Experiences of Physiotherapy Students, Health Care Providers, and Patients with a Role-Emerging Student Clinical Placement in an Emergency Department: A Qualitative Study

Abstract

Purpose: To understand the experiences and perspectives of physiotherapy (PT) students, their clinical instructor, nurses, physicians, and patients with a role-emerging student clinical placement in an emergency department (ED) and to identify barriers and facilitators in implementing this placement model. Method: We conducted qualitative semi-structured interviews with 6 PT students, 1 PT clinical instructor, 15 nurses, 12 physicians, and 17 patients. Five researchers independently coded the transcribed interviews and performed thematic analysis in an interpretive description tradition with frequent peer debriefing and reflexive discussions. Results: Students and their clinical instructor reported that the placement setting provided a unique learning opportunity. Patients and ED staff noted that involving the PT students in patient care delivery improved the musculoskeletal assessments and self-management advice provided to patients. Identified barriers included students’ inability to chart in the electronic medical record, lack of bed space, and lack of clarity about students’ scope and abilities. Reported facilitators included positive perceptions of the students’ supervision and a perceived positive impact on patient care and the health care team. Conclusions: Participants reported positive experiences with the student ED placement and recommended similar placements in the future. Understanding barriers and facilitators in implementing PT student clinical placements in an ED can inform future placements.

Emergency departments (EDs) in Canada have experienced increasing pressure and overcrowding, with annual visits increasing by over 5% and length of stay increasing by over 30% since 2014.¹ Musculoskeletal disorders are leading contributors to years lived with disability² and are among the most common reasons people seek care in an ED.³ Non-urgent ED visits for musculoskeletal disorders contribute to overcrowding, longer wait times, and increasing patient visits annually.^4–6

Physiotherapists can play an important role in the ED due to their expertise in the assessment and management of musculoskeletal conditions.⁷ Multiple countries have integrated physiotherapists within EDs, including the United Kingdom,⁸ Australia,⁹ Singapore,¹⁰ Denmark,¹¹ and the United States.¹² Evaluations of physiotherapists in EDs have found reduced patient wait times, increased patient satisfaction, reduced pain and disability, and decreased workload for other ED staff.^9,10

EDs across Canada have begun introducing physiotherapists into the ED team.^7,13,14 Entry-level physiotherapy (PT) education needs to evolve to prepare physiotherapists for this environment. Situated learning theory suggests that embedding students in authentic practice contexts facilitates greater learning¹⁵; however, establishing PT clinical placements in EDs can be difficult because many EDs lack full-time PT staff. Traditional PT student placement models involve a physiotherapist providing mentorship to students in settings where the roles of the profession are well established.¹⁶ Role-emerging placements, in contrast, involve placing students where there currently is no PT.¹⁷

Role-emerging placements in EDs provide an opportunity for PT students to develop competencies required for an ED role, but evidence evaluating the experiences and learning outcomes associated with emerging-role placements in the ED is lacking. Research on role-emerging placements in occupational therapy has suggested that this type of placement can improve students’ flexibility to work in diverse environments and provide positive student experiences.^16–18 Little research has examined role-emerging placements in PT, and literature from other health professions on such placements has focused on the experiences and perspectives of students.¹⁹ Evidence is needed on the perspectives of other stakeholders involved in the placement, such as patients and health care team members.

The study reported in this article addresses these research gaps by evaluating an emerging-role placement offered by the PT programme at Queen’s University in an urgent care centre (UCC) within the ED at Kingston Health Sciences Centre. The purposes of this qualitative study were (1) to understand the experiences of the students, their clinical instructor, health care providers, and patients involved in this role-emerging placement and (2) to identify the barriers and facilitators in implementing the role-emerging PT placement within the UCC.

Methods

Study design

We used an interpretive description qualitative methodology^20,21 to understand the experiences and perspectives of the stakeholders in the role-emerging placement. Interpretive description involves identifying patterns and meaning in descriptions of a phenomenon in order to inform clinical practice. This methodology uses an interpretive orientation that recognizes the constructed nature of individuals’ experiences of a phenomenon and allows for shared realities. Interpretive description therefore is a suitable approach to guide inquiry into the experiences of the role-emerging placement in the UCC from the multiple perspectives of students, their clinical instructor, health care providers, and patients.

