Clinical Practice in Education: Panacea, Placebo or Suppository

Posted on April 2, 2014



Having written more than one blogpost criticising the use of medical language and metaphors in education, I rather find myself on the back foot with the title of this post and its content. Let me deal with that straight away.

My concerns about Big Research in the form of Randomised Control Trials (taken from the medical world, applied to the educational sphere, championed by Dr. Ben Goldacre), is that they “are used widely for showing causal relations in health and social care because their study design is the only one that is able to control for unknown or unmeasured confounders”. There is nothing wrong with this in and of itself, but the notion of causality in education is one that I struggle with.

What, for example, causes the underachievement of a small group of students with seemingly every advantage in the world and how might we go about intervening? How can we even come close to isolating the variables within this situation? How do we begin to get beyond the use of poor proxy indicators (for example, the use of FSM for socioeconomic status) to ensure that the randomisation process has no impact on the results? How do we isolate an intervention and be sure that staff are not ‘compensating’ for the control group, or that fellow students are not sharing the interventions with their friends in the playground? How do we do all of this in a self-disciplined way that may take years to bear fruit, when the here and now demands that we achieve results immediately? How do we do all of this at a small-scale or do we accept that in participating in RCTs we are only one piece of a very large jigsaw? And if so, how do we motivate our staff to be part of the process of research when we see only the tiniest part of the big picture and when their interventions are tightly controlled by outside forces (and where we may not even be intervening at all, as members of the control group).

But, of course, RCTs are only one part of medical research, primarily designed to measure such things as the impact of changes to healthcare interventions or the dispensation of drugs. They have a significant role to play in medicine because the physical properties of human bodies and drugs tend to conform to expectations precisely because, more often than not, they obey physical laws about which we know a lot in comparison to the socio-physical-psychological-whatever lawlessness that is the learning process. The RCT approach to medicine is, therefore, one that has as it’s raison d’être a focus on the outcomes of medical interventions: the curing of illness. Similarly, in education, the focus of Big Research RCTS of the kind promoted by the DfE (and its major funding body the Education Endowment Fund) is on the outcomes for students: closing the gaps between underachieving students and their peers.

There is, however, a whole lot more to medical research than RCTs, because there is a whole lot more to medicine as a profession than the predictability of physical processes and chemical reactions. In my view a better medical comparison for teacher research is with clinical practice rather than clinical trials: the complex array of knowledge, skills, experience, intuition, learnt behaviour and psychology that a medical clinician brings to their interactions with patients, other medical practitioners, families and whoever else has an opinion about the quality of their care. Rather than a focus on the outcomes of medical interventions, a clinical practice approach focuses on the inputs to medical treatment that can only be made by the well-trained and well-educated medical practitioner her or himself.

In this post I would like to contend that we need a similar focus on the inputs in education that can only be made by the well-trained and well-educated teacher her or himself, rather than yet another accountability-driven focus on the measurable outputs of improved exam performance. However noble the intention of the ‘closing the gap’ focus of state-sponsored RCTs in education is, we can achieve better and more sustainable improvements (with fewer unintended consequences due to perverse incentives) if we look after the professional development of teachers as clinical practitioners in order to allow them to look after the educational development of students through their ‘clinical practice’.

As a result this post draws upon a growing body of theory, research and case studies into how a ‘clinical practice’ approach to Initial Teacher Education (ITE) can benefit these teachers, their mentors, the schools within which they work and the education system generally, making each one far more research-informed, inquisitive and responsive to the needs of students.

I have attached a Dropbox Bibliography link at the end of this post which, I have to warn you, will be lengthy. Although there are occasional direct quotations from this reading, the post is intended as a summary of findings rather than a literature review.

Some Problems with Educating Teachers

City et al make a claim that “education is essentially an occupation trying to be a profession without a professional practice”, and this is largely as a result of a limited approach to ITE, in which the responsibility for induction into the ‘occupation’ is divided up between divided university and school sectors. Traditionally (often via PGCE courses) universities are responsible for the theoretical elements of teacher education, heavily front-loaded and divided from the practical elements of teacher education that are heavily end-loaded at schools. More recently, with the advent of School Direct and other school-based routes into teaching, the theoretical elements have been (are being?) marginalised as the universities have been squeezed out of the picture in favour of a seemingly government-sanctioned ‘craft’ approach to teaching, perhaps underpinned by an equally (seemingly) government-sanctioned market approach to ITE.

