Impact of short-term patient education intervention on the teaching skills of physical therapy students: a randomized controlled trial

Abstract

Background

Patient education is an important aspect of physiotherapy. Effective education is based on quality communication and understanding of patients’ needs. For a successful practice, it is necessary to recognize the factors that affect the ability to teach the patient and prepare new physiotherapists for this task. The research aims to determine the effect of training on the self-efficacy and skills of physiotherapy students in patient education.

Methods

Final-year physiotherapy students were randomized into an intervention group (52 students) and a control group (51 students). The intervention group participated in 2.5 hours of lectures, discussions, simulated exercises with colleagues, and video examples of patient education. Students in the control group received standardized instruction without the additional intervention provided to the experimental group. All students performed a self-assessment of their teaching abilities. Patient education was assessed by a blinded evaluator using the Objective Structured Clinical Examination from an audio-recorded simulated clinical practice task.

Results

The results show no differences in demographic variables, while a significant improvement was achieved for the intervention group after the training. The intervention group before the experiment did not perform differently than the control group on self-efficacy items (p>.05), but they did perform significantly better than the control group after the experiment (p<.001). The intervention group showed better results than the control group in almost all observed fields.

Conclusion

Short-term educational intervention significantly enhances physiotherapy students’ self-efficacy and patient education skills, emphasizing the value of structured educational interventions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-024-06360-8.

Background

Patient education is defined as “planned teaching in which methods such as instruction, consultation, and behavior modification are utilized to alter the patient’s actions and knowledge regarding health” [1]. It is a relatively new discipline in healthcare that previously predominantly involved knowledge transfer and biomedically-based advice. As healthcare shifted from traditional paternalistic approaches toward patient-centered care, patient education had to adapt to individual needs [2]. Current research supports the pivotal role of patient education in enhancing health outcomes, as demonstrated in a literature review and meta-analysis encompassing over 360 studies investigating the impact of patient education on chronic diseases [3]. Conversely, the absence of patient education in healthcare settings is correlated with adverse outcomes, including hospital readmissions, incorrect therapy adherence, and inadequate follow-up [4–7]. Compared with other healthcare professionals, physiotherapists when given their direct and prolonged interactions with patients are uniquely positioned to establish therapeutic relationships [8]. Despite its significance, there is a lack of defined strategies for effectively implementing patient education in practice and determining the required competencies [9]. Available evidence indicates that healthcare professionals, including physiotherapists, often provide unplanned, spontaneous, and informal patient education as part of broader care approaches [10]. Therapeutic patient education facilitates disease management and yields both health and financial benefits. However, many healthcare providers lack the skills for effective patient education [11]. Forbes et al. conducted a study to compile a comprehensive list of competencies for patient education among physical therapists’ expertise. Identifying key competencies in this domain will facilitate the assessment of patient education and enhance the educational and professional roles of physiotherapists [12]. Previous research indicates that 99% of physiotherapists consider patient education essential, with over 90% incorporating individual patient education into their treatment plans [13–15]. Research increasingly supports the importance of patient education in physiotherapy. Purposeful educational interventions help patients identify harmful beliefs and behaviors, improve performance, and lead to better outcomes such as pain management, reduced disability, and improved function [16–20]. Wittnik et al. stress that physiotherapists should prioritize making information understandable to all patients, avoid medical jargon, and assess learning outcomes [2]. Few studies have examined how physiotherapy students develop patient education skills. Hoffman et al. identified courses within the physiotherapy curriculum that include communication training, focusing on teaching these basic skills [21]. Australian researchers highlighted a gap in students’ practical experience, noting limited interaction with patients during their studies [22]. The literature emphasizes the importance of patient education, particularly in healthcare programs targeting professionals such as physical therapists [23]. Effective education can improve student engagement, motivation, and skill acquisition. Given that competencies develop over time, ongoing training is necessary to maintain communication skills [23–26]. Despite this, healthcare professionals and students often report inadequate information about patient education and limited opportunities for professional development [25–31]. To health profession students, patient education is presented as an individual skill that does not require specialized training, with any instruction in this area often considered “random” [32]. Understanding and assessing how current curricula prepare students to become effective educators, and whether providing instruction can enhance physiotherapy students’ self-efficacy and proficiency in patient education, are critical endeavors [33]. This research aimed to investigate how physiotherapy students handle the responsibility of patient education, self-assess their teaching abilities, and determine whether patient education training can enhance their instructional skills. By answering these questions, we can improve the teaching of physiotherapy students and patient education in practice.

