The process of curriculum development, resultant Physio Hub and preliminary evaluation represent the results of this paper.
Dimension 1. Future Orientation of Healthcare Practices: the why?
In the first dimension, the focus was on ‘the why’? Why is this novel model of clinical education needed? Whilst healthcare professional curricula fittingly respond to the requirements of registration and accreditation bodies(20, 21) it is imperative that they be responsive to service demands and shaped through work-based, inter-professional, inter-sectoral and public health foci (17). Ireland as elsewhere is facing unprecedented health system challenges with an ageing population and a high prevalence of chronic, lifestyle diseases, demanding a shift in the focus of health care from an acute hospital service model, which treats disease, to a service which focuses on prevention and health promotion in community care settings (22-30). Acknowledging that University and health system based learning opportunities may differ between Higher education institutions in Ireland, in the three year period of 2009 to 2012, only five percent (n=171/3142) of all physiotherapy placements in Ireland were in primary healthcare settings (31) with a lack of student community health promotion and exercise education opportunities in the primary healthcare setting (32) (Table 1). Despite progress in appointing more Primary care teams in Ireland, significant shortfalls persist in terms of students gaining the relevant clinical experience and acute hospital approaches continue to dominate within health systems(27, 33-35). Recent national chronic disease curriculum project work (36, 37) revealed a lack of experiential learning opportunities, for the recommended physical activity promotion interventions, within healthcare professional curricula.
Whilst exercise related learning occurs across a continuum of theory (eg. Exercise physiology), clinical skills and practice education modules, our curriculum review identified that it was in the domains which focus more on translating exercise prescription into practice (clinical practice education) that gaps existed (32, 38)(Table 1). This evidence base, in combination with a shortage of practice education opportunities in community settings, the changing employment landscape for many HCPs and ongoing stakeholder feedback, were the key drivers for the ‘Physio Hub’ initiative. A mission statement was agreed that encapsulates why the ‘Physio Hub’ was established, what it stands for, what it considers to be its fundamental purpose and its overall ethos;
“To optimise the health of our students, staff and the wider community through the provision of evidence informed community health promotion and exercise services, led by health professionals and supported by health professional students. Underpinning this is a philosophy of integrating service provision with student education and research, consistent with best international practice”
Dimension 2. Defining graduate capabilities: the what?
Dimension 2 was concerned with identifying learning outcomes, expressed in relation to standards and sets of attributes, knowledge, skills and capabilities as well as dispositions. Health professional practice is multidimensional, contextually specific and relationally complex, and this must be reflected in the capabilities of graduates(17). Although UCD’s HCP programmes have clearly articulated graduate capabilities, mapping to international professional standards, the need to reflect the changing healthcare landscape demanded that the curriculum review team identify additional capabilities specific to community healthcare and exercise prescription. More generic graduate attributes of autonomy, leadership and advocacy coupled with those more specific to community health promotion and exercise prescription were identified as important by way of the stakeholder consultation process, literature review, professional and accrediting body position statements and competency documentation (39) (6, 11, 32, 37, 40, 41). Clinical exercise physiology, cellular and systemic implications of exercise, health behaviour change, physical activity and public health and integrating PA and exercise into health systems were identified as key exercise learning domains for healthcare professionals. Stakeholders identified that other capabilities, including development of strategies for exercise promotion and building inter-professional and inter-sectoral networks among exercise and healthcare professionals are often more challenging to address at traditional clinical education sites.
Key learning outcomes articulated for students include achievement of competence in: assessment of physical activity levels, pre exercise screening and risk stratification, exercise programme design, delivery of safe and evidence informed exercise programmes, creation of exercise and health promotion resources for clients, interaction with clients (individual and group) which reflects behaviour change theory, measurement of outcome, client advocacy, leadership, interdisciplinary and inter-sectoral communication skills and administrative aspects of integrating physical activity in health systems.
Dimension 3. Teaching Learning and Assessment: the how?
