R E S E A R C H A R T I C L E C l in ic a l E d u c a t i o n : A U n i v e r s i t y o f D u r b a n - W e s t v il l e C a s e S t u d y A B S T R A C T : C linical education has been recognised as an im portant com pon en t o f the undergraduate p h ysio th era p y program m e. A s such it has received considerable attention in the literature. H ow ever the aspect o f offering this com ponent effectively to large n um bers o f students has n o t been addressed. The p urp ose o f this retrospective study w as to analyse a n d com pare both quantita tively a n d qualitatively the effects o f one highly structured a n d three sem istructu red m od els o f clin ica l educa tio n using a 12 to 1 student: clinical in structor ratio. The study p op ula tio n co nsisted o f the 1999 third y e a r class o f 39 students w ho were clinically supervised by f o u r lecturers. The students ’ block m a rks as w ell as th eir subjective im pressions were a n a lysed a n d su m m a rized respectively. The results show that there were no sign ifican t differences betw een stru ctu red a n d sem i-structured m odels. In a ddition a 12: 1 student: clinical instructor ratio can p ro d uce g o o d clinica l education outcom es. K E Y W O R D S: C LIN IC A L ED U C ATIO N , STU D ENT: C LIN IC A L IN ST R U C T O R RATIO, S T U D E N T P E RFO RM AN C E, S T U D E N T IM P R E S SIO N S NADASAN T (B. Physio, DOT, HED, M . Physio)1; PUCKREE T (BSc Physio, M . ED, MS, PhD)2 1 Lecturer, Department of Physiotherapy, University of Durban-W estville. Senior Lecturer, Department of Physiotherapy, University of Durban-W estville. INTRODUCTION C linical ed u catio n is an im p o rtan t com ponent o f the learning strategies used to optim ize clinical com petence in un d erg rad u ate p h y sio th erap y stu ­ dents (Tiberius and G aiptm an, 1985; L adyshew sky, 1993; De C lute and L adyshew sky, 1993). De C lu te and L adyshew sky (1993) suggest that the quality o f future health care is dependent on w ell-developed clinical education program m es. The latter is dependent on available facilities which include the variety o f affiliating sites as well as a variety o f patients at these sites, the num ber o f students to be educated, the num ber o f support and tutoring clinical and academ ic staff. L iteratu re from clinical educators in several parts o f the world (De C lute and Ladyshewsky, 1993; Tiberius and G aiptm an, 1985) suggests a 1:1 student CORRESPONDENCE TO: T Puckree Private Bag X54001 Durban 4000 Tel: (031) 204-4977/204-4817 (w) (031) 204-4817 (h) Fax: (031) 204-4817 Em ail: 1 puckree @ pixie.udw.ac.za in stru c to r ra tio to obtain the best learning outcom es. However, due to staff shortages, and decreased ex p e­ rience levels in available clinical staff, 2:1 (De C lute and Ladyshewsky, 1993; Ladyshewsky, 1993; Lopopolo, 1984; Grandy, 1988) and 3:1 (Emery, 1986) student : clinical instructor ratios have been sug gested and im plem ented in developed countries such as the United States o f America. The benefits o f the 2: I ratio include financial benefits, the benefit to staff shortages by increasing the productivity o f the team (Lopopolo, 1984), peer support system for students (Gandy, 1988), and increased student p lacem en ts in p a rtic u la r affilia tio n s (Lopopolo, 1984; Gandy, 1988). The U niversity o f Durban W estville is one o f eight Physiotherapy training centres in South Africa. To m eet the physiotherapy needs o f the province which has severe staff shortages the school had to increase its intake from approxim ately 15 students in the first year prior to 1996 to approxim ately 40 thereafter. T he acad e m ic staff com plim ent how ever increased from about seven to ten in the sam e period. T he school offers clinical education, w hich starts in the second year o f the program m e and continues up to the 4th y ear o f the four-year program m e. This im plies that at any one point in time approxim ately 120 students are in cli­ nical placem ents, only within the greater Durban area. The clinical education o f these students has had to be distributed am ongst the 10 m em bers o f staff, which effectively produces a student: clinical instructor ratio o f 12:1. The structure o f the provincial health care system with its staff shortages offers minimal help from clinical physiotherapists placing the entire burden o f clinical education on the academ ic physiotherapists. T he purpose o f this retrospective study was to determ ine strategies used to cope with the large student: clinical instructor ratio to ensure optim al clinical education. The follow ing issues were questioned as points o f departure: 1. Did a structured organization o f the clinical e x p erien c e in flu en ce the learning outcom es with this unusually high student: clinical instructor ratio? 