Good Practice in Australian Physiotherapy Education

Assessment is known to drive learning, so for learning objectives to be met, assessment must reflect those objectives to allow students to demonstrate the nature of their learning. (Gibbs 1995). Where integration of various aspects of learning is important, a challenge exists to find ways of teaching and assessing which provide opportunity for that integration to occur and its importance and relevance to be appreciated. A further challenge is to find a way of assessing students, which is in itself a continuation of learning and an enjoyable experience. A possible solution can be found in the concept of "performance" in the form of role-play.
Students in year one undertake a course with major themes in 'communication', 'understanding disability' and 'developing professionalism'. It is anticipated that by the end of the course students will have acquired both knowledge and skills. To test the integration of knowledge and skill and the ability to actually apply them in a real world situation, students are organized into self -selected groups of six students and required to develop a role -play response to a given scenario. In the role play, the dialogue and actions are to be used to illustrate the group's awareness and acknowledgement of human / patient rights, their understanding of communication skills and their ability to make caring attitudes explicit to a patient. A short summary report is prepared and presented to clarify which elements of the play represent fulfillment of these objectives. The play and the verbal presentation are part of the assessed exercise, which includes a two- minute question time. Total time for the presentation is 12 minutes. Students receive this information by handout, which also includes information on the assessment criteria. A copy is posted to the Web CT.
 
Groups are given their scenario once all students are allocated. The scenarios are developed by the teaching staff and raise a range of issues that require attention to patient rights, good communication skills, professional conduct and sensitivity and compassion in patient or client management. Individual mark sheets for each scenario are prepared, reflecting the expectation of the issues to be raised.
Students allocate the workload and responsibilities within their group and are required to sign an acceptance of the shared mark based on equity of load carried. The group scenario presentation has an assessment weight of 15%.
 
Question time allows both the students and the examiners, who have taught in the course, an opportunity to clarify issues or to extend the learning of the group around issues that arise from the handling of the scenario.
There has been strong group cooperation and commitment to the exercise. There is strong evidence of integration of the learning and skill development as well as strong indication by the use of humor (and cross dressing !), that student learning has been an enjoyable experience in modules of a course that are heavily focused in small group discussion and peer supported learning.
 

As a part of initial introductory clinical placements in years 1 and 2, students complete Clinical Practice Workbooks. The workbooks are designed to enhance the clinical experience by encouraging student to seek out, perform and document specific structured tasks, and to reflect on their performance. Workbook activities require students to relate the clinical impairments documented in assessment tasks to the patients' quality of life assessed through discussions with patients. In addition, the workbooks encourage students to learn about the physiotherapist's work environment through tasks that require reflection on management and safety issues, manual handling, and equipment use. Clinical reasoning is enhanced through tasks that require the student to discuss observations from patient charts or interviews that are necessary for clinical decision-making. Students present a patient case to their peers following their first placement, and presentations are guided by their clinical workbook activities.

Students attend a tutorial session related to the issues surrounding caring for patients with end stage disease in adults and children. This is a joint session between Cardiopulmonary and Neurological Physiotherapy courses. The focus is mainly on end stage neuromuscular and/or respiratory disease.
Physiotherapists are frequently confronted with these situations and students are generally unprepared when it comes to dealing clinically with the complexities of managing the patient with end stage / terminal disease. It was determined that a tutorial session examining the role of the physiotherapist, clinical decision making and the emotional aspects of end stage disease was necessary.
 
Students are provided in advance with short case studies of patients with end stage neurological, neuromuscular and respiratory disease. These are case studies in which the tutors have been personally involved. Questions are provided for each case study which direct the students toward exploring and reflecting on:

• The effects of end stage disease on body systems and function
• The role of the physiotherapist in treating patients with end stage disease
• Clinical decision making and clinical reasoning in treatment planning for those with end stage disease
• The effects on the patient and family of terminal / end stage disease
• Their own emotional response and concerns related to caring for such patients.
   

The tutorial session activities include general discussion and identification of the student's issues and concerns related to the physiotherapy management of patients with terminal / end stage disease. Times when students have actually come into contact with end stage patients are identified.
 
