Investigating the learning experiences of student physiotherapists with visual impairments: An exploratory study

Abstract

This article discusses the exploratory phase of a study to understand the learning experiences of physiotherapy students with visual impairments (VI) in higher education (HE). The purpose of the study was (1) to explore semi-structured interview as a data collection method for this population, (2) to identify barriers and enablers to learning physiotherapy for students with VI, and (3) to identify individual strategies for tackling barriers in physiotherapy education. Three purposively sampled participants consented to be interviewed; two were recent physiotherapy graduates and one was a current physiotherapy student. The findings identified that physiotherapy students experienced similar barriers and enablers to learning that students with disabilities experience in HE, and that they had developed similar and specific strategies to enable learning in physiotherapy. Staff behaviours, resources, and the time and effort of being a visually impaired student were identified as the main barriers. Staff behaviours and resources were also identified as enablers to learning physiotherapy. Specific physiotherapy and VI-related barriers were identified that will be explored further in the main phase of data collection and will be disseminated through future publications.

Keywords

Barriers enablers higher education physiotherapy visual impairment

Physiotherapy as a profession for people with visual impairments

Physiotherapy has traditionally been an accessible career choice for people with visual impairments (VI) unlike physical disability, which has previously excluded people from becoming a physiotherapist (CSP 1984 cited in French, 1988). There is a long history of blind and partially sighted physiotherapists working in healthcare (Atkinson & Owen-Hutchinson, 2005, 2013; Owen-Hutchinson & Atkinson, 2010). While physiotherapy is an excellent option for people with disabilities, challenges of access and inclusion within higher education (HE) exist for people with VI (Atkinson & Owen-Hutchinson, 2013).

Physiotherapy became an all-graduate profession in 1992. All physiotherapy courses in the United Kingdom are now professionally orientated and as such are strongly regulated (Bithell, 2007). For physiotherapists to be deemed ‘fit for practice’, they must have completed a pre-registration physiotherapy degree course that satisfies the regulatory requirements of the CSP (The Chartered Society of Physiotherapy), HCPC (Health and Care Professions Council), and the QAA (Quality Assurance Agency).

The traditional, although not exclusive route to qualification of a visually impaired person as a physiotherapist, was by the completion of a graduate diploma in physiotherapy from the Royal National Institute for the Blind School of Physiotherapy which closed in 1995 (French, 1993, 2006). Students with VI now study physiotherapy alongside their sighted peers at the institution of their choice, reflecting the mainstreaming agenda for students with disabilities in HE and the principles of inclusive education described by Booth & Ainscow (2002) and the Higher Education Authority (HEA) (Morgan & Houghton, 2012).

There has been a growth of research into the experiences of students with disabilities in HE in the United Kingdom over the last two decades, possibly in response to policy and legislation such as the Disability Discrimination Act (Office of Public Sector Information [OPSI], 1995), Special Educational Needs and Disability Act (SENDA) (OPSI, 2001), and more recently, The Equality Act (OPSI, 2010) which aligned all anti-discrimination policy. Although inclusive education practices ensure that access to education is not limited by a person’s disability (Moran, 2009; Veck, 2007), both the HEA (Morgan & Houghton, 2012) and the CSP (Owen-Hutchinson & Atkinson, 2010) have published guidance to ensure that curricula are inclusive. This suggests that challenges for students with disabilities, including students with VI may exist in physiotherapy education.

Barriers and enablers in learning

Barriers and enablers are terms that feature in the literature in relation to the social model of disability (French & Swain, 2008, p. 28; Oliver, 2004, p. 21; Oliver & Barnes, 1998). The social model suggests that disability is not caused by the person’s impairment but by barriers caused by society, culture, economic constraints, and the environment; for people with disabilities to be able to function in society, these barriers must be removed and access, awareness, acceptance, and participation enabled (Open University, 2006; World Health Organization [WHO], 2011).

Students with disabilities in higher education.

