Academic performance-based sequencing of inpatient and outpatient placements enhances learning in physiotherapy undergraduates: a controlled study

Abstract

Background

To evaluate whether performance-based sequencing of clinical placements improves learning outcomes compared with randomized sequencing in undergraduate physiotherapy education.

Methods

Undergraduate physiotherapy students from six universities in China were randomly assigned to experimental and control groups. The experimental group’s placement order (inpatient or outpatient) was determined based on theoretical and clinical performance, while the control group’s order was randomized. Mini-Clinical Evaluation Exercise (Mini-CEX), theoretical performance evaluation and the Clinical Reasoning and Reflection Self-Rating Scale (SACRR) were evaluated before and after placement using t-test.

Results

112 students participated in the study. Both groups showed significant improvements in clinical and theoretical performance post-placement. The experimental group had greater improvements in Mini-CEX scores (41.02 ± 12.37 vs. 38.35 ± 9.65, p = 0.031), with significant gains in history taking (p = 0.005), professionalism (p = 0.006), and counseling (p = 0.007). Theoretical test scores improved more in the experimental group (from 51.83 ± 9.89 to 69.00 ± 8.93 vs. 54.56 ± 7.62 to 66.52 ± 10.71, p = 0.038). The SACRR scores also showed greater improvements in the experimental group (92.13 ± 11.72 to 109.48 ± 10.63 vs. 91.30 ± 10.02 to 97.93 ± 10.63, p < 0.001), with significant gains across all subdomains.

Conclusions

Sequencing clinical placements according to student performance yielded greater improvements in history taking, professional attitude, and communication skills, as well as theoretical knowledge and clinical reasoning, compared with randomized sequencing. These findings suggest that performance-based placement scheduling can strengthen key patient interaction and reasoning competencies in physiotherapy students.

Background

Clinical practice is an integral component of the physiotherapy programs [1]. It provides students with the opportunity to apply theoretical knowledge in a clinical setting, develop practical skills, and gain first-hand experience interaction with patients, supervisors, co-workers and peers. Supervised clinical placements are essential to ensure students develop the necessary clinical skills and are able to apply theoretical knowledge into clinical practice. Thus, clinical placement efficacy remains a high priority in the educational quality agenda [2]. Despite their importance, the structure of clinical placements has traditionally been understudied. Placement structures, including hours per day, days per week, and duration in weeks, vary significantly across different programs and are determined at the institutional level [3]. Factors influencing these variations include educators’ previous experience, underlying assumptions, institutional resources, and logistical considerations. The traditional block placement model has commonly been used in clinical education but some authors argued that this approach may hinder students development due to insufficient time to adequately address student needs [4]. According to a study conducted by the University of British Columbia in Vancouver, Canada, physiotherapy students complete six 5-week clinical education placements at approved clinical education sites [5]. In China, the undergraduate physiotherapy program typically consists of three years of theoretical coursework, followed by a final year dedicated to clinical practice. This continuous placement model is advantageous for students to maintain and develop clinical skills, as well as early professional acclimatization due to the regularity of clinical exposure [6]. However, students are still required to rotate through different specialties in a block format.

A critical yet underexplored aspect of placement structure is the sequence of rotations, particularly inpatient versus outpatient settings. Most programs assign placement order according to clinical site availability or administrative loads, rather than pedagogical rationale [2]. Given the differing case types, skill demands, and reasoning processes required in outpatient and inpatient settings, the sequencing of experiences may influence students’ development of clinical reasoning, hands-on competencies, and communication skills.

Physiotherapy students struggle to integrate patients’ needs and experiences with their own reasoning and decision-making [7]. They often report feeling unprepared for the demands of real patient care [8] as they must rapidly translate theory into practice [9] while acquiring communication, decision-making, and time-management skills in unfamiliar teams and settings. Thus, clinical placement sequencing may affect the development of adaptability and practical skills by exposing students to different learning opportunities in distinct clinical environments. An early study on medical training indicated that there were differences between inpatient and outpatient settings and that doing outpatient rotations prior to inpatient clinical placement can be beneficial [10] since outpatient rotations offer multiple benefits including exposure to specific clinical scenarios and therapeutic interventions applicable only in the outpatient setting [11]. A more recent study reported the evidence-based performance is weaker for physiotherapist who practiced in intensive care unit compared to those who practiced in outpatient settings [12]. Despite the known differences between inpatient and outpatient settings, there is limited research on how the sequence of these placements influences physiotherapy students’ learning outcomes. To date, no study has been found that has systematically examined the effects of clinical placement order on educational outcomes in physiotherapy programs. This study aims to provide insight into the impact of academic performance-based placement order strategy on educational outcomes.

