ABSTRACT
Background and Purpose
The impact of the COVID-19 pandemic on physiotherapy education meant that innovative responses were needed quickly. This paper describes a scholarly approach to changes within an entry-level physiotherapy program where one of its clinical placements was replaced with a fully online unit during 2020, as well as exploring the experiences of students who completed this newly developed online unit.
Methods
A mixed methods approach was used. Sixteen of a possible 31 students responded to an online survey comprising quantitative and open-ended questions.
Results
The majority of participants were satisfied with the unit and reported that: the unit helped them to learn valuable skills; feedback from educators was helpful; and that they were able to apply to future contexts. Small numbers of students were more ambivalent about the use of online media and tools including discussion boards, the workload and being part of a learning community.
Conclusion
The online unit described in this research is evidence that non-traditional forms of clinical education might also address clinically important learning outcomes, provide sustainable options and alleviate some of the stresses that both tertiary providers and healthcare settings endure. However, these types of placement experiences require a paradigm shift from educators, the profession, accrediting bodies and even future students.
Introduction
Clinical education, a form of health professional placement, fieldwork, or work-integrated learning is a core component of health professional education and preparation for practice. Traditionally clinical education involves students learning in specific healthcare environments via direct patient contact and under the supervision of qualified health practitioners. With the number of physiotherapy programs growing internationally each year, the demand for clinical education experiences is also rising, meaning placements are often difficult to source. Clinical education places pressure on healthcare systems too as education needs to be balanced against patient care. Fieldwork is inherently risky and there are financial costs to be considered too. Many of these factors have become more challenging recently as a result of the pandemic and in light of an increasingly stretched health workforce.
The pandemic had an immediate effect on the ability of tertiary providers to provide such clinical education experiences to health professional students. Anecdotally, every Australian physiotherapy program (degree) was impacted in some way; it is likely that that claim could be made of every health professional program across the globe. A key impact was that healthcare providers withdrew placement opportunities in order to free frontline staff for patient facing roles and to streamline their services so as to respond to the uncertainty of the pandemic. The inability to provide placements had potential consequences for the progression of students through their enrolled program, raising issues for the graduation of students and their ability to join the workforce at a time of great need. It was also in the best interests of tertiary providers to both retain and graduate students. Innovative responses were required and quickly.
Some responses from physiotherapy programs took professional placements into new realms focusing on different roles of the health practitioner such as research (Dario and Simic, Citation2021) and project management (Lawton, Vaughan, Jones, and Pacey, Citation2021). However, many responses across healthcare programs remained focused on placement experiences directed toward clinical care through simulated placements using mannequins and simulated participants, telemedicine, online and/or virtual placement replacement modules involving case studies and consolidation of practice-based skills (Dadswell, Williams, Bowser, and Hughes, Citation2021; Diaz and Walsh, Citation2021; Hong et al., Citation2020; Lawton, Vaughan, Jones, and Pacey, Citation2021; Prasad et al., Citation2020; Salter, Oates, Swanson, and Bourke, Citation2020; Twogood, Hares, Wyatt, and Cuff, Citation2020).
Some of the existing literature about curricula responses during the pandemic is descriptive rather than evaluative, and the responses more practically oriented than educationally informed. This paper adds to those conversations, by describing a scholarly approach within an entry-level physiotherapy program that replaced one of its clinical education experiences with a fully online unit during the height of the pandemic in 2020 as well as exploring the experiences of students who completed this newly developed online unit. It is a response to the call by Cleland et al. (Citation2020) to educators: “to record and evaluate their educational innovations implemented in response to COVID-19. The world post COVID-19 is going to be a different world, socially, financially and educationally. The information collected during these difficult times will probably shape the future of health professions’ education and training forever and in doing so, could just lead to real transformative and transformational learning for all of us”.
This scholarship has the potential to create change in the way that professional education is thought about and enacted in physiotherapy, other health professions and potentially other professions too. These changes include creating more flexibility in degree programs, saving costs, reducing risk and easing pressures on industry that often has dual responsibilities for patients/clients/customers and students.