Characteristics of the role-emerging placement

The three 6-week placement periods (2 students per placement period) took place between April and August 2018 in the Hotel Dieu Hospital UCC within the Kingston Health Sciences Centre emergency department. Before their placement began, all students participated in an orientation session that included introduction to the health professionals, processes, and patient flow in the emergency department. The PT students worked 40 hours per week with overlapping schedules to cover the UCC from 8 a.m. to 8 p.m. from Monday to Friday. The placement supervisor was an experienced physiotherapist who did not usually work in the UCC; he provided direct supervision 20 to 25 hours/week, additional on-call consultations when necessary, and review of all student documentation. Students were responsible for conducting PT assessments and providing initial management for ED patients with musculoskeletal conditions. The supervising physiotherapist used a competency checklist to assess the students before entrusting them with performing assessments and providing treatments independently.

The decision to focus on musculoskeletal conditions was associated with the stage of learning of 1st-year PT students. In collaboration, the UCC team, supervising physiotherapist, and clinical education coordinators decided to maintain consistent referral criteria and processes throughout the three clinical placement periods. While upper-year students may have been well prepared to offer care to a more diverse population, the musculoskeletal patient population was better suited to the stage of learning of the 1st-year students, whose training before the placement had focused primarily on physiotherapy for musculoskeletal conditions. The attending or resident physician saw all of the patients the PT students saw.

Research team

Six Master of Science in Physical Therapy (MScPT) students from Queen’s University (JW, CZ, TN, JB, NK, and EG), an ED physician and researcher (R. Brison), and three PT faculty members (ML, R. Booth, and JM) conducted the study. The student researchers conducted all interviews; they did not personally know the health care providers and patients who participated, but they did know the six PT students, who were peers, and the clinical supervisor. The interviewers made all informants aware that they were PT students at Queen’s University.

Participant recruitment

Purposive sampling was used to identify the PT students, clinical instructor, health care providers, and patients who were involved in the role-emerging placement. Eligible patient participants were adults (18–64 years of age) who saw the PT students in the UCC for musculoskeletal injuries. PT students and the clinical instructor were eligible because they participated in the 6-week student placements in the UCC. Health care providers at the UCC were eligible if they worked at least one shift with students. Eligible health care providers, students, and the clinical instructor were invited to participate by email. Research assistants (emergency medicine research staff) recruited patient participants in person in the UCC.

Data collection

Interviewers (i.e., the student researchers) conducted semi-structured interviews with the students, clinical instructor, and health care providers in person in private rooms in the UCC. They completed the patient interviews by telephone within 4 weeks of the patient’s encounter with a PT student. The interviewers used four piloted, semi-structured interview guides with questions tailored to each type of informant. See the online Appendix for the interview guides.

The interviewers audio recorded and took field notes for all interviews. A professional transcriptionist who had signed a confidentiality agreement then transcribed the interviews verbatim and checked the transcripts for accuracy.

All PT students and the clinical instructor completed interviews. Recruitment of and interviews with patients and health care providers continued until research team members agreed they had achieved sufficient information power for these informant groups.²² The interviewers obtained informed consent from all participants. The Health Sciences and Affiliated Teaching Hospitals Research Ethics Board at Queen’s University in Kingston, Ontario, approved the study.

Analysis

The interviewers imported all transcripts into NVivo Version 12 (QSR International, Doncaster, VIC, Australia). The research team used thematic analysis to analyze the interview transcripts²³; we first familiarized ourselves with the data and then generated codes for each interview. Seven researchers (JW, CZ, TN, JB, NK, EG, JM) independently reviewed and identified codes for the first two transcripts of each informant group; they then met to discuss the codes and agree on initial codes for each group. For each informant group, two researchers coded the remaining transcripts independently, meeting after every two or three transcripts to discuss the codes for each transcript and update the coding scheme.

