Physiotherapy students’ and clinical teachers’ perspectives on best clinical teaching and learning practices: A qualitative study

Background: Clinical education forms a core component of the training of physiotherapy students. Little research on the efficacy of commonly used physiotherapy clinical learning and teaching opportunities are available. Objective: This paper sought to identify the clinical teaching and learning opportunities that undergraduate physiotherapy students and clinical teachers viewed as effective in enhancing learning, as well as the reasoning behind their views. Design: A qualitative research design was used. Data was analyzed using content analysis. Data was coded, cate gorized and conceptualized into key themes and patterns. Participants: All third year (n=40) and fourth year (n=40) physiotherapy students as well as their clinical teachers (n=37) were eligible to participate. Semi-structured individual interviews were conducted with a purposive sample consisting of six third-year students, six fourth-year students and six clinical teachers. Results: The results indicated that learning is best facilitated in open, relaxed environments. Demonstrations of patient management by teachers and students, discussion of patient cases, feedback and formative assessment were identified to be effective strategies to enhance development of clinical competence. Conclusion: Clinical education, using focused and structured processes, could ensure that students are exposed to a range of learning opportunities for development of clinical competence.


INTRODUCTION
Clinical education is defined as the provision of guidance and feedback on personal, professional and educational development in the trainee's experience of providing appropriate patient care (Kilminster et al. 2007).Appropriate clinical education within the context of providing patient care is important for the development of health profes sionals (Grant et al. 2003, Kilminster et al. 2007, Lekkas et al. 2007, Strohschein et al. 2002).Clinical learning takes place in a complex social context, where the patients' and students' needs are con sidered (Chan 2001) and consequently, a careful balance between patient care and student learning is essential.
What and how a learner learns is influenced by many factors, including the organizational learning culture, learner characteristics, learner approaches to learning and teacher characteristics (Kilminster and Jolly 2000, Schunk 2004, Best et al. 2005).The learner's Correspondence to: D.V. Ernstzen Division Physiotherapy, P O Box 19063, Faculty of Health Sciences, Stellenbosch University, Tygerberg, 7505 Email: dd2@sun.ac.zaWalker and Openshaw (1994).Several reviews on the efficacy of clinical education programmes across disciplines (Kilminster and Jolly 2000, Rushton and Lindsay 2003and Strohschein et al. 2002) emphasize the need for an evidencebased approach towards clinical education.
Despite its importance, there is limi ted indepth knowledge about which teaching strategies are potentially effective to facilitate learning and why some strategies might be more effective than others (Babyar et al. 2003 Objective: This paper sought to identify the clinical teaching and learning opportunities that undergraduate physiotherapy students and clinical teachers viewed as effective in enhancing learning, as well as the reasoning behind their views.
Design: A qualitative research design was used.Data was analyzed using content analysis.Data was coded, cate gorized and conceptualized into key themes and patterns.
Participants: All third year (n=40) and fourth year (n=40) physiotherapy students as well as their clinical teachers (n=37) were eligible to participate.Semi-structured individual interviews were conducted with a purposive sample consisting of six third-year students, six fourth-year students and six clinical teachers.
Results:  2003).Ernstzen et al. (2009) found that certain teaching and learning opportunities are perceived to be key elements for facilitating learning during clinical education.These opportunities included demonstrations and discussion on patient management, feedback on clinical skills, and assessment.The current article explores the teaching and learning opportunities from the context of qualitative data collected subsequently to the above findings.
This paper sought to identify the clini cal teaching and learning opportunities that undergraduate physiotherapy students and clinical teachers viewed as effective in enhancing learning, as well as the rea soning behind their views.

