Exploring student fitness to practise in physiotherapy--strategies from the coalface.
In Australia, physiotherapy students are supervised by clinical educators who are usually clinicians working in health services. In some parts of New Zealand these clinicians are known as clinical supervisors. For consistency, we will use the Australian term in this paper.
Health professionals including clinical educators experience distress and challenges to personal wellbeing (Balogun et al., 2002). Wellbeing is recognised as being mentally challenged, enjoying work and achieving success in one's personal and professional life (Shanafelt and Dyrbye, 2012). Student fitness to practise (FTP) issues have been found to impact on clinical educators' wellbeing (Lo et al., 2017a). According to Parker (2006) FTP issues are those that impact on clinical competence, physical and/or mental health and professionalism.
Student FTP issues also impact on clinical educators' work satisfaction. Of a sample of 75 clinical educators, 83% reported that physiotherapy student FTP issues affect their work satisfaction (Lo et al., 2017a). This is due to time pressures, lack of appreciation and quality of care conflict. Quality of care conflict describes how an educator balances allowing students to learn or gain independence while maintaining effective treatments for clients (Lo et al., 2017a).
The more generalised underperforming student is also a source of educator stress. When supervising underperforming students, Bearman and colleagues (2012) found that physiotherapy clinical educators tend to provide more of the same strategies and more of themselves. This can further impact on educators' wellbeing.
The study of the value of students in the workplace has focused on the benefits of improved staff recruitment and creation of a 'learning environment' (Baldry Currens and Bithell, 2000). However, with current demands on the healthcare system and workforce shortages, there are concerns about the impact of student supervision on service productivity and clinician burnout.
Burnout is characterised by a state of emotional, mental, and physical exhaustion combined with reduced personal accomplishment caused by prolonged stress (Maslach and Jackson 1981). In a sample of 66 newly graduated physiotherapists, 60% showed moderate to high levels of emotional exhaustion (Scutter and Goold, 1995). This study showed that physiotherapists within the first five years after graduation demonstrate higher levels of burnout than those with a longer history of work. However, this is not necessarily attributable to student supervision (Solowij, 1995). Some literature exists regarding strategies to improve burnout and improve self-care in health practitioners (Skovholt and Trotter-Mathison, 2014). One strategy that has been helpful is the support offered by university academic staff with nursing preceptors more likely to supervise students in the future if academic support is provided (Luhanga et al., 2008a). Another example is the model of education at the University of Otago which involves experienced clinicians employed by the University making weekly visits to students while they are on placement (Higgs, 2017). A further strategy shown to improve clinician wellbeing is mindfulness, the quality of being attentive to the present moment (Krasner et al., 2009).
The key reason for the present study was to elucidate academics' and clinical educators' perceptions of supporting students with FTP issues. The research question to be answered was "How do we support the supervision of students with FTP issues more effectively?"
Data were collected on two separate occasions. The first was at an Australian Physiotherapy Association conference session in 2013. The second was at a meeting of physiotherapy Clinical Education Managers from Australia and New Zealand (CEMANZ) held in 2015. Ethics approval was granted by Monash University Human Research Ethics Committee, approval number CF10/1321 - 2010000703.
A qualitative design was used to gather information on participants' perceptions of FTP.
The conference session was a Personally Arranged Learning (PeArL) Session entitled 'Supervising students with fitness to practise issues--how do we support clinicians more effectively?'(Lo et al., 2013). The PeArL session was 45 minutes in duration with the presenter and participants considered equals discussing common problems. The initial presentation was approximately 5 minutes duration including three slides. The remainder of the session was a facilitated discussion framed around three challenging questions that the presenters were grappling with. Attendees at this session included tertiary education providers from physiotherapy programmes and physiotherapy clinical educators.
The lead author was invited to a Clinical Education Managers from Australia and New Zealand (CEMANZ) meeting as part of a FTP discussion. A component of the agenda included a one hour focus group on student FTP. The author presented some information on the current research on FTP (Lo et al., 2017b, Lo et al., 2014, McGurgan et al., 2010, Parker, 2006) but was particularly interested in finding out how participants perceived FTP. In order to facilitate discussion about FTP, participants were asked two focus questions: What do other universities do? and What needs further work? The CEMANZ meeting included approximately 20 physiotherapy clinical education managers from tertiary institutions across Australia and New Zealand. The clinical education managers are university staff who oversee and organise clinical placements.
All PeArL participants were provided with an explanatory statement about the project and asked to contact the lead investigator if they did not consent to the data being used for research purposes. Our ethics approval allowed us to use de-identified written, audio and video data recorded in this session. In a facilitated discussion participants were asked to respond to three questions: 1. What strategies support clinical educators' wellbeing when managing students with FTP issues? 2. How can we create a culture that is supportive of clinician wellbeing? 3. What can educators do in their daily practice to support their wellbeing?