Methods

Sample population

Undergraduate physiotherapy students from six domestic higher education institutions underwent clinical placements at the Department of Rehabilitation Medicine, Sun Yat-sen University were recruited. All participants completed the placement between September 2022 and August 2024. The included students had not participated in clinical placement prior to the study commencement.

Sample size was estimated based on our previous pilot results of Mini-CEX total score means and standard deviations (performance-based group: n = 15, mean score of 39.80 ± 6.84; randomized order group: n = 16, mean score of 34.13 ± 7.32) in G*Power statistical software (version 3.1.9.4; http://gpower.hhu.de). α value was set to 0.05 with a target power of 0.80. The analysis indicated that 35 participants per group would be required to achieve sufficient statistical power to detect minimal difference of 5 points in Mini-CEX score between the two groups.

Study setting

This was a quasi-experimental, two-group comparative study conducted in the First Affiliated Hospital, Sun Yat-sen University’s Department of Rehabilitation Medicine. Two academic cohorts were included. Students in the 2023–2024 cohort followed the usual institutional allocation (random sequencing) and formed the control group. Students in the 2022–2023 cohorts received a performance-based sequencing where they were assigned to either the “Outpatient First” or “Inpatient First” rotation groups based on their academic performance. Specifically, students with lower theoretical performance (i.e., those with a lower theory grade than clinical grade) were assigned to the “Outpatient First Rotation Group.” This was based on the hypothesis from previous studies [13] suggesting that outpatient rotations may improve theoretical performance by focusing on cognitive skills and theoretical learning. Students with higher theoretical performance but lower clinical scores were assigned to the “Inpatient First Rotation Group” to enhance their clinical skills through more hands-on, patient-centered learning in inpatient settings. The students in the “outpatient first” group were prioritized to have outpatient rotations of different specialties including musculoskeletal outpatient and pediatric outpatient over an 8-week period, followed by an 8-week rotation in the inpatient department. The “inpatient first” group first completed an 8-week rotation in the Rehabilitation Department’s ward and other departments offering bedside rehabilitation, including adult and pediatric physical therapy, followed by an 8-week rotation in the outpatient departments.

In both groups, mentoring was randomly assigned by experienced clinical educators within the corresponding departments. Students had opportunities to observe, ask questions, and perform practical procedures during their placements. All participating students attended department lectures and training sessions. They also underwent regular learning assessments, presentations, and evaluations, ensuring uniformity in the learning process across both groups, with the exception of the order of department rotations.

Outcome measures

The theoretical and clinical performances of the participants, along with their self-evaluation, were assessed at the beginning of the placement (at 0 week) and after 16 weeks of the placement (at 17 weeks).

Theoretical performance evaluation

The theoretical performance of students was assessed using a test consisted of 50 multiple-choice questions selected from the “Rehabilitation Medicine and Therapeutic Techniques” question bank [14], published as part of the ‘National Health Professional and Technical Qualification Examination’. The question bank covers core competencies across the curriculum, including foundational knowledge, clinical knowledge and clinical application. Foundational knowledge includes scientific principles such as anatomy, physiology, biomechanics, and kinesiology, which provide the basis for understanding human movement and rehabilitation techniques. Clinical knowledge covers physiotherapy theories, evidence-based practices, and management strategies for medical conditions. Clinical application refers to the theoretical knowledge of clinical practice, including patient assessment, treatment planning, and decision making in clinical scenarios. These questions align with the content covered in the students’ coursework. The total score was 100 points, with each question worth 2 points. Higher scores indicated better theoretical performance.