The research team held frequent team meetings, which included peer debriefing and reflexive discussions, to encourage analytical rigor.²⁴ In these meetings, we identified, defined, and labeled themes within each informant group. To come to a more complete understanding of participants’ experiences and barriers and facilitators in implementation from multiple perspectives, we used the following triangulation protocol proposed by Farmer and colleagues²⁵:

1. Sorting of the findings from each informant group into categories (themes) that addressed the research questions

2. Convergence coding to compare findings within each informant group to determine areas of agreement, partial agreement, silence, and dissonance among the informants

3. Convergence assessment to compare themes across informant groups to identify areas of convergence and dissonance

4. Completeness assessment to analyze key differences among informant groups in terms of scope and coverage

5. Researcher comparison and feedback on findings of convergence, dissonance, and data completeness to clarify interpretations of and degree of agreement on triangulated findings.

Results

One hundred seven individuals (6 PT students, 1 clinical instructor, 25 nurses, 37 physicians, and 38 patients) received invitations to participate. Fifty-one participants (6 PT students, 1 clinical instructor, 15 nurses, 12 physicians, and 17 patients) took part in interviews, which were 20 to 90 minutes in length. Four PT students were men and 2 were women; 4 were first-year and 2 were second-year students. The PT clinical instructor was a 44-year-old man with 10 years of clinical experience. Tables 1–3 summarize the characteristics of the nurse, physician, and patient participants, respectively. In the sections that follow, we present major themes and supporting informant observations, organized by study objective. Figure 1 depicts the themes and the informant groups who contributed data in each theme.

Table 1 .

Demographic Information for Nurse Participants (n = 15)

Characteristic	No. (%)*
Age, y, median (range, min-max)	43 (28–65)
Gender
Men	1 (7)
Women	14 (93)
Professional role
Registered nurse	13 (87)
Registered practical nurse	2 (13)
Work status
Full time	10 (67)
Part time	4 (27)
Casual	1 (7)
Duration of work at urgent care centre, median (range, min-max)	12 y (4 mo–18 y)
Highest level of education
Master’s degree	1 (7)
Bachelor’s degree	8 (53)
College diploma	6 (40)

^*Unless otherwise indicated.

Table 3 .

Demographic Information for Patient Participants (n = 17)

Characteristic	No. (%)*
Age, y, median (range, min-max)	48 (18–74)
Gender
Men	8 (47)
Women	9 (53)
Area of injury
Foot	3 (18)
Ankle	3 (18)
Knee	2 (12)
Hip	1 (6)
Low back	3 (18)
Thumb	1 (6)
Arm	1 (6)
Shoulder	3 (18)
Work status
Full time	6 (35)
Part time	5 (29)
Off work due to injury or pain	1 (6)
Retired	5 (29)
Highest level of education
University degree	7 (41)
College diploma	7 (41)
High school diploma	3 (18)

^*Unless otherwise indicated.

Figure 1 .

Themes and contributing informant groups, by study objective.

Experiences with the role-emerging placement in the UCC

The interpretive description of the experiences of the students, clinical instructor, health care providers, and patients involved in the PT student clinical placements in the UCC included the following themes: the placement as a unique learning opportunity, increased confidence among patients and the interprofessional team in the students’ competence, challenges for students in navigating perceived hierarchical relationships in the UCC, and increased self-confidence among students over the course of the placement.

A unique learning opportunity

Students, nurses, and the clinical instructor highlighted the value and comprehensiveness of the learning experiences students gained during the role-emerging placement in the UCC. They cited opportunities to engage in independent learning, manage a high volume of patients, participate in inter-professional collaboration, and be exposed to a variety of conditions.

Table 2 .

Demographic Information for Physician Participants (n = 12)

Characteristic	No. (%)*
Age, y, median (range, min-max)	53 (29–62)
Gender
Men	6 (50)
Women	6 (50)
Professional role
Attending physician	10 (83)
Resident physician	2 (17)
Work status
Full time	11 (92)
Part time	1 (8)
Duration of work at urgent care centre, y, median (range, min-max)	10 (3–32)
Education received
Medical doctorate	12 (100)
Master’s degree	2 (17)
PhD	1 (8)

^*Unless otherwise indicated.

I believe that these students [administered] … 150 to 175 new assessments each. … There was endless opportunity for learning with regards to patient history taking, documentation, collaboration, and communication with the interprofessional team … so many aspects of the placement that offered learning opportunities that do not exist in other placement settings. (Clinical instructor)

UCC team and patients were confident in student competence

Health care providers and patients reported confidence in PT students’ competence in managing musculoskeletal conditions.

