“This patient is not appropriate”: Perspectives of physiotherapy students and clinical educators on exposing students to patients with complex needs during clinical practice placements

ABSTRACT

Background

Clinical practice placements play an important role in preparing students for challenging areas of clinical practice. Little is known about student learning needs for working with patients with complex needs during clinical practice placements, and clinical educator decision-making that underpins this exposure.

Purpose

To explore the perspectives of physiotherapy students and clinical educators on exposing students to working with and learning from patients with complex needs during clinical practice placements across Queensland and New South Wales, Australia.

Methods

Six semi-structured focus groups with pre-registration physiotherapy students undertaking clinical practice placements (n = 19) and semi-structured one-on-one interviews with clinical educators (n = 20). Data were analyzed using reflexive thematic analysis.

Results

Four overarching themes were generated following analysis: 1) Complexity is challenging; 2) Tension between student exposure and patient care; 3) Variance in expectations; and 4) Readiness for complexity.

Conclusion

Physiotherapy students and clinical educators recognize the challenges and importance of exposure to patients with complex needs. Student learning experiences are influenced by clinical educator decision-making, which is often unclear, leading to varying opportunities. This study highlights the need for enhanced support from clinical educators to prepare students for working with patients with complex needs.

KEYWORDS:

• Clinical placement
• clinical education, patient complexity
• physiotherapy student
• decision-making

Introduction

Advances in healthcare have led to an aging population and an increase in the prevalence of chronic disease, multimorbidity, and complex patient comorbidity (Monrouxe et al., 2017; Nicolaus, Crelier, Donze, and Aubert, 2022; Safford, 2015). The term “complex patient” is widely used within the literature and in health care settings. However, clarifying a definition is difficult due to variations in perceptions of what exactly makes a patient complex (Manning and Gagnon, 2017) and thus the term remains poorly understood (de Zwart et al., 2023). Nicolaus, Crelier, Donze, and Aubert (2022)further imply that variation in understanding of patient complexity is partly clinician dependent. In their narrative literature review, the authors highlight an interplay between medical and non-medical issues resulting in a diverse array of characteristics that include the presence of chronic conditions, the burden of disease, cultural background and belief systems, geographical location, health literacy and mental health and coping strategies. The authors therefore propose a holistic approach when conceptualizing complexity, encompassing medical, biopsychosocial, socioeconomic, cultural, behavioral, and environmental factors.

Physiotherapy is the fourth largest health profession in Australia (Wiggins, Downie, Engel, and Brown, 2022) and is considered a core discipline within multi-disciplinary healthcare teams. As first contact practitioners, physiotherapists independently assess, diagnose, and manage a wide variety of patients (Australian Physiotherapy Association, 2023) including those with complex needs. It has been asserted that aligning the clinical expectations of physiotherapy students and new graduates is essential to ensure graduates are well prepared and capable of autonomous clinical practice upon completion of their training (American Council of Academic Physical Therapy Clinical, 2020; Sherman, Berg, and Talley, 2021). Despite these acknowledgments, growing evidence suggests that new graduate physiotherapists feel inadequately prepared for and overwhelmed by independent clinical practice upon workforce entry (Atkinson and McElroy, 2016; Martin, Mandrusiak, Lu, and Forbes, 2020; Merga, 2016; Stoikov et al., 2022). This included being ill-prepared to manage the increased complexity and volume of patients that is expected of them compared to their experience as a student (Chesterton, Chesterton, and Alexanders, 2023; Kennedy et al., 2022; Stoikov et al., 2022). These challenges are not exclusive to physiotherapy where new graduates in nursing (Hofler and Thomas, 2016) and occupational therapy (Moir, Turpin, and Copley, 2021) have reported similar concerns.

A lack of exposure to real life clinical experiences and expected workloads has been suggested as making the transition from student to autonomous clinician more challenging (Phan et al., 2023; Stoikov et al., 2022). It has been reported by physiotherapy new graduates that their clinical learning experiences as students were directly impacted by clinical educator decision-making (Patton, Higgs, and Smith, 2018). Further, Sherman, Berg, and Talley (2021) identified that differing caseload expectations amongst clinical educators may compound inequality in learning experiences. Consequently, new graduates express a sense of being sheltered by protective clinical educators (Stoikov et al., 2022). Similar concerns have also been voiced in other health professions, with occupational therapy new graduates reporting that they feel sheltered from opportunities to work with patients with complex needs during placements (McCrombie and McElroy, 2016). Lewthwaite, Gray, and Skinner (2023) reported physiotherapy students value direct patient contact and were worried about the negative impacts on their learning due to restricted exposure to an adequately diverse and complex caseload. Similarly, medical students (Fong, Tan, Czupryn, and Oswald, 2019) and nursing students (Suikkala, Koskinen, Katajisto, and Leino-Kilpi, 2021) report that direct exposure to patients is valuable for their learning. These findings suggest that restricting exposure to patient load and complexity may reduce beneficial learning opportunities impacting preparation for professional practice.

Recent research (de Zwart et al., 2023) reports that physiotherapists view direct experiences with patients whom they consider to be complex as crucial for improving clinical problem solving, suggesting that this leads to enhanced professional competence thereby reducing the challenges associated with managing patients with complex needs. Furthermore, managing patients with complex needs supports learning by enabling physiotherapists to reflect on their decisions and performance, thus enhancing their clinical skills (de Zwart et al., 2023). These findings support earlier research that promotes clinical learning as a key strategy to manage complexity (Stander, Grimmer, and Brink, 2019; Willis, Campbell, Sayers, and Gibson, 2018).

