The Impact of Studying a Postgraduate Course in Clinical Biomechanics on Professional Practice

Background There is a continual need for allied health professionals to maintain an active CPD portfolio for registration. Profession specic postgraduate studies have been shown previously to clinically enhance practice leading to extended scope and leadership roles. It is not well known though if completing an interprofessional, subject specic award has any impact on clinical practice. The aim of this paper was to retrospectively review what the clinical and professional practice impact was from gaining a postgraduate award in Clinical Biomechanics had on alumni’s practice. Methods 25 multidisciplinary alumni from Staffordshire University, Clinical Biomechanics suite of postgraduate awards, responded to a questionnaire designed to review any changes in clinical practice and the impact studying had had for participants. Results Thematic analysis of results highlighted trends in competency development and clinical impact of postgraduate study, indicating professional development and improved condence in work interprofessional practices. Conclusion This study supports interprofessional cohorts of postgraduate study for a wider subject area, which has shown to enhance the evaluation of specic clinical practice whilst taking on a broader perspective of the topic, developing stronger and wider clinical conclusions.


Background
The last twenty years has seen an increase in the responsibility Allied Health Professionals (AHP) have in the management and care of patients. This was driven initially in 2000, when the NHS plan acknowledged the expanding roles AHP's play in social and health provisions and more recently in the development of rst contact practitioners delivering musculoskeletal (MSK) services in primary care [1,2].
AHP's delivering extended roles have been shown to be cost effective and are accepted by patients as being capable [3].
To provide these services the available workforce needs to be clinically competent in their eld and have completed the relevant training to equip them with suitable skills. Studying postgraduate masters awards in manual therapy has previously shown to enhance clinical practice with graduates gaining consultant and extended roles [4]. Similarly, it has been acknowledged that a clinical expert is better equipped with a postgraduate quali cation [5] and engagement in regular continued professional development (CPD) [6].
Provision of subject and profession speci c postgraduate training is well established [7][8][9] and is often used to follow a career framework within the chosen specialism.
Clinical Biomechanics is a broader specialist area that applies biomechanical principles to injury and pathology seen in clinical therapeutic practice. Application of postgraduate training in Clinical Biomechanics crosses a multidisciplinary eld and within therapies includes all practitioners that deal with MSK related problems. In particular, Podiatry; Physiotherapy; Osteopathy; Orthotists and Chiropractors. Yet the clinical impact of completing this interprofessional postgraduate programme has gone unreported. The aim of this paper, therefore, is to retrospectively review the clinical impact of completing a postgraduate masters award in Clinical Biomechanics on the career progression and specialism of the awards alumni.

Questionnaire
The questionnaire was a 15-item questionnaire which included both open-and closed-ended questions. The rst part of the questionnaire asked alumni for demographic information including what postgraduate study they undertook, modules they studied, year of completion, and information about current job role. The second half of the questionnaire asked respondents to re ect on the impact of completing a postgraduate quali cation, including how this had in uenced their career progression and current clinical practice.

Analysis
A mixed-methods approach was employed to explore the impact of completing a postgraduate Clinical Biomechanics award on students' career progression and clinical practice. Quantitative data (responses from 7 closed-ended questions) was extracted from the questionnaires and entered into Statistical Package for the Social Sciences (SPSS version 26) in order to conduct descriptive analysis. Qualitative data (responses from 8 open-ended questions) was exported into NVivo Pro 12 software (QSR International Pty Ltd, 2018) in order to conduct thematic analysis. The qualitative analysis was guided by the 6 stages of thematic analysis [11] (which were: familiarization, initial coding, searching for themes, reviewing themes, de ne and name themes, report ndings).

Results
Twenty-ve alumni who had graduated from a postgraduate Clinical Biomechanics award at Staffordshire University between 2002-2020 ( Fig. 1)

Summary of Thematic Analysis ndings
The thematic analysis produced two main themes, which were Competency development and Clinical impact of postgraduate study. The ndings from the thematic analysis suggest that students who have completed a postgraduate course in Biomechanics have developed professionally, enhancing their clinical practice and contributing to improved patient care. Students hold the perception that the postgraduate training that they undertook aided them to acquire a greater depth of subject knowledge, and to advance their clinical skills, which has supported students to improve their clinical reasoning and helped change their perceptions related to clinical practice.

Thematic analysis Competency development
The rst theme discusses how students have developed their capabilities during and implemented them following the completion of a postgraduate course. This theme has three sub-themes which describe how students have acquired a greater depth of knowledge, which has promoted enhanced clinical skills and has improved their clinical reasoning.

