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

2009; 31: e102–e115

WEB PAPER

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

D.V. ERNSTZEN1, E. BITZER1 & K. GRIMMER-SOMERS2

1Stellenbosch University, South Africa, 2University of South Australia, Australia

Abstract

Background: The attainment of clinical competence is a key outcome of physiotherapy programmes worldwide. Clinical

education forms a core component of the training of physiotherapy students.

Aims: The study on which this article is based aimed to investigate what physiotherapy students and clinical teachers at one

physiotherapy training institution perceive as effective opportunities to facilitate learning in a clinical context.

Methods: A survey of staff and students at the physiotherapy division at Stellenbosch University was undertaken as one element

of a situational case study. All enrolled physiotherapy students with clinical education experience and all clinical teachers involved

in the clinical education of these students were invited to participate. A purpose-built questionnaire was developed and validated

before being administered.

Results: The response rate was 80%. The clinical teaching and learning opportunities deemed most valuable for learning by

students and teachers were demonstrations of patient management, feedback, discussions and assessment. Teachers and students

varied in their perceptions of the learning value of peer assessment, self-assessment and reflection.

Conclusions: The study provided indications for teachers on the valuable learning opportunities as perceived by students and

teachers in a physiotherapy clinical setting. The activities perceived as most effective in facilitating learning in the clinical milieu were

demonstrations of patient management, discussion, feedback and assessment. Participants indicated that they valued individual

contact with teachers and that they learnt productively from discussions with the teachers. It was reported that immediate and verbal

feedback improved the learning experience. Both formative assessment in the form of a mock assessment and summative

assessment in the form of an end-of-block test were identified as important in facilitating learning. Further research is required on

peer assessment, self-assessment and reflection to establish the role of these aspects of learning.

Introduction

Clinical education and the supervisory process it involves is

an important and distinct part of health care education.

During clinical experience, theory consolidates into practice

and students learn to combine and integrate the knowledge,

skills, attitudes, values and philosophies of the profession.

The clinical learning environment is the ideal area in

which to facilitate professional skills (Strohschein et al.

2002), as students are learning within the context of clinical

practice.

A number of authors around the world have investigated

the importance of clinical education for the development of

professional skills. Several authors across disciplines empha-

sise the importance of clinical training, for example, in

medicine (Hesketh et al. 2001; Cottrell et al. 2002; Grant

et al. 2003; Van der Hem-Stokroos et al. 2005; Kilminster et al.

2007), in nursing (Chan 2001; Conrick 2001), in radiography

(Williams & Web 1994), and in physiotherapy (Higgs 1992,

1993; Walker & Openshaw 1994; Stiller et al. 2004; Lekkas

et al. 2007). Rushton and Lindsay (2003), Strohschein et al.

(2002) and Kilminster and Jolly (2000) reviewed the literature

on the efficacy of clinical education programmes across

disciplines and they reiterate its importance.

Kilminster et al. (2007) define clinical education as the

provision of guidance and feedback on personal, professional

and educational development in the trainee’s experience of

providing appropriate patient care. Clinical education is thus

important for the development of the health professional and

for providing quality patient care (Kilminster & Jolly 2000;

Grant et al. 2003; Kilminster et al. 2007).

Practice points

. Activities effective in facilitating learning in the clinical

milieu are demonstrations of patient management,

discussion, feedback and assessment.

. Formative assessment creates a valuable learning

opportunity.

. The use of reflection, self-assessment and peer assess-

ment as learning opportunities in the clinical learning

environment requires further investigation.

Correspondence: D.V. Ernstzen, Division Physiotherapy, Faculty of Health Sciences, Stellenbosch University, South Africa,. Tel: þ27 21 938 9300;

fax: þ27 21 931 1252; email: [email protected]

e102 ISSN 0142–159X print/ISSN 1466–187X online/09/030102–14 � 2009 Informa Healthcare Ltd.

DOI: 10.1080/01421590802512870

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Despite the importance of supervisory practice during

clinical education in medicine, Kilminster and Jolly (2000)

conclude from their review of the literature that it has little

empirical and theoretical basis. Kilminster et al. (2007) also

state that clinical supervision is the least researched topic in the

area of medical clinical training and that supervisory practice

in medicine is highly variable. The research done by Kilminster

and her team found that the effectiveness of the clinical

supervisory process depends more on the supervisory

relationship and less on the supervisory methods used

(Kilminster & Jolly 2000; Cottrell et al. 2002; Kilminster et al.

2002; Kilminster et al. 2007). Rolfe and Sanson-Fisher (2002)

emphasise the need to develop guidelines for supervisors’

clinical education practice and advocate a need to re-evaluate

methods by which doctors are taught clinical skills. The above

aspects highlight the need for research and guidelines in

clinical education practice. Van der Hem-Stokroos et al. (2005)

support this notion.

Little has been reported on research into the processes and

outcomes of teaching and learning in physiotherapy clinical

environments. Both Babyar et al. (2003) and Lekkas et al.