Clinical practice placement experiences form a fundamental component of physiotherapy pre-registration training (Hills et al., 2019; Milanese, Gordon, and Pellatt, 2013; Patton, Higgs, and Smith, 2018). In Australia, students enrolled in entry-level physiotherapy training programs are required to complete five-week clinical practice placements that include community, acute, and rehabilitation settings and allow students to work with patients across the lifespan (Australian Physiotherapy Council, 2023). Clinical educators, who support learning on placement, are responsible for framing student learning experiences (Clouder and Adefila, 2017) by being adaptive and responsive to the complexity that students will encounter in clinical practice as new graduates (Berger et al., 2019). However, the factors clinical educators consider when deciding to expose students to complex patients has received little attention. Furthermore, no studies to our knowledge have endeavored to understand the experience of physiotherapy students working with patients who have complex needs and the opportunities the students perceive to be valuable to support their learning during clinical practice placements. Understanding the views of both clinical educators and students may enhance clinical practice placement experiences by better understanding how students can be supported to experience working with patients with complex needs leading to enhanced learning. Thus, the aims of this study were to explore physiotherapy student and clinical educator perspectives on exposing students to working with, and learning from, patients with complex needs during clinical practice placements.

Methods

Design

A qualitative research design that used reflexive thematic analysis (Braun and Clarke, 2019) was employed for this study. All interviews and focus groups were conducted via video conferencing platforms and both audio and video were recorded for future analysis. Semi-structured interview (Table 1) and focus group (Table 2) guides were developed collaboratively by the research team consisting of physiotherapy academics, researchers, and clinicians, designed to facilitate an in-depth exploration of the study aims. The semi-structured guides formed a narrative framework designed to facilitate discussions permitting participants to speak freely about lived experiences and personal perspectives, thus enabling the research team to gain a thorough understanding of the drivers that influence actions and behaviors (Tuckerman, Kaufman, and Danchin, 2020). Prior to implementation, guides were piloted with one clinical educator and one student, who were then not involved in the study, to ensure adequate depth and timing of questions and minor changes were made to the final framework structure. Ethical approval for this study was provided by The University of Queensland Institutional Human Research Ethics, approval number 2,023,000,693.

Table 1. Example semi-structured interview guide for clinical educators.

Interview framework
1. Do you believe that it is important that students should have the opportunity to work with patients with complex needs while on placement?
2. What factors do you consider when deciding to assign or withhold a patient with complex needs from students?
3. Can you provide examples of the strategies that you use to introduce patients with complex needs into clinical placements?
4. In what ways do you think students should be best exposed to working with patients with complex needs on placement?
5. Thinking about a time a student responded well to working with a patient with complex needs, what factors do you think influenced this?
6. Thinking about a time a student struggled working with a patient with complex needs, what factors do you think influenced this?
7. What preparation do you feel students need prior to placement to help them when it comes to working with patients with complex needs?

Table 2. Example focus group questions for students.

Interview framework
1. Have you had the opportunity to work with complex patients during your clinical placements?
2. Can you describe your experiences working with complex patients.
3. Do you believe that it is important that you should have the opportunity to work with complex patients while on placement? Why do you think this?
4. What strategies do you think clinical educators could use to introduce patients with complex needs during your clinical placements?
5. Did you feel prepared to assess, treat, and manage a complex patient on placement?
6. Do you feel your university training prepared you for working with complex patients?
7. What areas of training or other opportunities would have made you feel better prepared to work with patients with complex needs prior to commencing your clinical placements?

Participants

Physiotherapy clinical educators and final year pre-registration physiotherapy students were recruited for this study from across Queensland and New South Wales in Australia. Clinical educators were recruited via a snowballing strategy with some purposive elements to seek clinical educators across different areas of clinical practice. Inclusion criteria required clinical educators to have provided clinical education, in a supervisory capacity, in the twelve months preceding the study to capture current practice. Two members of the research team (EM, RF) approached six professional contacts via e-mail with an invitation to participate in the study.To ensure that the sample of clinical educators represented all specialty areas where students undertake clinical practice placements, additional recruitment was conducted through advertising on social media platforms. The lead researcher (EM) sought expressions of interest to participate in the study through the Australian Physiotherapy Association social media network member groups. Once interest was expressed via e-mail to the lead researcher potential participants were provided with a participant information sheet and asked to provide written consent. Once consent had been received a second e-mail was sent to arrange a mutually agreed time for an online one-to-one interview. Following participation in the study recruited participants were asked to approach colleagues who met the inclusion criteria.

A convenience sample of pre-registration final year physiotherapy students undertaking clinical placements within student-led clinics at The University of Queensland were recruited for the study. Gatekeeper approval from the School of Health and Rehabilitation Sciences clinic research steering committee was granted to conduct the study. Inclusion criteria required students to have completed at least two five-week full-time block clinical placements to ensure participants had relevant clinical experiences to reflect upon. All students received an invitation letter during their orientation day of their clinical placement explicitly detailing that participation was voluntary and would not influence final assessment grading. Potential participants expressing interest in participating in the study were asked to provide an e-mail address to be contacted by the lead researcher who then issued a participant information sheet and a request to provide written consent. All eligible students who provided consent were recruited to the study. Once consent had been received a final e-mail was sent by the lead researcher to arrange a mutually agreed time for an online focus group.

Data collection

Two members of the research team (EM, RF) were involved in data collection. Demographic information was requested from all participants prior to participation in the study. Focus groups were conducted with students capitalizing on attendance at a shared placement site to streamline participant coordination and scheduling. Interviews were carried out with clinical educators due to pragmatic scheduling considerations, allowing for flexible arrangements that accommodated individual participants. Data collection occurred between May and September 2023, at which point no new insights or themes were generated from the data signaling that theoretical sufficiency was reached. The research team concluded that the diverse range of participants had contributed sufficiently rich and in-depth perspectives to address the aims of the study.

Clinical educator one-on-one interviews (n = 20) and six student focus groups (n = 19) were conducted via video conferencing platforms Zoom and Microsoft Teams, depending on participant preference. Clinical educator interviews were conducted by the lead researcher (EM), who was known to some of the participants through professional interactions while working clinically as a physiotherapist. The clinical educator interviews ranged from 21 to 52 minutes (mean = 37). Student focus groups were conducted by two members of the research team (EM, RF) who were known to all participants due to their roles within the University, physiotherapy clinical educator and senior physiotherapy lecturer respectively, however, neither were involved in the student’s clinical education while on placement in the clinics. The focus groups ranged from 25–44 minutes (mean = 34).