Research Design
A qualitative research approach was used in order to understand the con text specific, real world setting without manipulating the environment (Golafshani, 2003).The study was con ducted at the Division Physiotherapy, Faculty of Health Sciences (FHS), Stellenbosch University (SU), South Africa (SA).The study reported on formed part of a larger mixed method study that employed a survey as a first phase (reported on in Ernstzen et al. 2009).The current paper reports on the second phase of the study, which employed a qualitative methodology.
Data was generated using onetoone, semistructured individual interviews.Topics discussed in the interviews are included in Box 1. Interviews were conducted by the primary researcher in the language of choice for the participant (i.e.either in English or Afrikaans).
The interviews took place at the Division of Physiotherapy, lasted an average of 35 minutes and were recorded using a digital voice recorder.Field notes were kept to provide a sum mary of the process and the recorded interviews were transcribed by an independent transcriber.Unique serial numbers were given to each data set.The selected participants were invited to view and comment on transcripts to assist with validation (Mays and Pope 1995; Creswell 2003).codes were revised after being checked by an external auditor to aid valida tion.The codes were then grouped into categories by the researcher in conjunc tion with the external auditor.Categories lead to the development of patterns and themes within the data to explore their possible relationships.The process resulted in an understanding of learning within the context of the clinical teach ing and learning opportunities used.

Profile of the participants
An overview of the profile of the partici pants is presented below in Table 1.
The fields that clinical teachers were teaching in, included orthopaedics (2), medical and surgical (1) and neurology (1).Two clinical teachers were involved in teaching in all three of the above fields.The level of health care taught at were: primary health care (1), secondary health care (2), tertiary health care (2) and a private practice setting (1).

Key findings of the interviews
The key themes identified through the interview transcripts are presented in The protocol for the study was approved by the Committee for Human Research at the FHS, SU, SA (reference number N05/08/144).Permission to undertake the study was obtained from the chairperson of the Physiotherapy Division, and written informed consent was obtained from the participants prior to each interview.

Participants
All enrolled undergraduate physio therapy students at SU who had had clinical experience, and all physio therapists involved in the clinical edu cation of these students during 2005 were eligible to participate.Purposive sampling was used to select six parti cipants from each of the three groups (third year students, fourth year students and clinical teachers).

Data analysis
Data was analyzed using content ana lysis.The transcripts were analyzed and interpreted using specific analysis strate gies (Creswell 2003, Krippendorf 2004) including familiarisation with the data, interpreting the data by coding, catego rizing and contextualizing texts.Final

Specific probing questions
What methods/opportunities for learning/teaching are of most value to you during clinical rotations and why.
• Probe for all, including: During teacherled demonstrations, the teacher acted as a role model with regard to cognitive, social and technical skills, highlighted by the following quotes: Student 2: "The demonstration by the teacher gave me direction in management options for the patient.It directed my thought processes as it provided a pattern of thinking and doing; it helped me to identify the type and logic of questions to ask.I started thinking in the same manner and could put the theory and practical together in a clinical setting." Teacher 3: "When performing demonstrations I hope that learners may learn a specific pattern of thought or process of assessment/treatment of the patient.Not a recipe, but an approach.
These illustrate how students can learn cognitive skills from teachers, especially their approach to clinical problem solv ing.
The clinical teacher was reported to be a role model for technical skill as Student 4 pointed out: "It helped me to observe the teacher's physical handling skills.It showed me how to adapt my techniques, for example my grip, to make the technique more effective and comfortable to the patient." Participants also reported learning productivity during studentled demon strations.Studentled demonstrations they value feedback from more than one clinical teacher.Demonstrations of patient management and guidance on patient management played a role in creating a good learning environment.These two factors contributed to learning from the teacher when the teacher acts as role model for cognitive, social and technical skill, which is explored in the next section.

