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Qualitative

Study

Physiotherapy students’ and clinical teachers’


perspectives on best clinical teaching and
learning practices: A qualitative study.

Abstract: Background: Clinical education forms a core component


of the training of physiotherapy students. Little research on the efficacy of Ernstzen DV, BSc, MPhil1
commonly used physiotherapy clinical learning and teaching opportunities Bitzer E, D Ed1
are available. Grimmer-Somers K, PhD2
Objective: This paper sought to identify the clinical teaching and learn-
ing opportunities that undergraduate physiotherapy students and clinical Stellenbosch University, Tygerberg.
1

University of South Australia.


1

teachers viewed as effective in enhancing learning, as well as the reasoning


behind their views.
Design: A qualitative research design was used. Data was analyzed using
content analysis. Data was coded, cate­gorized and conceptualized into key themes and patterns.
Participants: All third year (n=40) and fourth year (n=40) physiotherapy students as well as their clinical teachers
(n=37) were eligible to participate. Semi-structured individual interviews were conducted with a purposive sample
consisting of six third-year students, six fourth-year students and six clinical teachers.
Results: The results indicated that learning is best facilitated in open, relaxed environments. Demonstrations of
patient management by teachers and students, discussion of patient cases, feedback and formative assessment were
identified to be effective strategies to enhance development of clinical competence.
Conclusion: Clinical education, using focused and structured processes, could ensure that students are exposed to a
range of learning opportunities for development of clinical competence.

Key words: Best practice; Clinical training/education; Physiotherapy; Teaching


and learning.

INTRODUCTION thoughts, beliefs, attitudes, values Walker and Openshaw (1994). Several
Clinical education is defined as the and learning style play an important reviews on the efficacy of clinical
provision of guidance and feedback on role in the learning process. Many education programmes across disciplines
personal, professional and educational of the theories that contribute to our (Kilminster and Jolly 2000, Rushton
development in the trainee’s experience understanding of learning highlight it and Lindsay 2003 and Strohschein
of providing appropriate patient care as a social process and as a product of et al. 2002) emphasize the need for
(Kilminster et al. 2007). Appropriate the environment. Torre et al. (2006) an evidence-based approach towards
clinical education within the context indicate how some learning theories clinical education.
of providing patient care is important (namely behaviourism, cognitivism, Despite its importance, there is limi­
for the development of health profes­ humanism, social cognitivist theory ted in-depth knowledge about which
sionals (Grant et al. 2003, Kilminster et and constructivism) can be applied in teaching strategies are potentially
al. 2007, Lekkas et al. 2007, Strohschein health care education. Best et al. (2005) effective to facilitate learning and why
et al. 2002). Clinical learning takes also provide a description of the use some strategies might be more effective
place in a complex social context, where of learning theories during clinical than others (Babyar et al. 2003, Lekkas
the patients’ and students’ needs are con­ education.
sidered (Chan 2001) and consequently, Several authors across various dis­
a careful balance between patient care ciplines emphasize the importance of Correspondence to:
and student learning is essential. clinical training to achieve clinical D.V. Ernstzen
What and how a learner learns is competence (Kilminster et al. 2007, Division Physiotherapy,
influenced by many factors, including the Chan 2001 and Williams and Web P O Box 19063,
organizational learning culture, learner 1994). The importance of clinical edu­ Faculty of Health Sciences,
characteristics, learner approaches to cation for physiotherapy is investigated Stellenbosch University,
learning and teacher characteristics and reiterated by Baldry Currens and Tygerberg,
(Kilminster and Jolly 2000, Schunk Bitchell (2003), Higgs (1993), Lekkas 7505
2004, Best et al. 2005). The learner’s et al. (2007), Stiller et al. (2004) and E-mail: dd2@sun.ac.za

