Clinical learning spaces: Crucibles for practice development in physiotherapy clinical education.

This paper, through a deep examination of clinical workplaces as learning spaces, uses a holistic interpretation of clinical education and offers a practice development crucible metaphor as a useful way to deepen how clinical education can be conceptualized. An in-depth conceptualization of clinical education is needed if educators are able to develop wise educational practice and optimize the time students spend in clinical learning settings. The research reported here was undertaken in the qualitative paradigm guided by philosophical hermeneutics. Data collection strategies included observation, semi-structured interviews, focus groups and photo-elicitation. Twenty-four undergraduate physiotherapy students and twelve physiotherapy clinical supervisors participated in this research. Consistent with hermeneutic principles of dialogue of question and answer and hermeneutic circle, data analysis was achieved through an iterative process of reading, interpreting and re-reading the transcripts resulting in the emergence of a deeper understanding of clinical education that is represented for the reader. Clinical education has been revealed as a multidimensional learning space where workplace influences, engagement in professional practices, clinical supervisors' intentions and actions in combination with students' dispositions interact to shape and challenge students' clinical learning. A practice development crucible metaphor has been introduced as a way to represent this complexity and conceptualize clinical education, not as a set of techniques or supervision ratios but as a relational, fluid, complex space where learning is catalyzed. Importantly, the crucible metaphor assists academics, clinical supervisors and students to harness the power of clinical education to facilitate learning during clinical placements.

Using theories of learning in workplaces to enhance physiotherapy clinical education.

Clinical education has long been accepted as integral to the education of physiotherapy students and their preparation for professional practice. The clinical environment, through practice immersion, situates students in a powerful learning context and plays a critical role in students' construction of professional knowledge. Despite this acknowledged centrality of practice and clinical environments to the students' experiential construction of professional knowledge, there has been limited exploration of learning theories underpinning clinical education in the literature. In this paper, we explore a selection of learning theories underpinning physiotherapy clinical education with a view to providing clinical educators with a firm foundation on which to base wise educational practices and potentially enhance physiotherapy students' clinical learning experiences. This exploration has drawn from leading thinkers in the field of education over the past century.

Collaboration: what is it like? - phenomenological interpretation of the experience of collaborating within rehabilitation teams.

Although a core component of many current health-care directions, interprofessional collaboration continues to challenge educators and health professionals. This paper aims to inform the development of collaborative practice by illuminating the experiences of collaborating within rehabilitation teams. The researchers focused on experiences that transcended team members' professional role categorizations in order to bring individuals and their lived experiences to the forefront. An inclusive view of "teams" and "collaboration" was adopted and the complexity and multifaceted nature of collaborating were explored through a hermeneutic phenomenological approach. Semi-structured interviews were used to gather data about experiences of collaborating in nine rehabilitation teams. Sixty-six team members across nine teams were interviewed. Eight interdependent dimensions, core to the experience of collaborating, emerged from the analysis of the data. Five dimensions expressed interpersonal dimensions of endeavor: engaging positively with other peoples' diversity; entering into the form and feel of the team; establishing ways of communicating and working together; envisioning together frameworks for patients' rehabilitation and effecting changes in people and situations. Three reviewing dimensions, reflexivity, reciprocity and responsiveness, operated across the endeavor dimensions. By identifying meaning structures of the experience of collaborating, this study highlights the importance of seeing beyond team members' professional affiliations and being aware of their contextualized interpersonal and activity-related collaborating capabilities.

Core components of communication of clinical reasoning: a qualitative study with experienced Australian physiotherapists.

Communication is an important area in health professional education curricula, however it has been dealt with as discrete skills that can be learned and taught separate to the underlying thinking. Communication of clinical reasoning is a phenomenon that has largely been ignored in the literature. This research sought to examine how experienced physiotherapists communicate their clinical reasoning and to identify the core processes of this communication. A hermeneutic phenomenological research study was conducted using multiple methods of text construction including repeated semi-structured interviews, observation and written exercises. Hermeneutic analysis of texts involved iterative reading and interpretation of texts with the development of themes and sub-themes. Communication of clinical reasoning was perceived to be complex, dynamic and largely automatic. A key finding was that articulating reasoning (particularly during research) does not completely represent actual reasoning processes but represents a (re)construction of the more complex, rapid and multi-layered processes that operate in practice. These communications are constructed in ways that are perceived as being most relevant to the audience, context and purpose of the communication. Five core components of communicating clinical reasoning were identified: active listening, framing and presenting the message, matching the co-communicator, metacognitive aspects of communication and clinical reasoning abilities. We propose that communication of clinical reasoning is both an inherent part of reasoning as well as an essential and complementary skill based on the contextual demands of the task and situation. In this way clinical reasoning and its communication are intertwined, providing evidence for the argument that they should be learned (and explicitly taught) in synergy and in context.

