Factors affecting physiotherapy clinical education in the United Arab Emirates: Perceptions of students and clinical educator.

Background Clinical education is the cornerstone of physiotherapy education. Clinical educators play a pivotal role in shaping students’ attitude towards their future role as physiotherapist. But the implementation of physiotherapy clinical education varies signicantly between institutions. Research has shown several factors inuencing the clinical education. Therefore, the aim of this study was to explore the factors affecting physiotherapy clinical education in the United Arab Emirates (UAE). Methods This research used mixed-methods approach and recruited participants through purposive and convenience sampling. Data was collected through a survey using questionnaire and face-to-face interviews. Thirty-four physiotherapy students completed a questionnaire after attending 12 weeks of clinical placements. Twenty-six clinical educators and 9 students participated in the interview. Descriptive statistics including frequency percentage, median and percentiles were used for quantitative data analysis. Thematic analysis method was used for qualitative data analysis. Results Quantitative study found greater student satisfaction in clinical education. But the qualitative study identied several factors affecting clinical education in the context of this study. These factors include student interest, learning style, culture, and ability to cope with challenges. In addition, clinical educator workload, teaching strategies, curriculum knowledge, academic-clinical partnership, peer learning, placement model and expectations were the other factors that inuenced physiotherapy clinical education within the UAE. The ndings of this study are useful to physiotherapy clinical educators, students, and faculty. It provides insight into various factors affecting physiotherapy clinical education. Furthermore, it recommends evidence-based strategies to neutralize those factors inuencing clinical education.

healthcare systems and the complexities in providing seamless interface may reduce the opportunities for students. Several factors affect students learning in clinical settings and it include the model of clinical education, attributes of clinical educators, teaching strategies, performance evaluation tools and the environment (3). The challenges for clinical education become multifold when 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 scal pressure associated with healthcare delivery may impact the clinical education (4).
A previous study identi ed clinical educators' distrust on students during clinical practice, lack of familiarity with professional ethics among hospital personnel and students' negative attitude towards their profession as the three main factors in uencing nursing and midwifery clinical education (5). Providing independence and opportunities to practice different tasks and giving feedback to the students are facilitating factors whereas distrust on students by supervisors, lack of continuity during supervision, lack of opportunities to practice and perception of the their own insu ciency by students were the obstructing factors identi ed by students in an earlier study (6). There must be a strategic link between the curriculum delivered at the college level and the clinical education. The effective clinical education can be provided by improved faculty monitoring of clinical education when the colleges depend on preceptor model for student training. There is an identi able gap that exists over the primary responsibility of clinical teaching. It is important to identify the alternate possibilities to organize clinical teaching and reduce the theory-practice gap (7). The current models of clinical education include mentoring, collaborative and shared responsibilities. The studies do not recommend any one approach and no model is superior to another. There is a need for research that evaluates the factors in uencing the clinical education to improve the quality (8). While studying the perceptions of students and clinical educators about factors affecting clinical education, the mixed model analysis is important to identify the contextual factors. The satisfaction surveys alone may not help in identi cation of these factors.

Purpose
In the context of this study, physiotherapy faculty members did not take active part in clinical education.
This was due to restrictions of Department of Health (DoH) a regulatory authority for health professions including physiotherapy. Unlike in most countries, DoH do not control teaching practice of health professions within the United Arab Emirates (UAE). Therefore, faculty members did not possess a license to clinical practice and are unable to provide clinical supervision to students. This was a concern for students and clinical educators which was reported in several stakeholder forums. It was reported that clinical educators did not have the necessary insiders' background of the physiotherapy curriculum taught at the institution. Further, newly established physiotherapy program and the use of noncontextualized curriculum presented multiple challenges for clinical education. In addition, literature search did not yield any similar studies on this topic within the region. Therefore, it was necessary to explore the factors affecting clinical education in the UAE.

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To identify the factors that affected physiotherapy clinical education in the UAE.

Research question
What are the factors affecting physiotherapy clinical education in the UAE?

