Factors underlying effective clinical education: Perceptions of physiotherapy students and preceptors.

Background Clinical education is the cornerstone of physiotherapy education and it plays a pivotal role in shaping physiotherapy students’ attitude towards future professional practice. But the implementation of physiotherapy clinical education varies significantly between the institutions. Clinical educators adapt various strategies to teach students in the clinical settings which have several advantages as well as disadvantages. Research has shown several factors influencing the clinical education of healthcare students and the objective of this study was to explore the factors that affect the effectiveness of clinical education of physiotherapy students. Methods This research used mixed-methods approach and included 34 physiotherapy students and 26 clinical educators. Data collection was conducted in two stages. First stage of data collection used a 13 items survey at the end of 12 weeks of clinical placements to collect the student’s perspectives about clinical education. Then the second stage of data collection used semi-structured interviews that included both students and clinical educators. Results Descriptive statistics of the survey was useful to analyze the survey results and majority of students reported clinical education was effective and high levels of satisfaction was found among the students about the placement environments and clinical educator skills. Clinical education fulfilled students learning needs and the educators provided necessary support and supervision. However, the findings showed few factors hindering the effectiveness of clinical education and the qualitative study was useful in exploring those factors that are related students, clinical educators and the physiotherapy curriculum. Conclusion The findings of this study are useful to clinical educators, students and academic leaders in physiotherapy as it provides an insight into the factors that affect the effectiveness of clinical education and recommends evidence-based educational strategies to overcome those factors.

clinical education of healthcare students and the objective of this study was to explore the factors that affect the effectiveness of clinical education of physiotherapy students.
Methods This research used mixed-methods approach and included 34 physiotherapy students and 26 clinical educators. Data collection was conducted in two stages. First stage of data collection used a 13 items survey at the end of 12 weeks of clinical placements to collect the student's perspectives about clinical education. Then the second stage of data collection used semi-structured interviews that included both students and clinical educators.
Results Descriptive statistics of the survey was useful to analyze the survey results and majority of students reported clinical education was effective and high levels of satisfaction was found among the students about the placement environments and clinical educator skills. Clinical education fulfilled students learning needs and the educators provided necessary support and supervision. However, the findings showed few factors hindering the effectiveness of clinical education and the qualitative study was useful in exploring those factors that are related students, clinical educators and the physiotherapy curriculum.
Conclusion The findings of this study are useful to clinical educators, students and academic leaders in physiotherapy as it provides an insight into the factors that affect the effectiveness of clinical education and recommends evidence-based educational strategies to overcome those factors.