Written notes were used to record the content of the PeArL session. The notes were recorded by one researcher (HC) as the session was conducted. These were verified by another researcher (KL) at the end of the session. Participants were provided with an opportunity during the session to view the notes and suggest corrections for inclusion to minimise interpretive bias.
Approval was also granted to use de-identified written, audio and video data recorded at a CEMANZ meeting in Queensland, April 2015. Consent was gained from all meeting attendees prior to the commencement of the meeting by either an electronic consent form or a paper-based form for those who had not given prior consent. Due to an error in the audio recording, written notes were recorded by a researcher (KL) and verified by attendees. These notes were used to record the outcomes of this meeting. We were therefore unable to transcribe written quotes to illustrate points made in this meeting for the purpose of this paper.
The qualitative data were summarised independently by two researchers. There was a period of consensus to determine whether the summaries reflected the clinical educators' and physiotherapy tertiary education representatives' key messages. Data were then recoded independently by both investigators (HC and KL) and analysed into the themes using the thematic analysis process described by Braun and Clarke (2006).
Strategies to support clinical educators
Australian Physiotherapy Association conference 2013 PeArL session
1. What strategies support clinical educators' wellbeing when managing students with FTP issues?
The following themes were identified from participant discussion:
Types of FTP issues: Educators discussed that students with clinical competence issues were not so difficult to manage. Educators felt that mental health issues were much more challenging to ascertain and manage, particularly if undisclosed.
Support: Educators stated that staff members needed some peer-support / advice. Supportive relationships with the university were helpful, involving good links to key people in the tertiary education sector. These faculty members act like a mediator.
Feed forward information: Handovers to feed forward information and openly disclose issues were helpful to address factors such as anxiety.
Early identification: Early identification was highlighted as a very useful strategy. This needed the support of senior staff and structures in place to reduce angst in junior educators.
Too much care: A question was posed, whether educators care too much due to the caring nature of the profession. Participants wanted advice as to where to draw the line as often students were kept closely supervised when there were issues. Educators were not sure when to let students out of their reach. Educators asked "Is it a clinician's responsibility to get students over the line?" The consensus was that seniors helped advise less experienced educators. However the main consideration is to provide a clinical placement with no expectation to pass the student. There were comments about physiotherapists having to work out their educator identity, many said they used their nurturing nature to benefit the student. There were discussions on the importance of autonomy, role definition, and boundaries for the clinical educators.
Labelling difficult students: There were concerns about labelling or defining the difficult student and whether there may be associated FTP issues present.
Educator preparation: There were also concerns regarding the education of junior staff who are often perceived to be "thrown" into the educator role with limited to no preparation.
It was also noted that educators themselves may not be fit to practise.
2. How can we create a culture that is supportive of clinician wellbeing?
From this question arose the following themes:
Workload: 12 weeks of supervising students leads to exhaustion and there may be a need to change the continuous load on educators over this prolonged period. The importance of giving staff breaks was highlighted, as was the importance of teamwork.
Peer-learning: There were discussions about the positive aspects of peer-learning and that there were benefits in having two students on placement at a time. This enabled students to talk and provide support to each other independent of the supervisor. This also gave the supervisors a break.
3. What can educators do in their daily practice to support their wellbeing?
Regular breaks: There was a need for structured downtime or strategic breaks to rejuvenate educators. This included strategies to help them have time to eat each day and do their other administrative and clinical tasks.
Strategies of relevance to university staff in supporting students
CEMANZ meeting, Queensland, April 2015
"How do we support the supervision of students with FTP issues more effectively?"
The following themes arose during this meeting to answer this question.
1. What do various universities do?
Inherent requirements: Inherent requirements are the components of a course/unit that are seen as essential skills to achieve the core learning outcomes of the course/ unit. The University of Sydney has a list detailing the inherent requirements of the physiotherapy course including communication, observation and sensory tasks, physical and intellectual tasks and interpersonal and social interactions (The University of Sydney, 2014a). For students with physical, intellectual, cultural, religious or other factors that impact on their ability to meet these requirements, the University will make reasonable adjustments to help support them. These inherent requirements are made transparent to both prospective and current students thus enabling students to make informed decisions about the course and their associated career path. Monash University also have a "Practical Considerations for Clinical Components of the Bachelor of Physiotherapy Degree" document that has a list of the physical, mobility, mental and emotional requirements of the course. This encourages students to self-declare whether they wish to discuss any FTP issues with an academic staff member (Lo et al., 2017b).