(2007) highlight this situation, particularly the lack of informa-

tion on the effectiveness of various teaching methods used

during physiotherapy clinical education. A review of the

literature on physiotherapy clinical education made it evident

that most research focussed on models of clinical education

(Ladyshewsky 1993; Baldry Currens 2003; Baldry Currens &

Bithell 2003; Moore et al. 2003; Stiller et al. 2004; Frieg &

Lochner 2005) and the role of the clinical teacher during

clinical education (Harris & Naylor 1992; Onuoha 1994; Cross

1995; Mbambo 1999; Frieg & Rhoda 2006; Laitinen-Vaananen

et al. 2007). There is less focus on teaching and learning

opportunities (Onuoha 1994; Walker & Openshaw 1994; Cross

1998; Babyar et al. 2003). The literature studied indicated that

the effectiveness of teaching and learning opportunities for

facilitating learning during physiotherapy clinical training

requires further investigation.

Investigating effective teaching and learning opportunities

is important, as the clinical and classroom learning environ-

ment differs vastly. In the classroom, learning activities may be

planned and structured within an environment that is flexible

to deal with student enquiries. In the clinical learning

environment, patients are present and expect treatment.

Unplanned events often occur with patients or other health

care providers, and these can constrain opportunities to learn.

Furthermore, since the aims of health care centres are to

provide quality health care to patients whilst providing

students with training opportunities, student education may

sometimes take a secondary role to patient care. The role of

the student as service provider may influence the learning

process of the student. Thus, the challenge for clinical

education programmes is to be both patient-centred and

student-centred.

In recent years, a paradigm shift has taken place in higher

education from a teacher-centred to a student-centred focus.

Barr and Tagg (1995) state that a higher education institution

exists to produce learning, not to provide instruction. The

emphasis in student-centred education is on the student’s

learning experience. The teacher’s role is to create powerful

learning environments. Characteristics of the student-centred

education include: learning by discovery, active construction

of knowledge, specific learning results and assessment

throughout learning. In the student-centred paradigm the

student’s experience is seen as most important, but in clinical

education the patient’s care is most important and the student

takes the role of a service provider. There is a need to assess

specifically what ‘student-centredness’ in the clinical context

means.

What and how a student learns is influenced by factors

such as the culture of learning, the environment and climate of

learning in the learning organisation, the student and the

student’s approaches to learning (Entwistle, in Knight 1995;

Ramsden 2003). Several theories on the process of learning

exist. These include the behavioural learning theories, where

learning is seen as the product of environmental influences

where associations are made between stimuli and responses

through selective reinforcement (Schunk 2004). The Social

Cognitive learning theory of Bandura highlights learning as

a social process and as a product of the environment. The

theory emphasises that learning can occur through

observing others (vicarious learning) and/or imitating beha-

viour (enactive learning) (Schunk 2004). The theories of Piaget

and Vygotsky had a major influence on the development of

constructivism which is a learning perspective. Constructivismt

focusses on construction/formation of learning and under-

standing by integrating learning activities and experiences

(Schunk 2004). Vygosky, through his cognitive development

theory, proposed that every learner has a potential ability for

learning/development which he calls the Zone of Proximal

Development (ZPD) (Jarvis et al. 2003). The ZPD emphasises

learning by socialisation, as it asserts that what learners can do

with assistance is more indicative of their mental capacity than

what learners can do on their own. Conditional knowledge

and metacognition is central to the learning theory of

cognitivism. Reflection is a metacognitive strategy through

which learning may occur (Mezirow 1991, in Merriam 2004).

Kolb’s (1984) theory of experiential learning describes learning

as a four-step cyclical process involving a concrete experience,

reflective observation, abstract conceptualisation and active

experimentation. In the humanist orientation to learning,

learning is a personal act needed to achieve the learner’s full

potential. The learner thus becomes autonomous and self-

directed (Torre et al. 2006)

Examining the ways students learn in and interpret clinical

learning environments may provide a better understanding of

learning, which can be used to adapt the learning environ-

ment, since students ultimately respond to what they perceive

as important (Chan 2001). The learning environment is

influenced by the roles and attributes of the clinical teacher,

the student and the patient; the teaching and learning

opportunities offered; the models of clinical education used;

student assessment; and the atmosphere and facilities at the

health care setting (Ernstzen & Bitzer 2006). Two aspects of the

learning environment, namely teaching and learning opportu-

nities and clinical teacher roles and attributes, have been found

to be the most significant in influencing learning (Gandy 1997;

Chan 2001).

Perceptions of clinical education

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The study on which this article is based aimed to identify

what physiotherapy students and clinical teachers viewed as

effective teaching and learning opportunities during phy-

siotherapy clinical education.