Background context
To be an approved course of study in Australia, tertiary entry-level physiotherapy programs must demonstrate that the quality and quantity of clinical education is sufficient to produce a graduate competent to practice with a range of individuals and populations from across the lifespan in a range of environments and settings (Australian Physiotherapy Council, Citation2021a). The accreditation standards are outcomes focused rather than specifying a particular model or total number of clinical hours (Australian Physiotherapy Council, Citation2021b). During the early stages of the pandemic, the Council recognized the challenges to both the healthcare and educational sectors and was suitably responsive in its governance processes (Australian Physiotherapy Council, Citation2020).
The two-year graduate entry-level Masters physiotherapy program of an Australian tertiary institution provides the context for this research. The program comprises 18 units (subjects), four of which are clinical placements located at partner healthcare organizations. Students complete two clinical placements at the end of the first year of study, and the remaining two during their second (final) year. Clinical placements are assessed using a nationally recognized tool, the Assessment of Physiotherapy Practice (APP) (Keating, Dalton, and Davidson, Citation2009). The APP reflects the Physiotherapy practice thresholds and the minimal level of competence needed by a graduating physiotherapist (Physiotherapy Board of Australia and Physiotherapy Board of New Zealand, Citation2015). In essence the 20 APP criteria inform institutional unit learning outcomes for placement oriented units. The program of focus in this study is based in Melbourne (Victoria), which had one of the longest series of lockdowns in the world between March 30, 2020 and October 26, 2021, totaling 257 days across six different lockdowns. The first cohort enrolled in mid-2019, meaning the program was in its infancy when the pandemic, restrictions and lockdowns were announced and enforced. In early April 2020, it was clear that there would not be a sufficient number of clinical placements to offer to all students in May when the students’ first clinical placement was scheduled; placement offerings by partner organizations were reduced in all of the different placement teaching periods but not in totality. This meant that providing the four placement experiences as scheduled for each student was impacted, potentially delaying program completion and graduation for the whole first cohort; if this happened, there would likely be subsequent impact on future cohorts as well, especially given the number of lockdowns that resulted in Victoria. The disruption to normal practice however provided an opportunity for change. The Master of Physiotherapy responded by designing and delivering a fully online placement experience, replacing one entire clinical placement unit within the program. This unit was offered to students when face-to-face placement offerings were low or restricted, meaning that the online unit was offered three times across 2020 (i.e. some students were on placement while others were learning online).
While the unit was a pragmatic response in some respects with only two weeks notice to develop the curriculum, a strength of the design was that it also drew on pedagogical theory including:
1) practice-based education: curriculum that has practice (i.e. the customary activities of a profession, its sayings and doings and its people) as its central, organizing feature (Boud, Citation2012); 2) simulation: an educational practice that places learners in situations that replace or amplify real experience (Gaba, Citation2007); 3) ways of thinking and practicing: the knowledge base, methods, values, philosophies and worldview of a discipline (Anderson and Hounsell, Citation2007; Barradell, Barrie, and Peseta, Citation2018; Hounsell and Anderson, Citation2009); 4) sustainable assessment: assessment for [formative] and of learning [summative] but also considering learning needs during future placements (Boud, Citation2000); and 5) purposeful online interactions with content/resources, peers and educators (Bernard et al., Citation2009; Mehall, Citation2020).
Physiotherapy clinical placements, at least in Australia, are characterized by continuous assessment using the APP (Keating, Dalton, and Davidson, Citation2009) and small student to staff ratios. They tend to be focused on direct patient care of individuals, located in public health settings although this focus is shifting and, at a minimum, providing learning opportunities in the areas of cardiorespiratory, musculoskeletal and neurological physiotherapy. The structure of the unit and the design of activities () was informed by these characteristics and aimed to replicate aspects of a placement journey and areas of competence (i.e. APP criteria) (Supplementary Material) that students would be assessed on. The online environment however afforded an opportunity to more easily follow a patient journey through the healthcare system (i.e. across weeks and months) and explore different areas of practice than a face-to-face placement ordinarily would. Simulated case notes, including videos, photos and scans, were utilized in almost all activities. There were three assessments: 1) completion of, and participation in, weekly activities contributed to a continuous assessment for learning (individual); 2) a series of case-based tasks over a week that contributed to formative assessment (individual); and 3) a group discussion board related to prioritization of a service caseload that was also a formative assessment.