The way that they presented the cases seemed very competent … They described the anatomy well; they described their concern and a plan … I was comfortable trusting them in the assessment and a few cases [in which] I had very little involvement with the patient. (Physician 03)

Managing perceived hierarchical relationships was challenging

Students expressed frustration that UCC staff and patients valued physicians’ opinions more than their own. The students felt limited by the requirement to obtain a referral to see each patient.

I think sometimes it depends on just the way our health care system is, um, set up. There’s definitely, in the general public’s eye, sort of a hierarchy, with doctors on the top, being the smartest and the most knowledgeable. … I won’t say that’s untrue, but I think, you know, doctors are experts in their field, and we’re experts in our field. (Student 02)

PT students’ self-confidence increased through the placement

The placement setting and supervision model were intimidating to students at the start of their placement. They reported having low confidence as they integrated into the team, saw a high volume of patients, and approached physicians for referrals. All students reported greater confidence as the placement progressed.

At the start, … I was a little less confident than I would’ve liked. But as the volume of patients increased and I saw similarities and patterns between common conditions, I became more confident, and pretty confident towards the end of placement in my diagnoses and exercise prescription. (Student 04)

Facilitators of the role-emerging placement in the UCC

Informants perceived several experiences to be facilitators of the PT student clinical placements in the UCC: positive perceptions of student supervision, positive impacts of students on patients and the UCC team, the potential for PT students to positively impact health care utilization, and positive perceptions of professional and keen students.

Positive perception of student supervision

The health care providers and students reported high confidence in the clinical instructor and supervision model. They described the clinical instructor as knowledgeable, competent, and accessible to students, which was described as a facilitator of positive placement experiences and future placements in the UCC.

It’s great, because you get a lot more time for self-evaluation and self-reflection. … You’re on your own a lot, but you get used to that, and that’s real life, right? … [The clinical instructor] is great, too. He’s always available by phone [for questions]. … It’s mostly self-directed, but there is still supervision that you can turn to if you need it. (Student 03)

PT students had an important impact

Participants described how PT students had a positive impact on patients and the UCC team. This positive experience was perceived as a potential facilitator of ongoing placements in this setting.

Positive student impacts on patients

All informant groups described the positive impact PT students made. They reported PT students spending extra time with patients, performing more comprehensive musculoskeletal assessments, and providing additional self-management and discharge education to patients. Informants suggested that PT students in the UCC increased access to PT care for people with access barriers.

Honestly, I just really didn’t expect them to spend so much time. … I thought, kind of, going through with an injury that wasn’t a very serious one might have just been quickly dismissed, but I wasn’t expecting to get so much information on what I can do and how to make it better. So it was very good – was very surprised. (Patient 14)

A lot of our patients … are in the demographic that they may or may not have coverage for physiotherapy. … I think it’s quite beneficial in musculoskeletal injuries, or even things like chronic back pain, … to give [these patients] the opportunity to even interact with the physiotherapists, who can … let them know exercises to do, strengthening things. (Physician 13)

Positive student impacts on the UCC team

Nurses reported that the PT students helped decrease their workloads with some patients, allowing them to focus more on other patients. Many of the health care providers felt that PT students added to the care the team was able to offer patients.

I found [the students] extremely helpful in lightening up my load, taking those tasks. … It was wonderful to let someone else who had more, I will say, more knowledge … so I could go someplace else and give my excellent nursing care elsewhere. (Nurse 05)

Potential for students to impact health care utilization

Students felt they had the potential to decrease unnecessary diagnostic imaging, prescriptions, and repeat UCC visits.

I think we can hopefully have an impact on diagnostic imaging … which would probably reduce costs and wait time as well. … If we don’t think there’s a fracture, then why would you send someone for X-ray? (Student 01)

However, several physicians reported no change in patterns of prescriptions or diagnostic imaging with PT students present.

I don’t think it really affected the imaging. Often imaging is done to rule out and/or sometimes to ease anxiety. … I don’t think it affected the experience I had; I wouldn’t have imaged more or less patients, nor would I prescribe differently than I would normally. (Physician 06)

Perceptions of professional, keen students

Health care providers saw having students who were eager to work with patients and who took initiative in identifying appropriate referrals for PT services as an important facilitator for placements.

