AJHPE Vol 6, No 2 (2014) by HMPG

AJHPE

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African Journal of Health Professions Education

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AJHPE

African Journal of Health Professions Education | October 2014, Vol. 6, No. 2, Suppl 1 EDITORIAL

EDITORIAL BOARD EDITOR-IN-CHIEF Vanessa Burch University of Cape Town

SUPPLEMENT EDITOR Susan Hanekom Stellenbosch University INTERNATIONAL ADVISORS Deborah Murdoch-Eaton Sheffield University, UK Michelle McLean Bond University, QL, Australia

178 Mapping of a curriculum renewal journey: Lessons learned S Hanekom

SENIOR DEPUTY EDITORS Juanita Bezuidenhout Stellenbosch University

R ESEARCH 180 Deriving criteria by which to determine core curriculum content: A high engagement process S D Hanekom, M Unger, F Cilliers

Jose Frantz University of the Western Cape

185 Does a problem-based learning approach benefit students as they enter their clinical training years? Lecturers’ and students’ perceptions S B Statham, G Inglis-Jassiem, S D Hanekom

DEPUTY EDITORS Jacqueline van Wyk University of KwaZulu-Natal Julia Blitz Stellenbosch University ASSOCIATE EDITORS Francois Cilliers University of Cape Town

192 What does an enquiry-based approach offer undergraduate physiotherapy students in their final year of study? G Inglis-Jassiem, S Statham, S D Hanekom

Lionel Green-Thompson University of the Witwatersrand

198 Integrating evidence-based principles into the undergraduate physiotherapy research methodology curriculum: Reflections on a new approach M Burger, Q A Louw

Ntombifikile Mtshali University of KwaZulu-Natal

203 Teaching my peers: Perceptions of tutors in physiotherapy practical skills training M Unger, L Keiller, G Inglis-Jassiem, S D Hanekom

Ben van Heerden Stellenbosch University

207 Evaluation of clinical sites used for training undergraduate physiotherapy students: Factors that may impact on learning L G Williams, D V Ernstzen, S B Statham, S D Hanekom 211 Learning experiences of physiotherapy students during primary healthcare clinical placements D V Ernstzen, S B Statham, S D Hanekom

Dianne Manning University of Pretoria

Marietjie Nel University of the Free State

Marietjie van Rooyen University of Pretoria Gert van Zyl University of the Free State Elizabeth Wolvaardt University of Pretoria

HMPG

Editor Janet Seggie

217 Physiotherapy students’ perceptions about the learning opportunities included in an introductory clinical module D V Ernstzen, S B Statham, S D Hanekom

Consulting Editor JP de V van Niekerk

222 Benefits of curriculum renewal: The Stellenbosch University physiotherapy experience M Unger, S D Hanekom

Editorial Systems Manager Melissa Raemaekers

Deputy Editor Bridget Farham

Scientific Editor Ingrid Nye Technical Editors Emma Buchanan Anne Hahn Paula van der Bijl Head of Publishing Robert Arendse Production Coordinator Bronlyne Granger Art Director Brent Meder DTP & Design Carl Sampson Online Manager Gertrude Fani ISSN 1999-7639

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Editorial Mapping of a curriculum renewal journey: Lessons learned If students can’t learn the way we teach, maybe we should teach the way they learn. (Ignacio Estrada)

A curriculum is described as an expression of educational ideas in practice.[1] It is a living document which should be adaptable to a changing environment. When faced with specific contextual challenges that required curriculum renewal, we took a phronetic approach. The process was predominantly based on craft knowledge and relied in most part on the insightfulness of staff. The curriculum renewal provided a unique opportunity to evaluate both the content and the mode of delivery. In this edition of AJHPE we share the valuable lessons learned along the journey of curriculum renewal. We started with the end in mind by defining the profile of the Stellenbosch University physiotherapy graduate (Table 1). The curriculum aimed not only to assist the development of physiotherapy-specific knowledge and psychomotor skills but also to develop generic skills (graduate attributes), which would equip our students to practise as first-line practitioners within the South African healthcare context. This

is in line with an editorial in the Lancet which states that curricula should be designed to think

globally but to act locally.[2] The curriculum is vertically and horizontally aligned (Fig. 1).

Registered physiotherapist

Physiotherapy practice

Clinical physiotherapy

Research methodology

Real world Applied physiotherapy

Human sciences (psychology; sociology)

Pathology

Pharmacology

Physiotherapy science

Basic sciences (chemistry; physics; biology)

Medical sciences (anatomy; physiology)

Fig. 1. Structure of the curriculum.

Table 1. Profile of the Stellenbosch University physiotherapy graduate The recently graduated Stellenbosch University physiotherapist will have the basic knowledge and skills to function in the South African health context as a reflective practitioner within the philosophy and values intrinsic to the physiotherapy profession This philosophy and the values of the physiotherapy profession are encapsulated in three domains, namely professional accountability, client management and the organisation of services. The qualities of the recently graduated physiotherapist are reflected as follows within the three domains: Professional accountability • Be ethically accountable towards the profession, client and community • Execute a safe, effective and professional practice • Demonstrate a positive attitude in terms of continued professional development • Develop interpersonal relationships • Comprehend the importance of involvement with professional organisations • Communicate appropriately and effectively with clients, family members as well as with other healthcare team members Patient management • Demonstrate knowledge of the normal and abnormal functioning of the human body and psyche • Show insight in terms of the impact of cultural environment on the outcomes of health services • Possess the necessary skills to evaluate a client’s status (physical, functional and psychological), to analyse his/her needs and be able to formulate a physiotherapy diagnosis and prognosis • Be able to develop an outcomes-based intervention plan and to implement it based on evidence-based practice • Should be able to re-evaluate the effectiveness of this intervention and incorporate the findings in future practice Organisation of services • Should be able to plan, implement and evaluate appropriate, cost-effective physiotherapy services within the South African health context • Use appropriate technology to support, analyse and improve physiotherapy services

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Editorial Identifying the core content of a curriculum is a daunting task. Hanekom et al.[3] describe the use of a high engagement methodology to determine the core content within the context of an expanding professional knowledge base. In addition to defining the content, curriculum designers have lobbied for the inclusion of a variety of didactic strategies to optimise learning and adequately prepare students to function in a dynamic environment.[4] Student-centered approaches were explored which could provide learning opportunities to facilitate the development of professional and generic skills. Despite a body of work describing the use of problem-based (PB) and enquiry-based (EB) approaches to learning, these two pedagogical approaches remain controversial.[5] Statham et al.[6] compare the perceptions of students and staff to the success of a hybrid PB learning module using a theorybased evaluation approach. Inglis-Jassiem et al.[7] report on the lessons learned when implementing an EB approach to learning. Two examples of pedagogical innovation are included in this edition.[8] Evidence-based practice (EBP) is widely recognised as a key skill for health professionals. Developing competent evidence-based practitioners on entry to the profession is a cornerstone of an undergraduate programme. Burger and Louw[9] explain the rationale for adopting a secondary research approach as a vehicle to teach the principles of EBP as part of the undergraduate physiotherapy research module. In addition they share implementation strategies and lessons learnt on this path of restructuring. The five-step model has been offered as a simple and an efficient model for clinical skills training.[10] However, increasing student numbers hinder the immediate feedback, correction and reinforcement needed to cement the correct performance. Unger et al.[11] describe an innovative strategy using near-peer-assisted tutorials to address this challenge. The data reflect the added value of this strategy to the professional development of tutors. The primary aim of the undergraduate programme is to produce competent physiotherapists who can function as first-line practitioners on entry to the profession. The importance of providing authentic learning opportunities in this process is widely acknowledged. Three papers in this edition focus on clinical education. While much has been written about the social aspects of clinical environments there is a paucity of data on the physical requirements of clinical placements.[12] Williams et al.[13] describe the clinical sites and exposure of students based on a self-developed site evaluation tool. The importance for academic institutions to develop partnerships with health service providers is evident from the data. They argue for a more active role of universities in the development of clinical education sites. Ernstzen et al.[14] explore whether the learning experiences of the primary healthcare clinical rotation was appropriate to enable students to reach the learning outcomes for the rotation. The data highlight the need for programme designers to evaluate and align learning opportunities that are offered at clinical sites. A second paper by Ernstzen et al.[15] adds to the conversation around transitional issues experienced by students on entry to the clinical environment.[16] The clinical learning opportunities perceived by learners to assist in the transformation from classroom to clinical practice are presented.

While curriculum renewal in health education is not novel, Unger and Hanekom[17] reflect on the impact of the process. The reflection is based on data comparing the perceptions of students from the ‘old curriculum’ with the revised curriculum. It is hoped that by sharing our experiences of a curriculum renewal process, debate can be stimulated: (i) within the physiotherapy profession regarding future curriculum content and design; and (ii) among educationalists regarding strategies to optimise the training of healthcare professionals in a resource-restricted environment. Susan Hanekom Supplement editor sdh@sun.ac.za

1. Thomas PA, Kern DE. MPH internet resources for curriculum development in medical education: An annotated bibliography. Gen Intern Med 2004;19(5):599-605. [http://dx.doi.org/10.1111/j.1525-1497.2004.99999.x] 2. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. Lancet 2010;376(9756):1923-1958. [http://dx.doi.org/10.1016/S01406736(10)61854-5] 3. Hanekom SD, Unger M, Cilliers F. Deriving criteria by which to determine core curriculum content: A high engagement process. African Journal of Health Professions Education 2014;6(2 Suppl 1):180-184. [http://dx.doi. org/10.7196/AJHPE.496] 4. Abela J. Adult learning theories and medical education: A review. Malta Medical Journal 2009;21(1):11-18. 5. Colliver JA. Effectiveness of problem-based learning curricula: Research and theory. Acad Med 2000;75(3):259-266. [http://dx.doi.org/10.1097/00001888-200003000-00017] 6. Statham SB, Inglis-Jassiem G, Hanekom SD. Does a problem-based learning approach benefit students as they enter their clinical training years? Lecturers’ and students’ perceptions. African Journal of Health Professions Education 2014;6(2 Suppl 1):185-191. [http://dx.doi.org/10.7196/AJHPE.529] 7. Inglis-Jassiem G, Statham SB, Hanekom SD. What does an enquiry-based approach offer undergraduate physiotherapy students in their final year of study? African Journal of Health Professions Education 2014;6(2 Suppl 1):192-197. [http://dx.doi.org/10.7196/AJHPE.532] 8. Graffam B. Active learning in medical education: Strategies for beginning implementation. Med Teach 2007;29(1):38-42. 9. Burger M, Louw QA. Integrating evidence-based principles into the undergraduate physiotherapy research methodology curriculum: Reflections on a new approach. African Journal of Health Professions Education 2014;6(2 Suppl 1):198-202. [http://dx.doi.org/10.7196/AJHPE.516] 10. George JH, Doto FX. A simple five-step method for teaching clinical skills. Fam Med 2001;33(8):577-578. 11. Unger M, Keiller L, Inglis-Jassiem G, Hanekom SD. Teaching my peers: Perceptions of tutors in physiotherapy practical skills training. African Journal of Health Professions Education 2014;6(2 Suppl 1):203-206. [http:// dx.doi.org/10.7196/AJHPE.497] 12. McCallum CA, Mosher PD, Jacobson PJ, Gallivan SP, Giuffre SM. Quality in physical therapist clinical education: A systematic review. Physical Therapy 2013;93(10):1298-1311[http://dx.doi.org/10.2522/ptj.20120410] 13. Williams L, Ernstzen DV, Statham SB, Hanekom SD. Evaluation of clinical service sites used for training undergraduate physiotherapy students in a resource-restricted environment: Identifying factors that may negatively impact on students’ learning. African Journal of Health Professions Education 2014;6(2 Suppl 1):207-210. [http:// dx.doi.org/10.7196/AJHPE.528] 14. Ernstzen DV, Statham SB, Hanekom SD. Learning experiences of physiotherapy students during primary healthcare clinical placements. African Journal of Health Professions Education 2014;6(2 Suppl 1):211-216. [http://dx.doi.org/10.7196/AJHPE.530] 15. Ernstzen DV, Statham SB, Hanekom SD. Physiotherapy students’ perceptions about the learning opportunities included in an introductory clinical module. African Journal of Health Professions Education 2014;6(2 Suppl 1):217-221. [http://dx.doi.org/10.7196/AJHPE.524] 16. Le Maistre C, Pare A. Learning in two communities: The challenge for universities and workplaces. Journal of Workplace Learning 2004;16(1/2);44-52. 17. Unger M, Hanekom SD. Benefits of curriculum renewal: The Stellenbosch University physiotherapy experience. African Journal of Health Professions Education 2014;6(2 Suppl 1):222-226. [http://dx.doi.org/10.7196/AJHPE.519]

AJHPE 2014;6(2 Suppl 1):178-179. DOI:10.7196/AJHPE.527

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Research Deriving criteria by which to determine core curriculum content: A high engagement process S D Hanekom,1 MSc (Physio), PhD; M Unger,1 MSc (Physio), PhD; F Cilliers,2 MB ChB, BSc (MedSc) Hons, MPhil (Higher Education), PhD Division of Physiotherapy, Department of Interdisciplinary Health Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa

Education Development Unit, Faculty of Health Sciences, University of Cape Town, South Africa

Corresponding author: S Hanekom (sdh@sun.ac.za)

Background. During curriculum revision, an important task is identifying a core curriculum. Deciding what criteria to use to determine core content is crucial and impacts on graduate outcomes and patient care. Objective. To identify criteria to apply in order to determine core content. Methods. A high engagement process involving eleven staff and two undergraduate student representatives was used. The process consisted of a stimulus question; brainstorming; sharing, clarification and clustering of ideas; second-phase brainstorming, clarification and clustering; prioritisation; and finally vote tally and categorisation. Results. The group initially identified 28 criteria to use when deciding on core content. The criteria were reduced stepwise to 15, and finally 3 criteria that enjoyed widespread support were identified. Content would be included in the curriculum if: (i) it was relevant to the South African context; (ii) it would ensure safe and effective practice by first-line practitioners; and (iii) it was evidence-based. Conclusion. The process lends itself to the participation of multiple stakeholders in an engaging yet anonymous manner. It helps ensure that all voices are heard and ideas included in prioritisation. The process easily manages a multiplicity of ideas; similar ideas are efficiently identified and clustered. Finally, the process is time-efficient. AJHPE 2014;6(2 Suppl 1):180-184. DOI:10.7196/AJHPE.496

When revising a curriculum, a common task is identifying a core curriculum.[1,2] Curriculum designers are confronted with an array of new things that beg for inclusion in contemporary health professions education curricula.[3,4] An ever-expanding knowledge base provides an enticing and growing menu of content to include. Professions, and the health profile of communities they serve, change over time. Ideas like graduate attributes, interprofessional education and social accountability are propagated.[5] This places ongoing pressure on those entrusted with managing the curriculum. Is the curriculum relevant? Can graduates be prepared, in the time available, to tackle the challenges they will face? The expansion of new knowledge and a greater understanding of existing knowledge have characterised the coming of age of physiotherapy as a profession. Since first being published online in 1999, the number of randomised controlled trials (RCTs) indexed in the physiotherapy evidencebase database (PEDro) have doubled every 3 - 5 years.[6] In 2010 it was calculated that 18 000 RCTs and 3 500 systematic reviews of RCTs were indexed in PEDro. It has been argued that with the expansion of information, knowledge should be greater and practice should be more effective.[7] As regards changing population healthcare needs, the World Health Organization (WHO) has highlighted the increased prevalence of lifestyleassociated diseases.[8] Within the context of global economic changes the expectation is that the prevalence of these diseases is also likely to increase in the developing world, while the impact of infectious diseases (like HIV infection, tuberculosis and malaria) is still worrying. Some have argued that this change in disease profile necessitates a realignment of physiotherapy practice[9] and consequently the education of therapists. These changes are forcing expansion of the scope of physiotherapy practice.

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However, the time available to teach physiotherapy-specific skills and knowledge at an undergraduate level is limited.[10] The South African Qualifications Authority (SAQA) requires that 4-year bachelor degrees be limited to 480 credits, where one credit equals 10 notional hours. There are thus 1 200 hours available per year for students to attend structured academic activities, study, and complete assignments and assessments. This includes a minimum of 1 000 hours for clinical training that is mandated over the 4-year period. Facilitating the development of critical cross-field outcomes in higher education and generic graduate attributes of healthcare professionals is also increasingly being recognised, [5] and therefore requires dedicated time. Another challenge faced by physiotherapy curriculum designers in South Africa, is that entry-level programmes are required to deliver professionals who can practise as unsupervised first-line practitioners on graduation.[11] This is in contrast to professions like medicine, accountancy and law, where graduates have to complete a supervised internship before assuming an independent professional role. All of the factors outlined above directly challenge curriculum content. One approach to managing these competing demands is the identification of a core curriculum. The concept of a core curriculum is not new.[12,13] Various reasons have been advanced for adopting a core curriculum; prime among these is content overload, which has a negative influence on the quality of student learning: ‘Students haven’t forgotten, they never learned that which we assumed they had. In demanding coverage of a broad landscape of material, we often win the battle but lose the war. We expose the students to the material and prepare them for the tests, but we don’t allow them to learn the concepts.’[14]

Research The very idea of â&#x20AC;&#x2DC;coreâ&#x20AC;&#x2122; implies criteria by which content is determined to be core or not, yet deciding what those criteria are and applying them is not straightforward.[15] Various methods have been described to determine core content. These include the use of document analysis,[16] questionnaires,[2,17] the Delphi technique[3] and interdisciplinary or inter-institutional working groups.[18,19] Given the potential impact on graduates of these judgments, deciding what criteria should be used to determine core content is crucial. Furthermore, if the process of determining and applying these criteria is alienating to some lecturers, the likelihood is that the resultant curriculum will not be fully implemented as planned.[1] When the undergraduate physiotherapy curriculum at Stellenbosch University (SU) was revised, the decision was therefore taken to use a consensus-building process to determine criteria to apply to determine core content. Three consensusbuilding processes have been described in the healthcare context. These include the nominal group technique (NGT), the Delphi process and a consensus development conference.[20] These structured methodologies attempt to overcome issues associated with group decision-making processes by allowing all participants to contribute to the discussion. The aim of this paper is to describe the high engagement process we used to reach consensus.

Methods Participants

All full-time staff members of the physiotherapy division at SU in 2006 were invited to participate. In addition two final-year students who were elected members of the undergraduate programme committee were also invited. The reason for limiting participation was twofold: (i) during a major curriculum update in 1999 the structure and content of the physiotherapy curriculum were renewed after consultation with key stakeholders including clinicians, students and multidisciplinary team members; and (ii) time and financial constraints precluded the advocated involvement[1,21] of role players outside of the university. The renewal of the curriculum included an update of the content, and organisation of the curriculum within the existing structure.

Process

An institutional staff member from the universityâ&#x20AC;&#x2122;s Centre for Teaching and Learning facilitated the session. The facilitator holds qualifications in medicine and higher education and was trained in the Participlan process.[19] This process was adopted as it allowed full, anonymous participation from all group members. It also allowed visual display of all ideas, thus ensuring that at the stage of prioritisation, all ideas were visible for consideration. Power differentials in the group, e.g. between senior and junior staff, and between students and staff, were thus diminished. Furthermore, no single member of the group could dominate discussions and steer the outcome in a particular direction. The outcome of the process therefore represented the opinion of the group rather than any one or two persuasive, articulate and powerful members of the group. A six-step process was used. In preparation for the session, large sheets of paper were affixed to the wall of the venue. Participant contributions, written on sheets from small note pads, were subsequently attached to these display sheets. Step 1. Stimulus question The following open-ended question was posed to all participants: Which criteria will we use to define the core content of the revised curriculum? The question was posed verbally and a printed version was attached to one of the display sheets against the wall. Step 2. Brainstorming Participants were afforded the opportunity to brainstorm ideas and jot their ideas down on small note pads. This step was completed individually by all participants in silence. Participants were instructed to write each idea on a separate page. Step 3. Sharing, clarification and clustering of ideas Participants were each invited to select three ideas they felt particularly strongly about. The selected pages were handed to the facilitator. The facilitator read each idea aloud. Participants then guided the placement of the ideas on the display sheets. If an idea was similar to an idea already displayed, it was placed touching that idea. If an idea was new, it was placed separately.

Table 1. Profile of participants Area of interest

Highest qualification

Experience (clinician, years)

Experience (academic, years)

Cardiopulmonary

MSc

Paediatric neurology

BSc Hons

Orthopaedics; sport injuries

MSc

Orthopaedics

BSc

Orthopaedics; neuro-musculoskeletal

M Phil

Adult neurology

Diploma

Orthopaedics

PhD

Orthopaedics

BSc

Community health; paediatric neurology

MSc

Paediatric neurology; exercise

MSc

Orthopaedics; biomechanics

MSc

Student 1

Completed fourth year

Student 2

Completed third year 10.82 (5.35)

10.27 (6.36)

Mean (SD)

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Research Participants were invited to comment on or interrogate any ideas that were displayed, as well as question how the clusters of ideas were being developed. In some instances, clusters of ideas were separated into two or more clusters when it became evident that similar but distinct ideas had been incorporated in a cluster. In other instances, two separate clusters were merged when it became apparent that they related to the same idea. During this process, there was no onus on the participant whose idea was under discussion to take ownership of the idea. Anonymity of contributions was thus preserved. Step 4. Second-phase brainstorming, clarification and clustering After all first-round ideas had been placed, participants were afforded the opportunity to select any further ideas they had written down and that were not already represented on the display sheets for discussion and placement. Participants could also write down and submit new ideas. Step three was then repeated.

Step 5. Prioritisation Participants were each given three adhesive dots with which to vote. Each cluster of ideas was numbered and participants selected the three clusters they wished to vote for. Participants then stuck their dots to the label identifying each cluster they wished to vote for. Step 6. Vote tally and categorisation Votes were tallied to identify the criteria enjoying most support. These criteria were subsequently grouped into categories to yield the final set of criteria to be used for the determination of core content for the revised curriculum.

Results

Eleven staff members and two students participated in this process. Participants had a mean (standard deviation (SD)) 10.82 (5.35) number of

Table 2. Results of the six-step process* Steps 2 - 4: Criteria identified by participants

Step 5: Prioritisation n=13 (%)

Step 6: Categorisation

Step 6: Final tally (total votes) n=39

Relevant to [SA] context

14 (33.3)

Minimum skills needed for effective, safe and relevant physiotherapy practice

13 (33.3)

9 (69.2)

Evidence-based

8 (20.5)

5 (38.5)

Minimum building blocks needed

4 (10.2)

Relevant Appropriate to ... [SA]

7 (53.8)

[SA] context Driven by needs → [HPCSA]??? Official national health plan Requirements of practice

7 (53.8)

Prevalent pathology

Patient numbers

Health structures

Safe and effective and an adequate amount of techniques to treat a patient appropriately in SA and internationally

7 (53.8)

Identify the patient that you can help Evaluate↑↑↑; plan ↑↑; do ↑ (hands-on, or refer) Refers to the extent of training: students need to be equipped with skills related to evaluation, planning and management

7 (53.8)

Research findings Evidence-based ‘Evidence’ – knowledge or practical Evidence-based techniques Evidence-based levels Core knowledge on which physiotherapy science is based Basic principles Building blocks basic/base concepts and principles Definition of physiotherapy: role as described by the HPCSA

Clinical value based on expert opinion

Selected techniques ↑↑↑ – basic knowledge of others. Develop other opportunities to expand technique base

Level of the student

International

What is needed to reach the newly defined profile of the Stellenbosch graduate

SA = South Africa; HPCSA = Health Professions Council of South Africa. *Ideas submitted by respondents are reported verbatim.

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Other

Research years’ experience as clinicians and 10.27 (6.36) number of years in academia. The profiles of participants are depicted in Table 1. The group initially identified 28 potential criteria to be used when deciding on core content (Step 3) (Table 2). After Step 4, 15 criteria remained. Following the voting process (Step 5) and categorising of the criteria, 3 criteria were identified to be used to determine the core curriculum (Table 2). The process took 2 hours from start to finish.

Discussion

Through a high engagement process, we identified 3 essential criteria deemed appropriate for determining the core content of a revised undergraduate physiotherapy curriculum that enjoyed widespread support among participants. Content would be included in the curriculum if: (i) it was relevant to the South African context; (ii) it would ensure safe and effective practice by first-line practitioners; and (iii) it was evidence-based. The high engagement process we used has not been widely documented in literature, but is similar in some respects to the NGT.[22] The advantages and drawbacks of the process may therefore be similar to those of the NGT. One distinct advantage of the process described here is that it is very efficient. It could be argued that the degree of challenge posed by a process of reaching consensus within one department is insignificant compared with that of reaching consensus across multiple departments as would be the case in, say, a medical curriculum. However, the process lends itself to the participation of multiple stakeholders in an engaging yet anonymous manner. It helps ensure that all voices are heard and included in prioritisation. We therefore believe that the process would be effective even under more complex circumstances. The generation of too many ideas during the initial process of brainstorming when using the NGT can pose challenges to participants and facilitators.[20,23] In contrast, the Participlan process easily manages a multiplicity of ideas, and duplicate ideas are efficiently identified and clustered as part of the process. Almost half the ideas generated during the brainstorming phase were duplications. This could be an indication that group members were too similar in their thought processes, although as indicated in Table 1, all participants had extensive experience both as clinicians in different fields and as academics. Nonetheless, the ideas generated may not represent those of a broader group.[22] On the one hand, this could have been countered by involving physiotherapists from other institutions and stakeholders from outside of physiotherapy. Subsequent validation of the results of this process by obtaining feedback from stakeholders like students, clinicians and employers could also have addressed this issue. However, as mentioned, resource limitations precluded this eventuality. Furthermore, the goal of this work is to describe the process used. We hope that by publishing our process and outcome we can stimulate conversation and debate around the important question of which criteria should be used to identify core content for undergraduate physiotherapy training. While the NGT has been promoted as a way of reaching consensus, this view is not always supported in the literature.[22] In our case, the process adopted did facilitate attainment of consensus in the group. Group members only voted for 6 of the 15 potential criteria during Step 5; with 1 criterion receiving majority support (evidence-based). We hypothesise that this was because the group decided to retain some criteria as distinct criteria despite apparent similarities. After voting was completed, the group was happy to group similar criteria during

a categorisation process (Step 6). This process clarified the various dimensions of each criterion. The process allowed for all views to be considered equally. The 3 criteria that we ultimately decided on received 89.7% (n=39) of all possible votes. Given the limitations identified above, what of the validity of the criteria identified? Although the purpose of this paper is to describe the process used rather than the results obtained, we believe there is a case to be made for the validity of the criteria identified. Firstly, regarding relevance to the local context, the importance of producing therapists who can address the healthcare needs of specific communities is increasingly being recognised and encouraged. Physiotherapy is an internationally recognised profession and graduates are encouraged to travel abroad. While there are generic skills that define physiotherapy, the scope of physiotherapy practice varies across contexts. The importance of developing curricula which are relevant to the health and social needs of each particular nation was acknowledged in the World Confederation of Physical Therapy (WCPT) guideline (2012) for physical therapist professional entry-level education.[24] Regarding the criterion that core content should ensure safe and effective practice by first-line practitioners, a first-line practitioner within the South African context has been defined as: ‘… a person who can make an independent diagnosis and can treat such a condition, provided it falls within his/her scope of practice. Should the condition fall outside of their scope of practice, this practitioner will refer on. This person is autonomous in professional decisionmaking. It is acknowledged that with “first line practitioner status” come accountability and legal responsibilities.’[11] Although this definition was only published 6 years after we embarked on identifying core content, the definition validates the group’s decision to ensure that the core curriculum includes knowledge and skills which will enable students to identify patients who would benefit from physiotherapy intervention. In the revised curriculum greater emphasis was thus placed on evaluation techniques and students’ ability to formulate a differential diagnosis, and less on treatment techniques. A number of physiotherapy techniques can be used both for evaluation and management of conditions. However, this is not always the case. The implication of this decision is that students may not always have the necessary skills to address the patients’ problems efficiently and optimally. The decision to equip students with the ability to accurately identify patients’ problems at the expense of optimal management at first contact was regarded as the lesser of two evils. Our physiotherapy division is currently consulting with relevant stakeholders (universities, clinicians, employers) regarding our revised curriculum to develop innovative collaborative strategies to address this potential shortcoming in our students’ training. Finally, regarding evidence-based practice, in a policy statement the WCPT[25] has endorsed the concept of evidence-based physiotherapy practice. The importance of developing educational strategies which would ensure the development of the necessary skills for evidence-based practice in entry-level practitioners has also been advocated.[7] It is evident from the policies and documents published since we embarked on this process, that the decisions we made find support internationally. We argue that the high engagement process we used to decide on criteria for a core curriculum facilitated the quality of the decisions made. The effect of these decisions on the quality and ability of the therapists produced will need to be investigated.