At the start of all interviews and focus groups participants were provided with a working definition of a complex patient, being: “The literature has identified several components of patient complexity, including multi-morbidity and disease chronicity; psychological and emotional wellbeing; environmental and social factors, all of which appear to accumulate over time interacting with each other” (Nicolaus, Crelier, Donze, and Aubert, 2022; Safford, 2015). This was provided to ensure a common understanding amongst all participants and guide subsequent discussion.

Data analysis

Reflexive thematical analysis (Braun and Clarke, 2019) was undertaken to analyze data. Reflexivity is by definition “the researcher’s reflexive and thoughtful engagement with their data and their reflexive and thoughtful engagement with the analytic process” (Braun and Clarke, 2019). To achieve this, a key phased approach to thematic analysis developed by Braun and Clarke (2006) in their seminal work was utilized. This consisted of familiarization with the data, coding, generating, refining and defining themes. Data familiarization involved the lead researcher watching saved audiovisual recordings, making notes on non-verbal communication used by participants (e.g. pauses, silences, gestures and facial expressions), transcribing interviews and focus groups verbatim, and subsequent reading and re-reading of transcripts assessed against the audiovisual recordings to facilitate a deep immersion in the entire dataset. Through this process, the researcher engaged in reflexive practices to critically assess their positionality within the study and their interactions with participants, ensuring their own perspectives were acknowledged and accounted for in data analysis (Braun and Clarke, 2019) and that adequate depth of questioning was maintained (Smith and Sparkes, 2016).

Preliminary coding was undertaken to analyze the first five clinical educator interview transcripts. Clinical educators possess valuable insights into the dynamics and challenges of clinical practice, analyzing their perspectives first provided a foundational understanding of the clinical environment which helped contextualize and interpret student data more effectively. The lead researcher identified and collated sentences and sections of text with similar implied meaning or reflecting similar ideas into an initial coding framework relevant to the aims of the study. Codes were then examined and organized together into sub-themes that captured notable patterns (Braun, Clarke, and Weate, 2016). These foundational codes and sub-themes were reviewed by the research team and consensus achieved. These codes and sub-themes were then used as a framework for the analysis of subsequent clinical educator interview and student focus group data, with new codes added if additional sub-themes emerged. Finally, sub-themes were further organized into broader overarching themes, each with its own focus. These themes underwent multiple reviews and scrutiny by the research team to ensure that when combined they reflected the data and addressed the overall aims of the study.

During analysis, several steps were taken to maximize rigor and reflexivity. To uphold credibility, two researchers (EM, RF) independently completed the processes of analysis of codes, sub-themes, and themes. These processes were then reviewed by all members of the research team and regular review meetings were held throughout data collection, analysis, and result writing. To improve transferability of results, clinical educators across a range of clinical specialties and students who had attended more than one clinical practice placement were selected to represent a range of perspectives. Reflexivity requires researchers to consider their role in knowledge construction (Olmos-Vega, Stalmeijer, Varpio, and Kahlke, 2023) and how data interpretation may be influenced by viewpoints or perspectives (Mays and Pope, 2000) to ensure accountability, transparency, and trustworthiness of research findings. The researchers integrated reflexivity into data collection and analysis by iteratively questioning data interpretations, assessing the impact of their decisions on outcomes and maintaining critical awareness of personal biases and perspectives ensuring these were taken into account. The lead researcher (EM) conducting data collection and analysis is a physiotherapy clinical educator with over 15 years clinical practice experience and has significant experience in supervising students. This may have contributed to a deeper understanding of the impact and challenges of introducing complex patients during clinical practice placements. The second researcher (RF) who conducted all steps of data analysis independently is a physiotherapy educator, physiotherapist, and experienced qualitative researcher.

Results

Twenty-four clinical educators and twenty-two students indicated interest in the study following an invitation to participate. Of these, twenty clinical educators met the inclusion and criteria and provided consent, four were excluded as they had not provided clinical education, in a supervisory capacity, in the twelve months preceding the study. All twenty-two students provided consent however, only nineteen participated in the focus groups with no explanation provided for their nonattendance at the scheduled meeting time.

Demographic information was requested from all participating clinical educators (Table 3) via an online survey, seventeen responded (response rate 85%). On average, clinical educators had 15 years (range: 6–26) years of clinical practice experience and 8 years (range: 2–20) years of clinical education experience. 76.5% identified their primary role as clinician. During student clinical education, 82% retained their typical caseloads, with approximately half maintaining consistent workloads throughout the 5-week clinical practice placement. Further demographic data is outlined in Table 3. Student participants provided demographic information verbally prior to each focus group. On average, students had completed 2.7 placements (range: 2–5) across various specialty areas as detailed in Table 4.

Table 3. De-identified clinical educator demographic information.

Participant	Age	# years practicing	# years as a CE	# students per year	Clinical speciality
1	37	14	5	15	Neurological
2	48	26	20	1	Paediatrics
3	41	19	15	2	Community
4	34	12	9	4	Neurological
5	52	26	10	2	Community
6	30	8	7	6	Cardiorespiratory
7	NA	NA	NA	NA	Rehabilitation
8	35	9	7	30	Musculoskeletal
9	31	8	3	5	Musculoskeletal
10	NA	NA	NA	NA	Paediatrics
11	55	25	9	5	Cardiorespiratory
12	38	14	11	6	Orthopaedics
13	30	8	3	6	Private Practice
14	NA	NA	NA	NA	Rehabilitation
15	30	6	3	1	Rural Paediatrics
16	31	8	7	20	Acute Wards
17	41	17	15	6	Neurological
18	30	9	5	3	Rural Paediatrics
19	32	10	2	4	Private Disability
20	58	NA	3	36	Private Practice

*NA – not available.