Clinical performance evaluation

The Mini-CEX was used to evaluate clinical performance. This tool includes seven key evaluation domains: history taking, physical examination, clinical reasoning, counseling, organization/efficiency and overall clinical competency [15]. Each domain is scored on a 9-point scale, with 0–3 points being below the standard, 4–6 points being in line with the expected standard, and 7–9 points being higher than the expected standard. The evaluation was performed by clinical educators after direct observation of the students’ performance during patient interactions. Rating and feedback were completed in 5–10 min after the observation of the first and final clinical performance that the student performed. The Cronbach’s alpha coefficient of the Chinese version of the Mini-CEX was 0.932. Criterion-related validity for Mini-CEX overall competence with the end examination of rotation was 0.53 [16]. The Mini-CEX evaluation was conducted by examiners who were blinded to the group allocation of the students.

Self-evaluation

Clinical reasoning and reflection were assessed using the Chinese version of the Self-Assessment Clinical Reflection and Reasoning (SACRR) [17]. The scale consists of 26 items rated on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree) [18].The evaluation content of the scale includes 4 major items: exploratory factor analysis, information system, analysis of problems, finding truth and reflective ability. The Cronbach’s alpha of the Chinese version of SACRR was 0.754 and the total scale test-retest reliability was 0.785.

Data analysis

Statistical analyses were performed using SPSS version 20.0 (IBM, Inc., Armonk, NY, USA). Descriptive statistics were calculated for all variables. Kolmogorov-Smirnov test was used to evaluate the normality of the data distribution. The homogeneity of the dataset was assessed by the Levene test. For the between-group analyses, independent-samples t-tests were conducted for continuous variables that were normally distributed. For continuous variables that did not meet the assumption of normality, even after log transformation, the Mann-Whitney U test was applied. Categorical variables were compared using chi-square tests. If significant interactions between groups were found, further independent-samples t-tests were conducted to explore these differences. To compare the pre- and post-clinical practice scores within the same group, paired-samples t-tests were used. All statistical tests were conducted with an a priori significance level of 0.05.

Results

A total of 112 physiotherapy students participated in the study, with 54 students in the control group and 48 students in the experimental group. Statistical analysis results showed that there were no significant differences in demographic data between the two groups. There were no significant differences in the baseline measures of the outcome measures between two groups. Both the experimental and control groups demonstrated improvements in clinical performance, theoretical knowledge, and self-reported clinical reasoning following their clinical placements. The experimental group consistently outperformed the control group in several key areas.

For the total Mini-CEX score, the experimental group improved significantly from 26.23 ± 11.90 to 41.02 ± 12.37, while the control group improved from 28.28 ± 5.48 to 38.35 ± 9.05. The experimental group demonstrated a larger improvement in the total score (p = 0.031). Subdomain analysis indicated that the experimental group had significantly greater improvements in several areas. In history taking, the experimental group increased from 3.38 ± 1.92 to 5.94 ± 1.74. The control group increased from 3.94 ± 1.11 to 5.37 ± 1.65, with the experimental group showing a larger improvement (p = 0.003). Professionalism scores also improved more in the experimental group, increasing from 3.69 ± 1.89 to 5.98 ± 1.82, compared to an increase from 4.04 ± 1.23 to 5.46 ± 1.33 in the control group (p = 0.006). A significantly greater improvement in counseling was observed in the experimental group. Scores increased from 3.56 ± 1.95 to 6.08 ± 1.74 in the experimental group, while the control group improved from 4.13 ± 1.08 to 5.65 ± 1.64 (p = 0.007).

The theoretical test scores also demonstrated significantly greater improvement in the experimental group. Scores raised from 51.83 ± 9.89 to 69.00 ± 8.93 in the experimental group. In the control group, scores increased from 54.56 ± 7.62 to 66.52 ± 10.71. The improvement was significantly larger in the experimental group (p = 0.038). Table 1 shows the pre- and post-clinical placement scores for the Mini-CEX and theoretical test in both groups.

Table 1.

