Patients’ perceptions and experience of hospital-based,student-led physiotherapy treatment interventions: A survey

Abstract

BACKGROUND:

Clinical education (CE) is an integral part of physiotherapy degree programmes. CE presents a unique learning opportunity for students to implement classroom-based teaching directly with patients and clients. Despite patients being central to CE, limited research exists around patients’ opinions of CE and the impact of student involvement in patient care. To our knowledge, there has been no study exploring patient perceptions of being treated by student physiotherapists in Ireland.

OBJECTIVE:

The aim of this study was to explore the perceptions and experiences of patients who have been assessed and treated by pre-registration MSc Physiotherapy students.

METHODS:

This was a cross-sectional survey study, involving both quantitative and qualitative content analysis.

RESULTS:

A total of 42 inpatient participants male n = 24 (57%) female n = 18 (43%) with 30 participants (71%) aged ≥70 were included in this study. All participants reported satisfaction with the treatment received by a student physiotherapist and reported they would avail of further treatments in the future. The benefits identified from interaction of participants with physiotherapy students included patient education and interpersonal skills. No disadvantages of being assessed and treated by a student physiotherapist were identified. Considerations for improvements identified included timing of physiotherapy sessions, frequency of sessions and the consideration of use of technology with patients.

CONCLUSIONS:

This study identified that all participants were very satisfied from receiving treatment interventions led by a student physiotherapist. Increased patient education and interpersonal skills were highlighted as key advantages from participants being assessed and treated by a student physiotherapist in clinical practice.

Keywords

Clinical education physiotherapy students patient experience survey

1 Introduction

Clinical education (CE), also known as practice placement, is an integral part of physiotherapy curricula worldwide [1]. In many countries such as Ireland, Australia, New Zealand, and the United Kingdom student physiotherapists need to acquire 1000 hours of supervised clinical placement which must include the core areas of neurology, respiratory and musculoskeletal physiotherapy to meet State Regulatory standards of accreditation [2]. Clinical education presents a unique learning opportunity outside the classroom-based [3], which enables students to apply knowledge and work directly with patients and clients [4]. Clinical scenarios are less controlled than in the classroom, which exposes students to a variety of complexities [3]. Therefore, CE is essential to help students integrate theoretical knowledge with practical skills in a supportive environment [1 –4]. Exposure to clinical practice can foster professional competence, empathy, and a sense of professional identity among future healthcare practitioners [1 , 4]. It can also significantly increase healthcare students’ emotional intelligence [5]. In Ireland, physiotherapy students are graded during CE using a standardised Clinical Assessment Form (CAF) which assesses clinical and professional competency under several domains, including patient assessment, treatment, documentation, and communication. Patient satisfaction is not evaluated.

The current study complements a previous qualitative questionnaire-based study [3] which explored students’ and clinical educators’ perspectives (n = 48) of CE. Students were asked to rate patient-centred learning activities and reported that adequate discussion and immediate feedback was most beneficial to learning. Students also found that tasks which were not directly related to patient care as least valuable. The benefits reported by clinical educators supervising students are also plentiful, including enjoyment sharing knowledge, personal growth, improving teaching skills and satisfaction seeing students develop [2]. Benefits for CE sites include exposure to evidence-based practice knowledge, improved confidence, and expertise of staff in supervision, opportunities to undertake quality assurance projects or research and potential future staff recruitment [2].

Despite patients being central to CE, limited research exists around patients’ opinions of physiotherapy student performance while on CE and the impact involvement in patient care [4]. Patient Centred Care (PCC) is understood to be the gold-standard approach to healthcare; it can improve quality of care while increasing satisfaction of both patients and staff [6]. It involves the consideration of the biological, psychological, and social needs of a patient. Respect, shared decision-making, and communication are crucial elements for PCC [6]. To ensure PCC, the impact and patients’ perceptions of student-led care must be considered [1]. However, some work has been done. Scheffer et al. [4] in Germany found that patients (n = 528) treated by medical students on a CE ward reported better patient-physician interaction and appreciated the patient centeredness of students. Medical treatment success was similar on the CE ward to normal ward. Similarly, a study in Sweden [7], examined quality of care on a CE ward versus a non-CE ward. This study found that patients on the CE ward reported significantly higher levels of participation in decision making regarding treatment and received more information regarding home help and consideration of their home situation prior to discharge. The CE ward team in this study consisted of student teams (medical, nursing, physiotherapy, and occupational therapy) [7]. To our knowledge, there has been no study exploring patient perceptions of being treated by student physiotherapists in Ireland. Addressing this gap in the literature will ultimately lead to better patient-centred care and provide an opportunity to assess if classroom-based learning carries through to CE. Therefore, the aim of this study is to explore the perceptions and experiences of patients who have been assessed and treated by MSc Physiotherapy (pre-registration) students in Ireland.

