An overnight shift towards remote teaching and learning of musculoskeletal physiotherapy in Karelia University of Applied Sciences in Finland

Article accepted

This article has been accepted for publication. Peer reviews and author responses are available at the end of the article.

Authors: Maiju Issakainen1, Sini Puustinen1, Raija Kuisma1
Institutions: 1Karelia University of Applied Sciences, Joensuu, Finland
DOI: 10.14426/art/1355
Date submitted: 04/06/2020
Date accepted: 27/10/2020

Abstract

Background: Musculoskeletal physiotherapy (MSK) is learned and practiced in a classroom with the guidance of a physiotherapy teacher. In Karelia University of Applied Sciences, a flipped classroom approach has been implemented and developed actively since 2017 in MSK courses in physiotherapy education. However, the COVID-19 pandemic changed everyday life very fast all over the world. Karelia, like all other schools, moved all activities into remote mode very quickly and "normal" teaching methods had to change. Aim: This article describes how the change from contact to remote teaching was implemented in MSK courses in the physiotherapy programme at Karelia in Finland, using a flipped classroom approach. The article also highlights students’ experiences of remote teaching in these courses, although theoretical analysis and discussion on the impact on students' learning is not considered in this Research Note. We are planning to continue exploring the impact and practice of this remote teaching approach, which is becoming the new normal. Conclusion: Well-planned pedagogical manuscript implemented with a flipped classroom approach seems to work well in teaching physiotherapy theory and skills remotely. Carefully planned learning tasks and individual feedback are particularly important for learning during remote teaching. Video and text material in theoretical and practical MSK topics seemed to support students’ learning during the remote teaching and video feedback especially, could be used more in the future.

An overnight shift towards remote teaching and learning of musculoskeletal physiotherapy in Karelia University of Applied Sciences in Finland

Introduction

Physiotherapy in musculoskeletal (MSK) disorders requires skills in examination, clinical reasoning, pain management, therapeutic exercise, manual therapy, and other physiotherapy modalities e.g. electrophysical therapies. Traditionally in physiotherapy education, these skills have been learned and practised in a classroom with the guidance of a physiotherapy teacher. In Finland, like all over the world, the Covid-19 pandemic changed everyday life very quickly on March 15th 2020, when the government imposed special restrictions for the whole country and all aspects of life. Karelia University of Applied Sciences moved all activities into a remote mode and teaching methods in physiotherapy education had to change quickly. Karelia University of Applied Sciences (Karelia) has bachelor level physiotherapy programme lasting 3,5 years with two intakes in a year. The physiotherapy student population is approximately 200 with ten physiotherapy teaching staff. Karelia is situated in eastern Finland and offers 21 degree programmes, 16 bachelors, and five at the master level, in seven study fields that accommodate about 4000 students (www.karelia.fi/en).

This article describes how the change from contact to remote teaching was implemented in MSK courses in physiotherapy at Karelia. MSK courses are included across first to fourth semesters and there are four MSK courses with one in each semester varying from three to ten ECTS. This article highlights students’ experiences in different stages of their studies of remote teaching in MSK courses and three out of these four groups had no experience in clinical placements. The anonymous feedback was collected from Karelia’s online course feedback system.

Flipped learning and flipped classroom are types of blended learning. According to the Flipped Learning Network (2014), “Flipped Learning is a pedagogical approach in which direct instruction moves from the group learning space to the individual learning space, and the resulting group space is transformed into a dynamic, interactive learning environment, where the educator guides students as they apply concepts and engage creatively in the subject matter”. Flipped classroom refers to a pedagogical ideology where students are encouraged to study independently before contact lessons. Contact lessons are then used in applying knowledge and practice skills with the guidance of a teacher (Toivola, Peura & Humaloja 2017.) 

The flipped classroom approach has been implemented and developed actively since 2017 in Karelia Physiotherapy education in MSK courses. In higher education, the flipped classroom approach usually includes a “pedagogical manuscript”, a vision of how independent studying, learning assignments and contact lessons support students’ learning. Independent learning is often structured by a learning assignment, which includes specific learning objectives, content, and materials. Independent studying can occur in teams or individually. Learning materials are listed and available online, consisting of videos, articles, books, etc. Karelia uses the Moodle e-learning environment, which enables the versatile use of pedagogical options.

In the beginning there was…

The decision from the start of the remote teaching period on 16th of March was that lessons were held according to the planned timetable, with only minor changes in MSK courses. The planned timetable included scheduled theory and practice sessions, both teacher led and independent, individual and group work sessions. Contact lessons, which included applying theory into practice and practising physiotherapy skills, were held online in the Moodle learning environment using the Collaborate tool instead of in a classroom.