Methods

Study design

The Methods section describes a randomized controlled trial assessing the effectiveness of physiotherapy students in patient education after a brief training session. The trial involved final-year physiotherapy students at the University of Mostar, Bosnia and Herzegovina, who provided prior consent to participate. The intervention and assessment occurred at their faculty (Fig. 1) from January to April 2024. All 103 participating students were randomly assigned to either the intervention (n=52) or control group (n=51). Each participant completed a 21-item patient education self-efficacy assessment from research by Forbes et al. [22] (author approval obtained) and the Objective Structured Clinical Examination (OSCE) questionnaire for clinical skills and patient education [34]. The intervention group completed the OSCE after training, while the control group completed it before training. To ensure linguistic and cultural consistency between the English and Croatian versions of the OSCE and questions about self-efficacy, the questionnaires were translated following the World Health Organization’s Guide for Translation and Adaptation of Instruments. The translation process involved forward and backward translation, followed by final proofreading.

Fig. 1.

Diagram of the research protocol

Participants

The inclusion criterion for this study was that the students were in their final year of physiotherapy at the University of Mostar, while the exclusion criterion was that they were physiotherapy students with previous work experience.

Intervention

The participants in this study were students from the University of Mostar. Before the commencement of the research, all respondents were briefed on the aim and purpose of the study, and their written consent was obtained for participation. A total of 103 students were surveyed using demographic questions. Group allocation was determined by an independent researcher using a list of random numbers. The experimental group underwent a 2.5-hour intervention, which included instruction on patient education, implementation, evaluation, practical exercises, and a video demonstration. Subsequently, both groups participated in a simulated practical clinical task with peers acting as simulated patients, and their performance was assessed by an independent examiner. The clinical skills of physiotherapy students in patient education were evaluated using the Objective Structured Clinical Examination (OSCE). Following the intervention and OSCE testing, the experimental group completed a self-efficacy questionnaire. To prevent cross-group contamination and bias, as per similar study protocols, both the intervention and assessment were conducted on the same day for all participants. The intervention for the experimental group was administered by researchers and a communication specialist, while OSCE testing for all participants was conducted by an independent physiotherapist (blinded to group assignment). The components of the educational intervention are detailed below and summarized in Table 1.

Table 1.

Components of educational intervention

Components	Content	Duration
Teaching	- Review of theory and evidence on patient education; How to assess the educational needs of the patient, adapt the education to the patient, and assess and evaluate learning; Video examples of patient education in practice and discussions.	45 min
Simulated practice of patient education	- Presentation of a clinical case with a structured simulated patient; Students work in groups of two to plan and perform each component of patient education: assessment, implementation, evaluation, and observation of other students.	45 min
Feedback	- Physiotherapists and students provide structured feedback to each student for the completed patient education task.	15 min
Discussion and Report	- Examination and discussion regarding cases, challenges faced, and how to overcome barriers to patient education.	45 min

Control group

Students in the control group underwent the same assessment process as those in the intervention group. Initially, participants completed demographic questions and underwent OSCE testing with peers portraying simulated patients to evaluate their patient education skills and self-assessment of their teaching abilities. Following the completion of testing by all students, the control group received identical training to the intervention group.

Outcome measures

Although formal measures for assessing physiotherapists’ skills in patient education are lacking in the literature, previous research has utilized the OSCE test to evaluate students’ clinical skills [22]. Participants completed a 21-item patient education self-efficacy assessment alongside demographic questions (gender, program enrollment). The OSCE test was employed to evaluate skills in patient education. A patient scenario was devised to enable students to communicate and counsel a patient in a clinical setting. Each student had 10 minutes to study the case and devise their education strategy, followed by 10 minutes to interact with a peer-simulated patient. The same patient scenario was utilized for all students, and an independent physiotherapist, blinded to group affiliation, assessed all participants via OSCE, with audio recordings utilized for clinical assessment. The 8th item of the performance measure (“Provides family or caregivers with information”) could not be assessed in the OSCE because no parent or caregiver was needed.

Methods of analysis

Study instruments

The reliability of the performance measure was evaluated by calculating internal consistency using Cronbach’s alpha across the performances, yielding a Cronbach’s alpha efficiency of 0.858 (an acceptable level of internal consistency).

