Manual analysis technique in NVivo was preferred ahead of the auto analysis in order to get a deeper understanding of the qualitative data gathered from the participants through interviews. Transcripts were individually analyzed and compared to other transcripts to identity if there are similar concepts, experiences and feeling reported by the participants. All closely related concepts were categorized as a code and several codes were identified in this process which include students’ interest, willingness, attitude, culture, curriculum, peer learning and environment.
Clinical education is an important element of physiotherapy education and it is important to understand the effectiveness of clinical education that forms one third of the physiotherapy curriculum. Though the findings of the quantitative study showed positive experience for students in clinical education, there were some potential factors potential that hindered the effectiveness of clinical education. The aim of the qualitative study was to explore those factors underlying effective clinical education and the data collected from physiotherapy students and clinical educators in interview was useful to draw conclusion about the factors underlying effective clinical education. These factors were mostly related to the students, clinical educators and curriculum. The findings of the qualitative study are presented below in three main themes that include several sub-themes which illustrates the underlying factors for an effective clinical education.
Theme 1: Student Factors
Student related factors were mainly their area of interest, learning style, personality, cultural issues and their ability to cope up with challenges arising during the clinical placements.
There should be coherence between the student’s interest and placement focus. But the placements were arranged according to curricular needs and capacity framework. The mismatch between the student expectation and placement focus was one of the main factors that affected the effectiveness of clinical education. Several clinical educators and the students reported this in their interviews. For an example, one of the clinical educators stated that,
Our outpatient department focuses on musculoskeletal conditions and the inpatient focuses on neurological rehabilitation. I found some students were really interested in and willing to be in the outpatient’s unit than inpatients. (CE 11)
One of the students expressed similar views on this,
In the last rotation I was in stroke unit. I didn’t like neuro, so it was a bit difficult. If you compare the neuro patients to musculoskeletal patients, they are much more difficulty to do the assessment, position and explain. (ST 5)
Student’s learning styles:
There were differences in students learning style, some were enthusiastic and motivated but the other were not motivated to learn in clinical settings. Attitude for self-directly learning was missing in some students. Several educators confirmed this in their interview.
I can’t paint them all with the same brush. My last student was excellent but the one before that was not really very good. (CE 7)
Some are not proactive. They are anxious and have a feeling that they may harm the patient. So, they are apprehensive. (CE 24)
You find students who are very inquisitive. On the other hand, there might be a passive student who would need a lot of prompts. (CE 25)
The culture within the context of this study had a significant impact on students learning in clinical settings. All the students were females and grown up in the Arabic culture and they have had their own restrictions to handle male patients and to develop a working relationship with male clinical educators. Several clinical educators and students reported in their interview that culture is a major barrier for students learning in clinical placements.
I have seen many of the students initially expressed the concerns to see the male patient. (CE 1)
I am man, so a female student takes more time to become familiar with me. When handling male patients who are adult and, in their adolescence, then there is some shyness. (CE 12)
When we ask them to practice on us, they were very shy and nervous to do that. So that does come across with patients. (CE 17)
I am a little bit shy in dealing with male patients especially if they are locals. (ST 5)
Student’s ability to cope with challenges:
In this context, students attended clinical placements within a busy healthcare environment that presented lot of challenges to students and they were overwhelmed by the multicultural patient populace and healthcare workforce. Students demonstrated varied abilities in overcoming these challenges. The following quotes from clinical educators highlight the student’s abilities to manage challenging situation.
Sometimes they have challenging patients who are refusing to treatment or family members requesting more therapy when not indicated and issues around discharge planning. They were quite good at communicating with the patient and their family members in a very calm way. They know when to seek assistance and refer to clinical educator. (CE 16)
We found some students raising to the challenges and although they would be uncertain, they would really try to find their ways out, but some would shrink back. (CE 3)
In one of the sessions we have had two students and me. Patient was not onboard with what the plan of treatment was, and in an agitated state, and was not agreeing with the plan of care. One student was leading the session at that time, she got nervous and almost gave up, and wouldn’t want to talk to the patient at all. I think, she was just taken back by the whole situation and couldn’t cope up with it. On the other hand, the second student did take over and she was able to really communicate with that patient in a way that the patient left the session agreeing to plan of care. So, we had two personalities there. (CE 25)
Three of the students reported the following in their interview.
I treated patient with amputation and psychological issues, and I felt like crying. (ST 1)
I cried twice when I was saw patients who were dying. It was emotional. (ST 5)
Timing was not easy, and it was too long without break. (ST 6)
Theme 2: Clinical Educator Factors
Several factors related to the clinical educators were influencing the effectiveness of clinical education. These include their workload, instructional strategies and awareness of physiotherapy curriculum.
Clinical Educator’s Workload:
Clinical educators had to manage a dual role of providing care of their patients and teaching the students. It was obvious that the priority for the physiotherapists was their patients which hindered their additional responsibility of being a clinical educator. In this context, clinical educators were asked to teach, supervise and assess the physiotherapy practice of students attending the clinical trainings. This was a humongous task considering their operational needs that demanded them to see loads of patients and no dedicated time to teach the students.