2. W hat were the students perceptions of their clinical block? METHODS: The population for this critical analysis consisted o f 39 third year students who rotated through fo u r clin ical blocks namely, subacute and chronic facility 2 8 SA J o u r n a l o f P hysiotherapy 2001 V o l 57 No 3 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) (m ostly burns, neurology, pediatrics, orthopedics - block 1); acute facility (all conditions with a short hospital stay o f less than three days - block 2); com m unity (block 3); and facility cater­ ing for conditions com plicating from tuberculosis and spinal cord injuries (adult and pediatrics - block 4), in 1999. There were essentially three groups o f ten and one group o f nine students in any particular block at a tim e block, which lasted six weeks. An academ ic staff m em ber was responsible for each block. A sem i-structured form at for clinical education existed but each academic sup ervisor follow ed his or her own format. A clinical education workshop was carried out by the academ ic super­ visors for each group o f students in all four clinical areas before com m encing the clinical education program m e. In addition all students were given a cli­ nical record book containing inform ation on the clinical program m e, departm ental regulations, general and specific guide­ lines and objectives for all four clinical areas, lists o f conditions to be seen /treated, time schedules to record cli­ nical hours and the assessm ent forms. To answ er our questions a structured form at was applied in block 4. T he form at followed for block 4 were as follows: The academ ic supervisor met with the clinical person in charge o f the faci­ lity before the com m encem ent o f each block. This allowed the supervisor to com pile a list o f patients to be treated by students, to organise a student register, theatre and x-ray visits and to assist with m onitoring o f student attendance and professional behavior. On the first day o f the block the academ ic supervisor discussed the spe­ cific guidelines and objectives, record keeping and assessm en ts w ith the students. In addition a separate handout on guidelines o f weekly student expec­ tations were given and discussed. W eek 1: Students w ere given individual su p erv isio n /g u id an ce with assessing and w riting up o f patient assessm ents and treatm ents. Students were requested to hand in their written assessm ents for m arking each Friday morning. Feedback was given to students on an individual basis. Group discus­ sions and tu to rials w ere also held. Students working in pairs were assigned a case study patient which entailed an in-depth study o f the condition, detailed assessm ent, daily progress reports, over­ all m anagem ent in all stages o f rehabi­ litation, consultation with the family, o th er h ealth care p ro fessio n a ls and presentation (written and treatment). W eek 2: Students were given indi­ vidual supervision and presented patients to the supervisor only. Clinical hours, perfo rm an ce o f assessm en t/treatm en t techniques (indicated as good or needs im provem ent) and co n d itio n s seen/ treated were recorded in all students’ clinical books. F eedb ack was given to students on an individual basis as well as collectively, sum m arizing com mon problem s. W eek 3: Students presented their patients individually to the supervisor and the rest o f the group. Students were encouraged to constructively criti­ cize the presentation. Continuous eva­ luation and updating o f the clinical record book (as above) was carried out for all students. Week 4: Each student was exam ined on their com petent use o f therapeutic procedures for 30 minutes. The clinical record book was updated. Feedback was given to students on an individual basis. Com m on problem s were discussed and clarified. Week 5: Students worked in pairs to present the case study patient to the supervisor and the rest o f the students. The rest o f the students constructively criticized and made suggestions to