Independent work sessions were structured around preplanned learning tasks and students submitted evidence of their learning in different formats into Moodle. Collaborate made it possible to divide the cohort into smaller groups during the learning session. Students were encouraged and instructed to use Collaborate in individual group work. According to the students, staying in the planned timetable helped them to organise their everyday life schedule and kept up the motivation to study. For teachers, it meant the chance to follow pre-planned pedagogical manuscripts of the courses systematically.

Remote teaching and learning

Following the Flipped Learning principle, before the online lessons, students worked with learning tasks independently, e.g. watched online lectures, videos or read about the new subject, as planned in the pedagogical manuscript. For example, based on a study guide, students were palpating bony landmarks and marked them to their partner which they then photographed and returned to Moodle for the teacher to evaluate. Students felt that these learning tasks during remote teaching, improved their learning: “Assignments and course materials were designed to support learning.”

Online lessons were broadcast mostly via Collaborate LTI (Moodle tool). Usually, online lectures started with a discussion about theories or concepts of the topic. The Collaborate LTI includes easily used audience response system, that is, a polling tool which enabled fast iteration of core concepts or level of learning. It was also an easy way to activate all participants in the beginning of the lesson, for example, when the teacher showed a pre-recorded video of a skill application students could then practice remotely.

Students reported that it was important during remote lectures to be able to ask questions that had arisen with the pre-assignments. Students felt that the threshold to ask questions during online lessons was low: “Remote learning was useful because the questions to be considered were answered.” This way discussions and exchange of ideas arose easily. Students were also encouraged to exchange their own experiences of the discussed subjects during the online lessons in a similar way as for contact lessons. Flipped classroom and learning approach enabled students to deepen their learning together by discussions and teamwork during online lectures.

In the beginning, the challenge of teaching and learning practical and manual skills needed in MSK physiotherapy was due to the restricted live video streaming, which was caused by the fear of the system collapsing. This meant that existing teaching materials had to be supplemented with photos, videos, and/or additional instructions, teacher-made or existing videos from the internet. Students were engaged in providing teaching materials and learning from each other. For assessing practical skills and getting feedback, students provided video-recordings demonstrating their manual therapy and mobilisation techniques.

Video materials supported students’ learning and with them most students were able to choose the time and place to practice skills with their classmates. During the remote teaching period, teachers provided or linked relevant videos to Moodle e-learning environment for students to support their learning. Students were also encouraged to find and share reliable and suitable material by themselves. It allowed students also to practice information retrieval and critical evaluation skills. In addition to the videos, teaching material was also in text format to support different learners and this also received positive feedback: “The materials were in the form of videos as well as readable texts, which was a good thing for learning.”

Some students felt that it was easier to focus on learning in lessons online than during normal classes: “At home, I was able to focus better on listening. So, there were also positive aspects to remote teaching.” Some students wished that participation in some lessons remotely should be possible in the future as well because it gives students the freedom to choose a suitable place for studying. Students found that online lessons suited especially for theoretical topics but also that teachers were able to implement functionality to lessons. “Teaching was offered well and remote lessons were also functional. These could even be used in some form in the future.”  

The importance of feedback

Students made video material of their own practical skills, including examination and manual mobilisations, which teachers had chosen and instructed them to practice during the online lessons. Safety aspects and contraindications to manual techniques were taught and discussed with students before their independent practical tasks. Students were instructed to self-evaluate their own practical skills after each completed task.

Students uploaded their tasks and self-evaluations to the Moodle e-learning environment for the teacher to evaluate and then the teacher gave written formative feedback for the students after each task. Students found this feedback meaningful and beneficial for their learning. Some students also felt that they received more feedback of their manual skills during the remote teaching period than in normal classes: “I would have liked to get more feedback of the manual skills in the class, but it was corrected when Corona struck and the teacher commented on the videos that were made about the manual skills.” From the teacher’s perspective video-recording and reviewing helped students to focus on self-evaluation of practical skills and noted the successful and correctable details. Self-evaluation is more difficult for students during the face-to-face lessons.

Teachers in MSK courses decided that they will give additional feedback to the students on their independent tasks and videos of the practical skills, which students perceived to be very helpful for learning: “The individual feedback from the teacher on the tasks was relevant and important.”  It seems that written feedback is especially important to students. Students felt that they received feedback of their theoretical and practical competence which encouraged them to study.  Surprisingly, during the remote teaching, satisfaction with the amount of feedback was higher than normal: “The feedback from the teacher was extensive and rewarding.”

What next?

