Perceived Constraints to Clinical Education in Private Practice and How to Overcome Them

The following has largely been derived from Rorke's 2005 discussion paper, commissioned by QOTFC: "Clinical Education in Private Practice - creating win-win-win for students, universities and private practitioners".
 

Perceived Constraints to Student Clinical Education in Private Practice

• cost (to the company or sole practitioner) - non-accountable time spent with student orientation, education, training, feedback and evaluation
   
• "time is money" or potentially longer hours and difficulties meeting employee billing obligations
   
• caseload fluctuations (too much or too little work) and less structured work environment
   
• limited "hands on" client contact time (nature of the work) to offer student
   
• risk and Legal/Ethical issues (professional liability, issues of disclosure, consent, service delivery issues, intellectual property and student autonomy)
   
• student characteristics (preparation of student for consulting role, personal characteristics or students for the setting/student selection issues)
   
• travel (time for students to travel to the placement, cost of travel, insurance issues related to injury to students)
   
• lack of student space; working from home
   
• clients would experience decreased satisfaction with service if treated by a student
   
• potential reluctance of third party payers such as Insurance companies, to pay for student delivered therapy services
   
• students would decrease practice productivity
   
• uncertainty about the criteria for effective student clinical education in a private practice setting
   
• use of intellectual property (IP) and implications of improper IP use by students
   
• the emotional cost
   
• Poor relationship with the universities, curriculum and recognition of their contribution

(Rorke, 2005; see also Doubt, Paterson & O'Riordan, 2004 and Potts, Babcock & McKee,1998)
 

Recommendations for Overcoming Perceived Constraints

Here are some helpful recommendations for ways to address perceived constraints to having student placements in private practice, as outlined by Rorke (2005) in her QOTFC commissioned discussion paper "Clinical Education in Private Practice. Creating "Win-win-win" for students, universities and private practitioners":
 

Third Party Payers and fee-for-service paying clients

• Provide clear student identification : always introduce student as a student or trainee occupational therapist (in accordance with the Occupational Therapists Registration Act 2001, section 121{3}).
   
• Develop a written consent form for client/third party consent: for student involvement particularly with medico-legal claims and for lower fee paying services conducted by students. Refer to:Template 1.1: Client informed consent form - Private Practice
  Reference Document 1.1: Client Informed Consent Form. UQ Health and Rehabilitation Clinics. "We always inform the customer and paying party of the students' involvement in our quote. When they accept our quote and book our service, they are consenting to student involvement" Kerry Adam, OT CE, private practice, 2007).
   
• Transparency of level of student involvement: Consider use of a student charter to clearly outline the conditions of student involvement with clients and involved parties of your practice. Refer to:Reference Document 1.2: UQ Student Charter. Worker's Compensation and CTP Services
• Use of verbal consent : may be appropriate in certain circumstances such as the performance of a small part of an intervention ie conducting oedema massage during a hand therapy consultation, and for observation of consultations and interventions.
   
• Gain client confidence : Consider involving the student once you have performed the initial consultation and assessment and once client has had opportunity to meet the student. Grade the level of student involvement to help the client to build trust and confidence in the student's ability.

Risk and Legal Issues

Insurance

• Become familiar with conditions of insurance cover by universities for :
   
  • Student public liability cover: UQ and JCU Universities both provide students with cover for actions that lead directly to third party personal injury or property damage (excluding motor vehicles) whilst on clinical placement or whilst engaged in course-required volunteer work. For information refer to: Reference Document 1.3: The University of Queensland - Student Insurance Letter
    Reference Document 1.4: James Cook University Student Insurance Letter
  • Professional Indemnity: UQ and JCU universities both provide students with cover for breach of professional duty which may include situations where advice is given by a student that has lead to consequences resulting in legal action.

    In some instances, the clinical educator may bear some of the liability. For instance, where the clinical educator has failed to take appropriate responsibility for ensuring the student's competency prior to delivery of interventions, or for checking performance, recommendations and documentation provided by the student (e.g. failure of the clinical educator to check a workplace suitable duties program and the contents of the program resulted in injury) or, failure to provide adequate direction and monitoring of performance or to provide adequate orientation to workplace health and safety procedures.

    It is important to be familiar with the Student Clinical Placement Agreements between respective Universities and Private Practitioners, which include a section on Supervision and Indemnity. This agreement is signed by both the university and the clinical placement representative.
     

  • Workers Compensation/Personal Accident Insurance: UQ and JCU universities both provide insurance cover for injury (including death or hospitalization) to students whilst engaged directly in course-required activities, including clinical placements and direct travel to and from such activities.
     