Context of the Study

The study was conducted at the Physiotherapy Division,

Faculty of Health Sciences (FHS), Stellenbosch University (SU),

South Africa (SA). The physiotherapy programme is a 4-year

degree course. The first 2 years of training form the foundation

years. During the third and fourth year of training, students are

introduced to work-based learning, where they take respon-

sibility for patient management. Students rotate in groups to

different clinical areas (community physiotherapy, medical

and surgical, neurology and orthopaedics). Groups consist of

three to eight students and clinical rotations were 6 weeks in

duration at the time of the study.

Physiotherapy students are supported during their clinical

education by the physiotherapy clinician at the health care

centre and by a clinical lecturer. The clinician supervises and

advises the students on a day-to-day basis and students report

to the clinician. The clinician is responsible for writing a report

on the students’ progress on the clinical placement, using

specific criteria. The clinical lecturer mentors the students and

spends 1 hour or more per week with each student. During

this time, formal teaching and learning opportunities are

offered. The clinical lecturer assesses the student’s clinical

competence at the end of the clinical rotation.

In this article both the clinician and the clinical lecturer will

be referred to as ‘the clinical teacher’, as both play a role in the

clinical education of the student.

Methodology

Ethics

The protocol for the study was approved by the Committee for

Human Research at the FHS, SU, SA. Permission to undertake

the study was obtained from the respective chairpersons of the

physiotherapy departments involved. Written consent was

obtained from all participants.

Research design

The study formed part of a larger situational case study. An

in-depth focus was taken on one institution/organisation, in

an attempt to explore in-depth perspectives and differences

between stakeholders in that setting (Denscombe 1998;

Mouton 2001). A mixed method approach was used, generat-

ing both quantitative and qualitative data. During the first

phase of the study, a survey was undertaken to investigate the

teaching and learning opportunities that participants viewed as

effective in producing learning. During the second phase,

qualitative methodology was employed to ascertain why these

teaching and learning opportunities were deemed valuable in

producing learning. The qualitative results, focussing on

students’ and teachers’ experiences during clinical education

opportunities, will be presented in a follow-up article.

The larger study also investigated the role and attributes of

the clinical teacher in creating an optimal learning environ-

ment (Ernstzen & Bitzer 2006).

Sample

The study population included all physiotherapy students at

SU who had clinical experience, as well as all physiotherapists

involved in the clinical education of these students. All enroled

physiotherapy students who had clinical experience in taking

responsibility for patient management in 2005 were invited to

participate in the study. The total number of students in this

category was 80 (40 third-year and 40 fourth-year students).

All 23 clinical lecturers, and 14 clinicians directly involved in

the clinical education of these students, were also invited to

participate.

Instruments

Purpose-built questionnaires were distributed to all students

and teachers in the sample.

Questionnaire development

The questionnaires comprised three parts. Part one focussed on

demographic information of the respondents, while parts two

and three focussed on teaching opportunities offered during

clinical education. Prior to questionnaire development,

a review of the literature was undertaken and general

themes, key concepts and issues on clinical education were

identified. All teaching methods that had the potential to

enhance learning were considered a teaching and learning

opportunity (TLO). These were then categorised into factors

which could play a role in the learning experience of the

student in the clinical setting according to the model of Hesketh

et al. (2001). Categories in the model included TLOs, approach

to teaching and professional role. A summary of the key

concepts for the questionnaire is illustrated in Table 1. A full

description of the questionnaire development is available in

Ernstzen and Bitzer (2006).

The elements of the questionnaire were informed by

studies from various disciplines. Hesketh et al. (2001)

describes a framework for the clinical education of doctors.

It is based on examination of literature, clinical education

courses in medicine and discussion with colleagues. It

encourages active participation, collaborative learning, self-

directed learning, feedback, self-assessment, learning contracts

and assessment as TLOs. The Cleveland Clinic’s Clinical

Effectiveness Instrument as developed by Copeland and

Hewson (2000) also informed questionnaire development.

Hewson (2000) describes a course in clinical education for

physician educators. The course focusses on coaching, bed-

side teaching, small-group discussions, lectures, effective

feedback and designing curricula as TLOs.

In a study by Williams and Webb (1994), radiography

students reported several TLOs as important for learning.

These included encouragement of active participation during

learning, the clinical teacher using her knowledge to help

students understand experiences, teaching by comprehension

D.V. Ernstzen et al.

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and problem solving and by relating theory to practice, and

lastly, high expectations of the students.

Babyar et al. (2003) report on his survey that physiotherapy

students ranked the following TLOs for clinical reasoning from

most effective to least effective: discussion on patient case,

discussion on patient in class, problem solving via hypothetical

patient, problem solving via videotape of actual patient, role

playing with peers, case-study assignments, brainstorming and

reviewing a journal article. The students were also asked to

identify their preferred method of learning clinical reasoning

in the clinical setting. Discussion of a patient case before and

after interaction with the patient was identified by 60.8% of the

participants. However, the above study yielded a low response

rate (22%) and did not consider the students’ level of clinical

experience which might influence their preferred TLO. The

study thus identified that discussions on an actual patient seem

to be useful to facilitate learning.