There is evidence that students with a disability tend to encounter particular barriers to learning in HE, which may relate to entry and disclosure (Holloway, 2001; Tinklin & Hall, 1998), methods of teaching and assessment (Borland & James, 1999; Fuller, Bradley, & Healey, 2004a; Fuller, Healey, Bradley, & Hall, 2004b; Hanafin, Shevlin, Kenny, & McNeela, 2007; Madriaga et al., 2010; Tinklin & Hall, 1998; Vickerman & Blundell, 2010), and attitudes of university staff (Fuller et al., 2004a; Goode, 2007; Hanafin, Shevlin, Kenny, & McNeela, 2007; Holloway, 2001). It has also been suggested that greater time and ‘emotional effort’ is needed by students with disabilities in HE, compared to students without disabilities (Goode, 2007; Mullins & Preyde, 2013). Several studies have also identified factors and practices that enable learning (Healey, Bradley, Fuller, & Hall, 2006; Holloway, 2001).

Students with visual impairments

Studies have shown that VI in itself was not a barrier to entering further education or HE or in academic attainment of students (Douglas, Pavey, Corcoran, & Clements, 2011; Richardson, 2009; Richardson & Roy, 2002). Investigations into the barriers and enablers experienced by visually impaired students revealed the main issues were students’ attitude, institutional provision, external support, the amount of reading required, attitudes of academic staff, availability of textbooks and written material, reliance on visual teaching methods, and lack of timely access to accessible materials (Bishop & Rhind, 2011; Reed & Curtis, 2012). Difficulty using adaptive technologies, group work, and access to demonstrations or visual media were specific barriers identified by students with VI (Reed & Curtis, 2012).

‘Individual Differences’

Healey et al. (2006) suggested that considering ‘disabled students’ as a whole is problematic, as not all students with disabilities experience problems in accessing teaching and learning, rather like their non-disabled peers. Indeed, considering students with VI as a homogenous group is also problematic (Warren, 1994); all students will have individual and different experiences and will have individual support needs (Reed & Curtis, 2012). Therefore, Warren’s (1994) ‘individual differences’ approach is relevant when considering the experience of physiotherapy students; some students with VI will experience barriers to learning and some will not. Students with VI in physiotherapy may need to overcome barriers by developing strategies to manage learning where visual methods are frequently used to gain clinical information for example. Reasonable adjustments, specialist equipment, and modifications to practice may be required to ensure that students can participate fully in their education and future profession (Owen-Hutchinson & Atkinson, 2010, p. 159).

Summary, research questions, and aims

The aim of this exploratory study was to develop an understanding of the barriers and enablers of students with VI in university-based physiotherapy education. In order to consider this, the following research questions were posed:

What are the barriers and enablers to learning physiotherapy that affect students with a visual impairment?

What are the individual strategies, factors, or behaviours that enhance learning for physiotherapy students who have a visual impairment?

Methodology

As no specific research evidence into the learning experiences of physiotherapy students with VI exists, a multiple case-study design was used (Yin, 2009). Case study is a flexible way of exploring something that is unknown, providing a ‘rich picture’ (Thomas, 2011, p. 23) about the ‘particular’ of a phenomenon; for example, how learning is experienced by a ‘case’ of physiotherapy students with VI (Thomas, 2011, p. 4). By creating a focus on people who are experiencing the phenomenon, in-depth knowledge, understanding, and meaning of their experience will be gained (Bryman, 2008). A constructivist perspective therefore underpinned the use of a qualitative design (Creswell & Plano Clark, 2010). Ethical approval was gained from the HE institution within which the study took place prior to the commencement of data collection.

Participants

Within the case-study design, ‘knowledgeable people’ (Cohen, Mannion, & Morrison, 2007, p. 115) are purposively chosen to provide ‘first-hand experience’ of the issue being explored (Speziale & Carpenter, 2007, p. 29). For the exploratory study, each ‘case’ was

A registered student physiotherapist or recent student with a disclosed VI on a recognised Physiotherapy degree course at a single UK Higher Education institution.

Participant 1 (P1) and Participant 2 (P2) were recent female graduates. Participant 3 (P3) was a current male physiotherapy student in his second year of study. All participants were print readers with magnification representing all visually impaired students registered at the time of data collection.