Study design
This research used mixed methods design. Initially, quantitative data was collected from physiotherapy students through online survey using a questionnaire. Then face-to-face interviews were conducted to gather information from students and clinical educators. Quantitative method was useful in nding out students' satisfaction with clinical education. Qualitative method was useful to gather participants' views about their lived experience in clinical education.
The context and location of study This research was conducted in a health sciences institution in the United Arab Emirates. The undergraduate physiotherapy program was established in 2013 using Australian based transnational curriculum. The integrated curriculum is structured with themed modules. First-year of the program focused on musculoskeletal physiotherapy and the second year included neurological and cardiorespiratory physiotherapy. Advanced physiotherapy practice modules formed half of the third year and the remaining 18 months of the program involved clinical education. Clinical education structured as blocked placements and students attended fulltime clinical placements covering core, advanced and elective areas of physiotherapy practice. Physiotherapy program was taught in English language and institution admitted only female students.
This study was conducted on the second and third cohort of students of physiotherapy program. At the time of this study those students were in their nal and fourth year of physiotherapy program, respectively. Clinical education was organized in a liated teaching hospitals. Students attended clinical placements in 10 different hospitals within the region. These were both public and private healthcare sectors providing acute, sub-acute and long-term care services. Students were supervised by physiotherapists employed at the hospitals.
Participants rst language varied. Almost all students were native Arabic speakers whereas clinical educators spoke different rst languages. The medium of instruction for clinical education was in English. However, students often communicated in Arabic as patients were predominantly Arabic speakers.

Participant recruitment and ethical considerations
Purposive sampling was used to recruit the participants for quantitative study. All 34 students who completed 12 weeks of clinical placements were asked to complete the survey. Qualitative study used convenience sampling to recruit participants. A total of 9 students and 26 clinical educators were willing to participate and all were interviewed. Participants' pro le presented in tables 1 and 2 below.  The principal investigator (PI) was familiar to most of the participants through his role as lecturer. Hence, there was an ethical dilemma due to potential power relationship (9). However, the PI did not in uence participants' decision to participate or not participate in this study. In this study, the PI was involved in conducting an in-depth study of participants experiences and understand their feelings. Participants were enabled to express their feelings based on their lived experience in practice placements. In addition, participants were encouraged to answer questions in an authentic, honest, and open manner. Power dynamics was balanced at various stages of this study, as researchers sought approval from Institutions Research Ethics Committee, protected participants' privacy, and anonymity, and ensured open communication during interviews to allow the freedom to express. The PI showed respect and empathy for all participants and provided a comfort zone during the data collection process. In addition, the PI rechecked the verbatim transcripts with participants to validate their expressions in the interview. The PI was self-critical throughout the process of conducting this research and ensured that personal bias did not in uence the interpretation of ndings. The PI showed re exivity while interpreting results of the study and discussed research implications by making assumptions (9). All these measures have minimized the bias.
Quantitative study procedure A questionnaire was developed based on the tool designed to evaluate nursing students' perception about clinical education experience (10). The questionnaire consisted of 13 items about learning outcomes, clinical educator, supervision, environment, and feedback (see table 1 for questionnaire). Likert scale (0-strongly disagree to 5-strongly agree) was used to provide a response to each item. Questionnaire was piloted with selected students, faculty, and experts in the eld to establish face and content validity.
Questionnaire was administered through an online survey using Google Forms. An email invitation with survey link was sent to all physiotherapy students who have completed 12 weeks of clinical placements in the rst semester of core and advanced clinical education. Survey results were in text-numeric form and it was converted to numeric form for analysis in SPSS. Descriptive statistics including median and inter quartile range were used for quantitative data analysis.
Qualitative study procedure At the time of the study, the PI was pursuing PhD and worked as a lecturer whereas the other author was PhD quali ed and worked as Assistant Professor and both were males. Authors possessed adequate training in both quantitative and qualitative research methods, and they have been teaching physiotherapy for more than a decade. Phenomenology research design was used to understand the factors affecting clinical education. Therefore, individual interviews were used to explore participants' lived experience. A sample of convenience was used to recruit the participants. An invitation explaining research purpose was emailed to students and clinical educators. The response was limited from students to take part in the interview after two reminders. All students were females and represented traditional Arabic culture which might have been a factor for limited response. Among the 34 students who took part in the survey, only 9 were willing to participate in the qualitative study. Researchers believed that participants' perceptions about the effectiveness of clinical education would be useful to validate quantitative study ndings.
All willing students (n=9) and clinical educators (n=26) were interviewed. The PI conducted all interviews. One-to-one interview was arranged in privacy at the convenient place of participants. Separate interview guides were developed and piloted with two educators and two students. Their feedbacks were incorporated into the nal interview guide (appendix 1). Participants consented to audio record their interviews. Additionally, researcher made eld notes. Interviews lasted approximately 30 minutes long on average (appendix 2). The PI briefed eld notes to participants at the end of the interview to cross-check accuracy of information. Interviews were transcribed verbatim and returned to participants for validation.
There was no requirement for repeat interview at this stage. The PI did not see data saturation which forced to interview all willing participants. Limited number of student participants and clinical educators representing different sites were the possible reasons that data saturation did not occur in this study.
Analysis of qualitative data was performed using NVivo 12 software. Student and clinical educator interview transcripts were analyzed separately. Initially, auto-coding was conducted to identify related concepts from transcripts. This produced numerous concepts because the software identi ed repeated words and phrases as codes. The intention was to identify concepts from participant response and therefore, the researchers chose manual coding option using the same tool. The researchers independently and thoroughly read the interview transcripts. Highly related concepts were categorized as nodes in NVivo. Repeated reading of those nodes for further analysis identi ed three major themes for discussion. Extracts of participant interview transcripts were quoted to illustrate the qualitative study ndings and were presented under each theme. To protect participant identity, mock identi ers CE# for clinical educator and ST# for student were used in the order of interview. For example, the rst clinical educator was identi ed as CE1 and the rst student as ST1.
The research purpose was to explore factors affecting clinical education in the United Arab Emirates. Therefore, it was important to understand the participants' experiences, feelings, and opinions. Interviews were useful and effective to gather these information (11,12). Thematic analysis helped to gain deeper insight into the research problem (13).

