EFFECTIVE TEACHING CONFERENCE PREPARING STUDENTS FOR CLINICAL PRACTICE - APPLYING LEARNING IN CONTEXT

Rosemary Isles and Robyn Cupit Department of Physiotherapy, School of Health and Rehabilitation Sciences
University of Queensland

Health Science graduates need to be more than competent clinicians. They are expected to be professionals, to be on-going learners who continually up-date their knowledge and to be accountable for the quality and effectiveness of their practice. (Curry, Wergin et al, 1993) They will need to be flexible and develop skills to be effective in the twenty-first century, a time of rapid and continuous technological and social change (Higgs and Edwards, 1999). More demand will be placed on them and they will need 'an awareness of politics, directions of health care and skills in health promotion and in coping with change'. ( Adamson A, Harris L, Heard R and Hunt A, 1996) The University of Queensland also recognises the need for generic graduate attributes that include attributes related to learning, communication and social interaction. ( University of Queensland, 1996)

Within the four year Bachelor of Physiotherapy program at the University of Queensland, students are introduced to clinical practice via independent fieldwork and clinical visits in years 1-3. It is during fourth year however, that they participate in their major assessable clinical practice experience. Over 6-8 clinical placements, they integrate their knowledge, skills and professional behaviour to become physiotherapists. Their integrated clinical reasoning competence and applied professional practice is assessed against the Competency Standards of Entry-level physiotherapists as defined by the Australian Physiotherapy Association. (ACOPRA,1994)

It is recognised that students have concerns about entering clinical practice and how they will cope with the changing learning environment.( Cupit,1988) In response to this awareness and feedback from the profession, a course has evolved to prepare students for various aspects of clinical practice - PT341, Professional Studies and Principles of Physiotherapy Clinical Management. The course is co-ordinated by the first author and delivered primarily by the authors. It includes three separate learning modules:

1. Health service delivery models
2. Management issues and their impact on physiotherapy services
3. Student learning in clinical practice

In planning this course, the authors wanted students to explore topics in groups at different times in the course and in different 'real-life' contexts. Boud (1993) suggests that learning occurs best in context as learning is socially and culturally constructed. Ladyshewsky and Edwards (1999) interpret this concept and state that "learning contexts which employ groups of learners and engage learners and teachers are imperative". Learning in groups learning usually involves collaborative peer learning which has been acknowledged as a valuable tool in facilitating optimal student learning in tutorials and in clinical practice (Anderson G., Boud D., Cohen R. and Sampson J., 1998). Best, Cust and Prosser (1999) also support independent learning methods and state that" 'deep' learning is enhanced when students are given some choice, variety and control in relation to the content and methods of learning".

1. Health service delivery models

The module on Health Service Delivery includes lectures and seminars and provides information on the Health System including hospital and community physiotherapy roles, health issues with different cultural groups including ATSI clients. Another aspect covers health promotion from a physiotherapist's perspective. Assessment of this module is by written paper and an assignment where groups of 3-4 produce either a verbal presentation, written magazine article or webpage form of patient education that targets a specified group. Students made independent choice of topics and target groups and this is reflected in such diversified topics as osteoporosis education for teenagers, healthy exercises for well elderly, prevention of injury in schoolgirl netballers or advice to parents of asthmatic children. Students generally work well in groups and the standard of projects is impressive as students gain a deeper understanding of the particular chosen health issue and its implications for the client.

2. Management issues and their impact on physiotherapy services

Higgs and Edwards (1995) mention the importance of understanding management issues, quality assurance and information technology in the development of the future 'beginning practitioner'. This module is the newest in the evolution of the course and reflects students' need to understand how organisational management issues and other factors such as use of information technology affect their clinical management of the client and their function within health service delivery. It also includes topics on the roles of other allied health professionals and complementary health workers, vital knowledge for physiotherapy students in developing teamwork skills. Students

The authors wanted students to develop an understanding of the concepts and issues from their own perspective and decided to allow students in groups to research the topics and prepare material and information to present to the year group. This type of 'discovery' learning allows students freedom and choice in the way they find information and present it and encourages them to explore several real-life organisational workplaces.