2 Methods

2.1 Study design

This was a cross-sectional survey study, involving both quantitative and qualitative content. Ethical approval for this study was obtained from the Clinical Research Ethics Committee of the Cork Teaching Hospitals.

2.2 Participants and recruitment

Participants were recruited from an inpatient medical and surgical ward setting in a single teaching hospital between the 22nd of May 2020 and 6th of September 2022. A convenience sampling framework was used and all patients meeting the set inclusion criteria were eligible to participate.

2.2.1 Inclusion criteria

In-patient on a medical or surgical ward in Mercy University Hospital (MUH).

Have the cognitive capacity to give informed consent.

Ability to understand and communicate in English.

Obtain at least three contacts by a physiotherapy student on the MSc Physiotherapy Programme, University College Cork.

2.2.2 Exclusion criteria

Cognitive Impairment (Mini Mental State Examination (MMSE)<20).

Patients who are significantly unwell (NEWS Score >6).

Eligible participants were invited to participate in the study by the MUH Clinical Educator. Interested participants were given an information leaflet outlining details regarding participation in the study and a consent form. Written informed consent was obtained from eligible participants prior to participating in the study.

2.3 Data collection

A patient survey (Appendix I) consisting of open-ended and multiple-choice questions was developed by the research team (JMcV, TOS, EL, AH and AOS). The survey was piloted with five eligible participants to determine usability and length of administration. After finalising the survey, a hard copy of the survey was distributed to participants, and later collected, by researcher (EL) during their hospital stay in MUH.

2.4 Data management

The researchers ensured that all participant data was pseudonymised throughout the research process. All raw hard-copy data were stored in a safe drawer with a lock system; only one researcher (EL) had access to this data, and it was destroyed upon completion of the study. All data pertaining to the study was collated on a Microsoft Excel file, which was stored in a password protected folder. Only members of the research team had access to these files. De-identifiable data will be stored securely by the principal investigator and destroyed in line with the agreed data storage policy.

2.5 Data analysis

Data was inputted and collated on Microsoft Excel. A double-check entry method involved cross-checking by an independent researcher to minimize risk of incorrect data entry [9]. Quantitative data analysis (Survey Questions 1–17) was completed using Statistical Package for Social Sciences (SPSS Inc, Chicago); analysis included means (±SD), frequency counts, and a Chi-squared test for independence to identify relationships between categorical variables. Qualitative data (Survey Questions 18–21) to identify perceptions and experiences of patients treated by students were analysed using content analysis which involved three phases [10]:

Immersion with the data involved two researchers (AOS and TOS) reading all responses to familiarise themselves with the content, taking notes and writing memos to represent the key characteristics of responses that begin to emerge.

Reduction of data was utilized to reduce the amount of raw data that was relevant to the research question. Initial codes to represent key characteristics of responses were created by researchers (AOS and TOS) to organise data. Codes were reviewed with regards to coded extracts and the entire data set to ensure important information expressed by participants was captured accurately.

Interpretation of coded extracts involved further analyses to formulate results. Data was re-assembled, using the codes, to facilitate interpretation and identify patterns and significance of codes. Consensus meetings were held with the research team to discuss content analysis and to develop the final output. The final report was created including compelling extract examples, with analysis relating to the research question.

2.6 Scientific rigour

The following strategies were utilised to promote credibility, dependability, and confirmability of findings [9]:

Survey development involved multiple members of research team (JMcV, TOS, EL and AOS) to increase credibility.

A comprehensive methodological description was outlined promoting dependability and confirmability.

Two researchers (TOS and AOS) coded the data independently to limit researcher bias.

Data analysis outcomes were verified by multiple researchers adding confirmability and credibility to results.

Frequent debriefing sessions were held by the research team enhancing data dependability and credibility.

3 Results

Forty-two participants were included in the study. All participants that were approach consented to participate. All included participants meet the set eligibility criteria before completing the survey. Participant characteristics are reported in Table 1. The majority of participants were aged ≥70 years (71%), 26 participants (62%) were receiving inpatient care for an acute medical diagnosis and 36 participants (86%) were treated by second-year MSc pre-registration physiotherapy students. The remaining six participants (14%) received treatment by first year pre-registration MSc physiotherapy students.