Table 1. Outline of unit activities mapped to Assessment of Physiotherapy Practice (APP).
Table 2. Activities for the Guillain Barre Syndrome (GBS)* case.
Methods
Design
A mixed methods approach was adopted to explore different aspects of the student experience of the online unit that replaced one of the program’s professional placements. Ethics approval was obtained from the Human Research Ethics Committee of Swinburne University of Technology (20204300–5733).
Participants
Purposeful sampling was used to recruit participants with all Master of Physiotherapy students enrolled in the unit in 2020 invited to participate.
Procedure (data collection and analysis)
A survey link was provided to all enrolled students through an announcement on the learning management system (i.e. Canvas). The survey was administered via Qualtrics and completion of areas of the survey indicated consent. The survey included both closed and open-ended questions. The closed questions used a 10-point scale that was familiar to students as it was also used in the university’s unit student feedback processes. Descriptive statistics were performed to analyze. The open questions are indicated within the Results section. Due to the small sample and smaller number of responses, a simple inductive thematic analysis was performed to summarize the key points reflected in these responses. Analysis commenced only after all students had completed the unit (i.e. at the end of the third teaching of the unit). All responses were read in their entirety first to get a sense of the students’ experience as a whole. Responses were then read more closely to isolate words and statements. This form of coding was guided by the following questions (Liamputtong, Citation2020): What is the mentioned concern or course of events; Who is involved or mentioned; In what ways is the concern mentioned (i.e. strength, helpful, and limiting); How often is the concern represented; Are reasons provided; and Are suggestions provided? Subsequent analysis looked for the experiences that were common or shared across the students’ responses. These commonalities are summarized within the Results.
Results
Sixteen of a possible 31 participants completed aspects of the survey ().
Table 3. Participants.
Closed questions
represents the results from the closed questions (i.e. quantitative part of the survey) as descriptive statistics (i.e. mean, standard deviation and mode). The responses indicate very high levels of satisfaction across the surveyed areas.
Table 4. Survey results.
Open ended questions
represent the raw data from the survey’s four open-ended questions, accompanied by a summary analysis here. The majority of participants were satisfied with the unit and indicated that the unit helped them to learn valuable skills and that they were able to apply their learning to future contexts. Specific cases and modules based around healthcare settings (i.e. acute, subacute, and community) rather than streams (i.e. cardiothoracic, musculoskeletal and neurological) appeared to help students to consolidate their past learning. Students seemed to be appreciative of the response made to keep them progressing through the course and clinical placement suites. Students generally found feedback from educators to be helpful and particularly enjoyed the synchronous classes, which provided an opportunity to formally connect with peers, staff and content. Some students found the workload for the unit high. Others appreciated the accountability that came with regular deadlines; key advice to other students was focused on time management. Suggested areas of improvement related to timing of release of case information and quantity of feedback. Small numbers of students were also ambivalent about the use of online media and tools including discussion boards and being part of a learning community.
Table 5. Responses to question: Considering both the limitations associated with the COVID-19 crisis and the aims and objectives of the unit, please comment on your experiences during this unit and their influence on your professional growth and development.
Table 6. Responses to question: In my opinion, the strengths or best aspects of this unit were.
Table 7. Responses to question: In my opinion, areas of this unit that could be improved are….
Table 8. Responses to question: If I were to give advice to another student who is considering taking this unit in the future, I would say….