Comparison of Mini-CEX and theoretical test before and after clinical practice in two groups

		Exp(n = 48)				CG (n = 54)
		pre	post	z	p	pre	post	t/ z	p
Mini-CEX	history taking	3.38 ± 1.92	5.94 ± 1.74	-5.41	< 0.001	3.94 ± 1.11	5.37 ± 1.65	-4.70	< 0.001
	physical examination	4.15 ± 1.71	5.52 ± 1.94	-4.10	< 0.001	3.91 ± 1.14	5.20 ± 1.31	-4.90	< 0.001
	professionalism	3.69 ± 1.89	5.98 ± 1.82	-5.19	< 0.001	4.04 ± 1.23	5.46 ± 1.33	-5.18	< 0.001
	clinical reasoning	4.08 ± 1.70	5.88 ± 1.89	-4.64	< 0.001	4.00 ± 1.08	5.39 ± 1.39	-5.17	< 0.001
	counseling	3.56 ± 1.95	6.08 ± 1.74	-5.48	< 0.001	4.13 ± 1.08	5.65 ± 1.64	-5.17	< 0.001
	organization/efficiency	3.65 ± 1.94	5.88 ± 1.90	-5.06	< 0.001	4.07 ± 1.15	5.20 ± 1.42	-4.18	< 0.001
	overall clinical competency	3.73 ± 1.72	5.75 ± 1.93	-5.35	< 0.001	4.15 ± 1.23	6.07 ± 1.54	-5.70	< 0.001
	total score	26.23 ± 11.90	41.02 ± 12.37	-7.96	< 0.001	28.28 ± 5.48	38.35 ± 9.05	-8.55	< 0.001
theoretical test		51.83 ± 9.89	69.00 ± 8.93	-14.3	< 0.001	54.56 ± 7.62	66.52 ± 10.71	-6.73	< 0.001

Keys: Exp-Experimental group, CG-Control group

Table 2 presents the pre- and post-placement scores for SACRR. Both groups demonstrated significant improvements in overall SACRR scores after clinical placements. The experimental group’s total score increased from 92.13 ± 11.72 to 109.48 ± 10.63 (t = -14.3, p < 0.001), while the control group’s total score improved from 91.30 ± 10.02 to 97.93 ± 10.63 (t = -5.13, p < 0.001). Subdomain analysis indicated significant improvement across all four subdomains in the experimental group. The control group demonstrated significant gains in information system, (p < 0.001) and exploratory factor analysis (p < 0.001), but showed no statistically significant improvements in analysis of problems (p = 0.145) or finding truth and reflective ability (p = 0.792).

Table 2.

Comparison of SACRR before and after clinical practice in two groups

SACRR	Exp(n = 48)				CG (n = 54)
	pre	post	t/ z	p	pre	post	t/ z	p
information system	45.94 ± 6.38	54.15 ± 4.89	-12	< 0.001	43.89 ± 5.64	48.52 ± 5.49	-6.32	< 0.001
analysis of problems	29.65 ± 3.84	33.75 ± 3.20	-8.39	< 0.001	30.81 ± 3.92	31.70 ± 4.21	-1.48	0.145
exploratory factor analysis	14.06 ± 2.05	16.92 ± 2.02	-5.94	< 0.001	13.91 ± 1.65	15.17 ± 1.99	-4.35	< 0.001
finding truth and reflective ability	2.48 ± 0.65	4.67 ± 0.48	-6.23	< 0.001	2.50 ± 1.06	2.54 ± 1.19	-0.26	0.792
total score	92.13 ± 11.72	109.48 ± 10.63	-14.3	< 0.001	91.30 ± 10.02	97.93 ± 10.63	-5.13	< 0.001

Keys: Exp-Experimental group, CG-Control group

Table 3 presents the pre-post differences in Mini-CEX and theoretical test scores for both the experimental and control groups. The experimental group demonstrated significantly greater improvements in history taking, professionalism, and counseling compared to the control group (p < 0.05). However, the differences between the two groups were not statistically significant for physical examination, clinical reasoning, or overall clinical competency. For the theoretical test, the experimental group’s improvement was significantly greater than that of the control group (p = 0.038).

Table 3.