The problem with the traditional route into teaching is, as McIntyre discusses at length, that there are different strategies for educating trainee teachers at universities and at schools. The net result, widely explored in the literature on ITE, is that the initially-taught theoretical aspects of PGCE courses become swamped by the ‘survival instincts’ of proving competence in the classroom (a position surely not enhanced by the Ofsted grading of trainees) and by the fact that the ‘signature pedagogies’ of school-based teacher education is so different to the ‘signature pedagogies’ of university-based teacher education. Schools are currently not set up, resourced or organised for adult academic learning and their default (sometimes overwhelmingly so) pedagogy is ‘reflective practice’, whereby the trainee observes and reflects, then teaches and reflects, then teaches and reflects ad infinitum.

Add into this mix the fact that in-school mentors are not given sufficient time, training or responsibility for the rounded, theoretical-cum-practical development of their charges and we are left with a situation where new teachers frequently jettison their university-taught academic grounding in the profession in favour of those craft-driven experiences that shape their everyday experiences in schools. In short, the theory-into-practice approach to ITE is not working.

The new paradigm of school-centred ITE (or ITT as it is frequently labelled, nominally dropping all pretence at an educative and academic function) is potentially the worst of all worlds, whereby theory plays no part in induction to the profession whatsoever. In this model there is the very real possibility (probability?) that even less time will be given or taken for joint planning between universities and schools as genuinely collaborative equals. The likely result is that schools will become even more dependent upon their signature pedagogy of reflective practice with, in the words of Shulman, a concomitant “rigidity” and “inflexibility” leading, over time, to an increasing sense of “pedagogical inertia” whereby nobody – trainees or trainers – challenges the status quo of what is taught nor how it is taught in teacher education.

Shulman concludes that radical change is needed to break out of these signature pedagogies, so what might this look like in ITE? How might we achieve a view of teaching, put forward by Alter and Coggshall, which is neither merely a craft, nor merely a profession, but “an academically taught clinical practice profession”?

Collaboration Between Schools and Universities

If we are to move to a ‘clinical practice’ model of ITE then the first, and most important, change we need to make to the way we are currently doing things is to make better and stronger connections between the current locus of theory, universities, and the current locus of practice, schools. As schools are increasingly being seen as the dominant partner in provision for new entrants to the profession, we need to seek out university partners who are committed to significant changes to how the currently balkanised theory and practice work together in the teacher induction process.

In a ‘clinical practice’ model we need to abandon the inherent assumption that universities are for theory and schools are for practice. To do so we need to engage with Higher Education Institutions (HEIs) as equals, and be confident in doing so. As a starting point we need to collaborate in identifying with academics what the big questions of teaching are and come to agreement on the standards we expect novice teachers to reach by the end of their training period and beyond. In doing so we need to blend the expectations of what ITE participants should know (theory) and be able to show (practice), and be prepared to state these explicitly, coherently and consistently.

Once we have agreed upon the overarching principles, we then need to continue to work as collaborative equals to co-design a curriculum – and its associated pedagogies – which weaves the warp of classroom practice into the weft of theoretical understanding (Grossman et al). This curriculum needs to be planned as an entity to be entirely co-taught, utilising academics within the school context and practitioners within the university context. As part of this we need to strengthen the analytical research component of classroom practice and the practical reflection element of academic learning.

But co-design and co-delivery of the ITE curriculum need to be superseded in our priorities by a collegial approach to constant monitoring of the programmes we deliver. University and school staff, including and especially mentors, need to meet very regularly, initially each year to articulate anew their vision and their vision in practice. Beyond this, the partnership must come together frequently to ensure ongoing evaluation of the taught curriculum, reviewing its impact upon the academic understanding and practical application by new teachers and explicitly measuring the effect upon the achievement of the students they teach and the schools they teach in.

Without these far-reaching changes in the relationship between schools and universities it will not be possible to move to a situation that improves upon the status quo and takes us to a place where theory and practice are routinely interdependent. Without these far-reaching changes, the notion of a research-informed ‘clinical practice’ profession outlined in the remainder of this post will fail to be realised.

The Ethos and Aims of a ‘Clinical Practice’ Approach to ITE

Alter and Coggshall suggest that there are five key characteristics of any ‘clinical practice’ profession: the centrality of the client, its knowledge demands, the use of evidence and judgment in practice, a community if standards and practice and the education of new professionals for clinical practice. These are a strong starting point for collaborative school/university partnerships.

Another key document pointing the way to a ‘clinical practice’ approach is the BERA review which, on page 6, outlines six principles. These include acknowledging the strengths and limitations of decontextualised research, appreciating the “rich seams of knowledge, understanding and skill” within schools and the need for all teachers to “test all ideas offered to them”.

McIntyre, who played a key role in the best British model of a ‘clinical practice’ programme, the Oxford Internship Scheme, summarises the aims of the programme as being rooted in using “theory to critique practice and practice to critique theory”. Most importantly for that programme, though, he says that this mutually critical approach should not seek to expect consensus: Trainee teachers are instead welcomed to bring their own research to the table, even (and perhaps especially) where it challenges the research upon which their training is based, working out for themselves if it leads to better practice within their own teaching.

Running through each of these articulated approaches, and through many other of the documents on ‘clinical practice’, is the need for any such programme to have a conceptual and structural coherence which put student needs (both the ITE students and the students they teach) ahead of the teaching routines which are dominant in both the traditional PGCE and emergent school-based routes into teaching. Kriewaldt and Turnidge call this ‘clinical reasoning’ and suggest it needs to replace the existing ‘development over time’ and ‘born not made’ orthodoxies of most ITE programmes.

Fundamentally though, such an approach cannot emerge without two final considerations being taken into account when schools work with universities to devise a ‘clinical practice’ approach to the development of new teachers. The first of these is that the clinical work of ITE students needs to be “extensively and intensively” supervised, with mentors given the support they need to be able to work in iterative cycles that interlock theoretical review with practical application and systematic review.

The second of these considerations is the need to see a ‘clinical practice’ programme as being enacted by communities, not individuals. New teachers need to have opportunities to articulate and be challenged in their pedagogical decision-making with colleagues and (perhaps most importantly) to be able to listen to and challenge the pedagogical decision-making of experienced teachers within the community of practice. In doing so, not only will schools be “helping novices develop and refine a set of core practices for teaching”, they will themselves be continuing to develop and refine their own at an institutional level.

The Role of Research in ‘Clinical Practice’

If we are to move from ‘imitation’, ‘trial and error’ and ‘reflective practice’ in ITE it is vital that we base a ‘clinical practice’ model on a solid evidence base, ensuring that student teachers become both discerning consumers of research and expert producers of it.

In order to achieve the former of these, advocates of ‘clinical practice’ argue that school and university partnerships will need a powerful research infrastructure. This will include the need to ensure that the co-designed curriculum is research-informed in terms of content, structure, sequence and data collection. We have to model that which we expect to see in our new teachers, which means ensuring that the research evidence we present to students is not uncontested or presented in the simple format and digestible nuggets of ‘what works’.

In order to foster students as producers of research, we also need to be open to multiple sources of evidence. ITE students need to be strongly encouraged to pick their own way through research that they think can inform their practice, responding with an enquiring stance that demands that participants interrogate and test out in their practice the theory that they hypothesise will improve outcomes within their classrooms. Crucially, in achieving this, we will need to empower new teachers to collect research data, in both qualitative and quantitative forms, about the students and classes that they teach so that they can use it to evaluate the taught curriculum of their courses. Perhaps, rather than inducting teachers into teaching routines that we ‘know’ work (but which are in reality highly contextualised and subject to a startlingly high number of variables) we need to see student teachers as action researchers, explicitly – rather than implicitly, as at present – testing out theoretical assumptions in the laboratory/crucible of the classroom.

McIntyre calls this two-way relationship between educational theory as learnt and practice as enacted, “practical theorising” and, however it is achieved by school/university partnerships, it needs to be an underpinning element of a move to a ‘clinical practice’ paradigm of ITE.

Creating a ‘Clinical Practice’ Curriculum

Grossman et al assert that the current curriculum of most ITE programmes fail to identify the “core practices” of teaching, and instead rely upon “introducing theory at the relevant moment” which may be too late or too early in the professional development of student teachers to have the best impact on their practice. One of the co-authors of this, Hammerness, talks elsewhere of the need instead of a “backwards design” of the curriculum that starts with what we expect of fully developed teachers.

The challenge for school/university partnerships in a ‘clinical practice’ paradigm is then to weave this through approach into a single, integrated curriculum with carefully graduated learning tasks that are underscored by what Darling-Hammond calls a “tight coherence between coursework and clinical work”. At present, too many student teachers produce academic coursework that, if not divorced from their practical experiences within schools, is almost entirely divorced from the input of their in-school mentors.