• Provide orientation to workplace health and safety issues in the practice environment. Provide reading material, direct to Practice policy and procedures and provide physical demonstration of safe practices as appropriate
   
• Ensure competence of the student before the student conducts the service/assessment. Revise list of student competencies provided by the university and check at the start of the placement; monitor student performance and competency through documented observation and supervision of students in action with clients before assigning independent practice of clinical activities, check the proposed assessments and written treatment program designs prior to the student implementing them; check case studies for accuracy of content; provide regular supervision sessions that include reflective and active questioning regarding student clinical reasoning processes and application of theory to practice, and for provision of feedback. (The University of Queensland, 2007)
   
• Always carefully check student's documentation or written reports prior to signing.
   
• Check student understanding of any directions given regarding performance of an intervention or procedure prior to performance. Ask student to describe what they are going to do and why, ask student to re-phrase to you their understanding of what is expected of them.

Intellectual Property

• Provide students with explicit guidelines about access to information and copying of resources specific to and developed for your private practice.
   
• Consider developing a site-specific written and signed confidentiality agreement between you, the practitioner and the student regarding the proper use of confidential information and intellectual property. Such an agreement should specify the practitioners' rights and the consequences of misuse of information, as well as provide recognition of the intellectual property rights of the student for resources developed by the student whilst on clinical placement and under what conditions the Practice may utilize these resources. Refer to: Template 1.2: Confidentiality Agreement.
• For information regarding university policies on intellectual property and how to protect your IP rights, please refer to: Fact Sheet 1.4: Intellectual Property and Confidentiality.

Medico-legal assessment

• Due to significant risks to the practitioner and public, a registered practitioner should always be present during any student involvement in any part of a Medico-legal assessment
   
• At the discretion of the clinical educator, students may be given responsibility for small aspects of the assessment under the direct supervision of the practitioner e.g. assessing range of motion.

Home Visiting

Home-visiting without the practitioner has associated risks for both the student, and also for the practitioner if for instance it is considered that adequate assessment of the risk was not performed by the practitioner prior to approving the independent home-visit by the student.

Due to the differing contexts, settings, clientele and associated risks with home visiting, universities rely on the organisation or practice that is providing the student clinical placement to develop or reference a home visit policy specific to their setting. It is recommended that you develop or review a :

• Home-visit policy to reduce any risk to students who are performing home-visits on private practice placements and to assist with decision making regarding appropriateness for home-visiting without supervision. Can include:
  • mobile phone use and communication re. home visiting ie time, address, client, estimated time of return, contact details client and student.
  • Student's previous contact with the client
  • Clinician's knowledge of the client (ie. Mental state, home situation)
  • Experience required by the student
     
• Home visit risk checklist specific to the practice setting and clientele to help in determining any risks, prior to a home-visit, that would contraindicate a student safely performing a home visit independently. Refer to: Template 2.2: Home or Site visit Student Safety Checklist provides an example that you could modify to suit your practice setting. Or, the following web-links may provide useful examples:
  http://www.ncoss.org.au/projects/ohs/downloads/resources/checklists/homevisit_checklist_OHS.pdf and
  http://www.ncoss.org.au/projects/ohs/downloads/resources/checklists/excursion_checklist_OHS.pdf.

Fees for service

It may be a concern to you whether to charge full payment or reduced payment for services conducted by students. Although there are as yet no defined guidelines regarding this issue, it is of importance that you provide clear communication to the client or paying party about the nature of fees at your practice, for the level of supervised student involvement and for obtaining client consent for students to be involved in their care. It is also important that if full price is to be charged, that the practitioner takes full responsibility for the service and for all documentation/report writing ie. oversees and supervises all aspects of intervention and revises and co-signs all documentation. This may be particularly important for services where the client is seeking a rebate from a third-party payer. Policies on this issue differs amongst health insurance and work compensation companies, so it is important to become familiar with the policies or guidelines of such parties regarding payment for services with student involvement. "Students need to learn about the cost-dimension" of service and private practice - that the business needs the paying customer, that cost is something we do discuss with the customer. It helps to clarify for them the value of OT. They need to quickly gain that level of understanding." K.Adam, OT clinical educator, workplace rehabilitation practice (personal communication, May 10, 2007)

Rorke (2005) has summarized in her report the perspectives gained from a number of common third party payers including Medibank Private, MBF, WorkCover and HIC. For Rorke's summary, please refer to:

• Explore safe ways of utilizing students to perform paid services, taking student competency and provision of adequate supervision and support strongly into account.
• Offer a lower-fee paid service where students are largely involved in client assessment, treatment planning and interventions, with adequate if not full supervision.

Student Characteristics/Selection Issues

Current UQ Student Placement Agreement Section 2.4 states "The institution shall be responsible for the selection of the students for the participation in the field placement but offers no assurances as to the suitability of the students to undertake specific tasks as part of the field placements".

Whilst the universities do not actively take a role in the selection of students for private practice placements based on criteria of preferable characteristics, the university does aim to promote student's interest and understanding of the occupational therapy role in private practice and to educate students about attributes and learning styles that are considered beneficial to working in this setting. The universities also offer students opportunity to nominate clinical placement setting preferences, which can assist the interested students to successfully access private practice clinical placements.