SA Journal of Physiotherapy 2010 Vol 66 No 3 25


et al. 2007 and Rushton and Lindsay Box 1: Main interview schedule
2003). Ernstzen et al. (2009) found
Interview schedule
that certain teaching and learning
opportunities are perceived to be key Opening questions
elements for facilitating learning during
Describe your best clinical learning/teaching session (story or incident) OR
clinical education. These opportunities
Describe your ideal clinical learning/teaching session (story or incident)
included demonstrations and discussion
on patient management, feedback on Specific probing questions
clinical skills, and assessment. The
What methods/opportunities for learning/teaching are of most value to you
current article explores the teaching and
learning opportunities from the context during clinical rotations and why.
of qualitative data collected subsequently • Probe for all, including:
to the above findings. • Demonstrations
This paper sought to identify the clini­ • Feedback
cal teaching and learning opportunities • Discussion
that undergraduate physiotherapy students • Assessment (self, peer, competency)
and clinical teachers viewed as effective • Reflection
in enhancing learning, as well as the rea­
soning behind their views. What are your views on facilitating learning of:
Problem solving skills?
METHODS Clinical reasoning skills?
What aspects of clinical learning opportunities affects:
Research Design
Responsibility for learning?
A qualitative research approach was
Motivation for learning?
used in order to understand the con­
text specific, real world setting
without manipulating the environment
(Golafshani, 2003). The study was con­
ducted at the Division Physiotherapy, The protocol for the study was codes were revised after being checked
Faculty of Health Sciences (FHS), approved by the Committee for Human by an external auditor to aid valida­
Stellenbosch University (SU), South Research at the FHS, SU, SA (reference tion. The codes were then grouped into
Africa (SA). The study reported on number N05/08/144). Permission to categories by the researcher in conjunc­
formed part of a larger mixed method undertake the study was obtained from tion with the external auditor. Categories
study that employed a survey as a first the chairperson of the Physiotherapy lead to the development of patterns
phase (reported on in Ernstzen et al. Division, and written informed consent and themes within the data to explore
2009). The current paper reports on was obtained from the participants prior their possible relationships. The process
the second phase of the study, which to each interview. resulted in an understanding of learning
employed a qualitative methodology. within the context of the clinical teach­
Data was generated using one-to-one, Participants ing and learning opportunities used.
semi-structured individual interviews. All enrolled undergraduate physio­
Topics discussed in the interviews are therapy students at SU who had had RESULTS
included in Box 1. Interviews were clinical experience, and all physio­
conducted by the primary researcher in therapists involved in the clinical edu­ Profile of the participants
the language of choice for the participant cation of these students during 2005 An overview of the profile of the partici­
(i.e. either in English or Afrikaans). were eligible to participate. Purposive pants is presented below in Table 1.
The interviews took place at the sampling was used to select six parti­ The fields that clinical teachers were
Division of Physiotherapy, lasted cipants from each of the three groups teaching in, included orthopaedics (2),
an average of 35 minutes and were (third year students, fourth year students medical and surgical (1) and neurology
recorded using a digital voice recorder. and clinical teachers). (1). Two clinical teachers were involved
Field notes were kept to provide a sum­ in teaching in all three of the above
mary of the process and the recorded Data analysis fields. The level of health care taught at
interviews were transcribed by an Data was analyzed using content ana­ were: primary health care (1), secondary
independent transcriber. Unique serial lysis. The transcripts were analyzed and health care (2), tertiary health care (2)
numbers were given to each data set. interpreted using specific analysis strate­ and a private practice setting (1).
The selected participants were invited gies (Creswell 2003, Krippendorf 2004)
to view and comment on transcripts to including familiarisation with the data, Key findings of the interviews
assist with validation (Mays and Pope interpreting the data by coding, catego­ The key themes identified through the
1995; Creswell 2003). rizing and contextualizing texts. Final interview transcripts are presented in

26 SA Journal of Physiotherapy 2010 Vol 66 No 3


Table 1: Profile of the case population and sample
3rd year students 4th year students Clinical teachers

Population

Number in category 40 40 37*


Gender 39 female 35 female 34 female
1 male 5 male 3 male
Average age (SD) 21,53 (1,78) years 22,73 years (1,74) years 37 (7.51) years

Sample

Number of participants 6 6 6
Gender All female 4 female 5 female
2 male 1 male
Average age (SD) 21,83 (1,33) years 22,17 (1,17) years 34,33 (5.54) years
Clinical 1 year 2 years 1 – 11 years
education experience

