Physiotherapy students’ and clinical teachers’ perceptions of clinical learning opportunities: A case study

Abstract

Background: The attainment of clinical competence is a key outcome of physiotherapy programmes worldwide. Clinical education forms a core component of the training of physiotherapy students.

Aims: The study on which this article is based aimed to investigate what physiotherapy students and clinical teachers at one physiotherapy training institution perceive as effective opportunities to facilitate learning in a clinical context.

Methods: A survey of staff and students at the physiotherapy division at Stellenbosch University was undertaken as one element of a situational case study. All enrolled physiotherapy students with clinical education experience and all clinical teachers involved in the clinical education of these students were invited to participate. A purpose-built questionnaire was developed and validated before being administered.

Results: The response rate was 80%. The clinical teaching and learning opportunities deemed most valuable for learning by students and teachers were demonstrations of patient management, feedback, discussions and assessment. Teachers and students varied in their perceptions of the learning value of peer assessment, self-assessment and reflection.

Conclusions: The study provided indications for teachers on the valuable learning opportunities as perceived by students and teachers in a physiotherapy clinical setting. The activities perceived as most effective in facilitating learning in the clinical milieu were demonstrations of patient management, discussion, feedback and assessment. Participants indicated that they valued individual contact with teachers and that they learnt productively from discussions with the teachers. It was reported that immediate and verbal feedback improved the learning experience. Both formative assessment in the form of a mock assessment and summative assessment in the form of an end-of-block test were identified as important in facilitating learning. Further research is required on peer assessment, self-assessment and reflection to establish the role of these aspects of learning.

Introduction

Clinical education and the supervisory process it involves is an important and distinct part of health care education. During clinical experience, theory consolidates into practice and students learn to combine and integrate the knowledge, skills, attitudes, values and philosophies of the profession. The clinical learning environment is the ideal area in which to facilitate professional skills (Strohschein et al. 2002), as students are learning within the context of clinical practice.

A number of authors around the world have investigated the importance of clinical education for the development of professional skills. Several authors across disciplines emphasise the importance of clinical training, for example, in medicine (Hesketh et al. 2001; Cottrell et al. 2002; Grant et al. 2003; Van der Hem-Stokroos et al. 2005; Kilminster et al. 2007), in nursing (Chan 2001; Conrick 2001), in radiography (Williams & Web 1994), and in physiotherapy (Higgs 1992, 1993; Walker & Openshaw 1994; Stiller et al. 2004; Lekkas et al. 2007). Rushton and Lindsay (2003), Strohschein et al. (2002) and Kilminster and Jolly (2000) reviewed the literature on the efficacy of clinical education programmes across disciplines and they reiterate its importance.

Table

Practice points
Activities effective in facilitating learning in the clinical milieu are demonstrations of patient management, discussion, feedback and assessment. Formative assessment creates a valuable learning opportunity. The use of reflection, self-assessment and peer assessment as learning opportunities in the clinical learning environment requires further investigation.

Kilminster et al. (2007) define clinical education as the provision of guidance and feedback on personal, professional and educational development in the trainee's experience of providing appropriate patient care. Clinical education is thus important for the development of the health professional and for providing quality patient care (Kilminster & Jolly 2000; Grant et al. 2003; Kilminster et al. 2007).

Despite the importance of supervisory practice during clinical education in medicine, Kilminster and Jolly (2000) conclude from their review of the literature that it has little empirical and theoretical basis. Kilminster et al. (2007) also state that clinical supervision is the least researched topic in the area of medical clinical training and that supervisory practice in medicine is highly variable. The research done by Kilminster and her team found that the effectiveness of the clinical supervisory process depends more on the supervisory relationship and less on the supervisory methods used (Kilminster & Jolly 2000; Cottrell et al. 2002; Kilminster et al. 2002; Kilminster et al. 2007). Rolfe and Sanson-Fisher (2002) emphasise the need to develop guidelines for supervisors’ clinical education practice and advocate a need to re-evaluate methods by which doctors are taught clinical skills. The above aspects highlight the need for research and guidelines in clinical education practice. Van der Hem-Stokroos et al. (2005) support this notion.

Little has been reported on research into the processes and outcomes of teaching and learning in physiotherapy clinical environments. Both Babyar et al. (2003) and Lekkas et al. (2007) highlight this situation, particularly the lack of information on the effectiveness of various teaching methods used during physiotherapy clinical education. A review of the literature on physiotherapy clinical education made it evident that most research focussed on models of clinical education (Ladyshewsky 1993; Baldry Currens 2003; Baldry Currens & Bithell 2003; Moore et al. 2003; Stiller et al. 2004; Frieg & Lochner 2005) and the role of the clinical teacher during clinical education (Harris & Naylor 1992; Onuoha 1994; Cross 1995; Mbambo 1999; Frieg & Rhoda 2006; Laitinen-Vaananen et al. 2007). There is less focus on teaching and learning opportunities (Onuoha 1994; Walker & Openshaw 1994; Cross 1998; Babyar et al. 2003). The literature studied indicated that the effectiveness of teaching and learning opportunities for facilitating learning during physiotherapy clinical training requires further investigation.

