Sari SM et al.

, JPKI, 2023;12(1):95-101
doi: 10.22146/jpki.71819

I AM HPE RECOMMENDATION

FACILITATING CLINICAL EDUCATION IN MEDICAL AND HEALTH

PROFESSION EDUCATION
Sylvia Mustika Sari1*, Subha Ramani2, Ova Emilia3, Yoyo Suhoyo3
1
Medical Education Department, Medical Faculty, Universitas A. Yani, Cimahi – INDONESIA
2
Department of Medicine and Brigham Medical Institute, Brigham and Women’s Hospital and Harvard Medical School, Boston –
USA
3
Medical Education and Bioethics Department, Universitas Gadjah Mada, Yogyakarta – INDONESIA

Submitted: 03 Jan 2022, Final Revision from Authors: 04 Apr 2022, Accepted: 10 May 2022

ABSTRACT
Background: The clinical supervisor's roles influence the quality of clinical education as a teacher and their
interaction with students. Underlined the importance of refreshment on clinical teaching skills for clinical
supervisors, the 3rd Webinar series of IAMHPE has inspired the recommendations on essential elements in
the clinical education of medical and health profession education.
Gaps: Recent studies have highlighted the complexity of facilitating clinical education and the socio-cultural
influence on clinical supervisor-student relations. As a gap, Indonesia has a hierarchical and collectivist
culture and thus the potential to hinder improving students' learning development during clinical education.
Recommendation: An understanding of the Gaps between literature and Indonesia's socio-cultural
influence on clinical education, we develop several recommendations, including 1) Building Clinical
Supervisor-Student Relations that support students' development; 2) Making role modeling explicit and
integrating into teaching and learning; 3) Facilitating the gradual development of students' clinical abilities,
and 4) Re-conceptualization of feedback in clinical education as a “dialogue”.

Keywords: clinical education, role modeling, feedback, Indonesia

PRACTICE POINTS
• The relationship between clinical supervisors and students is fundamental to improving clinical
education quality.
• Role modeling is a clinical learning method that can be developed by facilitating dialogue and
students' self-reflection skills.
• The clinical learning process requires the ability of clinical supervisors to facilitate and coach the
gradual self-development of students.
• The clinical supervisors need to reconceptualize the feedback in clinical education as a form of
bidirectional dialogue and facilitate students’ improvement.

*corresponding author, contact: sylvia.mustikasari@lecture.unjani.ac.id

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INTRODUCTION approach has shown the specificity of each culture