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Research Conclusion

Through a six-step high engagement process we identified 3 criteria which were used to determine the core content of a revised physiotherapy curriculum. The process lends itself to the participation of multiple stakeholders in an engaging yet anonymous manner. It helps to ensure that all voices are heard and ideas included in prioritisation. The process easily manages a multiplicity of ideas; duplicate ideas are efficiently identified and clustered. Finally, the process is time-efficient; the process described above took 2 hours from start to finish. Content was included in the curriculum if: (i) it was relevant to the South African context; (ii) it would ensure safe and effective practice by first-line practitioners; and (iii) it was evidence-based. These criteria are offered for critical reflection and as a basis for a national (or international) debate on core content of a physiotherapy curriculum. Author contributions. All authors contributed to the conception, design, analysis or interpretation of data. S Hanekom drafted the manuscript. All authors provided critical revision and approval of the manuscript version to be published. References 1. Bandaranayake R. The concept and practicability of a core curriculum in basic medical education. Med Teach 2000;22(6):560-563. [http://dx.doi.org/10.1080/01421590050175523] 2. Bax ND, Godfrey J. Identifying core skills for the medical curriculum. Med Educ 1997;31(5):347-351. [http:// dx.doi.org/10.1046/j.1365-2923.1997.00676.x] 3. Syme-Grant J, Stewart C, Ker J. How we developed a core curriculum in clinical skills. Med Teach 2005;27(2):103106. [http://dx.doi.org/10.1080/01421590500046403] 4. Fishman SM, Young HM, Lucas Arwood E, et al. Core competencies for pain management: Results of an interprofessional consensus summit. Pain Med 2013;14(7):971-981. [http://dx.doi.org/10.1111/pme.12107] 5. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. Lancet 2010;376(9756):1923-1958. [http://dx.doi.org/10.1016/S01406736(10)61854-5]

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6. Elkins MR, Moseley AM, Sherrington C, Herbert RD, Maher CG. Growth in the Physiotherapy Evidence Database (PEDro) and use of the PEDro scale. Br J Sports Med 2013;47(4):188-189. [http://dx.doi.org/10.1136/ bjsports-2012-091804] 7. Dawes M, Summerskill W, Glasziou P, et al. Sicily statement on evidence-based practice. BMC Med Educ 2005;5(1):1. 8. World Health statistics. 2013. http://www.who.int/gho/publications/world_health_statistics/EN_WHS2013_ Full.pdf. (accessed 16 September 2014). 9. The First Line Practitioner Status of Physiotherapists Position Paper 2012. http://www.physiosa.org. za/?q=node/161 (accessed 20 February 2014). 10. Harden RM, Davis MH, Crosby JR. The new Dundee medical curriculum: A whole that is greater than the sum of the parts. Med Educ 1997;31(4):264-271. [http://dx.doi.org/10.1111/j.1365-2923.1997.tb02923.x] 11. McManus IC, Wakeford RE. A core medical curriculum. BMJ 1989;298(6680):1051. [http://dx.doi.org/10.1136/ bmj.298.6680.1051] 12. Harden RM. AMEE Guide No. 21: Curriculum mapping: a tool for transparent and authentic teaching and learning. Med Teach 2001;23(2):123-137. 13. Haddad D, Robertson KJ, Cockburn F, Helms P, McIntosh N, Olver RE. What is core? Guidelines for the core curriculum in paediatrics. Med Educ 1997;31(5):354-358. [http://dx.doi.org/10.1046/j.1365-2923.1997.00675.x] 14. Verma, S, Paterson, M, Medves J. Core competencies for health care professionals: What medicine, nursing, occupational therapy, and physiotherapy share. Journal of Allied Health 2006;35(2):109-115. 15. Rizk DE, Elzubeir M. Identifying core obstetric and gynecologic skills required of, and used by, graduates of the Faculty of Medicine and Health Sciences, United Arab Emirates University. Teach Learn Med 2000;12(2):66-71. [http://dx.doi.org/10.1207/S15328015TLM1202_1] 16. Bligh J, Brice J. Further insights into the roles of the medical educator: The importance of scholarly management. Acad Med 2009;84(8):1161-1165. [http://dx.doi.org/10.1097/ACM.0b013e3181ace633] 17. Broberg C, Aars M, Beckmann K, et al. A conceptual framework for curriculum design in physiotherapy education – an international perspective. Advances in Physiotherapy 2003;5(4):161. [http://dx.doi. org/10.1080/14038190310017598] 18. O’Keefe M, Jones A. Promoting lay participation in medical school curriculum development: Lay and faculty perceptions. Med Educ 2007;41(2):130-137. [http://dx.doi.org/10.1111/j.1365-2929.2006.02666.x] 19. Thomas P. Training in the Participlan process 2011. http://www.participlan.co.za/business-executive-coachingtraining (accessed 20 February 2014). 20. Jones J, Hunter D. Consensus methods for medical and health services research. BMJ 1995;311(7001):376-380. 21. Snyman MA. Assessment of professional behaviour in occupational therapy education: Iinvestigating assessors’ understanding of constructs and expectations of levels of competence. M Phil Health Sciences Education, Stellenbosch University, Stellenbosch, 2012. 22. Lloyd-Jones G, Ellershaw J, Wilkinson S, Bligh JG. The use of multidisciplinary consensus groups in the planning phase of an integrated problem-based curriculum. Med Educ 1998;32(3):278-282. [http://dx.doi.org/10.1046/ j.1365-2923.1998.00221.x] 23. Lloyd-Jones G, Fowell S, Bligh JG. The use of the nominal group technique as an evaluative tool in medical undergraduate education. Med Educ 1999;33(1):8-13. [http://dx.doi.org/10.1046/j.13652923.1999.00288.x] 24. World Confederation for Physical Therapy. WCPT guideline for physical therapist professional entry level education 2012. http://www.wcpt.org/guidelines/entry-level-education (accessed 20 February 2014). 25. World Confederation for Physical Therapy. Policy statement: Evidence based practice 2011. http://www.wcpt.org/ policy/ps-EBP (accessed 20 February 2014).

Research Does a problem-based learning approach benefit students as they enter their clinical training years? Lecturers’ and students’ perceptions S B Statham, MSc (Physio); G Inglis-Jassiem, MSc (Physio); S D Hanekom, PhD Division of Physiotherapy, Department of Interdisciplinary Health Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa Corresponding author: S B Statham (sbs@sun.ac.za)

Background. This paper presents the findings of a study completed to establish the differences between the lecturers’ and students’ perceptions of a hybrid problem-based learning (PBL) approach in successfully completing a PBL module in the third year of physiotherapy training at Stellenbosch University. Objectives. To assess the perception of the achievement of the PBL benefits, the module outcomes, the barriers to learning and positive aspects of the module. Methods. A theory-based evaluation approach using both qualitative and quantitative methods was used. All students and lecturers involved with the new module were invited to participate in the study. The participants consisted of 37 students and 11 lecturers. The data were collected using questionnaires and focus group discussions for both groups. The different components of the theory (PBL methods) were used as the guiding themes for the analysis of the qualitative data. The quantitative (ordinal) data are presented using descriptive statistics. Results. The results indicated that the module was enjoyed by both groups. The achievement of the generic outcomes for the module produced mixed results. Areas of agreement and areas of differences in perceptions relating to the achievement of the expected PBL benefits are discussed. Conclusion. PBL as a new methodology presents challenges for both groups; however, many of the benefits of PBL, in particular self-directed learning, were achieved. Some areas of shortfall are discussed. AJHPE 2014;6(2 Suppl 1):185-191. DOI:10.7196/AJHPE.529

A variety of educational objectives have been postulated to be possible using a problem-based learning (PBL) approach. These include: (i) the structuring of knowledge to facilitate use in clinical contexts; (ii) the development of an effective clinical reasoning process; (iii) the development of selfdirected learning skills; and (iv) the increased motivation for learning’.[1,2] Additional benefits of the PBL approach have been reported. These include improvement in problem-solving abilities, effective literature sourcing, increased ability to work in teams, as well as gaining the knowledge skills and expertise needed for clinical practice. [3,4] Since 2006 it has been a legal requirement of the Health Professions Council of South Africa for new graduates to complete a year of community-based practice before registration as a professional physiotherapist. Many of the settings where the community service is completed are lower socioeconomic rural areas with little or no professional guidance or supervision. The development of aforementioned skills through a specific didactic approach could be very useful for new graduates. The decision to introduce a PBL approach into the curriculum was not taken lightly because of the number of conflicting reports relating to PBL.[5-7] The major debate in the literature is that there is little conclusive evidence that PBL makes a measureable change in any of the aforementioned reported outcomes. A lack of any major effect size has been shown.[7] Owing to the debate in the literature, a number of sessions examining the potential of introducing such a didactic approach were held with various experts in tertiary education and particularly in medical education. It was decided to introduce a hybrid problem-based module[1,8] during the third year of the 4-year physiotherapy training programme at Stellenbosch University (SU). This approach gave the benefit of using traditional pedagogies in the early years of training and then introducing a new method in the third year; therefore a hybrid model was used.

A hybrid programme may provide a more structured learning environment and may be more appropriate for students.[8,9] In our case the third year of training is the one in which extensive exposure to the clinical platform is introduced. We decided to implement the module as the students were entering their clinical years. Owing to the controversy surrounding the benefit of PBL, we wanted to compare the perceptions of students and staff of the effect of this didactic method on the specific outcomes for the module.

Context

Implementation

Generic outcomes for all cases (Table 1) were established for the module; however, each case had specific outcomes that were aligned with some or all of the generic outcomes. These generic outcomes were aligned with the critical cross-field outcomes as required by the South African Qualifications Authority (SAQA).[10] Faculty members were divided into task teams and the case scenarios were designed. The cases were based on most prevalent conditions treated by undergraduate physiotherapy students in clinical settings.[11] The database used was developed by the department and recorded the pathologies seen by students during the 5 years prior to the implementation of the revised curriculum. The complexity of the cases was established and the cases were presented in order of increasing difficulty throughout the year. These cases were then organised into theoretical blocks, namely preclinical, basic, and intermediate. The students were exposed to the most basic and general cases before entering the clinical platform and then rotated in and out of a theory rotation and a clinical rotation for the remainder of the academic year. The multidisciplinary nature of management of patients with complex disease profiles and/or complex social circumstances was part of the focus of the cases.

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Research Table 1. Generic outcomes for the applied physiotherapy module 1. To integrate the theoretical concepts and principles of the biomedical sciences (pharmacology, pathology), social sciences (psychology, sociology) within the concept of physiotherapy practice (client management) 2. Have a sound knowledge of the medical and surgical management of the client, as well as disease processes applicable to physiotherapy intervention 3. Understand the role of the other team members in the total management of the patient 4. Have a basic knowledge of diagnostic tests (CXR, MRI, blood gases) and understand their impact on patient management 5. Execute the necessary evaluation techniques skillfully, with the necessary adaptations on a model 6. Interpret the findings of an evaluation, formulate a physiotherapeutic diagnosis/hypothesis and prioritise problems 7. Motivate the choice of selected physiotherapeutic interventions and/or the different approaches that can be followed in the management of patients 8. Execute the selected physiotherapeutic interventions skillfully, with the necessary adaptations on a model 9. Set specific, measureable, realistic aims that are attached to a time scale 10. Source and analyse literature CXR = chest X-ray; MRI = magnetic resonance imaging.

Format of presentation

Each case was presented, discussed and completed in 3 days. The first session was an introduction to the case and the seven-step process for learning was used.[12] The second session on the second day was a practical session for all the practical skills needed for the treatment and/or management of the case. No new skills were taught in these sessions. Students were required to adapt skills (when necessary) already acquired during the physiotherapy science module in the second year of study. During the final session on the third day, students presented the information which they had sourced to solve the clinical case and discuss the proposed management of the case.[13]

Monitoring

This was organised by the module coordinator. The monitoring of the implementation process was done through regular focus groups with the students conducted by two of the researchers. Additional feedback could be given via an anonymous suggestion box, individual student appointments and through formal feedback systems. Meetings for the lecturers to discuss any problems that arose and plan the changes required were held on a regular basis, and any further training, e.g. group dynamics, was provided.

Assessment

Assessment of the students in this module was done through web-based multiple-choice tests after each theory block (four blocks) and a case-based integrated essay type exam which was conducted twice a year. The practical components of the module were assessed through directly observed practical skills tests (DOPS) which were performed on patients during clinical rotations.[14]

Methodology

A theory-driven evaluation approach was used to provide a framework for the research of the study. [1,6,13,15-17] The theory used in this study included the basic components of a PBL approach: • If the students (small groups) are given appropriate (clear and easy to understand) cases (problems) to analyse and develop outcomes for, then the students (small groups) will work out a plan of action to solve the problem. • If the students work out the action plan, then they will learn where to find the resources to answer the problem. • If the students find the resources and necessary information, then they will be able to solve the problem.

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• If the students have solved the problem (using the resources), then they will learn the content (knowledge, critical reasoning and practical skills) of the cases and then they will be able to achieve the outcomes for the Applied Physiotherapy III module. A concurrent mixed-methods approach included student questionnaires, lecturer questionnaires, student focus-group interviews, and lecturer focus-group interviews. The questionnaires yielded both quantitative and qualitative data.

Sampling

Purposive sampling was used and all students (n=39) and lecturers (n=11) participating in the new module were invited to participate in the study. From a class of 39 a total of 37 students took part in the study.

Data collection and procedure

The formulation of the questions was based on the theory (provided above), thus giving guiding themes. This applied to the design of the questionnaires and the focus-group questions for both groups. The questionnaires were also reviewed by an external consultant, who has published widely in the field of PBL.[18,19] All changes and suggestions were included in the final questionnaires which used a five-point Likert scale. The questionnaires were sent to a translator and were back-translated to ensure accuracy. All the data were collected post implementation of the module and before the final exams. Ethical approval was obtained from SU Human Research Ethics Committee (N08/10/301). All participants were voluntary and written informed consent was obtained from all participants before data collection. All transcripts were de-identified, thereby maintaining the anonymity of the participants, and numerical ciphers were used for all transcripts. The qualitative data generated by the focus groups were recorded using a digital voice recorder and were downloaded and saved on compact discs (CDs) after the interviews.

Data management and analysis

The quantitative data from the questionnaires were entered on an Excel spreadsheet and statistical analysis was done using Statistica 12. Mann-Whitney test for non-parametric data, χ2 test and frequency tables were calculated. This was done to establish if there was agreement between lecturers and students regarding the different aspects of the PBL methods of the module.

Research The qualitative data were transcribed from the tapes by an independent transcriber, and thereafter analysed by an independent and experienced research assistant using content analysis.[20] This process included: familiarising oneself with the data; identifying themes; creating a theme list (codebook); coding and categorising data; interpretation of data; and checking. The researchers checked the coding and themes to aid trustworthiness. Both the questionnaires and the focus-group questions were designed by a researcher who was not involved in the module. The other researchers reviewed the questions to ensure that nothing had been excluded. Data were collected by the independent researcher.

Results

From a class of 39 a total of 37 students took part in the study. All 11 lecturers involved in the module took part in the study. The following results are presented detailing the perceptions of both the students and the lecturers on the achievement of the generic outcomes, the perceived positive aspects of the module and the barriers to learning. The results will be presented in the

following order: quantitative results, qualitative responses by students and lecturers regarding the implementation of the PBL module, and finally the suggestions by both groups.

Quantitative results

Table 2 presents a summary of the results to the questionnaires. The agreement between the two groups was measured using the Mann-Whitney test for non-parametric data. As can be seen from the table there were a number differences between the students and the lectures. A p-value <0.05 indicates the two groups responded differently, and therefore no agreement between the groups was attained. The groups were in agreement most of the time so it appears that the module was successful as a whole. The differences between the groups will be dealt with in the discussion relating to each component of the PBL methods. Tables 2 and 3 show there was agreement between the groups; however, this agreement was being unsure if the Outcomes 9 (set specific measureable aims) and Outcome 10 (source and analyse the literature) were achieved (Table 3).

Table 2. Mann-Whitney test results: Staff and student perceptions of the implementation of the module Mann-Whitney U test (with continuity correction) by variable position Responses

p-value

2*1 sided exact p

Valid N lecturer

Valid N student

Cases easy to analyse

0.432

0.498

†

Cases became more difficult

0.011

0.016

Resource lists were useful

0.017†

0.024†

Students could find more resources

0.225

0.319

Facilitation helped with problem analysis

0.040†

0.082

Facilitation helped with planning

0.490

0.513

Facilitation students understood the cases

0.831

0.847

Group work became easier

0.265

0.344

Roles in the group ensure effective functioning

0.021†

0.038†

Self-directed learning

0.455

0.513

Knowledge was acquired

0.632

0.663

Skills workshops enough time

0.717

0.749

Skills workshops feedback given

0.411

0.465

Skills workshops appropriate for cases

0.220

0.286

Skills workshops helped in clinical

0.004

0.006

Assessment aligned with cases

0.008†

0.012†

Assessment aligned with practical skills

0.340

0.404

Outcome 1

0.121

0.214

Outcome 2

0.072

0.150

Outcome 3

0.013

0.031

Outcome 4

0.210

0.296

Outcome 5

0.005

†

0.011

Outcome 6

0.037†

0.049†

Outcome 7

0.083

0.136

Outcome 8

0.090

0.164

Outcome 9

0.989

0.981

Outcome 10

0.146

0.180

†

Marked tests are significant at p<0.05000.

†

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Research The large number of neutral responses in these cases indicate that a large percentage of the cohort did not feel that the particular outcome had been reached, and both groups agreed on this. Table 3. Frequency tables for Outcomes 9 and 10 All groups N=48 Category

Count (%)

Outcome 9 Strongly disagree

1 (2.08)

Disagree

6 (12.50)

Neutral

20 (41.67)

Agree

19 (39.58)

Strongly agree

2 (4.17)

Outcome 10 Disagree

3 (6.25)

Neutral

18 (37.50)

Agree

21 (43.75)

Strongly agree

6 (12.50)

Qualitative results

Table 4 presents the responses from both groups on the facilitators/benefits of the module, with the most comments first to enable recognising the most important facilitators/benefits as experienced by the two groups. Table 5 presents the responses from both groups on the barriers to learning, with the most comments first to enable recognising the most important barriers to learning as experienced by the two groups. Table 6 summarises the most important suggestions from the two groups. The similarities between the groups are notable and help with planning the improvements to the module.

Combined results

The use of cases In the design of the cases both groups were positive about the cases being easy to analyse and focused; this is important as this is the basis of the PBL approach and a necessary step in the

ability of the students to master this module. However, in the suggestions for improvement both groups suggested some revision of the cases. The students felt the complexity of the cases did not increase over the year (p=0.015). Lecturers were more positive about the increasing difficulty of the case studies than the students were. Lecturers used the pathology and clinical reasoning as guides to making the cases more difficult; this form of scaffolding should help the students. Accessing resources The groups agreed on the ability of the students to find new resources. Strategies to improve the students’ abilities to search for information included workshops with the librarians on searching techniques, providing the students with resource lists. However, they did not agree on finding the resource lists helpful (p=0.02). The lecturers were more positive about the lists than the students were. This is possibly due to

Table 4. The main categories of the students’ and lecturers’ responses regarding the facilitators/benefits of the module Students, N=37

Responses, n

Comments

Improved clinical reasoning

‘Learnt how to do clinical reasoning and how to defend my answers in a group’. (SQ1) translated ‘I really did learn to reason clinically better as well as became more independent in my own learning process and gaining of knowledge.’ (SQ33) ‘Much more practical and could apply it directly on my clincal blocks.’ (SQ36) translated

Group work (positive)

‘Group work. It was nice to work with fellow physio students and to tackle & solve a problem.' (SQ3) translated ‘The groupwork was fun! & I like the fact that we had such a broad spectrum of information to collect even if it was not necessarily important for the tests.' (SQ12) translated ‘Watched how other people noticed certain things & reasoned. Learnt from others.’ (SQ14) translated

Information gathering and organisation of information

‘You were in charge of your own learning so that the onus was on you to gather all that you thought you required and from that establish your goals.’ (SQ 35) ‘It taught us how to look for information on conditions & physio approach.’ (SQ 5)

Personal growth

‘Personal growth especially the small classes and individual attention.' (SQ2) translated ‘I was never bored.’ (SQ10) translated ‘That I can look back now and say it was worthwhile and that I feel beter prepared for next year.' (SQ13) translated ‘Our class was very supportive and we worked together.' (SQ7) translated

Real life issues

‘It taught me to handle the situation realistically as if it was really happening. And learn realistically.' (SQ24) translated ‘Get a chance to apply your knowledge on cases that are relevant to everyday life.' (SQ15) translated

Increase students’ responsibility

‘… that the students learn to take responsibility for their own learning.’ (LQ9) ‘Some students were able to identify their weaknesses and were able to find help within their groups.’ (LQ10) ‘Self-directed learning.’ (LQ6) ‘Increased participation of students.’ (LQ8)

Changing critical thinking skills

‘Students have developed critical reasoning skills a lot quicker.’ (LQ1)

Improvement in students’ confidence and attitude

‘Self-confidence of students.’ (LQ6) ‘The students’ growth in dealing and adapting to the process.’ (LQ5)

Lecturers, N=11

SQ = student questionnaire; LQ = lecturer questionnaire.

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Table 5. The main categories of students’ and lecturers’ responses to the barriers to learning in the module Students, N=37

Responses, n

Comments

Test and related matters

‘Clinical reasoning is tested in WebCT, but we never get a chance to demonstrate it even up to to-day. And today there was too little time to reason fully and show it.' (SQ2) translated ‘It is another way of evaluating and one we have got... had to get used to.’ (SQ19) translated ‘The shift from testing theoretical knowledge to testing clinical reasoning.’ (SQ4) translated

New methods of learning

‘Way of learning has to be adapted (difficult after 13 years to change your methods of studying.' (SQ1) translated ‘Study methods: I did not know how to study for the tests even up until now.’ (SQ26) translated ‘Changing studying methods to understanding rather than parrot fashion learning.’ (SQ33)

Group work (negative)

‘All members of the group according to me did not always deliver sufficient information/research and this really frustrated me a lot because I always want to be as comprehensive as it is possible to be.' (SQ1) translated ‘Groupwork is a problem if you like completeness, and then you get info from someone who gives very little and does not go to trouble. Then I do it again later.’ (SQ29) translated ‘Group work trusting each member to get the relevant information.’ (SQ33)

Quality assurance

‘The fact that everyone has different information (different groups).' (SQ20) translated ‘No quality assurance of the work that I learn.’ (SQ24) translated ‘Quality of work between groups.’ (SQ32) translated

Facilitators and the process

‘Different facilitators told different groups to focus on different aspects.’ (SQ9) ‘Lecturers per group differed during the beginning and feedback, so you get different outcomes and ideas for each that eventually oppose each other.’ (SQ2) translated

Practice session

‘The practice sessions often focused too much on work covered in Physio II and not on specific tests and Rx methods that were new in Physio III.’ (SQ 5) ‘Didn’t practise new techniques for long enough and spent too much time on old.’ (SQ9)

Lack of critical analysis

‘Unable to extract “relevant” to the cases info.’ (LQ1) ‘Students did not critically evaluate the literature and did not know the topic they presented to the group – just read.’ (LQ3)

Web CT tests

‘The unknown process, e.g. WebCT test (in the beginning).’ (LQ8) ‘WebCT test ++ unclear? – suitability/appropriateness of our questions.’ (LQ1) ‘WebCT – our setting of the questions improved during the year and the students became more familiar with the WebCT tests and that also reflected in their marks. Although I felt that the preparation for the tests was left quite late; we could have circumvented some of the problems if we had done that. I think a lot of the students did not change their study methods although they were encouraged to do so. In terms of the integration of higher thinking the students were not doing that very well. I think that influenced how they performed and how they understood and answered the questions.’ (LFG 2)

Attitudes to learning

‘Students NOT taking responsibility for own learning.’ (LQ2) ‘Students did not attend all the sessions.’ (LQ3) ‘Students attitudes originally – very negative!!’ (LQ1) ‘I had a practice session with them, before the time. I made special notes with different colours, etc. to motivate them to prepare and I explained what they should prepare and where to get the information. They arrived unprepared, not in the correct clothing for practising. They were also not motivated. The demands on the lecturer are increasing more and more and they are not co-operating.’ (LFG 3) translated

Group process

‘Some students worked so much harder than others – seemed that the hard workers always did the "difficult" or most important parts of the cases.’ (LQ 3) ‘Expectations of what each member’s role was in the group.’ (LQ9) ‘In the cases that I was involved in, yes, I do think they reached their outcomes. There was one specific case when due to ineffective time management at the feedback session they did not discuss this one important thing, a lot of time was spent on other things but not this one so what we did was they came back half an hour early the next day to give feedback about this thing – we did it then.’ (LFG L2)

Literature source information

‘Skills to literature sourcing.’ (LQ 7) ‘Info that they brought back to the table wasn’t accurate but the lecturers don’t have time to check the notes.’ (LQ 11)

Lecturers, N=11

SQ = student questionnaire; LQ = lecturer questionnaire; LFG = lecturer focus group.

the fact that the resource lists were short, so as to guide the students but ensure that they still needed to find resources themselves. Outcome 10 (ability to source and analyse literature) indicated the groups felt neutral

about achieving this outcome. When combining the data, one could interpret this as the literature analysis being a skill that students find difficult to master.