Table 4. De-identified student demographic information.

Participant	Age	# full-time 5-week placements	Placement specialty
1	21–25	3	Orthopaedics, Private Practice, Neurological
2	21–25	3	Orthopaedics, Neurological, Private Practice
3	21–25	3	Private Practice, Cardiorespiratory, Neurological
4	21–25	3	Cardiorespiratory, Musculoskeletal, Neurological
5	21–25	3	Community Paediatrics, Neurological, Private Practice
6	21–25	3	Cardiorespiratory, Musculoskeletal, Neurological
7	21–25	3	Private Practice, Cardiorespiratory, Neurological
8	21–25	2	Private Practice, Neurological
9	21–25	5	Private Practice x2, Musculoskeletal, Cardiorespiratory, Neurological
10	21–25	2	Musculoskeletal, Neurological
11	21–25	2	Private Practice, Neurological
12	41–45	3	Neurological, Community, Private Practice
13	21–25	2	Cardiorespiratory, Private Practice
14	26–30	3	Neurological, Cardiorespiratory, Private Practice
15	21–25	3	Cardiorespiratory, Neurological, Private Practice
16	26–30	3	Cardiorespiratory x2, Private Practice
17	21–25	4	Neurological, Cardiorespiratory, Disability, Private Practice
18	26–30	3	Residential aged care, Neurological, Private Practice
19	21–25	4	Orthopaedics, Cardiorespiratory, Neurological, Private Practice

Four overarching themes were generated following data analysis: 1) Complexity ischallenging; 2) Tension between student exposure and patient care; 3) Variance in expectations; and 4) Readiness for complexity.

Theme 1: complexity ischallenging

Students and clinical educators recognized that there are many factors contributing to patient complexity including pathophysiology and comorbidity; social situation; psychological, behavioral, and emotional well-being; discharge planning; and multi-disciplinary team involvement. Both participant groups suggested that it is often a combination of these different facets that contribute to complexity. There was consensus amongst participants that working with patients with complex needs can be overwhelming and challenging for students due to the additional layers for students to consider and manage beyond physiotherapy-specific knowledge and skills gained in their university training:

Complexity I think can come both from the medical history and day-to-day management … that adds a whole other element to a student’s workload that they might not have thought about beforehand. (Clinical educator P1)

It’s quite overwhelming if you’re not used to that background cause it’s a lot of extra to learn that’s not really necessarily physiotherapy as such, but you still need to consider it as a physiotherapist. (Student P12)

There was a strong agreement between both participant groups that exposure to patients with complex needs is crucial to prepare for the realities of new graduate working life. There was acknowledgment amongst participants that students need to be guided and supported when working with patients with complex needs, with some clinical educators suggesting they will not have this support network as new graduates. Clinical educators acknowledge that they have a responsibility to develop a student’s ability to clinically reason, reflect upon decisions made, and understand the meaning behind them to best prepare them for managing complexity in less supported environments as new graduates:

You have to deal with it (patients with complex needs) when you’re out and sometimes in a in a less supervised environment, I think it’s agreat way for them to be introduced to a level of complexity where they do have supervision and support and the ability to reflect and debrief about situations afterwards. (Clinical educator P12)

If we don’t get the opportunities to practice, and we can get feedback and it’s in a safe environment where someone can step in if something goes wrong, then we’re definitely not going to be able to do it by ourselves. (Student P1)

Theme 2: tension between student exposure and patient care

There was agreement amongst clinical educators that their role is two-fold. Not only do they have a responsibility to provide adequate training and support to students they also have a duty of care for their patients. There was a strong belief that duty of care was their paramount priority during clinical practice placements and thus meeting patient care needs is given higher priority than the learning needs of students. Consequently, student learning opportunities were overshadowed:

I think I feel a duty to the client even more than the students. (Clinical educator P16)

The patient has to come first and the student has to come second. So even if there is good learnings to be had from a student working with a particular patient, if it’s not in the patient’s best interest the student does not get the opportunity. (Clinical educator P17)

Clinical educators reported that they screen patients to “try and get patients probably that are more suitable, for want of a better word, for the student.” (Clinical educator P1) resulting in some students not being provided with opportunities to engage in clinical practice with patients with complex needs. Clinical educators perceive a vital component of clinical practice placements is the development of physiotherapy-specific technical skills, including practical assessment and interventions, and as such will endeavor to select patients that allow students to advance in these areas. Further to this, clinical educators reported screening and selecting patients that they perceived would create opportunities for students to succeed. There was a shared perception among clinical educators that this scaffolds and builds students’ confidence gradually over the duration of the practical placements and allows them to directly experience the impact of their own success:

I think pitching the complexity to what you know the student can manage so that it’s successful. It’s helpful to build their confidence and not giving too high a caseload and too much complexity if you know the student isn’t going to manage that because it’s not going to help them to progress. (Clinical educator P3)

Student participants reported that clinical educators did not routinely provide them with any context regarding their decision-making when selecting patients for the student’s caseload. Students overwhelmingly acknowledged the importance of interactions with patients with complex needs during clinical practice placements and believed that having an understanding of why particular patients were not appropriate for their caseload would be helpful for their learning. Students believed that this would allow them an opportunity to reflect on their current knowledge and skills and address specific learning needs to ensure they are adequately prepared to provide proficient clinical care as a new graduate:

I do think that it would be better policy to talk to us about why they are they changing our patients. My CE did do this fairly regularly and it was really useful because she gave us an understanding of what skills were needed to do a patient correctly. (Student P18)

The time point during the five-week clinical practice placement when clinical educators begin to introduce patients with complex needs onto a student’s caseload varied. However, there was general agreement amongst both participant groups that it typically occurs somewhere around mid-way during the placement as this allows clinical educators time in the first half of the placement to monitor and assess a student’s ability to manage “straight forward” patients first (Clinical educators P4, 8, 9, 12, 14):