*23 clinical lecturers and 14 clinicians in this category

Table 2: Summary of themes generated from interviews


Opportunity Description Perceptions

Demonstrations Teacher-led Teacher as role model


Collaborative learning
Student-led Identification of student capability
Collaborative learning
Role of communication
Guides self-development
Peer-led Challenges concept of self and others
as therapists
Feedback to peers and to self
Discussions Group discussion Can include interdisciplinary learning
Communication skills
Collaborative learning
Patient specific Clinical reasoning
Teaching Feedback
and Feedback Timing of feedback During demonstrations
learning After demonstrations
opportunities
Nature of feedback Edifying
Strengths and shortcomings

Assessment Summative Less drive for learning


assessment
Mock assessment Self assessment
Preparatory
Guides learning
Feedback opportunity
Peer assessment Uncertainty; mixed responses
Difficult to judge peers
Opportunity for self assessment
Self assessment Uncertainty; mixed responses
Timing
Limited self knowledge
Needs feedback/discussion

SA Journal of Physiotherapy 2010 Vol 66 No 3 27


Table 3: Summary of factors involved in creating an optimal learning environment
Factor Verbatim Quote

Open/relaxed “Where help is readily available and I could quickly ask for advice
environment (Student 1)
Where there is freedom to ask questions.” (Student 4)
“I create an open learning environment by being enthusiastic,
approachable and open for feedback.” (Teacher 1)
Open discussions “Where students can regularly discuss their clients progress.”
Descriptions (Student 9 )
of a good
Different sources of “Where you can obtain input from different sources.” (Student 3)
learning
information
environment
Demonstrations “Demonstrations at the beginning of the rotation have always helped
me.” (Student 5)

Guidance on patient “Guidance on patient management and suggestions for improvement


management has improved my learning experience.” (Student 10)

Equipment “ It does help if the basic equipment is available.” (Student 5)

Table 2 and 3. Demonstrations of patient they value feedback from more than During teacher-led demonstrations, the
management, collaborative discussions one clinical teacher. Demonstrations teacher acted as a role model with regard
between the student, clinical teacher and of patient management and guidance to cognitive, social and technical skills,
peer group, feedback on various learn­ on patient management played a role in highlighted by the following quotes:
ing aspects, and mock assessments were creating a good learning environment. Student 2: “The demonstration by the
all confirmed to enhance the learning These two factors contributed to teacher gave me direction in manage-
process. There was some uncertainty learning from the teacher when the ment options for the patient. It directed
about the learning value of peer assess­ teacher acts as role model for cognitive, my thought processes as it provided a
ment and self assessment. These teach­ social and technical skill, which is pattern of thinking and doing; it helped
ing and learning activities, with their key explored in the next section. me to identify the type and logic of ques-
themes are elaborated on in the section tions to ask. I started thinking in the same
below to explore how they influenced Demonstrations of patient manage- manner and could put the theory and
the learning process. ment practical together in a clinical setting.”
The themes presented in Table 2 Participants identified three types of Teacher 3: “When performing demon-
are intertwined within the creation demonstrations of patient care, namely; strations I hope that learners may learn
of an optimal learning environment, teacher-led, student-led, and peer-led. a specific pattern of thought or process
as summarized in Table 3. Students During teacher-led demonstrations, the of assessment/treatment of the patient.
consistently reported their best clinical teacher demonstrated patient care to one Not a recipe, but an approach.
learning experience as occurring in or more students. During student-led These illustrate how students can learn
clinical placements where an open, demonstrations one student demon­ cognitive skills from teachers, especially
relaxed atmosphere existed between strated while the teacher provided their approach to clinical problem solv­
students and the clinical teacher, and guidance and feedback. Peer-led demon­ ing.
where the students felt free to ask strations was characterised by peers The clinical teacher was reported to
questions and make mistakes. The providing feedback during or after a be a role model for technical skill as
attributes and roles of the clinical student demonstration. Demonstrations Student 4 pointed out:
teacher were reported to play a key role were reported to be valuable as they “It helped me to observe the teacher’s
in the creation of an optimal learning helped students to think creatively and physical handling skills. It showed me
environment. The participants reported imaginatively by assisting reasoning. how to adapt my techniques, for exam-
that the clinical teacher can create an Student 4 stated: ple my grip, to make the technique
optimal learning environment by being “Demonstrations help me to think more effective and comfortable to the
enthusiastic, approachable and flexible out of my boxes of theory and practi- patient.”
with regard to learning opportunities cal. They help me to mix my boxes of Participants also reported learning
(Table 3). Students appreciated diverse different subjects, thus integrating theory productivity during student-led demon­
sources of information, indicating that with practice.” strations. Student-led demonstrations