the presentation. The record book was again updated. Week 6: Rem edial w ork was under­ taken to rectify deficits in cognitive, affective and psychom otor skills. The supervisor com pleted the continuous evaluation form s for all students. This en tailed looking at each stu d e n t’s portfo lio o f all p atient assessm ents, treatm ents, progress reports, case study, other additional inform ation collected on their patients, all their previous presen­ tations (individually to the supervisor as well as to the group) and feedback from the clin ical head o f d ep artm en t on professional aspects. Students evaluated the block reflecting on their clinical education and experience. They also highlighted the strengths and w eakness­ es o f the experience and suggested pos­ sible solutions. T he fo llo w in g p o in ts w ere also em phasized: Every Friday morning three students w atch ed o p eratio n s in theatre. The students also signed the register, entered patient nam es in the list book and made recordings in the clinical book daily. S tudents spent tw o h o urs on x-ray interpretation sessions carried out by a radiologist. T h ere was a g radual increase in patient load initially. T hereafter students had to have at least 5 or m ore patients at all tim es. C o n tinuou s assessm ent occurred throughout the block. Students had to notify the supervisor when addi­ tional tutorials were required on specific problem areas. Additional reading on the clinical conditions was com pulsory. Students had to cover their clinical hours in the case o f absences. Student Evaluations: The final end o f block m ark consisted o f the continuous assessm ent, which made up 50% o f the mark. A formal exam i­ nation o f a therapeutic procedure by the supervisor made up the other 50%. This w as sim ila r fo r the stru ctu red and unstructured clinical education models. Data Analysis: The perform ance o f each student in each block was tabulated as a percentage change o f their perform ance in the first block and com pared across blocks and with the perform ance in the last block for the year. Student t-tests were used to determ ine statistical significance with a p ro b ab ility o f 0.05. T he su b jective im pressions o f the students were sum ­ m arized in broad categories. RESULTS: As shown in Figure 1 there was no significant difference in the perform ance o f students in the d ifferen t blocks regardless o f w hether they were struc­ tured or not. However the subjective im pressions o f the student are sum m a­ rized in the follow ing section. SA J o u r n a l o f Physiotherapy 2001 V o l 57 No 3 2 9 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Figure legends: Figure 1: Percentage change in student performance in each of the four clinical blocks and clinical rotations. T h e n u m b e rs a t th e to p o f e a c h b a r re p re s e n ts th e b lo c k in w h ic h th e s tu d e n ts w e r e a t a p a r t ic u la r tim e . S tu d e n t g r o u p 1 s ta r te d in b lo c k fo u r, p r o c e e d e d to b lo c k 3 , th e n b lo c k 2 th e n b lo c k 1. S tu d e n t g r o u p 2 r o ta te d fr o m b lo c k 1 to b lo c k 4 to b lo c k 3 to b lo c k 2 . S tu d e n t g r o u p 3 r o ta te d fr o m b lo c k 2 to b lo c k 1 to b lo c k 4 to b lo c k 3 . S tu d e n t g r o u p 4 r o ta te d fr o m b lo c k 3 to b lo c k 2 to b lo c k 1 to b lo c k 4 . 120 -i l o o ­ s ’ 8 0 - | 6 0 - * £ 4 0 m a . 20 . 2 3 1 2 Clinical Rotations | Student G ro up 1 | | Student G ro up 2 Student G ro u p 3 | | Student G ro up 4 A subjective assessm ent was done by all four groups o f students for block 4 in order to obtain their im pressions about their clinical experience. Students had to com m ent constructively on the block by identifying the strengths, w eaknesses and possible solutions. Exposure: The students felt that the facilities for clinical education in term s o f patient variety and supervisors were adequate. H ow ever they also felt that the gym na­ sium was too sm all to accom m odate m ore than 10 students and their patients. This therefore resulted in the equipm ent being inadequate to m eet the needs o f all students. The students felt that if the use o f the gym nasium was scheduled to prevent overcrow ding, then all students w ould have the opportunity to use all types o f equipm ent and rehabilitate their patients optimally. The staff was friend­ ly and helpful and gave good advice. Students felt