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Research

Table 6. Similarities between the students' and lecturers' suggestions Students’ categories

Lecturers’ categories

WebCT test revision (n=13)

Increased resources (n=8), lecturers’ support

Revision of cases (n=10)

Facilitation process (n=3)

Facilitation (n=10)

Revision of cases (n=3)

Practical sessions (n=8)

Changes in WebCT test (n=2)

Quality assurance (n=5)

PBL facilitation The two groups agreed that the facilitation of the cases provided help with problem analysis, planning on the outcomes for the case and that the students understood each case at the end of the final feedback session. The lecturers found the facilitation process a challenge as it required a very different approach to the traditional teaching model. A number of workshops were held regarding the best way forward, and as can be seen from the results both groups were in agreement. Group work The group work became easier through the year although the two groups did not agree that the roles helped with the effective group functioning (p=0.03). To help the development of effective groups the 7-Jump process was used. The students were more positive in their answers to the group roles than the lecturers were. Module outcomes As seen in Table 2 the two groups’ responses were in agreement on seven of the ten outcomes. The responses showing agreement between the groups are divided into two groups: firstly, the agreement on achieving the outcomes; and secondly, agreement on being unsure if the outcomes had been achieved. For Outcomes 1 (theoretical concepts), 2 (knowledge of medical and surgical management), 4 (knowledge of diagnostic tests), 7 (motivate for choice of physiotherapeutic interventions) and 8 (execute physiotherapeutic interventions), the results showed agreement between both groups, and they were positive about the achievement of the Outcomes. For Outcomes 9 (setting aims) and 10 (sourcing and analysing literature) both groups responded similarly, indicating that they were unsure if these outcomes were achieved. The responses that differed included Outcomes 3, 5 and 6. For Outcome 3 (understanding other team members’ roles) (p=0.03) students were more positive

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about achieving this outcome. For Outcome 5 (executing evaluation techniques) (p=0.01) the students were positive about reaching this outcome, while lecturers were neutral about it. Outcome 6 (interpreting findings to formulate a hypothesis for patient management) (p=0.04) indicated a significant difference between the two groups; again the students felt more positive than the lecturers did about the achievement of the outcome. In each case the students were more positive about the achievement of the outcome than the lecturers were. Both execution of evaluation techniques and interpretation of findings require higher-order cognitive processes[21] and therefore a lot of practice; it is likely that the students will fully master these skills with further practice in their final year of training. The mixed response to the achievement of the outcomes gave valuable information that will be needed when the case design is adapted; it highlights the areas that need to be enhanced further. The lecturers tend to be more cautious because of their experience and responsibility to deliver competent physiotherapy graduates. Practical skills sessions Including a PBL approach in practical skills development is not commonly used, but because a hybrid model was used the basic knowledge and skills had been taught earlier in the course and the practical skills sessions could build on the students’ previous knowledge. Both groups agreed that there was enough time allocated to learning the new skills, that feedback was provided to the students regarding their skills, and that the new skills were appropriate for the cases; however, they did not agree on whether the skills helped on the clinical platform (p=0.006); the students were positive about the skills helping them clinically and the lecturers were more negative about this achievement. The value of the skills sessions can also be seen in the achievement of Outcomes 7 and 8 as these both worked specifically with physiotherapeutic modalities.

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Barriers and facilitators Facilitators. The students perceived the main benefits to be improved clinical reasoning, group work, information gathering and organisation, and personal growth. This links with the expectations of PBL. The lecturers perceived the main benefit to be an increase in students taking responsibility. This is the most common benefit voiced in the literature. Both groups’ perceptions of the benefits are aligned with the expectations from the literature.[1-4] Barriers. The most important feedback regarding adapting to the new learning method related to the perceptions of barriers. The students’ main barriers to learning in this module were tests, new ways of learning, group work, quality assurance and the case lecturers. Numerous stressors or barriers to learning have been documented in the literature.[22-23]

Discussion

Students and staff differed in their perceptions of whether outcomes were reached. The mixed response to the achievement of the outcomes gave valuable information needed when adapting the case design as to the areas that need to be enhanced further. The responsibility of the lecturers to deliver competent professionals can be seen by their more cautious responses. The more cautious evaluation of the success of the new pedagogy has been reported.[22,24]It was surprising that both groups perceived that the module ensured that they had reached the more content-related outcomes, while uncertainty was expressed whether the more generic outcomes like literature sourcing were attained. The qualitative data presented a different picture. The students perceived the main benefits of the PBL module to be improved clinical reasoning, group work, information gathering, organisation and personal growth. The lecturers perceived the main benefit of the module to be an increase in students taking responsibility for self-directed learning. Both groups’ perceptions of the benefits are aligned with the expectations from the literature.[1-4] The practical skills sessions were a very important part of the introduction of this module. Including a PBL approach in practical skills development has not previously been reported. Students and staff perceptions regarding the value of the skills on the clinical platform were different. The majority of students perceived that the skills sessions were beneficial to their clinical practice, while the minority of staff perceived the

Research skills sessions as clinically beneficial. It is possible that the staff perceptions were based on anecdotal negative feedback regarding student performance from clinicians. The clinical supervision of the third year cohort is done by ad hoc appointed clinical educators. Staff therefore did not have firsthand experience of third-year students’ ability on the clinical platform. The most important feedback regarding adapting to the new learning method related to the perceptions of barriers. The students’ main barriers to learning in this module were tests, new ways of learning, group work, quality assurance and the case lecturers. These stressors are confirmed in literature.[22-23] This was a surprising finding as the didactic methodology was only utilised in the third-year of study and students had the benefit of lecture-based teaching methods in the first two foundational years. These stressors could thus be aligned with the implementation of the new pedagogy rather than the implementation of a specific pedagogy – in this case PBL. The experience of the students was not dissimilar to that of students in other countries when exposed to a new approach. However, these studies do not include practical skills and usually only the students’ perceptions are investigated. There was a wide range of student experiences, again reflecting the diversity of students who have very different approaches and learning styles. This has been reported in other studies.[5,13,22,24] However, the perceptions of lecturers are not well reported and add valuable insights.[25] We acknowledge a number of limitations to the methodology used which could influence the interpretation of results. We only reported on one cohort of students and staff and only after the first year of implementation. The inherent difficulty in implementing practice change has been widely reported. Much of these uncertainties observed in student and staff perceptions could be related to practice change. Data from this cohort of staff and students will be compared to later years to ensure a more comprehensive view of perceptions of the potential benefit of a hybrid PBL module. However, the data presented in this paper could be informative for programme designers who are thinking of implementing a hybrid PBL module. We acknowledge that the data provide a subjective view of students and staff perceptions of the effect of a hybrid PBL module. Objective data are needed to measure the effectiveness of this module.

Conclusion

Lecturers and students enjoyed the hybrid PBL module and found the experience beneficial. Both groups agreed that the content-related outcomes for the module were reached. Students perceived the main benefits of the PBL module to be improved clinical reasoning, group work, information gathering, organisation and personal growth. The lecturers perceived the main benefit of the module to be an increase in students taking responsibility for their own self-directed learning. The value of the skills

sessions on clinical performance needs further investigation. Programme designers can use the hybrid PBL methods later in an academic programme requiring skills development, thereby using both new and traditional methods of teaching and learning. Funding. This project received FINLO funding from the Centre for Teaching and Learning at Stellenbosch University. Author contributions. All authors contributed to the conception, design, analysis or interpretation of data. SS drafted the manuscript. All authors provided critical revision and approval of the manuscript version to be published.

References 1. Barrows HS. A taxonomy of problem‐based learning methods. Med Educ 1986;20(6):481-486. 2. Norman G. Problem‐solving skills, solving problems and problem‐based learning. Med Educ 1988;22(4):279-286. 3. Morris J. How strong is the case for the adoption of problem-based learning in physiotherapy education in the United Kingdom? Med Teach 2003;25(1):24-31. [http://dx.doi.org/10.1080/0142159021000061387] 4. Crang-Svalenius E, Stjernquist M. Applying the case method for teaching within the health professions – teaching the teachers. Med Teach 2005;27(6):489-492. [http://dx.doi.org/10.1080/01421590500136154] 5. Polyzois I, Claffey N, Mattheos N. Problem‐based learning in academic health education. A systematic literature review. European Journal of Dental Education 2010;14(1):55-64. [http://dx.doi.org/10.1111/j.16000579.2009.00593.x] 6. Norman GR, Schmidt HG. Effectiveness of problem‐based learning curricula: Theory, practice and paper darts. Med Educ 2000;34(9):721-728. [http://dx.doi.org/10.1046/j.1365-2923.2000.00749.x] 7. Colliver JA. Effectiveness of problem-based learning curricula: research and theory. Acad Med 2000;75(3):259266. [http://dx.doi.org/10.1097/00001888-200003000-00017] 8. Hung W. Theory to reality: A few issues in implementing problem-based learning. Educational Technology Research and Development 2011;59(4):529-552. [http://dx.doi.org/10.1007/s11423-011-9198-1] 9. Hartling L, Spooner C, Tjosvold L, Oswald A. Problem-based learning in pre-clinical medical education: 22 years of outcome research. Med Teach 2010;32(1):28-35. [http://dx.doi.org/10.3109/01421590903200789] 10. South African Qualifications Authority. The National Qualifications Framework and Curriculum Development. 2000. http://www.saqa.org.za/structure/nqf/docs/curriculum_dev.pdf (accessed 14 February 2014). 11. Stellenbosch University Physiotherapy Department Database. 2004-2006. 12. Schmidt HG. Problem-based learning: Rationale and description. Med Educ 1983;17(1):11-16. [http://dx.doi. org/10.1111/j.1365-2923.1983.tb01086.x] 13. Rogal SM, Snider PD. Rethinking the lecture: The application of problem based learning methods to atypical contexts. Nurse Education in Practice 2008;8(3):213-219. 14. Morris A, Hewitt J, Roberts C. Practical experience of using directly observed procedures, mini clinical evaluation examinations, and peer observation in pre-registration house officer (FY1) trainees. Postgrad Med J 2006;82(966):285-288. [http://dx.doi.org/10.1136/pgmj.2005.040477] 15. Mouton J, Babbie E. The Practice of Social Research. Cape Town: Wadsworth, 2001. 16. Rossi PH, Lipsey MW. Evaluation: A systematic approach. Thousand Oaks, CA: Sage, 2004. 17. Chen H. Applying mixed methods under the framework of theory‐driven evaluations. New Directions for Evaluation 1997;1997(74):61-72. 18. Murray E, Alderman P, Coppola W, Grol R, Bouhuijs P, van der Vleuten C. What do students actually do on an internal medicine clerkship? A log diary study. Med Educ 2001;35(12):1101-1107. [http://dx.doi.org/10.1046/ j.1365-2923.2001.01053.x] 19. Perrenet J, Bouhuijs P, Smits J. The suitability of problem-based learning for engineering education: Theory and practice. Teaching in Higher Education 2000;5(3):345-358. [http://dx.doi.org/10.1080/713699144] 20. Mouton J. How to Succeed in your Masters and Doctoral Studies: A South African Resource Book. Pretoria: Van Schaik Publishers; 2001. 21. Krathwohl DR. A revision of Bloom’s taxonomy: An overview. Theory into Practice 2002;41(4):212-218. [http:// dx.doi.org/10.1207/s15430421tip4104_2] 22. Pepper C. ‘There’s a lot of learning going on but NOT much teaching!’: Student perceptions of problem-based learning in science. Higher Education Research & Development 2010;29(6):693-707. [http://dx.doi.org/10.1080 /07294360.2010.501073] 23. Solomon P, Finch E. A qualitative study identifying stressors associated with adapting to problem-based learning. Teaching & Learning in Medicine 1998;10(2):58-64. 24. Keiller L, Louw A. Approaches toward learning in physiotherapy. South African Journal of Physiotherapy 2013;69(1):36-40. 25. Miles S, Leinster SJ. Comparing staff and student perceptions of the student experience at a new medical school. Med Teach 2009;31(6):539-546. [http://dx.doi.org/10.1080/01421590802139732]

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Research What does an enquiry-based approach offer undergraduate physiotherapy students in their final year of study? G Inglis-Jassiem, MSc (Physio); S Statham, MSc (Physio); S D Hanekom, PhD Division of Physiotherapy, Department of Interdisciplinary Health Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa Corresponding author: G Inglis-Jassiem (gakeemah@sun.ac.za)

Background. Physiotherapy students in their final year at Stellenbosch University (SU) complete a module that follows an enquiry-based learning (EBL) approach. This module exposes them to higher-order problem solving and was developed to facilitate independent self-directed learning and improved higher-order thinking skills. Objective. To describe the perceptions of undergraduate physiotherapy students on the impact of this EBL approach on their learning. Methods. A cross-sectional descriptive study was conducted with three consecutive cohorts of final-year undergraduate physiotherapy students. A questionnaire was used to obtain information related to the students’ perception of this module. Coding and identification of themes were done independently using an inductive approach. Initial themes were compared and discussed to achieve consensus regarding the final themes reported. Results. Students reported the development of skills such as the ability to source relevant information and problem-solving abilities. Students attributed improvements in their clinical reasoning and performance during clinical work to the skills they developed during this module. The main themes identified as barriers to learning during this module were availability of learning materials, quality assurance and time constraints. Group work was identified as both a facilitator and a barrier to their learning. Conclusion. Physiotherapy students at SU perceived the introduction of a module following an EBL approach positively. They developed skills such as sourcing information and problem-solving, which they perceived improved their clinical work. The main barriers to learning were time constraints and concerns regarding quality assurance of learning material. Group work was regarded as both facilitatory and a barrier to learning. Programmes considering the implementation of EBL should ensure sufficient resource material and that quality assurance mechanisms are in place to address students’ anxiety regarding learning material. Guidance and support to students during the initial implementation phase of an EBL approach are necessary to allay fears and frustrations. AJHPE 2014;6(2 Suppl 1):192-197. DOI:10.7196/AJHPE.532

Khan and O’Rourke[1] consider enquiry-based learning (EBL), sometimes called inquiry-based learning (IBL), as a broad overarching term used to describe studentcentred learning approaches driven by enquiry. EBL forms part of a family of approaches such as case-based and problem-based learning (PBL). [2,3] These approaches, especially PBL, are widely used in medical and allied health curricula to enhance problem solving, critical thinking and self-directed learning skills in both undergraduate and postgraduate students.[4,5] PBL has been widely used in undergraduate physiotherapy programmes,[6] but the utilisation of EBL is less documented.[1,7] EBL is a learning approach that inspires students to be self-directed learners engaged in problem solving of realistic scenarios and often complex problems.[2,4,5] It may entail small-scale investigations, projects that result in products for industry or research-based projects which are assessed.[1] It may be used to facilitate learning and completion of a singular task, as an approach for a module, or incorporated into traditional curricula, and therefore be referred to as hybrid EBL. This approach has been reported in different fields such as engineering, nursing and dentistry.[5] Hutchings[8] encourages the use of EBL approaches if a deep level of engagement with complex problems is required. It has been hypothesised that multifaceted problems will force students to work creatively, to grapple with differing views and find novel solutions, or to come to the realisation that the loop of enquiry remains ongoing and solutions are often elusive.[1,8] Jackson[9] considers EBL a vehicle to

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prepare graduates for continually expanding and changing information by teaching them skills on how to acquire and appraise knowledge for a particular purpose rather than content only. Although PBL and EBL have similar attributes, EBL is considered more advanced where students are empowered to take ownership of their learning, thereby fostering a deeper level of engagement.[2] In contrast with PBL, there has been no structured process described for EBL.[3] Similarities have been noted in the roles of lecturers that facilitate learning rather than the source of knowledge.[7] In EBL an enquiry begins with a general theme to trigger learning and may take the form of a reallife scenario or stimulus question, for which there is usually no known answer.[10] Students have to identify what resources they need to solve the problem and embark on a journey of constant questioning, problem solving and seeking evidence-based and relevant solutions.[6] Facilitators in EBL provide guidance to students on the learning process rather than content knowledge. This may take the form of coaching students on how to pose researchable questions, how to access and critically appraise information, and how to reflect on the progressive development of the students’ own enquiry skills.[1,10] Facilitators are encouraged to model effective enquiry themselves and promote opportunities for reflection on learning.[10] Student engagement is further enhanced in EBL by the synthesis and creation of new knowledge.[1] It has been hypothesised that the synthesis of new information results in deeper learning.[2] Group work is the mainstay of enquiry-driven approaches, but students may also do self-directed

Research individual study and utilise a wide range of information sources to tackle the problems, such as research articles and web-based information sources.[1] Assessment in EBL could be formative or summative in nature and might be completed by facilitators and/or peers. Facilitators may provide feedback on the quality of questions, the depth of study or nature of information sourced. Peer feedback may be useful to identify problems in collaborative learning and communication within groups.[10] Summative assessment could entail a research report or product for industry. Palmer[11] reports on the successful use of written and oral presentations where psychology students presented their research of self-selected topics to the class. Students following an EBL approach report satisfaction with their training, better retention of knowledge, deeper understanding of subject matter and the ability to apply their skills in solving new and complex scenarios.[7,12] The collaborative nature of small-group learning in EBL facilitates the development of teamwork, communication and leadership skills. It has been reported that an EBL approach is suited to the development of interpersonal and social skills. [13] Cairncross [14] considers these transferable skills prerequisites for successful professional careers. In addition, Kahn and O’Rourke [1] highlight the many advantages that EBL poses for contemporary issues in higher education related to the goals

for student learning. Some of these include preparing graduates for employability, and the development of skills and personal attributes to ensure lifelong learning. Small-group teaching approaches are often staff, resource and time intensive.[7] The literature recommends that staff and students should be supported when embarking on EBL, especially during the transition phase between other more traditional pedagogies.[1] The complexity of the clinical scenarios faced by physiotherapy students in the real world necessitates higher-order problem solving and clinical reasoning. Students are required to work as first-line practitioners on graduation. The ability to solve complex problems and develop new understanding of an ever-changing multidimensional healthcare context are necessary skills to help students to function independently as healthcare practitioners on entry to the physiotherapy profession. EBL – as progression to PBL – has been identified as a strategy that could facilitate students’ transition to this higher-order thinking and level of functioning. The aim of this paper is to describe the perceptions of undergraduate physiotherapy students on the impact of this EBL approach on their learning.

University (SU). The curriculum consists of 2 years of didactic teaching in basic sciences and physiotherapy modules followed by a PBL approach in the third year and EBL in the final year. The aim of these two modules is to provide students with the opportunity to integrate knowledge, techniques and concepts covered during the two foundational years within the context of pathology, personal circumstances of patients and healthcare structures. This level of integration is essential for clinical reasoning. The EBL module consists of five complex cases spread over the academic year. These cases are facilitated by academic staff over a 3-week period with contact sessions once per week. Students work clinically for the rest of the week. The whole class or smaller groups may attend contact sessions. Various stimulus activities are used at the start of cases, e.g. clinical guidelines, videos or clinical records of patients. Students complete self-directed research and/or group work to source, appraise and synthesise information in an attempt to solve the complex EBL case scenarios. Assessments entail individual and group tasks. The final product may be a pamphlet or an educational talk in a community setting. Tables 1 and 2 provide information regarding the various cases and how each was assessed.

Context

Methods

A hybrid curriculum was implemented in 2007 in the Division of Physiotherapy, Stellenbosch

Table 1. Outcome of fourth-year module following an EBL approach By the end of this module, the student will be able to: • Integrate the theoretical concepts and principles of the biomedical sciences (e.g. pharmacology, pathology); social sciences (psychology, sociology) within the concept of physiotherapy practice (client management) • Have a sound knowledge of the medical and surgical management of the client, as well as disease processes applicable to physiotherapy intervention • Understand the role of the other team members in the total management of the patient • Have basic knowledge of diagnostic tests (e.g. chest X-ray, MRI, blood gases, etc.) and understand their impact on patient management • Execute evaluation techniques skilfully, with the necessary adaptations, on a model • Interpret the findings of an evaluation, formulate a physiotherapeutic diagnosis/hypothesis and prioritise problems • Motivate the choice of selected physiotherapeutic interventions and/or the different approaches that can be followed in the management of patients • Execute physiotherapeutic interventions skilfully, with the necessary adaptations, on a model • Set specific, measurable, realistic aims that are attached to a time scale • Source and critically appraise relevant subject literature PBL = problem-based learning; EBL = enquiry-based learning; MRI = magnetic resonance imaging.

A cross-sectional descriptive study was conducted. Ethical clearance was obtained from the SU Health Research Ethics Committee (N08/10/301). Participants were assured of confidentiality and all provided written informed consent. The project was conducted with three consecutive cohorts of final-year physiotherapy students from 2008 to 2010. A questionnaire was designed to obtain information on the perception of students of the EBL approach. This paper reports on the two open-ended questions students were posed regarding facilitators to their learning and barriers to their learning. All the data were collected after implementation of the module. The questionnaire was completed during scheduled class time before the final assessment opportunity. Responses were typed in Microsoft Word (SS) and coded by the research team (SS, SH, GIJ). Coding and identification of themes were done independently by two researchers in the team using an inductive approach. Initial themes were compared and discussed to achieve consensus regarding the final themes.

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Research

Table 2. EBL module content – information related to cases Diagnosis or clinical context

Stimulus given at start of case

Assessment (final product)

Head injuries (HI)

Direct observation of patients with HI (different clinical presentations)

Scientific written task on evidence-based physiotherapy management of patients with HI

Intensive Care Unit (ICU)

Records of patients admitted and managed in ICU

Development of a patient assessment form to facilitate evidence-based practice in ICU

Whiplash

Clinical guidelines for the management of whiplash-associated disorders (WAD)

Group presentations on evidence-based physiotherapy management of WAD

Headaches

Evidence-based physiotherapy management of headaches

Educational talk at community health centre on prevalence, pathogenesis and physiotherapy management of headaches

Guillain-Barré syndrome (GBS)

Video of patients with GBS (psychosocial impact and prognosis)

Educational pamphlet on role of physiotherapy in GBS

EBL = enquiry-based learning.

Table 3. Student feedback related to additional skills development with implementation of EBL approach Sub-theme

Quotes

Source information

‘Improved my ability to research for evidence based information & my ability to interpret that information.’ ‘This module, as difficult as it was to adapt to, gave us the skills to problem solve and find resources by ourselves to find out more about things.’

Problem solving/clinical reasoning

‘We learnt a lot about research & how to base your Rx (treatment) on evidence, this enables you to ensure that you are effective.’ ‘I learnt to think more practically and to research and have evidence-based arguments/knowledge with treatment of my patients. Clinical reasoning rather than “parrot learning” of theory is more important.’

Life skills

‘Learnt to be strong.’ ‘Achieving knowledge and practical skills. Learned how to be responsible when made student facilitator.’ ‘Taught me not only physiotherapy skills but life skills as well.’

Critical appraisal of information

‘Helped me to source appropriate information and analyse information.’ ‘Criticising research.’

Independent learning

‘Learn to help yourself and source information on your own.’ ‘Was responsible for own progress.’

Scientific writing skills

‘Improved scientific writing.’

EBL = enquiry-based learning.

Results

All final-year students were invited to participate over the 3-year period of this study. Questionnaire response rates were 85% (n=35/41) in 2008, 86% (n=37/43) in 2009 and 89% (n=41/46) in 2010.

Facilitators to learning

The main themes identified in this category were skills development, collaborative learning, impact on clinical reasoning, and integration across modules. All three cohorts commented on the development of additional skills with the new learning approach (Table 3). Feedback centred on the ability to source relevant information, solve clinical problems and critical appraisal of literature. Students attributed improvements in their clinical reasoning and performance in clinical work to skills developed during the EBL module. Comments reflected an improved ability to problem solve with patients. They felt empowered to source information and follow similar steps in critical appraisal of information. Improved patient outcomes were attributed

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to their ability to assess patients more holistically and develop relevant management plans. A few comments described how this module facilitated integration of theoretical and practical components across modules. Some students found the collaborative learning of group work enjoyable and insightful in terms of self-knowledge and getting to know their peers. They appreciated peers as colleagues and sources of knowledge with new insights. They enjoyed working together and learned to value different opinions. However, there were students who experienced group work as a barrier.

Barriers to learning

The barriers to learning were availability of learning materials, concerns regarding the quality of sourced information, time constraints and group work (Table 4). Some students experienced difficulty in sourcing relevant literature. Students were particularly concerned about the quality of information and felt insecure about the accuracy and relevance of information received from peers. Lack of lecturer-developed hand-outs remained a source of anxiety for students and left many frustrated. Preparation for assessments was particularly daunting.

Research

Table 4. Student feedback related to facilitators of and barriers to learning Facilitators of learning

Quotes

Clinical reasoning

‘I found it easier to get a holistic picture of the patient and as a result plan and implement a treatment plan for the patient.’ ‘You had a much better ability to adapt in the clinical setting as the cases were focused but you had to adapt what you had to your own patients.’ ‘My clinical reasoning and skills improved a lot and by the end of the year problem solving was much easier. This will help me in future with patient management.’

Group work

‘It was fun to consult with colleagues and challenge the ideas to ultimately get to the best solution.’ ‘We learnt a lot from each other and got to know each other at other levels.’

Barriers to learning

Quotes

Availability of learning materials

‘Was sometimes difficult to source the correct references.’ ‘Everything must be evidence based, but for certain topics no best evidence articles could be found (Pubmed).’ ‘Not getting info from other groups regarding the topic being researched; only researching a small aspect of the topic.’ ‘The information you receive depends on other students. Everyone is not as motivated to perform well.’ ‘We did not receive well-compiled information sheets or learning material.’ ‘There were no notes provided which was a barrier to the learning process.’

Quality assurance of learning materials

‘We did not receive feedback on the information we sourced, so we did not know whether what we read and what we are supposed to do is the same.’ ‘No real control over the correlation of information between groups.’ ‘Everyone’s information was not necessarily the same.’

Time constraints

‘Sometimes time (clinical, research, social, sport) was limited.' ‘Time management of clinical and applied physiotherapy cases, as well as researching the first semester.’ ‘Spending too much time at individual task and none at understanding cases as a whole.’ ‘It feels as if I spent 80% of my time sourcing literature instead of learning.’

Group work

‘Not always easy to work in groups with diverse personalities.’ ‘Group members not doing their work/not supplying enough information.’ ‘Lack of enthusiasm from some group members.’

There were many comments related to time management. Students indicated not having sufficient time to prepare for contact sessions, to source and appraise information, or to study and consolidate learning. They ascribed it to a full academic programme and commitments to other modules, especially clinical work. Some students focused more on assessment activities such as the completion of the final product than the process of learning. Dysfunctional groups with diverse personalities or lacking in cooperation reported more negative comments related to group work. Some students were unhappy if group members delivered poor quality work and did not meet agreed expectations.

