FACILITATING CLINICAL EDUCATION IN MEDICAL AND HEALTH PROFESSION EDUCATION

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”.


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.

INTRODUCTION
Clinical education is the final stage in health profession education which determines the quality of future healthcare professionals and thus health services. 1,2[3][4] Harden and Cosby classified six significant tasks of the medical teacher as 1) information provider, 2) the role model, 3) the facilitator, 4) the assessor, 5) the curriculum planner, and 6) the resource material creator. 1,5In clinical education, these tasks are often performed simultaneously with clinical supervisors' role as physicians.The problems that arise in clinical education are the workload of clinical supervisors in healthcare services and facilitating students' learning. 1,4However, the roles of clinical supervisors as physicians are renewed frequently by training in clinical competence, contrasting the limited training to enhance their role as a teacher. 1 The complexity of clinical education underlined our recommendation for facilitating clinical education for medical and health professions education.Therefore, the 3 rd IAM HPE webinar series focused on clinical supervisors' skills in Facilitating Clinical Education and inspired the authors to develop this recommendation.

GAPS BETWEEN GUIDES AND PRACTICES IN THE INDONESIAN CONTEXT
7][8] The social interaction between clinical supervisors and students is the main factor in forming conducive relationships and supporting students' progress in achieving their competencies. 2,6,7The study on clinical education through a socio-cultural approach has shown the specificity of each culture and subculture.Wong finds that there is a tendency for residents in Thailand to work in a team, while residents in Canada tend to work more individually. 8n line with that, Wilbur et al. found differences in the perspectives of Canadian and Qatari clinical supervisors in clinical assessment. 9Ramani et al. explored the influence of institutional subcultures on feedback at the residency stage in the USA. 10 In Indonesia, the socio-cultural influence in clinical education has been studied using the Hofstede national culture classification.Hofstede classifies the culture of the Indonesian state with a hierarchical relationship pattern or high power-distance index and collectivist.11Within Indonesian cultural characteristics, studies shows that clinical supervisor position themselves as a parent, the student tends to have less autonomy or ownership of their learning, and the dominance of unidirectional top-down conversations.12-14This mindset is likely to become a significant socio-cultural barrier in the clinical education process in Indonesia.
2][13][14] Bridging the gap from the literature in the Indonesian context, recommendations are needed to strengthen Indonesia's quality of clinical education.

I AM HPE RECOMMENDATION
We formulate four main recommendations that we will describe in ten specific interrelated recommendations for improving Indonesia's quality of clinical education.Our main recommendations are 1) Building clinical supervisor and student relations; 2) Making role modeling explicit and integrating into teaching and learning; 3) Facilitating the gradual development of students' clinical abilities; and 4) Reconceptualizing feedback in clinical education

A. Building Clinical Supervisor-Student Relationship
In the initial part, we recommended the clinical supervisors' awareness in developing a relationship that supports students' competence development.
Recommendation 1. Paying attention to the student learning process According to the concept of adult learning, students are learners who have experience and self-concept that will influence the way they think.In improving their abilities, adult learners need to involve and reflect on their experiences. 16Thus, students will reach their optimal skills gradually.Students need to learn how to be responsible, aware of their limitations, and determine their steps to improve their abilities through self-reflection skills. 15,163][14] The clinical supervisors can start a conversation by asking about their experiences, impressions, strengths, and improvement areas. 1,12,16n this case, the clinical supervisors need to have the flexibility to behave and be willing to take the time to discuss effectively. 1,17,1commendation 3. Facilitating growth mindset A growth mindset is a well-known psychological theory that represents the ability to learn from challenges and mistakes, thus stimulating selfimprovement. 19Based on this understanding, we recommend that clinical supervisors develop a growth mindset.In that way, clinical supervisors can facilitate student changes towards a growth mindset through supportive relationships and dialogue that trigger students' self-development. 1,10,19commendation 4. Facilitating student selfreflection ability Based on the self-reflection cycle from Gibs, 16,17 clinical supervisors need to facilitate students to reflect on their feelings and thoughts in the clinical experiences they have faced.This self-reflection ability is an important aspect in preparing conceptualization and constructing new knowledge in students. 3,16,17

B. Making role modeling explicit and integrating it into teaching and learning
There are two main definitions of role modeling which we will discuss in this recommendation.Firstly, the definition of role modeling as a learning method that emphasizes the demonstration of clinical skills or professional behavior from a "role model".Secondly, several other studies define role modeling as a natural process when students observe clinical traits, behaviors, or procedures that are exemplified by clinical supervisors and then adopted or imitated.Based on these two definitions, role modeling is a process that is implicit primarily in the clinical learning experience. 18,20,21Therefore, we suggest that clinical supervisors deliberately use role-modeling as a teaching strategy and debrief these experiences with their learners.