Discussion
The online unit described in this research is evidence that non-traditional forms of clinical education might also address clinically-relevant learning outcomes, provide sustainable options and alleviate some of the stresses that both tertiary providers and healthcare settings endure. It is not proposed that units such as the one investigated here should fully replace clinical education. Clearly many areas of physiotherapy necessitate actual contact with patients and clinical personnel. Furthermore, a complex situationism exists in workplace learning that contributes to professional socialization and identity formation (Kell, Citation2014). Students learn the ways of thinking and practicing of a profession through seeing, doing and experiencing with and alongside others in healthcare settings. However, being a health professional involves a range of different roles and responsibilities such as self-directed learner, collaborator, leader and researcher and not all learning needs to happen face-to-face or in direct contact with others. The student responses suggest that the online learning environment helped them to develop relevant ways of disciplinary thinking and practicing, at the same time as potentially developing professional attitudes and values.
New types of placement experiences require a paradigm shift from educators, the profession, accrediting bodies and even future students. It is not surprising that many of the responses to placement shortages from health professional programs still involved patient care in some way (i.e. forms of telehealth, mannequins, and remote simulated participants) (Dadswell, Williams, Bowser, and Hughes, Citation2021; Diaz and Walsh, Citation2021; Hong et al., Citation2020; Lawton, Vaughan, Jones, and Pacey, Citation2021; Prasad et al., Citation2020; Salter, Oates, Swanson, and Bourke, Citation2020; Twogood, Hares, Wyatt, and Cuff, Citation2020). Fieldwork involving patient care is a signature pedagogy of the health professions (Shulman, Citation2005). Our learnings from the pandemic suggest that more innovation is possible, feasible and meaningful and might even develop graduates capable of responding to persistent health challenges Barradell (CitationUnder Review).
Becoming a health professional involves many transitions and students often find the changes in contexts and responsibilities challenging (Atherley et al., Citation2019; Kilminster, Zukas, Quinton, and Roberts, Citation2011). The students within this sample reported that the experience helped them to become familiar with certain expectations and conventions and develop strategies they took forward to face-to-face placements. The experience provided an opportunity to connect and integrate learning from university-based subjects that had tended to be structured around siloed areas of practice. The learning environment might be considered a low stakes one in terms of clinically oriented learning and seemed to help build their confidence while consolidating their learning. A partially online placement or even an online experience of reduced length could reasonably achieve the same benefits and ease the transition from university to healthcare environments. For example, the first few weeks of an initial placement might be located in the relative safety of the online space before students begin at a clinical site, or an orientation experience might happen for a week or two online before students transition to health settings. Additionally, similar models could be a significant opportunity globally for developing health professional capabilities in professionals seeking qualification recognition in another country or from resource poor regions, as well as areas where geographical barriers impact opportunities for face-to-face interactions. More investigation about different models of professional learning or learning experiences is warranted.
This unit was developed quickly in response to a crisis situation and as such might be considered to represent a form of “emergency remote teaching” (Hodges et al., Citation2020). No educational design support was provided, information technology support was limited to routine help with (understandably) very long wait times, other resourcing was very lean (i.e. staff workload), existing case-based resources were utilized albeit in new and unintended ways and only available infrastructure was employed (i.e. the university learning management system). The design and development was also necessarily context dependent (Tolsgaard, Cleland, Wilkinson, and Ellaway, Citation2020) and mindful of: institutional responses to the pandemic; needs of industry partners and the profession; future development as the physiotherapy program had not yet graduated its first cohort; and the local and national healthcare contexts. In light of these constraints the positive student experience is truly commendable. Despite a lack of sophisticated online features, the unit did adopt a consistent learning design plan and structure aiming to connect learners with content, peers and educators; that approach aligned with the institution’s subsequent blended learning framework. It is likely that with focused professional development and a relatively small financial outlay that the unit design and activities could be developed in ways that shift it more toward being representative of online learning not “panicgogy” (Annamalai, Tangiisuran, and Daud, Citation2022).