Data analysis

Data were collected in a Microsoft Excel database, and statistical analysis was performed using SPSS 10.0 software (SPSS Inc., Chicago, IL, USA). The Kolmogorov-Smirnov test assessed the distribution of the results on the primary outcome measures. Parametric statistical procedures were used to evaluate the data, and the comparison of the performance results of the groups was performed using independent t-tests. In contrast, a comparison of results was achieved by one-way analysis of variance (ANOVA) followed by the LSD post hoc test. The significance level was set at p < 0.05.

Results

Patient education performance

Out of 106 eligible students recruited, 103 completed the study, three of whom declined to participate. The baseline characteristics of the participants were comparable between the intervention and control groups (refer to Table 2).

Table 2.

The baseline characteristics of the participants

Characteristic	Intervention group N (%) N= 52 (50.6)	Control group N (%) N= 51 (49.0)	P value
Gender
- Male	25 (48.08)	24 (47.06)	0.886
- Female	27 (51.92)	27 (52.94)	1
Physiotherapy Program Type
- Graduate level	14 (26.92)	13 (25.49)	0.847
- Undergraduate level	38 (73.08)	38 (74.51)	1

This table presents the baseline demographics of participants in both the intervention and control groups. The table shows the distribution of gender and physiotherapy program type among participants, along with the corresponding percentages and p-values.

Patient education performance

Patient education performance scores differed significantly between groups, with participants from the intervention group achieving higher scores for nine of the ten assessable items (p < .001). Students from the intervention group demonstrated OSCE outcomes prevalence over those from the control group (seeking patient perceptions and concerns related to appropriate questioning, reflective questioning, and shared decision-making; selecting and using appropriate learning content tailored to the best interests of the patient; employing effective and engaging communication styles, language, and/or materials tailored to patients; explaining the patient’s condition or problem; providing lf-management education and reinforcing the patient´s ability to manage; effectively summarizing information; utilizing the “teach-back” (verbal or demonstration) method to evaluate learning; identifying when educational needs have been met). Table 3 provides a detailed breakdown of these findings.

Table 3.

Differences in performance OSCE outcomes between the intervention and control group

Performance item	Intervention group (n = 52)	Control group (n = 52)	d (effect size)	Mean difference (p-value)
	Mean (SD)	Mean (SD)
Overall result	32.769 (1.664)	19.157 (3.849)	4.591	< .001
1. Seeks patient’s perceptions and/or concerns using appropriate questioning	3.21 (0.667)	2.06 (0.968)	1.383	< .001
2. Uses reflective questioning	3.46 (0.699)	2.20 (1.020)	1.441	< .001
3. Uses shared decision making	3.13 (0.658)	1.75 (0.956)	1.633	< .001
4. Select and use appropriate learning content tailored to the best interests of the patient	3.27 (0.717)	2.08 (1.036)	1.336	< .001
5. Uses effective and engaging communication styles, language, and/or materials that are tailored to the patient	3.31 (0.755)	1.59 (0.983)	1.962	< .001
6. Effectively explains the patient’s condition or problem	3.37 (0.658)	1.98 (0.927)	1.729	< .001
7. Provides self-management education and reinforces patients ability to manage	3.31 (0.729)	1.84 (1.065)	1.611	< .001
8. Provides family or caregivers with information	NA	NA	NA	NA
9. Effectively summarizes information	3.29 (0.776)	1.75 (0.997)	1.724	< .001
10. Uses the “teach back” (verbal or demonstration) method to evaluate learning	3.19 (0.687)	1.84 (1.173)	1.404	< .001
11. Identifies when educational needs have been met	3.23 (0.703)	2.08 (1.294)	1.104	< .001

This table presents the differences in performance scores between the intervention and control groups, along with their respective means, standard deviations, effect sizes (d), and mean differences with p-values.

Self-efficacy of students in intervention and control groups

The intervention group did not perform differently from the control group on self-efficacy items before the experiment (T1), and their average results are shown in Table 4 (p > .05). However, they significantly outperformed the control group after the experiment (T2, p < .001). The LSD post hoc test results also indicated that the self-efficacy scores of the intervention group were significantly higher after the intervention, demonstrating a statistically significant difference in self-efficacy scores between the intervention group before and after the intervention. The determined differences on individual questions follow the stated differences in the overall result, except for the ninth question, where there are no significant differences between the groups.

