EXPERT OPINION: Clinical Education In Physiotherapy - PROF.LATA SHROFF

Physiotherapists work in a health care climate of rising complexity and rapid change, of economic restraint and demands for accountability, of scrutiny from both internal and external sources. In such a climate, the ability to respond appropriately to these pressures is critical, not only for professional growth but also for professional survival. New generations of physiotherapists emerging from professional programs require more than a solid foundation of clinical skills. They require an educational foundation that is reinforced with attitudes and skills that will enable them to build their profession as well as their own professional practice. These attitudes and skills are believed to include the desire to engage in lifelong learning and professional growth and an ability to identify and critically evaluate their own practice and the underlying theories and perceptions that inform the practice of physical therapy. This article focuses on several aspects of clinical education process in physiotherapy, including its need and importance in the current context.Clinical Education is important in preparing Physiotherapists for working with patients and it has long been recognized as a necessary part of Physiotherapy education.

 In 1968, Callahan et al. stated that the purpose of clinical education was to:

1) Build bridges between theory and practice 2) Assist the student to correlate clinical practices with basic sciences;3) Acquire new knowledge, attitudes and skills 4) Develop observational skills,5) Evaluate , to develop realistic goals and plan effective treatment programs; 6) Accept professional responsibility with accountability; 7) Maintain a spirit of inquiry and 8) Develop a pattern for continuing education.

Clinical education incorporates both affective and psychomotor learning objectives: Historically, clinical education has occurred in settings in which administrators, directors, educators and, most importantly, Physiotherapy teachers have been willing to provide it. In India, Physiotherapy colleges have mushroomed recently most of the Physiotherapy institutes have a memorandum of understanding signed with various hospitals for clinical exposure / education. This probably is a factor that is regulated. Also Physiotherapy clinical education has moved from hospitals’ to a variety of community-based centers, including outpatient health care facilities, district hospitals, clinics, industries, geriatric  homes, occupational environments, sports and schools/ colleges  etc.The modern teaching hospitals also have large exclusive intensive care units where Physiotherapy students have short-term access to critically ill patients who only represent a small portion of the total spectrum of Physiotherapy practice. Students get a fuller view of the quality of life of a patient when the patient is seen not only during acute illness requiring hospitalization but also in outpatient clinics where patients are treated for movement related disorders that impact everyday activities. In addition, nowadays Physiotherapists work with individuals to prevent the loss of mobility before it occurs (Health Promotion) by developing fitness and wellness-oriented programs for healthier and more active lifestyles, providing services to individuals and populations to develop,  maintain and restore maximum movement and functional ability throughout the lifespan. The spectrum of clinical experiences that a student thus can have is tremendous.

Theoretical knowledge and fundamental skills taught in the Physiotherapy classroom and laboratory may be actually a patient problem orientation, but students rarely, if ever, learn the clinical context until their first clinical experience. According to Dr. Scully & Shepard the clinical teaching situation has organizational and human factors that influence the type, quality, and quantity of the student learning. Organizational factors are primarily ground rules that emanate from academic programs, health care institutions, and the Physiotherapy departments within those institutions. The human factors are the perspectives Clinical Teachers hold and the level of professional maturity students bring to the clinical setting. The number of students, the level and quality of their training, their part-time or full-time assignments to clinical settings, and the time of year and length of these assignments, the distance between clinical treatment areas, the total number of patients, fluctuation of patient load, availability of patients during scheduled treatment times, and the complexity of evaluation and treatment programs all influence clinical education.

There is overwhelming agreement in the literature regarding the value and importance of clinical education in Physiotherapy and other allied health programs. Although the importance of clinical teaching is universally acknowledged in the health professions, little formal training is offered to prepare practitioners for this important role. What does a student need to know on day one of a clinical learning experience? What is best taught in the classroom or the laboratory? What is best learned during a clinical education experience? All these are prerequisites to clinical learning. Lifelong reflective practice is a hallmark of professional behavior. With so much to learn in the brief periods of clinical education, it is important to plan how does a student begin this endeavor?  In our institute we have laid down objectives of different clinical areas, for different years of Bachelor of Physiotherapy program, as also of the Master of Physiotherapy. The first day of any new experience can be overwhelming therefore a well-planned orientation session is conducted, that introduce the student to necessary details both faculty and infrastructure and provide pragmatic information the student needs. The student's are not only informed of the specific goals and objectives pertaining to their respective year, but are also made to note the same in their daily assessment books.  There is a pre decided list of skills that the students learn.

