A Student Supervised Neurological Physiotherapy Clinic
In October 2015 I started an optional Student Supervised Physiotherapy clinic for neurologically impaired patients. The primary aim of the clinic is to provide an experiential learning environment for Levels 5 and 6 students. The secondary aim of the clinic is to provide an assessment, review and treatment to local service users experiencing neurological problems and who are seeking further/alternate physiotherapy within a learning environment. The clinic is the first dedicated student supervised neurological physiotherapy clinic in the UK that we are aware of.
Prior to teaching I worked as a clinical neurological specialist in an adult neurological community setting. Regular student placements were allocated to me and it became evident fairly quickly that students ‘learned by doing’ and generally found contextualising the theory from University difficult. Following a career move into lecturing this became further apparent when analysing the module feedback for the undergraduate neurological physiotherapy module where "interacting with service users" and "observing neurological assessments" were positively evaluated. I had a strong desire to really engage students in neurological physiotherapy and aid a deeper understanding as part of a constructivism pedagogy (1,2), where real life situational learning provides more concrete experience and learning.
It has been shown that having real patients is an effective method promoting deeper learning within neurological physiotherapy; alongside this there are other factors which further promote student supervised clinics such as, having a relaxed (unassessed) but fully supervised environment allows students to assess, accommodate and assimilate information alongside clinically reason and justify treatment decisions in a supportive environment (1).
A study by Mayya et al (3) found that any clinical situation which allowed students the opportunity to adopt a deeper learning approach alongside building confidence had a positive correlation to student success. Although this study was primarily looking at learning styles with 149 physiotherapy students (undergraduate and postgraduate) it did conclude that those students who performed better both academically and in assessed clinical skills had adopted a deeper learning approach, and these students demonstrated more successful clinical skills when compared to students who had adopted a surface learning approach. Recommendations from this study suggest that teachers should consider the learner environment and maximise practical opportunities in order to achieve effective and efficient teaching methods.
This study agreed with earlier work by Ramsden & Entwistle (4) (although not specific to physiotherapy students) whereby students who adopted a surface learning approach were found to struggle to contextualise the learning and had not being given/ taken up the opportunity to apply acquired knowledge to a practical situation. These are similar findings to Sellbeim (5) who found that physiotherapy students adopted a surface learning approach when they struggled to see the relevance in what was being taught or assessed or where curriculum was overloaded with content.
A further study by Mountford et al (6) found that learning within physiotherapy comes from teaching, studying and experiencing. This study analysed 206 physiotherapy students on entry to a programme in Australia via Honey & Mumford’s Learner Style Questionnaire (7). The findings are supportive of physiotherapy students as active learners as the majority of students scored in the Activist and Reflector categories which are synonymous with doing and observing clinical activity respectively. This is further supported by a narrative study of physiotherapy students’ professional development (8).
Most of the existing research promotes experiential learning in physiotherapy in order to access higher cognitive domains and therefore have a deeper understanding. It is therefore surprising that specific physiotherapy student clinics have not provided further research in favour of this within the UK; with ongoing developments within the physiotherapy curriculum and its delivery, further research in this area is warranted.
A five-week inter-professional clinic study was carried out in Australia in 2014 (16), this study was specifically looking at experiences of inter-professionals working in a student-led neuro-community clinic. It was a mixed method study over five weeks and involved final year Occupational Therapy students, Speech Therapy students and one Physiotherapy student. The small sample, limited timeframe and single physiotherapy candidate limit the validity of this study; however, some interesting conclusions were highlighted. Within the study there was an argument as to whether the benefits of an interdisciplinary clinic outweigh the benefits of a profession specific clinic, but with no comparison and qualitative data from focus groups, evidence is limited. The critical discussion resulting from this research debates whether students should be challenged to an inter-professional working clinic within their undergraduate degree in order for them to work better as an interdisciplinary team member when they qualify or should the clinics be uni-professional to aid profession specific skills and clear understanding of own roles prior to inter-professional working? Again suggestive that further research is needed within this field.
It is clear from the evidence that physiotherapy students’ learning can be accelerated and deepened by access to student led clinics providing direct service user contact.
What is unclear is how and when these clinics should run, who should be involved and at what stage in their training should they attend.
I set up the Student Supervised Neurological Physiotherapy Clinic in October 2015, running one evening per week (optional for students to attend). I carried out a service evaluation earlier this year to try to answer some of the questions unanswered from the existing research (discussed above) and to determine the following:
- Is the student supervised neurological physiotherapy clinic effective for students' learning?
- Why do some students opt not to attend?
- Is the student supervised neurological physiotherapy clinic effective for service users with a neurological condition?
- Would the service users recommend the student clinic to their family and friends?