While the impetuses for the development and delivery of this unit were placement shortages and student progression, a strength was its consideration and application of educational scholarship and practice. Physiotherapy education demands the same scholarly attention as clinical practice (Barradell, Citation2017, Chipchase, Dalton, Williams, and Scutter Citation2009; Patton, Higgs, and Smith, Citation2013). Not only was the unit development attentive to the rhythms and routines of a placement experience, it considered evidence-based ways to make the learning experience meaningful and help students to learn necessary professional learning outcomes. Physiotherapy is a practice profession and the focus of physiotherapy education is on students learning about what physiotherapists do, with whom, when and where (Barradell, Peseta, and Barrie, Citation2021). In Australia, those practices are assessed against the APP. The activities within the online unit mapped to most of the APP criteria, with the exception of areas requiring certain hands-on or demonstrable skills. With more resourcing and longer development times, it would be possible to address more of the criteria and/or in more depth and areas of practice through, for example, telehealth options, curated simulations and video analysis, to further enhance the authenticity of activities.
Students enroll in physiotherapy programs with expectations of what they will learn and how (Barradell, Citation2023; Barradell, Peseta, and Barrie, Citation2017). There was some resistance from a small number of students who were disappointed not to have 100% of their clinical program in a healthcare setting. This disappointment is reflected in some of the responses to the open ended questions. The survey also indicates that some students were not prepared for the study workload, despite clinical placements involving 32 contact hours per week and additional personal study time. The uncertainty of the pandemic, the sudden and unrelenting changes to policy and processes and the impact of isolation and restrictions is likely to be associated with how students were feeling and responded, as well as a lack of awareness and understanding about the demands of learning in clinical environments. Staff were also not immune to the psychological and emotional toll of the pandemic’s impact and quickly became aware themselves of how much longer tasks took to complete. A reduced daily load was factored in to the assigned tasks but it is possible more could have been done to support students to feel less anxious and manage expectations. Interestingly, there is some evidence from occupational therapy contexts that suggests that students who transitioned to fully online learning contexts experienced high levels of motivation and self-directed learning although their learning was not necessarily enjoyable (Brown et al., Citation2022). There will always be tensions between student engagement and satisfaction, highlighting the importance of developing capabilities such as agency and resilience.
Limitations and future research
The participant sample is small however it is drawn from the entirety of the population of students who shared experience of the online unit. The study did not seek to explore academic performance, although this information may be interesting especially as to whether the sequence of clinical placement experiences (i.e. online unit before face-to-face placement) had any relationship to results.
The unit was only operationalized in 2020 when placements were very difficult to source. All placement units have since returned to face-to face experiences in traditional healthcare settings. However, this practice is under review as placement demand again increases, this time now also in response to rapid enrollment growth.
Data about staff experiences was not collected and this would have provided a useful perspective. O’Brien et al. (Citation2023) however provided institutional interdisciplinary insight from health professional colleagues that is likely to have some crossover. Lastly, the research did not explore costs associated with the online unit, but this would help to understand the longer-term viability of alternative forms of clinical education.
Conclusion
This research describes and evaluates an alternative form of physiotherapy placement. While the motivation for its development was triggered by the impact of the COVID-19 pandemic, it connects practice-based knowledge and educational scholarship and represents a paradigm shift in terms of enculturation to practice. Moving forward, hybrid forms of curriculum, teaching and learning are likely to become more of the norm in entry-level health professional programs, and partially online placements or use of online modules for certain learning interactions, such as transitioning from university to healthcare settings, may be very valuable. Such changes could create more flexibility in programs, save costs, reduce risk and ease pressures on staff. Additionally, hybrid or online models might be of benefit in other areas of health professional education where resourcing is limited or geographical challenges exist. It is important that innovations are informed by both pedagogical and professional knowledge and initiatives are evaluated from multiple perspectives.
Supplemental Material
Download Zip (104.3 KB)Acknowledgments
Thank you to physiotherapy colleagues who were involved in the delivery of this unit and to the Council of Physiotherapy Deans of Australian and New Zealand who shared resources that were utilized in the development of this unit. Thank you also to Amani Bell for providing valuable feedback in the draft stages.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Supplementary material
Supplemental data for this article can be accessed online at https://doi.org/10.1080/09593985.2023.2231529.
Additional information
Funding
References
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