that exposure to see surgical procedures allowed for a clearer understanding o f their patients, and was interesting. However, the surgeons could have provided m ore explanations for procedures undertaken. Students felt that a first structured block allow ed for a system atic approach in other blocks, w hich were not struc­ tured. T his approach e n su red that students were exposed to a variety o f patients, w hich im proved their confi­ dence. The experience in rehabilitation w as patient oriented. Som e students felt that a w orkshop on spinal rehabilita­ tion ju st prior to the block w ould have benefited them more. A ctivities to prom ote learning and for continuous assessm ent: form ative evaluation In order to facilitate and m onitor progressive learning in this structured clin ical b lo ck the clin ical ed u ca to r included case studies, presentations and a com petency profile in the form o f a record book. The students found the case study interesting and participatory, it improved their ability to integrate inform ation, allow ed for peer evaluation and cog­ n itiv e , a ffe c tiv e an d p sy c h o m o to r learning. On the negative side, it was tim e c o n su m in g e sp ecially w hen academ ic facilities like the library were inadequate. Exposure to a variety o f patients w ould have enhanced this m ode o f learning. The record book was well formulated, user friendly and provided adequate guidelines for clinical education through­ out the block. It also allo w ed for students to easily record their clinical hours. T he p re sen tatio n fo rm a t in cluded in d iv id u al stu d en t to lectu rer only, individual to gro up o f students and su p erv iso rs, and third ly in pairs. Students felt that individual p re sen ­ tations w ere less intim idating and they w ere able to perform better. Individual student problem s w ere identified and rem ediated, w hich positively reinforced the students. One to one interactions with the clinical educator allow ed for con­ structive criticism , advice and guidance. The individual to group and super­ visor presentations w ere very inform a­ tive, allow ed for com m unication and was a good learning experience. It was also a good follow up to the case study and also allow ed for constructive criti­ cism , advice and guidance. T he paired presentations encouraged team work, allow ed sharing o f work and im proved attention given to patients. The strategy also m otivated them and each student received good input from the partner. A llow ed for peer socializa­ tion and learning. The only problem was that students found it difficult to m eet after-hours to discuss the case further. The suggestion was that the pair o f stu­ dents stayed on at the clinical facility for a further 15 m inutes to discuss the case. In sum m ary the form ative evaluation was not intimidating. Summative Evaluation Students felt that the end o f block evaluation was fair and appreciated the feedback and was o f the opinion that constructive criticism facilitated learn­ ing. Som e students felt that they did not have sufficient experience related to the 3 0 SA J o u r n a l o f Physiotherapy 2001 V o l 57 No 3 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) condition that they were exam ined on. Som e students carried negative expe­ rien ces from p revious blocks and were fearful o f the criticisms encountered in the end o f block evaluation. O ther students felt that the duration o f the final summative examination should be longer. Organization of the Block The students felt that it was well orga­ nized and stru ctu red w ith ad equ ate contact tim e with the clinical educator, a good variety o f patien ts, su fficien t patient load for allocated time and with specific goals. Students did not have to share patients. Som e students requested more exposure to spinal patients. The transfer o f patients from the wards to the gym nasium was tim e consum ing due to poor co-ordination o f nursing care and porterage. Time management Clinical time was not wasted because students always had patients to treat for the duration o f the clinical slot. Schedules w ere clear and prevented wastage o f tim e even during formal evalu atio n s. To reh ab ilitate patients, the students required more time and therefore all patients could not be treat­ ed adequately. Some students felt that the six-w eek block was too long and should be reduced. Supervision This asp