I think [they] took initiative, so a lot of the times they would recognize, you know, “Hey, there’s an ankle waiting to be seen; do you mind if I see this patient?” That kind of initiative was really nice, and by the time I went to assess the patient, they already had a comprehensive kind of history. My involvement was, I think, a little bit less than it would normally be. … And then they could provide more detailed instructions to the patient than I would be able to, so it was very helpful. (Physician 07)

Barriers to the role-emerging placement in the UCC

Barriers to the PT student clinical placements in the UCC included a lack of shared electronic medical record (EMR) access for the students to document care, limited bed space and the potential to slow the flow of patients, difficulty building relationships because of frequent physician turnover, providers’ lack of understanding of the PT role and PT student abilities, medico-legal ambiguity, and the lack of a process for order of care.

Lack of shared EMR

Students had access to view the EMR but not to document the care they provided. Patient charts were locked upon discharge, so students had to complete documentation on paper for the clinical instructor to review and co-sign, which meant that other health care providers had difficulty accessing their charting. Providers saw this as a barrier to continuity of care.

If they had access to [the EMR] and they could put in their own little physio note, to say their impression, … then they could document their physical exam and their recommendations for the patient. I actually think that would be an important component, in terms of continuity of care. (Physician 06)

Slowed flow of patients

Health care providers reported that the time students spent with patients and miscommunications about patient discharge occasionally held up beds and slowed down department flow.

We could have 3 or 4 patients waiting for physio, right? So, it holds up a bed and slows me down being able to move other patients through the department. … That’s a minor thing, and the benefit of having [the students] here, I think, way outweighed that. (Nurse 04)

Frequent physician turnover

Frequent physician turnover made it difficult for students to build collaborative relationships.

It is also hard to … establish, like, a really strong relationship with the doctor because they are rotating all the time. But there’s nothing you can do about that … it’s the schedule. (Student 03)

Not understanding of the PT student abilities

Health care providers described a lack of understanding of the PT scope of practice related to primary care and diagnosis and unclear expectations regarding the students’ abilities.

I never was able to get a good sense of where they were in their education, … what should be my expectation of what their abilities are, and what their scope is. … I kind of thought all along it would be nice to have just a bit more of a clearer idea as to who were the appropriate patients, from our perspectives, to be sending their way. (Physician 01)

Medical-legal ambiguity

A few physicians noted it was unclear to them who was responsible for student supervision and who was legally responsible for the care provided by the students when the clinical instructor was not present.

[My concern] would be just the medico-legal fallout. If a patient, for example, wasn’t assessed by a physician and went on a physio student’s kind of history [and] physical – for example, didn’t order an X-ray and it turned out to be a fracture – I’m not sure who would bear that medical responsibility. And also oversight for the students – I’m not sure who they report to [when the clinical instructor is not there]. … I can’t teach or, um, supervise a physiotherapy student that well. (Physician 03)

Lack of a process for order of care

Physicians each had their own preference for whether they saw the patient first or after the student. Students noted that in some cases, inconsistency in the order of care was a barrier to their involvement in patient care and learning.

There’s a few physicians that like to go in and see the patients first, and if they think it’s appropriate, they kinda refer to you, whereas other physicians, they’ll give you that referral sheet if it sounds kinda musculoskeletal. They say, “Yeah, go for it. Go see whatever and report back to me.” (Student 06)

Discussion

The PT students and health care providers in this study reported that the role-emerging clinical placement in the UCC offered unique independent and interprofessional learning opportunities with a high volume of assessments with patients who had a variety of musculoskeletal conditions. Health care providers and patients, as well as the students and their clinical instructor, described the students’ contributions to the inter-professional team and improved care for patients.

Our findings indicate that informants were satisfied with the role-emerging placement experience, the care PT students provided, and the perceived reduced workload for staff. These results align with findings from previous research evaluating the integration of physiotherapists into EDs. Multiple studies have found that PT management of musculoskeletal conditions in the ED can result in high levels of patient satisfaction,^8,26,27 confidence in the services provided, and reduced workload for the ED team.²⁸ Similarly, our findings that informants saw value in the time PT students spent with patients²⁷ and their contributions to the UCC team²⁹ align with research on the integration of physiotherapists in EDs.