Table 4.

Differences in self-efficacy scores between the intervention and control groups

Self-efficacy item	Intervention group T1 (n = 52)	Intervention group T2 (n = 52)	Control group (n = 52)		d (effect size)	Mean difference (p-value)
	Mean (SD)	Mean (SD)	Mean (SD)
Overall result	85.7885 (7.135)	101.558 (7.508)	85.196 (7.349)		1.033	< .001
1. I understand the role of patient education	2.94 (1.178)	3.98 (0.828)	2.69 (1.175)		0.307	< .001
2. I understand the impact of social, cultural, and behavioral variables on patient learning	3.13 (1.067)	3.88 (0.704)	3.20 (0.939)		0.259	< .001
3. I understand the principles of adult learning	3.10 (1.125)	3.73 (0.866)	3.06(0.988)		0.232	< .001
4. I feel confident in using questioning to seek the patient’s perceptions and concerns about their condition	3.06 (1.127)	3.73 (0.843)	2.98 (0.927)		0.256	< .001
5. I feel confident in obtaining information from the patient assessment to understand their learning needs	2.69 (1.058)	3.62 (0.867)	2.71 (0.923)	.363		< .001
6. I feel confident in using reflective questioning (questions that allow the patient to reflect out loud)	3.13 (1.112)	3.83 (0.901)	3.24 (1.050)	.150		.007
7. I feel confident in selecting and using a range of appropriate learning content that is tailored to the patient	3.02 (1.244)	3.94 (0.895)	3.04 (1.248)	.260		< .001
8. I feel confident to explain the patient’s condition to them	3.10 (1.125)	3.73 (0.866)	3.08 (1.129)	.124		.002
9. I feel confident in using shared decision-making (i.e., outlining options to the patient and reaching a decision about treatment together)	3.73 (0.952)	3.73 (0.952)	3.73 (0.961)	.000		.999
10. I feel confident in providing self-management strategies to the patient and reinforcing their ability to manage	2.83 (1.115)	3.60 (0.799)	2.84 (1.120)	.293		< .001
11. I feel confident in providing family or caregivers with information (where they are present)	3.06 (0.988)	3.73 (0.843)	3.10 (1.071)	.256		< .001
12. I feel confident in tailoring communication styles, language, and materials to the patient	3.10 (1.071)	3.87 (0.817)	3.12 (1.070)	.270		< .001
13. I feel confident to control attention and engagement when educating the patient	2.77 (1.198)	3.69 (0.853)	3.06 (0.988)	.338		< .001
14. I feel confident in providing educational content that is in the best interests of the patient	3.02 (1.229)	4 (0.840)	3 (1.233)	.360		< .001
15. I feel confident in recognizing and effectively managing barriers to effective education (i.e., identify where learning may be compromised and act to discuss or modify these barriers)	2.90 (1.071)	4.27 (0.630)	3.24 (1.050)	.465		< .001
16. I feel confident in summarizing information for the patient	3.17 (1.339)	4.29 (0.825)	3.20 (0.939)	.352		< .001
17. I feel confident in integrating evidence-based practice into patient education	2.42 (0.957)	3.12 (1.022)	2.41 (0.942)	.309		<.001
18. I feel confident to provide education within the limits of my practice and seek advice or refer to another professional where appropriate	2.48 (0.896)	3.23 (1.041)	2.69 (1.122)	.289		<.001
19. I feel confident in identifying when patient learning has been achieved through evaluation	2.54 (1.111)	3.21 (1.194)	2.75 (1.111)	.248		<.001
20. I feel confident to review the progress of the patient’s learning	2.50 (1,057)	3.13 (1.205)	2.69 (1.104)	.218		<.001

This table presents the self-efficacy scores for each item between the intervention group before (T1) and after (T2) the experiment, and the control group, including the mean values, standard deviations, effect sizes, and p-values.