Walker and Openshaw (1994) also investigated TLOs used

by clinical teachers in physiotherapy. All clinical teacher

respondents used demonstrations on patients and observation

(with feedback) of students as TLOs. One-to-one tutorials and

self-directed learning respectively were used by 77% of the

clinical teachers. Small-group discussions were used by 73%

and small-group practice sessions by 64% of clinical teachers.

Lectures and brainstorming were used by 27% of

clinical teachers. However, the researchers selected these

TLOs to be ranked by the participants, thereby limiting

options.

Paschal (1997) identified several other factors that are seen

as central in the process of physiotherapy clinical education.

These factors include bridging the gap between theory and

practice, putting knowledge to work, professional socialisation

and critical analysis of clinical competence (through role

modelling and self-assessment). Assisting the student to move

from assisted to self-directed learning has also been cited.

Oldmeadow (1996) describes a pathway of developing clinical

competence during clinical education that follows the princi-

ples of progressive mastery, which is in line with the move

from assisted to self-directed learning.

Higgs (1992) avers that the student is a self-directed learner

in the clinical setting by being responsible for and aware of his

own learning process and outcome, performing learning

activities and problem solving associated with learning tasks,

giving active input regarding the learning task, and through

collaborative learning. The need for reflection, self-assessment,

self-directed learning and lifelong learning skills are thus

emphasised. These skills are important for physiotherapists to

contribute to the knowledge base of the profession and to

demonstrate professional autonomy, competence and

accountability (Hunt et al. 1998). Reflection on experience

may be used to encourage learning. Donaghy and Morss

(2007), Higgs (1992) and Gandy (1997) regard reflective

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

Teaching and learning opportunities

Appropriate levels of autonomy Appropriate feedback; prompt feedback;

feedback on knowledge and competenceHigh-quality/good clinical teaching skills Reflection on learning

Active learning; promotes active student participation Promotes self-assessment

Use of student-centred strategies Demonstrations

Facilitation of learning; facilitation skills Patient discussions

Organising skills Observation — with feedback

Linking theory to practice One-to-one tutorials

Variety of learning experiences Small-group discussions

Flexible learning structure Role playing

Organisation Peer tutoring

Give direction on clinical work Lectures

Negotiation and assertiveness skills Brainstorming

Emphasis on research Clinical reasoning and problem solving

Constructive alignment Assessment skills

Group teaching skills; collaborative learning Case assignments

Journal review

Approach to teaching/personal factors

Communication Enthusiasm

Approachable Open-minded

Interpersonal skills Have high expectations form learners

Preceptor attitude/mentoring skills Communicates expectations

A humanistic orientation, concern for students Non-threatening/risk-free atmosphere

A positive orientation towards teaching Recognises learner individuality

Caring, supportive Recognises learner contribution

Counselling and appraisal skills Gives constructive feedback

Reassurance

Professional role

Clinical competence

(including critical inquiry, problem solving and reflective practice)

Professional skills

Professional socialisation

Role modelling of professional characteristics

Knowledge

Concerned with patient care

Interest in the learning process

Self-aware

In control

Organisation/clarity of clinical education

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


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practice as an important contributor to successful student-

centred teaching clinical education. Brockbank and McGill

(1998) define reflection as: the ‘process or means by which an

experience in the form of thought, feeling or action is brought

into consideration, while it is happening or subsequently’, and

as ‘the creation of meaning and conceptualisation from

experience and the potentiality to look at things as other

than they are’.

Feedback to students was also identified as an important

variable in the efficacy of physiotherapy clinical education

(Harris & Naylor 1992). According to Kilminster and Jolly (2000),

feedback creates feelings of confidence and competence and

improves relationships. These authors emphasise that feedback

to students should be clear and unambiguous so that they

become aware of their mistakes and weaknesses.

Assessment powerfully influences the way students

respond to courses and behave as learners (Gibbs 1999). It

influences the quality of the learning and teaching experience.

SU emphasises outcomes-based and student-centred assess-

ment (SU Assessment Policy 2004). Adopting a student-centred

approach implies that the assessment should have the student

as the main concern, having both summative and formative

functions. Formative assessment in clinical education could

include simulated clinical competency tests, technique tests,

peer assessment, self-assessment, assessments completed by

patients and specific learning tasks.

Self-assessment involves the ability to critically assess one’s

work against certain criteria or standards (Brew 1999). Self-

assessment and reflection are often thought to be the same, as

both focus on learning and experience. However, Brew (1999)

states self-reflection is a more exploratory activity, while self-

assessment has specific aspects of achievement.

During peer assessment, students make judgements and

comment on each other’s work (Brew 1999). Peer assessment

may encourage thinking, increase learning and increase

students’ confidence; it may contribute to the cohesiveness

of a group, but may also disrupt the group (Baldry Currens &

Bithell 2003). Brew (1999) emphasises the importance of

self-assessment and peer assessment to develop skills of

negotiation and discrimination.

Validation

The above-mentioned themes were drafted into questions,

which were made available in Afrikaans and English.

Language experts of the SU language centre were consulted

to assess the language and user-friendliness of the draft

questions. A statistician was consulted to determine if the

questions were framed in a way suitable for statistical analysis.

The content validity of the draft questions was then assessed

by five experienced higher-education practitioners (a profes-

sor in higher education, a senior researcher in higher

education, the physiotherapy clinical education coordinator,

an experienced physiotherapy clinical lecturer and head of the

school for Allied Health Sciences at SU). Minor changes were

made to the questions, which were then framed into the study

questionnaire.

After the content validation of the questionnaire items,

a pilot study was undertaken to determine if the questions and

instructions were understandable and to establish an estimated

time for the completion of the questionnaire. A sample

consisting of one physiotherapy class and two clinical teachers

from another physiotherapy department in SA was recruited

for this purpose. The questionnaire was further modified. The

resultant questionnaire is provided in Appendix.

Each questionnaire was coded according to the group to

which the participant belonged. The student questionnaire

was administered to students in the sample by allocating time

to complete the questionnaire after a learning session. The

clinical teachers’ questionnaire was mailed to them together

with a stamped, self-addressed return envelope. A covering

letter included the aim of the study, the return date for the

completed questionnaire and the researcher’s contact informa-

tion. Non-responders were followed up by sending a reminder

via e-mail or mail.

Data handling and analysis

The questionnaire data were recorded in a purpose-built data-

collection sheet in MS Excel. Data were then analysed on

a statistical program (Statistica 7), using proportions, means

and appropriate variability measures. A non-parametric test

(Mann–Whitney U-test) was used to determine differences

between students’ and clinical teachers’ questionnaire

responses. Although the aim of the study was not to compare

the views of the clinical teachers and students, it was

considered important to know where differences existed, as

this could guide the development of clinical education

programmes for teachers and students. Statistical significance

was determined at p < 0.01 as the study focussed on

perceptions of participants.

Results

The response to the questionnaire was 80% (88% for students

and 62% for clinical teachers). Thus, 70 students and 23 clinical

teachers returned completed questionnaires.

The perceived learning values of different TLOs are

illustrated in Table 2. Participants had to select six TLOs

which they experienced as having the highest learning value.

Demonstrations of patient management, feedback, discussions

with the teacher, individual learning sessions, mock assess-

ment and facilitation of learning received the highest number

of votes. Most students preferred discussions to be in the form

of individual-learning sessions rather than group-learning

sessions. However, in contrast to the student participants,

clinical teacher participants viewed individual discussions and

group discussions as equally important. It is interesting to note

the low number of votes for reflection, independent learning

(learning on one’s own) and peer assessment.

The TLOs used were also further explored in the

questionnaire by posing differentiating questions regarding

demonstrations, different types of discussion, feedback,

assessment and other learning experiences. The results are

reported in Table 3. Those responses with statistically

significant differences ( p < 0.01) between students and tea-

chers are marked with a designator ‘‘a’’.


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Table 3 provides information that supports the findings in

Table 2, namely that demonstrations are a valued clinical

teaching activity. The students and teachers agreed that

students learnt most when the student demonstrated clinical

practice and the teacher facilitated the process. This notion is

strengthened in that student learning was rated high when

the teacher observed the student’s clinical practice and gave

subsequent feedback (Table 3). However, students and clinical

teachers alike disagreed on the value of a demonstration given

by the clinical teacher, students rating its learning value more

highly. Students and clinical teachers also had significantly

differing views on peer observation during clinical practice.

Students rated the learning value of peer observation more

highly than did the clinical teachers. It is noteworthy that both

students and teachers considered routine management of

a patient to have reasonable to high learning value.

In Table 3 (Panel B), the different types of discussions are

considered. Table 3 (Panel B) indicates that both groups

perceived individual contact with the teacher as well as

discussions in small groups as having a high learning value.

However, students reported individual discussions with the

teacher to have superior learning value. This concurs with

the findings in Table 2. Students were reported to have

learnt productively from X-ray discussions, ward rounds and

presenting patient cases to fellow students.

Table 3 (Panel C) highlights student preference regarding

feedback during clinical education. The findings indicate that

for these participants, immediate feedback is preferred,

feedback on students’ strengths and limitations (thus mixed

feedback) is valuable and feedback specifically on the

development of technical skills is beneficial.

Self-assessment was reported to have reasonable to

minimal learning value by both groups, as indicated in

Table 3 (Panel D, (a)). In Table 3 (Panel D, (b)), it is reported

that peer assessment has reasonable to high learning value.

This finding differs from the finding in Table 2 where peer

assessment received only 15% of the votes. Of all the

assessment options given in the questionnaire, students

regarded a formative assessment tool, namely the use of

mock assessment, as the most valuable for learning (Table 3

[Panel D, (d)]. Students attributed a higher learning value to the

end-of-block competency assessment activity than clinical

teachers did. However, this difference was not statistically

significant.

Participants agreed that students and teachers should share

the responsibility for learning (Table 3 (Panel E, (a) and (b))).

Neither students nor teachers considered students managing

their own learning to be a preferred practice (Tables 1, Table 3

(Panel E, (a) and (f))); strengthening the notion of students and

teachers as co-producers of knowledge. Clinical teachers’ and

students’ rating and self-reflection differed significantly, as

shown in Table 3 (Panel E, (b)), with clinical teachers

attributing higher learning value to self-reflection.

Discussion

This study provides important information on students’ and

teachers’ perspectives of learning in a clinical setting, and adds

to the body of knowledge on effective clinical teaching

practices. It is highlighted that, for students and teachers in this

study, the most effective TLOs in enhancing student learning

in the clinical environment were demonstrations of patient

management, feedback, discussion and formative assessment,

which are all centred on providing physiotherapy care for

patients. It is therefore suggested that these activities form an

integral part of the clinical education programme.

Demonstrations of patient management in the students’

learning process were strongly valued by students and

teachers alike. Students reported that they learnt more when

they performed the demonstration (i.e. student-centred

education where students actively participated in learning)

compared with when the teacher performed the demonstra-

tion. Students valued teacher-led demonstrations more than

teachers did, because teachers appeared to regard their

demonstrations as passive learning by the student, while

students perceived their involvement as active learning.

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

Teaching and learningopportunities

Percentages and(number) of students who

selected the activity

Percentages and (number)of clinical teachers

who selected the activity Total selections in %

Demonstrations of patient management 93% (65) 70% (16) 87

Feedback 73% (51) 74% (17) 73

Discussions with the teacher 79% (55) 52% (12) 72

One-to-one learning sessions 77% (54) 48% (11) 70

Mock assessment 63% (44) 43% (10) 58

When learning is facilitated 39% (27) 61% (14) 44

Group-learning sessions 33% (23) 48% (11) 37

Discussion with peers 36% (25) 30% (7) 34

Coaching 33% (23) 13% (3) 28

Reflection 17% (12) 48% (11) 25

Questioning 20% (14) 30% (7) 23

Learning on own 14% (10) 4% (7) 18

Peer assessment 9% (6) 35% (8) 15

Clinical tasks 3% (2) 30% (7) 10

Lectures 9% (6) 9% (2) 9

Other 0% (0) 0% (0) 0

Note: Total students¼ 70, total clinical teachers¼23


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Observing the teacher performing the demonstration may

be seen as learning by observation, and performing the

demonstration may be seen as learning by doing. These

forms of learning are supported by the behaviourist

learning orientation (Torre et al. 2006) and the social cognitive

learning theory (Bandura, in Schunk 2004). By observing

others, people acquire knowledge, rules, skills, strategies,

beliefs and attitudes. Observation of and interaction with the

clinical teacher may thus influence the student’s learning

process. Babyar et al. (2003) and Chan (2001) support the

value of the teacher as role model during social interaction

with students. Medical students in a study by Van der Hem-

Stokroos et al. (2005) also found observation of clinical

practice to be most beneficial during the clinical learning

experience.

Another supported TLO in this study was feedback. Prompt

feedback on students’ strengths and limitations seemed most

preferred in enhancing learning. Verbal feedback was found to

be more beneficial than written feedback. Students seemed to

value feedback on skills more than feedback on knowledge,

skills and attitudes. The findings concur with those of

Kilminster and Jolly (2000) who found that feedback improves

students’ confidence and that it improved relationships

between students, teachers and patients. Van der Hem-

Stokroos et al. (2005) agrees that feedback should be a key

element in clinical education programmes.

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

Students’ mean score (SD) Teachers’ mean score (SD)

Panel A: Demonstrations

(a) The teacher demonstrates patient evaluation/treatment. 1.89a (0.10) 2.48a (0.17)

(b) The teacher observes clinical practice of student and comments. 1.77 (0.10) 1.87 (0.17)

(c) The student demonstrates clinical practice and the teacher facilitates the process. 1.77 (0.11) 1.78 (0.18)

(d) The student observes a peer during clinical practice. 2.81a (0.07) 3.13a (0.16)

(e) The teacher facilitates reflection after a demonstration. 2.43a (0.09) 1.81a (0.17)

(f) The student completes a patient documentation form. 2.91 (0.10) 2.61 (0.18)

(g) Routine evaluation/treatment of the patient by the student. 2.69 (0.09) 2.74 (0.16)

Panel B: Discussion

(a) The teacher does a one-to-one tutorial with the student. 1.69 (0.11) 2.08 (0.19)

(b) The student participates in small-group discussion on patient management. 2.06 (0.10) 2.09 (0.18)

(c) The student participates in a discussion on X-rays. 1.93 (0.10) 2.26 (0.18)

(d) The student is tutored by a fellow student. 2.94 (0.08) 3.13 (0.14)

(e) The student participates in a ward round. 2.82 (0.12) 2.78 (0.21)