The unfortunate events caused by the Covid-19 pandemic have led to great changes and disruption to everyday life. However, we have learnt some positive lessons for the future. Students were better prepared for practice by studying the theory in-depth beforehand and resolving some questions between themselves online. Video-recording their own practice before attending classes in the future would fit the flipped classroom principle and will be used in the future. This will give the teacher more time for individual feedback. From the physiotherapy teaching experience at Karelia, we will take these learnt lessons into developing our teaching and empowering students to take responsibility for their own learning. “A teacher cannot learn for the students, the students must do it themselves” (Anonymous), and by giving them responsibility with systematic guidance, we can achieve this, as has been shown during the period of remote learning.

Conclusion

In summary, a well-planned pedagogical manuscript implemented with flipped classroom and learning approach seems to work well for remote teaching of physiotherapy theory and skills. Carefully planned learning tasks and individual feedback are particularly important for learning. It supports the students’ learning process and enables the deepening of learning.

Video and text material in theoretical and practical MSK topics seemed to support students’ learning and video material especially could be used more in the future. This experience confirmed that students are very capable in self-directed, teacher-guided learning, and are able to search and find appropriate, relevant and evidence-based learning material on MSK physiotherapy. They are also capable and keen to share learning material and learn from each other. After the three-month remote teaching period, the teachers also learned to trust and give the responsibility of learning to students, where they can take it and learn regardless of the circumstances. “The teacher can only open the door; the student must walk in and discover” (Anonymous).

References

Flipped Learning Network (2014). What Is Flipped Learning? Retrieved from https://flippedlearning.org/wp-content/uploads/2016/07/FLIP_handout_FNL_Web.pdf 2.6.2020.

Toivola, M., Peura, P. & Humaloja, M. (2017). Flipped Learning. Edita, Helsinki.

Reviews

Author: Karen McCreesh
Review date: 17 July 2020
DOI: 10.14426/opj/20200717
Permalink: Review - An overnight shift towards remote teaching and learning of musculoskeletal physiotherapy in Karelia University of Applied Sciences in Finland

Thank you for a very interesting article describing your experiences in moving physiotherapy teaching online in response to the pandemic. I very much appreciate the opportunity to read your paper, as an academic facing the same challenges. There is a wealth of learning to be gained from the paper in terms of how you have described the approaches taken to meet the challenges of practical MSK teaching and in particular reading the student perspectives. You have opened up the idea of how we teach and assess practical skills in a way that is relevant beyond the current crisis.

My comments and queries below are aimed at making the paper more practically useful and directly applicable to the reader. The questions below are the ones I had while reading the paper, and so it would be great if some of them could be addressed to make the piece more informative.

I suggest including an abstract would help orientate the reader to the paper.

I feel what I’m missing in the paper is a sense of the context.

Consider adding detail on:

University (size and scale), numbers of students, level of degree, year/stage of students (had they undertaken placement yet? Have they had previous MSK teaching?), staff-student ratios. Did any students have additional learning needs and if so how were these accommodated?

Is this a single MSK module being described? How many ECTS? What were the usual assessments (formative and summative) and how were these changed?

I think the learning activities could be more tangible and accessible for the reader if you could provide more concrete examples (just like the case-based approach you describe using with your students). For example, I’d like to see a worked example of how you used flipped classroom methods in traditional teaching versus online, using a table or diagram, and the information from the “pedagogical manuscript”.

“Flipped classroom and learning approach enabled students to deepen their learning together by discussions and teamwork during online lectures”. How was the teamwork managed during online lessons? Were online ‘breakout rooms’ used? Did students work in the same groups throughout? Did they engage in the same groups outside of contact lessons?

“Students were engaged in providing teaching materials and learning from each other. For assessing practical skills and getting feedback students provided video-recordings demonstrating their manual therapy and mobilization techniques. Especially videos as learning materials supported remote learning process and most students were able to practice skills with classmates in their own environment.” MSK skills: Did the students source and post videos on a discussion forum? In what way did the shared learning occur? How did they practice with classmates?

“Video-recording and reviewing their own work helped students self-evaluate their practical skills and note the successful and correctable details, which are normally more difficult during the lessons. The teacher also reviewed the videos and gave written feedback to each student.” Describe more about how the students produced and submitted their own videos- was there clear guidance for what had to be submitted and how often? How was the self-evaluation conducted – was there a reflective submission involved? How often was feedback provided? How burdensome was this for teachers?

How were the practical skills assessed? Were the videos used to provide a summative assessment for clinical competence?
I think it would also be useful to present your views and perspectives on whether the summative assessment used are ‘fit for purpose” and likely to be acceptable for assessing competencies for professional accreditation purposes.

Regarding the case-based learning was there any patient involvement in presenting this material, or any use of the ‘patient voice’?