The change from baseline in Mini-CEX and theoretical test

		Exp(n=48)	CG (n=54)	t/z	p
Mini-CEX	history taking	2.56±2.03	1.42±1.80	2.82	0.005*
	physical examination	1.38±1.98	1.30±1.51	0.23	0.821
	professionalism	2.29±2.06	1.43±1.51	2.73	0.006*
	clinical reasoning	1.79±2.01	1.39±1.50	1.16	0.251
	counseling	2.52±2.04	1.52±1.60	2.78	0.007*
	organization/efficiency	2.23±1.95	1.52±1.60	3.07	0.003*
	overall clinical competency	2.02±2.01	1.93±1.64	0.22	0.634
	total score	14.79±12.87	10.07±8.66	2.19	0.031*
theoretical test		17.17±11.76	11.96±13.06	2.10	0.038*

Keys: Exp-Experimental group, CG-Control group.‘*’ p < 0.05

The pre-post differences in SACRR scores for the two groups are illustrated in Table 4. All subdomains and the total SACRR score of the experimental group were significantly higher than the control group (p < 0.001).

Table 4.

The change from baseline in SACRR.

SACRR	Exp(n = 48)	CG (n = 54)	t/z	p
information system	8.21 ± 4.74	4.63 ± 5.38	3.54	0.001*
analysis of problems	4.10 ± 3.39	0.89 ± 4.42	4.08	< 0.001*
exploratory factor analysis	2.85 ± 1.64	1.26 ± 1.77	4.70	< 0.001*
finding truth and reflective ability	2.19 ± 0.64	0.04 ± 1.35	7.40	< 0.001*
total score	17.35 ± 8.40	6.63 ± 9.51	6.01	< 0.001*

Keys: Exp-Experimental group, CG-Control group.‘*’ p < 0.05

Discussion

The present study investigated the impact of clinical placement order based on individuals’ academic performance in undergraduate physiotherapy students. The results indicated that students in both the experimental and control groups had significant gains in theoretical knowledge and clinical skills. The students in the experimental group, whose placement order were arranged according to their academic performance, demonstrated greater progress in areas such as history taking skills, communication skills, and theoretical knowledge. These findings suggest that clinical placement sequencing based on academic performance may be an effective strategy for enhancing core competencies in physiotherapy education.

Physiotherapy education requires students to develop a set of core competencies, including clinical reasoning, communication, patient management, and practical skills [19, 20]. Clinical reasoning is an essential ability for practicing health professionals. The results of this study indicated that students in the experimental group, who had their clinical placement order tailored to their academic performance, showed greater improvements in their perception of clinical reasoning compared to the control group. These findings align with studies by Cook et al. and King et al., where placements facilitated optimal learning outcomes through targeted exposure to different clinical environments, which enhanced skill development and learning outcomes [21, 22].

In this study, students allocated to inpatient-first rotations were those with lower baseline practical scores, under the performance-based sequencing rule. The allocation strategy was designed to target skill gaps by sequencing inpatient or outpatient exposure accordingly. Although our analysis combined both outpatient-first and inpatient-first in the performance-based cohort, the theoretical rationale suggests that earlier inpatient exposure may have strengthened communication and organizational skills through sustained patient contact. Most interventions in physiotherapy are of a long-term nature. The inpatient environment provides an opportunity to observe and manage longitudinal care, which can enhance the development of communication skills [23]. In the inpatient setting, physiotherapist students are often involved in ward rounds. During ward rounds, multidisciplinary teams review patients’ conditions, determine their current status, and plan subsequent treatments [24]. These rounds provide students with valuable opportunities to work within a team, observe inter-professional collaboration, and develop communication and decision-making skills. A survey reported that participating in ward rounds not only enhances inter-professional skills but also improves professional confidence [25].

Outpatient rotations were associated with broader learning opportunities. Early studies comparing learning in outpatient and inpatient settings found that students encountered a greater variety of conditions in outpatient rotations [26]. This broader exposure may contribute to improved theoretical knowledge, as students manage a larger number of diverse cases and experience more frequent opportunities to apply their learning and consolidate their theoretical knowledge. This might lead to better theoretical knowledge improvement during outpatient rotation due to the breadth of cases encountered. According to Experiential Learning Theory [27], learning is most effective when students can cycle through concrete experiences, reflective observation, abstract conceptualization, and active experimentation. The outpatient setting may facilitate this cycle by presenting a wide array of cases that encourage frequent application and consolidation of theoretical knowledge.

