Clinical education of students is critical to our future healthcare and is an important aspect of health professions because it plays a fundamental role in shaping the students’ approach towards future professional practice (Alsiö et al., 2019; Senthilnathan et al.,2020). Its role in physiotherapy education cannot be over-emphasized as it equips students with the competencies, skills, and confidence necessary for clinical practice.
Clinical education is a core component of physiotherapy professional training, which involves the assimilation of attitudes, values, and behaviours that define a physiotherapy professional (Delany & Bragge, 2009). During this phase of student learning, direct patient care is experienced (Odole et al., 2014). Clinical instructors who are specialists in the different areas of physiotherapy share their knowledge and professional expertise with the students. They also give direct supervision in various areas of clinical learning using the best teaching strategies in a good learning environment. Hence, clinical experience is not only an essential element of the health care education programme but it is paramount for the development of good clinical reasoning and professional skills in students (Chan, 2004; Benner et al, 2008). The early years of physiotherapy education are focused on basic scientific and medical knowledge, whereas clinical teaching, which primarily comprises of bedside demonstrations, is introduced later in the curriculum (Bench, 1999). Currently, such clinical teaching models are now evolving since medical education is rapidly changing in response to the developments in health care delivery systems (Duncan et al., 2005).
Generally, there are three variations of physiotherapy clinical education organisations. The first is the internal version which is no longer in existence in which the same institution provides both the foundational/clinical sciences theory and the student’s clinical experience. There is also an external version which is very common in the United States of America in which students’ clinical training takes place in free-standing hospitals, clinics, and centres. Common in British Commonwealth countries, including Nigeria, is the bridge version in which students gain their clinical experience in a teaching hospital specifically affiliated with the University (Bench, 1999).
Clinical education is believed to be different from classroom education as it requires key attributes for effective learning including communication, questioning, one-to-one evaluation, and small group skills (Knox & Morgan, 1985). Students engage in supervised learning sessions in health-care settings during clinical education, giving them the opportunity to put what they’ve learned in the classroom into practice. As a result, the clinical experience acquired by students during the clinical education phase of their programme may be grossly influenced by the teaching attributes of the clinical instructor as well as the nature of the student’s clinical environment (Knox & Morgan, 1985). Therefore, student learning could be maximised if the clinical experience is impacted by clinical instructors who possess the ideal teaching attributes such as adequate clinical competence, good teaching abilities, professional ethics, substantial clinical experience, and effective communication skills. In addition, an optimal educational environment that provides opportunities for learning experiences that contribute to the achievement of learning objectives, professional socialisation and the quality of care provided to patients during professional practice maximises students learning.
Thus, clinical learning experience provides a context for the application of prior knowledge and the integration of new learning. Students, therefore, have to combine and integrate knowledge, skills, values, and philosophies of the profession that they have learned in the classroom and apply these to the real patient, with medical dysfunctions (Demiroren et al., 2008). Clinical learning is therefore an important part of physiotherapy education as it is a key determinant of curriculum and a silent index of both students’ and teachers’ behaviour (Demiroren et al., 2008). However, obtaining feedback from students regarding their clinician’s teaching attributes and their clinical learning environment is an important element of health care as it provides a useful basis for modifying and improving the quality of teaching and learning. Several studies have been conducted in various health professions to evaluate clinical students’ perceptions of their learning environment and clinician’s teaching attributes. Arzuman, et al. (2010), Salminen et al. (2016), and Shar et al. (2019) carried out a study on Medical Students’ Perception of the Clinical Learning Environment. Demiroren et al. (2008) conducted a study on the perception of students in Different Phases of Medical Education of their educational environment. Alammar et al. (2020) studied nursing students’ perception of the clinical learning environment. Wilsom et al. (2021) conducted a study on nursing students’ perceived effective clinical teacher behaviours. Nyante et al. (2020) studied physiotherapy students’ satisfaction with their clinical learning environment and supervision at the University of Ghana.