Clinical education is the final stage in health and subculture. Wong finds that there is a tendency
profession education which determines the quality for residents in Thailand to work in a team, while
of future healthcare professionals and thus health residents in Canada tend to work more individually.8
services.1,2 To achieve qualified clinical education, In line with that, Wilbur et al. found differences in
the progression from a medical student to a doctor the perspectives of Canadian and Qatari clinical
is shaped through participation in practice, the supervisors in clinical assessment.9 Ramani et al.
curriculum, the clinical environment, and students' explored the influence of institutional subcultures
interaction with clinical supervisors.1-3 Therefore, on feedback at the residency stage in the USA.10
clinical supervisors have an essential role in leading In Indonesia, the socio-cultural influence in clinical
the student to become healthcare professionals.1-4 education has been studied using the Hofstede
Harden and Cosby classified six significant tasks national culture classification. Hofstede classifies the
of the medical teacher as 1) information provider, culture of the Indonesian state with a hierarchical
2) the role model, 3) the facilitator, 4) the assessor, relationship pattern or high power-distance index
5) the curriculum planner, and 6) the resource and collectivist.11 Within Indonesian cultural
material creator.1,5 In clinical education, these tasks characteristics, studies shows that clinical supervisor
are often performed simultaneously with clinical position themselves as a parent, the student tends to
supervisors' role as physicians. The problems have less autonomy or ownership of their learning,
that arise in clinical education are the workload and the dominance of unidirectional top-down
of clinical supervisors in healthcare services and conversations.12-14 This mindset is likely to become
facilitating students' learning.1,4 However, the roles a significant socio-cultural barrier in the clinical
of clinical supervisors as physicians are renewed education process in Indonesia.
frequently by training in clinical competence, Current studies on clinical education have indicated
contrasting the limited training to enhance their the importance of contextual factors, especially
role as a teacher.1 socio-cultural factors, in determining the quality of
The complexity of clinical education underlined our clinical education.6-8,10 Meanwhile, the hierarchical
recommendation for facilitating clinical education and collectivist culture in Indonesia has the
for medical and health professions education. potential to serve as an obstacle to the establishment
Therefore, the 3rd IAM HPE webinar series focused of conducive and supportive relationships for
on clinical supervisors' skills in Facilitating Clinical students' development.11-14 Bridging the gap
Education and inspired the authors to develop this from the literature in the Indonesian context,
recommendation. recommendations are needed to strengthen
Indonesia's quality of clinical education.
GAPS BETWEEN GUIDES AND PRACTICES IN
THE INDONESIAN CONTEXT I AM HPE RECOMMENDATION
According to the complexity of clinical education, We formulate four main recommendations
works of literature also highlight the socio- that we will describe in ten specific interrelated
cultural perspective that explains the importance recommendations for improving Indonesia's quality
of interaction between clinical supervisors and of clinical education. Our main recommendations
students in clinical education.6-8 The social are 1) Building clinical supervisor and student
interaction between clinical supervisors and relations; 2) Making role modeling explicit
students is the main factor in forming conducive and integrating into teaching and learning; 3)
relationships and supporting students' progress Facilitating the gradual development of students'
in achieving their competencies.2,6,7 The study clinical abilities; and 4) Reconceptualizing feedback
on clinical education through a socio-cultural in clinical education

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Table 1. Subjects’ Characteristics and Their Responses to the Virtual Neurology Examination (N=12)
I AM HPE Recommendations
A. Building Clinical Supervisor-Student 1. Paying attention to the student learning process
Relationship 2. Initiating dialogue
3. Facilitating Growth mindset
4. Facilitating student self-reflection ability
B. Making role modeling explicit and 1. Deliberate role-modeling effort
integrating it into teaching and learning 2. Facilitating the process of reflective dialogue and follow-up on
modeling results
C. Facilitating the gradual development of 1. Understanding the clinical stage of the student development process
students’ clinical abilities 2. Facilitating the development of abilities through mentoring
D. Reconceptualization of feedback in 1. Understanding feedback as a "dialogue" process
clinical education as "dialogue." 2. Giving directions using the "coaching" method to improve
students’ performance

A. Building Clinical Supervisor-Student theory that represents the ability to learn from
Relationship challenges and mistakes, thus stimulating self-
In the initial part, we recommended the clinical improvement.19 Based on this understanding, we
supervisors' awareness in developing a relationship recommend that clinical supervisors develop a
that supports students’ competence development. growth mindset. In that way, clinical supervisors can
facilitate student changes towards a growth mindset
Recommendation 1. Paying attention to the student through supportive relationships and dialogue that
learning process trigger students’ self-development.1,10,19
According to the concept of adult learning, students
Recommendation 4. Facilitating student self-
are learners who have experience and self-concept
reflection ability
that will influence the way they think. In improving
their abilities, adult learners need to involve and Based on the self-reflection cycle from Gibs,16,17
reflect on their experiences.16 Thus, students will clinical supervisors need to facilitate students to
reach their optimal skills gradually. Students need reflect on their feelings and thoughts in the clinical
to learn how to be responsible, aware of their experiences they have faced. This self-reflection ability
limitations, and determine their steps to improve is an important aspect in preparing conceptualization
their abilities through self-reflection skills.15,16 and constructing new knowledge in students.3,16,17

