Enhancing Clinical Education in Physiotherapy: Students' Perceptions of Effective Teaching and Learning Opportunities – Prospective Cross-Sectional Study

Download PDF Article Download Graphical Abstract Enhancing Clinical Education in Physiotherapy: Students' Perceptions of Effective Teaching and Learning Opportunities – Prospective Cross-Sectional Study Abstract The study examined final-year physiotherapy students’ perceptions of effective teaching and learning opportunities and the roles and attributes of clinical teachers during clinical education. Conducted at the Faculty of Health Sciences, University of Ljubljana, Slovenia, the study used a culturally adapted, structured questionnaire based on validated instruments. Students identified demonstrations, feedback, and discussion as the most valued teaching and learning opportunities. Clinical teachers were mainly seen as knowledge providers, feedback givers, and role models. Key personal attributes included communication skills and approachability. The findings underscore the importance of standardised training for clinical teachers to promote consistency and enhance the quality of clinical education. Keywords physiotherapy, clinical education, teaching and learning opportunities JEL Classification I20, I21 1. Introduction Clinical education is a cornerstone of physiotherapy training, offering students the opportunity to integrate theoretical knowledge with hands-on skills in real healthcare settings. This experiential component is vital for developing competencies required for independent clinical practice. Unlike classroom-based learning, clinical placements focus on patient care, which can sometimes conflict with or overshadow educational objectives (Ernstzen et al., 2009). The variability and unpredictability of clinical environments pose challenges for providing consistent learning experiences and achieving equitable outcomes for all students (Rindflesch et al., 2009). To address these challenges and support continuous quality improvement in physiotherapy education, the present study investigates final-year physiotherapy students’ perceptions at the Faculty of Health Sciences, University of Ljubljana (FHS UL). Specifically, it explores the most effective teaching and learning opportunities (TLOs) and the roles and attributes of clinical teachers that support student learning. The goal is to inform institutional strategies to systematise clinical education and align it with evolving professional standards. 2. Literature Review Recent changes in educational philosophy have emphasised constructivist and student-centred approaches, adding complexity to the landscape of clinical learning. These models assume that students construct their own understanding, and that learning is most effective when students are involved in goal setting, reflection and decision making (Lee & Hannafin, 2016). In clinical contexts, this requires educators to transition from traditional instructors to facilitators who support students’ self-directed learning and professional growth (Milanese et al., 2013). However, for this model to succeed, students must possess or be supported in developing metacognitive skills to manage the complexities of clinical practice (Fewster-Thuente & Batteson, 2018; Nagel et al., 2024). A stable and effective clinical learning environment is shaped by multiple interrelated factors, including the quality of TLOs, clinical teachers’ roles and attributes, patient involvement, institutional support, and assessment models (O'Brien et al., 2020). Among these, the pedagogical competence of clinical teachers and the availability of meaningful learning opportunities are consistently associated with student satisfaction and learning outcomes. Yet, the absence of standardised guidelines and limited educational training for clinical teachers often lead to inconsistent experiences and varied educational quality (Van der Hem-Stokroos et al., 2005; Robertson et al., 2003). Previous researchers found that the attributes of the clinical teacher and the relationship between the student and the teacher have a powerful effect on learning (Kilminster & Jolly, 2000). Attributes such as approachability, enthusiasm, communication skills and the desire to share knowledge have been identified as important attributes for clinical teachers (Bennett, 2003; Ramakrishnan & Bairapareddy, 2022). Behaviours such as being a competent physiotherapist, being available, answering questions without belittling the student, and providing useful and constructive feedback were perceived by students as the most effective clinical teaching behaviours (Ernstzen & Bitzer, 2012). The aim of the study was to find out what final year physiotherapy students enrolled at the FHS UL in Slovenia consider to be effective teaching and learning opportunities during clinical education and what they consider to be the role and attributes of an effective clinical teacher. 3. Methodology The cross-sectional study design was used as it is suitable for this research as it allows the collection and analysis of data from a defined population — final year physiotherapy students enrolled at the FHS UL in Slovenia for the academic year 2021/2022 — at a single point in time. As all participants had completed their clinical placements at the time of data collection (March to April 2023), this design allows for the systematic assessment of the variables of interest in a stable and comparable context. The clinical placements were completed in August 2022, and the data collection was conducted in March and April 2023, approximately 7 to 8 months later. This timeframe was considered appropriate as students could still clearly recall their clinical placement experiences in relation to the study objectives. Physiotherapy students at the FHS UL complete around 700 hours of supervised clinical training in various healthcare facilities. Training takes place in small groups (one mentor per three to five students) under clinical mentors who are experts in their respective fields and ensure both high standards of training quality and student and patient safety. After each clinical module, students submit a written report which is assessed by their mentor. Cross-sectional designs are particularly suitable for the evaluation of outcomes that do not require follow-up over time. It also ensures the feasibility and efficiency of data collection while maintaining relevance to the study objectives. Importantly, the homogeneity of the cohort (i.e. students at the same stage of their academic career) also minimises confounding due to differences in exposure or duration of education, thereby increasing the internal validity of the results. A self-administered, structured questionnaire was used for data collection, based on a questionnaire used by Milanese et al. (2013) and Ernstzen et al. (2009) in studies on physiotherapy students' perceptions of effective practices for teaching and learning in the clinical setting. The survey was administered in Slovenian. Before translating the questionnaire into Slovenian, we obtained permission from the authors Ernstzen et al. (2009) of the original questionnaire to use the questionnaire and adapt it to our context. The translation process of the original questionnaire from English into Slovenian followed the recommendations of Squires et al. (2013), which consider cross-cultural aspects of translation, where questions, expressions and concepts from the source culture (English) are carefully adapted to the target culture (Slovenian), considering the specific characteristics of the Slovenian language, cultural norms, values and context. The translation process was completed before data collection began. Ten participants evaluated the suitability of the content of the questionnaire in the pilot study and rated its main features, including clarity, simplicity, conciseness and time required to complete the questionnaire, on a scale from 1 (strongly disagree) to 5 (strongly agree). The average rating for clarity was 4.6 (±0.5), for simplicity 4.4 (±0.7), for conciseness 4.6 (±0.52) and for time required 3.8 (±0.63). Following minor adjustments based on the pilot testing, the internal consistency of the Slovenian version of the questionnaire was assessed using Cronbach’s alpha coefficient. A threshold of α ≥ 0.70 was considered indicative of acceptable internal consistency. The results showed good internal consistency (α = 0.85), indicating good reliability of the measurement instrument. The questionnaire asked for basic demographic information (age, gender) and specific questions about their clinical placements. From the fifteen TLOs listed in the questionnaire, students selected the five most important ones where they learnt the most. Of the ten roles that are most important to the clinical teacher and the twelve characteristics of the clinical teacher that students consider necessary for optimal learning that were listed in the questionnaire, students selected the five most important. An electronic version of the questionnaire was sent to final year students via the website MojaAneketa.si.web. Before completing the questionnaire, all participants were informed of the following: the purpose of the survey, the voluntary nature of participation, the anonymity of responses and the fact that the data collected will only be used for professional and scientific purposes and/or for publication in scientific journals. Completion and submission of the questionnaire signified informed consent. Collected data were entered into Microsoft Excel spreadsheets and analyses were performed using IBM ® SPSS Statistics (v22) (Armonk NY, US). Descriptive statistics were calculated to describe the demographic data, including frequencies and percentages for categorical variables and mean and standard deviation (SD) for continuous variables. Ethical approval for the study was granted by the Dean of the Faculty of Health Sciences, University of Ljubljana (approval no.: ZF DEK 469/2023, 9 February 2023), who confirmed that the study met institutional ethical standards. 