Results
Majority of students were highly satis ed with their clinical education experience. The survey ndings showed that students learning needs were met, and that they received good support and supervision. Participants reported high level of satisfaction as majority of responses were between agree to strongly agree on all the items of survey tool. Percentage of participants response to each item of the questionnaire on Likert scale presented in table 3 below. Median, minimum, maximum and percentile statistics for each item of the questionnaire presented in gure 1 below.

Figure 1 Median and IQR Statistics
Findings of the qualitative study showed several factors affecting physiotherapy clinical education in the United Arab Emirates. Those factors were related to students, clinical educator and other academic aspects of physiotherapy program delivered at the host institution. Factors affecting clinical education are presented under these three themes. Extracts of participant interviews were useful to interpret and report the qualitative study.
Theme 1: Factors related to student Student's interest, learning style, personality, culture, and the ability to cope with uncertain situations in clinical placements are the factors that affected their clinical education experience.

Interest
The placement focus did not match with students' interest. This was reported by several clinical educators and students. For example, below extracts from clinical educator and student shows that students' interest is an important factor which affected their clinical education experience.
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) In the last rotation I was in stroke unit. I didn't like neuro, so it was a bit di cult. (ST 5) Learning style According to clinical educators, individual student learning style was another factor that in uenced their clinical education experience. Coping with challenges Students' ability to cope with challenging situation was also a factor that affected clinical education.
According clinical educators, each student's ability to cope with uncertainties was not the same and this affected their clinical education experience which was acknowledged by few students.
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. Teaching strategies Inconsistency in teaching strategies applied by clinical educators was another factor that affected clinical education within the context of this study. Participants reported that bed side teaching and empowering students to make decisions were some of the strategies enhanced clinical education experience for students, whereas unsupervised practice opportunities hindered their learning experience.
We make them do the presentation to the team. They re ect on their theory to a case and present. Often, we ask them to re ect why they made that decision and what their clinical reasoning is? (CE 9) 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 con dent, but we do not have much experience. (ST 2) Some of the educators were friendly, exible and welcoming. One therapist supported me in being independent but not all of them are same. (ST 3)