Students with lower practical scores, when starting inpatient settings first, showed greater gains in history taking, communication, and organizational skills compared to the control group. The inpatient setting may offer students opportunities to handle complex cases that may facilitate the development of clinical skills [25]. Additionally, the inpatient environment requires ongoing patient management and provides more clinical support, making it potentially beneficial for students to develop practical competencies.

The non-significant differences in clinical judgment and overall clinical competency between the experimental and control groups suggest that these competencies may require longer exposure or may develop later in the educational journey. This may be related to the cognitive apprenticeship theory, which proposes that certain skills require a scaffolding process involving incremental knowledge building, practice, educator feedback, gradual responsibility, and periods of reflection [28]. Clinical judgment, in particular, may develop through extended reflection and repeated exposure to cases rather than short-term interventions [29]. Thus, improvement in these two areas may not depend on the order in which clinical placement took place.

Limitations

First, while the SACRR provided valuable insights into students’ clinical reasoning and reflection, it is a self-reported measure and may not fully capture objective behaviors or actual performance in clinical practice. Incorporating direct observational assessments or standardized patient scenarios could provide a more comprehensive evaluation of these skills. Second, the study relied on a single cohort from six institutions, which may limit the diversity of educational practices and student backgrounds represented. Lastly, the study design did not account for potential confounding factors such as differences in mentoring quality, patient complexity, or case exposure between the inpatient and outpatient settings, which could influence the observed outcomes. Future studies should aim to control for these variables to strengthen the robustness of the conclusions.

Educational institutes may consider allocating students with lower practical scores to inpatient rotations, where longitudinal care and ward-round exposure can enhance history taking, communication, and organizational skills. Students with stronger practical performance may benefit from outpatient-first placements to consolidate theoretical knowledge. Additionally, clinical judgment development may require more extended exposure and should be supported through scaffolding across rotations, with progressive transfer of responsibility and regular reflection with educator feedback.

Conclusion

This study provides evidence that tailoring the order of clinical placements based on individual students’ theoretical and practical performance can enhance learning outcomes in undergraduate physiotherapy education. Compared to the randomized sequencing, performance-based placement order resulted in significantly greater improvements in key clinical competencies of history taking, communication skills, and professional attitude, as well as in theoretical knowledge and self-assessed clinical reasoning. While most competency domains benefited from performance-based rotation sequencing, overall clinical judgment and competency may require additional exposure or a longer learning timeframe. By arranging placements in accordance with individuals’ performance, students may develop core competencies more effectively compared to traditional, random placement methods. Future research should explore optimal sequencing of clinical placements and assess its impact on long-term professional competencies.

Abbreviations

CG

Control group

Exp

Experimental group

Mini-CEX

Mini-Clinical Evaluation Exercise

SACRR

Clinical Reasoning and Reflection Self-Rating Scale

Authors’ contributions

Yiyi Zheng: Writing – review & editing, Formal analysis, Conceptualization. Yongxue Li: Writing – review & editing, Kun Zheng: Data curation, Writing – original draft, Meizhen Liang: Data curation, Formal analysis, Conceptualization. Xi Chen: Writing – review & editing, Supervision. Wai Leung Ambrose Lo: Writing – review & editing, Project administration.

Funding

This study is supported by Guangdong Basic and Applied Basic Research Foundation (No. 2024A1515012368), the National Natural Science Foundation of China (No. 82202786) and the program of Guangdong Provincial Clinical Research Center for Rehabilitation Medicine (2023B110003).

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The study was performed in accordance with the ethical standards of the Declaration of Helsinki. The protocol was approved by the Institutional Research Ethics Committee of the First Affiliated Hospital, Sun Yat-sen University (Registration number: [2023]33). Written informed consent was obtained from all individual participants included in the study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.