Previous research from other health professions on role-emerging placements has focused on understanding students’ perspectives.^16,18,19 Our study included interviews with multiple informant groups, allowing for in-depth examination of experiences, barriers, and facilitators from multiple perspectives. As a result, we identified themes we would not have identified in interviews with students alone. For example, the UCC team, but not the students, identified the potential barriers of slowed patient flow and medico-legal uncertainty. These aspects of our study provide important information to inform future placements in the ED and important methodological considerations for evaluating other role-emerging placements in the future.

Students highlighted several aspects of the role-emerging placement that contributed to their learning, including being part of the interdisciplinary team, adapting to the unique and challenging environment, and engaging in autonomous and peer learning opportunities supported by the partial supervision model. These findings align with previous research suggesting that key aspects of role-emerging placements that enhance student learning are interdisciplinary mentorship,³⁰ non-traditional environments,^16–18 and a shift from traditional apprenticeships to a more hands-off supervision approach,¹⁸ which may facilitate self-directed and self-regulated learning. Importantly, all informant groups reported feeling confident in the student supervision model, which will be critical to implementing similar placements in the future. Students perceived adapting to the UCC environment to be challenging; they reported difficulties building collaborative relationships, given frequent staff rotations, and navigating hierarchical relationships within the UCC. While students perceived this adaptation as a challenge, previous literature has suggested that challenging students to adapt to a unique environment is a key benefit of role-emerging placements.^16–18

Informants identified several modifiable barriers to successful student placements in the UCC. Students and health care providers reported a lack of clarity on the processes for order of care and patient flow. UCC team members also expressed uncertainty about medico-legal responsibilities, the PT scope of practice, and expectations for students’ abilities at that point in their training. Previous studies have identified the need for clarification of the PT role and order of care.^29,31

Stakeholders can use the results of this study to inform future PT student placements in the ED. They can develop strategies to address the barriers we identified – for example, providing preplacement education to inform the UCC team about the PT scope of practice in this setting and ensure shared expectations for student competence, supervision, and medico-legal responsibilities. Additionally, the methodological approach we used in this study can provide a framework for evaluating future role-emerging placements.

The findings of this study suggest multiple areas for future research. One of the overarching objectives of role-emerging placements is to develop physiotherapists’ competencies for emerging roles. We found evidence that these placements are feasible in the ED, but future research should evaluate changes in student competencies. Future research could also evaluate the impact of role-emerging placements in the ED on team workloads, patient outcomes, wait lists, imaging utilization, and readmission rates, which our informants perceived as important impacts of the role-emerging placement.

Our study has two limitations. First, an inherent limitation of qualitative research aiming to understand a specific phenomenon in a local context is that results are not necessarily generalizable or transferrable to other settings. This study took place in a single UCC in Kingston, Ontario, and it is unclear whether the findings are transferrable to other EDs. Second, the interviewers were peers of the student participants. While the researchers made their positionality transparent, these pre-existing relationships may have influenced the information the student participants shared in the interviews.

Conclusion

All informant groups reported a positive experience with this role-emerging PT placement in a UCC. Stakeholders in future role-emerging placements in EDs can use our findings on barriers and facilitators to improve their placement programme. Further research should evaluate learning outcomes of role-emerging clinical placements for PT students.

Key Messages

What is already known on this topic

Musculoskeletal conditions are among the most common reasons people seek care in an emergency department (ED). Physiotherapists can play an important role in the ED because of their expertise in managing musculoskeletal conditions. Physiotherapists have been integrated into EDs in multiple countries, resulting in decreased wait times, improved patient outcomes, and reduced staff workloads. Role-emerging placements allow physiotherapy (PT) students to gain experience in settings where physiotherapists do not currently practise.

What this study adds

Previous studies on role-emerging placements have focused on student perspectives. We examined experiences, barriers, and facilitators in a role-emerging placement in an ED through interviews with PT students, their clinical instructor, ED team members, and patients. The results of this study can inform future role-emerging placements by providing a better understanding of the experiences, barriers, and facilitators in implementing a role-emerging PT student clinical placement in an ED.