Recommendation 2. Initiating dialogue B. Making role modeling explicit and

Based on the consideration of Indonesian culture's integrating it into teaching and learning
hierarchical and collectivist aspects, the dialogue There are two main definitions of role modeling
process needs to be initiated by the clinical which we will discuss in this recommendation.
supervisors.12-14 The clinical supervisors can start Firstly, the definition of role modeling as a learning
a conversation by asking about their experiences, method that emphasizes the demonstration of
impressions, strengths, and improvement areas.1,12,16 clinical skills or professional behavior from a "role
In this case, the clinical supervisors need to have the model". Secondly, several other studies define role
flexibility to behave and be willing to take the time modeling as a natural process when students
to discuss effectively.1,17,1 observe clinical traits, behaviors, or procedures that
are exemplified by clinical supervisors and then
Recommendation 3. Facilitating growth mindset adopted or imitated. Based on these two definitions,
A growth mindset is a well-known psychological role modeling is a process that is implicit primarily

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in the clinical learning experience.18,20,21 Therefore, C. Facilitating the gradual development of

we suggest that clinical supervisors deliberately use students’ clinical abilities
role-modeling as a teaching strategy and debrief Following the experience-based clinical learning
these experiences with their learners. model, mentoring can facilitate students' journey
towards clinical competence. Students' progress
Recommendation 5. Deliberate role-modeling effort requires a "positive state of mind," which is facilitated
The modeling process begins with observation; in clinical supervisor-student relations that support
therefore, the clinical supervisor as a role model student progress.1,3,10
needs to have "awareness" that they are being
observed e by students or deliberate the role- Recommendation 7. Understanding the clinical stage
modeling.18 Strengthening the learning process, role of the student development process
modeling requires learning objectives that can be In facilitating the development of student abilities,
stated in the form of a briefing at the beginning of clinical supervisors need to understand the stages
the session. We recommended the learning cycle of of professional development. In the first stage,
remodeling in figure 1. students will act as passive observers. The clinical
supervisor can implement role-modeling as a
Recommendation 6. Facilitating the process of deliberate teaching approach at this stage. The
reflective dialogue and follow up on modeling results second stage is an active observer or observing and
After determining the learning objective of helping, so the clinical supervisor can determine
remodeling observation, the next step is to facilitate the initial skills that students can do. In the third
dialogue with students to trigger self-reflection stage, students can contribute, which means that in
skills. We recommended that the clinical supervisors the clinical experience, the clinical supervisor can
initiate the dialogue and be open-minded and provide opportunities for students to contribute
willing to accept comments from students.18,21 and show their performance. The final stage is for

Figure 1. Making Role Modeling Explicit and Integrating to Teaching and Learning

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Sari SM et al., JPKI, 2023;12(1):95-101