The case studies are presented and discussed. Specific physiotherapeutic management clinical reasoning, treatment plans and techniques for the patients concerned are explored. Time is then spent discussing the effect of terminal / end stage disease on the patient's family, carers and involved health care workers. Students are encouraged to reflect on their own emotional response and concerns. Practical strategies for dealing with the emotional aspects of treating patients with terminal / end stage disease are identified and discussed.

Clinical Conference is a 10CP capstone course undertaken by students in the last/final semester of studies prior to the final 8 weeks of clinical placements. The course aims to fully integrate the student's prior learning in exercise science with evidence-based physiotherapy knowledge and skills using complex clinical cases. These cases are complicated by 'real-life' moral, ethical and medico-legal issues. The students study four separate cases in detail and in a holistic manner, examining the progress of patients through a continuum of care (eg, early diagnosis, acute care, sub-acute needs, rehabilitation and through to re-integration back in to the community). Sessions are led by various members of different disciplines from the healthcare team that might be involved with such cases. The cases are updated and modified each year depending on medical advances or social change.

Case studies are used to provide a 'systems integrated' approach to the curriculum. They provide a platform for applying discipline knowledge, reinforcing principles and concepts, problem solving, clinical reasoning and critical thinking. The case studies also provide a medium for incorporating psychosocial, cultural and ethical issues and an international perspective into the undergraduate curriculum. The case studies are used to assist students with the management of patient problems with increasing levels of complexity whilst ensuring that they understand the limitations of their own skills. Whilst these case studies are horizontally integrated into the curriculum, students are also facilitated to develop skills for lifelong learning.
Whilst all streams use case studies for their teaching and learning, the Psychosocial and Professional streams have dedicated sessions that are used to consolidate and motivate student learning. These occur as tutorial sessions and master classes.
 
For the tutorial sessions, real life case studies of increasing complexity are developed and students are required to prepare relevant written work prior to class using self directed activities to guide their learning. Tutorial classes of two hours duration are used to develop students' critical thinking, problem solving and communication skills and explore the clinical reasoning associated with client problems. In the week following the class, students are required to submit a written report that requires students to reflect on their learning in the session and develop a patient evaluation, analysis, management plan and any other information required specifically for the rehabilitation of the patient.
Master classes provide an opportunity for students to observe an experienced physiotherapist assess and treat a real patient/client and discuss the clinical reasoning process used to determine the most appropriate management plan. Prior to the master class, students are encouraged to review the theory and practice related to the client's problem.
The session begins with an explanation and discussion of relevant background information, assessment and treatment of the patient/client, followed by further discussion of the assessment findings, clinical reasoning processes used in determining the results of assessment findings, development of a problem list and intervention strategies using an evidence-based approach. During this session, students participate in active discussion prior to and following the arrival of the client. These sessions allow students to participate in the critical thinking processes required in client management.

The teaching and learning strategy revolves around the students using problem solving techniques to develop knowledge in key clinical areas. This knowledge is developed through group interaction and individual learning founded on keystone lectures that are provided at the commencement of each module. Learning issues that are developed by each group provide the evolutionary structure and timeframes for the learning process in each group to occur. The collaborative tutorial times enable the educators to provide minimal but directed input where required but in essence the learning is driven by the students

In the 2nd year of the course students complete separate subjects in the core physiotherapy areas of musculoskeletal and cardiopulmonary physiotherapy. An example of the cross specialty teaching is in a practical/tutorial class scheduled towards the end of the session; classes in the two areas are combined and facilitated by teaching staff from both areas. Students are presented with two case studies and are then guided in the process of clinical reasoning about these cases. The client problems used in the case studies involve chest wall and thoracic spine pain, and thus reflect the overlap between these two areas of practice. The cardiopulmonary lecturer deliberately facilitates the case study in which the client's problems are primarily musculoskeletal in origin and the musculoskeletal lecturer facilitates reasoning in the case where the problems are primarily cardiopulmonary in origin.
The aim of the strategy is to encourage students to access and integrate knowledge from both clinical areas. The case studies are deliberately chosen to elicit students' assumptions about the different areas of physiotherapy practice. This process of shared facilitation challenges them to recognize how they may have segregated their knowledge and then challenges them to develop strategies that take a more holistic approach to patient care.
 
We feel that introducing this strategy at a 2nd year level influences students' learning as they develop further knowledge in core areas and prepares students for latter subjects that require more advanced integration of knowledge and reasoning, such as Complex case management.