The role of context in establishing university clinics.

Healthcare systems have a vested interest in employing work-ready graduates. The challenge for universities is to find ways to provide workplace learning that incorporates student education and high quality patient care. Inland areas of Australia, similar to other rural locations globally, experience additional challenges including a relatively high incidence of ill health, increasing demand for health services, chronic workforce shortages and ageing of the existing rural health workforce. In this paper, we conceptualise and describe the research findings related to context from a consultative enquiry into university clinics conducted in 2008. Interview participants were drawn from twenty university clinics in Australia and New Zealand. A consistent theme throughout the interviews was tensions that arose between the role of education and healthcare provision within university clinics. Many interview participants described ways they managed these tensions to meet the expectations of students, educators and the community. The patient supply is the most critical factor in the context of university clinic operations. It is vital to both the educator and the healthcare provider roles. In inland areas with sparse populations a number of strategies, such as outreach clinics, hospital or health centre- based clinics and multi-disciplinary sites, will have to be developed if university clinics are to operate effectively for students and patients.

Interprofessional collaborations in integrative medicine.

OBJECTIVES: Little is known about the implementation of integrative medicine (IM) in Australian health care and the nature of interprofessional collaborations that have been established in IM. The aim of this research was to examine the relationships among general medical practitioners (GPs) and complementary and alternative medicine (CAM) practitioners and their respective roles in co-located integrative practices. DESIGN: This research adopted hermeneutic phenomenology as an effective methodology for revealing people's experiences of IM and the meanings they attached to these experiences. Three (3) data collection methods were used: cumulative case studies, focus groups, and key informant interviews. Data analysis consisted of constant comparison of data from multiple sources to identify patterns and meta-themes. SETTINGS/LOCATION: The setting for this research was Australian IM clinics where GPs and CAM practitioners were co-located. RESULTS: Three (3) practice styles were identified among IM practitioners in this research: (1) mutually empowering when GPs and CAM practitioners regarded each other as peers, (2) GP-directed with varying levels of autonomy afforded CAM practitioners, and (3) limited collaboration where patients were offered mainstream medicine and CAM, which GPs performed themselves. CONCLUSIONS: IM practice styles differed in terms of interprofessional power-sharing and roles assigned to CAM practitioners. Practice styles where CAM practitioners were highly valued and able to exercise high levels of professional autonomy were perceived as making effective use of the available CAM workforce. Both GP-directed and intragrative practice styles (where GPs practiced CAM themselves without referral to CAM practitioners) were perceived by many GPs and CAM practitioners as enhancing patient safety.

Integrative medicine: enhancing quality in primary health care.

OBJECTIVES: Integrative medicine (IM) is an emerging model of health care in Australia. However, little is known about the contribution that IM makes to the quality of health care. The aim of the research was to understand the contribution IM can make to the quality of primary care practices from the perspectives of consumers and providers of IM. DESIGN: This interpretive research used hermeneutic phenomenology to understand meanings and significance that patients and practitioners attach to their experiences of IM. Various qualitative research techniques were used: case studies; focus groups; and key informant interviews. Data sets were generated from interview transcripts and field notes. Data analysis consisted of repeatedly reading and examining the data sets for what they revealed about experiences of health care and health outcomes, and constantly comparing these to allow themes and patterns to emerge. SETTING: The setting for this research was Australian IM clinics where general medical practitioners and CAM practitioners were co-located. RESULTS: From the perspective of patients and practitioners, IM: (1) provided authentically patient-centered care; (2) filled gaps in treatment effectiveness, particularly for certain patient populations (those with complex, chronic health conditions, those seeking an alternative to pharmaceutical health care, and those seeking health promotion and illness prevention); and (3) enhanced the safety of primary health care (because IM retained a general medical practitioner as the primary contact practitioner and because IM used strategies to increase disclosure of treatments between practitioners). CONCLUSIONS: According to patients and practitioners, IM enhanced the quality of primary health care through its provision of health care that was patient-centered, effective (particularly for chronic health conditions, nonpharmaceutical treatments, and health promotion) and safe.

Effect of experience on clinical decision making by cardiorespiratory physiotherapists in acute care settings.

This article investigates clinical decision making in acute care hospitals by cardiorespiratory physiotherapists with differing degrees of clinical experience. Participants were observed as they engaged in their everyday practice and were interviewed about their decision making. Texts of the data were interpreted by using a hermeneutic approach that involved repeated reading and analysis of fieldnotes and interview transcripts to develop an understanding of the effect of experience on clinical decision making. Participants were classified into categories of cardiorespiratory physiotherapy experience: less experienced (<2 years), intermediate experience (2.5-4 years), and more experienced (>7 years). Four dimensions characteristic of increasing experience in cardiorespiratory physiotherapy clinical decision making were identified: 1) an individual practice model, 2) refined approaches to clinical decision making, 3) working in context, and 4) social and emotional capability. Underpinning these dimensions was evidence of reflection on practice, motivation to achieve best practice, critique of new knowledge, increasing confidence, and relationships with knowledgeable colleagues. These findings reflect characteristics of physiotherapy expertise that have been described in the literature. This study adds knowledge about the field of cardiorespiratory physiotherapy to the existing body of research on clinical decision making and broadens the existing understanding of characteristics of physiotherapy expertise.

Promoting children's health and well-being: broadening the therapy perspective.

Physical activity is essential to promote children's health and well-being. Increased sedentary behavior in children is a factor contributing to the escalation in childhood obesity in the general population. Clinical conditions, particularly physical disabilities, which reduce physical activity, may also lead to a higher risk of being overweight or obese. This paper reviews physical activity and sedentary behavior and illustrates how habitual (daily) physical activity, motor performance, and the capacity to be active are distinct and important aspects of a child's activity behavior. Positive health outcomes are linked to achieving adequate habitual levels of physical activity. This paper also highlights how pediatric therapists can promote health for those children who are already overweight or obese or are at higher risk of being overweight or obese. Physical and occupational therapists are encouraged to embrace a broad perspective of physical activity and extend children's therapeutic and health-promotion programs to include assessment of habitual level of physical activity and sedentary behavior, and promotion of recommended levels of daily physical activity. This role can also be extended beyond the area of disability.

What do parents and preschool staff tell us about young children's physical activity: a qualitative study.

BACKGROUND: Physical activity and small screen recreation are two modifiable behaviours associated with childhood obesity and the development of chronic health problems. Parents and preschool staff shape behaviour habits in young children. The aims of this qualitative study were to explore the attitudes, values, knowledge and understanding of parents and carers of preschool-age children in relation to physical activity and small screen recreation and to identify influences upon these behaviours. METHODS: This research involved a focus group study with parents and carers of the target population. A purposive sample of 39 participants (22 parents, 17 carers) participated in 9 focus groups. Participants were drawn from three populations of interest: those from lower socioeconomic status, and Middle-Eastern and Chinese communities in the Sydney (Australia) metropolitan region. RESULTS: All participants understood the value of physical activity and the impact of excessive small screen recreation but were unfamiliar with national guidelines for these behaviours. Participants described the nature and activity patterns of young children; however, the concept of activity 'intensity' in this age group was not a meaningful term. Factors which influenced young children's physical activity behaviour included the child's personality, the physical activity facilities available, and the perceived safety of their community. Factors facilitating physical activity included a child's preference for being active, positive parent or peer modelling, access to safe play areas, organised activities, preschool programs and a sense of social connectedness. Barriers to physical activity included safety concerns exacerbated by negative media stories, time restraints, financial constraints, cultural values favouring educational achievement, and safety regulations about equipment design and use within the preschool environment. Parents considered that young children are naturally 'programmed' to be active, and that society 'de-programs' this behaviour. Staff expressed concern that free, creative active play was being lost and that alternate activities were increasingly sedentary. CONCLUSION: The findings support the relevance of the socioecological model of behavioural influences to young children's physical activity. In this age group, efforts may best be directed at emphasising national guidelines for small screen recreation and educating families and carers about the importance of creative, free play to reinforce the child's inherent nature to be active.

Characteristics and processes of physiotherapy clinical decision making: a study of acute care cardiorespiratory physiotherapy.

BACKGROUND AND PURPOSE: Physiotherapists have been increasingly interested in investigating physiotherapy clinical reasoning and decision-making processes. Cardiorespiratory physiotherapy has received little attention within this increasing body of research. This study aimed to investigate characteristics and processes of cardiorespiratory physiotherapy decision making and to contribute to the broader understanding of physiotherapy reasoning and decision making. METHODS: Fourteen cardiorespiratory physiotherapists took part in the study. Qualitative research methods were used, guided by a philosophical hermeneutic approach. Participants were observed undertaking their usual daily patient care activities and were later interviewed about their decision making. In-depth, iterative hermeneutic strategies were used to interpret the texts created by these processes to identify the nature and processes of decision making. RESULTS: Clinical decision making in cardiorespiratory physiotherapy is focused on making decisions about the nature of patients' problems, physiotherapeutic intervention and interaction, and evaluation of effectiveness of actions. Cardiorespiratory physiotherapy decisions varied in their difficulty according to the attributes of the decisions. The variable nature of decisions influenced the reasoning processes used. Clinical decision making involved complex reasoning processes that were cyclic, evolving and flexible in nature, with interdependence and interrelation between the different foci of clinical decision making. Clinical decision making was also found to be a social and collaborative process. CONCLUSIONS: This study contributes to the body of literature on physiotherapy reasoning and decision making by revealing details about the characteristics and processes of cardiorespiratory physiotherapy decision making. This research can be used to shape the education of beginning practitioners and provide practicing physiotherapists with a basis for critical appraisal of their decision making.