Table 1
Participant characteristics

Characteristic n (%)^*

Gender

Male 24(57%)

Female 18(43%)

Age, years

≥70 31(74%)

50–69 10(24%)

30–49 1(2%)

18–29 –

Diagnosis

Medical 26(62%)

Surgical 16(38%)

Reason for physio referral

Mobility 28(67%)

Respiratory 1(2%)

Mobility &respiratory 13(31%)

Year of physio student training

Year 1 ‘6(14%)

Year 2 36(86%)

Number of treatments, mean 6.12

Characteristic	n (%)^*
Gender
Male	24(57%)
Female	18(43%)
Age, years
≥70	31(74%)
50–69	10(24%)
30–49	1(2%)
18–29	–
Diagnosis
Medical	26(62%)
Surgical	16(38%)
Reason for physio referral
Mobility	28(67%)
Respiratory	1(2%)
Mobility &respiratory	13(31%)
Year of physio student training
Year 1	‘6(14%)
Year 2	36(86%)
Number of treatments, mean	6.12

^*Percentages do not always equal 100 due to rounding.

3.1 Patient care

Participants (n = 42) felt that students received a sufficient level of supervision from their supervisor, that treatments were sufficient and fully explained, that students were kind, caring and courteous and that students considered their privacy, dignity, and comfort. Goals were identified in conjunction with the student in all cases. All participants (n = 42) were “very satisfied” with the level of treatment they received and reported they would avail of further treatments from physiotherapy students if asked in the future.

3.2 The patient perspective

The benefits, disadvantages, and potential future improvement strategies of student interactions from a patient’s perspective were examined. Commonly occurring categories and sub-categories are summarised in Fig. 1.

Fig.1

Key emerging categories and sub-categories.

3.3 Benefits

Benefits to student interactions were widely reported by participants. Participants’ perceived benefits of physiotherapy student interactions during their hospital stay were sub-divided into two categories: patient education and interpersonal skills.

3.4 Patient education

“Excellent patient education” (P20) was a commonly expressed benefit for participants regarding their interactions with a student physiotherapist. Many participants described “great communication” (P36) with student physiotherapists as a key benefit. Participants felt that students “explained things very well” (P28), they were “able to explain in detail treatment sessions” (P04) and provide “clear rehab cueing” (P40).

Others enjoyed “the exercises and advice given” (P13) by the student therapists. One participant reported that “being told how to be active and what to do to get home” (P06) was the main benefit. Generally, all elements of participant interactions were praised from: “How they planned, assessed, took instructions and assisted me the patient” (P31).

3.5 Interpersonal skills

Interpersonal skills were another key finding which emerged from patient surveys. This again highlights the high praise provided by patients regarding student communication. Participants described student physiotherapists as “very courteous and informative” (P14). It was clear from the participants’ perspectives that they felt well informed and could “understand her [student] well” (P26):

“Excellent communication skills, very clear about what was required and why. Fully answered all questions clearly and always asked if I had further questions prior to finishing the session. Open and chatty during walks to keep them from being a chore. Very encouraging also.” (P36)

The participants felt as though student physiotherapists put “the patient first and foremost” (P32) and helped “get [their] independence back” (P23). Participants found the students “efficient” (P18) and felt there was “no rushing” (P22) during their interactions.

3.6 Disadvantages/ future improvements

When asked about disadvantages of being assessed and treated by student physiotherapists, none were identified. With regards to suggestions to improve the student care provided the feedback was largely positive; areas of improvement which were identified included increasing: “time of sessions” (P14) and “frequency” (P12). One participant (P31) suggested the “use of technology with patients” although this point was not discussed further by the participant it may be postulated whether this may imply the use of technology in the education of patients as part of their physiotherapy treatment and management.

However, many participants said, “nothing needs to change” (P39). They “very much appreciated” (P36) their care from students and “would not expect any more than the treatment received” (P40); with one participant exclaiming “send more students to the hospital” (P23).

4 Discussion

The aim of this study was to explore the perceptions and experiences of patients who have been assessed and treated by MSc Physiotherapy students in Ireland. The findings obtained from this survey demonstrates positive patient perceptions and feedback following their experiences of being assessed and treated by student physiotherapists.

To our current knowledge this research is the first study undertaken investigating patient perceptions of being treated by a student physiotherapist within Europe. The results obtained from this survey is in line with similar research undertaken by Stiller and colleagues [11] who investigated patients’ attitudes towards being assessed and treated by a student physiotherapist in a rehabilitation centre in Australia. Out of 61 completed surveys they found a high level of degree of patient satisfaction following their interaction with the students. Stiller et al. [11] identified areas for development, reporting 10% of participants (n = 6) were unsure if consent was sought prior to the patient session and 11% of participants (n = 7) unsure or did not think they would continue with their treatment if they were not satisfied with the treatment provided by the physiotherapy student. It must be noted there are some limitations to this research including a small sample size and the study was undertaken in a single rehabilitation centre thus potentially limiting the generalisability of findings.