Recommendation 5. Deliberate role-modeling effort
The modeling process begins with observation; therefore, the clinical supervisor as a role model needs to have "awareness" that they are being observed e by students or deliberate the rolemodeling. 18Strengthening the learning process, role modeling requires learning objectives that can be stated in the form of a briefing at the beginning of the session.We recommended the learning cycle of remodeling in figure 1.

Recommendation 6. Facilitating the process of reflective dialogue and follow up on modeling results
After determining the learning objective of remodeling observation, the next step is to facilitate dialogue with students to trigger self-reflection skills.We recommended that the clinical supervisors initiate the dialogue and be open-minded and willing to accept comments from students. 18,21

C. Facilitating the gradual development of students' clinical abilities
Following the experience-based clinical learning model, mentoring can facilitate students' journey towards clinical competence.Students' progress requires a "positive state of mind," which is facilitated in clinical supervisor-student relations that support student progress. 1,3,10commendation 7. Understanding the clinical stage of the student development process In facilitating the development of student abilities, clinical supervisors need to understand the stages of professional development.In the first stage, students will act as passive observers.The clinical supervisor can implement role-modeling as a deliberate teaching approach at this stage.The second stage is an active observer or observing and helping, so the clinical supervisor can determine the initial skills that students can do.In the third stage, students can contribute, which means that in the clinical experience, the clinical supervisor can provide opportunities for students to contribute and show their performance.The final stage is for establish the credibility of feedback. 10,13,24Therefore, we recommended that clinical supervisors be aware of facilitating feedback as a form of dialogue and providing their growth mindset.
Recommendation 10.Providing direction using the "coaching" method to improve students' performance The trend in the definition of feedback is a bidirectional dialogue or conversation.Following this approach, Sargeant et al. developed a feedback model known as the R2C2 model, namely 1) Build the relationship.The clinical supervisor initiates the conversation from collegial relationships that allow bidirectional discussion and conversation be created.This sets the stage for the supervisor to observe the student during a clinical interaction; 2) Explore Reactions, namely encouraging students to explore their reactions, including emotional responses, to the clinical experience and stimulate self-reflection; 3) Understanding of Content, where the supervisor discusses their observations of the clinical encounter, checks the accuracy of their observations with students, clarifies areas of disagreement.In this stage, the learner should be able to develop 1-2 rooms that they would like to improve 4) Coach for Change, the clinical supervisor guides the learner in formulating action plans for improvement, focusing on the performance areas identified by the student. 25long with the awareness of feedback dialogue and socio-cultural barriers, we recommend the R2C2 as one of the alternative models for facilitating feedback in clinical education.
Studies show that clinical supervisor teaching skills such as building supportive relationships, deliberate role modeling, and facilitating reflective feedback have improved clinical education quality.Therefore, these recommendations potentially became a part of clinical supervisors' awareness of their roles during clinical teaching.
However, Indonesia's hierarchical and collectivist culture potentially became a barrier to implementing these recommendations.Therefore, these recommendations also open opportunities for culturally specific studies in clinical education in Indonesia.
students who can perform skills independently (performers), then the clinical supervisor plays more of an observer role.Based on these stages, the clinical supervisors' role is crucial in determining students' success to achieve their capabilities.

D. Re-conceptualization of feedback in clinical education as a "dialogue"
Initially, feedback is defined as providing information from clinical supervisors to students about students' performance and directing them to further performance. 22From this definition, students are only allowed to listen to the opinion of the clinical supervisors.However, since the 2000s, researchers have begun to question the role of students in feedback. 24Since then, more studies have focused on the relationship between clinical supervisors and students as the starting point for successful feedback. 9,10,11,12commendation 9. Understanding feedback as a "dialogue" process Supportive relationships and opportunities for students to ask questions and gradually improve themselves will support feedback credibility. 10,24ndonesia, with the collectivist culture, allows clinical supervisors to perceive a superior position in interacting with students, which has the potential to hinder the dialogue process (bidirectional) needed to

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

Table 1 . Subjects' Characteristics and Their Responses to the Virtual Neurology Examination (N=12) I AM HPE Recommendations
1,3 main principle is providing feedback and facilitating student self-reflection, which is carried out in debriefing/post-round sessions.The session can always be applied at every stage of student capability.1,3