Methods

A semi-structured interview was used as there was a clear focus, with specific issues (e.g. exploring the barriers and enablers in learning of a specific group of students) that ensured that all participants were asked about the same themes (Bryman, 2008, p. 315). To ensure that the research questions could be addressed, the interview schedule (Appendix 1) was informed by the following (Kvale, 2007):

World Health Organization (2011) Report on Disability;

International Classification of Functioning, Disability, and Health (ICF, WHO, 2001) which used the terms ‘barriers’ and ‘enablers’;

Findings from the literature review into the experiences of students with disabilities including VI in HE;

‘Into Physiotherapy; Welcoming and supporting Disabled Students’ guidance published by the CSP for students and educators (Owen-Hutchinson & Atkinson, 2010).

Data collection process

Participants were provided with a Participant Information and Consent form in their preferred accessible format. After introductions and an explanation of the research study, informed consent was gained and any issues raised from the participant information sheet discussed.

Interviews were carried out at a time and location of the participant’s choice to ensure that the participant felt comfortable. The prepared semi-structured interview schedule was used by the researcher and interview recording commenced. As face-to-face interviews were used to collect data, an open, friendly, and collaborative environment was created to facilitate honest and insightful data.

Data handling and analysis

Interview recordings were transcribed verbatim; pseudonyms (P1, P2, and P3) were used to identify the participants anonymously within the text (Gibbs, 2007). The key themes identified in the literature were used to structure the analysis. Data were analysed using NVivo (2009) to organise and code the transcribed interview data (Denzin & Lincoln, 2008) using the themes identified from the literature: Staff behaviours, Resources, Equipment, Formats, Attitudes, Identity, Visibility, Time & effort, and Fear of disclosure. This enabled meaning to be attached to the participants’ words or sentences to allow later identification in the transcriptions for further analysis (Kvale, 2007, p. 105).

During analysis, constant comparison was used to increase validity; this process ensured that the data were being dealt with consistently and comprehensively (Gibbs, 2007). As the researcher transcribed and analysed the data alone, reliability was promoted by discussing the analysis with two colleagues to act as ‘critical friends’ to review and cross-check the findings throughout the process of analysis (Cohen et al., 2007; Gibbs, 2007).

Findings

Analysis of the exploratory data showed the existence of all themes identified from the literature. The themes were illustrated using quotes from the participants (P1, P2, and P3) to provide context and examples of the ‘lived’ world experienced by the participants (Gibbs, 2007). Four themes were identified as being particularly relevant to the participants in this study: Staff behaviours, resources, time and effort, and fear of disclosure. These themes are described below with examples of participants’ quotes.

Staff behaviours

Staff behaviours affected learning both positively and negatively, for all three participants, suggesting that staff acted as both barriers and enablers for learning. Positive staff behaviours reflected time and interest: those who actively checked that students were accessing learning and provided information prior to class in an accessible format. Specifically in practical classes, where physiotherapy skills were being taught, the use of one-to-one demonstrations in addition to the whole-class demonstration ensured learning:

What helped me most was when the tutor would take my hands and show me how it was done or whatever, and then watch me do it after to see if it was right or not . . . you know just me and them. (P2)

Where staff had taken the time to discuss support needs with students and could provide options or adaptations, optimal learning was facilitated:

They would ask if they could come and show me. I didn’t have to ask that much’ (P2)

Participant (P3) identified that some lecturers were unable to adapt their teaching to make it accessible:

They expect a normal person to be able to understand but it’s different for a visually impaired student. (P3)

When lecturers were unable to provide teaching in an accessible way, it was a barrier for learning. The lack of accessible learning methods, such as demonstrations in addition to verbal instruction, was identified:

In my second year when we did the shoulder in a lecture, there was no demo; it was just read off the screen. Even if someone just talks it through, if you can’t feel it in front of you it’s still very hard to make sense of . . . I found it hard to get it without the physical re-enforcement. (P2)

For another participant, barriers were created by purely visual methods:

. . . when we are expected to do skills off a projector or the board. (P3)

If a lecturer failed to explain fully what was written or shown on the board, participants had to access the material in other ways:

I ask my mates. I tend to listen to what a lecturer is saying, not read it, but then go home and read the lecture. (P3)

How a lecturer spoke about visual material was also a barrier:

Lecturers saying things like ‘this’, ‘that’, ‘there’, all those phrases are just no good if they’re a chronic ‘this and that-er’ you lose out, you’ve lost the whole train of what’s going on. (P2)

Resources

Resources were identified by all three participants as having either positive or negative effects on learning physiotherapy. Having timely access to resources such as equipment and library books enabled learning; however, lack of accessible resources created a barrier to independent learning. Library staff also enabled learning, supporting the previous theme of staff behaviours:

They (the librarians) were really helpful, you just went to the service desk and they would help you to find books. (P1)

The participants had various experiences of reading books. Participant (P2) had their own closed circuit television (CCTV) equipment that allowed them to read without difficulty. However, although another participant could access books and could read them, they did not want to access written material in the university setting:

I have a magnifier that I can use and read in my own time. (P3)

Extra time and effort was involved in reading textbooks, compared to using electronic material. However, although digital copies of books were preferable, gaining access to them was problematic:

To get a digital copy, there’s the hassle factor, it’s much easier for students who can read books than for the people that might want digital copies. The barriers aren’t to do with me or the university it’s just how books work. (P3)

Inequity of access to the breadth of appropriate books for students was identified by two participants, creating a barrier. This was compounded by other factors such as fatigue and time:

You certainly don’t read the volume of what other students read because you don’t have the time to do it and you get tired quickly reading as well. (P1)

Other learning resources also created barriers. PowerPoint presentations, although provided for the students electronically in advance, were inaccessible due to specific individual requirements to enable reading:

You can’t play around with the colours and sizes of diagrams. (P2)

Similarly accessing PDFs caused problems for two participants:

PDFs were a nightmare, they didn’t obey my rules to have them white on black, when I did zoom in the problem is that you spend forever clicking to finish a sentence so your reading speed is terrible. (P2)

While it appears that the increased use of technology in teaching has provided greater access to information for all students, for some students with VI, technology may be a barrier, resulting in inequitable access to the same resources as other students.

Time and effort

All three participants felt that that having a VI required more time and effort to learn than their non-disabled peers, and created fatigue. This was despite the provision of equipment which enabled timely access to learning materials for students:

CCTV really helped for reading and reading books . . . but I did struggle, I got tired a lot especially working during the day. I’ve always found concentrating for long periods hard and my eyes were getting tired, especially in second year I got quite stressed. (P2)

Extra time and effort affected getting around at university too:

I didn’t know how I was going to find these places . . . (laughs). I remember a staff member said ‘I’m sure you can meet up with people on the course . . . but you can’t really, when you first start you can’t seem to recognise people, so how do you know who is on your course in a big open space?! (P2)

Two participants talked about being strategic with their time and effort, both in terms of getting around and in relation to learning:

The things that you have to learn to go and do, you went and learnt, but some things you could get around . . . like I always met up with somebody before practical classes. (P2)

The heavy workload on the physiotherapy course required some strategic use of time for independent study:

. . . the effort of using the library is more, you can’t just go into short loans and pick up a book, and choose which bits you want to quickly read. (P1)

Despite positive support from the library staff, the effort required was magnified for the students with VI, and compounded the issue of access to a limited range of titles. One student stated that the reading list was a good place to start, however, the time required to study meant that strategies were necessary to optimise time:

In terms of general searching I would look at what they referenced in their article and I would snowball it, cross-referencing. I was a slightly savvy student and I had to use my time wisely. (P2)

Another student was equally honest, identifying that she took ‘short cuts’. Needing to become more independent in learning than required at school was an additional barrier:

If you’re just trying to read around the subject you take the short cut! All of a sudden you’re in a situation where you have to put more effort into finding out and reading around, so actually time and effort wise I’m going to just be able to do the basics. And do the basics well and leave it at that. (P1)

Fear of disclosure

Although all three participants had fully disclosed, one participant expressed concerns about disclosing their VI to their peers. The same student appeared to demonstrate some discomfort with their identity as a student with VI, and their disability:

I suppose I could’ve taken the opportunity to explain myself to the other students. In hindsight that might have helped me get into the 2^nd year a bit better, if I had talked to the whole year, not just the people that I work with on a regular basis. A lot of them know now, some of them don’t. (P3)

There was also a concern about having to tell teaching staff about having a VI:

I’d rather it was out there . . . I wasn’t confident in how other people would react to it that was the main thing. (P3)

The participant’s experience showed that they hoped that staff would already know, perhaps indicating fear of being judged within the educational setting:

. . . the Learning Support Agreement (LSA), that’s supposed to be sent out to the lecturers . . . some lecturers find it a surprise when they find out that I’ve got a visual impairment, and I think what was the point of filling out that form in the first place? (P3)

Having to ask staff for support in class and being singled out was also a barrier to learning:

If there was a way that lecturers could help you without personalising it that would help. It’s nice to know that someone’s there helping you specifically. . . but at the same time it’s that ‘single-out’ factor, I don’t want to be separated out just because I’ve got a disability. (P3)

Discussion

The main findings of this exploratory study confirmed that the use of semi-structured interviews is valid for this population, identifying that barriers and enablers in physiotherapy education co-exist for students with VI. The barriers and enablers identified in this study reflect those recorded for students with other disabilities in HE. However, it was evident that much of the experience described by the participants related to academic staff behaviours and practices, both positively and negatively; learning was best facilitated by staff who were aware of the different needs of individual students, and who could provide access to appropriate resources and learning opportunities in the classroom. Conversely, learning was impeded by difficulty with access to and teaching with learning materials in an inappropriate format, by the additional time and effort required to read and to become familiar with the environment.

The findings showed that some academic staff appeared to be unable to provide inclusive and accessible teaching and learning material for students with VI. This supports Fuller et al. (2004a, 2004b) and Vickerman and Blundell (2010) who suggested that staff were sometimes unaware of support needs resulting in inaccessible teaching, or were unable to adapt to specific individual’s needs in class. Unsurprisingly, the importance of individual support was mentioned many times by all three participants, reflecting the findings of Tinklin and Hall (1998), Borland and James (1999), and Holloway (2001), and supporting Warren’s (1994) theory of ‘individual differences’. Although all the three students had a VI, they had different and individual learning and support needs in their physiotherapy education. It was clear from the findings that where open discussion between staff and students had occurred and there was an awareness of individual support needs, that individual learning and independence could be facilitated. It was also evident that these factors should be expressly identified by the participants through prior discussion, rather than being assumed, perhaps based on previous experience (Owen-Hutchinson & Atkinson, 2010).

Two student approaches were evident in the findings: a proactive and participatory approach for ensuring access to learning, and a second, more reactive approach to support and learning. Where the participants faced barriers in class, those who were proactive and unafraid to ask were able to gain the support they needed, particularly in practical classes where teaching methods were very visual. The examples of instruction in practical classes suggested an assumption that all students could see to learn. This may suggest that staff were unaware of their use of descriptive language during teaching, and may indicate a need for more careful and detailed explanation when demonstrating or teaching. It is possible that addressing these practices would improve the learning experience for all students, supporting Atkinson and Owen-Hutchinson (2010). Positive staff behaviours for learning reflected time and interest; staff who actively checked that students were accessing learning and provided information prior to class in an accessible format that enabled learning. Specifically in practical classes, where ‘hands-on’ physiotherapy skills were being taught, the use of one-to-one demonstrations in addition to the whole-class demonstration enriched learning.

Each of the participants had different issues with resources such as books and learning material. Timely provision of accessible and appropriate (individual) learning materials was a barrier, reflecting the findings of Fuller et al. (2004a), Hanafin et al. (2007), Reed and Curtis (2012) and echoing some of the comments made by the participants with VI in Bishop and Rhind’s (2011) study. However, even when resources were provided in a timely fashion, reliance on reading was a barrier due to accessing the library, using technology or becoming tired, and struggling to concentrate. These findings reflected the ‘emotional effort’ of having a disability described by Goode (2007) and Holloway (2001) that is an additional barrier to learning for students with VI.

The findings did, however, identify some good practice in equipment and resource provision, suggesting that the issues were not always related to support. However, the implications of extra time and effort required to study may not have been considered fully by academic staff, particularly for an intense course of study such as physiotherapy. Strategic use of time was identified by all three participants; this may not necessarily be a positive factor in HE where the underlying philosophy is to gain a breadth and depth of knowledge in a subject. However, as Curtis and Reid (2011) identified similar issues in high school students, this may indicate wider issues about the transition from school to university education. While some barriers such as access to breadth of material could be supported through reasonable adjustments, developing independence in learning may create greater barriers for students with VI than for other students. This suggests that students with VI need to develop additional skills to their non-disabled peers, which further impacts on the ‘emotional effort’ of having a disability described earlier.

While fear of disclosure was a recurring theme in the HE disability literature (Fuller et al., 2004b; Goode, 2007; Holloway, 2001; Miller, Ross, & Cleland, 2009; Ryan, 2011), it was only discussed by one participant in this exploratory study. One explanation was the choice of participants; the inclusion criteria for this study stated that participants must have a disclosed VI and so would have been eligible for support during their physiotherapy education. However, there were issues around willingness and comfort to disclose; the participant did not want to be singled out or treated differently to peers. This reflects the findings of Atkinson and Owen-Hutchinson (2013) who identified that physiotherapists with VI often minimise or conceal their disability so that they do not initially appear disabled. Fear or embarrassment about a VI that may not be immediately obvious may be a hidden barrier to accessing specific support, which may impact on learning. The need for early and effective communication with students by supportive staff about support mechanisms and processes is clearly important in the creation of an enabling learning environment that develops independence. The case for choosing specific academic tutors with the willingness, experience, and time required to provide students with individual support requirements may enhance support and engagement.

These findings have identified the importance of staff engagement and involvement in support of learning for students with VI. The importance of individual and specific support in teaching and learning physiotherapy was mentioned many times by all three participants, reflecting the findings of Tinklin and Hall (1998), Borland and James (1999), and Holloway (2001). It was clear that the attitude and teaching methods of staff affected learning, both positively and negatively, supporting the findings of Holloway (2001) and Fuller et al. (2004a). Providing accessible physiotherapy education relies on open communication between staff and student, and awareness of both staff and student’s own needs in accessing and delivering physiotherapy education in the university setting. Although there is a requirement to support students with disabilities in HE within the Equality Act (OPSI, 2010), some staff may not have the awareness, or insight into their own teaching methods to identify inaccessible practices. In order to provide individual support to students in their classes, support and development may be required for academic staff, which would indicate the need for further study.

Limitations of the study

This was a small study, with a limited choice of participants from one institution, which could have biased the findings. However, analysis demonstrated that different experiences of similar teaching practices were gained, reinforcing the need for individual support even within one institution.

Conclusion

This article has considered the process of designing and successfully carrying out an exploratory study into the learning experiences of physiotherapy students with VI using semi-structured interviews. The findings showed that there are similarities between the experiences of students with disabilities in HE cited in the literature and physiotherapy students with VI in a single institution. Although similar experiences of learning in HE have been described here, there are specific examples in relation to both physiotherapy and VI that add to the themes described in relation to students with other disabilities.

This is the exploratory stage of a wider study. In order to gain understanding of the learning experiences of this small and unique group of students, it is vital to ‘seek out, listen to and act upon the voices of disabled students’ (Fuller et al., 2004b, p. 316) through research. The second phase of the study has considered barriers and enablers experienced by student physiotherapists with VI, in both university and clinically based education in the United Kingdom to broaden the findings of this exploratory work.

It is hoped that the insights into barriers and enablers identified from the students’ perspective will improve teaching and learning in physiotherapy education. Awareness and acceptance of barriers to learning will ensure that learning and participation for future students in university and practice settings can be enabled. Those responsible for the successful transition from student to practising physiotherapist must continue to work alongside students with VI to ensure that their individual differences are respected and their voices heard.

Footnotes

Appendix 1 Acknowledgements

The author would like to thank Dr Yvonne Thomas for her guidance and support in this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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