Knowledge of physiotherapy curriculum
Clinical educators reported that they were not fully aware of the physiotherapy curriculum taught at the college. Participant demographic information was useful to understand the diversity among clinical educators. They quali ed from different countries and their experiences varied. Hence, it was vital for them to get in-depth background of what students have learnt at the university so that they can adapt the learning activities for students in clinical settings. Therefore, limited knowledge of physiotherapy curriculum for clinical educators was also a factor that affected clinical education in the UAE.

Physiotherapy faculty involvement in clinical education
According to clinical educators, academic staff were not involved in teaching and assessment of students in clinical education. Participants reported that faculty involvement would have strengthened clinical education. Clinical educators expected the academics to provide support to students to bridge theory-practice gap and jointly assess students' performance. In the given context, faculty were not involved in clinical education and this affected 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 speci c 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)

Placement expectations
The ndings showed that there was a mismatch in expectations among students, clinical educators, and the college. Clinical educators have reported that there were inconsistencies in the expectations set to them by the college regarding students' level of knowledge and skills. Similarly, students raised concerns about the way their clinical educators have graded their performance in clinical placements.
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 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)

Clinical education model
Clinical educators reported that the placement duration was very short, and students expressed concerns with the unintegrated nature of placements. Shorter duration did not help students to settle in a new place. Additionally, placements did not run parallel to theory courses. Below quotes from participant interviews con rm that both these factors affected clinical education.
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 bene ted. (CE 16) We need more time, one month is not enough to achieve all the learning objectives. (ST 7) I think the clinical placements should go along with the courses so that we can get real-time experience and bene t. For example, if we learn about assessment of a condition then we should simultaneously apply in real patients. (ST 5)

Peer learning
According to clinical educators, there was peer learning opportunities for students in clinical placement.
This helped them to overcome di cult situations and promoted self-directed learning. Hence, peer learning was reported as one of factors that positively in uenced clinical education.
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) In this mixed methods study, ndings of quantitative study showed high level of students' satisfaction with clinical education. Conversely, the qualitative study ndings showed mixed responses and identi ed several factors affecting clinical education within the context of the study.