Registering practitioners was also discussed. All students are required to apply to the Australian Health Practitioner Regulation Agency (AHPRA) to register as a health practitioner. Universities must submit the details of any students that are eligible for graduation to the AHPRA board. Thus, once the course requirements are fulfilled, students are eligible to become primary health practitioners.
Feed-forward information: Students were encouraged to discuss what the issues are and the strategies they have in place.
Additional preparation for clinical placements: Some universities such as Melbourne University offer extra tutorials for atrisk students to help prepare them for clinical placements. Participants then asked "What are the different issues that trigger supports to be put in place in preparation for clinic?" The two main factors specified were learning issues and communication issues, in particular non-English speaking students and students with autism spectrum disorder were referenced. There was a request for discussion and a sharing of any practices that support these particular student issues.
2. What needs further work?
Reporting FTP issues to Australian Health Practitioner Regulation Agency (AHPRA): A question asked by participants was "Can the university report FTP issues to AHPRA?" Australian universities are mandated to disclose issues of student 'notifiable conduct' to AHPRA. A second question posed was 'What triggers initiate an AHPRA report?" Issues of notifiable conduct include:
"Practising while intoxicated by alcohol or drugs, sexual misconduct in the practise of the profession, placing the public at risk of substantial harm because of an impairment (health issue), or placing the public at risk because of a significant departure from accepted professional standards" (Australian Health Practitioner Regulation Agency, 2016).
Specifically, education providers are obliged to report students with an impairment or health issue that may, "Either in the course of study or clinical training, place the public at substantial risk of harm". There was further discussion as to what factors may trigger significant concern requiring further academic intervention. These were considered by participants to be criminal issues and plagiarism and possibly multiple unsubstantiated applications for special consideration for tests or exams. The third item that arose as part of this discussion was the need for mandatory reporting to be a formal step in any FTP policy flowchart.
Learning disabilities: Learning disabilities were specifically discussed with reference to what constitutes reasonable adjustments to support students' learning. It was thought that students need to satisfactorily pass the units but could have supports in place, such as additional time to read notes for those with dyslexia. It was important, however, to note that students must be able to fulfil the duties of a health practitioner on graduation, frequently without these additional supports in place.
Assessment: There was a call for practical exams / Objective Structured Clinical Examinations (OSCEs) to have a component that assesses communication. This may assist in preparing students for clinical placements.
A comparison of the qualitative data from the two discussion groups (PeArL session and CEMANZ meeting) is displayed in Figure 1.
Figure 1. Comparison of data from clinical educators and clinical education managers Clinical educators (PeArL session) FTP issues Support Feed forward Early identification Too much care Labelling difficult students Educator preparation Workload Peer-learning Regular breaks Buddy systems Clinical Education Managers (CEMANZ meeting) Inherent requirements Registration of practitioners Reporting FTP issues Learning disabilities Feed forward Additional preparation for clinical placements Assessment
Participants provided valuable insights into the complexity of physiotherapy student FTP issues. Strategies to enable more effective support in supervising students with FTP issues were discussed.
Strategies to support clinical educators' wellbeing
Educators' comments about mental health issues were supported by Lo and colleagues (2016) who demonstrated that physiotherapy clinicians feel significantly less confident and comfortable managing student mental health issues than problems with incompetent practice. Students and their clinical educators need to have accessible strategies to identify and support student mental health issues. This might include mental health first aid (Bond et al., 2015, Hadlaczky et al., 2014).
The benefits of supportive tertiary staff have been discussed previously. Luhanga et al. (2008a, 2008b) reported that faculty support enabled nursing preceptors to make critical decisions about student progress, and that clinicians may otherwise be reluctant to fail underperforming students (Luhanga et al., 2008b). Preceptors who consider faculty unsupportive or unresponsive may also be unwilling to supervise future students (Luhanga et al., 2008a). Thus faculty need to prepare educators with appropriate orientation, particularly regarding the support of FTP issues. Faculty may also assist educators to process challenging experiences (Kemper, 2007).
The merit of open disclosure of FTP issues has been discussed in the literature (Lo et al., 2016). Student self-declaration is used to institute proactive strategies to support student FTP. There are factors which encourage self-declaration of FTP issues and these are confidentiality, a positive relationship with university staff (i.e. trust, familiarity, rapport), a willingness to help and a supportive environment (Lo et al., 2014). Educators discussed that strategies to feed-forward information and openly disclose issues were helpful to address issues such as anxiety. Educators felt it would be beneficial to make the feed-forward of information compulsory. There are however difficulties with the feed-forward of information due to a creation of potential bias. There are also difficulties associated with a lack of feed-forward of information with the learning approach being fragmented due to a lack of information about students' previous placements (Bearman et al., 2012).