Within the current Student Supervised Neurological Physiotherapy Clinic student numbers are limited as there is only one clinician; so after consultation with service users and carers at the steering group it was felt appropriate for four students per session. Due to the limited number of students and to enable all students to have the chance at experiencing the Student Supervised Neurological Physiotherapy Clinic it would not be equitable to allow the same students to continue with the care if others want to attend. The same clinician however does oversee the care and where there is a change in students, the clinician briefs them prior to the patient coming into the clinic so as to save the patient repeating any information and to ensure the students are aware of any goals, treatment plans and home exercise programmes.
The Student Supervised Neurological Physiotherapy Clinic does continue to run during holiday periods although they change to once every two weeks rather than weekly – again this decision was made after consulting students, service users and carers at the steering group.
There is one clinician in the clinic at any one time. The clinician is a Physiotherapy Lecturer with a clinical background in Neurological Physiotherapy. There is only one patient in the clinic at any one time and up to four students also. The students are from levels 5 and 6 of the undergraduate physiotherapy course.
The clinic started on 6th October 2015. A steering group was also set up, this included students from Levels 5 and 6, service users and carers, university teaching staff, management and two external physiotherapists working in a neurological field (one NHS, one private).
The aim of the steering group is to further develop and promote the student supervised neurological physiotherapy clinic and to ensure the clinic continues to adhere to its aims.
In order to set the clinic up I had to meet with the Physiotherapy Teaching Staff and the Clinical Lead who runs the successful musculoskeletal (MSK) student clinics at the university. I went to some of the MSK clinics to observe initially and had discussions with staff. I liaised with clinical colleagues and patients and explained about my personal student experiences and of those reported to me from students on clinical placements. I explained what I thought the outcomes of a neurological student clinic would be and did a scoping exercise to see if there was anything similar at Universities in the UK. Many universities have student clinics but I did not come across any that had a unique Student Supervised Neurological Physiotherapy Clinic. With this information the idea then became a unique selling point for the University. From the agreement from managers to open the clinic to actually opening took approximately three months (as I was doing this alongside my day to day role – potentially this could have been sooner).
I changed my working hours to accommodate the evening clinic and contacted university security with regards to vulnerable patients being on campus in an evening (just to make everyone aware in the case of emergency). The MSK clinic room is not in use on a Tuesday evening so there were not any issues with a room or equipment as we use what is already there.
With regards to support and commitment – I have had the full support of the Physiotherapy team at the University of Bradford and the Steering Group have also been very supportive and forthcoming with ideas for development further (many from the students). I have managed the clinic alongside my other duties as a Physiotherapy lecturer.
The clinic is an optional clinic which means it cannot run when students have timetabled sessions - this has forced the clinic to run on an evening - which showed in the evaluation to be one of the main reasons for non-attendance from some students. However, it was seen to be a positive time for a clinic from the service users. Future developments are looking at running a second clinic on a different day and time to try to meet the needs of students and service users and maximise the potential to attend.
Promoting the clinic initially was via the university of Bradford staff briefing and word of mouth. We did get a small advertisement in a local newspaper also and used personal social media accounts to promote further. We have since had promotional flyers printed and a large advertising space on the main campus.
Promoting the clinic was problematic initially due to it being perceived as competition from NHS. Lots of work has been carried out with local trusts to advise of the aims of the clinic and to ensure that the clinic is an educational clinic and not a private entity. Also promotional work has had to be minimal due to capacity and demand.
The clinic was set up by myself and is run by myself on only one evening per week. I therefore had to be careful not to over promote and then run the risk of having a waiting list. This has been difficult to manage to ensure we have enough service users and to ensure the clinic is achieving what it set out to achieve.
All service users to date have attended clinic via self-referral (the majority via an internet search). The clinic is charged to cover overhead costs only with an assessment costing £20 and follow ups at £10. This is similar to the other university clinics where student learning is the primary aim. Future developments are looking at a further clinic as mentioned above. This will allow room for future promotional work.
One of the problems I encountered was that some service users needed other discipline involvement or liaison with GP's. As the clinic runs only one evening this was very difficult to contact other agencies and or GP's and it was often a follow up job that I would complete the following morning when it was easier to contact people. However, this again was part of the experience the students need to engage in and develop some of the transferable communication skills required. This again justifies the need for a secondary clinic held at an alternate time. For those patients that did require follow up this was all done via liaison with their GP. Examples of some of the follow up conversations were regarding onward referral to Speech and language therapy, liaison regarding scan results and requesting further investigation.
To evaluate the service, questionnaires were sent out to all students who attended the clinic within the study period, October 2015 to April 2016, (n=32), all levels 5 and 6 students who were invited to attend but chose not to attend (n=37) and all service users who had attended and had consent to be contacted for research purposes (n=9).
Completed questionnaires were returned from:
- Students who attended (n=18, 56%)
- Students who were invited to attend but chose not to (n=9, 24%)
- Service Users (n=3, 33%)
Despite the limited response, the service evaluation demonstrated that the Student Supervised Neurological Physiotherapy Clinic is an effective learning tool for both students and service users. The results concur with the surrounding literature stating that in subjects where content is heavily loaded or in areas where students may struggle to contextualise their learning, students learn best by doing and observing activity. Both can be achieved within the clinic environment.