Demonstrations of patient management
Participants identified three types of demonstrations of patient care, namely; teacherled, studentled, and peerled.During teacherled demonstrations, the teacher demonstrated patient care to one or more students.During studentled demonstrations one student demon strated while the teacher provided guidance and feedback.Peerled demon strations was characterised by peers providing feedback during or after a student demonstration.Demonstrations were reported to be valuable as they helped students to think creatively and imaginatively by assisting reasoning.Student 4 stated: "Demonstrations help me to think out of my boxes of theory and practical.They help me to mix my boxes of different subjects, thus integrating theory with practice." Table 2 and 3. Demonstrations of patient management, collaborative discussions between the student, clinical teacher and peer group, feedback on various learn ing aspects, and mock assessments were all confirmed to enhance the learning process.There was some uncertainty about the learning value of peer assess ment and self assessment.These teach ing and learning activities, with their key themes are elaborated on in the section below to explore how they influenced the learning process.
The themes presented in Table 2 are intertwined within the creation of an optimal learning environment, as summarized in Table 3. Students consistently reported their best clinical learning experience as occurring in clinical placements where an open, relaxed atmosphere existed between students and the clinical teacher, and where the students felt free to ask questions and make mistakes.The attributes and roles of the clinical teacher were reported to play a key role in the creation of an optimal learning environment.The participants reported that the clinical teacher can create an optimal learning environment by being enthusiastic, approachable and flexible with regard to learning opportunities (Table 3).Students appreciated diverse sources of information, indicating that Teacher 5: "A mock test teaches students how to approach the assessment situation and alerts the student to assessment criteria." Mock tests prepared students for the final clinical competence assessment as it promoted discussion and guided remedial action without the pressure of a 'real' assessment.

DISCUSSION
This paper presents information which elaborates on teacher and student per spectives on strongly valued elements that produce clinical learning.The findings suggest that quality clinical education is dependent on planning learning carefully to incorporate par ticular teaching and learning oppor tunities.Key factors that play a role in the creation of an optimal learning environment were found to be teachers' attributes and key teaching and learning opportunities (demonstrations of patient management, discussions, feedback and formative assessment).
The processes of performing a demon stration and receiving/giving feedback through discussion were central to facilitating learning in this context.

Feedback during/after demonstration of patient management
Feedback during or after demonstrations was identified as providing direction to a student's development.Feedback was considered important in terms of it's content, the manner in which it was given, and it's timing.The follow ing quotes illustrate that the nature of feedback played a role in the way it was perceived.
Student 4: "If feedback is given immediately, you can apply it immediately, or immediately adapt your technique.

Constant interruptions during my demonstration disturb my thoughts and concentration."
Student 1: "Feedback can be given any time during the demonstration, depending on how it is given.If feedback is given in an unnerving manner, it makes me uncomfortable and nervous." The relationship between the student and the clinical teacher influences the way feedback is interpreted.The comments below highlight the need for feedback to be immediate, specific, appropriate, empathic, and accompanied by advice.
Student Clinical teachers confirmed the value of studentled demonstrations as providing opportunities for needs analysis, clinical reasoning and the development of communication skills, substantiated by the quotes below: Teacher 2: "It provides the opportunity for the teachers to identify students' strengths and limitations and to provide feedback on the students' clinical reasoning and performance of techniques." Teacher 3: "It develops communication skills, as students are required to present information and reveal their thought processes to others while they are demonstrating.When students give a demonstration, they are being prepared for communication with colleagues and patients." Students preferred studentled demon strations rather than peer led demonstrations.However, they acknowledged the value of peer led demonstration as follows: Student 4: "I was able to identify others' mistakes, which helped me to realize that I often make the same mistakes." Despite the many positive contri butions from peer observation, students, as observers, admitted that they were unwilling to comment on the clinical performance of other students.Clinical teachers agreed with this notion.
Student 3: "It is difficult to judge peers.I find it difficult to be objective.I am careful, in case I offend them.There has to be a well thought through process to manage peer observation and feedback."well as more diverse teaching and learn ing opportunities.The gender bias in this study is highlighted.The value of self assessment and peer assessment also warrants further research.The study only focused on teaching and learning opportunities, whereas a more holistic study that included factors related to personal and professional development is recommended.

CONCLUSION
The study confirms that clinical place ments offer a rich opportunity for stu dents to learn.Clinical teachers played a central role in facilitating students' learning by addressing clinical, theoreti cal and social constructs that are present when providing patient care.Students' learning experience is strengthened by a supported learning environment that is enriched with visual and cognitive modelling.