Greater depth of knowledge
Students discuss that completing a postgraduate course has helped them acquire a greater depth of knowledge and understanding which can be adapted for use within their professional careers, and this has led to the revision of their working practices. Further, this underpinning knowledge is adaptable to support the treatment of a variety of conditions. "It is the underpinning of my knowledge of lower limb biomechanics and gives me the foundation to understand all mechanical injuries that come through my clinic door, whether they are tendinopathies or stress bone responses" (Respondent 7). Furthermore, the students express that being part of an interprofessional cohort has contributed to their learning process. Respondents converse that by exchanging knowledge with other professions allows for a greater level of understanding from a different perspective.
"It is also good to work with different Professions such as Physios and Orthotist to enhance shared knowledge." (Respondent 25) "Perhaps by listening and observing how other students on the course worked biomechanically." (Respondent 4) Moreover, this acquisition of knowledge has led to improved professional con dence.
"Support through learning helped with con dence as growing underpinning knowledge was learnt" (Respondent 17) and has "enhanced and given me more con dence in my clinical treatment" (Respondent 15).
Enhanced clinical skills Students disseminated that this greater level of knowledge informed from course content has supported them to enhance their clinical skills. This has supported student innovation by helping them think differently about patient conditions, and be clearer about treatment options, which can impact the effectiveness of treatment.
"My understanding of biomechanics has allowed me to address overuse injuries with greater success, working backwards to target the causes of their problems not just treat the symptoms" (Respondent 13). These skills are adaptable and have allowed students to treat a range of conditions by using enhanced strategies to evaluate complex conditions. "It has given me the skills to research and formulate treatment pathways for a variety of conditions" (Respondent 11).
"I apply biomechanical principals[sic] and tissue stress to all foot pathology from diabetic wounds to tendinopathy not just Podiatric paradigm theories. This has given me a better understanding of how to treat the root cause and not just the symptoms." (Respondent 25) Improved clinical reasoning The completion of a postgraduate course has facilitated students to advance their clinical reasoning. Students suggested that they have adopted a more critical and re ective methodology within their professional practice which has also enhanced their problem-solving abilities within a clinical setting. Students are using their renewed understanding to challenge their perspective of their professional 'landscape' [12] which has supported the modi cation of their professional thinking.
"I was able to move away from the dogmatic approach taught at undergraduate level to be more critical. It elevated my problem-solving skills when you realise that there are so many more factors to consider" (Respondent 8).
Students have become more analytical not just about their own practice, but the practices of others with the aim to improve practice. The postgraduate course has given students con dence to communicate in a professional setting.
"It has given me the foundations to challenge existing practice and try to improve patient care" (Respondent 11).
"To implement new changes in the NHS which are researched base [sic] and give me more con dence in questioning and arguing the case for improvements within the department." (Respondent 5) "The MSc made me analyse and critically think about everything I was doing (to a higher level than as an undergraduate) the depth in which we covered the course content also gave me the con dence to challenge current systems." (Respondent 20)

Clinical impact of postgraduate study
The second theme discusses how, by students enhancing their clinical skills and capabilities through postgraduate study, it has made a positive clinical impact. This theme has two sub-themes which are clinical practice and professional development. These themes discuss how clinical practices have improved through evaluating problems in a broader sense, using a different perspective, which has helped improve assessment and treatment methods; this has also aided in better dialogue with patients. The acquired skills and knowledge have improved con dence which has supported professional development (external and internal).

Clinical practice
Students outlined that they have altered their approach in clinical practice by changing their perspective when treating patients.
"The in uence has changed the way I observe manage and treat patients with Biomechanical dysfunction especially from a foot-driven perspective." (Respondent 4) "Changed the way I thought and managed patients, altered materials used, ways of managing conditions changed and read a lot more". (Respondent 19) This has also informed process changes within clinical practice.
"Assessment process focussing on identi cation of structure causing tissue stress". (Respondent 17) Students' enhanced understanding has helped improve the dialogue with their patients by having the skills to better explain to patient's information regarding their conditions, leading to improved patient outcomes.
"I also feel better equipped to explain biomechanical causes of injury to patients in a way that they understand -which helps with compliance." (Respondent 13) "It has developed my ability to gain patient understanding of the condition." (Respondent 15) The improved con dence in their own clinical practice and communication skills has allowed students to work as part of an interdisciplinary team, which contributes to the improvement of interprofessional communication and collaboration.
"My master's module has enhanced my knowledge and allowed me to work integrated in a multidisciplinary team and given me the con dence to discuss concerns i have with paediatricians re my patients." (Respondent 2) "The course has given me con dence to pursue a leadership role across a multidisciplinary team." (Respondent 16) "Improved links with physiotherapy/joint clinics for adults and paediatric patients." (Respondent 5)

Professional development
The impact of completing a postgraduate course has helped students evolve and acquire skills and knowledge that have supported professional development, including the establishing of new clinics. The impact of the course is far-reaching: it has not only helped individuals to progress in their chosen profession, but it has allowed students to share their learning by educating their colleagues.

