Authors: Maiju Issakainen, Sini Puustinen & Raija Kuisma / Submitted: 04 June 2020.
This article is undergoing peer review.
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 fast on March 15th 2020, when the government imposed special restrictions for the whole country and all aspects of life. Karelia UAS moved all activities into a remote mode and normally used teaching methods had to change quickly, also in the physiotherapy education.
This article describes how the change from contact to remote teaching was implemented in courses of physiotherapy in musculoskeletal disorders in Karelia UAS. The article also highlights students’ experiences of remote teaching in these courses, collected from Karelia UAS course online feedback system.
Flipped learning and flipped classroom are types of blended learning. According to 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.) Flipped classroom approach has been implemented and developed actively since 2017 in Karelia UAS 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, contents, and materials. Independent studying can occur in teams or individually. Learning materials are listed and available online, consisting of videos, articles, books, etc. Karelia UAS uses Moodle e-learning environment, which allows 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. This meant that contact lessons, which included applying theory into practice and practising physiotherapy skills, were held online instead of in a classroom. According to the students, staying in planned timetable helped them to organize their everyday life’s schedule and kept up the motivation to study. For teachers, it meant the chance to follow preplanned pedagogical manuscripts of the courses systematically.
Remote teaching and learning
Following the Flipped Learning principle, before the online lessons, students worked with learning assignments, e.g. watched online lectures, videos or read about the new subject, as planned in the pedagogical manuscript. Students felt that the assignments, during the remote teaching, improved their learning “Assignments and course materials were designed to support learning.”
Online lessons were broadcasted mostly via Collaborate LTI (Moodle tool), where all students can participate simultaneously. Usually, online lectures started with a discussion about theories or concepts of the topic. The Collaborate LTI includes easily used audience response system, i.e. polling tool which enabled fast iteration of core concepts or level of learning. It was also an easy way to activate all participants. Students expressed that it was important to be able to ask questions during remote lectures 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 in 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 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 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. During the remote teaching period, teachers provided or linked relevant videos to the Moodle e-learning environment for students to support their learning but 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 the text format to support different learners which provided good feedback: “The materials were in the form of videos as well as readable texts, which was a good thing for learning.”
Students also made video material of their practical skills which they were advised to study more independently than usual. 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. 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.” This showed that remote teaching period had also good aspects for learning, even though students missed contact lessons and social contacts.
During the online lessons, the case-based approach was used regularly. The teacher gave example client cases from practical working life and students found answers to the given questions. For example, students designed the examination and evidence-based physiotherapy plan to the client cases. According to the students, this was a good way to learn, and some students found that case-based studying could have been used even more: “It would have been possible to repeat the examination procedure with the cases even more.”
The Importance of the Feedback
Teachers in MSK courses decided that they will give additional feedback to the students on their independent assignments and videos of the practical skills, which students perceived to be very helpful for learning: “The individual feedback from the teacher on the assignments 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, the satisfaction with the amount of feedback was higher than normal: “The feedback from the teacher was extensive and rewarding.”
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 time and 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.”
In summary, a well planned pedagogical manuscript implemented with flipped classroom and learning approach seems to work well also in 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 especially video material 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 learnt to trust and give the responsibility of learning to students, they take it and learn regardless of the circumstances. “The teacher can only open the door; the student must walk in and discover” (Anonymous).
The unfortunate world-shattering Covid-19 has caused great changes and disruption to everyday life. However, we have learnt some positives 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 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 the Karelia UAS, 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 in the last few months.
Flipped Learning Network. 2014. What Is Flipped Learning? 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.