28 SA Journal of Physiotherapy 2010 Vol 66 No 3


were valuable for identification of The processes of performing a demon­ Peer group discussions that ranged
student educational needs, provision of stration and receiving/giving feedback over a broader set of topics than patient-
feedback and planning for action. It through discussion were central to specific discussions were also high­
also enhanced technical skill, clinical facilitating learning in this context. lighted as important. The collaborative
reasoning, communication skills, self- discussions aided in self-assessment,
assessment and reflection, as illustrated Feedback during/after demonstration clinical reasoning skills and the faci­
in the quotes below. of patient management litation of communication skills, as well
Student 8: “Observing someone doing Feedback during or after demonstrations as assisting students to reflect on recent
something and then doing it yourself was identified as providing direction learning opportunities as indicated by
is quite different, you really only learn to a student’s development. Feedback the statements below.
when someone corrects you and gives was considered important in terms of Student 9: “Such discussions helped
you feedback on what you are doing.” it’s content, the manner in which it was me to express myself and handle critique.”
Student 2: “It can be very stressful to given, and it’s timing. The follow­ Student 2: “Discussions can aid in
give a demonstration, but it definitely ing quotes illustrate that the nature of clinical reasoning, especially if specific
helps you to develop your confidence. feedback played a role in the way it was questions are asked. It helps you by
The more you do it, the more confidence perceived. letting you do self assessment.”
you gain. It helps with communication Student 4: “If feedback is given imme- Teacher 6: “Discussion gives students
on a professional level.” diately, you can apply it immediately, the opportunity to discuss problem
Clinical teachers confirmed the or immediately adapt your technique. patients and interact with each other.”
value of student-led demonstrations Constant interruptions during my
as providing opportunities for needs demonstration disturb my thoughts and Mock assessment
analysis, clinical reasoning and the concentration.” Participants regarded mock assessment
development of communication skills, Student 1: “Feedback can be given any (formative assessment) as valuable for
substantiated by the quotes below: time during the demonstration, depend- learning, probably because the mock
Teacher 2: “It provides the oppor­ ing on how it is given. If feedback is test is a simulation of the actual clinical
tunity for the teachers to identify given in an unnerving manner, it makes competency test. Supporting quotes on
students’ strengths and limitations and me uncomfortable and nervous.” mock assessment include:
to provide feedback on the students’ The relationship between the student Student 4: “It helps you to identify
clinical reasoning and performance of and the clinical teacher influences your faults and to assess yourself. It
techniques.” the way feedback is interpreted. The provides the opportunity to clarify
Teacher 3: “It develops communication comments below highlight the need uncertainties.”
skills, as students are required to present for feedback to be immediate, specific, Teacher 5: “A mock test teaches
information and reveal their thought appropriate, empathic, and accompanied students how to approach the assessment
processes to others while they are by advice. situation and alerts the student to
demonstrating. When students give a Student 4: “Feedback should be assessment criteria.”
demonstration, they are being prepared specific, edifying and focus should be Mock tests prepared students for the
for communication with colleagues and on the way feedback is given. Feedback final clinical competence assessment
patients.” should provide suggestions or advice on as it promoted discussion and guided
Students preferred student-led improvements.” remedial action without the pressure of
demon­strations rather than peer- Student 3: “If you have a good a ‘real’ assessment.
led demonstrations. However, they relationship with the clinical teacher,
acknowledged the value of peer led- you can handle critique better.” DISCUSSION
demonstration as follows: This paper presents information which
Student 4: “I was able to identify others’ Discussion as a learning activity elaborates on teacher and student per­
mistakes, which helped me to realize The learning value of individual and spectives on strongly valued elements
that I often make the same mistakes.” group discussions with the clinical that produce clinical learning. The
Despite the many positive contri­ teacher focussed on the development findings suggest that quality clinical
butions from peer observation, students, of problem solving, clinical reasoning education is dependent on planning
as observers, admitted that they were skills, communication skills and reflec­ learning carefully to incorporate par­
unwilling to comment on the clinical tion. Comments pertaining to discussions ticular teaching and learning oppor­
performance of other students. Clinical for learning included the following: tunities. Key factors that play a role
teachers agreed with this notion. Student 8: “Discussions facilitated in the creation of an optimal learning
Student 3: “It is difficult to judge problem solving, decision-making pro­ environment were found to be teachers’
peers. I find it difficult to be objective. I am cess, as well as understanding.” attributes and key teaching and learning
careful, in case I offend them. There has Teacher 4: “During discussions we opportunities (demonstrations of patient
to be a well thought through process to focus on finding solutions for the problem management, discussions, feedback and
manage peer observation and feedback.” identified and reasoning on it.” formative assessment).