Discussion

We found that three cohorts of final-year physiotherapy students consistently reported the development of skills, such as enhanced clinical reasoning, integration across modules, and collaborative learning as facilitators to learning attributed to an EBL approach. Barriers to learning included time constraints, group work and anxiety due to the lack of lecturer-developed learning material. EBL has become increasingly popular as a teaching and learning approach in health education in recent years.[5] The reported benefits of an EBL approach are many and include improved understanding of evidence-based practice, use of information resources, and enhanced critical thinking

skills and clinical reasoning.[2,5] Koh et al.[13] believe that an enquirydriven approach to learning results in the development of interpersonal and life skills. Improvement in transferable skills such as interpersonal communication skills and holistic patient management was observed in physiotherapy students exposed to EBL.[4] The students in our study reported similar development in skills related to research, as well as personal growth. Khan and O’Rourke[1] advocate EBL as an approach to develop many key transferable skills needed for lifelong learning. The inclusion of an EBL module in our final year of the physiotherapy programme at SU offers unique opportunities to hone these skills in a classroom environment and could extend to clinical placements. It has been reported that, although students enjoy EBL,[15] these approaches do not directly lead to improved management of clinical cases in comparison to conventional curricula.[7,12] Gunn et al.[4] reported that physiotherapy students exposed to this approach demonstrated increased knowledge and client-centeredness which correlated with positive selfdirected learning behaviours. The student’s level of maturity, learning approach and motivation were key factors that influenced how different individuals performed and coped.[4] Although the students in our cohort partly ascribed their improved clinical reasoning to the new EBL module, it needs to be corroborated by other sources such as the clinical supervisors who facilitate their learning on clinical placements. Understanding why certain students in our cohort found an EBL approach challenging needs

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Research further study. We are in agreement with Gunn et al.[4] that mechanisms should be implemented to identify and support students who have difficulty applying EBL principles during clinical work, and therefore we need to investigate what strategies might be best suited to our context. The implementation of the EBL approach at SU was not without challenges and student feedback has highlighted areas that need further consideration. Our students’ perception that the open-ended nature of the enquiry cycle was daunting and anxiety-provoking is well documented in the literature. We reflected on whether students were adequately prepared for independent study and if they had received the necessary guidance to develop these skills. Simons and Ertmer[16] highlight that students who are supported through scaffolding and preparation tend to perform better and are able to transfer their problem-solving strategies more effectively. One could argue that students in the final year have skills and experience to deal with EBL as a result of the third-year PBL module. Training students to source literature coincided with the start of PBL and research methodology modules, where critical appraisal was a key learning outcome. We anticipated that the PBL module would facilitate collaborative learning and the skills needed for more complex scenarios. PBL supporters argue that students familiar with PBL who are exposed to a novel problem, are often better problem solvers because of their experience with the steps involved. In contrast, Kirwan and Adams[5] found that students exposed to EBL for the first time, found it challenging to adjust and had to adapt learning styles and time management. Srinivasan et al.[7] argue that senior students who have developed some context for their work would cope better with open enquiry. However, the more structured and guided enquiry in our PBL module may still provide insufficient preparation for advanced independent enquiry. Dahlgren and Dahlgren[15] reported that preprofessional students engaged in PBL were especially frustrated by the ambiguity of facilitation and unsure of the correct amount of information to source. It could be argued that our cohort were exposed to PBL in their third year and should have grappled and subsequently resolved some of these issues. Based on the findings of this study, our students continue to experience similar frustrations with the EBL module, especially with the lack of resources and not trusting the quality of information gathered by peers. Bruder and Prescott[17] are adamant that students’ prior knowledge and understanding influence their performance in EBL. Preconditions such as personality and learning style, exposure to group and independent work, and experiences with different learning strategies influence the success of learning situations.[15] This could explain why some of our students, who were grappling with basic concepts and knowledge gaps, coped less well with EBL, since it requires flexible application of prior knowledge and personal learning strategies. Students who perform poorly in foundation courses, especially the PBL module, might experience the EBL module as more challenging. One could argue that management of time to source, appraise and synthesise appropriate information would be challenging for these students too; this is an additional motivation for students seeking lecturerdeveloped notes or reassurance about the quality of information. Srinivasan et al.[7] see feedback on the process of enquiry as essential to the development of higher-order reasoning skills. An EBL approach becomes less effective when facilitators are inflexible and do not model enquiry behaviour during contact sessions.[17] According to Ashby et al.,[2] students new to EBL tend to have difficulty with the transition from traditional teaching and learning to a more self-directed approach to learning. This experience could be ascribed to the preparedness and

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willingness to change, of both lecturers and students. EBL facilitators are encouraged to create a safe space for peer interaction, to probe skilfully and make sense of students’ ideas, and to guide and support students to question assumptions and challenge one another’s viewpoints.[15] Students need to receive feedback on their progress during an EBL module to progressively develop these enquiry skills. To optimise the learning experience during our EBL module, one needs to reflect on how students may gain abilities in self-regulation to work successfully as individuals and in groups.[15] Ashby et al.[2] warn faculty wishing to adopt EBL to plan well, consider logistical management (especially resources like time) and to support students during the transition phase. Our advice to prospective users of this approach is to encourage students to set ground rules, to manage group dynamics proactively and timeously, to facilitate enquiry in terms of how to phrase questions, and offer support to students in information appraisal. The challenge remains as to the most suitable support to offer in the learning process. Academic staff requires support through professional development to hone facilitation skills and enhance feeling comfortable with the open-ended nature of EBL.[15] Student feedback was collected prior to the final assessment to obtain more objective reflection of the module and its impact on learning. Another strength is that the data were collected for three cohorts of students. The data only reflect the perceptions of students at a single institution and this can limit the generalisability of findings. However, the data provide some insight into students’ perceptions of EBL. Programmes considering the implementation of EBL should ensure sufficient resource material and time for students to engage in group discussion to enhance understanding and synthesis. Quality assurance mechanisms should be implemented to address students’ anxiety about learning material. Student preparation for the module should include reflection on learning strategies. Support during the initial implementation phase of an EBL approach is necessary to allay fears and frustrations of both staff and students.

Conclusion

Based on findings of this study we conclude that physiotherapy students responded positively to EBL. They developed skills such as sourcing information and problem solving which they perceived improved their clinical work. The main barriers to learning were time constraints and concerns regarding quality assurance of learning material. Group work was regarded as both facilitatory and a barrier to learning. Programme designers could use perceptions of our cohorts when planning an EBL module. Whether this approach is more effective in developing self-directed learners with higher-order thinking skills than other learning approaches will need to be established. Author contributions. GIJ, SDH and SS were all part of the original project team. SS developed the questionnaire as part of the SU physiotherapy programme monitoring and evaluation project and GIJ administered the questionnaires to students. GIJ drafted this manuscript but all authors consent to the publication and contributed to: (i) conception, design, analysis and interpretation of data; (ii) drafting or critical revision for important intellectual content; and (iii) approval of the version to be published. Acknowledgements. We would like to thank the final-year physiotherapy students who contributed to this project for their active participation in the module and for sharing their experiences.

Research References 1. Kahn P, O’Rourke K, eds. Understanding enquiry-based learning. In: Handbook of Enquiry and Problem Based Learning. Galway: CELT; 2005. www.aishe.org/readings/2005-2/chapter1.pdf (accessed October 2014) 2. Ashby J, Hubbert V, Cotrel-Gibbons L, et al. The enquiry-based learning experience: An evaluation project. Nurse Educ Pract 2006;6(1):22-30. [http://dx.doi.org/10.1016/j.nepr.2005.05.008] 3. Mahony MJ, Wozniak H, Everingham F, Reid B, Poulos A. Inquiry based teaching and learning: What’s in a name? In: Learning for an unknown future. Proceedings of the 26th HERDSA Annual Conference, Christchurch, New Zealand, 6-9 July 2003: http://www.herdsa.org.au/wp-content/uploads/conference/2003/papers/HERDSA34.pdf (accessed October 2014). 4. Gunn H, Hunter H, Haas B. Problem based learning in physiotherapy education: A practice perspective. Physiotherapy 2012;98(4):335-340. [http://dx.doi.org/10.1016/j.physio.2011.05.005] 5. Kirwan A, Adams J. Students’ views of enquiry-based learning in a continuing professional development module. Nurse Educ Today 2009;29(4):448-455. [http://dx.doi.org/10.1016/j.nedt.2008.09.003] 6. Morris J. How strong is the case for the adoption of problem-based learning in physiotherapy education in the United Kingdom? Med Teach 2003;25(1):24-31. [http://dx.doi.org/10.1080/0142159021000061387] 7. Srinivasan M, Wilkes M, Stevenson F, Nguyen T, Slavin S. Comparing problem-based learning with case-based learning: Effects of a major curricular shift at two institutions. Acad Med 2007;82(1):74-82. [http://dx.doi. org/10.1097/01.ACM.0000249963.93776.aa] 8. Hutchings B. Principles of enquiry-based learning. Centre for Excellence in Enquiry-Based Learning Resources, University of Manchester, England 2006. www.ceebl.manchester.ac.uk/resources/papers/ceeblgr002.pdf (accessed 10 October 2014). 9. Jackson NJ. Learning based on the process of enquiry conference. University of Manchester. Sep 1-2 2003. www. ltsn.ac.uk/genericcentre/index.asp?id=16893 (accessed 10 October 2014).

10. Roy D, Kustra E, Borin P. What is unique about inquiry courses? McMaster Institute for Innovation and Excellence in Teaching and Learning, Learning resources, McMaster University, 2003. http://cll.mcmaster.ca/ resources/misc/whats_unique_about_inquiry.html (accessed 10 October 2014). 11. Palmer S. Enquiry-based learning can maximise a student’s potential. Psychology Learning and Teaching 2002;2:82-86. [http://dx.doi.org/10.2304/plat.2002.2.2.82] 12. Castro-Sánchez AM, Encarnación M, Aguilar-Ferrándiz ME, et al. Problem based learning approaches to the technology education of physical therapy students. Med Teach 2012;34(1):e29-e45. [http://dx.doi.org/10.3109/0142 159X.2012.638011] 13. Koh GC, Khoo HE, Wong ML, Koh D. The effects of problem-based learning during medical school on physician competency: A systematic review. CMAJ 2008;178(1):34-41. [http://dx.doi.org/10.1503/ cmaj.070565] 14. Cairncross S. Special session - Enhancing graduate attributes through research-teaching linkages. 39th Annual Frontiers in Education Conference: Imagining and Engineering Future CSET Education, FIE 2009, 18 - 21 October 2009. [http://dx.doi.org/10.1109/FIE.2009.5350783] 15. Dahlgren MA, Dahlgren L. Portraits of PBL: Students’ experiences of the characteristics of problem-based learning in physiotherapy, computer engineering and psychology. Instructional Science 2002;30(2):111-127. [http://dx.doi.org/10.1023/A:1014819418051] 16. Simons KD, Ertmer PA. Scaffolding disciplined inquiry in problem-based learning environments. International Journal of Learning 2005;12(6). www.edci.purdue.edu/ertmer/docs/simons_lc05.pdf (accessed 10 October 2014). 17. Bruder R, Prescott A. Research evidence on the benefits of IBL. ZDM Int J Math Educ 2013;45(6):811-822. [http://dx.doi.org/10.1007/s11858-013-0542-2]

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Research Integrating evidence-based principles into the undergraduate physiotherapy research methodology curriculum: Reflections on a new approach M Burger, MSc (Physio); Q A Louw, PhD (Physio) Division of Physiotherapy, Department of Interdisciplinary Health Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa Corresponding author: M Burger (mbu@sun.ac.za)

Background. The research methodology module was reviewed as part of the overall revision of the undergraduate physiotherapy curriculum of Stellenbosch University. This created an ideal platform from which to assess how to align the principles of evidence-based practice (EBP) with research methodology. Fostering the principles of EBP provides students with research skills and attributes to be able to seek, evaluate and integrate new knowledge and to apply critical thinking in order to effectively facilitate professional growth and support lifelong learning. Objective. To describe the process of changing the undergraduate research methodology module from a primary research to a secondary research approach. Methods. We consulted international experts and searched the literature for ideas and concepts of how to incorporate the principles of EBP. The overall objective of the new research module was formulated to provide students with lifelong skills in obtaining, evaluating, synthesising and forming clinical recommendations, as well as applying research evidence to the clinical setting. Results. Structuring the research methodology module using an EBP teaching framework prepares students to formulate a research question, effectively search for and critically appraise the evidence and formulate clinical recommendations. The barriers and strategies of implementing the new undergraduate research methodology module, as well as lessons learnt, are presented. Conclusion. Utilising a secondary research approach in the form of a systematic review or meta-analysis in our undergraduate research methodology module provides the opportunity for students, as novice researchers, to be trained in the principles of EBP. AJHPE 2014;6(2 Suppl 1):198-202. DOI:10.7196/AJHPE.516

Undergraduate education plays an important role in fostering evidence-based practice (EBP) to meet the needs and challenges of the twenty-first century healthcare system.[1] Evidence-based care is widely recognised as a key skill for health professionals, and healthcare students are expected to be competent evidence-based practitioners by the time they graduate and embark on their clinical or academic career.[2] The World Confederation for Physical Therapy (WCPT) strongly advocates teaching the principles of EBP in undergraduate physiotherapy curricula.[3] Herbert et al.[4] defined physiotherapy EBP as ‘physiotherapy informed by relevant high quality clinical research, patients’ preferences and physiotherapists’ practice knowledge’. EBP facilitates quality healthcare by amalgamating clinical knowledge and expertise with scientific evidence and patients’ preferences.[5] An international consensus statement (the Sicily statement on EBP)[6] sets out a five-step approach to EBP and recommends that this approach be incorporated into academic curricula by teaching the following steps: Step 1. Translation of uncertainty into an answerable question Step 2. Systematic search for and retrieval of evidence Step 3. Critical appraisal of evidence for validity and clinical importance Step 4. Application of appraised evidence to clinical practice Step 5. Evaluation of performance and thus auditing evidence-based decisions. Based on the above model, undergraduate education should provide students with research skills to seek, evaluate and integrate new knowledge

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to facilitate professional growth and support lifelong learning.[7] Because of the time and curricular constraints within professional degree courses, it could be argued that the best place to introduce the principles of EBP is in research methodology modules. The aim of this paper is to explain the rationale for adopting a secondary research approach as a vehicle to teach the principles of EBP as part of the undergraduate physiotherapy research module. Implementation strategies and lessons learnt are also outlined.

Motivation for reviewing the research methodology module and introducing EBP

The research methodology module was reviewed as part of the overall revision of the undergraduate physiotherapy curriculum at Stellenbosch University (SU). This created an ideal opportunity to assess how to introduce and align the principles of EBP with the current mode of teaching research methodology and basic statistics to undergraduate students. The previous research methodology module spanned the final 2 years of the 4-year undergraduate physiotherapy curriculum and was delivered as didactic lectures covering a wide range of research design and statistical concepts. After completing the series of 30 1-hour lectures at the beginning of their third year, students were divided into groups and each group was tasked to conduct a research project. Two supervisors (physiotherapy lecturers) were assigned to a research group and mandated to assist the students in conceptualising a project, recruiting subjects, collecting data and writing up the research report. There were no guidelines or boundaries

Research regarding the type, nature and scope of the research projects, and typically the projects were limited by time and financial constraints only. Students were expected to write a primary research protocol, research paper/report and present their research findings at a forum attended by fellow students, clinical supervisors and independent evaluators. Although it was not one of the main outcomes of the research methodology module, publication was strongly encouraged. Despite this, these research projects yielded only two research publications in accredited journals over four decades. This mode of teaching research methodology was carried out for 40 years until the undergraduate curriculum was reviewed. During the curriculum revision process, all permanent academic staff participated in an in-depth analysis of the former research methodology module. The issues raised are listed below. • The course content focused on epidemiology, research techniques and statistical calculations rather than the application of research to patient care. • Design of studies was primarily limited to surveys which limited the ability of undergraduate students to recognise the link between research and clinical practice.

• The large number of surveys often duplicated previous research and thereby created research waste.[8] • The types of questions did not address important clinical issues and students could not translate their study findings into clinical practice. • Studies were limited to small sample sizes (because of time and financial limitations) and yielded inconclusive results. • Students had no exposure to systematic searching and no tools to critically appraise literature, implying that they lacked the core EPB skills and attributes for clinical application and lifelong learning. • Obtaining ethical approval from the Health Research Ethical Committee and relevant institutions imposed further time constraints for completion of the research projects. • No funding or equipment was available for undergraduate research projects. • There were concerns that the course objectives were too broad and did not allow consolidation of research methodology skills. After reviewing the content, mode and outcomes of the research methodology module, it was clear that the module needed substantial revision.

Table 1. Steps followed for teaching the five key principles of evidence-based practice as part of the research methodology module[12-15] Step 1 – asking clinically relevant questions by translation of uncertainty into an answerable question

• Students search for interesting systematic review or meta-analysis topics published in the past 3 - 5 years

Step 2 – finding the evidence: systematic search for and retrieval of evidence

• In consultation with a librarian, 3 hours of practical small-group library training are allocated to teach students how to conduct effective searches in at least seven different medical databases and how to define MeSH terms and Boolean operators

• Students determine if their chosen topic has not been published in the form of a systematic review/meta-analysis or protocol in the past 12 months • If no similar systematic review has recently been published, students proceed to formulate their PICO question and search terms. Searches in relevant databases are conducted to ensure that at least three eligible RCTs were published following the publication of the previous systematic review or meta-analysis. This does not form part of the primary search, but the purpose is merely to determine if eligible RCTs have been published to warrant a new systematic review on their chosen topic • Students then need to conceptualise their topic and ideas and write and submit a secondary research protocol

• A 2-hour library session is allocated to teach students how to utilise reference database software (RefWorks)[12] to capture, manage, and organise bibliographic citations • After approval of their research protocol, students conduct and tabulate structured searches with relevant search terms in at least seven of the following databases: PubMed, Cochrane Library, Cinahl - EBSCOhost, Proquest, Science Direct, Scopus, PEDro, SPORTDiscus – EBSCOhost, OT Seeker and Google Scholar

Step 3 – critically appraising the evidence for validity and clinical importance

• The eleven-item PEDro scale[13] is utilised to assess the study’s internal validity (criteria 2 - 9), external validity (criteria 1) and the statistical accuracy for interpretation purposes (criteria 10 - 11)

Step 4 – interpreting the evidence and applying research evidence: application of appraised evidence to clinical practice

• The adapted ‘JBI Data Extraction Form’[14] is used to extract the following data from the selected article: reference, type of study, participants, interventions (treatment and control group), outcome measures (including outcome measure tools), results, as well as the clinical status post-intervention and clinical implications thereof

• Students receive extensive training in how to use the PEDro scale for critical appraisal and their skills in using the PEDro scale are also tested as part of formative and summative assessment

• On completion of the data extraction, homogeneous data are combined using the RevMan Review Manager software 5.2[15] which pools data statistically in forest plots to determine the superiority of one intervention in comparison with the other. Heterogeneous data are summarised in a narrative form • Staff members guide and assist the students to extract relevant data and to interpret the data • Students are expected to interpret the relevance of the project findings to the local context and present contextualised recommendations for physiotherapists. Formal evaluation of their project findings and recommendations for clinical practice is done in presentation format at the Physiotherapy Division’s Research Day. They are also strongly encouraged to present at the Faculty of Medicine and Health Sciences Student Academic Year Day, as well as at the combined university Physiotherapy Research Day

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Research Developing an alternative teaching strategy for research methodology

One of the main drivers for the new research methodology module was to develop an understanding of the role of scientific research in informing clinical practice. While the previous mode of teaching research methodology was inclined towards equipping students with skills to conduct research, we decided to deviate from this approach and place the emphasis on the acquisition of skills to become efficient users of published research, rather than personally conducting primary research, i.e. being ‘doers of research’.[9] The primary aim of the newly revised undergraduate curriculum was therefore to train effective clinicians who are able to ask clinically relevant questions, find and critically appraise the evidence, and interpret and apply the evidence to their daily practice.

Methods

Journey to design a new research methodology module

We explored avenues to teach the principles of EBP and developed aims for the new research methodology module. During this process, we consulted international experts and searched the literature for ideas and concepts of how we could design a module which would facilitate the drive to understand scientific evidence and its role in clinical practice. We gained valuable advice from colleagues at the University of South Australia’s International Centre for Allied Health Evidence (ICAHE), Melbourne University’s Department of Physiotherapy and the South African Cochrane Centre. Based on discussions and feedback, we proposed secondary research, in the form of evidence syntheses, instead of primary research as our platform to teach the principles of EBP. In an attempt to reduce the variability of the scope and design of the projects, we envisaged only effectiveness reviews based on randomised controlled trials (RCTs) aimed to establish the effectiveness of a physiotherapeutic intervention. Evidence synthesis/meta-analysis of RCTs is viewed as level 1 evidence for effectiveness of interventions on many evidence hierarchies because it presents the least biased approach for the effectiveness of an intervention.[10] Therefore, it seemed to be an appropriate approach to assist students in understanding how scientific evidence, generated from research, can be used to inform clinical practice.

Description of the aim and outcomes of the newly designed research methodology module The overall aim of the module was to provide students with skills in obtaining, evaluating, synthesising and formulating clinical recommendations, as well as applying research evidence to the clinical setting. This module also assists the students to obtain knowledge and develop skills to find and assess evidence to answer a clinically relevant question. Moreover, students are required to work both individually and in teams, and this provides students with the opportunity to develop team skills that are a necessary part of effective clinical practice. The key learning outcomes of newly revised research methodology module outcomes of the third and fourth years are to: • design an effectiveness research question, using the PICO method (patient or problem, intervention, comparison and outcome);[4] • effectively search for and select the best evidence using all available medical databases via the webpage of SU’s medical library; • critically appraise the evidence for validity and clinical importance using a reliable appraisal tool, as well as evaluate and grade the articles’ hierarchical level of evidence;

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• extract and analyse data from primary research articles and apply basic statistical concepts (meta-analysis); • apply evidence to clinical practice and formulate clinical recommendations; • formulate implications and recommendations for future research. These outcomes concurred with the graduate attributes that are promoted by the Faculty of Medicine and Health Sciences, SU, and are also in keeping with the work of Laidlaw et al.,[11] who used different methodologies to define and rank the most important graduate attributes and skills for undergraduate medical programmes from both a research and a professional perspective. The seven most important graduate attributes and skills were listed as follows: • inquiring mind/curiosity • core knowledge • critical appraisal • understanding of the evidence base for professional practice • understanding of ethics and governance • ability to work in a team • ability to communicate. Laidlaw et al.[11] suggested that these core attributes should be mapped to current learning activities to ensure that there are opportunities within the curriculum for students to develop and practise these skills. Teaching strategies were set in place, aimed to incorporate at least four of the five-step principles of EBP into the undergraduate research methodology module (Table 1) to address some of the graduate attributes and skills as defined by Laidlaw et al.[11] A total of 120 hours were allocated in the third year and 110 hours in the fourth year of the physiotherapy curriculum to achieve these outcomes. The course materials included handouts and the textbook by Herbert et al.[4] on Practical Evidence-Based Physiotherapy. Step 1 of the five-step module was accomplished during the second term of the third year when the students were divided into groups of four to six members and had to formulate relevant research questions and complete a systematic literature review protocol. Steps 2 to 4 of the five-step module were completed in the first semester of the fourth year, when the students conducted a systematic literature review and wrote a systematic review article. As part of step 4, the students had to deliver a scientific oral report of their research findings at the Division of Physiotherapy’s Annual Student Research Day.

Action plans to implement EBP within the new research methodology module – barriers and solutions The main barrier was that less than a third of the permanent academic staff who were eligible to supervise undergraduate research groups had been trained in conducting systematic reviews. This barrier was addressed by training staff in conducting systematic reviews using a ‘train the trainer’ approach. Staff are required to ‘train/supervise’ students and therefore these skills are needed. The main training event was conducted by an expert from the University of South Australia’s ICAHE. The focus of these training sessions was to equip staff members with the Sicily statement’s five-step approach to EBP including question formulation, skills on how to conduct the most effective database searches, critical appraisal of RCTs as well as other types of research designs, and applying the evidence to clinical problems. After the initial training, staff members were trained and supported via a peer-mentoring approach by a fellow staff member who already had

Research a track record of published systematic reviews. Subsequently, this staff member (the mentor) attended a 5-day international course on training health professionals to conduct secondary research and on return trained colleagues in these skills. Newly appointed staff members supervised research groups with a trained colleague. In this way skills were imparted to new staff members in an experiential manner. Another barrier was ensuring that the staff and students were ready to change to the new research approach. At the time when we changed the research methodology module, there was much scepticism as it did not involve any primary data collection and required new methodological and statistical knowledge. This was addressed by the training outlined above, as well as bi-annual sessions with staff to update their knowledge and skills, and thereby improve their confidence and willingness to supervise research groups. A final barrier was to find suitable research topics to formulate an effectiveness question. Students often wanted to conduct a research project on a topic that interested them, only to discover after an extensive database search that a systematic review or meta-analysis had recently been published on the topic, or that they could not find any suitable RCTs to evaluate and include in their systematic reviews. We addressed this problem by guiding the students to search for interesting systematic review or meta-analysis topics that had been published in the past 3 - 5 years. Students needed to search for RCTs on the same topic published after the systematic review of their choice. Students could then utilise the recently published RCTs for secondary research in the form of evidence synthesis and compare their findings with the previous systematic review(s) on their topic. Students were thus encouraged, where possible, to conduct updates of existing systematic reviews or meta-analyses.

Results and discussion

Lessons learnt and the way forward

We managed to define the core research skills appropriate for undergraduate physiotherapy students, and by integrating EBP principles in the research methodology module we hope to foster important graduate attributes to equip new graduates for their professional career.[11] Structuring the research methodology module using an evidence-based teaching framework may successfully prepare our undergraduate students for a postgraduate academic career. We hope that teaching the principles of EBP will have a positive impact on improving clinical practice and their transition to a research career, and the throughput of current and future postgraduate students. From the time we implemented the revised research methodology module we noted a lack of high-quality evidence for many of the physiotherapy interventions which were reviewed by students.[16] Consequently RCTs of poor methodological quality often had to be included in the systematic reviews. Conclusive recommendations to support or refute current practices, as well as the translation of the new-found evidence into their clinical practice, were often impossible. This lack of evidence enhanced the students’ awareness of the need for high-quality research to advance EBP in the physiotherapy profession. It also nurtured and stimulated critical thinking and improved their appraisal skills of the current evidence. Similar traits were also reported by Seymour et al.,[17] who noted that undergraduate research resulted in a professional and personal growth experience with many transferable benefits such as critical and reflective thinking, problem

solving, and an increased confidence in students’ ability to effectively communicate, explain and defend their work to others. Since implementing the new research curriculum in 2007, we have published three undergraduate research papers[18-20] and another two are under review in accredited international journals. Annually, the best abstracts are also published in the South African Physiotherapy Forum. We have a much higher publication success rate with systematic reviews and meta-analyses (secondary research) in the revised undergraduate research methodology module as compared with the previous module. Supervisors of undergraduate research groups spend on average 100 hours per group assisting them in the research process and writing the scientific protocol and paper. We found that the students and supervisors who published their papers felt a great sense of achievement and that the hours spent synthesising evidence were not wasted. The way forward will be to support and encourage all supervisors of undergraduate research groups to ensure that evidence syntheses are published.

Limitations of incorporation of EBP principles as part of the research methodology module The key limitation of incorporating EBP principles is that it was not possible to fully incorporate and formally assess all five steps of the Sicily five-step approach to EBP,[6] namely the interpretation and application of research evidence into daily clinical practice (step 4) and the evaluation of performance and thus auditing evidence-based decisions (step 5). The best vehicle to fully incorporate steps 4 and 5 of the Sicily five-step module should be introduced during the undergraduate clinical training, and this still needs to be investigated.