If the student is demonstrating that they’re heading towards that way of being able to take on something more than just a routine patient, I try and start to plant those seeds towards mid unit so that we can see how they’re going and then we’ve got something to talk about and progress through that second half of the placement. (Clinical educator P6)

It was getting to the last few weeks and I think she just thought some more complex patients would give me a good opportunity to get through that clinical reasoning of why we would be choosing what we would do, just that experience if I ever had to encounter that in the future. (Student P16)

Clinical educators believed that observation is a fundamental way of introducing students to patients with complex needs. Observing clinical educators interact with patients with complex needs provides students with an opportunity to witness “best practice” (Clinical educator P2). Clinical educators suggested that not only is this important for physiotherapy-specific skill acquisition but through vicarious reinforcement students develop skills and strategies to better prepare them for managing challenging situations and behaviors. Clinical educators also identified that an important aspect of observation was the ability to de-brief with students following complex patient interactions. They placed great significance on the importance of these supportive conversations as a learning tool to discuss and reflect on their clinical reasoning and provide context for their decision-making:

They might watch me see a patient that has a complex set of circumstances and so there is a level of watch it be done once, we can debrief about it, we can then pick out similar things in future patients that they may then manage themselves. (Clinical educator P12)

Although clinical educators recognized the importance of providing opportunities for students to work with patients with complex needs, they frequently indicated that students will not be given the chance to lead or make any independent decisions regarding their physiotherapy management. Clinical educators indicated that they often retain governance over the direction of patient care and will delegate specific components of assessment and management to students. They attributed this to a number of reasons including students not yet having an adequate knowledge or skills; ensuring patient safety by minimizing the risk of harm; upholding a high level of quality care, and finally, which they like to remain in control and have ownership of a student’s caseload, which they ultimately view as their own:

So, it’s not like you see them or you don’t. Maybe you can assess this client and come up with some goals or some ideas for treatment, but then maybe I will do the treatment … rather than just letting them loose, so they’re building the skills but clients still getting a good treatment. (Clinical educator P3)

I think as physio’s we are just very protective of the patients and want them to have the best outcomes and maybe we are too protective … and we don’t wanna give whatever patients we have over to be able to challenge the students. (Clinical educator P14)

Clinical educators highlighted several external factors that they perceived created challenges in being able to effectively expose students to patients with complex needs. They suggest that “complex patients need more from the clinical educator” (Clinical educator P11) reporting that in practice placement models with a higher ratio of students this is often difficult to oversee. This creates conflict in a clinical educator’s ability to provide adequate supervision resulting in students being provided less opportunity to work with patients with complex needs. Workplace culture and policy creates challenges for clinical educators, they suggest that these impact their ability to provide students with opportunities to work with patients with complex needs creating limitations in “what experience I can offer” (Clinical educator P19):

Ultimately, I’m responsible for the patient. So yeah, if I’m finding that the patients are complex, they might have less complex patients under the four model than they would if there was only two students. (Clinical educator P11)

We’ve had scenarios where my boss has pretty much outright said we’ve gotta try and focus on the business so we can’t necessarily push getting patients to see the student because we have a bit of a policy that if they’ve seen the student then their obviously not gonna pay what they pay to see a physio. (Clinical educator P13)

Theme 3: variance in expectations

There was wide recognition among clinical educators that there are a number of student specific influencing factors that determine if patients with complex needs are assigned or withheld from students. An overwhelming factor was communication. Clinical educators explained that if students have “confidence” (Clinical educator P7) and “conviction” (Clinical educator P12) in their communication this increases their trust that the student will be able to gain the desired and correct information from patients. Clinical reasoning skill was an important factor forclinical educators, they reported that they need to feel confident a student will be able to prioritize assessments and interventions appropriately, recognizing problems and actively seek support in situations outside the limitations of their scope of practice. Students who were siloed in their approach failing to demonstrate flexibility and adaptability created feelings of doubt and uncertainty within clinical educators. They perceived that this may cause harm to patients with complex needs as the student may not be able to interpret information and consider additional compounding factors outside of initial diagnosis. As a consequence, they were given less opportunity to work with patients with complex needs:

I know all the things their thinking about and what they’re considering. They’re not just working from a list of dot points you can see that they’re considering all of those factors and so they’re almost ready to think about those extra things. (Clinical educator P12)

They have to have that insight into their own limitations and when they need to ask for help so that gives you the confidence that they will recognise and come to you with more complex patients. (Clinical educator P4)

Clinical educators reported the stage of students in their clinical placement year often influences their decision to assign or withhold patients with complex needs. This suggests that students who are nearing the end of their practice placements are afforded greater opportunity than those at the beginning. They believed that students who were in the early part of the clinical practice year and undertaking their initial placements required more time to become orientated and accustomed to clinical and team environments. As such clinical educators reported often sheltering students from patients with complex needs. There was no recognition from clinical educators that this may be students only opportunity to work with patients with complex needs in a particular area of clinical practice prior to working as new graduate. In contrast, they suggested students on their final practice placements would be provided with opportunities for realistic practice and are often exposed to a similar level of complexity that will be encountered as a new graduate. Clinical educators indicated this was due to the students having gained more experience and clinical skills enabling them to “hit the ground running a bit quicker.” (Clinical educator P4):

A student that’s towards the end of their university studies it’s their last placement or their second last placement they’ve got a lot more skills and yes, you can certainly look at giving them a few more patients or a few more complex patients. (Clinical educator P17)

If they’re sort of on those last few placements, they’re looking at hospitals,they’re interviewing for new graduate roles I definitely try and get them as realistic of an expectation as to what they would face as a new graduate. (Clinical educator P6)