Discussion
Continual development of practice is essential for AHP's to remain current in their education and is a core standard to remain registered on the Health and Care Professions Council (HCPC). Advanced professional development at a postgraduate level is thought to provide clinical competencies beyond routine care, yet previously the impact of a postgraduate interprofessional award has not been explored. The results from this questionnaire indicate that completion of a broader subject that can be applied across several different AHP's provides the student with altered clinical perceptions to practice with advanced clinical reasoning skills that have had a direct clinical impact on their work and developed their competency and con dence in advanced level care.
Delivering the awards to an interprofessional cohort is a key bene t as it allows students to appreciate other professions' perspective(s) and to recognise how they differ from their own. This type of learning environment allows students to evaluate speci c problems taking a broader perspective of the topic, developing stronger and wider conclusions [4]. Within this suite of awards the module content does not include taught speci c competencies but supports learning to apply principles, judgements, and to have practical interaction which encourages decision-making regarding the implementation of therapeutic intervention, within their own professional practice [13]. Students from this review highlighted that completing their award made their thinking process deeper, more complex and challenged embedded beliefs with a positive outcome. Their practice was also supported by an additional con dence in the decisions made for patient outcomes. Completing a postgraduate course has previously been identi ed as a factor that helps students to gain a greater depth of knowledge and enhance their clinical skills, supporting the improvement of professional con dence [12,14].
Conversations that develop within interprofessional groups, that are studying the same content, enhance the depth of understanding around the scope of other professional practice [15,16]. This change in perspective assists in the knowledge transferred into clinical conversations with patients and improves multidisciplinary team working (MDT). An MDT represents several professional working together in a speciality and represents best clinical practice for patient outcomes [17]. This improved dialogue with patients and other professionals was evident from the student's responses where improved skills in discussing pathology were highlighted. There can sometimes be differences in professional communication within health care settings because of differences in professional backgrounds [18,19].
This can lead to lone working and closed practice which could have a detrimental impact on patient outcomes. Interprofessional education is necessary to help foster collaborative practices and help improve patient outcomes [20,21]. Completing an interprofessional postgraduate award develops bridges to communicate outside of an individual profession and collaborate in an MDT. The awards draw upon students' professional diversity which supports students to understand and speak different professional languages supporting diverse informed discussions.
Furthermore, the awards delivered do not focus on improving clinical competencies but rather offer students the opportunity to learn broader adaptive techniques that can be utilised within a variety of professions, clinical settings and geographical locations. The geographical location of the students encompassed practices from all over the UK, Ireland and from Australia. This broad spectrum of working practice based in either a city or rural location and then including the diversity of National Health Service (NHS), private and military practice ensures that discussions are broad, distinct and thought provoking adding to the diversity of the students' experience.
With this approach to teaching the awards support innovative learning and aim to use translational research in education to bridge the gap between research and clinical practice. The postgraduate awards are underpinned by translational research which is developed by research-active professionals within the academic department and is translated, embedded, and disseminated through the awards course content. Translational research is described as the conversion of scienti c knowledge into clinical applications to improve health and health outcomes [22,23]. Translational research can bring together professionals from a variety of backgrounds as it allows adaptive learning with the goal of learning to communicate across disciplines and it prepares individuals to work adaptively in an array of settings [24]. Furthermore, knowledge acquired from translation-based education has been shown to help improve patient care and support better patient outcomes [25].
Research informed teaching and professional development also occurs within the student's own profession with enhanced CPD being delivered to NHS teams and private practice. Course exposure has helped support shared learning with the disseminating of new knowledge and skills to colleagues and junior team members, which helps to update working practice and improve mentalities, within their working environment. This provides an e cient and cost-effective dissemination of learning and changes the culture of clinical practice beyond the individual that has completed the award [26,27]. This extended development could alter clinical practice through mentoring and departmental frameworks. Knowledge sharing in this format also empowers the individual leading and developing strategies which is often aligned to leadership or senior roles within clinical practice. Students included in this study went on to build their own clinical business or development of original services in the (NHS).

Conclusion
It is evident from this retrospective review of Staffordshire University Clinical Biomechanics alumni that completing a postgraduate award not only bene ts the individual on a personal level but directly improves their clinical practice as well others that work alongside or are junior to them. Additionally, studying an award that recruits from many MSK disciplines develops skills and competencies to bridge