Discussion

The results of the research of physiotherapy graduate students at the University of Mostar showed a significant improvement in almost all students’ competencies in the intervention group compared to the corresponding control group. These findings suggest that an educational intervention that combines theoretical and practical teaching, including knowledge, observation, simulation, and experience, can significantly improve the performance of physiotherapy students in patient education. One of the largest differences in OSCE scores between the intervention and control groups relates to the assessment of patient perceptions and concerns using effective and engaging patient-friendly communication styles, language, and/or materials. The control group’s low scores in this area indicate that without specific training, this skill may be underdeveloped when students enter the clinical setting. Previous research points out that the most important aspect of improving patient-centered educational outcomes is the assessment of the patient’s learning needs, concerns, and preferences [35, 36]. The results of this research point to the shortcomings of the existing formal education, especially in the area of communication competencies of physiotherapists, which is also confirmed by Hoffman et al. [21] in their results, and the underdeveloped autonomy of physiotherapy in Bosnia and Herzegovina [37] also contributes to this. There is concern that teachers of health studies are not trained to teach communication skills and that there is a lack of teaching modules within the study program [38], which could also be linked to the results of this study.

Patient education plays a key role in physiotherapy, including clinical outcomes [24], however, research shows that physiotherapists are insufficiently familiar with communication strategies related to physiotherapy [39, 40].

Our result, as well as the results of a similar study [22], determines that a short training intervention can significantly improve the educational skills of final-year physiotherapy students. These results may indicate a relationship between student teaching performance and patient education.

Physiotherapy graduates with practical experience and training had significantly higher patient education self-efficacy scores than those who did not have all these experiences. These findings suggest that opportunities for practice and patient education during training, along with observation and feedback, are necessary for physical therapy students’ training. Similar studies also point out that practical experience makes it easier for beginners to apply knowledge and skills in practice [41] and helps them acquire communication skills and professional development [42]. For skill development in patient education, recommended educational strategies are: exposing students to appropriate role models, providing explicit opportunities to practice skills in real-world settings, and providing opportunities for feedback on performance [30, 43, 44]. Our results support these recommendations by demonstrating the link between teaching and skill development and their importance from the perspective of physiotherapy students. The results of this research show significantly higher self-efficacy in the intervention group of students, which is in line with the conclusions of the study among nursing students [45], where it was determined that the respondents achieved better results after the educational virtual training and expressed confidence in conducting conversations with patients, providing patient education and debriefing. Simulated patient education helps students improve performance and self-efficacy in communication and clinical skills [46, 47] which is also confirmed by our results. However, the limited availability of courses or continuing education on this topic certainly contributes to the low results before educational intervention [48]. In the existing communication educational programs at the University of Mostar, an educational model should be developed to encourage the development of effective communication skills of physiotherapy students for patient education.

Investigating the long-term implications of patient education on the self-efficacy and skills of graduate physiotherapy students is a challenge for further research. Future research should also consider continuous learning to maintain acquired skills through professional development or within a professional setting.

Limitations of the study

However, it is important to recognize the limitations of this study. Assessing patient education skills before the intervention may threaten internal validity due to awareness of the primary outcome measure. Positive feedback is linked to higher efficacy, regardless of skill performance [49]. Students used different teaching methods during classes that contributed to the development of teaching skills, but it is not clear which components had the greatest impact on outcomes. The intervention was conducted at a single educational institution and may not reflect the diversity of physiotherapy programs worldwide. Patient education involves verbal and non-verbal communication, and audio recordings alone cannot effectively assess non-verbal aspects, which is a notable limitation. Additionally, various factors influence physiotherapists’ communication skills, such as previous education, curriculum, clinical practice experience, and personal background. These factors introduce potential biases or limitations that should be considered.

Conclusions

Our findings demonstrate the benefits of a single, brief patient education intervention on physical therapy student skills and patient education performance. Interventions like this could fit into an existing physical therapy curriculum, providing an example of a practical and effective method for improving future physiotherapist competence. However, further research is needed to understand the long-term impact or maintenance of these skills and their sustained impact on patient outcomes.

Abbreviation

OSCE

Objective Structured Clinical Examination

Authors’ contributions

Conceptualization VG; methodology JŠ; formal analysis JŠ and VG; data curation ML; writing VG. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Data availability

The data presented in this study are not publicly available to protect the participants’ privacy, data are available from the author upon reasonable request.

Declarations

Ethics approval and consent to participate

The study was conducted following the Declaration of Helsinki and approved by the Research Ethics Committee at the Faculty of Health Studies, University in Mostar (protocol code 01-691/23). Informed consent was obtained from all subjects involved in the study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.