However, there are limited studies on physiotherapy students’ perception of their clinical learning environment and clinicians’ teaching attributes in Nigeria. Two studies were performed in Nigeria, one at the University of Ibadan (Odole et al., 2014) and another at Nigerian Universities (Oyeyemi et al., 2012). Oyeyemi et al assessed physiotherapy students’ perception of their clinicians’ teaching attributes while Odole et al assessed physiotherapy clinical students’ perception of their learning environment. Consequently, there is still a dearth of knowledge on the perception of the clinical learning environment and clinicians’ teaching attributes by physiotherapy students in Nigeria, despite the fact that these factors have been reported to have an enormous impact on the outcome of learning. Hence, there is a need for a regular evaluation of students’ feedback on the perception of their clinical learning environment and clinicians’ teaching attributes as a basis for monitoring, modifying, and improving the quality of teaching and learning. In addition, students’ opinion on their clinicians’ teaching attributes and the clinical learning environment needs to be constantly evaluated to ensure it’s in line with the recent innovations in patient care. Therefore, this study investigated physiotherapy students’ perception of their clinical learning environment and clinicians’ teaching attributes in Nigeria.
Design: This study utilised a cross-sectional research design.
Subject selection: Two hundred and fifty-eight (258) undergraduate physiotherapy students from two universities (University of Nigeria [UNN] and Nnamdi Azikiwe University [NAU]) that offer physiotherapy programmes in south-east Nigeria participated in this study. The inclusion criteria were: fourth and fifth-year students who are in their clinical phase of training and who were available and willing to participate. Convenient sampling was used to select the participants.
Instruments for data collection: Section A and B consisted of self-structured questions which assessed the socio-demographic characteristics of the participants and clinical instructors, respectively.
The McGill Clinical Teacher Evaluation Tool (CTE) was contained in Section C. This was used to assess physiotherapy students’ perception of their clinical instructors teaching attributes. McGill’s CTE instrument is a 25-item tool that has been validated for use among physical therapy clinical instructors (Oyeyemi et al., 2012). This tool is rated on a 5 point Likert scale: Very strongly agree=5, Agree=4, Unsure = 3, Disagree =2, Very Strongly Disagree=1. It has been assessed for reliability among Nigerian physiotherapy students in a pilot study and a reliability coefficient of 0.73 was obtained (Oyeyemi et al., 2012).
Section D contained the Dundee ready environment evaluation measure (DREEM). This was used to assess physiotherapy students’ perception of their clinical learning environment. It consists of five sub-domains with a total of 48 questions. Students’ perception of learning contains 11 questions, students’ academic self-perception contains 8 questions, students’ perception of teachers contains 10 questions, students’ perception of the atmosphere contains 12 questions and students’ self-perception contains 7 questions. The DREEM is rated on a 5-point scale as follows: Strongly agree = 4, Agree = 3, Unsure= 2, Disagree=1, Very Strongly Disagree= 0. Environmental perception of students as determined by DREEM is classified as “very poor” for scores between 0 and 50, “plenty of problems” for scores between 51 and 100, “more positive than negative” for scores between 101 and 150, and “excellent” for scores between 151 and 200 (Askari et al., 2018). The DREEM has been reported to have a high level of internal consistency with an overall Cronbach’s of more than 0.7 (Dimoliatis et al., 2010; Hammond et al., 2012). In addition, this measure has a high level of stability with a test-retest coefficient of more than 0.8 (Dimoliatis et al., 2010).
Procedure: Ethical approval was sought and obtained from the University of Nigeria Teaching Hospital Health Research Ethics Committee (NHREC/05/01/2008B-FWA00002458-IRB00002323). Written informed consent was obtained from the participants prior to data collection. The database of all fourth and fifth-year students was obtained from the various physiotherapy departments of the involved institutions. Text messages and e-mails were sent out to the students inviting them to participate. In addition, further notification was given to the students through their class representatives. All the students who were interested, willing, and available were recruited. All procedures were explained to the participants and confidentiality was assured. The questionnaires were distributed to all the participants that met the selection criteria. The students were asked to complete all the questions honestly. The questionnaires were distributed and collected in the classrooms of the participants.