students who can perform skills independently establish the credibility of feedback. 10,13,24 Therefore,
(performers), then the clinical supervisor plays we recommended that clinical supervisors be aware
more of an observer role. Based on these stages, the of facilitating feedback as a form of dialogue and
clinical supervisors' role is crucial in determining providing their growth mindset.
students' success to achieve their capabilities.3
Recommendation 10. Providing direction using the
Recommendation 8. Facilitating capacity development “coaching” method to improve students’ performance
through mentoring. The trend in the definition of feedback is a
With the previous recommendations, clinical bidirectional dialogue or conversation. Following
supervisors' skills are needed to encourage this approach, Sargeant et al. developed a feedback
students to reach the next stage of their learning. model known as the R2C2 model, namely 1) Build
The clinical mentoring model generally begins the the relationship. The clinical supervisor initiates the
session with a briefing/pre-round or as an initial conversation from collegial relationships that allow
commitment to learning outcomes. Furthermore, bidirectional discussion and conversation be created.
clinical experience sessions can vary according This sets the stage for the supervisor to observe the
to the stage of a student's abilities. Lastly, but student during a clinical interaction; 2) Explore
very importantly, the main principle is providing Reactions, namely encouraging students to explore
feedback and facilitating student self-reflection, their reactions, including emotional responses, to
which is carried out in debriefing/post-round the clinical experience and stimulate self-reflection;
sessions. The session can always be applied at every 3) Understanding of Content, where the supervisor
stage of student capability.1,3 discusses their observations of the clinical
encounter, checks the accuracy of their observations
D. Re-conceptualization of feedback in with students, clarifies areas of disagreement. In
clinical education as a "dialogue" this stage, the learner should be able to develop 1-2
rooms that they would like to improve 4) Coach for
Initially, feedback is defined as providing
Change, the clinical supervisor guides the learner in
information from clinical supervisors to students
formulating action plans for improvement, focusing
about students’ performance and directing them
on the performance areas identified by the student.25
to further performance.22 From this definition,
Along with the awareness of feedback dialogue and
students are only allowed to listen to the opinion
socio-cultural barriers, we recommend the R2C2
of the clinical supervisors. However, since the
as one of the alternative models for facilitating
2000s, researchers have begun to question the role
feedback in clinical education.
of students in feedback.24 Since then, more studies
have focused on the relationship between clinical Studies show that clinical supervisor teaching skills
supervisors and students as the starting point for such as building supportive relationships, deliberate
successful feedback.9,10,11,12 role modeling, and facilitating reflective feedback
have improved clinical education quality. Therefore,
Recommendation 9. Understanding feedback as a these recommendations potentially became a part of
"dialogue" process clinical supervisors' awareness of their roles during
Supportive relationships and opportunities for clinical teaching.
students to ask questions and gradually improve However, Indonesia's hierarchical and collectivist
themselves will support feedback credibility.10,24 culture potentially became a barrier to
Indonesia, with the collectivist culture, allows implementing these recommendations. Therefore,
clinical supervisors to perceive a superior position in these recommendations also open opportunities
interacting with students, which has the potential to for culturally specific studies in clinical education
hinder the dialogue process (bidirectional) needed to in Indonesia.

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ACKNOWLEDGEMENT 5. Harden R and Cosby J. AMEE Guide No 20:

Thank you to I AM HPE and all the webinar The good teacher is more than a lecturer the
committees for supporting us in developing the twelve roles of the teacher, Medical Teacher.
recommendation. 2000; 22(4) 22: 334- 347.
6. Ramani S, Konings KD, Ginsburg S, Vleuten
COMPETING INTEREST CP. Meaningful feedback through a socio-
We declare that there are no competing interests cultural lens. Medical Teacher. 2019 September;
related to the recommendations. pp. 1–11. DOI: https://doi.org/10.1080/014215
9X.2019.1656804

AUTHORS’ CONTRIBUTION 7. van der Zwet J, Zwietering PJ, Teunissen

PW, van der Vleuten CPM, Scherpbier AJJA.
Sylvia Mustika Sari - contributed the idea and
Workplace learning from a socio-cultural
design of the recommendation and wrote the
perspective: Creating developmental space
manuscript
during the general practice clerkship. Advances
Subha Ramani - contributed to the idea and design
in Health Sciences Education. 2011; 16(3): pp.
of the recommendation and reviewed the
359–373. DOI: 10.1007/s10459- 010-9268-x.
manuscript
Ova Emilia - contributed to the idea and design 8. Wong AK. Culture in medical education: Compar-
of the recommendation and reviewed the ing a Thai and a Canadian residency programme.
manuscript Medical Education. 2011; 45(12): pp. 1209–1219.
DOI: 10.1111/j.1365-2923.2011.04059.x.
Yoyo Suhoyo - contributed the idea and design of the
recommendation and reviewed the manuscript 9. Wilbur K, Driessen EW, Scheele F, Teunissen
PW. Workplace-Based Assessment in Cross-
Border Health Professional Education. Teaching
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