ect was good and students found it easy to d iscuss problem s. Students were com fortable and were encouraged to speak. The supervisor was always available for advice and correction but not “ hovering” . The indi­ vidual attention that was given motivated and encouraged them. Some students required supervision w ith the treatm ent o f all their patients. Other aspects In their first clinical block, students felt that “they were thrown in at the deep end” . B ut this enabled them to cope. T hey w ere able to see pro g ress in patients. The supervisor’s know ledge of the syllabus allow ed for its integration into the treatm ents. The supervisor had no preconceived expectations o f students and created an environm ent which was conducive to learning. The attention to detail and concern for students well being and acquisition o f know ledge and skills was noted. The goals for the block were achieved. CONCLUSION This study shows that a 12:1 student: clinical instru cto r ratio can produce good clinical education outcom es in third year students provided that the students w ere given a clear idea o f what the requirem ents were and the super­ visor was always at hand to m onitor progress and assist them. H ow ever the stru ctu re o f the clin ical education experience did not have a significant effect on the quantitative perform ance o f the students. Since there is no literature on a 12:1 student: clinical instru cto r ratio, we cannot com pare our results with those o f others. O ur objective data com pa­ risons are based on block assessm ents by the academ ic supervisors. This type o f assessm ent is usually subjective and open to bias in an unstructured format. Subjectivity can be improved by creating m any opportunities for evaluations and including other exam iners. It is im portant to provide the students with a good balance o f independent and collaborative experiences. This is required for professional practice as well as clinical productivity. Clinical instructors need to be flexible, because o f the need to adapt to changes in acti­ vities, different skills levels (Futter, 1986), personalities, schedule changes and unforeseen events throughout the block. Supervisors also need the support o f other staff m em bers in understanding the gradual increase in productivity of the student in term s o f increasing patient load and com petence. A lim itation o f this report is the absence o f subjective reports by stu­ dents from the other blocks. Student feedback form s an essential com ponent o f clinical education. The authors recom m end more struc­ tured prospective research into develop­ ing a m odel fo r su p erv isin g large num bers o f students. In addition it is im portant to determ ine the m ost objec­ tive means to form atively and summ a- tively assess cognitive, affective and psychom otor outcom es in large groups o f students. REFERENCES D e C lu te J, L ad y s h e w sk y R 1993 E n h a n c in g c lin ic a l c o m p e te n c e u sin g a c o lla b o r a tiv e c lin ic a l ed u c a tio n M o del. P h y sica l T h e ra p y 7 3 (1 0 ): 6 8 3 -6 9 7 E m ery M 1986 S tu d e n t-s ta ff clin ic s: cre a tiv e clin ic a l ed u c a tio n d u rin g tim es o f c o n stra in t. C lin ic a l M a n a g e m e n t 6 (2 ): 6 - 1 0 F u tte r M J 1986 T h e P ro g ra m m e o f c lin ic a l e x p e rie n c e and ev a lu a tio n e m p lo y e d at the U n iv e rs ity o f C a p e T o w n . S o u th A fric a n Jo u rn a l o f P h y s io th e ra p y 4 2 (2 ): 4 3 - 4 9 G an d y J S 1988 F isca l Im p lic a tio n s fo r c lin i­ cal ed u c a tio n . In: Issu es in C lin ic a l E d u ca tio n : P re se n t sta tu s / F u tu re n ee d s, p 67. A m erica n P h y sica l T h e ra p y A ss o c ia tio n , A le x a n d ria , Va. L ad yshew sk y R 1993 C lin ical teach in g and the 2:1 stu d e n t to clin ic al in stru c to r ratio . J o u rn al o f P h y sica l T h e ra p y E d u c a tio n 7: 3 1 - 3 5 L o p o p o lo R 1984 F in an cial m o d e l to d e te r­ m in e th e e ffe c t o f c lin ic a l ed u c a tio n p ro g ram on P h y sica l th e ra p y d e p a rtm e n ts . P h y sical T h e ra p y 6 4 :1 3 9 6 - 1402 T ib e riu s R , G a ip tm a n B 1985 T h e s u p e rv iso r- s tu d e n t ratio: 1:1 vs 2:1. C a n a d ia n Jo u rn a l o f O c c u p a tio n a l T h e ra p y 52: 179 - 183 SA J o u r n a l o f P hysiotherapy 2001 V o l 57 No 3 31 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )