Imagine stepping into a clinical site for the first time as a health science student. Your coursework and lab sessions have equipped you with a basic understanding of patient care, health-related diseases, and anatomy, but now you face the challenge of applying this knowledge in real-world scenarios. What would you do differently if given the chance? Would you advocate more effectively for your learning needs when faced with nonconstructive feedback, limited scanning opportunities, and clinical instructors who do not have time to teach you? Would you ask more questions to bridge gaps in understanding?

Now consider your role as a clinical instructor. How do you reflect on your own novice experiences? How do you foster an environment in which students feel encouraged—or unintentionally discouraged—from seeking guidance? Perhaps you find yourself balancing the demands of patient care with the added responsibility of mentoring students, sometimes wishing for the simplicity of working independently without the constant inquiries. These reflections highlight the complexities of clinical education, where both students and instructors play vital roles in shaping the learning environment.

In the dynamic, often unfamiliar, environment of clinical education, students must develop the ability to think critically, adapt to diverse instructional styles, and respond effectively to complex clinical situations. Behavioral engagement, often referred to as observational learning, is a fundamental, yet frequently overlooked, component of this process. It plays a pivotal role in clinical development by promoting active learning, critical thinking, and professional growth.

The Novice to Master Development Framework (NMDF), developed by the author and described in this article, explores the learning gap between novice learners and seasoned professionals, emphasizing the role of behavioral engagement, inquiry, and growth mindset strategies in fostering clinical success. Rooted in the work of Carol Dweck (2006) and Albert Bandura (1971), the power of questioning and mindset-oriented learning emerges as a critical tool for improving educational outcomes and enhancing clinical competency.

Science of Teaching and Learning Domains

Observation, questioning, and learning are intrinsically linked in the development of cognitive abilities. These elements create a dynamic interplay where observation and inquiry serve as catalysts not only for identifying solutions but also for uncovering potential problems. This interconnectedness lays the foundation for cognitive growth and problem-solving skills, essential components in both academic and professional contexts.

Jean Piaget (1952), renowned for his theory of cognitive development, explored how individuals acquire, construct, and apply knowledge. His collaboration with John Dewey further enriched this exploration, as they investigated the relationship between thought processes and the formulation of questions. They posed critical inquiries, such as, "In what ways is how we think related to how we ask questions?" (Cifone, 2013). Dewey emphasized that learning is an active process rooted in research and inquiry, where meaningful engagement arises through purposeful actions. He identified the essence of critical thinking as the ability to connect current experiences with relevant knowledge to effectively solve problems (Cifone, 2013).

Building on this foundation, the concept of a growth mindset, developed by psychologist Carol Dweck (2006), introduces a transformative perspective on learning and intelligence. A growth mindset refers to the belief that abilities and intelligence can be developed through dedication, hard work, and continuous learning. In contrast to a fixed mindset, which assumes that abilities are innate and unchangeable, a growth mindset fosters resilience, adaptability, and a willingness to embrace challenges. This mindset is particularly relevant in clinical education, where students must continuously refine their skills, respond to feedback, and learn from both successes and setbacks. By cultivating a growth mindset, students can enhance their problem-solving abilities, improve clinical competencies, and achieve higher levels of academic and professional success.

Integral to fostering a growth mindset is the role of effective feedback, a cornerstone of clinical education. Feedback shapes both the learning process and the professional development of students. According to Shepard (2000), instructors often assume that feedback will automatically lead to improved performance; however, its effectiveness relies heavily on how it is delivered and utilized. Shepard also notes that feedback is frequently limited to simple right or wrong statements, which can hinder deeper learning and critical thinking.

Further expanding on the impact of instructional strategies, Black and Wiliam (1998) emphasize that learning can be inadvertently constrained when instructors focus solely on eliciting specific responses rather than fostering open inquiry. This rigidity can limit students’ ability to develop independent thinking skills. Additionally, students are often given insufficient time to respond to questions before instructors provide answers themselves, discouraging active participation and diminishing opportunities for meaningful reflection.

At the core of effective learning strategies is behavioral engagement, commonly referred to as observational learning. Albert Bandura (1971), a pioneering psychologist, developed the theory of observational learning, emphasizing that new behaviors can be acquired either through direct experience or by observing others. Central to Bandura’s theory are four interrelated subprocesses—attention, retention, motivation, and imitation/motoric—which form the foundation of effective behavioral engagement:

• Attention: This process involves the learner’s ability to focus on key aspects of the model's behavior. Merely exposing a learner to a model does not guarantee effective observation or internalization of the behavior. Active engagement is crucial.
• Retention: Beyond observation, learners must retain critical information even after the model is no longer present. This phase highlights the importance of memory in the learning process.
• Motivation: While learners may progress through the initial sub-processes, it is motivation that ultimately drives them to translate observations into action. Positive reinforcement encourages behavior replication, whereas negative feedback may hinder performance.
• Imitation/Motoric: In this phase, learners attempt to replicate the observed behavior, relying on the model’s patterns and feedback for refinement. Feedback loops are essential for correcting errors and enhancing performance (Bandura, 1971).