4. Results and Discussions Of the total number (n = 76) of students enrolled in the final year of the 2021/2022 academic year at FHS UL, 46 students completed the questionnaire in full during the study period (response rate of 61%). Among the participants were 36 female and 10 male students with an average age of 22.7 years (range 22–29 years). The perceived learning values of the different TLOs are shown in Table 1. The most five useful domains for providing TLOs to students were demonstration of patient management, followed by feedback and discussion with the clinical teacher, clinical tasks and one-to-one teaching. Teaching and learning opportunities/ activities Percentages and (number) of students who selected the activity Demonstrations of patient management 93% (43) Feedback 85% (39) Discussions with the clinical teacher 76% (35) Clinical tasks 41% (19) One-to-one learning sessions 37% (17) Reflection 28% (13) Discussion with peers 26% (12) Group-learning sessions 22% (10) Learning on own 22% (10) Mock assessment 17% (8) Coaching 17% (8) Questioning 13% (6) Peer assessment 9% (4) Lectures 7% (3) When learning is facilitated 4% (2) Other 2% (1) Table 1. Students’ views on teaching and learning opportunities/activities where students learn the most The participants were asked to choose what they considered to be the most important roles of the clinical teacher. The results are shown in Table 2. From the results of the questionnaire, the five most important roles of the clinical teacher were selected: Reflector/feedback provider, knowledge provider, mentor, demonstrator of techniques and counsellor. Clinical teacher role Percentages and (number) of students who selected the role Reflector/feed-back provider 93% (43) Knowledge provider 91% (43) Mentor 89% (41) Technique demonstrator 80% (37) Counsellor 70% (32) Role model 35% (16) Assessor/Evaluator 15% (7) Facilitator of learning 13% (6) Questioner 9% (4) Friend 4% (2) Other 0% (0) Table 2. Clinical teacher role In this study, students identified the communication skills of the clinical teacher as the most important attribute that contributes to effective clinical education. Other highly valued attributes were the teacher’s respect for students and overall responsiveness. Conversely, the lowest rated attributes were the clinical teacher’s enthusiasm, listening skills and confidence (Table 3). Clinical teacher attributes Percentages and (number) of students who selected the attribute Good Communication 89% (41) Respects the student 78% (36) Approachability 72% (33) Shows concern for student 61% (28) Supports the student 59% (27) Organised 37% (17) Not prejudiced 35% (16) Gives recognition for student abilities 33% (15) Interpersonal skills 17% (8) Enthusiasm 11% (5) Listener 4% (2) Self-confident 4% (2) Other 0% (0) Table 3. Clinical teacher attributes The aim of this study was to explore physiotherapy students’ perceptions of teaching and learning activities within clinical education, with particular focus on their views regarding the key roles and characteristics of clinical teachers. Among the various clinical TLOs, students identified the clinical instructor's demonstration of patient management as one of the most valuable components of their clinical education experience. These demonstrations typically involve the teacher going through patient management step by step and illustrating each phase of the process. This includes reviewing the patient's chart, conducting the interview, planning and performing the physical examination, and implementing appropriate treatment strategies. Such demonstrations can help students understand how to initiate the process of patient care, identify key assessment points, and develop clinical decision-making skills (Stoikov et al., 2022). Observing the teacher can be considered learning by observing, while imitating the process is learning by doing (Yardley et al., 2021). Furthermore, teacher-led demonstrations can be more than just a passive experience; they can actively engage students and support deeper learning (Illing et al., 2019). Another important teaching and learning opportunity identified in this study was the provision of feedback. In line with the literature, feedback is widely recognised as a crucial component of clinical education (Allen & Molloy, 2017; Wijbenga et al., 2019). For feedback to be effective, it must be clear and unambiguous and allow students to recognise their errors and opportunities for improvement (Kilminster et al., 2007). The findings of this study are consistent with those of Mann et al. (2022), who emphasise the role of constructive feedback in enhancing students' self- confidence and promoting positive student–teacher relationships. The majority of students identified discussions with the clinical teacher as a particularly valuable TLO. Participation in case-based discussions, particularly those centred on specific patients (McDevitt et al., 2024), was found to significantly enhance learning by encouraging active cognitive engagement. Such discussions encourage students to develop clinical reasoning, synthesise and organise information, critically evaluate evidence and articulate and challenge different (Milanese et al., et al., 2022). As a of learning, discussions deeper and reflection through the of and promote both and clinical decision-making skills et al., 2022). The by the physiotherapy students in this cohort on TLOs such as and can be to These activities are not to real patient care, which lead students to as or to clinical practice. 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