that was good that clinicians adapted to whatever the client told them instead of trying to fight to get that back to where the clinician wanted:

“I like that they just adapted to whatever the person was telling them. I think one of them said that she had an idea of how the session was going to go and then when she got in there it was completely different, and instead of just trying to fight that and get it back to where she wanted, she just went along with it so I think that was good.”

Empathy and Understanding

Clinicians' empathy and understanding behaviours were also noticeable for the participants in this study as a student said: “I think they're definitely empathetic.” Students thought the clinicians in the video were understanding and accepting not pushy:

“I also think that they weren't pushy, even in this, or sometimes trying to understand why they didn't want to do certain things. They weren't like, ‘You need to get a hearing aid. You have to get one of them, you're going to have this, this, and this.’ It was very understanding and accepting, in a way. Like, ‘Okay, even though I personally think you should get one, if you don't want one, that's how it is.’ I think that was good.”

Positive and Deliberate Use of Language

It was also reported that clinicians in the video used positive and encouraging language that was important in person-centred service provision. A student expressed her belief that the clinical encounter could have gone differently, potentially worse, if the clinician changed her voice or closed up after seeing clients' resistance to hearing aids. Students thought it was important not to offend clients like the clinicians in the video who did not use “too intense” or “too extreme” language. Another student also said:

“I think they [clinicians] mostly use synonyms from what the patients were saying. They were just restating what they were saying, instead of assuming new points.”

Every Client is Different

Students interviewed in this study reported they learned that every client is different— “no two people are the same,” and clinicians need experience with different treatment programs to offer different clients. Students noticed that the clinicians in the video learned that “there isn’t one approach” that helps with all clients. Students also acknowledged that although every client is different, having some experience will help clinicians with providing recommendations:

“I think obviously, even if you have a lot of experience, everyone is still different. But I do believe that having some experience will help you know which recommendations are better. There might be a range of things that work for clients who are sort of like this. You can't put people in a box and say, ‘Okay, they have this disorder, therefore we're going to use this treatment with this many months, blah blah blah.’ But I do think if you have a little bit of experience, and you've seen a bit more, and you know a little bit more about it, that you would be more confident in dealing with individual preferences because you have had exposure to lots of different things.”

Theme 3: Workplace Culture Plays a Role in Skill Acquisition

Positive, Welcoming, Encouraging, and Respectful Meeting

The staff meeting shown in one of the videos was perceived by students to be positive and encouraging, conducted in a respectful environment that provided “an equal sharing ground of input” for clinicians to discuss the use of the new tools in their practice without a feeling of being “offended.” Students observed that at the start of the meeting, clinicians were “hesitant” in giving their feedback, however, once the clinicians had an opportunity to reflect, clinicians became confident and reflected on each other's experiences. Everyone was happy and open to expressing ideas in the meeting. Clinicians in the staff meeting were also perceived to be willing to listen to experiences, as managers were observed to make efforts to make the clinicians feel comfortable. Students thought clinicians and managers/trainers had a respectful conversation in a casual environment:

“The respect for each other, it seemed like a pretty relatively casual environment. Obviously, we have meeting and things like that, but it wasn't rigid, you talk, you talk, you talk. They were kind of just having a respectful conversation.”

Students found it helpful that instead of degrading each other, the staff meeting was collaborative, and staff understood each other: “You feel like you can reach out, ask for help and not just get slammed by not getting it exactly right the very first time.”

Collaborative Meetings without Arguments, Disagreement, Judgment, Blame, or Competition

Students spoke of how important it was that everybody was validating each other's opinions instead of disagreeing and arguing in the staff meeting. “There was no accusation,” or competition between clinicians, and nobody was overly judgmental or harsh. Meeting attendees were accepting that everyone may make mistakes, so no one (e.g., supervisors) blamed each other during the meeting: “Definitely a place where if something didn't work, it didn't feel like you're going to be hammered into the ground over it, or you might get in trouble or something.”

Meetings Contained Constructive Feedback and Reflective Discussion

Students found the staff meeting “analytic,” realising that mistakes and difficulties are associated with using a new tool. Students noticed clinicians' cooperation and desire to work together to talk about the tool and take on board each other's feedback. The staff meeting was about sharing their knowledge and experience of using the tool with “very warm” and “constructive” feedback. Students expressed that they liked how staff analysed the use and negative effects of the new tools. In addition, the reflective discussion was a noticeable point from the perspective of the students interviewed in the current study. Students expressed their beliefs that clinicians might not pick up on things at the session but when they reflected on themselves, they would pick up the issues which was helpful. Students thought clinicians had discussions focusing on improving the use of the tools for the next time rather than complaining about them. So reflection on the tool helped clinicians learn from each other:

“I think if they reflect on it, then they can share information on it. What worked for them, what didn't work for them because while one person might find it really effective, one person might struggle in trying to apply it in a natural and comfortable way within the clinical setting. And I think by sharing their ideas, they can all learn from each other.”

Everybody Wanted to Improve the Service

The student reported that although the practice had been the same for many years, the staff knew there was room for improvement, and they were navigating how to improve it. They were not all on the same page as there was not enough evidence (only two clinicians used it) but they all wanted improvements. Students also thought that managers in the video wanted clinicians to use the tools for the benefit of both clinicians and the business rather than an external requirement. A student also noticed that the Head of the audiology department wanted the best for their clients, so sharing the experience of using the tool with the head of audiology was a good decision as it gave the chance to other clinicians too to know about the usefulness of the tool. A student also said:

“They always want to improve but they don't want to, I don't know, they don't want to throw out a system completely if it is actually not going to work. They really wanted to solidify it with the patents so it showed that no matter who you are, or whatever team you work with or whatever, everyone's going to be on the same mental field of doing the best for the patients and that's the bottom line for everything, not this will be easier, and they don't have to waste all this time asking useless questions they know the answers to.”

Managers and Trainers’ Openness and Expectations

Students interviewed in this study liked the openness and support of the Head of the audiology department to the idea of change, and managers and trainers’ intention to help clinicians tailor the tool to carry out the questioning in the clinic. The tone of the feedback from managers was also natural and positive not offensive. However, students reported that the Head of the department had still his doubts because there was not enough evidence for use of the tool:

“But again, he still has his doubts just because there is no evidence. He's just got two people's opinions and with only, what four clients. So, I guess he might just be thinking, and as the manager as well, he probably has the more authoritative voice in taking on the tools.”

Managers and trainers’ expectations were reported to be clear to clinicians. Expectations included (1) clinicians reflect on how the tools could help them in their practice, (2) clinicians to know what was relevant from the tool to their practice and to get rid of what was not relevant, and (3) the use of the tool to be a positive experience for clinicians. Students reported that managers did not expect clinicians to love the tool the first time nor expect clinicians to be perfect straight away. Students also reported that managers restated the goal of using the tools allowing clinicians to integrate the tools more naturally, and were happy as long as clinicians express their opinions and feelings, were trying to reflect on the use of the new tool, and get better in the journey.

Students Would Like to Work in a Similar Environment

Finally, students expressed their desire, as new speech-language pathologists, to work (or have placements) in a positive environment like the video that gives them the opportunity of learning and growing with the help of assertive and experienced managers and knowledgeable staff. In such an environment that mistake is not the focus of the team, the student would be willing to make mistakes and learn from them. Students thought they would not be comfortable in an environment that everyone seemed they were perfect. A student said: “Just being in that environment, it would really make us more comfortable.”

This study aimed to investigate students’ observations of clinicians learning a new skill. In thematically analysing workshop discussions, we derived three key themes: students noticed that clinicians gradually learned how to use a new tool properly; the tools allowed clinicians to practice person-centred care; and workplace culture plays a role in skill acquisition. Within the categories of these themes, the behaviours and processes discussed give some indication of the features students attend to in reviewing video-recorded practice education material. While some guidance was provided for students in terms of the kinds of information they had observed (e.g., “What person-centred care did we see in the video?”; Appendix A), the directions taken by participants in this study highlight several interesting ideas.

Firstly, students clearly identified that the process of acquiring a new skill was one which emerged with practice, and that the initial attempt was far from polished. Students explicitly recognised that errors and discomfort were common early in the experience of trying a new strategy, and further that these established, experienced and relatable clinicians not only acknowledged and accepted the errors that they were making, but also made explicit explanations of how these mistakes could or were overcome. This may have implications for practice education via overt discussion with students about the prevalence of such mistakes, and potential disclosure of practice educators’ own experiences of learning new skills. The use of relevant educator disclosures can enhance students’ engagement and learning (Kromka & Goodboy, 2021).Although negative disclosures are often thought to lead to perceptions of weakness or lower competence (Miller et al., 2014), appropriate discussion of challenges educators have personally faced can increase students’ perceptions of educator credibility (Meluch & Starcher, 2019). This arguably provides students with a model for overcoming setbacks. Demonstrations of correct techniques alone, rather than modelling recovery from mistakes, may exacerbate perfectionism and emphasise outcome at the expense of process, potentially limiting clinical decision-making skills. Consequently, demonstration and discussion of errors and error recovery processes may help students to consider their own missteps from a strengths-based, proactive perspective with emphasis on how the issue can be resolved or prevented in future. The role of the workplace cannot be overlooked in this context; students’ observations that meetings were collaborative and contained constructive feedback, while also being free from judgement, blame and competition, highlight students’ potential sensitivities to these experiences. Extensive research on workplace culture demonstrates the benefits that can be reaped from supportive work environments (Newman et al., 2017; O’donovan & Mcauliffe, 2020): psychological safety of students in practice education is equally important (McClintock & Fainstad, 2022).