Each of these subprocesses contributes to the development of effective behavioral engagement, providing a comprehensive framework for clinical instruction and student learning. The seamless integration of observation, inquiry, growth mindset principles, and feedback mechanisms creates an environment in which students are empowered to evolve from novice learners to competent professionals.

Teaching and Learning Framework

Building on the literature review, the NMDF supports novice learners through Bandura's stages while guiding clinical instructors to remember the novice perspective. Learners move through these stages based on demonstrated competency, reflective self-assessments, and instructor feedback. Mastery at each stage is evaluated through observational assessments, skill demonstrations, and reflective journaling.

The NMDF offers steps to support the novice-to-master development in clinical practice. It outlines cognitive actions in each step, fostering both foundational knowledge and advanced clinical reasoning.

Step 1: Develop Empathy (REAL)

• Remember (R): Reflect on personal novice experiences.
• Examples (E): Share successes and failures with students.
• Activities (A): Create learner-centered tasks for engagement.
• Link (L): Connect teaching techniques with real-world clinical applications.

Step 2: Create Smaller Steps (PART)

• Present (P): Clarify protocols and objectives.
• Application (A): Apply knowledge through guided practice.
• Relationship (R): Bridge theoretical knowledge with clinical relevance.
• Time (T): Allow sufficient practice for skill development.

Step 3: Develop and Transfer Knowledge (WORLD)

• Wait (W): Encourage reflective thinking before responding.
• Optimism (O): Foster a supportive learning environment.
• Rubrics (R): Clarify expectations through defined criteria.
• Leadership (L): Model professional behaviors.
• Direct (D): Provide constructive feedback to guide learning.

Framework Application

Case Study: Addressing a Student Not Demonstrating New Knowledge and Clinical Skills

Scenario: Alex, a clinical student in the second clinical semester, struggles to demonstrate new knowledge and clinical skills despite multiple feedback sessions. Alex frequently fails to recognize clinical pathologies, demonstrates inconsistent approaches, and exhibits low confidence during patient interactions. His clinical instructor, Jordan, applies the NMDF to identify barriers and guide Alex's development.

Stage 1: Develop Empathy (REAL)

• Remember: Jordan reflects on the challenges faced as a novice, fostering empathy and identifying potential learning gaps from Alex’s perspective.
• Examples: Jordan shares relatable clinical scenarios where mistakes were learning opportunities, normalizing struggles as part of growth.
• Activities: Jordan implements targeted, hands-on activities focusing on image optimization, using simulation to reduce performance pressure.
• Link: Jordan connects technical skills to real clinical outcomes, emphasizing the importance of diagnostic accuracy for patient care.

Stage 2: Create Smaller Parts (PART)

• Present: Jordan clearly outlines expectations and protocols, providing structured learning objectives to reduce ambiguity.
• Application: Alex practices skills under supervision, applying specific feedback immediately, with Jordan adjusting the pace based on Alex’s comfort level.
• Relationship: Jordan builds rapport, creating a psychologically safe environment where Alex feels encouraged to ask questions without fear of judgment.
• Time: Additional one-on-one sessions are scheduled to reinforce concepts, allowing Alex the time needed to process and apply feedback effectively.

Stage 3: Develop and Transfer Knowledge (WORLD)

• Wait: Jordan resists the urge to immediately correct errors, instead prompting Alex to self-reflect and identify discrepancies in his work.
• Optimism: Jordan maintains a positive outlook, highlighting incremental progress to boost Alex’s confidence and motivation.
• Rubrics: Jordan introduces performance rubrics for self-assessment, guiding Alex to evaluate his images against objective criteria.
• Leadership: By modeling best practices and thinking aloud during complex cases, Jordan demonstrates expert reasoning strategies.
• Direct: Jordan provides targeted, constructive feedback regularly, focusing on specific areas needing improvement, with measurable goals for each clinical session.

Outcome: Through this structured, supportive approach, Alex gradually improves in technical proficiency, critical thinking, and confidence. While progress is slower than that of Alex’s peers, the framework allows personalized pacing, ensuring that competency is achieved through deliberate practice and reflective learning.

Case Study: Addressing a Student Not Progressing in Spatial Reasoning

Scenario: Sarah, a novice sonography student in her first clinical rotation, struggles with identifying vascular anatomy during carotid duplex imaging. Her clinical instructor, Michael, employs the NMDF to support Sarah’s development from a novice to a competent sonographer.

Step 1: Develop Empathy (REAL)

• Remember: Michael reflects on his early learning experiences, empathizing with Sarah’s challenges.
• Examples: Michael shares cases from his own practice with Sara, highlighting common mistakes and how he overcame them.
• Activities: Michael designs simple image-labeling exercises for Sarah to improve her anatomical recognition.
• Link: Michael connects these exercises to real patient scenarios, emphasizing their clinical relevance.