Students suggested that scaffolding increased responsibility and independence to manage patients with complex needs would be beneficial for clinical development. However, students highlighted that variability existed among clinical educators and the approach they adopted “I think it depended on the educator for me and I think it also depended how they viewed it.” (Student P12). As such they believed that they were not provided with ample opportunity to manage patients with complex needs independently. Consequently, this gave rise to feelings of concern and anxiety about being ill-prepared for the increased level of responsibility they will have as new graduates:

I think it’s a little bit worrying, we did 5 weeks and after interviews, subjective into the objective, treatment we would still come out at the end of each one and we never really got the chance to integrate them all together … I don’t feel like we ever got the opportunity to see a patient just really all the way through. (Student P5)

I’ve finished my placements now and that as much experience as I’ll get and I’m still not very confident handling it just cause the clinical educators, fair enough, they step in all the time. (Student P9)

Theme 4: readiness for complexity

Students and clinical educators acknowledged that clinical practice placement experiences are critical to prepare students for the transition to becoming a new graduate, and are thus integral to support working with patients with complex needs. Having support structures in place was perceived to be fundamental to achieving this. Clinical educators suggested supported graduated exposure to patients with complex needs is often adopted to “build into complexity” (Clinical educator P12). However, students indicated that they had become reliant on these support structures, particularly the supervision and leadership provided from their clinical educators, when working with patient with complex needs. This created additional fears and anxiety about their ability to practice as an autonomous new graduate physiotherapist. Some students indicated that the new graduate support structures provided by prospective employers will influence their decision to pursue new graduate roles with that employer. The need for constant supervision and feedback highlighted a lack of readiness for working with patients with complex needs in final year pre-registration physiotherapy students. Clinical educators also acknowledged a shift toward providing increased new graduate support in the workplace, indicating a lack of exposure to real-life clinical practice as a main contributing factor:

I think that going forward it’s probably taught all of us the importance of having mentors as we go out as new graduates and selecting jobs based on the mentoring that we will receive and I think that’s something we’ve all been discussing together as a group on this placement is how much we do want that support. (Student P14)

I have noticed that our new grad support and that whole new grad structure of supported learning is so much more than it was … there’s so much more hand holding now and maybe that’s a result of too. (Clinical educator P11)

Both participant groups strongly perceived pre-clinical training as vital to ensure students are adequately prepared for complexity. Both believed that university education providers have a responsibility to facilitate the transition from classroom learning to clinical practice by equipping students with sufficient foundational knowledge and skills to assess and manage patients with complex needs. However, students reported that they did not feel adequately prepared for complexity from their pre-placement education:

I was prepared for the simple patients but I don’t think I was prepared for the complex patients. (Student P1)

I guess if I had to give a word straight away I would say no because we didn’t do loads of complex cases. (Student P2)

Several pre-clinical strategies were suggested by both participant groups to improve a student’s readiness to work with patients with complex needs. These included clinically focused teaching, in the University context, that integrates theory rather than individual courses being separate entities “beautifully pigeonholed” (Student P12); learning in context through complex case scenarios allowing students to “put everything together” (Clinical educator P7); an increased volume of standardized patients that are incorporated throughout their university studies allowing students to consolidate theory in practice at the time of teaching; and more pre-placement observation opportunities that allow students to “get an impression of what it’s like in real life to better prepare for the placement.” (Student P7):

I feel like it wasn’t put into very much context or clinical scenarios as such … I was kind of like oh where do I even start cause most people getting a total knee have other issues too, when they don’t get up day one it’s like I haven’t fit the schedule so now what do I do. (Student P2)

It just seems like you learn your written, you learn your practical but don’t bring it together. (StudentP6)

It’s such a ginormous area that it would have been nice to have that maybe integrated more throughout the whole degree and I think that would have given me more confidence and instead of just having a week of standard patient maybe then they could have started introducing more complex patients. (Student P12)

Discussion

This study has explored the perspectives of physiotherapy students and clinical educators regarding students’ exposure to working with, and learning from, patients with complex needs during clinical practice placements. This is the first study to investigate these topics from the perspectives of both students and clinical educators, thus providing valuable insight into the factors that underpin clinical educators’ decision-making and the perceived impacts on student experiences during clinical practice placements.

The results of this study illustrate that both students and clinical educators align with the view that exposure to patients with complex needs is a vital component of clinical practice placements. This supports existing research not only in physiotherapy (Barradell, 2017; Phan et al., 2023) but across health professional education more broadly (Armstrong et al., 2023; Pullen and Ahchay, 2022). Students identified that opportunities to work with patients with complex needs during clinical practice placements is valuable to enhance their knowledge, skills and confidence thus, improving their readiness for new graduate practice. While no studies have focused on this topic from a student perspective, these findings align with the experiences of new graduate physiotherapists, who have reported feeling unprepared when faced with patients with complex needs during clinical practice, attributing this to limited real-life experiences during placements (Stoikov et al., 2022).

There was a strong acknowledgment amongst both participant groups that working with patients with complex needs is challenging and, at times, overwhelming for students. Students reported having to consider additional factors beyond physiotherapy knowledge and skills, often resulting in experiences of distress. These findings contribute to existing research that suggests physiotherapy new graduates experience overwhelm when faced with the expectations of managing patients with complex needs in clinical practice (Evans et al., 2022; Forbes and Ingram, 2021; Wells et al., 2021) corroborating that this is a common emotional response for novice clinicians. Both students and clinical educators, unanimously agreed upon the pivotal role of support when working with patients with complex needs, recognizing its importance in facilitating learning in preparation for independent clinical practice. Students highlighted the necessity of clinical decision-making discussions before encountering patients with complex needs, emphasizing the value of preparatory time to foster dynamic clinical discussions that allow them to be supported and guided in clinical decision-making based on their own clinical reasoning rather than directed by clinical educator’s decisions. This approach supports previous research in occupational therapy (Turpin et al., 2021), which found that new graduate’s benefit from formal support that guides clinical decision-making and promotes learning when working with patients with complex needs.