If we are to achieve the theoretical and practical coherence for trainee teachers, we need to ensure that their coursework is rooted in cyclical and iterative enquiry processes within schools with significantly more opportunities for observation and feedback that is developmental, rather than judgmental. In these cycles, ITE participants should gather data (research data and class data), analyse it, make decisions based upon it, implement change at the classroom level as a result and then evaluate the results in order to identify further data to be collected which will inform the beginning of their next practice-focused iteration. The resultant observations and evaluation should become the coursework that is assessed collegially by schools and universities to identify the strengths of student teachers and their areas for development, as well as informing the need for changes to the design of the course itself.

A further problem with the curricula of many ITE course is the lack of longitudinal study by participants. Advocates of a ‘clinical practice’ approach suggest the need for a ‘spiral curriculum’ in which student teachers engage in case studies of students and classes over the course of their training period. In this model, new academic learning about the core practices of teaching can be more thoroughly contextualised. At the same time, student teachers can develop the deeper and more holistic understanding of the specific issues facing specific students and their families (with the necessary caveat that these are not universal issues) that is crucial to the research-informed but not research-bound teacher as ‘clinical practitioner’.

The Pedagogies of ‘Clinical Practice’

The changes to ITE outlined above are significant and arguably pose a greater challenge to the university sector. The major challenge for schools in moving towards a ‘clinical practice’ approach is how we fundamentally alter the way in which we deliver the curriculum of such an approach.

I have referred earlier to Shulman’s concept of ‘signature pedagogies’, which he defines as “types of teaching that organise the fundamental ways in which future practitioners are educated for their new professions”. He argues that each of the professions has a dominant mode of teaching for inductees to that profession: in the legal profession it is case studies unpicked through Socratic questioning, whilst in the medical profession it is hospital rounds focused on analysis and discussion of the symptoms and medical history of specific patients. Whilst it is often a strength that each of these professions organises teaching towards a significant element of the practice of experts in the field, it can also function as a straitjacket upon innovative and transformational practitioners-in-waiting. He argues that radical change is needed to avoid (or reverse) pedagogical inertia, and strongly advocates that professional training in all professions need to utilise the ‘signature pedagogies’ of other professions.

In education, Grossman et al argue, we have as our ‘signature pedagogies’ those which are those of reflection: observing colleagues and reflecting upon what works for them in their lessons or identifying the ‘what went wells’ and ‘even better ifs’ of our own classroom practice. What we are missing, because they are ignored or marginalised in the education of new teachers, are “pedagogies of enactment”, those learning activities that come before or during the act of teaching that allow us to understand why certain activities are chosen in a certain context with certain children at a certain time.

Consequently, they and others argue that teacher education needs to move away from the much-valued “authentic” experiences of actual teaching of actual children into the realms of “approximations of practice”, in much the same way as trainee lawyers cut their teeth on case studies that have set precedents in their aspired-to field of expertise. According to the American group NCATE (the National Council for Accreditation of Teacher Education) student teachers need to be exposed to “virtual students, classrooms and schools” if they are to escape the gravitational pull of the authentic accountability that comes along with authentic teaching. Only in this way will they get to the stage that they are “learning from practice” as well as “learning for practice” (Darling-Hammond).

So what might these “pedagogies of enactment” look like in a ‘clinical practice’ environment? Amongst the studies that have informed this post, some suggest a much greater attention be paid to close analysis of teaching (and learning) methodologies outside of the student teacher’s own developing practice. This might involve ITE participant focusing on analysing the written work of students for whom they have no responsibility in order to identify what elements of good teaching and assessment have gone into it. It might involve them scrutinising the lesson plans of colleagues and seeking an articulation of why the expert practitioner has chosen to use one technique over another.

Another “approximation of practice” already discussed in this post is the use of case studies, where the student teacher identifies a specific child or group of children (again, apart from their own classes) to research on depth. This research might involve analysis of school-held data on these children, interviews and observations of them in and out of the classroom setting, discussion of their academic and behavioural history and – most crucially – application of their theoretical learning to these students to consider the impact of theory-into-practice.

Another “pedagogy of enactment” might be developed by the creation of a bank of “videoed vignettes of lessons” taught by experienced teachers that allow exploration of common dilemmas in education, or of exemplary practice (if such a thing exists) away from the threats created when asking students to analyse and evaluate the teaching or more experienced colleagues in an authentic classroom.

A final suggestion of how we might move from authenticity to “approximations of practice”, but do so within the context of a student teacher’s own classes, is to move towards an approach where students are regularly not just reviewing lessons that they have taught with mentoring colleagues, but are rehearsing lessons that they have yet to teach with them. In doing so they might be asked to hypothesise the likely impact upon their students of specific course of action and make explicit their thinking about each key point within their lesson plan.