In support of educators' comments that they may be too compassionate due to the caring nature of the profession, it has been found that physiotherapy educators do provide more of themselves when managing the underperforming student (Bearman et al., 2012). It is important for both the health services and the university to be clear about the boundaries of their role with respect to students' wellbeing. The research by Bearman and colleagues (2012) also discussed the phenomenon of the underperforming student being kept closely supervised when there were issues with educators being reluctant to let students out of their reach. There is a balance between facilitating independence and maintaining client safety. In Bearman and colleagues (2012) the minority of educators advocated for shifting the responsibility to the student to encourage them to take ownership of their learning whilst decreasing educator stress. Educators asked "Is it a clinician's responsibility to get students over the line?" The consensus was that senior clinical educators may provide advice to other educators but not create the expectation that the student will pass. Educators' reluctance to fail students is reported in the literature (Dudek, 2005). The reasons for this were identified as a lack of experience as an educator, reluctance to have students incur personal cost, educator feelings of guilt, reluctance to take on the extra workload, a lack of appropriate tools and time for sufficient student evaluation and pressure of perceived staff shortages (Luhanga et al., 2008b). There were comments about physiotherapists "working out" their educator identity, trying to use their nurturing nature to benefit the students. It has been noted that educators' identity is important with self-esteem issues, fear, anxiety and self-doubt occurring as a result of failing a student (Hrobsky and Kersbergen, 2002).
The support of senior staff and structures in place to reduce angst in junior educators was discussed by educators. This has been cited in previous publications which encourage students to be assigned to experienced clinicians to achieve positive outcomes (Kemper, 2007). This however may lead to stress in those repeatedly requested to supervise students. This is noted in comments on the limitations of 12 weeks of straight supervision. There were discussions of the importance of autonomy for the clinical educators. Literature supports that feelings of competence and autonomy relate to both emotional wellbeing (Reis et al., 2000) and job retention (Hanson et al., 1990).
There were concerns about labelling or defining the difficult student. The stigmatisation of students has been discussed previously with educators focussing on the negative aspects of supervising a previously underperforming student (Cleland et al., 2008).
There were also concerns regarding the education of junior staff who are often perceived to be "thrown" into the educator role with limited to no preparation. Orientation is recommended which focuses on preparation of the clinician as an educator (Kemper, 2007).
Strategies that educators can use in their daily practice to support their wellbeing
It was noted that educators may reduce their FTP-related burnout; high prevalence of burnout has been reported in health professionals and professional students (Block et al., 2013, Scutter and Goold, 1995, Sliwinski et al., 2014). Burnout affects the quality of care provided with an associated increase in error rates and lack of empathy (Shanafelt et al., 2010, West et al., 2006).
There were discussions about the positive aspects of peer-learning. The benefits of having two students on placement at a time was that these students could talk to each other and decrease the pressure on the educator. In a randomised controlled trial of peer-learning versus traditional clinical education, educators and students preferred traditional clinical education to peer-assisted learning, despite similar student performance outcomes (Sevenhuysen et al., 2014). There may be a need to educate students and clinical educators further as to the benefits of peer-assisted learning given the on-going pressures to provide clinical education to an increasing number of students.
The necessity for structured downtime or breaks to rejuvenate educators was discussed. An example of this is to use a 4-day per week clinical placement model rather than a 5-day per week model. It is well known that clinical educators are time poor and juggling heavy workloads in both the clinical and educational areas (Bearman et al., 2012). Further workplace incentives such as peer-assisted learning may be required to enable staff to manage clinical education as an ongoing part of their usual workload. Perhaps this could be extrapolated to a buddy system for clinical educators too to support each other.
The strategies universities use
A number of topics arose in the discussions between the university clinical education managers. The first was about inherent requirements, which links to the work at the University of Western Sydney on writing physiotherapy inherent requirement statements. Bialocerkowski and colleagues (2013), writing of their experiences at the University of Western Sydney, expanded upon an existing university approved framework and included items from the physiotherapy professional standards and the statutory requirements. There were eight prescribed domains: "ethical behaviour, behavioural stability, legal, communication, cognition, sensory abilities, strength and mobility, and sustainable performance" (Bialocerkowski et al., 2013). For each domain there was a statement of introduction, description of the inherent requirement, justification for the fundamental nature of the requirement and description of potential reasonable adjustments. These inherent requirement statements were deemed transparent and defensible requirements of physiotherapy study with potential to be transferable across other courses both within and potentially outside of Australia.