Investigating effective teaching and learning opportunities is important, as the clinical and classroom learning environment differs vastly. In the classroom, learning activities may be planned and structured within an environment that is flexible to deal with student enquiries. In the clinical learning environment, patients are present and expect treatment. Unplanned events often occur with patients or other health care providers, and these can constrain opportunities to learn. Furthermore, since the aims of health care centres are to provide quality health care to patients whilst providing students with training opportunities, student education may sometimes take a secondary role to patient care. The role of the student as service provider may influence the learning process of the student. Thus, the challenge for clinical education programmes is to be both patient-centred and student-centred.

In recent years, a paradigm shift has taken place in higher education from a teacher-centred to a student-centred focus. Barr and Tagg (1995) state that a higher education institution exists to produce learning, not to provide instruction. The emphasis in student-centred education is on the student's learning experience. The teacher's role is to create powerful learning environments. Characteristics of the student-centred education include: learning by discovery, active construction of knowledge, specific learning results and assessment throughout learning. In the student-centred paradigm the student's experience is seen as most important, but in clinical education the patient's care is most important and the student takes the role of a service provider. There is a need to assess specifically what ‘student-centredness’ in the clinical context means.

What and how a student learns is influenced by factors such as the culture of learning, the environment and climate of learning in the learning organisation, the student and the student's approaches to learning (Entwistle, in Knight 1995; Ramsden 2003). Several theories on the process of learning exist. These include the behavioural learning theories, where learning is seen as the product of environmental influences where associations are made between stimuli and responses through selective reinforcement (Schunk 2004). The Social Cognitive learning theory of Bandura highlights learning as a social process and as a product of the environment. The theory emphasises that learning can occur through observing others (vicarious learning) and/or imitating behaviour (enactive learning) (Schunk 2004). The theories of Piaget and Vygotsky had a major influence on the development of constructivism which is a learning perspective. Constructivismt focusses on construction/formation of learning and understanding by integrating learning activities and experiences (Schunk 2004). Vygosky, through his cognitive development theory, proposed that every learner has a potential ability for learning/development which he calls the Zone of Proximal Development (ZPD) (Jarvis et al. 2003). The ZPD emphasises learning by socialisation, as it asserts that what learners can do with assistance is more indicative of their mental capacity than what learners can do on their own. Conditional knowledge and metacognition is central to the learning theory of cognitivism. Reflection is a metacognitive strategy through which learning may occur (Mezirow 1991, in Merriam 2004). Kolb's (1984) theory of experiential learning describes learning as a four-step cyclical process involving a concrete experience, reflective observation, abstract conceptualisation and active experimentation. In the humanist orientation to learning, learning is a personal act needed to achieve the learner's full potential. The learner thus becomes autonomous and self-directed (Torre et al. 2006)

Examining the ways students learn in and interpret clinical learning environments may provide a better understanding of learning, which can be used to adapt the learning environment, since students ultimately respond to what they perceive as important (Chan 2001). The learning environment is influenced by the roles and attributes of the clinical teacher, the student and the patient; the teaching and learning opportunities offered; the models of clinical education used; student assessment; and the atmosphere and facilities at the health care setting (Ernstzen & Bitzer 2006). Two aspects of the learning environment, namely teaching and learning opportunities and clinical teacher roles and attributes, have been found to be the most significant in influencing learning (Gandy 1997; Chan 2001).

The study on which this article is based aimed to identify what physiotherapy students and clinical teachers viewed as effective teaching and learning opportunities during physiotherapy clinical education.

Context of the Study

The study was conducted at the Physiotherapy Division, Faculty of Health Sciences (FHS), Stellenbosch University (SU), South Africa (SA). The physiotherapy programme is a 4-year degree course. The first 2 years of training form the foundation years. During the third and fourth year of training, students are introduced to work-based learning, where they take responsibility for patient management. Students rotate in groups to different clinical areas (community physiotherapy, medical and surgical, neurology and orthopaedics). Groups consist of three to eight students and clinical rotations were 6 weeks in duration at the time of the study.