In all of these examples where ‘clinical practice’ course might replace (or bolster?) educational ‘signature pedagogies’ with those dominant in other professions, the importance of uncovering the tacit or implicit is vital. Whether it is the students themselves responding to an inquisition into their choices as practitioners, or whether it is they in inquisitorial mode about the ‘clinical practice’ of others, the move towards “pedagogies of enactment” is reliant upon the mentors of trainees ensuring that there is a constant “articulation of pedagogical decision making” (BERA). Kriewaldt and Turnidge refer to the same process as “deprivatising” pedagogical thinking, and this is vital for a profession such as teaching, which “is complex work that looks deceptively simple” (Grossman et al).

The Challenges and Rewards of a ‘Clinical Practice’ Model of ITE

There are three key challenges to schools and universities in developing models of ‘clinical practice’ for initial teacher education. The first of these is the need to not just change the way we work together, but to change how we perceive each other and how we perceive ourselves in relation to each other. Universities need to be less confident in the importance of research evidence isolated from the context of the classroom, whilst schools need to be committed to challenging their own uninformed practices and, simultaneously, be confident in the aspects of their own practice that are well-informed by the mass of contextual evidence on which they are built. Together the HEI and school sectors need to ensure that their relative strengths and relative limitations come together to ensure that partnerships engage in a careful selection of the clinical methods that will best support the professional learning of those entering teaching.

A second challenge in moving towards a ‘clinical practice’ model of ITE is rooted in personnel and, specifically, in the role of mentors to emergent clinical practitioners. The selection of these mentors is vital to the success of any such project and they need to be drawn for their ability to model both expert AND clinical practice. They need to be given the time, training and certification for a role as demanding and important as this, with schools recognising and supporting their contribution to the process appropriately.

Linked to this, schools need to meet a third challenge of developing an ethos around ‘clinical practice’ that prioritises the spirit of research-informed inquiry, the skills of responsive coaching as well as effective mentoring and the opportunities for frequent developmental feedback for all of its teachers. Without doing so for all of the experienced practitioners on the payroll, the move towards a ‘clinical practice’ approach for ITE students will have limited impact at best and ring hollow for student teachers at worst.

The rewards for schools in meeting these challenges is potentially transformative. With a commitment to ‘clinical practice’ for career entrants, schools can work at a deeper level with university partners to develop an incremental approach to introducing clinical practice to all forms of continuing professional development. Identifying, training and rewarding ‘master teachers’ as ITE mentors is only the first step.

Schools might want to devise career entry programmes for newly qualified teachers inducted in the ‘clinical practice’ approach that maintain the best of that practice as teachers meet the new demands of classroom autonomy and early leadership development.

Schools might want to weave a ‘clinical practice’ approach into Lesson Study CPD programmes, ensuring that they create the time and resources needed for all staff to access research evidence, meet colleagues in the spirit of collaborative inquiry and have the space to take a step back from their day-to-day accountability demands to think and learn how to become a better teacher.

Schools might want to move beyond the narrow parameters of ‘learning walks’ and instead utilise Del Prete’s ‘Teacher Rounds’ (see Dropbox Bibliography) model of ‘clinical practice’ which adopts most of the principles outlined in this blogpost. Further to this and beyond their own classrooms, Teaching Schools and other network leading schools might want to consider methods of school to school support that do not simply aim to mimic the format of Ofsted. Instead they may wish to use the ‘clinical practice’ model of ‘Instructional Rounds’ in which external clinical practitioners are invited into schools not to judge, but to assist them in their own hunt for answers to questions about their own practice in a research-informed manner.

I do not wish to suggest that ‘clinical practice’ is the panacea referred to in the title of this post, but I hope I have done enough to show that it is neither the placebo nor the suppository I pose as alternatives. But in carrying out the reading and reflection that has led to this post, I have become convinced that it offers a far better alternative for initial teacher education than that which it might replace, be it a traditional PGCE or a newer school-led model such as School Direct.

In their review BERA define teaching as “a process of hypothesis testing, requiring interpretation and judgment in action”. If this is true (and I rather think it is) then it’s about time we had an approach to the induction of new entrants to the profession that prepares them adequately to become hypothesis testers, interpreters and effective at making judgments. A ‘clinical practice’ model of ITE might just be the approach we’ve been looking for.

Click here for Dropbox Bibliography