Clinical learning is enhanced by interactions, teacher can yield information on matter learned in a classroom lecture, a text, or a previous clinical education experience this provides the clinical teacher with an understanding of the gaps in the essential knowledge of the student. The student may be asked to perform simple translations to the patient for e.g. explaining to the patient how low hemoglobin levels could affect his endurance, this enhances communication skills, explaining about ultrasound / interferential therapy to a patient gives an opportunity to a student to practice his / her classroom knowledge in to clear, concise and understandable terms for a patient.  The student further is made to participate in listing problems reaching a PFD, Physiotherapy diagnosis is very different from the medical diagnosis as it examines the actual physical & functional deficits / dysfunction that may have resulted from the disease / disorder / condition / trauma. Problem solving and clinical decision making are challenges that the student progressively takes.In India, still the concept of diagnosis before the thought of which modality is to be used to treat is yet to be engrained in the mindset of many physiotherapists. Clinical education has also been defined as the transfer of abilities, ideas, and beliefs from instructor to student through the direct interaction with patients. This definition emphasizes the importance of the role of the Clinical teacher. There is a relatively large amount of literature outlining effective and ineffective characteristics of the clinical educators. Essentially, the Clinical teachers are responsible for the construction of an environment in which the learner applies and integrates previously acquired information (Jody Shapiro Gandy, PhD, PT).

Clinical learning experiences or problems need to be selected based on the potential they provide for useful learning. General guidelines for the selection of clinical learning experiences must acknowledge that students need to learn routines and standards before they develop creative alternatives. Repeated actions over time will enable students to look for patterns, develop hypotheses, and learn to respond to the unexpected. Once the pattern of learning is established, challenge the known and dare the student to stretch beyond his or her comfort zone. A student with more advanced knowledge and skills may be asked to focus on a different learning experience with the same patient. Supervision includes monitoring a student's performances, providing supportive guidance, and directing instruction. Supervision should focus on encouraging independence and professional initiative in the broadest sense of patient care, while minimizing risk to patient and student. The purpose of evaluation is to measure performance, enhance attainment of goals, and minimize risk to patients. Formative evaluations need to occur throughout the learning experience as a continuous part of clinical teaching.It is imperative that the student learns to accurately self assess his or her capabilities and areas that need improvement. It is important for students to learn that professional development includes ongoing self-assessment and reevaluation followed by defining new goals targeted at enhancing knowledge and skills. Learning is a lifelong process that continues throughout clinical practice.

Students are often required to keep a daily assessment book, logbook / journal or may be asked to present a live case report as an in-service educational program during their clinical experiences.Explicitly defining the desired outcome for each clinical experience will dictate the appropriate timing in the curriculum, the duration of the experience, the type of setting, and the qualifications of the clinical teachers.  The expected outcome for any clinical education experience is formally defined by the academic program. Ultimately, however, the goal of clinical learning is for the student to progress from assisted to self assisted, supervised learning to independent, while developing patterns of learning that form the basis for a lifelong, reflective practice.Physiotherapists examine, assess, evaluate, plan, and treat. They observe, palpate, stabilize, assist, resist, mobilize, facilitate, and inhibit. They teach, motivate, simplify, and modify. Skilled performance of these actions comes only with practice, development, and refinement. Physiotherapy is a service-oriented profession. Clinical education occurs in settings where patients come to receive care. Patients are not exhibits who give time and money to come to a clinic to provide an example of a diagnosis for a student. They are real people with movement dysfunctions that limit their ability to live their lives the way they would choose. Students must learn what it means to provide service.In India we have number of Physiotherapy institutes, every year thousands of students qualify as Physiotherapists, many these days are with post graduate degrees, it is unfortunate however that as a recruitment policy of our institute when we assess clinical skills, our experience does not make us proud of what we see. We sometimes wonder whether Physiotherapists speak a common language.The current challenges facing the Physiotherapy profession are  meeting patients' needs, professional standard setting, measurement of health care outcomes, audit, research and development, the education of staff / faculty, organizational restructuring, re profiling, resource management and contracting.

Another challenge in Physiotherapy practice is addressing the needs of diverse patients/clients in response to known health disparities within our healthcare system. The profession needs to continue to work to increase the number and diversity of qualified applicants to Physiotherapy programs as well as further expand the number and diversity of qualified academic faculty and clinical educators who serve as role models and mentors for future Physiotherapists. 

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