There is agreement in the literature that allied health clinical educators have a responsibility for shaping student learning while conserving patient safety (Gibson and Palermo, 2021; Judd et al., 2023). In this current study, clinical educators agreed that their role primarily involves two responsibilities: providing adequate training for students and ensuring patient well-being. They emphasized that patient care takes priority, which often results in fewer opportunities for students to work with patients who have complex needs. Balancing patient care and student learning should not be the sole responsibility of clinical educators. Instead, clinical learning should be a collaborative effort involving universities, clinical placement hosts, and physiotherapy governing bodies. This partnership aims to provide students with more opportunities to work with patients with complex needs and to help educators better allocate resources, meeting patient needs while creating effective clinical learning environments. Given the advancing prevalence of complexity within healthcare and the clinical expectations placed upon new graduates to manage patients with complex needs upon entry into the workforce, this is an issue that requires ongoing attention. To our knowledge, this study is the first to address the issue of withholding patients with complex needs in health professional clinical education research. Consequently, there is a lack of literature available to determine if withholding patients with complex needs is common practice to maintain patient care. Recent research in rural health literature (Green et al., 2022; Quilliam and Bourke, 2021; Swanson and Quilliam, 2023) has demonstrated that service learning and non-traditional learning experiences can promote student learning without detracting from patient care. Although these studies focus on broader aspects of student learning in rural settings, they emphasize the importance of exploring innovative approaches to clinical education. This underscores the need for further research to inform future learning strategies regarding increasing students’ exposure to patients with complex needs during clinical practice placements.

There is a growing body of research suggesting that a significant challenge for clinical educators in the health professions is ensuring students are sufficiently prepared to manage patients with complex needs in their new graduate practice (Berger et al., 2019). In this current study, clinical educators reported actively assessing patient suitability for students to favor opportunities to develop technical skills. This bias in patient selection may limit students’ exposure to patients with complex needs. This aligns with previous research that indicated general practitioners endorsed the screening of patients for medical students to provide opportunities to practice examination skills while avoiding excessive complexity (Armstrong et al., 2023). Interestingly, this current study also found that the level of complexity selected for student caseloads is based on what clinical educators believe students can manage successfully. It was perceived that this deliberate selection of patients, to ensure success, builds student confidence. However, this often resulted in students missing opportunities to work with patients with complex needs and experiences to develop essential clinical skills required for new graduate practice. As a result, this may lead to students having a skewed view that all patient interactions should be successful. Notably, students emphasized a need for transparency in clinical educator decision-making to understand why certain patients are deemed unsuitable for their caseloads, enabling critical self-reflection on their learning needs and better preparation for proficient clinical care as new graduates. This aligns with previous research on clinical educator decision-making criteria for increasing student autonomy during placements (Clouder, Jones, Mackintosh, and Adefila, 2022), which suggests that students lacking insight into these decisions face learning disadvantages and limited opportunities for progression. Clouder and colleagues recommend open discussions during which educators transparently explain their decisions and students are given the freedom to negotiate for learning opportunities. Providing students with actionable insights into their knowledge and skill development needs, may create more opportunity to work with patients with complex needs thus improving their transition to new graduate practice.

Clinical educators reported evaluating student proficiency with patients that they deemed non-complex in the first weeks of a clinical practice placement, focusing on key competencies such as effective communication, basic assessment skills, safety, and seeking assistance appropriately. This practice aligns with previous research advocating for a progressive assumption of responsibility based on initial evaluations (Clouder and Adefila, 2017). However, findings from this current study indicate that this approach may result in inequality in the opportunities provided for students. Clinical educators highlighted students perceived as stronger are likely afforded more opportunities to engage in practice with patients with complex needs. This contributes to existing research from occupational therapy that indicates student performance directly influences clinical educator decisions to trust them with advanced clinical responsibilities thus creating variability in clinical learning experiences (Lundh, Palmgren, and Stenfors, 2019). Additionally, clinical educators in this current study reported students nearing completion of their clinical practice placement year are typically given more opportunity to work with patients with complex needs than those at the beginning. These findings contradict those by Clouder and Adefila (2017) who suggest that clinical educators, in most cases, do not perceive a student’s stage in their learning as a significant factor when deciding to give students increased responsibility. In a more recent study Berger et al. (2019) hypothesized that novice students would find working with patients with complex needs challenging. However, their findings disproved this theory suggesting that students were able to rise to the challenge and extend beyond their comfort zones perceiving these opportunities to be valuable for their professional growth.

Observation is considered to be a significant component of experiential learning in healthcare education, allowing students to learn and acquire essential skills and professional competencies required for clinical practice, while also enhancing confidence in complex clinical situations (Burgess, van Diggele, Roberts, and Mellis, 2020; Henshaw and Qasem, 2020; Mohammadi, Mirzazadeh, Shahsavari, and Sohrabpour, 2021; O’Regan, Molloy, Watterson, and Nestel, 2016). The findings of this current study contribute to this research emphasizing that observation serves as a fundamental learning tool through which students witness the practical application of theoretical knowledge, develop clinical problem-solving skills and experience behavior traits required for difficult encounters with patients. Of interest, students highlighted observation is an effective strategy to increase confidence to work with patients with complex needs. It is important that students are provided with opportunity to interpret and draw meaning from observations. Debriefing and reflective discussions play a vital role in facilitating student learning based on what they have observed (Rooney and Boud, 2019; Tutticci, Theobald, Ramsbotham, and Johnston, 2022). Results from this present study provide further evidence to support this, suggesting that providing protected time for post-observation debriefing is a valuable learning tool to contextualize clinical educator actions and decision-making.