Other studies have investigated patient feedback in relation to the involvement of medical students in individual patient care [4, 12], highlighting positive patient perceptions and experiences within their studies. Barksby [13], in a small study (n = 14) using semi-structured interviews, investigated service user’s perceptions of being treated by a student nurse. One of their main themes obtained from the completion of semi-structured interviews included the positive patient experience following the involvement of student nurses within their individual care.

Enhanced patient education was a positive category identified from individual patient perceptions in the current study. Patient education is an essential component of effective physiotherapy interventions [14]. With evidence demonstrating insufficient patient education negatively impacting both patient perceptions and their recovery [14]. Vijn et al. [15] recently conducted a scoping review investigating the provision of patient education by medical students in clinical practice. A total of 18 studies were included in this synthesis outlining the provision of patient education and the potential impact this may on increasing quality of care for patients [15]. The results from this study found that student provision of health education enhanced patient’s health knowledge, improved health behaviour, disease management and increased shared decision making [15]. There were a number of limitations in this review, including a total of 12 studies used obtaining a weak score on quality assessment and the search strategy used was limited to scientific literature without the use of grey literature.

Students may be reluctant to provide and deliver patient education if they have received a lack of training in this skill base [16], educators should include strategies to support students to develop the skills to deliver effective patient education while on clinical placements. Forbes et al. [16] undertook a randomised control trial RCT involving 164 final year physiotherapy students focusing on establishing if an education training programme could assist students in the delivery of patient education on clinical placement. The intervention group received a three and a half hour training intervention, consisting of videos, patient interaction and feedback. These authors reported significant improvements (p = <0.05) in both student self-efficacy and performance of patient education within the intervention group [16]. The findings of this study suggest a potential addition to physiotherapy curriculum to further support student performance and self-efficacy of the delivery of patient education on clinical placements.

Despite this study identifying the positive experiences and perceptions patients may have towards physiotherapy students on clinical placement there remains an ongoing shortage of available physiotherapy clinical placements in Ireland. McMahon et al. [17] investigated possible barriers and facilitators to providing physiotherapy clinical education within primary care settings in Ireland. Within this three round Delphi study they identified several barriers to the provision of clinical placement which included the lack of available staffing to support students (77%), available facilities (72%), insurance (70%) and lack of university support (29%) (17). Newstead et al. [18] additionally identified university support as an influencing factor for Australian physiotherapists to be involved in physiotherapy student clinical education. Facilitators for providing successful clinical education in primary care have been identified which include provision of university support in training of clinical staff in supporting students, increasing staffing numbers with appropriate allocation of administrative time, and increasing the number of staff willing to be involved in clinical education (17). This emphasises the need for ongoing university support in terms of training for Clinical Educators and the need for increased physiotherapy staffing levels to be able to appropriately facilitate and support physiotherapy students on clinical placement.

4.1 Limitations

This study had several limitations. A relatively small sample (n = 42) was included from a single hospital site in Ireland, therefore limiting the generalisability of the findings to the wider physiotherapy profession outside of the Republic of Ireland. Recruitment of participants was limited by the lack of student physiotherapist presence within acute care during the initial Covid-19 pandemic. Furthermore, the Clinical Educator involved in supervising the physiotherapy students additionally had a role in collecting the data which may have led to a risk of performance/observer bias. Future studies should seek to include a large sample size from a wide variety of diverse clinical sites.

5 Conclusion

Clinical placements are an essential aspect of physiotherapy student education. This study has demonstrated that patients report high levels of satisfaction from their experience of the process of consent obtained, supervision of students on clinical placement and the treatment interventions led by a student physiotherapist. The delivery of patient education and interpersonal skills demonstrated by student physiotherapists were identified as advantages by patients following their experience of treatment interventions. There were no disadvantages identified from patients following their individual student led treatment interventions. However, there is currently limited data supporting the benefits and identification of disadvantages of physiotherapy specific student led treatment interventions with patients. Future studies should explore surveying large multicentred acute and community clinical environments to determine the advantages and disadvantages perceived by patients following their experience of treatment interventions led by a student physiotherapist on clinical placement.

Consent

All participants (n = 42) reported being asked for consent by a qualified physiotherapist prior to student assessment or treatment. Similarly, all participants felt they received enough information about being treated by a physiotherapy student before consenting and that they were given the option to discontinue the treatment session if they were not satisfied with the treatment provided.

Ethical approval

Ethical approval for this research study was obtained from the Clinical Research Ethics Committee of the Cork Teaching Hospitals [CREC Reference Number: ECM 4 (h) 09/04/2020 & ECM 3 (iii) 16/06/2020].

Conflict of interest

All authors declare no conflict of interest.

Footnotes

The Appendix is available in the electronic version of this article: .

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