Conclusion

Utilising a secondary research approach, in the form of conducting a systematic review or meta-analysis to teach our new undergraduate research methodology module, provides the opportunity for physiotherapy students, as novice researchers, to acquire basic research skills and become clinicians who provide evidence-based clinical services. We were able to define and align core research skills with the graduate attributes as promoted by the Faculty of Medicine and Health Sciences. Evidence synthesis in the form of systematic reviews and meta-analyses is a time-efficient and sustainable method, which has led to an increase in undergraduate physiotherapy publication outputs. Integrating the principles of EBP into the undergraduate physiotherapy research methodology module may contribute to preparing our students to become healthcare professionals with an interest in EBP and/or researchers who advance the field of physiotherapy. Author contributions. Both authors contributed to: (i) conception, design, analysis and interpretation of data; (ii) drafting or critical revision for important intellectual content; and (iii) approval of the version to be published. References 1. Rudman A, Gustavsson P, Ehrenberg A, Boström AM, Wallin L. Registered nurses’ evidence-based practice: A longitudinal study of the first five years after graduation. Int J Nurs Stud 2012;49(12):1494-1504. [http://dx.doi. org/10.1016/j.ijnurstu.2012.07.007] 2. Olsen NR, Bradley P, Lomborg K, Nortvedt MW. Evidence based practice in clinical physiotherapy education: a qualitative interpretive description. BMC Med Educ 2013;13:52. [http://dx.doi.org/10.1186/1472-6920-13-52] 3. World Confederation for Physical Therapy. Policy statement: Evidence based practice. London: WCPT, 2011. www.wcpt.org/policy/ps-EBP (accessed12 December 2013). 4. Herbert RD, Jamtvedt G, Mead J, Hagen KB. Practical Evidence-Based Physiotherapy. Edinburgh: Butterworth Heinemann Elsevier, 2005.

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Research 5. Herbert RD, Sherrington C, Maher C, Moseley AM. Evidence-based practice â&#x20AC;&#x201C; imperfect but necessary. Physiotherapy Theory & Practice 2001;17(3):201-211. [http://dx.doi.org/10.1080/095939801317077650] 6. Dawes M, Summerskill W, Glasziou P, et al. Sicily statement on evidence-based practice. BMC Med Educ 2005;5:1-7. [http://dx.doi.org/10.1186/1472-6920-5-1] 7. Laidlaw A, Aiton J, Struthers J, Guild S. Developing research skills in medical students: AMEE Guide No. 69. Med Teach 2012;34(9):754-771. [http://dx.doi.org/10.3109/0142159X.2012.704438] 8. Chalmers I, Glasziou P. Avoidable waste in the production and reporting of research evidence. Lancet 2009;374(9683):86-89. [http://dx.doi.org/ 10.1097/AOG.0b013e3181c3020d] 9. Meats E, Heneghan C, Crilly M, Glasziou P. Evidence-based medicine teaching in UK medical schools. Med Teach 2009;31(4):369-374. [http://dx.doi.org/10.1080/01421590802572791] 10. Oxford Centre for Evidence-Based Medicine. The Oxford Levels of Evidence 2011. http://www.cebm.net/mod_ product/design/files/CEBM-Levels-of-Evidence-2.1.pdf (accessed 12 April 2014). 11. Laidlaw A, Guild S, Struthers J. Graduate attributes in the disciplines of medicine, dentistry and veterinary medicine: A survey of expert opinions. BMC Med Educ 2009;9:28. [http://dx.doi.org/ 10.1186/1472-6920-9-28] 12. RefWorks http://www.refworks.com/ (accessed 12 April 2014). 13. PEDro. Physiotherapy Evidence Database. PEDro Scale. http://www.pedro.org.au/english/downloads/pedroscale/ (accessed 12 April 2014).

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14. Pearson A, Field J, Jordan Z. Appendix 3: Data extraction tools. In: Evidence-Based Clinical Practice in Nursing and Health Care: Assimilating Research, Experience and Expertise. Oxford: Blackwell, 2009. 15. Cochrane Informatics and Knowledge Management Department http://tech.cochrane.org/revman/download (accessed 12 April 2014). 16. Miller PA, McKibbon KA, Haynes RB. A quantitative analysis of research publications in physical therapy journals. Physical Therapy 2003;83(2):123-131. 17. Seymour E, Hunter A, Laursen SL, Deantoni T. Establishing the benefits of research experiences for undergraduates in the sciences: First findings from a three-year study. Science Education 2004;88(4):493534. 18. Little K, Nel N, Ortell V, van Wyk H, Badenhorst M, Louw QA. The clinical effect of hippotherapy on gross motor function of children with cerebral palsy. South African Journal of Physiotherapy 2013;69(2):26-34. 19. Du Plessis M, Eksteen E, Jenneker A, et al. The effectiveness of continuous passive motion on range of motion, pain and muscle strength following rotator cuff repair: A systematic review. Clin Rehabil 2011;25(4):291-302. [http://dx.doi.org/10.1177/0269215510380835] 20. Duvenhage L, Mushaike T, Parker N, et al. A meta-analysis into the effect of lateral-wedged insoles with subtalar strapping versus traditional insoles in adults with medial knee osteoarthritis. South African Journal of Physiotherapy 2011;67(1):35-43.

Research Teaching my peers: Perceptions of tutors in physiotherapy practical skills training M Unger,1 BPhysT, MSc (Physio), PhD; L Keiller,2 BSc (Physio), MPhil (HSE); G Inglis-Jassiem,1 BSc (Physio), MSc (Physio); S D Hanekom,1 BSc (Physio), MSc (Physio), PhD 1

Division of Physiotherapy, Department of Interdisciplinary Health Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa

Centre for Learning Technology, Stellenbosch University, Cape Town, South Africa

Corresponding author: M Unger (munger@sun.ac.za)

Background. A near-peer tutorial system was introduced and implemented as part of a second-year module to assist physiotherapy students with the practising of manual techniques. Although not the primary drive for initiating this system, there are potential added benefits for the tutor reported in the literature. Objective. To determine the effect of near-peer teaching on the perceptions undergraduate physiotherapy students have of their own learning. Methods. A descriptive study utilising mixed methods was used. A pre-tutorial focus group discussion (FGD) format explored the expectations and perceptions of tutors’ own abilities and the proposed tutorial system. The researchers conducted a post-tutorial FGD to explore the experiences and perceptions of the tutors’ learning experiences. The responses were transcribed and analysed using deductive thematic analysis. A questionnaire was used to quantify which competencies or skills student tutors thought they had obtained through the facilitation of the tutorial sessions. The results were explored using a competency framework. Results. All ten tutors in the 2012 programme participated in the study. Students moved from unconscious incompetence to conscious incompetence, and seemed to have reached the phase of conscious competence by the end of the programme. Unconscious competence was not observed. More than half of the tutors agreed that the programme had a positive impact on their communication, ability to transfer skills and their own understanding of techniques and underlying theory, while two tutors felt that the programme did not improve their own theoretical basis of techniques. Conclusion. Participating and functioning as near-peer tutors had a positive influence on physiotherapy students’ perceptions of their own learning both in terms of own clinical technique competency, but also as teachers and facilitators of learning. It is hypothesised that these students will transition effectively between clinician and health advocator/teacher. AJHPE 2014;6(2 Suppl 1):203-206. DOI:10.7196/AJHPE.497

Peer-assisted learning (PAL) is well described in the literature as an effective collaborative teaching strategy to aid the development of knowledge and skills through deliberate helping and supporting among equals or matched cohorts.[1] One of the main reasons cited for this is that students are perceived as equals and identify more easily with student tutors; this also assists with gaining confidence when engaging in learning material with one another.[2] Lockspeiser et al.[3] proposed a ‘cognitive congruence hypothesis’ which states that a teacher with a similar knowledge base to the learner is more effective than one who is an expert in the field but with a disparate knowledge base. A near-peer, a senior student who is one or more years senior in training to more junior students,[4] may better understand the challenges students face, and could therefore explain concepts in a more appropriate manner and offer an alternative method for studying.[5] The described benefits related to PAL are, however, not always the primary rationale for implementing this mode of teaching and learning. A study by Haist et al.[6] showed that replacing medical faculty teachers with senior medical students did not compromise the learning of the students. Similarly, PAL of technical skills in a skills laboratory has been shown to be as effective as training provided by experienced faculty.[7] This evidence is frequently used to motivate for introducing PAL or peer teaching and learning (PTL) to help lighten teaching workloads for faculty.[5] This is especially true where resources are limited and where there is a growing

demand for training more health professionals to deal with the increasing burden of disease.[1,8] The potential benefits of PAL for the tutors themselves are also increasingly being reported. Consolidating own-learnt knowledge and refining (automating) skills,[1] development of leadership skills, increased social interaction and increased managerial skills[9] have all been reported in the literature. Following their review of the medical education literature, Ten Cate and Durning[5] identified that using the analogy of the guild concept, with the intermediate (journeyman) between the student (apprentice) and the health professional (master) is a valuable but underrecognised source of education in medicine. The opportunity to teach others what they have learnt recently consolidates own knowledge and prepares them for further cognitive development. This practice of peer teaching especially prepares students for their role as health educators, a graduate attribute stipulated in most competency charters for health professionals.[11] Owing to increasing student numbers and financial constraints, PAL tutorials were introduced and implemented as part of a second-year module to assist with practising manual physiotherapy techniques. The tutors (who were in their third year of study) were deemed suitable as they had already begun to use these techniques in clinical practice. Tutors were trained prior to the implementation of the tutorial programme by the Centre for Teaching and Learning (CTL) at Stellenbosch University (SU). Their training included cooperative learning principles and facilitation skills. The tutors were also mentored by staff members as an extra strategy to support

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Research their role as tutors. Although the primary drive for this initiative was to guarantee successful student throughput in an undergraduate physiotherapy curriculum, it was hoped that tutors would also benefit in that their own communication, listening, leadership, and skills-transfer abilities would improve. The aim of this paper is to describe the effect of student-facilitated tutorials on tutors’ perception of their own learning.

Methods

This descriptive study utilised both qualitative and quantitative data collection methods. Ethical approval was granted by the SU Health Research Ethics Committee (N12/04/018). Informed consent from all 2012 third-year tutors was obtained.

Data collection and analysis

expected to function as facilitators and not as teachers of new techniques, they still expressed concern regarding accuracy and consistency across the tutorial groups. With regard to the benefits of the programme, tutors believed that it would benefit their own learning because of the forced revision of the techniques, as well as positively contributing to the tutees through individual attention and immediate feedback. Their ability to position these techniques through mentoring, in the context of the broader programme for the tutees, was also seen as a potential benefit. This mentor role within this less intimidating environment would also contribute to relationshipbuilding between year groups.

Post-tutorial FGD

All ten tutors in the 2012 programme participated in the study. From the pre-tutorial FGDs, three themes emerged. Tutors had a tendency to focus on their concerns regarding competence, confidence and the logistics of the programme. They also verbalised their perceptions of how the programme might impact on themselves as well as the tutees. In the post-tutorial FGD, the themes which emerged highlighted the resolution of the concerns regarding competence, and focused more on the impact of the tutorial programme on their own competencies and skills. Tutors also identified additional benefits relating to relationship building, leadership skills development and the importance of time management.

Tutors recognised that learning styles of tutees differed and perceived a need to adapt their teaching style to the different needs of their tutees. ‘So there are people like me out there who learn better from having it done on ourselves and there are other people who learn by doing it, and there are other people who learn by watching.’ Similarly, students reported that they were able to pass on knowledge and skills in a contextualised manner and that this contributed to more effective learning. Tutors realised where they had gaps in their own learning and could address these accordingly while seeing an improvement in their own performance in clinical practice. ‘I remember the next day when I went to clinical, I had a patient that I needed to do that on and we had just done it the day before. I probably wouldn’t have remembered properly if I hadn’t done it again with the second years.’ Another comment – ‘I think it helped me in that I could better explain the effect of the techniques to my own patients now’ [translated] – further supports the overflow into their own clinical practice. Perceptions of tutors were that this process allowed them to develop deeper relationships with their peers, as well as between year groups, and this allowed them to learn from each other. ‘You feel a deeper connection to students because you have helped them and have seen them more…’ [translated] and ‘but getting to know some of the others, some from the other groups now also stop me in the passage and feel free to ask me questions, they know who we are’ are comments suggesting the value of these relationships. One tutor commented, ‘I would have wanted [liked] someone to talk to at the end of my second year.’ They also identified the improvement of their leadership abilities as the tutorial programme progressed, which included dealing with issues of discipline and seniority. Given that participating in this programme would impact on the time that they had available for their own third-year academic programme, the students recognised the importance of time management. The following comment was shared in the focus group: ‘We also have class, we also have tasks, we also have tests, and that needs to be worked out a little bit better.’

Pre-tutorial FGD

Post-tutorial questionnaire

Two semi-structured interview schedules were used for focus group discussion (FGD) with the tutors. A pre-tutorial FGD explored the expectations and perceptions of the new format of teaching and tutors’ own abilities. The post-tutorial FGD explored tutors’ experiences and perceptions of their own learning. These FGDs were conducted by the same researcher. In addition, a questionnaire was developed by the research team in collaboration with CTL to determine tutors’ perceptions of their own learning, and this was completed at the end of the programme. The questionnaire was piloted for face validity. The self-assessment questionnaire required tutors to indicate which competencies or skills they had developed through facilitation of the tutorial sessions. These skills pertained to communication, listening, leadership, helping, social and skills-transfer abilities. Tutors were asked to rate their skills in these domains on a fivepoint Likert scale (ranging from strongly disagree to strongly agree). They were also asked to rate whether their own understanding of the practical technique and the theory underpinning these techniques had improved. FGDs were audiotaped and transcribed. These transcriptions were deductively analysed independently by two researchers to determine the main themes. The data from the questionnaires were graphically presented and the total number of responses for each category was determined.

Results

There were tutors who perceived themselves to be responsible for the learning of their peers, some of whom were confident that they had the necessary knowledge to do so and some who expressed anxiety at the perceived high level of responsibility. They reported concerns that adaptations in the clinical setting of techniques learnt in the classroom would influence their tutoring. Tutors expressed concern that this might confuse the secondyear students not yet exposed to the clinical environment. Although tutors

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While the post-tutorial questionnaire required responses to eight items, the responses to the impact on listening, helping and social skills were seemingly misunderstood by participants. Fig.1 represents the students’ perceptions of how participating in this tutorial programme impacted on the remaining five items. More than 50% of the tutors agreed that the programme had a positive impact on their communication, ability to transfer skills, and their own understanding of techniques and underlying theory. Only two

Research

Own understanding of theory base of techniques

Own understanding of techniques practised Strongly disagree Ability to transfer skills

Disagree Neutral Agree

Leadership

Strongly agree Communication 0

n Fig. 1. Student perceptions of the impact on their own learning.

Table 1. Tutor comments supporting their rated perception of the impact of the near-peer tutorial programme Communication • ‘I feel more comfortable to talk to strangers.’ [Translated] • ‘I had to find new ways to explain concepts in ways that others understand it.’ • ‘I learned how to break things down to basics, to the how and why.’ [Translated] Leadership • ‘They had respect for me and I could just facilitate.’ [Translated] • ‘We had to take charge.’ • ‘Learned to take charge in the class and give guidance; it’s rather intimidating when everyone is looking at you at the same time.’ [Translated] Ability to transfer skills • ‘It was easy to transfer techniques, especially through demonstration.’ [Translated] • ‘That you have to explain and demonstrate something and the person has to show you themselves, then you know if they understood.’ [Translated] Own understanding of techniques • ‘If you can explain something to someone, it means that you understand the concept yourself.’ [Translated] • ‘Was able to better my clinical evaluation and treatment techniques due to repetition … and explaining to others.’ • ‘Was able to … [and] learn … from the students about better positions, etc.’ Own understanding of theory • ‘Yes; because we had to explain some of the theory behind the techniques to the students if they ask.’ • ‘It resulted in me having to read up on the theory again.’ [Translated]

tutors felt that the programme did not improve their own theoretical basis of techniques. Tutors provided comments to support their rating of each item (Table 1).

Discussion

The aim of the physiotherapy programme at SU is to prepare students to cope with entry into community service. As health promotion and prevention are

key aspects of primary healthcare, it is expected of healthcare professionals to spend much of their time in clinical practice as teachers. In addressing the needs of the division and those of the second-year physiotherapy students at SU, this near-peer tutorial programme created a space in which students as tutors were able to grow in confidence and increase not only their own clinical skills but their competency as teachers as well. The process by which tutors have benefited from the tutorial programme can be mapped using an adapted competency framework such as the one proposed by Taylor. [12] Using this framework,[12] once the tutors had begun to prepare for the tutorials through training and using the manual, students moved from a phase of unconscious incompetence to one of conscious incompetence, where they realised that although they were able to adapt their skills in facilitation from a student-patient relationship to a tutor-tutee relationship, there were specific techniques and theoretical concepts that they needed to revise. The revision of techniques and theory, added to the experience they gained in the early tutorial sessions, allowed them to reach a phase of conscious competence, in which they realised that they did have the skills necessary to facilitate and explain the basic concepts and relationships needed to their junior peers. The ultimate aim would be for these students to become unconsciously competent in their teaching skills. This, however, was not yet achieved by the tutors. From the literature it seems plausible, however, that it would be a natural progression for the students to reach this stage as they continue into clinical practice. The reflective competence phase,[12] though not explicit within the process, was apparent during their participation in the study data collection phase and participation in the FGD. It demonstrated that they were able to comment and reflect on their own strengths and weaknesses as facilitators of learning.

Limitations

The study is limited to the experiences of student tutors within our division only. Concerns expressed prior to the start of the programme were shared by the full cohort. The perceived benefits of PAL on their own learning and development did, however, vary among the students and warrant further investigation.

Conclusion

Functioning as near-peer tutors had a positive influence on physiotherapy students’ perceptions

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Research of their own learning, both in terms of own clinical technique competency, and as teachers/facilitators of learning. Further work is needed to determine whether peer-assisted learning helps graduates transition effectively between clinician and health advocator/teacher. Acknowledgements. The authors would like to acknowledge the Fund for Innovation Research in Learning and Teaching for funding this initiative and research. We wish to thank Mrs Josephine Kotze for her invaluable contribution to the conceptualisation and data collection. References 1. Topping KJ, Ehly SW. Peer assisted learning: A framework for consultation. Journal of Educational and Psychological Consultation 2001;12(2):113-132. [http://dx.doi.org/10.1207/s1532768xjepc1202_03] 2. Secomb J. A systematic review of peer teaching and learning in clinical education. Journal of Clinical Nursing 2008;17(6):703-716. [http://dx.doi.org/10.1111/j.1365-2702.2007.01954.x]

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3. Lockspeiser TM, O’Sullivan P, Teherani A, Muller J. Understanding the experience of being taught by peers: The value of social and cognitive congruence. Advances in Health Sciences Education 2008;13(3):361-372. [http:// dx.doi.org/10.1007/s10459-006-9049-8] 4. Bulte C, Betts A, Garner K, Durning S. Student teaching: Views of student near-peer teachers and learners. Medical Teacher 2007;29(6):583-590. [http://dx.doi.org/10.1080/01421590701583824] 5. Ten Cate O, Durning S. Peer teaching in medical education: Twelve reasons to move from theory to practice. Medical Teacher 2007;29(6):591-599. [http://dx.doi.org/10.1080/01421590701606799] 6. Haist SA, Wilson JF, Brigham NL, Fosson SE, Blue AV. Comparing fourth-year medical students with faculty in the teaching of physical examination skills to first-year students. Acad Med 1998;73(2):198-200. [http://dx.doi. org/10.1097/00001888-199802000-00020] 7. Tolsgaard MG, Gustafsson A, Rasmussen MB, Høiby P, Müller CG, Ringsted C. Student teachers can be as good as associate professors in teaching clinical skills. Medical Teacher 2007;29(6):553-557. [http://dx.doi. org/10.1080/01421590701682550] 8. Burch VC. Medical education in South Africa: assessment practices in a developing country. Erasmus University Rotterdam 2007. http://hdl.handle.net/1765/10152 (accessed August 2014) 9. Wamsley MA, Julian KA, Wipf JE. A literature review of ‘resident‐as‐teacher’ curricula. J Gen Intern Med 2004;19(5 Pt 2):574-581. [http://dx.doi.org/10.1111/j.1525-1497.2004.30116.x] 10. Haber RJ, Bardach NS, Vedanthan R, Gillum LA, Haber LA, Dhaliwal GS. Preparing fourth‐year medical students to teach during internship. J Gen Intern Med 2006;21(5):518-520. [http://dx.doi.org/10.1111/j.1525-1497.2006.00441.x] 11. Frank JR, Snell L. The Draft CanMEDS 2015 Physician Competency Framework http://www.royalcollege.ca/portal/ page/portal/rc/common/documents/canmeds/framework/framework_series_1_e.pdf (accessed August 2014). 12. Taylor W. The Conscious Competence Learning Model 2007. http://www.businessballs.com/ consciouscompetencelearningmodel.htm (accessed January 2014).

Research Evaluation of clinical sites used for training undergraduate physiotherapy students: Factors that may impact on learning L G Williams, MSc (Physio); D V Ernstzen, MSc (Physio), MPhil; S B Statham, MSc (Physio); S D Hanekom, PhD Division of Physiotherapy, Department of Interdisciplinary Health Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa Corresponding author: L G Williams (leonie@sun.ac.za)

Background. Clinical education forms an integral part of the training of undergraduate healthcare students. Clinical learning and education can be influenced by a number of factors. Objectives. To evaluate clinical service sites used to train undergraduate physiotherapy students at Stellenbosch University, in terms of: (i) the suit ability of the site as a training facility; and (ii) the range of clinical problems students encounter at these clinical service sites. Methods. A descriptive study was conducted. Data were gathered through structured clinical site visits, staff interviews and student record sheets documenting the number and type of patients students encountered at the clinical service sites. Results. Seven of the nine clinical sites used for training were evaluated. Close proximity to the Faculty was an identified strength of three of the sites. There were opportunities for the expansion of multidisciplinary services and group treatment classes. There were safety concerns at most of the sites visited. The number of qualified physiotherapists was low and there was also a lack of basic equipment needed for patient management at more than half of the clinical sites. Students’ exposure to the various fields of physiotherapy varied greatly at the tertiary service settings versus primary healthcare settings. On average students saw only two patients per day during a 5-hour clinical day. Conclusion. The suitability of healthcare service sites for training undergraduate students should be carefully evaluated prior to commencing training at these sites. The development of good clinical training sites for undergraduate healthcare students requires the availability of adequate resources such as equipment, an adequate complement of clinical staff and effective measures to ensure student and patient safety. AJHPE 2014;6(2 Suppl 1):207-210. DOI:10.7196/AJHPE.528

Clinical education forms an important and distinct part of all healthcare education.[1] In clinical education the student refines the knowledge, skills, values, attitudes and philosophies of the profession that she/he has learnt in the classroom or skills laboratories.[2] Clinical education provides the situation, task and human complexities necessary to integrate prior learning and a context for new learning. Clinical education is a multidimensional and complex process whereby students aim to reach entry-level clinical competence in real-time clinical practice.[3] It is reported that in clinical education students come to appreciate their role as healthcare providers with specific roles and responsibilities.[5] This central role as healthcare provider may integrate elements of other roles that form part of graduate attributes, such as collaborator, communicator, health advocate, etc.[5,6] As first-line practitioners it is important that newly qualified physiotherapists can demonstrate general competence and a range of abilities that will allow them to function satisfactorily and safely in their professional role. To reach this goal the Health Professions Council of South Africa (HPCSA) requires that students are placed in a variety of clinical areas for a minimum of 1 000 hours over a 4-year training period.[7] At Stellenbosch University (SU), physiotherapy students gain their first exposure to clinical practice in the second year of the 4-year degree course. From their third year of study they take responsibility for patient management as part of their clinical training. The creation of optimal learning opportunities for students to obtain the necessary clinical skills forms an integral part of the undergraduate programme and can be seen to facilitate the development of graduate attributes.[5] The integration of theory into the real-world environment is recognised as a primary purpose of clinical education.[8] Ideally this process should also incorporate an interdisciplinary and holistic

approach to healthcare.[9] However, the complexity of healthcare systems, rapid change in service provision, financial constraints and demands of accountability are increasingly being recognised as impacting on the learning opportunities that can be provided.[3] Several factors have been identified as playing a role in the clinical learning experience. These include the model of clinical education used,[2] clinical educator attributes,[10] teaching methods used by the clinical educator,[11] student assessment,[11] and the atmosphere, facilities and safety at the healthcare setting.[1] Kilminster and Jolly[12] found that the environment in which learning takes place profoundly affects what is learned and the students’ responses to learning. As the students’ learning occurs in the context of clinical practice, the clinical environment is also identified as the best area to facilitate the skills and attitudes needed.[3] National Core Standards for health establishments have been developed by the national Department of Health in South Africa with the aim to optimise the health services provided to patients.[13] Similarly there have been suggestions that clinical sites should be credentialed for the purpose of clinical education.[14] In addition, growing tension has been noted among clinicians attempting to provide optimal patient care while creating sufficient learning opportunities for students.[15] The literature is lacking with regard to the physical requirements of clinical training sites for optimal learning. The aim of this study was to evaluate the clinical sites used to train undergraduate physiotherapy students at SU and identify factors that may influence the clinical learning experience of these students.

Context

Students rotate through three clinical placements during the third year of study. These include orthopaedics, neurology and medical and surgical conditions. A

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Research number of clinical service sites are used to provide the specific exposure needed for students to reach the predefined outcomes for the respective placements. Students spend 5 weekday mornings for 5 weeks per clinical placement. Students are supported in their clinical learning by both the clinician and a clinical educator. The clinician provides the daily physiotherapy service to patients at the clinical site. The clinical educator is employed by SU and is responsible for weekly, individualised clinical facilitation sessions with students at the service site.

Methods

This project was registered with the institutional Human Research Ethics Committee at SU (N06/07/118). All participants provided written informed consent. The study took the form of a mixed-methods observational study design to generate both quantitative and qualitative data.

Sample

During 2006 all third-year physiotherapy students at SU (n=40) were invited to participate in the study. During the clinical site visits semistructured interviews were held with a representative at each of the service sites visited.