When the clinical case load is so busy, the time you have for students is often prioritized off and sometimes you are trying to teach the students at a particular time, but you might be pulled in several directions to attend MDT meeting and/or other things. (CE 16)
It’s hard for us to have the main responsibility in fairness to the students and the practitioner who must continue the same amount of work in the same quality with the added load of doing education to the students. (CE 21)
Clinical educators don’t concentrate on us. They concentrate more on the patients. (ST 7)
Clinical Educator’s Teaching Strategies:
Clinical educators used versatile approaches to teach the students on practice placements and adapted their teaching style to suit the student needs. Some wanted to empower the students and make them a reflective practitioner. Providing prior information about the cases and teaching at the bed side was found to be useful in enhancing the students learning. Two of the educators reported the following in their interview.
We make them do the presentation to the team. They reflect on their theory to a case and present. Often, we ask them to reflect why they made that decision and what their clinical reasoning is? (CE 9)
They have access to what patients come in the next day which gives them some work to do at home. The more prepared they are the more they can apply their knowledge. (CE 25)
Two students confirmed in their interview the differences in clinical educators’ teaching style.
Sometimes they use to send me alone to see the patients, but I was scared and nervous. I understand that they want us to be confident, but we do not have much experience. (ST 2)
Some of the educators were friendly, flexible and welcoming. One therapist supported me in being independent but not all of them are same. (ST 3)
Clinical Educator’s Awareness of Physiotherapy Curriculum:
Clinical educators in this context are physiotherapists that qualified from several countries and might have studied on different types of physiotherapy curriculum. But the physiotherapy curriculum that the students studied is Australian based and not contextualized. It was evident that the clinical educators were briefed about the college curriculum during their preparatory workshop. However, most of the clinical educators did not possess a good understanding the physiotherapy curriculum which the students studied, and this seemed to affect their ability to teach students during the practice placements. Two of the educators reported this in their interview.
We don’t know what they have learnt. I don’t have enough knowledge and background of the curriculum and rely on the student information about their background. (CE 13)
We didn’t have much information about what they have studied and learnt. (CE 23)
Theme 3: Academic Factors
Faculty support for clinical education, placement expectations, duration and preparation and the peer learning opportunities were the major curriculum or academic related factors that influenced the clinical education.
Faculty to support for clinical education:
The academic staff were not actively involved in clinical education and the burden was fully on the clinical educators. Though the faculty were facilitating student placements, they did not engage in the learning and assessment activities within the clinical settings which brings up questions about the reliability of assessment of physiotherapy practice of students. If the university lecturers get involved in clinical education, it will be helpful to bridge the theory-practice gap for students. Several educators reported the need for academic staff support in clinical education.
We meet with the faculty clinical supervisors once a week, but it needs to be more of a practical session. Maybe we can do assessment and treatment session together with the student, so we can correct them. It would make the marking better way. (CE 4)
It would be better if somebody allocated to students with a dedicated time to go through specific topics and see patients with students within the protected time. (CE 16)
More faculty involvement is needed to focus on the student and to take the burden out the clinician. Perhaps they can observe the patient care and discuss about it. (CE 21)
It is important to establish clear communication between the parties involved in clinical education. Clinical educators should understand the students’ background and their learning needs. Simultaneously, students must be aware of the expectations of each placement site as every place may have their own policies and procedures regarding patient care and clinical education. However, in this study the clinical educators possessed limited understanding of the placement expectations. The following excerpts from participant interviews confirm this finding.
It will good for us the educators to understand what the college wants from us. (CE 10)
We were asked to consider them when they were in the fourth year, they like a new graduate but that level was not there. (CE 14)
If we could have an understanding about what we expect from the students, so when they come they already have some idea of what kind of conditions they are going to see, what type of a setting it is, so that is not so much of a shock. (CE 3)
Some of the educators put low marks without reasons even if the student did very well. But I want to know the reasons for low scoring so that I can work on those areas. (ST 5)
I wanted to see different cases. Someone should explain to me, but this didn’t happen. (ST6)
Each placement rotation was four weeks long and it was not adequate for the students to accommodate to the new environment and learn effectively. When the students move to different placement sites and area of practice at four weeks interval, they seemed unsettled in all the places.
Placement for 4 weeks are quite shorter. Students take some time to get oriented to the hospital, so, perhaps longer placements for 6 to 8 weeks may be the student would be more benefited. (CE 16)
We need more time, one month is not enough to achieve all the learning objectives. (ST 7)
According to the physiotherapy curriculum, in this context clinical placements happen in the fourth year of the program. There is a long delay in providing real-life clinical exposure to students and this was the root cause for their theory-practice gap.
I think the clinical placements should go along with the courses so that we can get real-time experience and benefit. For example, if we learn about assessment of a condition then we should simultaneously apply in real patients. (ST 5)
Placement providers and coordinators must provide peer learning opportunities for the students. Peer learning was beneficial to the students especially in difficult circumstances and to enhance self-directed learning.
There is some self-directed learning when they are together and discussing cases. (CE 17)
The pairing helps because there are two of them, so they do not feel overwhelmed and they always consult each other. So, it makes it more calming for them. (CE 3)