SA Journal of Physiotherapy 2010 Vol 66 No 3 29


Demonstrations of patient manage­ Hewson and Little (1998) found that well as more diverse teaching and learn­
ment provided opportunities for the way in which feedback was given ing opportunities. The gender bias in
colla­­borative learning, the provision strongly affects students’ perceptions of this study is highlighted. The value of
of feedback, facilitation of clinical it’s helpfulness. self assessment and peer assessment also
reasoning and problem solving to Discussion between teachers and stu­ warrants further research. The study
integrate theory and practice. The dents occurred as part of demonstrations, only focused on teaching and learning
importance of the teacher as a role feedback and formative assessment. opportunities, whereas a more holistic
model and facilitator of learning was The learning value of discussion was study that included factors related to
underpinned by these findings, espe­ centred on facilitating understanding, personal and professional development
cially as they relate to the cognitive, clinical reasoning, decision making and is recommended.
affective and physical skills that are communication between participants.
inherent to physiotherapy practice. Discussion may also facilitate learning CONCLUSION
Students expressed the view that trough reflection and self-assessment. The study confirms that clinical place­
they learn from observing the teacher These findings concur with the views ments offer a rich opportunity for stu­
and even more so when the teacher of Gross Davis (2001), who argues dents to learn. Clinical teachers played
verbalized their cognitive processes. that through discussion, students gain a central role in facilitating students’
Learning by observation is supported practice in thinking through problems, learning by addressing clinical, theoreti­
by the social cognitive theory and organising concepts, formulating argu­ cal and social constructs that are present
behaviourist theory of learning (Schunk ments and counterarguments, evaluating when providing patient care. Students’
2004). Clinical reasoning is apparently the evidence for their own and others’ learning experience is strengthened by
facilitated when clinical teachers position, and responding thoughtfully a supported learning environment that
explain their thought processes while and critically to diverse points of view. is enriched with visual and cognitive
performing demonstrations. This con­ Babyar et al. (2003) found discussion modelling.
cept was termed by Meichenbaum as to be the most effective activity to facili­
cognitive modelling (Meichenbaum, tate clinical reasoning for physiotherapy Funding
1977 in Schunk, 2004). Students are students. The Fund for Innovation and Research
thus developing their learning poten­ Mock assessment was valuable as it into Teaching and Learning, Centre for
tial when interacting with a more encouraged learning, promoted self-
Teaching and Learning, Stellenbosch
knowledgeable other (the teacher). evaluation and improved the quality of
University, South Africa.
The range of roles played by the teaching. Robertson et al., in McAllister
teacher highlights the complexity of et al (1997) supports this notion.
Acknowledgements
the interaction between student, patient Formative assessment with feedback is
The authors would like to thank the par­
and teacher in the clinical setting. The supported as a reinforcement strategy
ticipants for their time and input.
rich and complex clinical environment for learning (Torre et al. 2006). Mock
is worthwhile for learning as it requires assessment could be a useful strategy to
Ethical approval
integration of theory, practice and social drive learning in the process of develop­
Committee for Human Research at the
skills. The unique and challenging learn­ ing clinical competence by combining it
Faculty of Health Sciences, Stellenbosch
ing experience that clinical environments with feedback and discussion.
University, South Africa (reference
offer is recognized by Cross (1995) and The findings of the study indicate that
number N05/08/144).
Baldry Currens and Bitchell (2003). a structured clinical education program,
The interpretation of feedback was that include the teaching and learn­
found to be influenced by the relation­ ing activities as discussed above could
ship between the student and clinical ensure quality in clinical education.
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