Clinician’s Commentary on Mori et al.

Clinical education is an essential and required component of the physiotherapy (PT) curriculum, both in Canada and around the world. Over the past 10 years, national PT organizations in Canada have developed more specific guidelines related to entry-to-practice competency milestones and PT programme accreditation requirements specific to clinical education (CE). This has improved national uniformity in graduating safe and effective entry-level physiotherapists while raising overall CE standards. At present, no student can graduate from any of the 15 Canadian PT programmes without completing a minimum of 30 weeks (1,025 h) of clinical experience, including a specified mix in certain settings (ambulatory care clinics, rehabilitation, acute care) and areas of practice (neurology, cardiovascular and pulmonary, musculoskeletal).² Requirements related to areas of practice must include a minimum of 100 hours in each essential area of practice (cardiovascular and respiratory, musculoskeletal, neurological), as described in the Clinical Education Guidelines for Canadian University Programs.³

In 2014, the proportion of the Canadian PT workforce practising in the cardiorespiratory (CR) area was relatively small at 3% (n = 421).⁴ This, combined with more stringent graduation requirements and recent increases in PT programme enrolment totaling more than 900 Canadian PTs students each year, has placed a cumulative strain on the ability of PT academic programmes to obtain adequate CR clinical placements. Fein outlined the limited availability of CR clinical placements as early as 1996,⁵ indicating that acute care (AC) hospital restructuring, shorter lengths of stay, and increased productivity pressure on AC physiotherapists had led to a decrease in the amount of time available to supervise students. Citing the literature, Mori and colleagues reported additional deterrents to placement offers:¹ lack of physical space, PT students’ lack of academic preparation, and the additional clinical instructor (CI) time and resources frequently required to assist students who may struggle during a clinical placement.

Mori and colleagues should be commended for undertaking a research study using a practice tutor to provide additional supports within the traditional internship model of one CI supervising one PT student.¹ To initiate a CE model that is novel to the AC tertiary facility, CIs and PT students require significant perseverance, time, collaboration, resources, and education. The findings of this study should, however, be interpreted with caution because of the small sample size. In addition, the findings may not be adequate to support implementing a practice tutor model without making certain modifications, and Mori and colleagues have suggested several.

Overall, one would have expected student and CI support for the practice tutor model to be higher, given that those who participated initially expressed interest. However, at the end of the study, only two of the six students said they would recommend this model to a PT classmate. One-half (four of eight) of the CIs indicated that the additional practice tutor support had given them more time to manage their caseload. This was one of the anticipated outcomes of implementing the model, so one would have expected a more positive response. The practice tutor spent between 10 and 15 hours providing AC education to the students, which the CIs would typically have completed in the traditional internship model. Five of the eight CIs indicated that they would recommend the model to a colleague. Caseloads were maintained or slightly increased, a result that is consistent with other models of clinical education supervision.⁶

Despite its limitations, the study does give Academic Coordinators of Clinical Education (ACCEs), CIs, and students some preliminary insights into the potential benefits of using a practice tutor model (it fosters student critical thinking through peer discussion; it increases student camaraderie; 50% of CIs report an increase in downtime) and disadvantages (location and timing of educational sessions interferes with patient care; some confusion was caused by differences in clinical practice presented by the CI and practice tutor; students considered the dual ACCE-practice tutor role a conflict of interest). As Mori and colleagues stated,¹ the goal of implementing a new model of clinical education support is to alleviate CIs’ concerns about supervising students and by doing so encourage CIs to offer more CR clinical placements on an ongoing, sustainable basis. However, they did not ask CIs whether they would offer more CR clinical placements as a result of implementing the practice tutor model.

Considering the costs and benefits of the practice tutor model, it is useful to ask the following question: Are the benefits sufficient to warrant the cost (practice tutor time and cost in wages)? To assist with the workload in Mori and colleagues’ study,¹ a final-year PT student took part in team meetings and helped develop the practice tutor manual (15 hours). The practice tutor role requires a significant time commitment (30.5 h), which primarily facilitates students’ educational sessions and case study discussions. Mori and colleagues recommended that in the future, the ACCE or other faculty participating in student clinical evaluation not be involved in the practice tutor role. Recruiting a CR physiotherapist from an AC facility could have several benefits but could also be difficult given the high current AC physiotherapist workload requirements. Each individual Canadian PT programme, in collaboration with its affiliated AC teaching hospitals, will need to consider whether the benefits, feasibility, and cost of the CR practice tutor model justify its implementation.

The educational sessions provided by the practice tutor were selected on the basis of feedback from the physiotherapists with the intention of reducing duplication of CI teaching on common AC and CR topics that most CIs typically review on site with their PT students. The results indicated that the CIs found these topics and sessions more useful than the students. However, both the students and the CIs agreed that the suctioning simulation session and the breath sounds tree were very valuable. This feedback demonstrates the effectiveness of simulation in the clinical education environment, a finding that has been noted by other authors.⁷ All the students rated the case study presentations and discussions as very valuable, and this result agrees with the previously reported value of case-based learning.⁸

Rather than conducting face-to-face educational sessions, academic PT programmes could consider developing e-learning CR modules to offer a more flexible model of education delivery, available at the learner’s convenience, that would have the potential to interfere less with hands-on patient care during a clinical placement. E-learning has been shown to produce changes in knowledge, skills, attitude, and satisfaction⁹ and to be effective in PT students’ skills acquisition.¹⁰ Several e-learning modules have been developed by teaching hospitals to meet provincial health and safety requirements, and many health care students are required to complete these online modules before beginning an AC clinical placement. Several key topics, such as fall prevention, electronic patient records, privacy and confidentiality, breathe easier, chain of transmission, hand hygiene, and infection control are currently available online.¹¹ Additional online CR modules could be developed to cover chest assessment, arterial blood gases and lab values, PT AC discharge planning, and chest X-rays.

In addition, PT programmes could collaborate with the Canadian Physiotherapy Association’s Cardiorespiratory Division to develop these key online CR resources, with the CR Division providing e-learning instructional design support. Although these online modules are often labour intensive to develop, once created they could be used in PT CR academic and clinical education programmes across Canada as well as by practising PTs requiring a CR refresher.

Looking ahead, academic PT programmes must continue to actively engage and collaborate with their AC hospitals and physiotherapists to develop CE strategies and models that best meet their individual AC environment and clinical practice culture, which can vary greatly from hospital to hospital. Promoting and adopting other clinical supervision models could also be considered. For example, implementing a collaborative or peer-coaching clinical education model (one CI to two students) has been the subject of discussion for several decades and has been shown to increase patient attendance, improve collaborative learning and critical thinking, and increase students’ time with patients.^12,13 Simulation learning experiences using humans or manikins have been shown to enable students to develop CR skills and clinical reasoning in an intensive care setting.⁷ However, these CR simulation hours are not yet recognized by Physiotherapy Education Accreditation Canada.² Unfortunately, Fein’s 1996 article “Maximizing Clinical Education Options in Cardiopulmonary Physical Therapy” sounds as current as if it had been written in 2019.⁵