Data collection and procedure

The data collection activities included student record sheets and clinical site visits. Student record sheets A data sheet was developed to record the number of treatment sessions provided per day, time spent on patient care, time spent on documentation, the number of patients treated per day and the pathology involved. Students received training on how to complete the data sheet correctly before data collection began. Patient statistics and the time spent on specific activities were documented by students for the last two clinical rotations of 2006. Data sheets were tracked for the duration of the two clinical rotations. Site visits The visit to the clinical site and an interview with a site representative (physiotherapist clinician/ clinical educator) were combined. Different observational teams among the research group were assembled to visit the different clinical sites. A site evaluation form (Table 1) was created by a research team member after an extensive search of the literature proved fruitless to find a tool to determine the suitability of clinical service

Table 1. Site evaluation tool Components needed

Criteria

Staff

• Staff available for consultation on the block • Staff available for clinical supervision on the block

Facilities

• Availability of treatment space/group treatment areas • No. of patients attending the facility • Equipment availability/electrotherapy, mats appropriate for the block, plinth, telephone, basin, desk and chair • Equipment in good working order • Laundry services

Students

• • • • •

No. of students on the block No. of patients seen by the students on an average day No. of hours a week that the students receive supervision on the block Student locker facilities Possibility of multidisciplinary work

Patients

• List of most common presenting conditions in the facility, and do they align with the outcomes for the block? • Compliance with appointments

Administration

• • • • • •

Transport

• Transport of students to and from the clinical site • Patient transport services

208

Availability of files and other patient information Availability of administrative staff Availability of support regarding evaluation forms, information sheets How are bookings made for the students? Referral system Systems for contacting outpatients

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sites for student training. The site evaluation tool was based on the minimum standards for clinical sites and focused on gathering information on facilities, apparatus, safety and security.[16] Information regarding the level of healthcare provided at the clinical sites, as well as the travelling distance from the Faculty of Medicine and Health Sciences (FMHS), was recorded. The researchers evaluating the clinical site had to document the presence or not of specific features, as well as provide additional comments regarding each feature assessed. Table 1 provides an illustration of the information gathered during the site visits which were deemed important factors for teaching and learning of undergraduate students. During the visit, the site evaluation form was completed by one of the researchers, while the site representative gave the team a tour of the facilities. Thereafter an interview was conducted with the site representative. The interview focused on: staff employed at the clinical site; interdisciplinary activities; community outreach activities; treatment protocols; patient profile; administration; and management. At the end of the visit, the visiting team together with the site representative formulated a summary of the visit by using the framework of a SWOT (strength, weakness, opportunity and threat) analysis of the site. This approach was used to extract the data into the significant SWOT aspects as relevant for physiotherapy undergraduate training, while immediately summarising the information.

Data management and analysis

The quantitative data generated by the time sheets were recorded in a purpose-built data collection sheet in MS Excel. Descriptive data analysis was performed using Statistica version 7. The qualitative data generated during the interviews were deductively analysed using the SWOT analysis as an analytical framework.

Results

Summary of site visits

Seven of the nine clinical service sites used for third-year placements were visited by the research team. Two of the sites could not accommodate the research team at the allocated times because of clinical activities. Strengths and opportunities Identified strengths included the travelling distance to the clinical sites, with three of the sites within close proximity of the FMHS, therefore

Research reducing the travelling time of students to and from the clinical site. The other clinical areas were located within a 20 - 45-minute drive from the Faculty. A valuable strength of the majority of clinical sites was the large patient numbers available and the variety of conditions the patients presented with that were suitable for third-year physiotherapy students. At three of the clinical sites, the staff were approachable and eager to have students at their facilities. Opportunities for development at the clinical site that could impact on the quality of learning of the students included the support and development of clinical physiotherapists at the sites who were eager to learn and grow. Two of the clinical physiotherapists were recent graduates themselves (2 years previously). The potential existed for the development and expansion of multidisciplinary services, a variety of group classes and/or factory visits at five of the clinical sites. Weaknesses and threats A number of weaknesses and threats were identified at these clinical service sites. One of the weaknesses that could impact on the learning of students was the lack of clinical physiotherapists. More than half the sites (57%, n=4) did not have full physiotherapy staff levels, whereas at one site the clinical physiotherapists had only sessional posts. Four of the seven visited sites lacked basic physiotherapy equipment needed for patient management, e.g. exercise equipment, electrotherapy machines, etc. Threats at the clinical sites included poor safety and security for patients, students and staff members. Six (86%) of the sites evaluated reported concerns relating to safety. Safety issues raised included theft of equipment (n=4) and the theft of valuables of staff and students, e.g. cell phones (n=2). At three of the clinical sites concerns related to lack of infection control protocols were also highlighted. Table 2 summarises the data relating to site evaluation problems.

Table 2. Site evaluation problems at seven sites Problems identified during evaluation of seven sites

N (%)

Physiotherapy posts not available/sessions

4 (57)

Insufficient individual treatment space

2 (29)

Insufficient basic equipment available

4 (57)

Safety of staff and equipment

6 (86)

Not enough patients

1 (14)

Lack of infection control

3 (43)

Student record sheets Similar patient statistics were recorded for the three clinical placements (orthopaedics, neurology and medical and surgical). Because of the small ratio of students versus referred patients at clinical sites, students only recorded an average of two treatment sessions per day. Table 3 shows that there was a significant difference in the clinical exposure of students during the respective clinical rotations. Students placed at a primary healthcare facility for their clinical placement in orthopaedics were more likely to see patients with cold orthopaedic pathology than students placed at a tertiary facility (p<0.0001). Students placed at a tertiary hospital were more likely to see patients suffering from acute neurological conditions when compared with students placed at a primary healthcare facility (p<0.0001). Students placed at a tertiary hospital were more likely to treat patients following surgery when compared with students placed at a secondary hospital (p<0.0001).

Discussion

This study identified a number of factors that could negatively impact on the learning of students placed at clinical service sites for practical training experiences. Firstly, the clinical sites utilised for the clinical placements offered variable clinical exposure to certain pathologies. Secondly, although the majority of clinical sites had large patient numbers, the ratio of patients to physiotherapy students was low at some clinical sites, which curtailed opportunities for students to interact with patients. Skoien et al.[1] reported on the value of patient interaction for the development of communication skills, practical skills and clinical reasoning. There have been calls to standardise the breadth of practice settings in clinical education, but further research in this field is required.[14] When students are first exposed to patients, it is very important for them to have sufficient space, time and the necessary equipment available for patient management.[1] In this study we found that space and equipment were limited at some clinical sites. This could be detrimental to studentsâ&#x20AC;&#x2122; ability to develop planning and organisational skills and prioritisation of physiotherapy services. Furthermore, patient care is likely to be compromised by the lack of basic equipment in the clinical sites. It has previously been reported that clinical physiotherapists at service sites act as role models and potential mentors for undergraduate students.[11] At more than half of the sites there was a lack of sufficient staff, which could have a negative impact on student learning.

Table 3. Student exposure to patient care Clinical rotation

Exposure conditions

Tertiary level placement % (n/N)

Secondary level placement % (n/N)

Primary level placement % (n/N)

p-value

Orthopaedics

Cold

0 (0)

74 (326/440)

<0.001

Sports injuries

0 (0)

1 (5/440)

0.32

Trauma

100 (130/130)

25 (109/440)

<0.001

Medical and surgical conditions

Medical Surgical Burns

8 (22/272) 85 (222/272) 10 (28/272)

52 (146/279) 33 (92/279) 15 (41/279)

<0.001 <0.001 0.12

Neurological

Acute

58 (84/145)

45 (47/105)

2 (6/262)

0.04

Rehabilitation

41 (60/145)

55 (58/105)

95 (250/262)

0.04

Traumatic injuries

0 (1/145)

0 (0)

2 (6/262)

0.42

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Research Safety, for both patients and students, was a big concern at the majority of the clinical sites visited; incidents of petty theft of personal items and physiotherapy equipment were reported. Safety of patients at healthcare facilities has been identified as one of the seven key domains of the National Core Standards for improving healthcare services in South Africa.[13] The lack of a safe and secure environment could negatively impact on students’ perceptions of healthcare. Furthermore, Brown et al.[17] noted that students prefer a more positive and relaxed environment as being conducive to their learning. We acknowledge that the data presented in this paper provide a limited snapshot of the clinical sites used for undergraduate physiotherapy training at one institution only. This aspect limits the generalisability of the specific findings but the data do provide an idea of the key elements of clinical training sites that require careful review before placing students at these sites. Based on our findings we propose that when selecting clinical sites for training healthcare students the following should be considered: (i) the physical environment and available facilities and equipment required for student training; (ii) equivalence of the clinical exposure students will have at the various clinical sites; and (iii) development of additional learning opportunities to optimise the clinical exposure in a clinical rotation. The site evaluation tool developed in this study could be useful in this regard. The tool could also be adapted and used by other programmes to investigate the viability of potential clinical service sites for the training of healthcare students. Finally, we argue for a more active, participatory role by universities in the clinical training of undergraduate healthcare students and the development of suitable clinical training facilities. The need for academic institutions to develop partnerships with health service providers is evident from the study results. The partnership should seek to inform the development of healthcare services that provide optimal care for the population, while also providing adequate learning facilities and opportunities for students. The development of a socially accountable evaluation framework for the accreditation of medical training programmes by the Medical and Dental Professions Board of the HPCSA is an encouraging advance in this direction.[5] It will be valuable for other

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health professions boards also to align their commitment to meeting these training programme requirements. Funding. Funding was received from the Fund for Innovation and Research into Teaching and Learning, Centre for Teaching and Learning, Stellenbosch University, South Africa. Author contributions. All authors were involved in conception, design, analysis or interpretation of data. LW drafted the manuscript. All authors critically reviewed the manuscript and approved the final version. Acknowledgements. The authors thank Mrs Ria Bester for her involvement in the study, as well as the participants, for their time and input. References 1. Skoien AK, Vagstol U, Raahiem A. Learning physiotherapy in clinical practice: Student interaction in a professional context. Physiotherapy Theory and Practice 2009;25(4):268-278. [http://dx.doi.org/10.1080/09593980902782298] 2. Lekkas P, Larsen T, Kumar S, et al. No model of clinical education for physiotherapy students is superior to another: A systematic review. Australian Journal of Physiotherapy 2007;53:19-28. 3. McCallum CA, Mosher PD, Jacobson PJ, Gallivan SP, Giuffre SM. Quality in physical therapist clinical education: A systematic review. Phys Ther 2013;93(10):1298-1311. [http://dx.doi.org/10.2522/ptj.20120410] 4. Higgs J. Managing clinical education: The educator manager and the self-directed learner. Physiotherapy 1992;78:822-828. 5. Van Heerden B. Effectively addressing the health needs of South Africa’s population: The role of health professions education in the 21st century. S Afr Med J 2013;103(1):21-22. [http://dx.doi.org/10.7196/SAMJ.6463] 6. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. Lancet 2010;376:1923-1958. [http://dx.doi.org/10.1016/S01406736(10)61854-5] 7. Health Professions Council of South Africa. http://www.hpcsa.co.za (accessed 8 September 2014). 8. Rauk RP. Knowledge integration: Theory and practice in physical therapy education. Journal of Physiotherapy Education 2003;17(1):39-47. 9. Higgs J, Burns A, Jones M. Integrating clinical reasoning and evidence-based practice. AACN Clinical Issues 2001;12(4):482-490. 10. Ernstzen DV, Bitzer E. The roles and attributes of the clinical teacher that contribute to favourable learning environments: A case study from physiotherapy. South African Journal of Physiotherapy 2012;68(1):9-14. 11. Ernstzen DV, Bitzer E, Grimmer-Somers K. Physiotherapy students’ and clinical teachers’ perspectives on best clinical teaching and learning practices: A qualitative study. South African Journal of Physiotherapy 2010;66(3):25-31. 12. Kilminster SM, Jolly BC. Effective supervision in clinical practice settings: A literature review. Med Educ 2000;34(10):827-840. [http://dx.doi.org/10.1046/j.1365-2923.2000.00758.x ] 13. National Core Standards for health establishments in South Africa. National Department of Health 2011. http:// www.sarrahsouthafrica.org/LinkClick.aspx?fileticket=YnbSHfR8S6Q= (accessed 8 September 2014). 14. Wetherbee E, Peatman N, Kenney D, Cusson M, Appelbaum D. Standards for clinical education: A qualitative study. Journal of Physical Therapy Education 2010;24(3):35-43. 15. Ladyshewsky RK, Barrie SC, Drake VM. A comparison of productivity and learning outcome in individual and cooperative physical therapy clinical education models. Phys Ther 1998;78(12):1288-1298; discussion 1299-1301. 16. Minimum requirements for equipment and physical facilities for physiotherapy services at all levels of care, 2003. http://saphysio.warpdemo.co.za/docs/default-source/community-service/minimum-standard-for-equipmentand-facilities-jan-2005.pdf?sfvrsn=2 (accessed 8 September 2014). 17. Brown T, Williams B, McKenna L, et al. Practice education learning environments: The mismatch between perceived and preferred expectations of undergraduate health science students. Nurse Education Today 2011;31:e22-e28 [http://dx.doi.org/10.1016/j.nedt.2010.11.2013]

Research Learning experiences of physiotherapy students during primary healthcare clinical placements D V Ernstzen, BSc (Physio), MPhil (Higher Ed); S B Statham, MSc (Physio); S D Hanekom, PhD Division of Physiotherapy, Department of Interdisciplinary Health Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa Corresponding author: D V Ernstzen (dd2@sun.ac.za)

Background. Primary healthcare (PHC) is necessary to address the health needs of communities. It creates the opportunity for the attainment of curricular outcomes through community-based education. Appropriate learning opportunities are needed to enable students to develop the necessary skills to attain these outcomes. Objectives. To describe the learning opportunities occurring during physiotherapy PHC placements and to explore the role the learning environment and learning opportunities played in attaining the outcomes for the placements. Methods. A descriptive case study was conducted using different strategies for data collection and analysis. Participants completed a record sheet to indicate time spent on different activities. Observational site evaluations, individual interviews with site representatives and focus-group discussions with students were conducted to explore their perceptions about PHC clinical placements. Results. The results indicated that the participants valued PHC placements as powerful learning environments. However, students did not have the opportunity to engage satisfactorily in activities that foster the principles of PHC. Participants acknowledged that several resource constraints existed in this context; however, they identified several potential valuable learning opportunities. Students suggested curriculum-specific strategies needed to prepare them for PHC, and recognised the need for healthcare services in the communities they served. Conclusion. While the PHC learning environment was rich and authentic, learning opportunities need to be optimised to enable students to fully reach the outcomes for the placements. Learning opportunities need to be crafted to foster collaborative learning, interdisciplinary learning, community engagement and empowerment. AJHPE 2014;6(2 Suppl 1):211-216. DOI:10.7196/AJHPE.530

The attainment of clinical competence is a key outcome of physiotherapy programmes worldwide. A goal of the physiotherapy undergraduate programme at Stellenbosch University (SU) is that new graduates will be able to function as reflective practitioners in the South African (SA) healthcare context. Therefore, optimal learning opportunities are crucial for students to develop the necessary skills to attain this outcome. Clinical education, a situated learning experience, is acknowledged as a powerful learning experience to develop studentsâ&#x20AC;&#x2122; skills and professional knowledge through social interaction.[1] Learning thus occurs within the community of practice (clinical environment) and necessitates participation and engagement to develop competence. Market expectations of physiotherapy reflect changing demands in competencies for graduates. A greater focus is now being placed on client centeredness, community-based care and management of chronic diseases.[2] In SA the healthcare context has been reformed to emphasise primary healthcare (PHC). PHC refers to healthcare that is provided in the community, addressing the health needs of the community within the community.[3] The components of PHC include community participation and empowerment while integrating preventive, promotive, curative and rehabilitation services. Improving access to healthcare and developing PHC has been at the centre of transforming healthcare.[4] To facilitate this transformational process for healthcare providers in SA, the Department of Health introduced a year-long compulsory community service for all newly qualified healthcare practitioners, including physiotherapists.[4] New physiotherapy graduates are thus placed in rural and under-resourced regions in an attempt to redistribute services to underserved communities.

It is imperative that new graduates are equipped with the necessary skills to function in such contexts. Therefore, physiotherapy curricula need to include the philosophy of community-based education (CBE) to develop the knowledge, technical and affective skills needed in a PHC context. CBE is advocated as necessary to equip health professionals for future and changing healthcare systems, to be responsive to community needs and to prepare students for future professional work at the community level.[5-7] CBE is described as learning activities that occur in the community, through active engagement with community members, while providing healthcare relevant to the community needs. PHC placements are thus ideally suited for learning and applying the principles of CBE. CBE has several advantages for the students and the community concerned. For students, the advantages include: opportunities to interact with people from different backgrounds; developing social responsibility; planning and delivery of healthcare interventions with the community; developing appropriate knowledge and skills; deepening understanding of health and social services; promoting client-centered care; enhancing interdisciplinary teamwork; and increased recruitment into PHC.[2] For communities, advantages are: improved access to healthcare; the specific needs of the community are considered and addressed; and participation in the care process.[5] CBE thus reinforces a strong social justice ethic, and provides opportunities to develop and use competencies that are needed to improve the health of citizens and society.[8] In the SA context, two studies investigated the perceptions of new physiotherapy graduates about their preparedness for community service.[4,9] Two other studies evaluated physiotherapy studentsâ&#x20AC;&#x2122; experiences about their community-based clinical placements,[10,11] while another study involved a document analysis of physiotherapy CBE curricula.[12] These studies found

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Table 1. The learning outcomes and opportunities for the primary healthcare (PHC) placements Learning opportunities

Screening

Interdisciplinary sessions

Daily duties community health centre

Home visits

Occupational visits

Therapeutic classes

Educational sessions

• Source appropriate information to plan a client assessment

• Conduct an interview with client/carer

• Plan, perform and motivate a physical evaluation of a client

• Develop a problem list focused on main problems and rehabilitation needs of the client

• Formulate appropriate rehabilitation goals with the client

• Select and perform appropriate intervention strategies for optimum rehabilitation

Outcomes

• Use appropriate outcome measures

• Teach clients/carers appropriate home/work interventions

• Advise clients/carers about applicable management

• Analyse home/work environments and suggest appropriate recommendations

• Present effective therapeutic classes

• Refer clients appropriately • Scientifically document all findings

• Become acquainted with safety and emergency procedures in the PHC environment

CBE to be a valuable learning experience which furthered the students’ understanding of social determinants of health.[10,11] However, these studies identified that students needed more preparation to succeed in the complex health environment of community physiotherapy.[4,9] In particular, a focus on the social, political and economic factors that impact health, the local burden of disease and cultural competence was advocated. The need for interdisciplinary collaboration was also highlighted. Moreover, Ramklass[4] advocates that curriculum design needs to be dynamic and responsive to local and global policies on CBE. The changes in healthcare provision in SA, the complexity of the healthcare system and the SU Division of Physiotherapy’s accountability towards its graduates and the profession, motivated the need to determine if the division’s PHC placements offered the necessary CBE components. The objectives of this study were to describe the learning opportunities occurring during physiotherapy PHC placements, and to explore the role the learning environment and learning opportunities played in attaining the learning outcomes for the placement.

Context of the study

Physiotherapy students at the Faculty of Medicine and Health Sciences (FMHS), SU, SA, rotate in groups of 2 - 4 students through a 6-week PHC placement in their final year. At the time of the study, four different PHC

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x x

clinical sites were used; one was rural and three were in peri-urban areas. Two of the clinical sites were based at community health centres (CHCs) and students used the CHC as their base. The other two sites lacked a CHC and students organised their services from their vehicles. At the latter two sites, the students served as the primary service providers of physiotherapy in the absence of permanently employed physiotherapists. Students were supported by a clinical facilitator from SU, and where applicable, also by the CHC physiotherapist. The outcomes for these placements are summarised in Table 1.

Methods

Research design

A descriptive, situational case study was conducted, to provide an in-depth description of the PHC clinical setting.[13] A mixed-method study generated qualitative and quantitative data which obtained input from different stakeholders, using different strategies.

Population

All final-year physiotherapy students completing their PHC rotation during 2006 were eligible to participate in the study (n=40), as were all physiotherapy clinical facilitators involved in these placements (n=6). Different data collection activities and different sampling strategies were used, as explained below.

Research Data collection and procedures

All data were collected during the last two clinical rotations of the year. The data collection activities included: student record sheets; site visits (observation using a site evaluation form); interviews with clinical facilitators; and student focus-group discussions (FGDs).

Table 2. Main interview schedule for the student focus-group discussions

Student record sheets To determine the type of activities that students were involved in during their PHC placement, and how much time they spent on different activities, an activity questionnaire sheet was developed. Purposive sampling was used, to include those students who were on the PHC placement at that specific time to generate realistic data for the timeframe, and to limit recall bias. Students on PHC placements (n=16) were invited to complete the two-page record sheet. The record sheet was set up by one member of the research team, and was checked and adapted by two other members. The students were trained in how to complete the data sheet to aid understanding and correct completion. The activities covered in the record sheets included: new patient (evaluation); individual patient treatment; group exercise classes; promotional talks; home visits; screening in clinics; ward rounds; documentation; feedback between team members; academic demonstrations; clinical supervision; and other. Participants indicated the time spent on different activities in units of 10 minutes.

• Do you think that interdisciplinary learning takes place during clinical practice placements?

Site visits and representatives

interviews

with

site

Different observational teams among the research group, including one external auditor, were assembled to visit the different PHC sites. A site evaluation form was developed by one member of the research team to guide the observational process. This form focused on facilities, apparatus, safety and security. The procedure for the site visits was as follows: An appointment for a visit was made; the team visited the site, and completed the site evaluation form; following the observation, an interview was conducted with the site representative (physiotherapy clinician and/or clinical supervisor). This interview focused on specific aspects identified on the site evaluation form, namely: staff employed at the site; interdisciplinary activities; community outreach activities; treatment protocols; patient profile; administration and management. These themes were addressed to provide a holistic

• What is your opinion of the clinical placements you were on? • What aspects of the clinical placements did you enjoy? • What value did the clinical placements add to your learning? • What were the problems that you encountered during clinical placements? • What suggestions do you have to improve the clinical placements? • Tell me about how you experience the service delivery part of your clinical training? • How did this service delivery impact on your learning experience during the placement?

picture of the healthcare setting. At the end of the visit, the visiting team, together with the site representative, developed a SWOT (strength, weakness, opportunity and threat) analysis of the site. This unique approach was used to extract the data into the significant SWOT aspects as relevant for physiotherapy undergraduate training. Focus-group discussions with students Four semi-structured FGDs were conducted by an independent interviewer. All final-year students were invited to participate in FGDs about their clinical experiences. FGDs were conducted after the final clinical placements. Four focus groups, consisting of ten participants per focus group, were invited to participate. Topics discussed are listed in Table 2. Appropriate probing questions were used to develop a deeper understanding of participants’ accounts. FGDs were conducted at the Division of Physiotherapy, SU, in English and/or Afrikaans according to the choice of the participants, and each lasted approximately 40 minutes.

Data management and analysis

The quantitative data generated by the time sheets were recorded in a purpose-built data collection sheet in MS Excel. Data were then analysed on a statistical program (Statistica 7), using proportions. The qualitative data generated by the site visits, combined with the interview of the site representative, were deductively analysed using the SWOT analysis as an analytical framework, as explained in the previous section. The qualitative data generated by the students’ FGDs were recorded using a digital voice recorder and were downloaded and saved after the FGDs. Unique serial numbers were given to each data set. The FGDs were then transcribed by an independent transcriber, and analysed by an independent

and experienced research assistant using content analysis.[13] This process included: familiarising oneself with the data; identifying themes; creating a theme list (codebook); coding and categorising the data; interpretation of data; and checking. The coding and themes were checked by the research team to aid trustworthiness. For the purpose of this manuscript, data pertaining to PHC were extracted. Data triangulation was done by using various data sources (students and clinical educators), methodological triangulation by using various techniques and instruments of data generation, and investigator triangulation by discussing findings within the research group. Triangulation is a valuable means of ensuring the credibility of the research as data are seen from different perspectives, and data may be corroborated.[14]

Ethical considerations

The protocol for the study was approved by the Health Research Ethics Committee (number N05/08/144) at FMHS, SU, SA. Permission to undertake the study was obtained from the Division of Physiotherapy chairperson. Persons eligible to participate in the study were contacted and the aim and procedures of the study were explained. Written informed consent was obtained from participants. The following measures were taken to ensure participant confidentiality: no identifying information was expected on the time sheet; the names of the clinical sites are not published; the voice recordings of interviews and the transcripts were coded using non-identifying particulars.

Results

This section elaborates on the main findings gathered through the student record sheets, observational site visits and the FDGs with participants.

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Fourteen of 16 students completed record sheets (88%). The data for all four PHC sites had the same pattern, and were therefore combined (Fig. 1). Students spent most of their time performing individual treatment sessions. This activity communicates a strong focus on the curative/treatment aspect of healthcare service. Little time was spent on promotive and preventive strategies such as group classes, educational talks, home visits and occupational (work) visits. This lack of focus on community participation and empowerment was not congruent with the philosophy of PHC.

Observational site visits representative interviews

and

site

Table 3 provides the combined SWOT matrix of the PHC sites as constructed from the observational site visits and site representative interviews. The strength of the PHC placements

was the variety that it offered. Staff shortages, as well as the lack of facilities and equipment, were shared weaknesses. The range of learning opportunities was diverse and abundant, ranging from the outright need for the healthcare services, to possibilities of participation in community activities. Staff and student burnout, as well as safety concerns, were identified as important threats.

FGDs with students

Students’ perceptions of PHC clinical placements are summarised in Table 4. The main theme, sub-theme and motivating verbatim quotes are provided. For the purpose of this article, some quotations have been translated from Afrikaans to English by the primary author. Five main themes emerged: • Preparation for PHC placements. • Guidance and supervision is much appreciated, but has not been a priority.

18 000

Time spent (10/unit)

16 000 14 000 12 000 10 000 8 000 6 000 4 000 2 000 0

) r s t t r n g n n d lks ck isi se in io he en he tio tio un ta ba ot en ot ta las vis ra ev ro tm h t r d t e n C c t a s r i l e d e m e a re en ar Sc on m (fe up Ho em lt He W ls em rt cu nt em ad ua a g o o c c d it e d a i D A ep vi in nt an pa di sr ie Cl M w In es at r e P N og Pr n

io at

alu ev

Clinical activities

Fig. 1. Summary of the time sheets of students on PHC placements (10-minute units per day).

• Learning opportunities are abundant, but are not always aligned with the outcomes. • Interdisciplinary learning advantages and disadvantages. • Preparation for the future clinical practice.