Teaching, learning and assessment, core to higher education, make up the ‘the how’? and are the focal point of dimension 3. Research conducted by the current authors (Table 1) and the stakeholder consultation process revealed the limitations of learning about exercise in the classroom context, the value of contextual learning (42)and the need to provide a more focused opportunity to facilitate theory-practice transfer (43). The social determinants of health and health behaviours (12) (13) are well recognised, including the interpersonal, social and environmental elements required to facilitate client PA and exercise(44). Thus, creating a clinical education environment with a socially mediated context such as a community gym to facilitate exercise learning was agreed on as an appropriate and realisable solution for the curriculum project team. The ‘Physio Hub’ is therefore located within UCD Sport (university sports complex) where it acts as a community health hub with a focus on exercise prescription for healthy sedentary and clinical populations and sports injury prevention both on campus and via outreach activity with community and health service partners (Figure 2). Initially it built upon a small number of existing physiotherapy led community exercise programmes based at UCD Sport but a further client base has been achieved by embarking on projects to increase inter-professional and inter-sectoral working, that serve both the university and wider community. Physio Hub services see health promotion and exercise prescription being realised for healthy and clinical populations across the lifespan, making student experiential learning in these areas a reality for our students (listed and described in Table 3). A university appointed physiotherapy clinical educator supervises students with the emphasis on facilitating self -directed learning (average of 1:5 as tutor: student ratio), using a a mix of direct, indirect and remote supervision, encouraging students to become confident in their practice, while assured that advice and mentorship is always available.
The underlying pedagogy is one of social constructivism (45) with a focus on advancing psychomotor, clinical reasoning and metacognitive skills and recognition of the social and environmental facilitators of exercise behaviours. Consistent with this pedagogical approach, students at the ‘Physio Hub’ are encouraged to lead, collaborate and negotiate with one another, their clinical educator, service-users and community partners, to be creative and to co-construct knowledge and resources in order to develop, market, deliver and formally evaluate research- informed exercise and community health initiatives in a socially mediated context. This learning is facilitated by embedding an action based learning project within their educational experience to address real world health challenges (46). Projects have included delivery of health promotion and exercise initiatives on campus that target the general population and community outreach activities that assist students’ inter-sectoral learning in community organisations including disability organisations, schools, sports cubs and local authority fitness facilities. Table 3 provides more detail. Students are encouraged to leverage technology in preparation for the rapidly changing and networked world of work (e.g. fitness apps, wearable sensor technology, social media)(47). Consistent with its translational research ethos, the ‘Physio Hub’ acts as a ‘living laboratory‘ to support exercise related research, facilitating BSc, MSc and PhD level research projects with students assisting in data collection, data entry and analysis. Standard assessment of student performance is conducted using the common assessment form (CAF) for Physiotherapy practice education with multiple learning outcomes grouped into five domains (Assessment , Treatment, Professionalism, Documentation and Communication) (48) and with additional assessment criteria utilised to reflect identified capabilities (Dimension 2) and related learning outcomes. Novel assessment strategies are embedded over the six week Physio Hub experience to drive learning that achieves the more context- specific learning outcomes. These include design and delivery of; exercise programmes, online resources, brief interventions, public health talks and presentations to multi-sectoral audiences regarding proposed new exercise services and their evaluation. Impact on student learning is captured by way of assessment rubrics which incorporate both generic and more specific exercise and health promotion learning outcomes in combination with student reflective learning portfolios and formal placement feedback surveys.
Dimension 4. Supporting Institutional Delivery - the where?
In developing new student learning opportunities to enhance curriculum, the organisational culture and context is crucial to the process. The Physio Hub project aligned well with the university strategy (appendix 1), providing an experiential learning environment to strengthen scholarship in disciplines, facilitate translation of theory to practice, build engagement locally and nationally, service student health well -being and sport and with demonstrated ability to attract international students via unique service learning opportunities (46). UCD has a programmatic approach to curriculum design and enhancement with emphasis on learning outcomes and graduate attributes and with health professional programme curricula needing to map to professional accrediting and state registration body requirements(20, 21). The top class exercise facilities at UCD, coupled with a history of positive working relationships and resource sharing between the physiotherapy academic, sport and leisure service units and clinical networks, was a key enabler with this ecosystem acting as a springboard for the new initiative. This project copper fastened shared goals and built the case for the redeployment of space to the Hub, leveraging of the existing client booking system, reception services and also linking into additional channels for promotion and ‘branding’ of the Hub activities. Governance, management and budgetary structures to enable the team’s vision were realised via consultation with representatives from UCD quality, legal, data protection, health and safety and existing clinical partners (Table 2). This resulted in the formation of a Physio Hub governance committee comprised of representatives from the UCD academic physiotherapy unit (CC, SMcM, CB) and UCD Sports Centre with a joint clinical governance arrangement between UCD and its clinical partners.