Thank you again for the sharing of your experiences – the paper has the potential to springboard some really valuable conversations about the “new normal” we find ourselves in for MSK physiotherapy.

Author: Jill Morgan
Review date: 12 June 2020
DOI: 10.14426/opj/20200612
Permalink: Review - An overnight shift towards remote teaching and learning of musculoskeletal physiotherapy in Karelia University of Applied Sciences in Finland

Thank you for the opportunity to review this paper which outlines the processes, implementation, and initial outcomes of rapidly moving aspects of a Physiotherapy curriculum into the virtual, online domain. 

The title alludes to the time pressures involved in these changes and highlights a topic which is certainly pertinent to most physiotherapy education programmes during a global healthcare pandemic. 

This commentary article provides a clear background to the obvious challenges of timescale and demand, which is framed to align with flipped classroom pedagogy.  It can certainly add to the growing body of work being collated by educators addressing the challenges of remote learning, however, there are a few areas which could be improved. 

Throughout the piece there are quotes from students; were these quotes taken from a range of students or just one or two? Including pseudonyms to highlight these quotes would improve transparency here.     

Perhaps some detail about the size of the cohort this method was applied to would provide more context – it appears easy to innovate, but how easy to upscale this innovation to larger cohorts? 

“Remote learning was useful because the questions to be considered were answered.” – this is a powerful quote.  What is it about remote learning that facilitated this thought?  Are students unable to engage in questioning as much in the classroom?  The anonymity of the online platform has the potential to reduce the fear of negative peer perception when posing questions and/or prevent dominant personalities shaping the conversations.  Perhaps in online sessions, students feel safer or have more opportunity to engage. 

The use of video and visual aids to supplement practical skill teaching is clear.  The novel aspects of this paper involve the use of student-created videos for self-assessment, learning and teacher-led formative feedback.  It would be helpful to consider the logistics of how these videos were created and the risks associated with unsupervised practice whilst doing so – for instance, who were they practising these skills on, were appropriate contraindications considered, are students able to modify the techniques rather than copy a video they have just watched?  Using case-based learning is a sensible way to further examine the students’ understanding, however.   

It is interesting to note that students found feedback on their online work ‘extensive and rewarding’.  Written feedback in this group seems to have been perceived as more individual, and relevant.  This raises some questions about student perceptions of feedback in ‘live’ practical skills teaching.  Most faculty staff would be used to ordinarily giving feedback during practical classes, but perhaps the cognitive load of performing the technique/skill itself as a novice diverts the student attention and the value of this feedback ‘in action’ is reduced.  Is formative feedback more accessible and powerful when students can view themselves on screen after the initial performance? 

The paper concludes with the positive outcome that certain skills can be showcased and learned by students in a remote fashion.  There is an important statement in this conclusion about teachers learning to trust students to be responsible for their own directed learning.  It seems clear that this cohort of students was sufficiently resilient to do this.  It offers an opportunity for physiotherapy education to reassess what is currently thought of as ’essential’ content and skills for developing independent clinicians of the future. 

The section pertaining to ‘Thoughts for what next…’ could be more imaginative in terms of how this process has influenced practice and could further do so in future.  For example, if student videos provide sufficient formative feedback with regards to competence in performance, is there an argument to reduce the need for summative assessment of practical skills within our curricula?  Students hone these skills to be ‘ready’ for clinical placement; assessing placement could be viewed as duplicating skills assessment.  Would it be pertinent therefore to reduce/remove practical skill assessment in the classroom? 

It would be useful to consider the previous experience of this group of students too.  Have they experienced practical teaching elsewhere on the programme?  Are they already comfortable with basic handling skills? Will a new cohort of students who have no practical experience respond as well to the remote style of learning in a similar way? 

The student voice is relatively clear through this paper, but it would also be useful to share the experience of staff/faculty.  It is clear that students have adapted well, but they may have done so because it was not a change for them. Changing behaviours of staff who have done things one way for several years can be more challenging.  What were the challenges encountered during this shift of activity?  How were barriers overcome?  Do staff feel that this is a sustainable development over the longer term? Is it feasible to expect that all students can participate in remote learning of this fashion, or could there be challenges with regards to inclusivity? 

Finally, there are a couple of sentences which could be re-worded to improve the grammar and thus the clarity.  The first sentence in paragraph 8 is an example. 

Papers of this nature are an important resource for educators during the current climate.  Sharing ideas of how to support education in ways that feel very alien to the ethos of a hands-on profession will be vital as we move forward during a time of rapid re-design.  There are many lessons to be learned and I appreciated the opportunity to review this paper.  I would be very happy to continue the discourse around the points I have raised above. 

Conflict of interest statement

The authors report no declarations of interest.

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