Discussion

The main findings of the study are that while the PHC learning environment was rich and authentic, the learning opportunities needed to be optimised to enable students to fully reach all outcomes for the placement. The activities that students participated in as part of their placement did not continually reflect a focus on PHC, as illustrated by Fig. 1 and Table 3. It was clear that amendments in learning opportunities would be required to optimise attainment of outcomes. Indeed, a revisit of the outcomes of the PHC placements was also pertinent. To be aligned with the philosopy of PHC, learning activities and outcomes should include a focus on community participation and empowerment through preventive, promotive and rehabilitation activities.[3,4] Participants in this study reported feeling unprepared for the activities and challenges that they faced during the PHC placements and made suggestions for curriculum content that would aid in their preparation. The following preparatory components were suggested: clarifying expectations for PHC; foundational aspects of group therapy and homebased care; social determinants of health; and the contextual factors of the communities being served. These suggestions by participants are congruent with literature about preparation for PHC clinical rotations.[2,4,5,8] Participants acknowledge the PHC placement as an authentic and rich learning environment. This environment was reported to create valuable learning opportunities that transcended personal and professional growth. However, several resource

Table 3. Combined SWOT analysis for the four physiotherapy PHC placements Strength

Weakness

Opportunity

Threat

Full-time physiotherapist employed (at two sites) Multiple professions at the site Reasonable teamwork Established site Variety of clinics Strong PHC focus (at 3 sites) Variety of activities and classes Good referral system in place (1 site)

No physiotherapist employed (at two sites) Insufficient space Lack of equipment/lack of suitable facilities Insufficient staff to cope with patient numbers, administration and students Little guidance and support for students No cardio-pulmonary rehabilitation

Enough patient numbers Diversity of patients Presence of volunteer workers Interdisciplinary activities Community health workers/homebased carers Volunteers Prospect of establishment of services not yet offered

Staff need/would like more support from employer Multiple locations may lead to fragmentation Little focus on PHC at 1 site No central work location (base) for students at the sites where there was no CHC Safety and security concerns regarding parking

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Table 4. Findings from student interviews Main theme

Sub-theme

Verbatim quotes

Preparation for PHC

Skills (not) taught in curriculum

‘It is mentioned that primary care is important, but there is not much emphasis on it and what they [educators] want us to do on a primary care block.’ (5.1) translated ‘They want us to present group classes, but we are never reallly taught to do it.’ (5.1) translated

Guidance and supervision

Assistance/guidance to students

‘So you get there, and you have your basic theoretical knowledge ... but no guidance.’ (5.1) translated ‘The physiotherapists are very busy on primary care blocks, there are lots of patients. They are often too busy to help students.’ (5.1) translated

Focus on patient care v. focus on student learning

‘And although they [clinical staff] want to help and they really want to be accessible, … .’ (5.2) ‘We had the best; you could always go and ask, really. But every now and then you could see there was so much going on that it was just difficult.’ (6.1)

Work overload

‘I don’t think there’s a lack of understanding on our part that, you know, that this person [clinical staff] is overloaded.’ (6.1) ‘All our diaries are booked with patients 3 weeks in advance, it is fully booked. I am lucky if I see a patient twice in these 6 weeks. So you can’t see how the patient progresses. At the end of the block you can’t refer the patient, because everybody is fully booked. The patients get angry. It is frustrating.’ (6.1) translated

The clinician as a source

‘The other thing is, that even though it’s such a busy place, I’ve had one of the best, I’ve learnt the most from that clinical supervisor. She told us, she’s very busy, but she made time for us.’ (5.2) ‘But for me, what is more valuable is the human resource. The person, be it the clinician who works there, or your supervisor. Just that you have somebody that is accessible’ (6.1)

Alignment with outcomes

‘I never did a home visit on my block at ...’ (5.4) translated ‘If I get a home visit in my final exam, I will not know what is going on. So maybe one should do a complete home visit.’ (5.4) translated

Formal interdisciplinary sessions are valuable, but can be misused

‘I think it is a showcase for the medical students so that they can see what physiotherapy and occupational therapy are about, and I don’t mind helping other people learn, but for me … I learnt nothing.’ (5.2)

Informal interdisciplinary discussions are valuable

‘We see a patient and then discuss what each would have done, the occupational therapist, the medical student. So, it was good.’ (5.2) translated ‘This is a problem, as everybody wants us to see the patient in a multidisciplinary team, but nobody really makes time for it in our day.’ (5.2) translated ‘It was nice to talk to the occupational therapist there. We spoke about a patient and could see where we overlap.’ (5.4) translated

For community service

‘For next year it is important, because you might be working in a clinic, and would then know how to manage apparatus and do registers.’ (5.3) translated ‘The lack of equipment forces us to be creative. Next year or some time we will be working in the community, but is diffucult to say how effective you might be if you don’t have all the equipment.’ (6.1) translated

For practice management

‘In primary care it was nice to see how the physiotherapist runs the practice. It was good to see how it works, how to complete the forms, how to order mobility aids, how to organise the practice, how to make posters and so on.’ (6.2) translated

Learning opportunities

Interdisciplinary learning

Preparation

constraints were identified as part of this environment. The infrastructure of all placements was limited, and this influenced learning in positive and negative ways. This finding is in keeping with that of Skoien et al.,[1] who found that physical surroundings such as space and materials can either inhibit or facilitate learning. The resource-constrained environment in this study challenged participants’ structured approach to tasks. However, these challenges provided students with the opportunity to think creatively and laterally to solve problems, as reported by Taukobong.[11] The challenge of a resource-constrained environment is a recurring theme in the literature regarding physiotherapy PHC, and includes (as also identified in this study) lack of equipment, facilities, staff constraints and safety concerns.[4,9,11] Despite the abovementioned resource constraints, the information gained from the site visits and interviews emphasised the tangible healthcare needs

of the community being served. This need was evident in the sheer number of patients who sought healthcare. Clinical staff and students reported feeling overwhelmed by the community needs. As a result, provision of healthcare focused on service delivery in the form of direct clinic-based patient care, and subsequently not on community participation (Fig. 1). Consequently, several learning opportunities appropriate for students were not identified, optimised or utilised. The tension noted between providing optimal patient care and the creation of sufficient learning opportunities is not unique to this study and is substantiated by other research findings.[15,16] The challenges of high patient volumes and minimal resources, together with need for sufficient physiotherapy staff support and improved management systems at PHC level, have been reported in several studies.[4,9] It is therefore not surprising that a lack of staff support was identified as a threat (Table 3).

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Research Accordingly, Boelen and Woollard[8] recognise the lack of staff in PHC as a global crisis. Several positive aspects of the PHC placements were acknowledged by participants. These placements prepared future graduates for community service and practice management. Preparing for community service has been cited as an important outcome of CBE;[6] however, at the time of the study, it was not an outcome of the PHC placement. The PHC sites were full of untapped learning opportunities. In particular, the opportunity for formal and informal interdisciplinary learning sessions was identified by students and staff. Interdisciplinary collaboration was described as the backbone of community physiotherapy.[9] However, the participants in the aforementioned study stated that in practice, team members are often ignorant about each other’s roles. Furthermore, Taukobong[11] found a lack of focus on interdisciplinary approaches during CBE in PHC. The study findings strengthen the need to include interdisciplinary learning sessions in the curriculum to foster collaboration and patient-centered care.[2] Participants in this study warned that careful monitoring of interdisciplinary sessions would be required to ensure benefit for all stakeholders. This study found the PHC learning environment to be complex and multimodal, where the situated context influenced learning in multiple ways. Several changes are needed to transform PHC placements to be able to address learning outcomes and the needs of the students, while considering the needs of the patients and staff. Indeed, the learning ecosystem needs to be taken into account when designing a curriculum.[17] The ecosystem approach implies that the needs of the local and broader community should inform curriculum design and implementation to enhance social accountability and holistic patient care. The study provides valuable lessons to be learned from the analysis of learning opportunities in PHC placements, although the context investigated in this study was specific and limited to a particular setting. The need for regular curriculum review to ensure that the provided learning opportunities sufficiently address learning outcomes was clear. The PHC placement was successful in increasing awareness among students about future professional work at the community level and responsiveness to community needs. These aspects were cited as important outcomes of CBE, and needed to be included in the outcomes of the PHC placement.[6,7] Although various role players were consulted in the review process, future studies should obtain information from different stakeholders, such as patients, community members and organisations.

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Conclusion

The learning opportunities that final-year physiotherapy students experienced as part of their CBE placements needed to be expanded. To optimise PHC placements, learning opportunities need to be crafted to foster collaborative learning, interdisciplinary learning, community engagement and empowerment. Funding. Funding was received from the Fund for Innovation and Research into Teaching and Learning, Centre for Teaching and Learning, Stellenbosch University, South Africa. Author contributions. All authors contributed to the conception, design, and analysis and interpretation of data. D Ernstzen drafted the manuscript. All authors provided critical revision and approval of the manuscript version to be published. Acknowledgements. The authors would like to thank Mrs Ria Bester for her involvement in the study. We also thank the participants for their time and input. References 1. Skoien AK, Vagstol U, Raaheim A. Learning Physiotherapy in clinical practice: Student interaction in a professional context. Physiotherapy Theory and Practice 2009;25(4):268-278. [http://dx.doi.org/ 10.1080/09593980902782298] 2. Lindquist I, Engardt M, Garnham L, Poland F, Richardson B. Physiotherapy students’ professional identity on the edge of working life. Med Teach 2006;28(3):270-276. [http://dx.doi.org/10.1080/01421590600605272] 3. Keleher H. Why primary health care offers a more comprehensive approach to tackling health inequalities than primary care. Australian Journal of Primary Health 2001;7:57-61. [http://dx.doi.org/10.1071/PY01035] 4. Ramklass SS. Physiotherapists in under-resourced South African communities reflect on practice. Health Soc Care Community 2009;17(5):522-529. [http://dx.doi.org/10.1111/j.1365-2524.2009.00869.x] 5. World Health Organisation. Primary Health Care – Now More Than Ever. 2008. http://www.who.int/whr/2008/ en/ (accessed September 2012). 6. Okayama M, Kajii E. Does community-based education increase students’ motivation to practice community health care? A cross sectional study. BMC Med Educ 2011;11(1):1-6. [http://dx.doi.org/10.1186/1472-6920-11-19] 7. Ezzat E. Role of the community in contemporary health professions education. Med Educ 1995;29 Suppl 1:44-52. [http://dx.doi.org/10.1111/j.1365-2923.1995.tb02887.x] 8. Boelen C, Woollard B. Social accountability and accreditation: A new frontier for educational institutions. Med Educ 2009;43(9):887-894. [http://dx.doi.org/10.1111/j.1365-2923.2009.03413.x] 9. Mostert-Wentzel K, Frantz J, van Rooijen AJ. A model for community physiotherapy from the perspective of newly graduated physiotherapists as a guide to curriculum revision. African Journal of Health Professions Education 2013;5(1):19-25. [http://dx.doi.org/10.7196/AJHPE.203] 10. Futter M. Developing a curriculum module to prepare students for community-based physiotherapy rehabilitation in South Africa. Physiotherapy 2003;89(1):13-24. [http://dx.doi.org/10.1016/S0031-9406(05)60665-7] 11. Taukobong NP. Community based clinical program: The Medunsa physiotherapy students’ experience. South African Journal of Physiotherapy 2004;60:7-10. 12. Mostert-Wentzel K, Frantz J, van Rooijen AJ. Status of undergraduate community-based and public health physiotherapy education in South Africa. South African Journal of Physiotherapy 2013;69:1-10. 13. Mouton J. How to succeed in your masters and Doctoral Studies: A South African Resource Book. Pretoria: Van Schaik Publishers, 2001. 14. Frambach JM, van der Vleuten CPM, Durning SJ. AM Last Page: Quality criteria in qualitative and quantitative research. Acad Med 2013;88(4):552. 15. Ladyshewsky R, Barrie SC, Drake VM. A comparison of productivity and learning outcome in individual and cooperative physical therapy clinical education models. Phys Ther 1998;78:1288-1298. 16. Currens JB. The 2:1 clinical placement model: review. Physiotherapy 2003;89(9):540-554. [http://dx.doi. org/10.1016/S0031-9406(05)60180-0] 17. Van Schalkwyk S, Bezuidenhout J, Burch VC, et al. Developing an educational research framework for evaluating rural training of health professionals: A case for innovation. Med Teach 2012;34(12):1064-1069. [http://dx.doi. org/10.3109/0142159X.2012.719652]

Research Physiotherapy students’ perceptions about the learning opportunities included in an introductory clinical module D V Ernstzen, BSc (Physio), MPhil (Higher Education); S B Statham, MSc (Physio); S D Hanekom, PhD Division of Physiotherapy, Department of Interdisciplinary Health Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa Corresponding author: D Ernstzen (dd2@sun.ac.za)

Background. Clinical education forms a core component of physiotherapy training. However, the transition from the classroom to clinical learning environments can be challenging. An introductory clinical placement with appropriate learning opportunities is therefore important to ensure that learning outcomes are reached. Objectives. To determine second-year physiotherapy students’ perceptions about the learning opportunities provided in an introductory clinical module and to determine their perception about the attainment of the learning outcomes. Methods. A descriptive case study was undertaken, using mixed methodology. All 39 second-year physiotherapy students were invited to participate. Data were collected using a self-developed questionnaire which focused on the outcomes of the module and the perceived value of the learning opportunities. A focus group discussion was conducted with a random subset (n=15) of the population. Results. The response rate to the questionnaire was 79% (n=31). Peer learning by observing senior students, demonstrations by clinical lecturers and the assessment of specific skills were perceived by students to be particularly useful. However, several learning opportunities did not contribute effectively to learning. Participants highlighted a transitional process between classroom and clinical environments during which they became aware and could respond mentally to the demands of a clinical placement. Conclusions. The clinical education introductory module provided valuable opportunities, where students learnt productively in a non-threatening learning environment. Junior students linked theoretical and practical concepts to clinical implementation. Peer mentoring and progressive mastering were valuable learning strategies. Reflection and students’ emotional adjustment to clinical practice are topics for further investigation. AJHPE 2014;6(2 Suppl 1):217-221. DOI:10.7196/AJHPE.524

Clinical placements offer a rich opportunity for physiotherapy students to learn while patients are receiving care.[1] They involve situated experiential learning and are an important strategy to facilitate professional socialisation and to integrate knowledge and skills in the developmental pathway towards clinical competence.[2] In the clinical learning environment, students are engaging in a socially authentic workplace environment and these experiences and circumstances shape their learning.[2] Learning in this environment is multimodal and complex, and its sociocultural nature may influence learning in several ways.[2] Consequently, learning in the classroom differs greatly from learning in the clinical environment. In the classroom, the learning conditions are controlled and learning activities can be planned and structured, while in the clinical environment, unplanned activities often occur and a flexible structure is needed. These two learning environments differ with regard to their distinct objectives, work tasks, rules and codes of conduct, processes, systems, complexity and community of practice.[2,3] It is therefore not surprising that students feel anxious and vulnerable at the start of clinical practice because of uncertainty, variability and unpredictability in the clinical environment.[4-8] The transition of the student into the role of practitioner requires the application of classroom content (e.g. theories, techniques) to the clinical context. While students focused on learning new knowledge and skills in the classroom, in the clinical environment those learnt skills now have to be implemented in practice.[3] Moving from being a learner to a novice practitioner creates a challenging experience. Novice practitioners become concerned with their level of skill and ability to deliver effective patient care.[9] It is therefore important to ensure that learning

opportunities sufficiently address novice practitioners’ needs at the start of clinical practice. Introductory clinical placements can reduce students’ anxiety about clinical education and improve their self-confidence.[4,5] The success of these placements lies in the fact that students can learn in a supportive and non-threatening environment where they are not expected to take full responsibility for patient care.[4,5,9] Further benefits of an introductory clinical programme include feeling more motivated and enthusiastic about entering the profession,[4] and adapting learning strategies towards a more clinical orientation.[10] While there are benefits to having peer mentoring and support as part of an introductory programme,[4,11] it is unclear which learning opportunities best facilitate the attainment of learning outcomes in an introductory clinical placement. The aim of the study was to determine second-year physiotherapy students’ perceptions about the learning opportunities provided in an introductory clinical module and to determine their perceptions about the attainment of the learning outcomes.

Context

The first 2 years of the 4-year Physiotherapy Programme, Division of Physiotherapy, Stellenbosch University (SU), South Africa (SA) are foundational and mainly classroom-based. During third and fourth year, students take responsibility for patient management at clinical placements. The Division presents a second-year clinical introductory module, as a transitional strategy between the classroom and the clinical learning environment. This semester course exposes students to clinical practice through visits to different clinical placements, without being responsible for patient management. The learning opportunities

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√

√ √

Ethics

√ √ √

Sample

Data analysis

The study population included all second-year physiotherapy students registered for the introductory clinical module during 2006 (N=39). All students were invited to complete the questionnaire. Fifteen students were randomly selected (via computed random numbers) and invited to participate in a focus group discussion to explore their perceptions of the learning opportunities provided in the introductory clinical module.

Viewing patient information folders

Written task

Documentation

√ Observing senior students

Reflection on activities

√ Group and individual interviews with patients

√

Data collection

A descriptive case study was undertaken at the Physiotherapy Division, SU. A mixed methodology was used. We employed a survey questionnaire and a focus group discussion in order to generate quantitative and qualitative data, respectively.

Instrumentation

Demonstrations of patient management by lecturer

Focus group discussion An interview schedule was developed to ascertain students’ perceptions of the module. The topics discussed in the interview included: experience and opinion about the introductory clinical module; main lessons learnt during the clinical exposure; barriers to learning; experiences with observing the final-year students; view on reflective tasks; suggestions for improvement. Probing questions were used to develop a deeper understanding of participants’ accounts of learning. The experienced interviewer ensured that there was no dominance of one participant over the other.

The questionnaire was distributed and returned during a rostered contact session. Students unwilling to participate were requested to remain in class while completing other tasks. One semi-structured focus group discussion was held at a time convenient for all participants. The discussion was conducted by SS in English and Afrikaans, according to participant preference and was recorded using a digital voice recorder. The interview lasted approximately 50 minutes and took place at the Physiotherapy Division, SU. The recorded interview was transcribed by an independent transcriber.

Research design

√

Methodology

√

√ √ √

√

Identify precautions

√

Develop clinical reasoning Plan basic patient management Plan a physical examination Develop listening skills Develop observation skills Conduct effective interview

Learning outcomes for module Table 1. Learning opportunities and learning outcomes of the introductory clinical module

offered to facilitate the attainment of module outcomes are summarised in Table 1. Assessment tasks include the ability to interview a patient; record key findings; analyse a video of a patient, focusing on listening and observational skills; and a written assignment, on a health condition encountered during clinical practice.

The protocol for the study was approved by the Health Research Ethics Committee, Faculty of Medicine and Health Sciences, SU (reference number N05/08/144). Permission to undertake the study was obtained from the chairperson of the Physiotherapy Division. Written informed consent was obtained from the participants by the primary author.

Learning opportunities

218

√

Develop documentation skills

Research

Questionnaire A purposely designed questionnaire was developed by the research team. The questionnaire focused on the learning value which the different learning opportunities presented. It also enquired about the students’ perceptions of knowledge and skills gained. The participants could indicate on a five-point Likert scale which learning opportunities they felt they learnt best or least. The participants could also indicate which outcome they felt they had achieved successfully.

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The quantitative data were recorded on a purpose-built MS Excel data sheet. Data were analysed using percentages. Qualitative data were analysed by an independent research assistant using content analysis.[12] This process included familiarising oneself with the data; identifying themes; creating a theme list (codebook); coding and categorising the data; interpreting of data; and checking. Final codes were checked and adjusted by the research team to aid validation.

Results

The response rate for the questionnaire was 79% (n=31). Table 2 indicates the percentage of participants who indicated that they had learnt most during the provided learning opportunities. Peer learning by observing senior students, demonstrations by clinical lecturers and the assessment of interviewing skills were perceived to be particularly useful. Fourteen participants (45%) reportedly did not learn from the reflection exercise. Participants also reported on the skills developed during the module (Table 3). The majority of participants perceived that the provided learning opportunities greatly facilitated the development of three of the eight module outcomes.

Research

Table 2. Percentage of students who reported that they learnt a lot/learnt an extreme amount in specific learning/assessment opportunities provided Learning/assessment opportunity

Percentage

Observing senior student

Demonstration by lecturer

Assessment of interviewing skills

Conducting an interview with a patient

Patient information folders

Assessment of documentation tasks

Video on listening skills

Pathology task

Documentation tasks

Feedback session

Reflection

Table 3. Percentage of students who reported that the learning opportunities provided in the introductory clinical module improved the following skills a lot/hugely Skill gained

Percentage

Interviewing skills

Observation skills

Listening skills

Clinical reasoning

Scientific documentation

Application of theory

Planning of the physical examination

The qualitative findings indicated that the module was perceived to be a positive learning experience for the participants. Four key themes emerged from the data, namely: • bridging experience • role models • emotional implications • reflection is challenging.

Bridging experience

The module provided participants with a bridging strategy to link classroom to the clinical experience. They reported that observing clinical sessions with facilitators assisted them to put skills they had practised in class into perspective. The module clarified the expectations and requirements that they needed upon entering clinical practice in their third/fourth years of the programme. They were thus introduced to the demands they would face during semi-dependent and independent clinical practice, as evidenced by the following verbatim quotations. ‘You see where the techniques done in class fit into clinical practice.’ ‘Some work done in classroom makes more sense now that you have seen it in clinical.’ ‘I am glad we did it – you slowly get used to it … and you don’t feel as if you have been thrown in at the deep end.’ ‘It was really good to give us exposure to an area where we will work in the future.’

‘If you are in your second year, you can’t do it on your own, so it is good to be with somebody who shows you what you are working towards.’ Introducing students to the first step of patient assessment alerted them to the process of conducting the interview, without the added stress of the content of the interview. This process strengthened their confidence. ‘Doing the interview helped to familiarise myself with how the interview should be done. So next year I can concentrate on the content of the interview.’ The participants mentioned several bridging experiences related to organisational aspects, which included becoming familiar with the hospital environment and obtaining patient information. Interestingly, interdisciplinary learning was facilitated even in this introductory clinical placement, as evident from the following quotation: ‘… this is the one place where you can see and understand the interaction between the different health professionals.’

Role models

Senior students played an important part in the learning experience by serving as role models. Learning from senior students depended on their attitude towards the second years. It was clear that senior students could facilitate valuable learning opportunities by being approachable and willing to assist, by involving themselves thoroughly in the process of leading the juniors and by explaining their clinical reasoning during observational sessions. The following quotations confirm this. ‘The fourth years were very helpful, they really went to a lot of trouble and they were nice to us.’ ‘We often worked with the fourth years, and some of them were very good; some students had a better experience because their fourth years were willing and open towards them.’ ‘Some fourth years were really good, you could ask them anything. They know their theory well … maybe they were just naturals, or had good training!’ However, not all senior students participated fully in the process, as a participant explained: ‘I don’t know what was communicated to the fourth years beforehand, but some of them did not know what to do, they did not know what to expect, they were a bit confused. Maybe they should be informed about our needs and how they can help us. Give them an indication of what they should show us.’ The participants offered suggestions on how the learning experience could be improved. These included clarifying expectations with senior students and allocating juniors only to committed senior students: ‘Maybe you should enquire which fourth years are willing to accommodate second years, because … if they care about us, they will help us.’

Emotional implications

Participants had to come to terms with patient distress and suffering. It appeared that caring for patients was important to them. Viewing patient care assisted them in seeing the person holistically. They also became familiar with an environment where the patients’ needs often take preference over students’ needs. The verbatim quotations below illustrate the emotional challenges faced during the first exposure to clinical work.

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Research ‘ Some of us have never been in such circumstances, and sometimes you see things that are disturbing, and you need to adapt to the situation. So I think the exposure was good to prepare us.’ ‘The other part is also the emotional attachment you get … it is hard. Like when you were in the intensive care unit, you see people on machines and lines. And you feel sympathy for them and work with them. It was difficult.’

Reflection is challenging

Participants found reflection challenging as they requested more time and guidance on content and how to reflect. Participants requested to be informed of the aims of reflection and guidance on the process of reflection: ‘I need more time to reflect, I need time to think about it …’ ‘Give us some guidelines that will force us to think about every aspect.’ ‘Is it required to say what we felt, or what we saw happened, or is it required from us to describe the clinical picture? What is required during reflection?’ Nonetheless, reflecting with senior students was seen as a collaborative approach towards learning: ‘It was really helpful when we reflected with the fourth years by sitting around the table with them and discussing what happened; they asked us questions and they explained everything to us.’

Discussion

The aim of the study was to determine second-year physiotherapy students’ perceptions about the learning opportunities provided in the introductory clinical module and to determine their perceived attainment of module outcomes. The main findings show that the learning opportunities facilitated some of the key learning outcomes for this module, but not all. Participants benefitted particularly from observation of senior students and lecturers. The findings are congruent with the participants’ self-reports that only three learning outcomes were successfully developed through the learning opportunities provided, namely the ability to observe, listen and to interview a patient. The findings emphasise the value of observation as a non-threatening learning opportunity. Learning by observation is a key component of the social cognitive learning theory,[13] and its value in situated learning contexts has been emphasised.[2] The qualitative data indicated that observation of the learning task was a crucial transitional strategy from one learning environment to the other. Specific transitional aspects included: putting skills taught into perspective, organisational aspects, mental adjustments and patient care. However, participants, through their feedback (Table 2), also confirmed that learning through observation is not enough. Learning was facilitated by performing and assessment of the learning task Learning was thus optimised when observation of the task was followed by doing of the task, that is ‘learning by doing’, as advocated in social cognitive learning theory.[13] The value of peer mentoring for the development of clinical skills was emphasised in this study, as in other studies.[4,5,11] Peer mentoring was enhanced by the personal attributes of the mentor and the mentor’s willingness to provide explanations. A personal, as well as a cognitive, component of peer mentoring was therefore indicated. However, peer mentoring was largely dependent on the mentor as role model. Senior students, who were unsure and less confident mentors, were perceived as ineffective mentors. Sprengel and Job[4] reported similar findings.

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Learning from peer mentors reverberates collaborative learning through the zone of proximal development (ZPD). [13] The ZDP emphasises learning by socialisation, where learners learn efficiently when interacting with knowledgeable others. The findings of the study confirm the clinical learning environment as authentic and situated, where students can apply their knowledge and skills.[14] Spencer[14] and Skoien et al.[11] emphasise the authenticity of the clinical learning environment as a strong motivator for learning, which facilitates active participation and the attainment of learning outcomes. In this case, students could apply their novice skills in a non-threatening learning environment. Learners were expected to perform small steps of the clinical process congruent with their level of experience and skill. This concept, known as scaffolding or progressive mastery, is described in behaviourist and social cognitive learning theories.[13] Progressive mastery was also successfully employed in introductory physiotherapy clinical education by Oldmeadow.[8] Skoien et al.[11] contend that professional competence develops over time, and that students’ responsibilities should be gradually increased over time in practice. This strategy might enable task attainment by the students which could in return boost self-confidence and the motivation to learn. However, several learning opportunities which had been offered did not contribute effectively to learning, as can be seen in Table 2. Participants were particularly uncertain about the written reflection exercise. In another study by Ernstzen et al.,[1] physiotherapy students also reported not learning efficiently from reflective activities. Similarly Muir[15] found that medical students and their teachers had an incomplete understanding of reflection. A greater emphasis on reflection may thus be needed in learning, teaching and assessment.[15] In the context of this study, participants requested guidelines on reflective strategies to optimise its learning value. Donaghy and Morrs[16] also advocate guided reflective practice. They argue that reflection should be closely linked to critical enquiry, problem solving and clinical reasoning in order to develop higher-order cognitive processes. The value of reflection as a meta-cognitive strategy to create meaning from experience is also clear from the literature.[13,15, 16] Participants in this case attached more value to verbal reflection (discussion with senior students) than to written reflection. A reflective discussion can be collaborative learning where students gain practice in thinking through problems, organising concepts, and formulating goals. Consequently, reflection in this introductory clinical placement needs to be revisited to include structure and support to optimise its learning value. An unexpected finding was that the learning opportunities contributed to a transitional experience with regard to the mental adjustment of the participants in coming to terms with human suffering. Skoien et al.[11] and Geddes et al.[17] also found this adjustment when developing a patienttherapist relationship[11] and with ethical aspects in the clinical practice context which challenged students’ roles as emerging physiotherapists. The field of novice practitioners’ mental adjustment to clinical practice is relatively unexplored in the literature and warrants further investigation. The findings of the study suggest that an introductory clinical placement needs to be carefully planned to ensure academic and personal development of students. Care should also be taken to align learning opportunities and outcomes. While reflection is important for transformative learning, novice learners seemed to require guided and collaborative reflective activities. The learning activities provided did not fully address the development of clinical reasoning, documentation, application of theory and planning skills.