Topics for the fifteen groups included:

• Management issues in
  • large hospitals
  • rural practice
  • nursing homes
  • private practice
• Budgeting and tendering; funding models including 'casemix'
• Marketing
• Continuity of care and clinical pathways
• Case management and managed care
• Occupational Health and Safety
• Information Technology
• Role of
  • Occupational Therapist
  • Speech Pathologist
  • Social Worker
  • Complementary health workers including Chiropractor, Acupuncturist, Naturopath

Students were provided with contact details for several resource personnel who are 'experts' in the field. Students then interviewed resource personnel in their different work settings, explored the literature, government regulations and any other source they wished. They had most of the semester to expedite their research and prepare presentations to the whole year group. Presentations were in groups of three thirty-five minute topics (two hours total).

Assessment for the module was based on a group assessment of the verbal presentation and a written resource, which supported the presentation. Assessment criteria included the accuracy and usefulness of the content of both the verbal presentation and the written handout, and the effectiveness of the presentation including quality of AV, ability to hold attention and evidence of originality and creativity in the presentation. The majority of student groups produced high quality presentations using elements of PowerPoint, video and role-play effectively and often humorously. Content was generally highly relevant and accurate, and students who attended the presentations were usually very attentive to the speakers and appreciated their efforts and creativity.

3. Student learning in clinical practice

The third module is designed primarily to prepare students for their clinical supervision by clinical physiotherapists. It also allows them to develop the necessary skills to facilitate learning in each other as 'peer-assisted learning' and in other personnel for example physiotherapy aides and students after graduation. This ability to 'supervise' is a required competency of an entry-level physiotherapist.( ACOPRA, 1994) The course does not include clinical reasoning per se as this is covered in several other courses where assessment, reasoning and treatment planning skills are developed. The module consists of :

1. Concepts of student learning
2. Skills for facilitation of clinical learning
3. Assessment procedures
4. Generic clinical skills
5. Understanding of the workplace
6. Managing change

a) Concepts of student learning in clinical practice
Students are introduced to concepts of student learning including factors influencing learning in the clinical context, models of supervision, and learning styles. It is known that students adapt their approach to learning depending on their perception of what the learning situation demands and how learning is to be assessed. (Entwhistle and Ramsden, 1983; Best et al, 1999) Clinical reasoning requires students to integrate knowledge, use critical thinking to make appropriate decisions and to implement a treatment program that often involves technical physical handling skills. ( Higgs and Jones,1995) This process clearly involves 'deep' learning and students need to be reminded that their ongoing learning needs to show understanding and not be superficial. Having responsibility for decisions and the management of their own 'real' patients can assist students to integrate knowledge and skills more effectively and students often express that ' things come together when you see them on a real patient'.

Giving students detailed information on variable supervisory processes and the expectations there will be of their performance should also give them a better understanding of the type of learning required, and at the same time allay their concerns. The influence of learning style differences between students and supervisors is discussed.

Students also discuss and decide individually the characteristics, which they consider, are desirable in effective clinical educators. Their findings in 2000 were remarkably consistent with past students' results and with the literature. Students ranked the most important educator characteristics as being 'approachable', ' good communicator', 'respectful' and 'giving constructive feedback' ahead of 'being knowledgeable' and 'clinically competent'. Cross (1995) found similar opinions in second and third year physiotherapy students who ranked 'approachable', 'good communicator', 'knowledgeable' and 'interested in the learning process' as the top four desirable characteristics.

The students' list of desirable characteristics for clinical learners ranked 'being theoretically prepared/ having appropriate knowledge base', 'willing to learn', 'accepting constructive criticism' and 'knowing limitations' as the most important characteristics. All suggested 'top ten' characteristics were admirable traits and students were asked to reflect on these when they commenced clinical practice.

Students were introduced to the concept of a 'contract' between educator and student defining fair expectations that one might have of the other. They were also given strategies for discussion with educators if they believed that the contract had been broken.

b) Skills for facilitation of clinical learning
Students have theoretical and practical input regarding facilitation of learning including concepts of feedback, coaching, questioning and counseling for change in performance. Examples are given as to how learning may be facilitated by supervisors or by other students during reciprocal peer learning. In practical sessions, video vignettes of student/ supervisor situations are used as triggers for discussion of skills used in supervision to extend learning and students also demonstrate understanding of concepts through participation in role-plays of student / supervisor and student / patient / supervisor interactions.