Background
Clinical education is the heart of physiotherapy education and high-quality clinical training is vital for students' learning in healthcare settings. Clinical education is powerful in shaping the students' attitude for physiotherapy practice in future. Physiotherapy preceptors use various strategies to teach within the clinical settings. Peer coaching, supervised practice, role playing, and questioning are some of the popular strategies used for clinical instruction. 1 Research has shown that experienced physiotherapy practitioners are effective clinical educators. 1 However, there are no standardized clinical education approaches to recommend to physiotherapy preceptors. Clinical education is of paramount importance to link the theory to practice and the experience in real-life setting is vital to crystallize therapeutic skills. Supervised practice helps the students to develop professional skills, competence and autonomy. 2 But the conceptualization and delivery of clinical education significantly varies across the globe which may affect the placement expectations. Providing optimal learning opportunities helps the students to develop clinical skills and attain the attributes of a physiotherapist. But the rapidly changing healthcare systems and the complexities in providing seamless interface may reduce the opportunities for students. Several factors affect the students learning in clinical settings and it include the model of clinical education adapted, attribute of preceptors and their teaching style, tools to evaluate students' performance and the environment. 3 The challenges for clinical education is higher when the students require additional support. 4 Clinical education usually occurs outside the university settings and the environment is often time constrained. Lack of human resources and the fiscal pressure associated with healthcare delivery may impact the clinical education. 4 In the context of this study, clinical educators are licensed physiotherapists. They are employed by the healthcare sectors and responsible of provide physiotherapy services to patients and supervise students attending placements. The college set up a memorandum of understanding with health services across the country and placed the students for clinical attachment. There was no funding to appoint an onsite student coordinator, instead the college relied on the physiotherapists employed by the hospital for student education. However, each faculty member was responsible for number of placement sites and visited on a daily or weekly basis as required. But they were not able to be involved in clinical education due to legal restrictions as they did not possess the license to practice as a physiotherapist. The health authority of the country provides registration only to the clinical 4 practitioners working within health services not for the academic staff in the higher education institutions. Therefore, they are not entitled for patient contact and as a result they are unable to supervise students during clinical encounter. The main objective of this study was to explore the factors that affect the effectiveness of clinical education.
Research question: What are the underlying factors for an effective clinical education? Methods Ten healthcare settings across the emirate of Abu Dhabi that accept the physiotherapy students for clinical placements were included in this study. These represent public and private healthcare sectors that offered acute, sub-acute and long-term care services. A total of 39 female students attended fulltime clinical placements across these sites for a period of 12 weeks. Both male and female physiotherapists working in the health services were the clinical educators. Purposive sampling was used, and all the students and clinical educators were invited to participate in this study. The Research Ethics Committees of the College of Health Sciences and Abu Dhabi Health Services company granted the permission for this study before the data collection. In addition, independent approval was granted by each participating site. The study acknowledges that there was a power relationship between the participants and one of the researchers. The participants were the students and professional colleagues of a researcher hence there was a position of authority that could influence the participants. However, the researchers ensured such power dynamics will not happen at any stage of the research process and the researchers respected the rights of all individuals who refused to participate in this study or decided to withdraw from the study at any stage without any explanation. It is almost impossible to be bias-free especially when including a qualitative methodology especially when the researcher has professional interest on the research problem and involved as a stakeholder within the research context. However, the researchers encouraged the participants to answer the questionnaire as well as the interview questions in an authentic, honest and open manner. The researcher was self-critical throughout the process of conducting this research and ensured that his own bias did not influence the results/interpretation of the findings. Researcher showed reflexivity while interpreting the findings of the study and discussing the implications of the same to construct knowledge by making some assumptions. 5 This is believed to have minimized the bias. In addition, the research was self-critical and has taken a neutral stand which helped him to accurately interpret the findings and minimized the bias in this research and ensured the validity of the data was maintained. Researcher showed respect and empathy for all participants and ensured a comfort zone during the data collection process.
This study used mixed-methods approach that included both quantitative and qualitative methods.
Quantitative study targeted only students and the qualitative study included both students and their clinical educators. A survey and semi-structured interviews were used in data collection. Researchers questions were asked when needed using the participants response as a probe. 6 First, a survey was conducted among the physiotherapy students who completed 12 weeks of fulltime clinical placements. The survey includes a consent question and all participant must consent in order to complete the survey online. Participants were asked to respond using a Likert scale response of 1 to 5 for each statement in the questionnaire. A response of 1 means the participant strongly disagrees with the statement whereas 5 indicates strongly agreement with the statement. Then, another invitation was sent to all the students and clinical educators to take part in the interview.
Nine students and 26 clinical educators were willing to participate. All of them were interviewed in privacy and participants gave a written consent prior to the start of the interview and selected their preferred ways to record the interview. Most of them consented for audio recording of their interview and two educators and two students asked the interviewer to handwrite the notes of their response to the questions. All participant interviews were verbatim transcribed and analyzed in NVivo12 which is a software for qualitative data analysis. Researchers carefully read the electronic copies of each interview transcripts. Statements and the phrases that were significant for answering the research questions were highlighted in files and sticky notes were inserted for cross referencing at a later stage. Several codes were identified during this process. Finally, comparisons were made between the transcripts and thematic analysis model of Braun and Clarke was used which produced few themes and this was useful to deepen the understanding of the research problem. 9

Results
The objective of the study was to explore the factors underlying effective clinical education.
Therefore, it was essential to includes views both the students and clinical educators as they were the stakeholders of physiotherapy clinical education. A total of 39 students attended 12 weeks clinical placements. 34 students responded to the survey conducted at the end of placements and the response rate was close to 85%. Descriptive statistics in SPSS was used to analyse the survey results.
Findings were useful to understand the physiotherapy students' perspectives about the effectiveness of clinical education. Table 1 provides the summary of survey findings which concludes that majority of the students reported that the clinical education was effective. It fulfilled their learning needs and they received good support and supervision from clinical educators. Students also reported high 7 levels of satisfaction with their clinical educators' ability to deal with students as well as the learning environment. 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 8 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.