Data Analysis of the students' results who attended the clinic:
- 100% (n=18) stated that attendance at the clinic had a positive impact on their learning.
- 94% (n=17) reported positive experiences linked to clinical reasoning, linking theory to practice and observational skills
- 78% (n=14) reported gaining experience in progressing treatment plans
- 67% (n=12) reported gaining experience in identifying and writing problem lists
- 61% (n=11) reported that they experienced therapeutic handling skills
83% (n=15) reported that their attendance at the clinic helped them to prepare for their clinical placements.
94% (n=17) felt that their confidence in relation to assessment and treatment of people with neurological conditions had improved following their attendance at the clinic.
Data Analysis of the students who were invited to attend but chose not to returned questionnaires showed:
- Reasons for non-attendance were:
- Timing of clinic
- Day of clinic
- Unable to book a place to attend
- Other commitments (Work, Sport and Family)
Data Analysis from the returned Service User Questionnaires:
- 100% (n=3) of respondents were satisfied with the timing and date of the clinic.
- 100% (n=3) of respondents felt the price of the clinic was satisfactory.
- 100% (n=3) found the clinic met their expectations and that attending the clinic helped resolve some of their problems.
- 100% (n=3) reported that they would recommend to family and friends.
Unfortunately the evaluation had a poor response rate, particularly from the Service User population. For future clinic evaluations the response time needs to be much longer and a reminder letter/email may improve response rates.
Cost and savings
The clinic is staffed by myself and four students. The service users are charged £20 for a new assessment and £10 for a follow up assessment to cover costs of the room and any equipment.
Although the service evaluation has looked at student learning and satisfaction from the service user perspective it has not looked at cost savings to any other services.
There is potential to investigate the module results of those students who attend the clinic versus those who do not to see if there is any correlation.
Student learning by doing is paramount and every opportunity to involve service users and provide ‘real life’ experience should be maximised. Neurological Physiotherapy is a difficult area to contextualise and is a difficult subject to teach - both become much easier when you have a real person experiencing real problems.
The clinic has received such a positive response from those who have attended and it is thoroughly enjoyable working in a clinical, non assessed environment.
Some of the skills students reported gaining from their attendance at the clinic were transferable skills such as subjective assessment, communication, confidence and placement preparation. As this is the case the steering group have decided to open the clinic up to first year undergraduate physiotherapy students also. A further evaluation will take place next year.
Top three learning points
1. Brandon Amy & All Anita (2010) Constructivism Theory Analysis and Application to Curricula Nursing Education Perspectives Vol.31, No.2 pp89-92
2. Klopper HC (2002) A Constructivist Strategy for Health Science Education South African Journal of Physiotherapy Vol.58, No.4 pp.13-18
3. Maaya et al (2004) Learnign approaches. Learning Difficulties and Academic Performance of Undergraduate Students of Physiotherapy The Internet Journal of Allied Health Sciences and Practice Vol.2 No.4 pp1-6
4. Ramsden P & Entwistle NJ (1981) Effects of academic departments on students approaches to studying British Journal of Educational Psychology vol.51 pp.368-383
5. Sellbeim DO (2003) Educational Factors Influencing Physical Therapy Student's Approaches To Learning Journal of Physical Therapy Education Vol.17, No.2, pp11-21
6. Mountford et al (2006) Learning Styles of Entry Level Physiotherapy Students Advances In Physiotherapy Vol.8 pp.128-136
7. Honey P & Mumford A (1992) The Manual of Learning Styles Peter Honey Publications
8. Korpi et al (2014) The story models of physiotherapy students' professional development Narrative Research European Journal of Physiotherapy vol.16, pp.219-229
9. Arlton D & Miercourt O (1980) A Nursing Clinic: The challenge for student learning opportunities Journal of Nursing Education Vol.19, No.1 pp.53-58
10. Seif et al (2014) The development of clinical reasoning and interprofessional behaviours: service learning at a student run free clinic Journal of Interprofessional Care vo.28, No.6 pp559-56
11. Jensen GM & Shepard KJ (2002) Handbook of Teaching for Physical Therapists Second Edition Butterworth Heinemann
12. Laitinen-Vaananen et al (2008) Physiotherapy under discussion: A discourse analytic study of physiotherapy students' interpersonal skills International Journal of Therapy and Rehabilitation Vol.10 pp2-8
13. Race P (2007) The Lecturers Toolkit Third Edition Routledge: London
14. Seymour CJ & Dybel GJ (1998) The effectiveness of three teaching methods for gait analysis using the Ranchos Los Amigos Gait Analysis Checklist Journal of Physical Therapy Vol.12, No.1 pp.3-9
15. Health and Care Professions Council (HCPC), (2009) Standards of Education and Training London
16. Gustafasson et al (2016) Healthcare students' experiences of an interprofessional, student led neuro rehabilitation community based clinic Journal of Interprofessional Care Vol.30, No.2, pp259-261