Physiotherapy students are supported during their clinical education by the physiotherapy clinician at the health care centre and by a clinical lecturer. The clinician supervises and advises the students on a day-to-day basis and students report to the clinician. The clinician is responsible for writing a report on the students’ progress on the clinical placement, using specific criteria. The clinical lecturer mentors the students and spends 1 hour or more per week with each student. During this time, formal teaching and learning opportunities are offered. The clinical lecturer assesses the student's clinical competence at the end of the clinical rotation.

In this article both the clinician and the clinical lecturer will be referred to as ‘the clinical teacher’, as both play a role in the clinical education of the student.

Methodology

Ethics

The protocol for the study was approved by the Committee for Human Research at the FHS, SU, SA. Permission to undertake the study was obtained from the respective chairpersons of the physiotherapy departments involved. Written consent was obtained from all participants.

Research design

The study formed part of a larger situational case study. An in-depth focus was taken on one institution/organisation, in an attempt to explore in-depth perspectives and differences between stakeholders in that setting (Denscombe 1998; Mouton 2001). A mixed method approach was used, generating both quantitative and qualitative data. During the first phase of the study, a survey was undertaken to investigate the teaching and learning opportunities that participants viewed as effective in producing learning. During the second phase, qualitative methodology was employed to ascertain why these teaching and learning opportunities were deemed valuable in producing learning. The qualitative results, focussing on students’ and teachers’ experiences during clinical education opportunities, will be presented in a follow-up article. The larger study also investigated the role and attributes of the clinical teacher in creating an optimal learning environment (Ernstzen & Bitzer 2006).

Sample

The study population included all physiotherapy students at SU who had clinical experience, as well as all physiotherapists involved in the clinical education of these students. All enroled physiotherapy students who had clinical experience in taking responsibility for patient management in 2005 were invited to participate in the study. The total number of students in this category was 80 (40 third-year and 40 fourth-year students). All 23 clinical lecturers, and 14 clinicians directly involved in the clinical education of these students, were also invited to participate.

Instruments

Purpose-built questionnaires were distributed to all students and teachers in the sample.

Questionnaire development

The questionnaires comprised three parts. Part one focussed on demographic information of the respondents, while parts two and three focussed on teaching opportunities offered during clinical education. Prior to questionnaire development, a review of the literature was undertaken and general themes, key concepts and issues on clinical education were identified. All teaching methods that had the potential to enhance learning were considered a teaching and learning opportunity (TLO). These were then categorised into factors which could play a role in the learning experience of the student in the clinical setting according to the model of Hesketh et al. (2001). Categories in the model included TLOs, approach to teaching and professional role. A summary of the key concepts for the questionnaire is illustrated in Table 1. A full description of the questionnaire development is available in Ernstzen and Bitzer (2006).

Table 1.  Factors and behaviours conducive to learning during clinical education

Teaching and learning opportunities
Appropriate levels of autonomy	Appropriate feedback; prompt feedback; feedback on knowledge and competence
High-quality/good clinical teaching skills	Reflection on learning
Active learning; promotes active student participation	Promotes self-assessment
Use of student-centred strategies	Demonstrations
Facilitation of learning; facilitation skills	Patient discussions
Organising skills	Observation — with feedback
Linking theory to practice	One-to-one tutorials
Variety of learning experiences	Small-group discussions
Flexible learning structure	Role playing
Organisation	Peer tutoring
Give direction on clinical work	Lectures
Negotiation and assertiveness skills	Brainstorming
Emphasis on research	Clinical reasoning and problem solving
Constructive alignment	Assessment skills
Group teaching skills; collaborative learning	Case assignments
	Journal review
Approach to teaching/personal factors
Communication	Enthusiasm
Approachable	Open-minded
Interpersonal skills	Have high expectations form learners
Preceptor attitude/mentoring skills	Communicates expectations
A humanistic orientation, concern for students	Non-threatening/risk-free atmosphere
A positive orientation towards teaching	Recognises learner individuality
Caring, supportive	Recognises learner contribution
Counselling and appraisal skills	Gives constructive feedback
Reassurance
Professional role
Clinical competence (including critical inquiry, problem solving and reflective practice) Professional skills Professional socialisation Role modelling of professional characteristics	Knowledge Concerned with patient care Interest in the learning process Self-aware In control Organisation/clarity of clinical education

Note: Adapted form the model of Hesketh et al. (2001).

The elements of the questionnaire were informed by studies from various disciplines. Hesketh et al. (2001) describes a framework for the clinical education of doctors. It is based on examination of literature, clinical education courses in medicine and discussion with colleagues. It encourages active participation, collaborative learning, self-directed learning, feedback, self-assessment, learning contracts and assessment as TLOs. The Cleveland Clinic's Clinical Effectiveness Instrument as developed by Copeland and Hewson (2000) also informed questionnaire development. Hewson (2000) describes a course in clinical education for physician educators. The course focusses on coaching, bedside teaching, small-group discussions, lectures, effective feedback and designing curricula as TLOs.