(f) The student presents a case study to fellow students/staff. 2.67a (0.10) 2.09a (0.17)

Panel C: Feedback

(a) The teacher gives verbal feedback. 1.76 (0.10) 2.30 (0.17)

(b) The teacher gives written feedback. 2.34 (0.10) 2.35 (0.18)

(c) The teacher gives immediate feedback. 1.59 (0.09) 1.30 (0.16)

(d) The teacher gives feedback on what the student did well. 2.11 (0.08) 1.74 (0.15)

(e) The teacher gives feedback on the student’s limitations. 1.74 (0.10) 2.22 (0.17)

(f) The teacher gives feedback on the student’s limitations and strengths. 1.52 (0.09) 1.26 (0.16)

(g) The teacher gives feedback on the student’s knowledge. 2.17 (0.10) 2.26 (0.17)

(h) The teacher gives feedback on the student’s skills. 2.01 (0.09) 1.96 (0.16)

(i) The teacher gives feedback on the student’s attitudes. 2.36 (0.12) 2.65 (0.2)

Panel D: Assessment

(a)The student assesses him/herself on patient management. 3.29 (0.11) 3.00 (0.20)

(b)The student is assessed by other students on patient management. 2.91 (0.09) 2.64 (0.16)

(c)The student is assessed by the patient on patient care. 3.09 (0.11) 3.22 (0.20)

(d)The teacher assesses the student using a mock test. 1.74 (0.11) 2.04 (0.20)

(e)The teacher assesses the student on the end-of-block test. 1.99 (0.12) 2.57 (0.21)

(f)The student assesses his/her own learning. 3.2 (0.10) 3.09 (0.17)

Panel E: Other teaching and learning opportunities

(a) The teacher allows the student to share responsibility for learning. 2.00 (0.10) 1.91 (0.17)

(b) The teacher gives a lecture on patient management. 2.36a (0.11) 3.26a (0.19)

(c) The student does role-play about clinical practice. 2.86 (0.11) 3.39 (0.19)

(d) The student observes surgery. 2.57a (0.11) 3.30a (0.19)

(e) The student observes a video on patient management. 2.8 (0.10) 3.09 (0.17)

(f) The student and teacher plan learning activities together. 2.44 (0.11) 2.13 (0.19)

(g) The student draws up a SWOT analysis on his/her clinical abilities. 3.37a (0.11) 2.65a (0.20)

(h) The student does self-reflection on clinical abilities. 3.16a (0.11) 2.30a (0.19)

(i) The student writes a report on patient management. 3.29 (0.09) 2.96 (0.15)

Note: aSignificant difference

Scale used:

1. I learnt an extreme amount.

2. I learnt a lot.

3. I learnt a reasonable amount.

4. I learnt a minimal amount.

5. I learnt nothing.


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Expanding on the notion of feedback, Gross Davis (2001)

says that she regards discussions as useful because they actively

involve the student. She argues that, through discussion,

students gain practice in thinking through problems, organising

concepts, formulating arguments and counter-arguments,

evaluating the evidence for their own and others’ position,

and responding thoughtfully and critically to diverse points of

view. A discussion is thus a collaborative learning event that

provides the opportunity to acquire knowledge and insight

through the exchange of ideas and opinions. Collaborative

learning is a central theme of the student-centred paradigm

(Barr & Tagg 1995). It is therefore not surprising that

participants in this study identified discussions with the

teachers as one of the most valued activities for enhancing

learning. In Babyar et al. (2003), physiotherapy students ranked

discussion on a patient case as most effective in facilitating

clinical reasoning. The students seemed to prefer individual

learning sessions more than group discussions, possibly

because they received personal attention because the teachers

addressed diverse students’ individual needs, as suggested in

the student-centred paradigm (Barr & Tagg 1995).

Discussion as a learning activity also concurs with the ZPD

of Vygotsky (Jarvis et al. 2003). The learners’ learning potential

is thus realised when they interact with more knowledgeable

others, in this case the clinical teacher. Vygotsky’s theory

emphasises potential, development and collaborative learning,

rather than independent learning (Bitzer 2004). Strohschein

et al. (2002) also reports better outcomes in learning during

collaborative learning opportunities.

The findings of the study contribute to the notion that

assessment powerfully influences learning (Higgs 1993; Gibbs

1999). Formative assessment in the form of a mock assessment

was perceived to be important in facilitating learning, probably

because the mock test is a simulation of the actual clinical

competency test. The primary goal of formative assessment is to

enhance learning by helping students to develop under

conditions that are non-judgemental and non-threatening

(Geyser 2004).