You can assist this process by :

• providing the university with some form of promotional material about your practice, for example a brochure or CD-ROM that includes description of the workplace setting, the clientele, the occupational therapy role and anecdotal information regarding work demands, beneficial attributes and some case studies. This could be distributed or loaned to students during relevant course subjects.
   
• approaching the university to provide a guest speaker presentation to students, promoting the role of occupational therapy in private practice and discussing desirable student characteristics from your perspective. "Students need to know enough about the setting to know if they are interested"
  (anonymous private practitioner, as cited in Rorke, 2005 p.3)

Caseload fluctuations, limited "hands on" client contact time

Occupational therapists are continuing to expand and increase their professional place in the area of private practice. Although the consistency of and variety of hands-on student clinical experiences may at times have limitations in this field, private practice as a clinical education environment provides many valuable learning opportunities for a student's professional growth and development. Some of these opportunities include:

• access to a diverse range of contexts and delivery systems in which to apply a variety of skills e.g work-site assessments
   
• development of skills in administration, marketing, networking and promotion of a service
   
• increased awareness of working within budgetary and legislative constraints
   
• development of professional reasoning and professional relationships for successful creation and running of a business
   
• enhanced knowledge of community resources
   
• development of formal report writing skills
   
• involvement in administrative projects such as marketing strategies, continuing education, updating of resources.
   
• observation of and liaison with other professionals in private practice and within the health care delivery system such as rehabilitation case managers.
   
• development of an identity as an occupational therapist and an understanding of the occupational therapy process.

WFOT revised guidelines (2002) do not specify the amount of 'hands-on' intervention required in clinical education. Rather, that there be a progression toward more independent levels of practice, the variability of such being dependant on issues of safety and complexity of work. For instance in areas where the work requires a high level of proficiency and risk the supervisor may need to be on-site and/or providing direct supervision, but not necessarily limiting the level of hands-on work for the student, nor the variety of experiences. (Rorke, 2005)

WFOT revised guidelines state that :
"All Occupational Therapists are expected to have substantial knowledge, skill and attitudes within the following five areas:
-    the person-occupation-environment relationship and its relationship to health
-    therapeutic and professional relationships
-    an occupational therapy process
-    professional reasoning and behaviour
-    the context of professional practice
 

All of the above areas can be developed through a clinical placement in private practice. Some suggested ways of developing the above five areas of skill, knowledge and attitudes in situations where hands-on involvement is limited are offered in Rorke's report (p38), based on literature and practitioner suggestions and listed below:

• Work shadowing opportunities incorporating observational learning of the clinician at work, note-taking during assessment and interventions and writing of "draft" reports based on observations.
   
• Stimulation of the occupational therapy clinical reasoning process through prompting discussion on the student's observations and exploration of goal setting and how they would plan and evaluate interventions on short and long-term basis.
   
• Use of case-studies to stimulate clinical reasoning and treatment planning.
   
• Giving student responsibility for planning and setting up a client consultation such as an assessment or treatment practice, from which level of competence, clinical reasoning and understanding of appropriate use of assessment tools can be assessed.
   
• The student conducts part of assessments or consultations in areas the students have demonstrated competency such as assessing range of motion, performing oedema massage, performing assessment interview of background medical history, or providing demonstration of manual handling with appropriate level of supervision.
   
• Allowing the student to perform assessments/treatments on friends and family, staff members or providing free services for customers such as certain preventative assessments.
   
• Developing a practice relevant student project that can be concentrated on during quieter times of the placement e.g literature review and research re. application of a particular treatment technique; design of an assessment template or proforma; updating of resources, or organize to spend time with other professionals or related agencies, peer interest groups during these times. Refer to:Suggestion Sheet 1.5: How to set up and manage a project-focused student clinical placement.

References:

Doubt, L., Paterson, M & O'Riordan (2004) Clinical education in private practice: An interdisciplinary approach. Journal of Allied Health, 33(1): 47-50. Retrieved April 27, 2007 from http://proquest.umi.com/pqdlink?did=590827301&sid=5&Fmt=3&clientId=20806&RQT=309&Vname=PQD

NCOSS (n.d) Occupational health and safety project. Checklists [electronic source]. Australia. Available from: http://www.ncoss.org.au/ohs/index.html

Potts, H., Babcock, J & McKee, M. (1998) Considerations for fieldwork education within a private practice. Canadian Journal of Occupational Therapy 65(2):104-108.

Rorke, L.(2005) Clinical education in private practice. Creating "win, win, win" for students, universities and private practitioners [Discussion paper]. Queensland Occupational Therapy Fieldwork Collaborative.

The University of Queensland (2007) Fieldwork guide for clinical educators. School of Health and Rehabilitation Sciences. Occupational Therapy Division. Australia