In a study by Williams and Webb (1994), radiography students reported several TLOs as important for learning. These included encouragement of active participation during learning, the clinical teacher using her knowledge to help students understand experiences, teaching by comprehension and problem solving and by relating theory to practice, and lastly, high expectations of the students.

Babyar et al. (2003) report on his survey that physiotherapy students ranked the following TLOs for clinical reasoning from most effective to least effective: discussion on patient case, discussion on patient in class, problem solving via hypothetical patient, problem solving via videotape of actual patient, role playing with peers, case-study assignments, brainstorming and reviewing a journal article. The students were also asked to identify their preferred method of learning clinical reasoning in the clinical setting. Discussion of a patient case before and after interaction with the patient was identified by 60.8% of the participants. However, the above study yielded a low response rate (22%) and did not consider the students’ level of clinical experience which might influence their preferred TLO. The study thus identified that discussions on an actual patient seem to be useful to facilitate learning.

Walker and Openshaw (1994) also investigated TLOs used by clinical teachers in physiotherapy. All clinical teacher respondents used demonstrations on patients and observation (with feedback) of students as TLOs. One-to-one tutorials and self-directed learning respectively were used by 77% of the clinical teachers. Small-group discussions were used by 73% and small-group practice sessions by 64% of clinical teachers. Lectures and brainstorming were used by 27% of clinical teachers. However, the researchers selected these TLOs to be ranked by the participants, thereby limiting options.

Paschal (1997) identified several other factors that are seen as central in the process of physiotherapy clinical education. These factors include bridging the gap between theory and practice, putting knowledge to work, professional socialisation and critical analysis of clinical competence (through role modelling and self-assessment). Assisting the student to move from assisted to self-directed learning has also been cited. Oldmeadow (1996) describes a pathway of developing clinical competence during clinical education that follows the principles of progressive mastery, which is in line with the move from assisted to self-directed learning.

Higgs (1992) avers that the student is a self-directed learner in the clinical setting by being responsible for and aware of his own learning process and outcome, performing learning activities and problem solving associated with learning tasks, giving active input regarding the learning task, and through collaborative learning. The need for reflection, self-assessment, self-directed learning and lifelong learning skills are thus emphasised. These skills are important for physiotherapists to contribute to the knowledge base of the profession and to demonstrate professional autonomy, competence and accountability (Hunt et al. 1998). Reflection on experience may be used to encourage learning. Donaghy and Morss (2007), Higgs (1992) and Gandy (1997) regard reflective practice as an important contributor to successful student-centred teaching clinical education. Brockbank and McGill (1998) define reflection as: the ‘process or means by which an experience in the form of thought, feeling or action is brought into consideration, while it is happening or subsequently’, and as ‘the creation of meaning and conceptualisation from experience and the potentiality to look at things as other than they are’.

Feedback to students was also identified as an important variable in the efficacy of physiotherapy clinical education (Harris & Naylor 1992). According to Kilminster and Jolly (2000), feedback creates feelings of confidence and competence and improves relationships. These authors emphasise that feedback to students should be clear and unambiguous so that they become aware of their mistakes and weaknesses.

Assessment powerfully influences the way students respond to courses and behave as learners (Gibbs 1999). It influences the quality of the learning and teaching experience. SU emphasises outcomes-based and student-centred assessment (SU Assessment Policy 2004). Adopting a student-centred approach implies that the assessment should have the student as the main concern, having both summative and formative functions. Formative assessment in clinical education could include simulated clinical competency tests, technique tests, peer assessment, self-assessment, assessments completed by patients and specific learning tasks.

Self-assessment involves the ability to critically assess one's work against certain criteria or standards (Brew 1999). Self-assessment and reflection are often thought to be the same, as both focus on learning and experience. However, Brew (1999) states self-reflection is a more exploratory activity, while self-assessment has specific aspects of achievement.

During peer assessment, students make judgements and comment on each other's work (Brew 1999). Peer assessment may encourage thinking, increase learning and increase students’ confidence; it may contribute to the cohesiveness of a group, but may also disrupt the group (Baldry Currens & Bithell 2003). Brew (1999) emphasises the importance of self-assessment and peer assessment to develop skills of negotiation and discrimination.

Validation

The above-mentioned themes were drafted into questions, which were made available in Afrikaans and English. Language experts of the SU language centre were consulted to assess the language and user-friendliness of the draft questions. A statistician was consulted to determine if the questions were framed in a way suitable for statistical analysis. The content validity of the draft questions was then assessed by five experienced higher-education practitioners (a professor in higher education, a senior researcher in higher education, the physiotherapy clinical education coordinator, an experienced physiotherapy clinical lecturer and head of the school for Allied Health Sciences at SU). Minor changes were made to the questions, which were then framed into the study questionnaire.

After the content validation of the questionnaire items, a pilot study was undertaken to determine if the questions and instructions were understandable and to establish an estimated time for the completion of the questionnaire. A sample consisting of one physiotherapy class and two clinical teachers from another physiotherapy department in SA was recruited for this purpose. The questionnaire was further modified. The resultant questionnaire is provided in Appendix.

Each questionnaire was coded according to the group to which the participant belonged. The student questionnaire was administered to students in the sample by allocating time to complete the questionnaire after a learning session. The clinical teachers’ questionnaire was mailed to them together with a stamped, self-addressed return envelope. A covering letter included the aim of the study, the return date for the completed questionnaire and the researcher's contact information. Non-responders were followed up by sending a reminder via e-mail or mail.

Data handling and analysis

The questionnaire data were recorded in a purpose-built data-collection sheet in MS Excel. Data were then analysed on a statistical program (Statistica 7), using proportions, means and appropriate variability measures. A non-parametric test (Mann–Whitney U-test) was used to determine differences between students’ and clinical teachers’ questionnaire responses. Although the aim of the study was not to compare the views of the clinical teachers and students, it was considered important to know where differences existed, as this could guide the development of clinical education programmes for teachers and students. Statistical significance was determined at p < 0.01 as the study focussed on perceptions of participants.

Results

The response to the questionnaire was 80% (88% for students and 62% for clinical teachers). Thus, 70 students and 23 clinical teachers returned completed questionnaires.

The perceived learning values of different TLOs are illustrated in Table 2. Participants had to select six TLOs which they experienced as having the highest learning value. Demonstrations of patient management, feedback, discussions with the teacher, individual learning sessions, mock assessment and facilitation of learning received the highest number of votes. Most students preferred discussions to be in the form of individual-learning sessions rather than group-learning sessions. However, in contrast to the student participants, clinical teacher participants viewed individual discussions and group discussions as equally important. It is interesting to note the low number of votes for reflection, independent learning (learning on one's own) and peer assessment.

Table 2.  Students’ and clinical teachers’ views on teaching and learning opportunities during which students learn the most

Teaching and learning opportunities	Percentages and (number) of students who selected the activity	Percentages and (number) of clinical teachers who selected the activity	Total selections in %
Demonstrations of patient management	93% (65)	70% (16)	87
Feedback	73% (51)	74% (17)	73
Discussions with the teacher	79% (55)	52% (12)	72
One-to-one learning sessions	77% (54)	48% (11)	70
Mock assessment	63% (44)	43% (10)	58
When learning is facilitated	39% (27)	61% (14)	44
Group-learning sessions	33% (23)	48% (11)	37
Discussion with peers	36% (25)	30% (7)	34
Coaching	33% (23)	13% (3)	28
Reflection	17% (12)	48% (11)	25
Questioning	20% (14)	30% (7)	23
Learning on own	14% (10)	4% (7)	18
Peer assessment	9% (6)	35% (8)	15
Clinical tasks	3% (2)	30% (7)	10
Lectures	9% (6)	9% (2)	9
Other	0% (0)	0% (0)	0

Note: Total students = 70, total clinical teachers = 23

The TLOs used were also further explored in the questionnaire by posing differentiating questions regarding demonstrations, different types of discussion, feedback, assessment and other learning experiences. The results are reported in Table 3. Those responses with statistically significant differences (p < 0.01) between students and teachers are marked with a designator ^“a”.

Table 3.  Focus on different constructs of teaching and learning opportunities

	Students’ mean score (SD)	Teachers’ mean score (SD)
Panel A: Demonstrations
(a) The teacher demonstrates patient evaluation/treatment.	1.89^a (0.10)	2.48^a (0.17)
(b) The teacher observes clinical practice of student and comments.	1.77 (0.10)	1.87 (0.17)
(c) The student demonstrates clinical practice and the teacher facilitates the process.	1.77 (0.11)	1.78 (0.18)
(d) The student observes a peer during clinical practice.	2.81^a (0.07)	3.13^a (0.16)
(e) The teacher facilitates reflection after a demonstration.	2.43^a (0.09)	1.81^a (0.17)
(f) The student completes a patient documentation form.	2.91 (0.10)	2.61 (0.18)
(g) Routine evaluation/treatment of the patient by the student.	2.69 (0.09)	2.74 (0.16)
Panel B: Discussion
(a) The teacher does a one-to-one tutorial with the student.	1.69 (0.11)	2.08 (0.19)
(b) The student participates in small-group discussion on patient management.	2.06 (0.10)	2.09 (0.18)
(c) The student participates in a discussion on X-rays.	1.93 (0.10)	2.26 (0.18)
(d) The student is tutored by a fellow student.	2.94 (0.08)	3.13 (0.14)
(e) The student participates in a ward round.	2.82 (0.12)	2.78 (0.21)
(f) The student presents a case study to fellow students/staff.	2.67^a (0.10)	2.09^a (0.17)
Panel C: Feedback
(a) The teacher gives verbal feedback.	1.76 (0.10)	2.30 (0.17)
(b) The teacher gives written feedback.	2.34 (0.10)	2.35 (0.18)
(c) The teacher gives immediate feedback.	1.59 (0.09)	1.30 (0.16)
(d) The teacher gives feedback on what the student did well.	2.11 (0.08)	1.74 (0.15)
(e) The teacher gives feedback on the student's limitations.	1.74 (0.10)	2.22 (0.17)
(f) The teacher gives feedback on the student's limitations and strengths.	1.52 (0.09)	1.26 (0.16)
(g) The teacher gives feedback on the student's knowledge.	2.17 (0.10)	2.26 (0.17)
(h) The teacher gives feedback on the student's skills.	2.01 (0.09)	1.96 (0.16)
(i) The teacher gives feedback on the student's attitudes.	2.36 (0.12)	2.65 (0.2)
Panel D: Assessment
(a)The student assesses him/herself on patient management.	3.29 (0.11)	3.00 (0.20)
(b)The student is assessed by other students on patient management.	2.91 (0.09)	2.64 (0.16)
(c)The student is assessed by the patient on patient care.	3.09 (0.11)	3.22 (0.20)
(d)The teacher assesses the student using a mock test.	1.74 (0.11)	2.04 (0.20)
(e)The teacher assesses the student on the end-of-block test.	1.99 (0.12)	2.57 (0.21)
(f)The student assesses his/her own learning.	3.2 (0.10)	3.09 (0.17)
Panel E: Other teaching and learning opportunities
(a) The teacher allows the student to share responsibility for learning.	2.00 (0.10)	1.91 (0.17)
(b) The teacher gives a lecture on patient management.	2.36^a (0.11)	3.26^a (0.19)
(c) The student does role-play about clinical practice.	2.86 (0.11)	3.39 (0.19)
(d) The student observes surgery.	2.57^a (0.11)	3.30^a (0.19)
(e) The student observes a video on patient management.	2.8 (0.10)	3.09 (0.17)
(f) The student and teacher plan learning activities together.	2.44 (0.11)	2.13 (0.19)
(g) The student draws up a SWOT analysis on his/her clinical abilities.	3.37^a (0.11)	2.65^a (0.20)
(h) The student does self-reflection on clinical abilities.	3.16^a (0.11)	2.30^a (0.19)
(i) The student writes a report on patient management.	3.29 (0.09)	2.96 (0.15)

Note:^aSignificant difference

Scale used:

1. I learnt an extreme amount.

2. I learnt a lot.

3. I learnt a reasonable amount.

4. I learnt a minimal amount.

5. I learnt nothing.

Table 3 provides information that supports the findings in Table 2, namely that demonstrations are a valued clinical teaching activity. The students and teachers agreed that students learnt most when the student demonstrated clinical practice and the teacher facilitated the process. This notion is strengthened in that student learning was rated high when the teacher observed the student's clinical practice and gave subsequent feedback (Table 3). However, students and clinical teachers alike disagreed on the value of a demonstration given by the clinical teacher, students rating its learning value more highly. Students and clinical teachers also had significantly differing views on peer observation during clinical practice. Students rated the learning value of peer observation more highly than did the clinical teachers. It is noteworthy that both students and teachers considered routine management of a patient to have reasonable to high learning value.

In Table 3 (Panel B), the different types of discussions are considered. Table 3 (Panel B) indicates that both groups perceived individual contact with the teacher as well as discussions in small groups as having a high learning value. However, students reported individual discussions with the teacher to have superior learning value. This concurs with the findings in Table 2. Students were reported to have learnt productively from X-ray discussions, ward rounds and presenting patient cases to fellow students.

Table 3 (Panel C) highlights student preference regarding feedback during clinical education. The findings indicate that for these participants, immediate feedback is preferred, feedback on students’ strengths and limitations (thus mixed feedback) is valuable and feedback specifically on the development of technical skills is beneficial.

Self-assessment was reported to have reasonable to minimal learning value by both groups, as indicated in Table 3 (Panel D, (a)). In Table 3 (Panel D, (b)), it is reported that peer assessment has reasonable to high learning value. This finding differs from the finding in Table 2 where peer assessment received only 15% of the votes. Of all the assessment options given in the questionnaire, students regarded a formative assessment tool, namely the use of mock assessment, as the most valuable for learning (Table 3 [Panel D, (d)]. Students attributed a higher learning value to the end-of-block competency assessment activity than clinical teachers did. However, this difference was not statistically significant.

Participants agreed that students and teachers should share the responsibility for learning (Table 3 (Panel E, (a) and (b))). Neither students nor teachers considered students managing their own learning to be a preferred practice (Tables 1, Table 3 (Panel E, (a) and (f))); strengthening the notion of students and teachers as co-producers of knowledge. Clinical teachers’ and students’ rating and self-reflection differed significantly, as shown in Table 3 (Panel E, (b)), with clinical teachers attributing higher learning value to self-reflection.

Discussion

This study provides important information on students’ and teachers’ perspectives of learning in a clinical setting, and adds to the body of knowledge on effective clinical teaching practices. It is highlighted that, for students and teachers in this study, the most effective TLOs in enhancing student learning in the clinical environment were demonstrations of patient management, feedback, discussion and formative assessment, which are all centred on providing physiotherapy care for patients. It is therefore suggested that these activities form an integral part of the clinical education programme.

Demonstrations of patient management in the students’ learning process were strongly valued by students and teachers alike. Students reported that they learnt more when they performed the demonstration (i.e. student-centred education where students actively participated in learning) compared with when the teacher performed the demonstration. Students valued teacher-led demonstrations more than teachers did, because teachers appeared to regard their demonstrations as passive learning by the student, while students perceived their involvement as active learning.

Observing the teacher performing the demonstration may be seen as learning by observation, and performing the demonstration may be seen as learning by doing. These forms of learning are supported by the behaviourist learning orientation (Torre et al. 2006) and the social cognitive learning theory (Bandura, in Schunk 2004). By observing others, people acquire knowledge, rules, skills, strategies, beliefs and attitudes. Observation of and interaction with the clinical teacher may thus influence the student's learning process. Babyar et al. (2003) and Chan (2001) support the value of the teacher as role model during social interaction with students. Medical students in a study by Van der Hem-Stokroos et al. (2005) also found observation of clinical practice to be most beneficial during the clinical learning experience.

Another supported TLO in this study was feedback. Prompt feedback on students’ strengths and limitations seemed most preferred in enhancing learning. Verbal feedback was found to be more beneficial than written feedback. Students seemed to value feedback on skills more than feedback on knowledge, skills and attitudes. The findings concur with those of Kilminster and Jolly (2000) who found that feedback improves students’ confidence and that it improved relationships between students, teachers and patients. Van der Hem-Stokroos et al. (2005) agrees that feedback should be a key element in clinical education programmes.

Expanding on the notion of feedback, Gross Davis (2001) says that she regards discussions as useful because they actively involve the student. She argues that, through discussion, students gain practice in thinking through problems, organising concepts, formulating arguments and counter-arguments, evaluating the evidence for their own and others’ position, and responding thoughtfully and critically to diverse points of view. A discussion is thus a collaborative learning event that provides the opportunity to acquire knowledge and insight through the exchange of ideas and opinions. Collaborative learning is a central theme of the student-centred paradigm (Barr & Tagg 1995). It is therefore not surprising that participants in this study identified discussions with the teachers as one of the most valued activities for enhancing learning. In Babyar et al. (2003), physiotherapy students ranked discussion on a patient case as most effective in facilitating clinical reasoning. The students seemed to prefer individual learning sessions more than group discussions, possibly because they received personal attention because the teachers addressed diverse students’ individual needs, as suggested in the student-centred paradigm (Barr & Tagg 1995).

Discussion as a learning activity also concurs with the ZPD of Vygotsky (Jarvis et al. 2003). The learners’ learning potential is thus realised when they interact with more knowledgeable others, in this case the clinical teacher. Vygotsky's theory emphasises potential, development and collaborative learning, rather than independent learning (Bitzer 2004). Strohschein et al. (2002) also reports better outcomes in learning during collaborative learning opportunities.

The findings of the study contribute to the notion that assessment powerfully influences learning (Higgs 1993; Gibbs 1999). Formative assessment in the form of a mock assessment was perceived to be important in facilitating learning, probably because the mock test is a simulation of the actual clinical competency test. The primary goal of formative assessment is to enhance learning by helping students to develop under conditions that are non-judgemental and non-threatening (Geyser 2004).

In the context of this study, clinical competency was assessed by means of a competency test at the end of the clinical placement. These summative assessments were also seen as important in the students’ learning experience. The students and teachers differed in their view of the value of the end-of-block test. The lower rating by clinical teachers could be possibly be explained by teachers providing a grading and feedback after the assessment, without an opportunity for remedial action, while students, who are actively involved in the process, might see the test situation as an opportunity to learn from their mistakes. Nonetheless, formative assessment is one way of achieving student-centred assessment by assessing throughout the learning experience (Barr & Tagg 1995)

Peer assessment raised a number of issues. The uncertainty regarding the learning value of peer assessment highlights that the value of peer assessment are diminished by the confidence in of the group in peer knowledge.

Students were of the opinion that they did not learn productively from self-assessment and reflection. The clinical teachers disagreed with this notion. It may be that students lack insight into the complexity of self-assessment, as clinical exposure challenges their personal and professional development. Perhaps reflection and self-assessment occurred without the students realising it. Reflection should thus be planned as part of experience, in this case the clinical encounter with the patient. By making use of reflection, learning is not left to chance; but is intentionally facilitated. Reflection can help connect theory to practice and help students to engage in consistent and intentional self-evaluation and professional growth (Strohschein et al. 2002). Students need systematic practice in judging their own work, and through utilising feedback they are able to develop their self-assessment skills (Brew 1999). The value of reflection as a meta-cognitive strategy to create meaning from experience is also clear from the literature (Higgs 1992; Brew 1999; Strohschein et al. 2002). Thus students’ perspective on self-assessment may need to be addressed in the clinical environment as a formal part of the learning process. The value of reflection and self-assessment needs to be emphasised in the clinical education programme to enhance awareness of their importance amongst students and teachers.

The results of the study should be considered in the light of certain limitations. It cannot be generalised as it focusses on one institution and the perceptions of a specific group. Therefore, a need exists for more research on TLOs. The information could inform stipulations regarding the content of clinical education programmes. Specific attention needs to be given to developing TLOs that could facilitate clinical reasoning and linking theory to practice. Furthermore, the clinical education programme needs to be evaluated on an ongoing basis, as part of quality assurance.

Conclusion

The study provided indications for teachers on effective learning opportunities as perceived by students and teachers in a physiotherapy clinical setting. The activities perceived as most effective in facilitating learning in the clinical milieu are demonstrations of patient management, discussion, feedback and assessment. Students indicated that they valued individual contact with teachers and that they learnt productively from collaborative learning events. The aforementioned can be seen as ways to create powerful clinical learning environments. It is suggested that these aspects of teaching and learning be incorporated formally into clinical placement educational strategies.

It was reported that immediate, verbal and mixed feedback improved the learning experience. Teachers should thus be trained in giving effective feedback. Formative assessment in the form of a mock assessment, as well as summative assessment in the form of an end-of-block test was identified as important in facilitating learning. The participants’ uncertainty about the learning value of reflection, self-assessment and peer assessment indicates that a greater focus is required on these elements when exposing students to clinical training opportunities. Since mixed responses from participants suggested that these activities were not optimally utilised during clinical placements, their learning value should be explored.

Acknowledgement

The project was funded by the Fund for Innovation and Research into Teaching and Learning, Centre for Teaching and Learning, Stellenbosch University, South Africa.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

Additional information

Notes on contributors

D.V. Ernstzen

D.V. ERNSTZEN, BSc Physiotherapy, MPhil (Higher Education), Lecturer, Division Physiotherapy, Faculty of Health Sciences, Stellenbosch University, South Africa.

E. Bitzer

E.M. BITZER, DEd, Professor, Centre for Adult and Higher Education, Stellenbosch University, South Africa.

K. Grimmer-Somers

K. GRIMMER-SOMERS, PhD, Professor, School of Health Sciences, Director of the Centre for Allied Health Evidence, University of South Australia, Australia.

Appendix

Title

Effective Clinical Education in Physiotherapy: Learners’ and Clinical Teachers’ views at Stellenbosch University.

Aim: To determine what Physiotherapy learners and clinical teachers view as effective educational strategies to enhance learning in the clinical environment.

Researcher: Dawn Ernstzen

Tel: [phone] or 021 938 9497

Fax: [phone]

Description of terms used:

Clinical Teacher: All Physiotherapists involved in the clinical learning experience of Physiotherapy students.

Teaching/Learning activities: Activities that the teacher uses, with the aim of enhancing learning.

Important: Has a considerable effect on the learning process.

Facilitation: The teacher helps the learner to discover knowledge and to take ownership of learning.

Clinical reasoning: The cognitive processes (thinking) used in the evaluation and management of a patient.

Problem solving: Steps involved in working toward a solution.

This study is financially supported by The Fund for Research and Innovation in Learning and Teaching (FIRLT), Centre for Teaching and Learning, Stellenbosch University.