In the context of this study, clinical competency was

assessed by means of a competency test at the end of the

clinical placement. These summative assessments were also

seen as important in the students’ learning experience. The

students and teachers differed in their view of the value of the

end-of-block test. The lower rating by clinical teachers could be

possibly be explained by teachers providing a grading and

feedback after the assessment, without an opportunity for

remedial action, while students, who are actively involved in

the process, might see the test situation as an opportunity to

learn from their mistakes. Nonetheless, formative assessment is

one way of achieving student-centred assessment by assessing

throughout the learning experience (Barr & Tagg 1995)

Peer assessment raised a number of issues. The uncertainty

regarding the learning value of peer assessment highlights that

the value of peer assessment are diminished by the confidence

in of the group in peer knowledge.

Students were of the opinion that they did not learn

productively from self-assessment and reflection. The

clinical teachers disagreed with this notion. It may be that

students lack insight into the complexity of self-assessment,

as clinical exposure challenges their personal and

professional development. Perhaps reflection and self-assess-

ment occurred without the students realising it. Reflection

should thus be planned as part of experience, in this case the

clinical encounter with the patient. By making use of

reflection, learning is not left to chance; but is intentionally

facilitated. Reflection can help connect theory to practice

and help students to engage in consistent and intentional

self-evaluation and professional growth (Strohschein et al.

2002). Students need systematic practice in judging their own

work, and through utilising feedback they are able to develop

their self-assessment skills (Brew 1999). The value of reflection

as a meta-cognitive strategy to create meaning from experi-

ence is also clear from the literature (Higgs 1992; Brew 1999;

Strohschein et al. 2002). Thus students’ perspective on self-

assessment may need to be addressed in the clinical

environment as a formal part of the learning process. The

value of reflection and self-assessment needs to be empha-

sised in the clinical education programme to enhance

awareness of their importance amongst students and teachers.

The results of the study should be considered in the light of

certain limitations. It cannot be generalised as it focusses on

one institution and the perceptions of a specific group.

Therefore, a need exists for more research on TLOs. The

information could inform stipulations regarding the content of

clinical education programmes. Specific attention needs to be

given to developing TLOs that could facilitate clinical reason-

ing and linking theory to practice. Furthermore, the clinical

education programme needs to be evaluated on an ongoing

basis, as part of quality assurance.

Conclusion

The study provided indications for teachers on effective

learning opportunities as perceived by students and teachers

in a physiotherapy clinical setting. The activities perceived as

most effective in facilitating learning in the clinical milieu are

demonstrations of patient management, discussion, feedback

and assessment. Students indicated that they valued individual

contact with teachers and that they learnt productively from

collaborative learning events. The aforementioned can be seen

as ways to create powerful clinical learning environments. It is

suggested that these aspects of teaching and learning be

incorporated formally into clinical placement educational

strategies.

It was reported that immediate, verbal and mixed feedback

improved the learning experience. Teachers should thus be

trained in giving effective feedback. Formative assessment in

the form of a mock assessment, as well as summative

assessment in the form of an end-of-block test was identified

as important in facilitating learning. The participants’ uncer-

tainty about the learning value of reflection, self-assessment

and peer assessment indicates that a greater focus is

required on these elements when exposing students to clinical

training opportunities. Since mixed responses from partici-

pants suggested that these activities were not optimally utilised

during clinical placements, their learning value should be

explored.


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Acknowledgement

The project was funded by the Fund for Innovation and

Research into Teaching and Learning, Centre for Teaching and

Learning, Stellenbosch University, South Africa.

Declaration of interest: The authors report no conflicts of

interest. The authors alone are responsible for the content and

writing of the article.

Notes on contributors

D.V. ERNSTZEN, BSc Physiotherapy, MPhil (Higher Education), Lecturer,

Division Physiotherapy, Faculty of Health Sciences, Stellenbosch

University, South Africa.

E.M. BITZER, DEd, Professor, Centre for Adult and Higher Education,

Stellenbosch University, South Africa.

K. GRIMMER-SOMERS, PhD, Professor, School of Health Sciences, Director

of the Centre for Allied Health Evidence, University of South Australia,

Australia.

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Appendix

Title

Effective Clinical Education in Physiotherapy: Learners’ and

Clinical Teachers’ views at Stellenbosch University.

Aim: To determine what Physiotherapy learners and clinical

teachers view as effective educational strategies to enhance

learning in the clinical environment.

Researcher: Dawn Ernstzen

Tel: 084 581 0693 or 021 938 9497

Fax: 021 931 1252

Description of terms used:

Clinical Teacher: All Physiotherapists involved in the clinical

learning experience of Physiotherapy students.

Teaching/Learning activities: Activities that the teacher

uses, with the aim of enhancing learning.

Important: Has a considerable effect on the learning process.

Facilitation: The teacher helps the learner to discover

knowledge and to take ownership of learning.

Clinical reasoning: The cognitive processes (thinking) used

in the evaluation and management of a patient.

Problem solving: Steps involved in working toward

a solution.

This study is financially supported by The Fund for

Research and Innovation in Learning and Teaching

(FIRLT), Centre for Teaching and Learning,

Stellenbosch University.

CLINICAL EDUCATION IN PHYSIOTHERAPY

Clinical

Teaching Learning

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Documents

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