Kyphosed seated postures: extending concepts of postural health beyond the office.

INTRODUCTION: The harmful effects of sustained sitting and the health of the spine are well documented. The focus of much of this investigation has been sedentary occupations. However, how people sit during leisure hours can impact on the health of the spine both in and out of working hours. METHODS: A literature search was conducted using Amed, Cinahl and OVID Medline databases. Papers published between 1985 and 2007 were selected for review. These included epidemiological and experimental studies that explored the relationships between seated postures and health of the lumbar spine. Until recently there was confusion in the scientific literature as to which seated postures were least harmful: lordosed or kyphosed. This article reviews and analyses these conflicts in relation to leisure sitting. RESULTS: Analysis of the literature demonstrates that kyphosed seated postures when sustained are more harmful to the health of the lumbar spine than lordosed seated postures. There is a misconception amongst designers and users of leisure seating that kyphosed relaxed postures are comfortable and that comfort equates with health. It is argued that sustained kyphosed postures are insidiously harmful to the spine in that they may contribute to disc degeneration in the absence of pain. Sustained kyphosed postures also adversely affect spinal ligaments, muscles and joints and lead to neuromuscular and cumulative trauma disorders and loss of spinal stability. CONCLUSION: Recent research demonstrates that postures popularly assumed in recreational or leisure seating lead to cumulative damage to soft tissues of the spine. These effects may still be present at the commencement of the following work day. In the prevention of work disability caused by sustained sitting, health professionals must consider the impact of leisure seating design and recreational sitting behaviour.

Learning to reason: a journey of professional socialisation.

One of the key attributes that health professional students and new graduates develop during professional socialisation is clinical reasoning ability. Clinical reasoning is a complex skill that is essential for professional practice. There is limited research specifically addressing how physiotherapists learn to reason in the workplace. The research reported in this paper addressed this gap by investigating how experienced physiotherapists learned to reason in daily practice. This learning journey was examined in the context of professional socialisation. A hermeneutic phenomenological research study was conducted using multiple methods of data collection including observation, written reflective exercises and repeated, semi-structured interviews. Data were analysed using phenomenological and hermeneutic strategies involving in-depth, iterative reading and interpretation to identify themes in the data. Twelve physiotherapists with clinical and supervisory experience were recruited from the areas of cardiopulmonary, musculoskeletal and neurological physiotherapy to participate in this study. Participants' learning journeys were diverse, although certain episodes of learning were common or similar. Role models, mentors and colleagues were found to be influential in the development of reasoning. An important implication for the professional socialisation of physiotherapists and other health professionals and for those involved in practice development is the need to recognise and enhance the role of practice communities in the explicit learning of clinical reasoning skills.

Physiotherapy decision making in acute cardiorespiratory care is influenced by factors related to physiotherapist and the nature and context of the decision: a qualitative study.

QUESTIONS: What factors influence the decision making of cardiorespiratory physiotherapists in acute care? How do cardiorespiratory physiotherapists manage multiple factors in their decision making? DESIGN: Qualitative study using observation and semi-structured interviews. PARTICIPANTS: Fourteen physiotherapists working in acute cardiorespiratory care. RESULTS: Cardiorespiratory physiotherapy decision making was affected by factors related to the nature of the decision itself (such as the complexity and difficulty of the decision), factors related to the context in which the decision occurred (such as physical, organisational and socio-professional factors), and factors related to the physiotherapists themselves (such as decision making capabilities, physiotherapy frames of reference, and level of clinical experience). CONCLUSION: Optimising the quality of decision making in the context of health care today requires an awareness and consideration of a range of factors influencing decision making.

Educating clinical educators: using a model of the experience of being a clinical educator.