It is also made known to students that within the course, they are receiving the same information as clinical educators receive at their clinical education workshops. If both parties understand the processes and influences on effective learning, student learning should be optimized.

c) Assessment procedures
As previously discussed, students learning is affected by the assessment methods used. (Entwhistle and Ramsden, 1983) it is therefore important for students to understand the process used in clinical practice to evaluate their competency. Students are informed of the detailed Clinical Behavioural Objectives for clinical practice and the specific criteria and standards for each placement, against which they will be assessed. The procedures for receiving formative and summative feedback are discussed. The actual assessment forms are introduced and their role in formative feedback explained in relation to development of strategies to assist learning. Students consider strategies for coping with specific 'problems' and also receive a written list of strategies. (Students receive a manual containing all rules regarding clinical practice, procedures, forms and strategies prior to commencement of placements in fourth year.)

At this point, students are presented with information on the structure of the whole program, the personnel involved linking the university with the placement, and details of how they can contact academic staff for advice or assistance. They are given information about placements and complete a detailed placement preference form for the following year.

d) Clinical skills
Most of these generic skills have been developed during other courses, independent fieldwork and clinical visits. Specific skills developed in this module include chart reading/interpretation, reading xrays and written recording requirements for patient medical and physiotherapy records. Students are given the opportunity to test some of these skills during clinical 'buddy' visits where they work with a clinician and usually, a fourth year student. Once again, they are learning in the 'real' clinical context in which they will complete extended placements in forth year. These visits allow them to observe both the supervisory relationship between the fourth year student and the educator and the clinical relationship with the clients. Workbook tasks also direct them to investigate various types of patient records, to observe the working environment and how student workload measurement is recorded. Subsequent reflection is encouraged by stimulus questions as students are reminded of the importance of reflection in developing as professionals. ( Schon,1987)

e) Understanding of the workplace requirements
Much of this information doubles from the previous management module and students need to understand the impact that organisation and management issues have on them as students , especially in Queensland Health placements. A visit to a major hospital allows students to hear the Director of Physiotherapy outline how students fit into the physiotherapy service at the hospital. Hierarchical issues, Occupational Health and Safety rules and workload measurement procedures for the hospital are expectations of student behaviour are outlined. A practical Fire Safety discussion and demonstration from a hospital safety officer follows this session. Once again, it is hoped that an 'on site' visit and input from specific hospital staff will add more meaning and relevance for the students.

f) Managing Change
In the last week of semester, students have a final opportunity to state any concerns about their entry into clinical practice and the changes in their learning. Their concerns are clarified during an interactive workshop. These concerns about change were discussed in the literature by Robyn Cupit as causes of stress in students entering clinical practice (Cupit,1988). Again, concerns have remained remarkably consistent and include fear that students don't know enough and could harm patients through to concerns about reduced time for outside work and social activities as the realisation of a relatively full-time clinical workload hits. Students also still express concern about possible communication problems or negative interactions with clinical educators, although these are usually based on the experiences of a few 'dissatisfied' students from previous years. A full and frank discussion of issues occurs in the hope of allaying any remaining concerns and students are also offered the option of discussion of issues with lecturers on an ongoing basis.

Conclusion

This course has attempted, through students' involvement and experiential learning within varied contexts, to prepare students for clinical practice. Students have sought and gained knowledge and skills through a range of group and individual activities. They have enjoyed most of these group activities. Their independent learning has been extended by the right combination of information and support.

In order to evaluate the success of the course, assessment grades can be examined. These show success in demonstrating some aspects of knowledge, a variety of communication and presentation skills and ability to work within small groups. Because the final module on student learning was not formally assessed and was provided to assist students to facilitate and optimize their learning in the future, there is no certainty that learning has been taken from that part of the program. It is to be hoped that the innovative methods and relevance to their goals have resulted in gains in understanding , but it could be cynically suggested that, because assessment drives learning (Entwhistle and Ramsden, 1983), some students will not have learnt effectively from the course. Indeed, there were times when attendances at some practical sessions and presentations were down so that some students have not received that important information content.

Students can be asked to evaluate the course, but it will only be after fourth year and beyond that an evaluation of whether the course has truly succeeded in it's objectives can occur. Feedback will be sought from clinical educators to evaluate students' preparation for and ability to maximize learning in clinical practice compared with students in past years. Directors of Physiotherapy will assess the competence of first year graduates whom they employ, across clinical and organisational areas.

Only then will it be clear whether students have integrated their clinical and organisational knowledge, skills and behaviour and developed the desirable professional and generic attributes of a graduate physiotherapist to cope with continual change in the twenty-first century.

References

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