Step 2: Create Smaller Steps (PART)

• Present: Michael presents carotid protocols, explaining image optimization techniques clearly.
• Application: Sarah applies this knowledge during live scanning, with Michael providing real-time feedback.
• Relationship: Michael bridges theory and practice, discussing how Doppler findings relate to patient symptoms.
• Time: Michael allows extra scanning time for Sarah to practice without pressure, reinforcing skill retention.

Step 3: Develop and Transfer Knowledge (WORLD)

• Wait: Instead of immediately correcting errors, Michael encourages Sarah to analyze her images critically.
• Optimism: Michael fosters a positive environment, celebrating small successes to build Sarah’s confidence.
• Rubrics: Michael introduces a rubric for image quality assessment, helping Sarah to evaluate her own work.
• Leadership: Michael models advanced techniques, inviting Sarah to observe and ask questions.
• Direct: Michael provides targeted feedback, directing Sarah toward specific areas for improvement.

Outcome: Through this structured approach, Sarah progresses from basic anatomical recognition to confidently performing and interpreting carotid duplex scans, demonstrating the framework’s effectiveness in bridging the novice-to-master gap.

Case Study: Managing a Student Who Resists Feedback

Scenario: Taylor, a student nearing the end of the clinical rotation, has become argumentative and resistant to applying feedback. Despite clear guidance and multiple attempts to address performance gaps, Taylor dismisses constructive criticism and often challenges the clinical instructor’s observations. The clinical instructor, Chris, employs the NMDF to manage the situation, promote reflective learning, and guide Taylor toward professional growth.

Step 1: Develop Empathy (REAL)

• Remember: Chris reflects on personal experiences with feedback as a novice, fostering empathy while maintaining professional boundaries.
• Examples: Chris shares stories from his early career about overcoming challenges through accepting feedback, emphasizing growth through reflection.
• Activities: Chris introduces reflective journaling exercises, encouraging Taylor to self-assess performance and identify areas for improvement independently.
• Link: Chris connects the importance of feedback to patient safety and clinical excellence, framing it as a professional, not personal, necessity.

Step 2: Create Smaller Steps (PART)

• Present: Chris clearly outlines expectations regarding professional behavior, communication, and clinical competencies, ensuring that Taylor understands these nonnegotiable standards.
• Application: Taylor participates in structured skill labs where feedback is embedded into performance checkpoints, reducing the perception of criticism as personal.
• Relationship: Chris fosters an open dialogue, acknowledging Taylor’s frustrations while reinforcing that feedback is part of the learning process for all professionals.
• Time: Additional one-on-one mentoring sessions provide Taylor with space to process feedback without feeling overwhelmed.

Step 3: Develop and Transfer Knowledge (WORLD)

• Wait: Chris allows Taylor time to reflect on feedback before responding, promoting thoughtful self-evaluation rather than reactive defensiveness.
• Optimism: Chris highlights Taylor’s strengths alongside areas for growth, creating a balanced perspective that fosters confidence and reduces resistance.
• Rubrics: Chris implements objective assessment rubrics, shifting the focus from subjective opinions to measurable competencies.
• Leadership: By modeling respectful, constructive feedback in peer discussions, Chris demonstrates how to give and receive professional critiques effectively.
• Direct: Chris provides clear, concise feedback with actionable steps, avoiding vague criticisms and focusing on specific behaviors needing improvement.

Outcome: Through consistent application of the framework, Taylor gradually shifts from defensiveness to receptiveness, recognizing feedback as a tool for growth rather than criticism. Taylor’s clinical performance improves, accompanied by enhanced professional communication skills and a more positive learning attitude.

Closing the Learning Gap

The NMDF is designed to close the learning gap between novice learner and master instructor. By focusing on behavioral engagement, the strategic use of inquiry, and the cultivation of a growth mindset, this framework supports the development of critical thinking, clinical reasoning, and technical proficiency in clinical education.

References

Bandura, A. (1971). Social learning theory. General Learning Press.

Black, P., & Wiliam, D. (1998). Assessment and classroom learning. Assessment in Education: Principles, Policy & Practice, 5(1), 7–74.

Cifone, M. V. (2013). Questioning and learning: How do we recognize children's questions? Curriculum and Teaching Dialogue, 15(1-2), 41-55.

Dweck, C. S. (2006). Mindset: The new psychology of success. Random House.

Penny, S. M., & Zachariason, A. (2015). The sonographic reasoning method. Journal of Diagnostic Medical Sonography, 31(2), 122-129.

Piaget, J. (1952). The origins of intelligence in children. International Universities Press.

Shepard, L. A. (2000). The role of assessment in a learning culture. Educational Researcher, 29(7), 4-14.

Heather Ruttkofsky, M.A., RVT, is Dean, Health Sciences, at Jackson College in Jackson, Michigan.

Opinions expressed in Learning Abstracts are those of the author(s) and do not necessarily reflect those of the League for Innovation in the Community College.