BACKGROUND: Clinical educators are expected to prepare students to be competent beginning practitioners, ready to enter the workforce and meet the demands of competent practice. As part of ensuring the quality of clinical education, universities that provide these programs need to be involved in the education and support of clinical educators. In this paper we examine the preparation and professional development of clinical educators based on research into the experiences of being a clinical educator (McAllister 2001). METHODS: The research approach involved a blend of hermeneutic phenomenology and narrative inquiry. In-depth interviews were conducted with five speech pathologists in Australia. Data were analysed using a phenomenological analysis process. RESULTS: Recurrent themes in the research were represented by 12 themed stories to richly portray participants' experiences of being clinical educators. An example is provided in this paper. The research produced a model of The Experience of Being a Clinical Educator. The six dimensions of this model are: a sense of self, of self-identity; a sense of relationship with others; a sense of being a clinical educator; a sense of agency or purposeful action; dynamic self-congruence; and the experience of growth and change. CONCLUSION: Becoming and being a clinical educator is a developmental process, mirroring in some ways the developmental process clinical educators strive to facilitate for their students. This journey of growth and development as a clinical educator requires active learning approaches coupled with reflection on one's practice as a clinical educator. The model can be used to educate clinical educators in speech pathology and other professions, given the commonalities in clinical educators' roles across professions. Interactive and reflective strategies are presented in the paper for the development and support of clinical educators across the continuum from novice to professional artist.

Being a clinical educator.

What is it like to be a clinical educator? How do clinical educators experience and describe their continuing journey of becoming a clinical educator? Within the model developed in this research, dimensions of being a clinical educator were identified. These dimensions include (a) having a sense of self (and the impact of bringing self into the clinical educator's role), (b) having a sense of relationship with others (and the place of this "interactive self" as a central feature of clinical education), (c) having a sense of being a clinical educator (and how this understanding relates to the previous two dimensions), (d) having a sense of agency (which is vital to the performance of many clinical education roles), (e) seeking dynamic self-congruence, and (e) growth as a clinical educator. This paper presents an overview of the model, discusses its strengths and limitations as a representation of speech pathology clinical educators' experiences, and briefly considers its value for professional development.

Physiotherapy students' attitudes towards and knowledge of older people.

The purpose of this study was to determine whether students' attitudes towards and knowledge of older people changed throughout the physiotherapy undergraduate program. Students' demographic information and attitudes towards and knowledge of older people were gathered via repeated question-responses over three points of time during the 4-year program. Validated instruments--the Geriatric Attitudinal Scale (GAS) and the Facts on Ageing Quiz 1 (FAQ1)--were used to measure participants' attitudes and knowledge of older people. The FAQ1 yielded two variables: knowledge as percentage of FAQ1 correct responses, and ignorance as percentage of FAQ1 Don't Know responses. The instruments were administered in Year 2 prior to the students' first clinical (Time 1), immediately after their first clinical (Time 2), and Year 4 just prior to completion of the program (Time 3). Changes over time were analysed using paired t-tests with significance set at p < 0.05. Participants initially demonstrated positive attitudes towards older people with a mean of 73.8% GAS positive responses with no significant change over time (p = 0.56). Initial knowledge about older people was poor with a mean of 43.6% FAQ1 correct responses which increased significantly over time to 51.7% (p = 0.0001). This improvement in knowledge was accompanied by a decrease in ignorance over the study period (p = 0.0001). While attitudes toward older people were positive and knowledge improved over time, the level of knowledge attained was below expectation for beginning practitioners. This finding has implications for the education and training of physiotherapy students.

Historical perspective milestones in the evolution of lumbar spinal postural health in seating.

The best knowledge on seated posture before the Enlightenment was not scientific, but influenced by sociocultural, economic, and manufacturing factors. Although the pursuit of knowledge related to spinal postural health was advanced with the advent of empirico-analytic research, academic opinion continued to be influenced by unsubstantiated information, often resulting in incorrect advice to the public. Only in the past decade has advice on "correct" seated posture, spanning the time from the Hippocratic texts to the present, been brought into question by evidence-based research. By exploring seating from 3100 B.C to the present, this article discusses key influences that have an impact on seating functional to spinal postural health. Emphasis is placed on the role of medical opinion.

Benchmarking in physiotherapy education: a collaborative project.

Many factors including demands for accountability and funding reductions give rise to the need for educational institutions to demonstrate their quality for purposes of public accountability and in order to attract students, both local and international. Benchmarking is a process which can address this need. Benchmarking also is a strategy for program evaluation and development which can be used in other fields such as clinical practice. The project reported in this paper concerns the school of physiotherapy in Australia and New Zealand. It utilises the concept of benchmarking within a collaborative context in order to incorporate the most positive aspects of seeking and achieving excellence within a peer review framework.