Secondly, and across all themes, students recognised the need for flexibility. Flexibility allowed clinicians to conduct care in a person-centred way that recognised individuality of patients and clinicians alike, but also gave clinicians the grace to make mistakes and to follow their client’s lead. For both these reasons, flexibility may provide a key opportunity for practice educators to guide students’ development, and may further allow students to connect with the deep, underlying purpose or skill of conducting a particular clinical activity (McClintock & Fainstad, 2022). In contrast, learning a script or process of clinical activities or via a mental checklist of tasks and behaviours without understanding the deeper purpose behind activities and interactions may result in graduates who are less able to effectively manage non-standard cases, miss important information, or are insufficiently sensitive to patients’ needs. Developing this deep understanding of the overarching purpose of clinical activities is likely to produce learning that is retained for longer and can be applied more flexibly than learning by. Research has demonstrated that cognitive flexibility in approaches to learning is related to academic achievement (Toraman et al., 2020). Our finding in this area is not isolated (Cano et al., 2018; Toraman et al., 2020); yet, overly rigid practice education risks an automatization and oversimplification of activities with quite profound meaning and opportunities for connection. Moreover, recognition of practitioner flexibility is consistent with principles of heutagogical strategies in which learners actively participate in the development of their education (Hase & Kenyon, 2013). By encouraging learners to find their own ways to think about and engage with materials and processes, information is thought to becomes more personally meaningful.

In terms of limitations, and like many other recent studies, this project has been subject to the unpredictable conditions of the COVID-19 pandemic. This resulted in some variability in workshop administration in terms of both group size and interviewing medium, which may have influenced outcomes. Recently-documented perceptions of qualitative research conducted on Zoom has suggested that some participants rate Zoom more highly than other methods of interviewing (Archibald et al., 2019). Consequently, there may have been differences in the types of responses received in this study subject to individual participants’ preferences, for which we did not control.

Additionally, this study made use of resources created for and by audiologists (Ida Institute, 2011, n.d.), yet the students were speech-language pathology students. This may have meant that students needed to make an additional cognitive leap to imagine how the techniques used by audiologists in the videos, were relevant to their own work as future speech-language pathologists. However, these students were in their first six weeks of their undergraduate training program and it is likely that their sense of the two disciplines’ idiosyncrasies was not consolidated to the extent that they needed to ‘unlearn’ information in order to see the relevance across the two, although it may have been difficult for them to see how features might apply in a speech pathology setting. Interprofessional education research highlights the importance of health students’ exposure to the work of other allied health disciplines and that this can foster considerable benefit when provided early in the students’ education (Reid et al., 2018). The opportunity for students to observe clinicians from an adjacent discipline may even provide the benefit of ensuring students are not distracted by discipline-specific content knowledge, rather than process knowledge possessed by health practitioners more broadly.

Despite these limitations, we make two recommendations for practice educators based on the information our participants provided. Practice educators often provide extensive psychosocial support to ensure the psychological safety of students, which can include inviting student input in learning activities (Fainstad et al., 2018), providing appropriate debriefing opportunities for constructive feedback (Fey et al., 2014) and promoting high-quality interpersonal relationships (McClintock & Fainstad, 2022). As an adjunct to these approaches, and if clinicians are not already doing so, we recommend they normalise the experiences of making mistakes and feeling awkward when attempting new strategies or techniques, and even providing examples from their own careers if they feel they are appropriate. Research indicates that similar strategies can not only increase students’ perceptions of educator approachability, but may further reduce student anxiety about making mistakes, freeing cognitive resources for understanding and implementing new information (Jakobsen et al., 2019; Wolf, 2016). Practice educators can further assist their students by emphasising flexibility in application of clinical strategies, allowing students to redirect their attention away from ‘getting it right’ to ‘understanding and responding to the patient’s needs’. Students with greater flexibility in their approach to clients and problem-solving with clients may display greater resilience in challenging clinical situations (Cano et al., 2018) and may have more opportunities to learn from their clients. While this approach may need to be balanced with the clinical necessity of ensuring competent practice, it is entirely consistent with person-centred care principles of respecting the individual and for the individual to be an equal member of the healthcare team.

In conclusion, the study conducted here has explored the information to which commencing speech-language pathology students attend when observing experienced clinicians learning a new skill. The thematic analysis conducted produced themes addressing flexibility, acceptance of mistakes by the self and workplace, and the key role person-centredness places in practicing new skills. Practice educators may wish to use these insights in understanding their students’ attentional focus when undertaking clinical observation and practice, aiding student development.

Competing interests

The authors declare no competing interests.

Ethical conduct

This research was conducted with approval from The University of Queensland (#2019001593). All participants provided written informed consent prior to participation.

Research funding

This research was funded by a grant from the Ida Institute awarded to Tulloch, Lind and Scarinci. The Ida Institute had no direct involvement in the research, and did not require review of findings.

Authors’ Contributions

Dr Tulloch was involved in all aspects of this research.

Dr Nickbakht was involved in the data analysis, interpretation and manuscript preparation.

Prof. Scarinci was involved in all aspects of this research.

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Table 1. Themes and categories
Themes and Categories	Illustrative Quotes
Theme 1: students noticed that clinicians gradually learned how to use a new tool properly
Clinicians were “awkward” and “uncoordinated” at start, but they became strong, confident, and capable in the following sessions	“When she did it the first time, she was very stiff, and she was very slow and uncoordinated with it” “… but at the end of it, they were a lot more natural and that was kind of... You could see that with the last person because the man shared a lot more information with the lady because she was much more open, relaxed, and yeah.”
Clinicians’ confidence, flexibility, and acceptance of mistakes helped with their success in using a new tool	“So, her confidence actually helped her succeed with that patient.” “They're actually willing to be flexible with it because they understand the final aim rather than each of the tiny little steps to get there.”
Students believe in the role of experience in using new tools	“I definitely think, and they said this too, but as you get more comfortable with things, you're less focused on what you're saying and more focused on what your patient is telling you.”
Theme 2: The Tools Allowed Clinicians to Practice Person-Centred Care
Clinicians asked individualised questions and provided individualised care to address clients' needs	“They would deliberately ask questions, so they could come up with a solution that directly addressed the needs of the things that were most important to the patient. If they really wanted to be able to hear in meetings, then that was the goal. If they wanted to be able to care their wife, when she was walking away like that was the most important goal. They could centre their treatment based on that.”
Clinicians helped clients with making an informed decision	“They [clinicians] were taking their time with their answers, and they were always clarifying. Like if they [clients] didn't understand the question, they [clinicians] would rephrase it.”
Clinicians tried to build a relationship with clients so that clients felt comfortable	“… but create that healthy relationship with the patient.” “She [clinician] constantly said thank you for... and showing the gratitude that she was willing to tell her stuff. Which ended up making her [client] feel a bit more comfortable about the situation.”
Clinicians were engaging and collaborative	“They weren't hiding in their little notes, like away in the corner. It was very collaborative.” “like I say, I just think overall they were just really good with engaging.”
Empathy and understanding of clinicians	“… they're empathetic towards what they're saying and that they understand it as well.”
Clinicians’ positive and deliberate use of language	“She was really direct and if I think the words they used weren't too intense; It wasn't too extreme.”
Students learned that every client is different	“She's just forgotten that everyone is different. And no two sessions are going to be exactly the same, not everyone is going to receive or perceive the same information the same way. It's all going to be different.” “… everyone is different, and they have different blah, blah, blah.”
Theme 3: Workplace culture plays a role in skill acquisition
A positive, welcoming, encouraging, and respectful meeting	“seeing the environment that that clinic, or that audiology clinic, whatever you might call it had, in that they clearly had quite a positive environment.” “they were quite encouraging. Yeah.”
Meetings were more collaborative and helpful and did not have arguments, disagreement, judgment, blame, or competition	“No one was going to the other person, and like, ‘You did this wrong. She made all these mistakes, blah, blah, blah.’ It was just talking about it and helping everyone. People weren't targeted as worse or better than using the tool or anything like that.”
Meetings contained constructive feedback and reflective discussion around the tool	“It [feedback] is like you did fine but I'm just saying do better.” “I think those reflection sessions that they had ... Were helpful.”
Everybody in the meeting wanted to improve the service	“I know he said that their practices have been the same for 20 to 30 years but it seemed that with that conversation at the end, they obviously knew there was room for improvement and they were just navigating how exactly they wanted to do that.”
Managers and trainers' openness and expectations	“It was all just a journey. As long as they were trying to reflect and get better every time, they [managers] were happy with that. They weren't monitoring them to find every single time they chipped up.”
Students would like to work in a similar environment	“Makes me hope that the placements that we're in have that kind of environment. I know places are going to be different but a place like that is really good for learning, I feel like.”

No competing interests reported.

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Speech-language pathology students’ experiences of viewing clinicians learning a new skill: A thematic analysis

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