Discussion
In this study, culture was one the factors that affected physiotherapy clinical education. Female physiotherapy students' cultural restrictions were reported as a barrier for developing interpersonal relationships during clinical placements. Particularly students were not collaborating well with male patients and educators and this was due to their cultural beliefs and tradition. The institution is not a coeducation place which did not help students to prepare for this experience. It is inevitable that health professionals like physiotherapists manage patients of both sexes. Therefore, it was vital for students to develop interpersonal skills without any restriction and clinical placements provided numerous opportunities for it. McBee and colleagues reported similar nding in their study in which culture was a major factor that in uenced clinical education. Furthermore, their study recommended that educators should develop strategies to address cultural barriers in clinical placements (14). Learning style and ability to cope with challenges were the other factors attributed to students that affected clinical education. Findings of previous research indicated that physiotherapy students preferred one of the four Kolb's learning styles. These include accommodating, assimilating, converging, or diverging style of learning (15). A systematic review of physiotherapy learners' learning style concluded that physiotherapy learners prefer active participation (16). Inability to cope with anxieties can affect learning and performance in clinical settings. Therefore, clinical educators must develop resilient measures to support students in clinical education. Delany and colleagues recommended to replace stressful challenges with positive coping strategies to develop self-e cacy for learners in clinical settings (17). The interest of learner was another factor that in uenced clinical education in the context of this study. Findings showed that physiotherapy students did not enjoy placements in areas that are not of their interest. A study on medical students at the University of Western Australia reported that students' preferred placements were found to be the most useful clinical placement compared to other placements (18). However, options cannot always be given to students because the physiotherapy program requires students to attend placements across several areas of physiotherapy practice to achieve various learning outcomes. On the other hand, placement providers and physiotherapy educators may consider students' interest where possible, for example, in elective placements.
In this study, workload of clinical educator was reported as one of the barriers for physiotherapy clinical education. This was consistent with previous research ndings on medical and physiotherapy clinical education in the United Kingdom and Australia respectively (19,20). This is an important factor to be addressed by the institution and physiotherapy educators to enhance the quality of clinical training within the UAE. In this study, clinical educators used different strategies such as problem-solving, self-directed directed learning and re ective practice in clinical education. But students' reported inconsistencies between clinical educators and it affected their clinical education experience. Previous studies also reported lack of consistency in the use of pedagogical principles for clinical teaching (21,22). Therefore, there is a need to innovate teaching strategies to t the needs of learners particularly in physiotherapy clinical education. Clinical educators have reported lack of knowledge of physiotherapy curriculum that developed the foundational knowledge and skills of students. This is another factor that impacted physiotherapy clinical education in the UAE. Knowledge of models and principles underlying the design of curricula is listed as a core competency for nurse educators (23) and this can be applicable for physiotherapy clinical education.
Lack of physiotherapy faculty involvement in clinical education was a concern for clinical educators. They reported increased burden and time constraints which did not help them in clinical education.
Academic-clinical partnership is of paramount importance and sharing of expertise helps to minimize theory-practice gaps (24). However, in this context faculty was not connected to clinical education, particularly in evaluation of students' performance in clinical placement courses. This brings up a question on the reliability of evaluating students' performance in clinical education. Therefore, physiotherapy educators and the institutions must develop a plan to overcome the barrier for faculty involvement in clinical education. The health authority and higher education institution need to collaborate to address this issue and enable physiotherapy faculty to be actively involved in clinical education in the UAE. Clinical education model and placement expectations were the other factors that in uenced clinical education in this context. The blocked model of placement with just four weeks duration did not help students. Moreover, the curriculum was designed in a way that clinical education was not integrated with academic courses. As a result, there was a potential theory-practice gap for students when they entered clinical placements at the later end of the program. The duration and structure of clinical placement was reported as important factors that determined the belongingness of nursing students in clinical education (25). Clinical educators and students recommended longer duration placements that runs parallel to theory courses. There was also a gap in establishing clear expectations between clinical educators, students, and academics. Lack of supervision for students and exceedingly high expectations provided to clinical educators were also considered as factors that affected clinical education in the context of this study. Early exposure to clinical education and incorporating supervision strategies are some of the ways to overcome these barriers (21,26). Research ndings indicate that clinical educators determine the quality of learning experience for students in clinical education. Clinical educator skills in providing a constructive feedback positively in uenced students' learning in clinical settings (27,28). Peer learning was another factor which in uenced clinical education. Clinical educators observed students supporting each other in overcoming their challenges. Previous research ndings showed peer-assisted learning reduced students' anxiety, enhanced safe feeling and collaborative working, and reduced clinical educator burden (29).
Research evidence indicate that respecting students, supporting their learning needs and good communication are some of the essential qualities of a clinical educator (30,31). Clinical educators have used several strategies to promote students learning. It is recommended that they make thinking visible to students by scaffolding ideas (32,33). Several studies have found re ective practice as a useful measure to manage anxieties, build con dence and promote life-long learning (8,34,35). Case study presentations and small group discussions are some of the ways to promote re ection in clinical education (36).
Limitations of the study include small sample size particularly student participation in the qualitative study. Hence it is di cult to make assumptions on ndings. The researchers tried to limit the bias through open communication. But still the power dynamics could have been a factor that limited student participation and could have in uenced the openness of students' responses. All students were female and therefore, perceptions and feelings reported did not include the views of male students. Though the study was limited to only one of the three institutions offering physiotherapy education within the UAE, ndings are useful to understand the factors affecting clinical education in this context. Availability of data and material: The data are not publicly available to protect privacy and con dentiality for the participants. Anonymous interview transcripts and survey results are available on reasonable request.