Preliminary Evaluation
Although the focus of this paper is on the process of curriculum development for UCD Physio Hub, some preliminary outcome evaluation has been conducted from both the student and institution perspectives.
Student Performance and Feedback
Levels of student engagement are excellent as evidenced by students rising to the challenge of addressing real world issues and excelling in delivering projects with tangible outputs (Table 3). Student grades achieved for the Physio Hub practice education module indicate a very strong student performance and verify the achievement of the National Common Assessment Form (48) learning outcomes which underpin the University’s practice education modules and are required by accrediting bodies. Student feedback on all clinical practice education and other academic modules at UCD is standard and student feedback from the Physio Hub has been utilised on an ongoing basis to inform enhancement of the learning experience. Overall feedback on the unique gym- based learning experience is very positive, although adapting to the less traditional and more self directing nature of this unique placement requires a shift in student thinking in the early stages of placement. UCD Physiotherapy students rank Physio Hub in their top five practice placement choices of 60 potential options.
In addition, online student surveys were conducted with all students, who completed a six week placement at Physio Hub from May 2019 to October 2020 (n=28) and consented to data reporting. Students were asked to rate their level of agreement (1 to 5) with a series of statements relating to achievement of learning outcomes informed by graduate capabilities (Dimension 2). Outcomes where > 80% of students reported achieving the learning outcome included: appraisal of exercise evidence, health promotion skills, exercise programme design and delivery, behaviour change communication skills, team work, collaboration, inter sectoral communication, producing written reports, chairing meetings and time management skills. In addition, formal assessment of the embedded ’real world’ action learning projects over multiple placements demonstrates students’ achievement of both planned and unplanned learning outcomes including; enhanced skills in community exercise prescription, inter-sectoral communication, project management, time management, advocacy, team work, exercise programme administration, marketing and design of health promotion resources.
Institutional Benefits
From an institutional standpoint, the Physio Hub has had many benefits supporting UCD’s stated goal of maximising relevance and impact on society, while at the same time augmenting the student learning experience and researcher engagement (Appendix 1).
Physio Hub has added significantly to practice education capacity, a major challenge for higher education institutions. To date, 140 BSc and MSc (graduate entry) physiotherapy students have completed blocks (4 to 6 weeks each) of professionally accredited practice education at the Physio Hub. The Hub placement started with only two students, whereas currently twenty six students are given the opportunity to complete a placement at the Hub each year. This represents 7% of the overall placement requirement for the physiotherapy programmes at UCD and with potential for expansion with further inter sectoral, community partnerships.
Physio Hub has enabled UCD Physiotherapy students to contribute both to the University community and broader society aligning with service learning models(49). The exercise and health promotion programmes delivered all represent examples of community engagement that would not otherwise occur (Table 3) with client contacts now in excess of 2200 per annum. Strategic partnerships with public and non-governmental agencies, education, community and professional organisations have been established, consistent with both a public engagement and community outreach ethos. Physio Hub initiatives map well to the ‘Healthy UCD’ staff and student well-being initiative and were integral to UCD achieving ‘Exercise is Medicine’ campus accreditation in 2020.
Formal Recognition of the Physio Hub as an Education Initiative has been achieved as follows:
- International ‘Exercise is Medicine’ Campus Accreditation Silver Award (Exercise is Medicine, 2020)
- European Network of Academic Sports Services Competitive Award (2018) (Students helping Students category) for Active Campus Europe Project
- UCD Teaching and Learning Competitive Award -‘Outstanding Contribution to Student Learning’ (2018)
- UCD Sustaining Partnerships Realising Change Award (2017) - Crumlin Olympic Challenge Project
- Dun Laoghaire Rathdown County Council MEDALIST programme funding to support a partnership (UCD staff and students & DLR) approach to exercise programme development and delivery for older adults in an area of social disadvantage