Factors that need further work
Where FTP issues arise there is a dual role for educators in providing support whilst being mandated to report more serious health issues that place the public at risk. In the physiotherapy literature, flags of possible FTP issues include clinical competency issues, mental and / or physical health issues, professionalism issues, communication issues and recognition of limits (Lo et al., 2016).
Learning disabilities were specifically discussed with reference to what constitutes reasonable adjustments to support students' learning. The Disability Discrimination Act specifies what adjustments need to be made to policies and procedures to provide fair access to those with disabilities (Turner and Robinson, 2011). These may be supported by university programmes such as additional tutorials for at-risk students. A recommendation suggested by the clinical education managers was to include the assessment of communication in OSCEs.
Some authors recommend narrative feedback to traditional checklist assessments of communication skills in OSCEs (Van Nuland et al., 2012). Early development of communication skills shows stable performance over a period of 18 months following an introductory course (Humphris, 2002), however the duration of the communication course is important with shorter duration courses of two hours being unsuccessful in demonstrating change in dental students' communication skills (Cannick et al., 2007). More comprehensive communication courses are indicated.
This study was a qualitative study of Australian participants attending a 45 minute session scheduled as part of an APA conference and a one hour meeting of 20 Clinical Education Managers from Australia (n=18) and New Zealand (n=2). As the data were gained as part of a conference presentation / meeting, the comments are brief and further examination of themes was limited. Due to an error in the audio recording, written notes were used to record the outcomes of the CEMANZ meeting thus we were unable to include written quotes. It is recognised that the data collected for this paper primarily pertains to Australia as limited New Zealand specific data were collected. The Australian issues discussed however will most likely resonate with those experienced in New Zealand.
Future research includes the potential to create consistency across Australia and New Zealand in managing students with FTP issues, especially in light of the new Physiotherapy Practice Thresholds in Australia and Aotearoa New Zealand (Physiotherapy Board of Australia and Physiotherapy Board of New Zealand, 2015). Further research is required into strategies to support wellbeing, minimise burnout and optimise work satisfaction in physiotherapy clinical educators. Approaches are also required to assist clinical educators in the support of students with mental health issues and the student remediation process. As described in a systematic review by Cleland and colleagues (2013) regarding the challenges of health professional remediation, rigorous approaches to both the development and evaluation of remediation interventions are required.
This paper describes potential strategies to support clinical educators when supervising students with FTP issues. Educators suggested the benefits of peer-assisted learning to support both clinical educators and students. There was a preference for feed forward mechanisms to support student learning needs. Educators valued faculty staff as a mediator for issues. Particular support for mental health issues was requested. Mentoring for junior staff was also encouraged to help support staff new to the educator role. The importance of teamwork and regular staff breaks from clinical education were discussed. Clinical Education Managers discussed the inherent requirements of physiotherapy courses including strategies to flag and support students with FTP issues.
1. Clinical educators felt that mental health issues were much more challenging to ascertain and manage than clinical competency issues.
2. Clinical educators felt that staff members needed peersupport and that supportive relationships with the university were important.
3. Early identification, feed-forward information, educator preparation and regular breaks for clinical educators were important supportive strategies.
4. Clinical education managers agreed that feed-forward strategies were helpful. They differed in opinion with respect to issues around inherent requirements, reporting and management of students with FTP issues, preparation of students for clinical placement and assessment of communication skills.
Kristin Lo BPhty (Hons)
Senior Lecturer, Department of Physiotherapy, Monash University, Melbourne, Australia.
Heather Curtis G.Dip (LLPros Biomech), G.Dip. (Musc Phty), B.Sc. (Hons) (Phty)
Musculoskeletal Stream Leader, Department of Physiotherapy Caulfield Hospital, Alfred Health, Melbourne, Australia.
Alison F. Cracknell B.App.Sci(Phty), gchpe
Clinical Education Manager, Department of Physiotherapy, Monash University, Melbourne, Australia.
The authors wish to acknowledge the participants at the PeArL session at the APA conference in 2013 and the Clinical Education Managers at the CEMANZ meeting in 2015.
ADDRESS FOR CORRESPONDENCE
Kristin Lo, Department of Physiotherapy, Monash University Peninsula Campus, McMahons Road Frankston, VIC, Australia 3199. Telephone: +61 3 9904 4137. Email: email@example.com.
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|Title Annotation:||RESEARCH REPORT|
|Author:||Lo, Kristin; Curtis, Heather; Cracknell, Alison F.|
|Publication:||New Zealand Journal of Physiotherapy|
|Date:||Jul 1, 2017|
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