Research Optimal strategies for facilitation of these skills for novice practitioners need to be actively sought. The study offers valuable insights into the introductory physiotherapy clinical placement at one institution. It was clear that both classroom and clinical learning environments are essential to prepare graduates for professional practice. The findings of the study confirmed that entrance to the clinical learning environment can be challenging, and that students need support in the transition from the classroom to the clinical learning environment.[4-8] Therefore, careful consideration needs to be given to the content of learning activities and support structures in the classroom and clinical learning environments to optimise learning, and to aid the transition from one context to the other. It is acknowledged that this study sought only the views of the junior students. The perceptions of the senior students who acted as mentors should also be investigated.

Conclusion

An introductory clinical education module was found to provide valuable learning opportunities, where junior students learnt productively in a non-threatening environment. It gave junior students the opportunity to link theoretical and practical concepts to clinical implementation. Peer mentoring and progressive mastery were valuable strategies to enhance learning in this context. The study highlights that reflection should receive more attention in teaching and learning applications, and that the mental adjustment to commencing clinical practice should be further investigated. Some learning opportunities described in this paper can be included in introductory clinical modules to facilitate content and process learning; however, learning outcomes and opportunities need to be aligned. Author contributions. All authors contributed to the conception, design, analysis of data and interpretation of data. D Ernstzen drafted the manuscript. All authors provided critical revision and approval of the manuscript version to be published.

Acknowledgements. The authors would like to thank Mrs R Bester and Mrs R Lochner for their involvement in the study. We also thank the participants for their time and input. Funding was provided by the Fund for Innovation and Research into Teaching and Learning, Centre for Teaching and Learning, Stellenbosch University, South Africa.

References 1. Ernstzen DV, Bitzer EM, Grimmer-Somers K. Physiotherapy students’ and clinical teachers’ perceptions of clinical learning opportunities: A case study. Medical Teacher 2009;31(3):e102-115. [http://dx.doi. org/10.1080/01421590802512870] 2. Billet S, Choy S. Learning through work: Emerging perspectives and new challenges. Journal of Workplace Learning 2013;25(4):264-276. [http://dx.doi.org/10.1108/13665621311316447] 3. Le Maistre C, Pare A. Learning in two communities: the challenge for universities and workplaces. Journal of Workplace Learning 2004;16(1/2);44-52. [http://dx.doi.org/10.1108/13665620410521503] 4. Sprengel AD, Job LJ. Reducing student anxiety by using clinical peer mentoring with beginning level nursing students. Nurse Educator 2004;29(6):246-250. [http://dx.doi.org/10.1097/00006223-20041100000010] 5. Faure M, Unger M, Burger M. Physiotherapy students’ perceptions of an innovative approach to clinical practice orientation. South African Journal of Physiotherapy 2002;58(2):3-8. 6. Chan DSK. Combining qualitative and quantitative methods in assessing hospital learning environments. Int J Nurs Stud 2001;8:447-459. 7. Massarweh L. Promoting a positive clinical experience. Nurse Educator 1999;24(3):44-47. [http://dx.doi. org/10.1097/00006223-199905000-00016] 8. Oldmeadow L. Developing clinical competence: a mastery pathway. Australian Journal of Physiotherapy 1996;42(1):37-44. [http://dx.doi.org/10.1016/S0004-9514(14)60439-6] 9. Delany C, Bragge P. A study of physiotherapy students and clinical educators’ perceptions of learning and teaching. Medical Teacher 2009;31:e402-e411. [http://dx.doi.org/10.1080/01421590902832970] 10. Cole B, Wessel J. How clinical instructors can enhance the learning experience of physical therapy students in an introductory clinical placement. Advances in Health Sciences Education 2008;13:163-179. [http://dx.doi. org/10.1007/s10459-006-9030-6] 11. Skoien AK, Vagstol U, Raaheim A. Learning physiotherapy in clinical practice: Student interaction in a professional context. Physiotherapy Theory and Practice 2009;25(4):268-278. [http://dx.doi.org/ 10.1080/09593980902782298] 12. Creswell JW. Research Design: Qualitative, Quantitative and Mixed Methods Approaches. 2nd ed. Los Angeles: Sage, 2003. 13. Schunk DH. Learning Theories: An Educational Perspective. 4th ed. Upper Saddle River, NJ: Pearson Education, 2004. 14. Spencer J. Learning and teaching in the clinical learning environment: ABC of learning and teaching in medicine. BMJ 2003;326:591-594. [http://dx.doi.org/10.1136/bmj.326.7389.591] 15. Muir F. The understanding and experience of students, tutors and educators regarding reflection in medical education: A qualitative study. International Journal of Medical Education 2010;1:61-67. [http://dx.doi. org/10.5116/ijme.4c65.0a0a] 16. Donaghy ME, Morrs K. Guided reflection: A framework to facilitate and assess reflective practice within the discipline of physiotherapy. Physiotherapy Theory and Practice 2000;16:3-14. [http://dx.doi. org/10.1080/095939800307566] 17. Geddes EL, Wessel J, Williams RM. Ethical issues identified by physical therapy students during clinical placements. Physiotherapy Theory and Practice 2004;20(1):17-29. [http://dx.doi.org/10.1080/09593980490425076]

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Research Benefits of curriculum renewal: The Stellenbosch University physiotherapy experience M Unger, BPhysT, MSc (Physio), PhD; S D Hanekom, BSc (Physio), MSc (Physio), PhD Division of Physiotherapy, Department of Interdisciplinary Health Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa Corresponding author: M Unger (munger@sun.ac.za)

Background. Driven by a changing healthcare environment, the Division of Physiotherapy (Stellenbosch University) reduced core content and adopted a multimodal approach to teaching and learning. The benefits of curriculum renewal, however, are seldom investigated despite ongoing internal appraisal. Evaluation of the BSc Physiotherapy programme was considered incomplete without determining the worth of the programme. Objectives. To determine whether there was a change in students’ perception of the impact of the programme on personal development; and whether the programme prepared them for community service. Methods. A descriptive comparative desktop analysis was conducted in which the data from the Faculty’s Programme Evaluation process were compared between students enrolled in the old curriculum (2006) and students enrolled in the new curriculum (2011) using pooled data and t-tests to compare responses between the two groups. A level of significance was set at p<0.05. Results. A significant increase in scores was noted for various graduate attributes developed as a result of the programme, such as critical thinking, clinical reasoning, communication and sourcing information (p<0.01). Similarly, students scored their perceptions related to programme structure significantly higher (p<0.01). No change was reported regarding students’ ability to maintain a balance between studies and other activities. Scores pertaining to their perception of readiness for community service or professional practice remained the same with both cohorts believing they were well prepared. Conclusion. The renewed format seemed to benefit students greatly in assisting the development of graduate attributes. Students were significantly more satisfied with the structure of the renewed curriculum and – despite extensive changes – the principles-based multimodal approach to teaching and learning was perceived as effective for preparing students for community service. Programmes undertaking curriculum renewal should not only focus on the curriculum content but also develop a variety of learning opportunities to facilitate the development of graduate attributes. The next cycle of evaluation should however reflect on clinical practice. AJHPE 2014;6(2 Suppl 1):222-226. DOI:10.7196/AJHPE.519

Curriculum renewal in health education is not novel. Educational institutions have an ethical obligation to produce quality graduates capable of addressing their communities’ healthcare needs. However, a worldwide ongoing change in the profile of disease with resultant increase in burden on personal and government resources means that health education programmes need to change. These programme changes should not just occur at content level but should also consider the changing profile of the undergraduate student which is affecting their readiness for tertiary level education.[1] Programme evaluation is therefore essential not just for ensuring effective and fiscally responsible use of government resources, but should also evaluate the impact change on the student stemming from this curriculum renewal.

Background

In 2007 a renewed physiotherapy curriculum was implemented at Stellenbosch University (SU) which aimed to meet these multiple challenges but still produce graduates capable of independent practice in a community setting. Although the scope of physiotherapy practice is rapidly expanding, the undergraduate programme was forced to cut back on content and students’ critical reasoning, problem-solving and managerial skills needed to improve. The profile of an SU physiotherapy graduate was revisited, and a new, more appropriate and flexible curriculum was developed which aimed to assist the development of manual skills while developing skills of reflection, communication, information gathering and critical analysis,

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safety, group work (team, organisation and community), evidence-based practice, professionalism, problem solving, ethical practice and lifelong learning. This skills set was aligned with the graduate attributes identified by the Faculty of Medicine and Health Sciences (FMHS), SU. A phronetic approach was taken in that the process followed for curriculum renewal was predominantly based on craft knowledge[2] and relied in most part on the intuitiveness of the current staff, none of whom had a formal background nestled in education. The framework that guided the process closely follows that of an instructional systems design using the ADDIE model (analysis, design, develop, implement/delivery & evaluation).[3] A SWOT analysis was used to identify the strengths, weaknesses, threats and opportunities of the changing learning and healthcare environment; a nominal group technique[4] was used to identify core content; and a survey of the literature guided decisions regarding best practice methods of teaching and learning.

The end product

The end product of the above process was a newly constructed physiotherapy undergraduate curriculum. The curriculum consists of four phases: Phase 1. This forms the scientific foundation for the practice of physiotherapy which is laid down in the first 18 months of the programme (years 1 and 2). Phase 2. Over the next 12 months there is a gradual integration of pathology and environmental factors into the science of physiotherapy and the early development of clinical reasoning skills (years 2 and 3).

Research hase 3. This phase is focused on refining clinical reasoning skills (years P 3 and 4). Phase 4. This phase can be viewed as pre-profession entry with increasing emphasis on autonomy and reflection (year 4).

The learning opportunities and teaching methods used were aligned with the outcomes of each module. A wide variety of formats for the presentation of content were selected. These included lectures, discussions, group work, self-study and experiential learning.[5] Didactic (lectures), small-group

Table 1. Summary of teaching and learning events: A comparison between the old and new curricula Old curriculum

New curriculum

Year

Learning events

Assessment

Learning events

Assessment

Anticipated benefits

Lectures

Theory paper (short Qs)

Lectures

Theory paper (short Qs)

↑ Knowledge base

Practical skills training

OSPE

Practical skills training

OSPE

Lectures

Theory paper (short Qs)

Lectures

Written integrated theory ↑ Knowledge integration tests (basic level – body areas and systems based)

Practical skills training

Practical tests (1 hr) case-based

Practical skills training

OSPE

WPBL

Nursing elective

WPBL

Clinical patient interviews; ↑ Communication; collect, analyse nursing elective, task: and organise information; be culturally ethics and understanding sensitive health services; observational review

Lectures

Theory paper (short Qs); development of a research proposal

PBL

MCQs; written integrated ↑ Clinical reasoning theory tests; development ↑ Awareness for evidence-based practice of a research (systematic ↑ Patient-centeredness review) proposal ↑ Multidisciplinary approach

Practical skills training

Practical tests (1 hr) case-based

Practical skills training & case-based skills training (skills lab)

DOPS

WPBL

Treatment of a known patient and evaluation of an unknown patient, block reports

WPBL

Treatment of known- and Community re-integration evaluation of unseen Communication patients; block reports; ↑ Clinical reasoning DOPS Work within a multi-professional team

Think critically Progressive mastery of technical skills

Think critically 4

Lectures

Theory paper (short & long Qs)

EBL

Tasks (case-based); Promote clinical reasoning self-development of Source relevant evidence-based literature an evaluation form; presentations; MCQs; written integrated theory tests

WPBL

Treatment of a known patient and evaluation of an unknown patient

WPBL

Treatment of knownand evaluation of unseen patients; block reports; DOPS; tasks (management, human rights, reflection and referral letter) and submit a portfolio; service learning project presentations

Source relevant literature

Article

Critical appraisal of the literature

Primary research project

Mini-thesis

Systematic review

↑ Critical thinking ↑ Health advocacy Teacher

Q = question; OSPE = objective structured practical exams; WPBL = workplace-based learning; PBL = problem-based learning; MCQs = multiple choice questions; DOPS = direct observational procedural skills; EBL= enquiry-based learning.

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Research problem-based (PBL)[6] and enquiry-based (EBL)[7] learning approaches are used to deliver prescribed knowledge; practical training sessions and a nearpeer tutorial system[8] are used to teach and practise manual evaluation and treatment techniques prior to entering the clinical ‘real world’ setting for continuous experiential learning. Both horizontal and vertical scaffolding of complexity in theory training was achieved by gradually progressing from basic knowledge related to a singular body structure to integrated theory and complex pathology case presentations to workplace-based learning (WPBL)[9] opportunities. Assessment should be constructively aligned with the teaching and learning opportunities and so a similar multimodal approach to assessment was adopted (Table 1). Practical skills development progresses from training and objective structured practical exams (OSPEs) performed on peers[10] to technique tests (direct observational procedural skills (DOPS)[11] performed on patients; to patient evaluation and treatment in the clinical environment (Table 1). A method of continuous assessment was employed. This bold change to the traditional format of teaching and learning employed by most of the eight physiotherapy programmes offered in South Africa (SA) required careful and close monitoring to ensure successful delivery, as well as ensuring ongoing development of this curriculum. To this end several internal audits by module coordinators (lecturers) were conducted to determine effect and perceptions of selected aspects of the 4-year degree programme. These allowed for identification of problem areas; amendments, where necessary, were made. Reports from the SU Centre for Teaching and Learning (CTL)[12] regarding lecturer, module and (at the end of their degree programme) programme evaluation, together with the internal audits, provided information as to content, presentation and perceived enjoyment. It was important to ensure that the division’s throughput rate of 98% was maintained. The question remained, however, as to whether the renewed curriculum, regardless of reduced core content, which has a strong selfdirected learning focus, would be perceived by students to have a significant effect on personal development and still be effective for preparing students for professional practice within the SA context.

Methods

A descriptive comparative desktop analysis was conducted in which the data from the Faculty of Medicine and Health Sciences Programme Evaluation process were compared for two BSc Physiotherapy cohorts. Responses from students enrolled in the old curriculum (2006) were compared with responses from students enrolled in the new curriculum (2011). CTL annually invites all final-year physiotherapy students to anonymously complete a paper-based programme evaluation feedback questionnaire at the end of their final academic year before their results are made known. The questionnaire has three sections aimed at obtaining information on: the extent to which the programme outcomes have been achieved; programme architecture; and programme (physiotherapy)-specific outcomes (Table 2). All 30 questions require response on a five-point Likert scale ranging from strongly disagree (1) to strongly agree (5). The first 10 questions assess whether the students feel that the programme empowered them across a wide range of generic skills including critical thinking, problem solving, taking responsibility for learning, working in a team, etc. The next 10 questions pertain to programme architecture in terms of communication, appropriateness of evaluation methods, structure, etc. The last 10 questions were more specifically related to physiotherapy; however, the responses to

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only two of these questions were deemed appropriate for analysis in this study, and pertained to whether the programme encouraged evidence-based practice and whether the programme prepared them sufficiently for their compulsory community service year. The questionnaire is handed out by an independent member from CTL to all students at the end of their last contact session with lecturers. All assessments, including the final professional clinical entry examination, have been completed by then.

Statistical analysis

For each of the 22 selected questions, CTL reports the feedback as an average mark for the year group on a continuum of 1 - 5 which varies between ‘strongly disagree’ to ‘strongly agree’. These data were then analysed in Statistica (version 11) in consultation with a statistician using pooled data and t-tests to compare responses between the two groups. A level of significance was set at p<0.05. As this was an internal audit, ethical approval was not required. Individual questionnaires were not reviewed and students could therefore not be identified.

Results

Responses from 36/41 (87.7%) graduates enrolled in the old curriculum (2006) were compared with responses from all 38 (100%) graduates enrolled in the new curriculum. Responses differed significantly between the two groups, with the students following the new curriculum reporting higher mean values for most of the questions or statements (Table 2). This was so for perceptions related to personal gain/development, as well as those regarding the quality of the programme. No improvement in their ability to balance their studies and other activities (Q7, Table 2) was noted. Questions 19 and 21 are similar and relate to students’ readiness for future professional practice; no differences in scores between the two groups were found. For the 2011 cohort an average score of 4 is reported compared with an average score of 3.8 for the 2006 cohort. Regarding the statement ‘If I were to start again I would follow the same programme’, no improved rating was found.

Discussion

Within our division we view programme evaluation as crucial for both accountability and development of learning. The findings of this desktop analysis suggest that the renewed curriculum was successful in maintaining students’ perception of their readiness for professional practice. The improved rating scores relating to perceptions of graduate attributes and programme design were very encouraging. The renewed curriculum produced students who rated themselves significantly higher than students enrolled in the old curriculum, especially those scores related to critical thinking (Q1) and clinical reasoning (Q2, 3 & 5), communication (Q6) and self-directed learning (Q8). Students also seemed more aware of the principle of evidence-based practice (Q21) and were able to function effectively as part of a multidisciplinary team (Q4). Similarly, various aspects of the programme architecture (Q11 - 18) were more positively rated by students in the new curriculum. To qualify as programme evaluation, it is argued that the programme must focus on either outcome (in this case, did students perceive the programme to have an impact on personal development and their perception of

Research

Table 2. Analysis of responses to Centre for Teaching and Learning's Programme Evaluation questionnaire (SU BSc Physiotherapy 2006 v. 2011) 2006 average* (SD)

2011 average* (SD)

Pooled SD

1.Think critically

3.92 (0.72)

4.68 (0.52)

0.1467

-5.181

<0.001

2. Solve problems reasonably

4.03 (0.64)

4.66 (0.53)

0.1370

-4.598

<0.001

3. Keep the bigger picture in mind when solving problems

3.97 (0.6)

4.61 (0.54)

0.1329

-4.814

<0.001

4. Work effectively with others as a member of the team

4.03 (0.83)

4.68 (0.46)

0.1572

-4.135

<0.001

5. Collect, analyse, organise and evaluate information

3.83 (0.76)

4.53 (0.6)

0.1597

-4.382

<0.001

6. Communicate effectively using language skills (orally & in writing)

3.78 (0.89)

4.63 (0.58)

0.1757

-4.839

<0.001

7. Manage myself and my activities effectively in such a way that I maintain a good balance between my studies and other activities

3.36 (1.06)

3.39 (1.14)

0.2558

-0.117

0.45

8. Take responsibility to acquire knowledge and skills

4.17 (0.7)

4.5 (0.72)

0.1651

-1.999

0.02

9. Be culturally sensitive

3.82 (0.78)

4.55 (0.59)

0.1614

-4.522

<0.001

10. Identify and explore opportunities in educational, career and business world

3.31 (0.84)

3.68 (0.65)

0.1753

-2.111

0.02

11. Programme outcomes were communicated to me clearly

3.17 (0.73)

4.13 (0.86)

0.1851

-5.186

<0.001

12. I achieved the programme outcomes

3.5 (0.55)

4.24 (0.7)

0.1460

-5.071

<0.001

13. T he assessment methods and criteria are appropriate and match the programme outcomes

3.0 (0.94)

3.68 (1.08)

0.2351

-2.894

<0.001

14. T he content of the programme is clearly aimed at a clearly identifiable profession

3.81 (0.74)

4.21 (0.92)

0.1936

-2.066

0.02

15. The modules in the programme form a meaningful unit

3.42 (0.86)

4.16 (0.63)

0.1760

-4.204

<0.001

16. T he programme is organised in such a way that knowledge and understanding have deepened from the first to the final year

4.36 (0.71)

4.58 (0.59)

0.1522

-1.446

0.08

17. Little unnecessary duplication occurs between modules

3.67 (0.85)

3.87 (0.77)

0.1889

-1.059

0.15

18. The programme is in line with contemporary knowledge

3.89 (0.92)

4.32 (0.61)

0.1825

-2.357

<0.001

19. The programme prepared me for the working environment

3.91 (0.650

4.11 (0.79)

0.1678

-1.192

0.12

20. If I were to start again I would follow the same programme

3.31 (1.09)

3.43 (1.39)

0.2896

-0.414

0.34

Questions A. The programme empowered me to:

B. State whether you agree with the following statements:

C. Physiotherapy-specific questions. State whether you agree with the following statements: 21. T he curriculum enhances the importance of science as support for the practice of the profession

3.76 (0.84)

4.39 (0.71)

0.1813

-3.475

<0.001

22. I feel adequately prepared for my community year

3.74 (0.6)

3.89 (0.75)

0.1575

-0.952

0.17

* Pooled statistics from a 5-point Likert scale rating where 1 = strongly disagree to 5 = strongly agree. Degree of freedom (df) = 72.

readiness for independent practice?), outputs (student grades or number of students graduating) or administration[13] (effect of processes followed). It is however our opinion that all three aspects are important for ensuring client satisfaction while maintaining standards and producing effective, independent first-line practitioners. While the primary focus of this paper is to describe the outcome related to students’ perceptions of self-development and readiness, throughput rate and students’ final marks were also observed and evaluated. There was no significant change in the distribution of marks. The throughput rate for the 2006 cohort was 100% and the throughput rate has since been maintained at 98%. It was our assumption that potentially negative effects of reducing core content and changing the approach to teaching this core content would become evident during the clinical rotations. Although the structure and format of student supervision and support had to change, it was the opinion of the external examiners following the clinical physiotherapy exit exam that

utilising a wide range of assessment methods contributed not only to patient evaluation and treatment skills, but also to producing critical thinkers and innovative students. The relatively low and unchanged score relating to the question: ‘would you follow the same programme’ was disappointing. It was hypothesised that the multimodal approach[14] would be welcomed by students, and with the increasing number of assessment opportunities students would perceive the system to be more reflective of their potential.[15] Potential contributing factors such as personal factors including career choice, individual learning style and personality factors were not investigated. Post hoc subgroup analysis of individual responses may have identified relationships between these factors and perceived ‘likeness’ of the renewed teaching and learning approach. Although not evident from the above results, the programme is extremely busy and despite the nature of problem-based and enquiry-based learning allowing for many non-contact hours, students still find it difficult to

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Research balance their studies with other activities. Participation in extracurricular activities is promoted at tertiary institutions and colleges in order to develop leadership, communication and time-management skills;[16] however, the physiotherapy students at SU seem to continue to struggle with time management and effective study methods. The ‘I can do it all’ mentality of peak performing students who embark on multiple academic, sport and social activities but have poor personal time management and inability to prioritise may be reasons for this. This was however not explored in this paper. This study has several limitations, ranging from questionable timing to appropriateness of the group data analysis. It is clear from the group SD that there was wide variable response to some of the questions/statements and a more in-depth subgroup analysis of individual responses may have provided opportunity for investigating factors other than curricular influences. Ethically, however, access to individual responses was not possible. Another limitation is that this paper reports on the outcome of the CTL Programme Evaluation of the first cohort of physiotherapy students only. Comparison with more recent cohorts will provide more reliable interpretation of the outcome of the renewed curriculum. The invitation to participate was issued prior to obtaining their results, which may have influenced their scoring; however, as this effect could have gone both ways, in that students typically either under- or overestimate their performance, it was considered a negligible effect. To accurately be able to judge whether this curriculum was effective in preparing students for their role as independent practitioners ready for community service, remains difficult. Follow-up 6 or 8 months into their community service year is recommended.

Conclusion

Changing the content and the teaching and learning events had a significant impact on students’ perception of their ability to: evaluate and treat clients;

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work effectively within a team; source information; and identify and explore opportunities in education, career and in business. Students felt prepared and ready for community and professional practice. Programmes undertaking curriculum renewal should not only focus on the curriculum content, but also develop a variety of learning opportunities to facilitate the development of graduate attributes. Ongoing evaluation and increasing student support regarding time management and study methods is recommended. The next cycle following graduation should reflect on clinical practice. References 1. Dell S. South Africa: Universities face more under-prepared students. University World News, 17 January 2010. http://www.universityworldnews.com/article.php?story=20100114190733824 (accessed August 2014). 2. Flyvbjerg B. Phronetic planning research: Theoretical and methodological reflections. Planning Theory & Practice 2004;5(3):283-306. [http://dx.doi.org/10.1080/1464935042000250195] 3. Castagnolo C. The ADDIE model - why use it. Ezine Articles 2007. [http://ezinearticles.com/?The‐ADDIE‐ Model‐‐‐Why‐Use‐It?&id=859615] (accessed February 2007). 4. Lloyd-Jones G, Fowell S, Bligh JG. The use of the nominal group technique as an evaluative tool in medical undergraduate education. Med Educ 1999;33(1):8-13. [http://dx.doi.org/10.1046/j.1365-2923.1999.00288.x] 5. Carl AE. Course notes: an introduction to curriculum development. Course: NetACT West Africa Curriculum Workshop, 2011 (accessed December 2013). 6. Norman GR, Schmidt HG. Effectiveness of problem‐based learning curricula: Theory, practice and paper darts. Med Educ 2000;34(9):721-728. [http://dx.doi.org/10.1046/j.1365-2923.2000.00749.x] 7. Kahn P, O’Rourke K. Understanding enquiry-based learning. In: Barrett T, Mac Labhrainn I, Fallon H, eds. Handbook of Enquiry and Problem Based Learning. Galway: CELT, 2005. 8. Ten Cate O, Durning S. Peer teaching in medical education: Twelve reasons to move from theory to practice. Medical Teacher 2007;29(6):591-599. [http://dx.doi.org/10.1080/01421590701606799] 9. Richardson B. Professional development: 2. Professional knowledge and situated learning in the workplace. Physiotherapy 1999;85(9):467-474. [http://dx.doi.org/10.1016/S0031-9406(05)65471-5] 10. Miller G. The assessment of clinical skills/competence/performance. Acad Med 1990;65(Suppl 9):S63-S67. [http://dx.doi.org/10.1097/00001888-199009000-00045] 11. Kneebone R, Nestel D, Yadollahi F, et al. Assessing procedural skills in context: Exploring the feasibility of an Integrated Procedural Performance Instrument (IPPI). Med Educ 2006;40(11):1105-1114. [http://dx.doi. org/10.1111/j.1365-2929.2006.02612.x] 12. Centre for Teaching and Learning Services. Policy with regard to student feedback on Modules, Lecturers and Programmes, 2013. http://sun025.sun.ac.za/portal/page/portal/AdministrativeDivisions/SOL/CTL%20Home%20 page/CTLServices/Student%20Feedback/Policy/SF_POLICY.pdf (accessed August 2013). 13. Vedung E. Public policy and program evaluation. New Brunswick, NJ: Transaction Publishers, 2008. 14. Kerby J, Shukur ZN, Shalhoub J. The relationships between learning outcomes and methods of teaching anatomy as perceived by medical students. Clin Anat 2011;24(4):489-497. [http://dx.doi.org/10.1002/ca.21059] 15. Newfield D, Andrew D, Stein P, Maungedzo R. ‘No number can describe how good it was’: Assessment issues in the multimodal classroom. Assessment in Education: Principles, Policy & Practice 2003;10(1):61-81. [http:// dx.doi.org/10.1080/09695940301695] 16. Eggleston T. Balancing academics with co-curricular activities, 2009. https://www.mckendree.edu/newsarchive/2009/balancing-academics-with-co-curricular-activities.php (accessed February 2014).