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. 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 Integrated placements: 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)
Peer learning: 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 selfdirected 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) Discussion Physiotherapy students appreciated the clinical educators who were friendly, kind and supportive and valued their feedback as it helped them to enhance their clinical reasoning and decision-making skills.
Students were critical of the educators who did not provide adequate supervision. Ludin  Clinical instructors who showed respect towards the students were found to be influential in motivating the students' learning and considered as a role model. But findings of this study showed lack of consistency in relationship between the students and clinical educators. Some students Clinical Educators have said that they are not completely aware of the placement expectations and they relied mostly on student information to know the placement expectations. Both educators and students have reported that the clinical placement focus was not maintained in some placements due to lack of resources and unavailability of cases in the specialty where the student was placed.
Students have criticized the clinical educators' evaluation of their performance and felt that the rationale for their low scoring was not appropriate. Both the students and educators felt that the placement duration was not adequate to provide an effective clinical education.
Peer learning is another factor that determined the effectiveness of clinical education. When two students are together, they support each other to overcome the challenges in clinical education and this enhances the overall learning experience. However, there may be barriers peer learning especially if the two students are not friends and they may shy away from one another and do not engage in an interactive learning. Sevenhuysen et al. (2015) concluded in their study that the peerassisted learning reduces anxiety among the students and provides a feeling of safety and reduces burden of the clinical educator and enhance collaborative working. 17 Culture plays a crucial role in deciding the effectiveness of clinical education and the local culture of the UAE had a strong influence on the clinical education. All the female students reported that their cultural beliefs were a big barrier for them to develop interpersonal relationship with male patients and educators. McBee et al., (2017) study reported that culture is a major factor that influences clinical education and the educators must incorporate strategies to address these in clinical placements. 18 Roman and Dison (2016) reported that South African universities faced a lack of student preparedness for clinical placements due to the multilingual needs and large intake. 19 Though the students initially experienced anxiety later they developed confidence and similar findings were reported in Ramli, Ruslan and Sukiman study. 20 According to Rowe, Frantz and Bozalek (2012), undergraduate education should prepare the students for reflective practice and life-long learning. 21 Ramli, Ruslan and Sukiman believed that, if the students reflect critically and learn from their mistakes it will deepen their learning. 20

Conclusion
This study was conducted on the physiotherapy students studying in a health sciences college in the UAE and there were two other universities that offered physiotherapy education. But the scope of the study was limited to only one institution where the researcher had access and the difference in curriculum followed at the other institutions limited the possibility of including the students of those institutions. However, the findings of this study provide strategies for effective clinical education that can be used across physiotherapy programs within the country and globally. The experiences and feelings reported by the students represented female sex and it will be interesting to explore the experiences of male students.
It is recommended that universities develop a clinical education framework that addresses all the factors that affected the effective delivery of clinical education. An understanding of the factors underlying effective clinical education will help the institutions to overcome their shortcomings. The findings of this study useful for leaders in healthcare education, academic, clinical educators and the students attending practice placements as it provides an insight to various factors influencing clinical education and recommend evidence-based strategies to overcome those variables. The findings of this study are expected to contribute to the literatures in healthcare educational research and believed to support the clinical teachers in devising their educational strategies. In addition, the mixed-methods research approach used in this study adds value as the previous studies that were either relying on quantitative or qualitative methodology. Consent for publication: Not applicable.
Availability of data and material: The datasets generated and/or analysed during the current study are not publicly available due to the privacy and confidentiality assured for the participants as the qualitative study collected data through interviews that were audio recorded with participant consents but the anonymous transcripts of interviews and survey results are available from the corresponding author on reasonable request.
Competing interests: The authors declare that they have no competing interests.
Funding: Not applicable.
Authors' contributions: SR is the primary investigator who conceptualized this study contributed to the methodology, investigation, data curation, formal analysis and writing the original draft of this manuscript. KB had significant contributions with the resources for this study and a major contributor 18 in reviewing and editing of the manuscript. All authors read and approved the final manuscript.