It is widely acknowledged within health education literature that new graduates are required to practice autonomously (Opoku, Van Niekerk, and Jacobs-Nzuzi Khuabi, 2020; Stoikov et al., 2022; Wells et al., 2021). Clinical educators thus have a duty to improve students’ autonomy during clinical practice placements (Clouder, Jones, Mackintosh, and Adefila, 2022; Türk, Karagözoğlu, Adana, and Hh, 2021). Despite this, students within this current study expressed concerns of fear, anxiety, and uncertainty about the prospect of working with patients with complex needs autonomously as new graduates. Clinical educators thus acknowledged the importance of providing students with opportunities to work with patients with complex needs through graduated exposure, in alignment with existing research (Lundh, Palmgren, and Stenfors, 2019; Peiris et al., 2023). However, they also suggested that students are typically not given the chance to take the lead or make independent decisions regarding physiotherapy management. Entrustable professional activities (EPA) are units of professional practice that are delegated to a trainee once they have demonstrated the requisite competence to carry out the task unsupervised (Cate and Taylor, 2021). EPAs have been introduced in health profession clinical education to gradually increase autonomy (Chen, van den Broek, and Cate, 2015; Zainuldin and Siew Khoon Tan, 2024). However, research into this area is largely dominated by the medical field. The shared experiences of students and clinical educators in this study advocates future research is warranted to consider developing EPAs that increase physiotherapy student’s autonomy during clinical practice placement to work with patients with complex needs. Indeed, the development of EPAs in the care of children with medical complexity has been shown to be a valuable guide to assist medical educators and trainees shape effective learning activities (Duncan et al., 2020), highlighting a need for the physiotherapy profession to explore this and investigate the impact EPAs may have for developing new graduates ready to meet the demands of autonomous clinical practice with patients with complex needs.

Implications

This is the first study to investigate this topic from the viewpoint of students and clinical educators, providing unique and valuable insights into the challenges both groups face when navigating the introduction and management of patients with complex needs during clinical practice placements. The findings drawn provide considerations for clinical educators, clinical placement sites, and university education providers to improve clinical learning experiences for students. However, the lack of a universally agreed upon definition of patient complexity underscores the need for further exploration. The factors identified by students and clinical educators in this study could serve as a foundation for future studies enabling deeper understanding of the multifaceted aspects of complexity within the context of physiotherapy practice.

Consideration needs to be given to ensure students are provided with opportunities to work with an appropriate volume of patients with complex needs at an adequate level of autonomy to best prepare them for new graduate clinical practice. The authors accordingly advocate for further in-depth qualitative research to gain a broad understanding of clinical educator’s decision-making regarding allocation of patients with complex needs and the impact this has on student learning across all health disciplines.

Additionally, this study hopes to inform the design of future clinical practice placement by providing strategies to address introducing and supporting students to work with patients with complex needs. Further research is warranted into the design, implementation, and efficacy of EPAs that encourage the development of autonomy via clinical educator mentorship and targeted learning activities. This may minimize disparity between clinical placement sites leading to equitable learning experiences for students. It is hoped that the findings of this current study may encourage other health professions to consider similar investigations and or implementations.

Finally, given the challenges and anxieties, students experience in the transition from classroom learning to clinical practice. This study advocates for the inclusion of increased pre-placement education within the university curriculum targeted to working with patients with complex needs. Consideration should be given to establishing learning activities that are dedicated to the complexities of working with patients with complex needs; increasing the opportunity to engage in learning activities with patients with complex needs via standardized patient encounters at the time of teaching; and more clinical observation opportunities.

Limitations

There are several limitations of the study that must be acknowledged. The research team members who conducted data collection were employed within the tertiary institution attended by participating students and were therefore known to the students. Additionally, the lead researcher conducting clinical educator interviews was also known to some of the clinical educator participants. This association may have introduced some personal bias. This was mitigated through discussion and reflection with other members of the research team and the team undertaking additional analysis of de-identified transcripts. Participants were aware of this research and may have provided answers in the interviews and focus groups that they believed to be supportive which would introduce bias. However, it should also be noted that while this is a potential limitation, existing relationships may also be viewed as advantageous in the study by allowing participants to feel at ease to express their perceptions and opinions candidly.

The demographic of participants was majorly limited to one state within Australia, with only one clinical educator practicing in another state. Students were recruited from one university within Australia, which might introduce bias into the generalizability of pre-clinical training needs due to providing only one viewpoint. Student participants were recruited if they had completed two or more placements, thus students who were earlier in their placement experiences may not have had enough exposure and breadth of clinical practice placement experience to report on thus influencing the results.

The nature of clinical placement setting presents a potential limitation. Private practice clinical educator participants cited workplace culture and policy as impacting on their ability to provide students with opportunities to work with patients with complex needs. The significant presence of private placement sites attended by students may have skewed the diversity and complexity of cases encountered. This contrasts with public healthcare facilities, which may offer a more varied spectrum of patients with complex needs more readily. Consequently, the variability in placement settings may impact the depth and breadth of clinical learning experiences, thereby limiting the generalizability of our findings.

Finally, student participants were invited to speak only about their experiences during their 5-week full time clinical practice placements, during which their competence to practice is formally assessed against new graduate entry-level standards. It is worthy to note that students’ focus on grades may influence their willingness to engage with patients with complex needs. Formal assessment may result in students being reluctant to challenge themselves clinically, conversely it may also serve as an incentive for students to seek out opportunities to work with patients with complex needs to demonstrate their growing proficiency. Having a deeper understanding of student factors would have provided a more comprehensive understanding in clinical education practice in this space.

Conclusion

This study provides valuable insights into the challenge of exposing students to working with and learning from patients with complex needs during clinical practice placements, uniquely considering both clinical educator and student perspectives. The results highlight the importance of exposure to patients with complex needs during clinical practice placements for learning and preparation for independent new graduate practice. Opportunities to work with patients with complex needs is variable, largely based on clinical educators’individual frame of reference and interpretation of student ability. The results provide considerations for clinical educators to shape future clinical placements, aiming to minimize disparity and ensure equitable learning opportunities for students while navigating complex patient care.

Acknowledgments

The author(s) wish to sincerely thank the physiotherapy students and clinical educators who participated in this study.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.