FUNDING
The Fund for Innovation and Research into Teaching and Learning, Centre for Teaching and Learning, Stellenbosch University, South Africa.
Hewson and Little (1998) found that the way in which feedback was given strongly affects students' perceptions of it's helpfulness.
Discussion between teachers and stu dents occurred as part of demonstrations, feedback and formative assessment.The learning value of discussion was centred on facilitating understanding, clinical reasoning, decision making and communication between participants.Discussion may also facilitate learning trough reflection and selfassessment.These findings concur with the views of Gross Davis ( 2001), who argues that through discussion, students gain practice in thinking through problems, organising concepts, formulating argu ments and counterarguments, evaluating the evidence for their own and others' position, and responding thoughtfully and critically to diverse points of view.Babyar et al. (2003) found discussion to be the most effective activity to facili tate clinical reasoning for physiotherapy students.
Mock assessment was valuable as it encouraged learning, promoted self evaluation and improved the quality of teaching.Robertson et al., in McAllister et al (1997) supports this notion.Formative assessment with feedback is supported as a reinforcement strategy for learning (Torre et al. 2006).Mock assessment could be a useful strategy to drive learning in the process of develop ing clinical competence by combining it with feedback and discussion.
The findings of the study indicate that a structured clinical education program, that include the teaching and learn ing activities as discussed above could ensure quality in clinical education.Clinical teachers play a powerful role in facilitating clinical learning and thus need to be supported in this role.
There are several limitations to this study which could impact the inter pretation of findings, as well as their generalisability.Participants in the study could only reflect on learning oppor tunities to which they were exposed to, and study findings can only be general ized to similar contexts.Future research could include a greater number of phy siotherapy schools to produce a more varied student and teacher population, as Demonstrations of patient manage ment provided opportunities for colla borative learning, the provision of feedback, facilitation of clinical reasoning and problem solving to integrate theory and practice.The importance of the teacher as a role model and facilitator of learning was underpinned by these findings, espe cially as they relate to the cognitive, affective and physical skills that are inherent to physiotherapy practice.Students expressed the view that they learn from observing the teacher and even more so when the teacher verbalized their cognitive processes.Learning by observation is supported by the social cognitive theory and behaviourist theory of learning (Schunk 2004).Clinical reasoning is apparently facilitated when clinical teachers explain their thought processes while performing demonstrations.This con cept was termed by Meichenbaum as cognitive modelling (Meichenbaum, 1977in Schunk, 2004).Students are thus developing their learning poten tial when interacting with a more knowledgeable other (the teacher).
The range of roles played by the teacher highlights the complexity of the interaction between student, patient and teacher in the clinical setting.The rich and complex clinical environment is worthwhile for learning as it requires integration of theory, practice and social skills.The unique and challenging learn ing experience that clinical environments offer is recognized by Cross (1995) and Baldry Currens and Bitchell (2003).
The interpretation of feedback was found to be influenced by the relation ship between the student and clinical teacher.A relaxed learning environment facilitated the interpretation of feedback.This is congruent with humanistic theory (Best et al., 2005), and is confirmed by Williams and Webb (1994) who found that a personal relationship with a clini cal teacher who demonstrates empathy, encouragement and care, assisted learn ing more positively than other teacher attributes.Clinical teachers need to be aware of the powerful learning effect that feedback has, if provided appro priately in terms of it's content, timing and the manner in which it is given.
Clinical education forms a core component of the training of physiotherapy students.Little research on the efficacy of commonly used physiotherapy clinical learning and teaching opportunities are available.
clinical learning/teaching session (story or incident) OR Describe your ideal clinical learning/teaching session (story or incident)

KEY WORDS: BEST PRACTICE; ClINICAl TRAININg/EDUCATION; PHYSIOTHERAPY; TEACHINg AND lEARNINg. Ernstzen DV, BSc, MPhil 1 Bitzer E, D Ed 1 Grimmer-Somers K, PhD 2 et
al. 2007 and Rushton and Lindsay The results indicated that learning is best facilitated in open, relaxed environments.Demonstrations of patient management by teachers and students, discussion of patient cases, feedback and formative assessment were identified to be effective strategies to enhance development of clinical competence.Conclusion: Clinical education, using focused and structured processes, could ensure that students are exposed to a range of learning opportunities for development of clinical competence.