Data Analysis: Descriptive statistics consisting of mean, standard deviation, and percentages were used to summarise the data. The Mann-Whitney U test was used to determine the difference in the student’s perception of their clinical learning environment and clinician’s teaching attributes amongst the institution of learning as well as the level of study. In addition, the Mann-Whitney U test was also used to determine the difference in the student’s perception of their clinician’s teaching attributes based on clinical instructors’ gender. The Kruskal Wallis test was used to compare the student’s perception of their clinician’s teaching attributes on the basis of their last clinical posting unit and the highest educational level of the instructors. All the data aspects were analysed using the statistical package for social science (SPSS version 21.0). Alpha level was set at 0.05.
298 questionnaires were distributed for the study. An 87% return rate resulted in 258 questionnaires being completed and returned. Table 1 shows the socio-demographic characteristics of the students while Table 2 presents the profile of the clinical instructors.
Clinical Learning Environment
The majority of the students (N=189; 73.2%) perceived their learning environment to have more positive than negative features. Out of the participants, 48 students (18.6%) perceived their learning environment to have “plenty of problems”, while 21 students (8.2%) perceived their learning environment “to be excellent”. The mean score of the various domains of DREEM showed that the domain on ‘students’ perception of learning had the highest mean (30.95±6.52) while the domain on ‘students’ social perception’ had the least mean (16.36±5.43). The remaining domain mean scores consisted of students’ academic self-perception (23.86±5.45), students’ perception of teachers (26.21±6.30), students’ perception of atmosphere (24.02±10.38). There was a significant difference in the rating of students’ perception of the learning environment based on the institution (p = 0.037) and the level of study (p = 0.031) (See Table 3).
Clinicians’ teaching attributes
Table 4 presents the order of agreement of student rating of their clinical instructors’ teaching attributes using the McGill CTE tool. There was no significant difference in the students’ perception of clinicians’ teaching attributes based on institution and level of study (Table 5).
No significant difference was observed in the students’ rating of their clinical instructors based on their last unit in clinical posting (p = 0.806) (Table 6.) However, the students rated clinical instructors who worked in the exercise immunology clinical posting unit higher (mean rank: 187.33) than clinical instructors in other postings units. Students’ rated their male clinical instructors higher than their female counterparts, but it did not attain significance (p = 0.654).
There was no significant difference in students’ rating of their clinical instructors’ attributes based on the highest educational qualification (p = 0.533). Clinicians with a Master of Science (M.Sc) degree were rated higher (mean rank: 130.48) than clinicians with Bachelor of Science (B.Sc) degree (mean rank: 116.56), while clinicians with a Doctor of Philosophy (Ph.D) had the lowest rating (mean rank: 114.36).
Clinical Learning Environment
The results showed that the majority of the students perceived their learning environment to have more positive than negative features. This finding was supported by several other studies that indicated that the response of the students was extremely positive with respect to their learning environment (Faure et al., 2002; Odole et al., 2014; Oyeyemi et al., 2012). This could be linked to the health sector’s constant advancements, which puts every department under pressure to meet the required standards so as to ensure that the clinical learning environment is suitable for students. The significant difference observed between the two institutions (UNN and NAU) in the rating of their clinical environment could be attributable to the difference in the curriculum in the two institutions. Students in NAU had higher mean scores than students in UNN in the rating of their clinical environment. In the course of this study, the researchers discovered that NAU’s curriculum is structured in such a way that students regularly undergo Student Industrial Work Experience Scheme (SIWES) postings which allow them to visit other teaching hospitals or special homes that provide physiotherapy services outside their state. Unfortunately, this is not obtainable in UNN where students only attend SIWES postings occasionally and do their clinical rotations predominantly in hospitals in their own state, thereby making the students more conversant with clinical environments in their area.
However, students had different perceptions of their learning environment based on their level of study. The fourth-year students had higher mean scores in the rating of their clinical environment than the fifth-year students. This supports the findings of a study carried out by Riquelme et al. (2009) to assess students’ perceptions of their educational environment. Their study reported that fifth-year students’ had lower scores in the sub-scales of the DREEM questionnaire compared to students in other levels of study. This is not surprising given that students in their third and fourth years of study have a greater desire to learn and explore new ground as they transition from the preclinical to the clinical phase of training. Furthermore, students who have recently moved from preclinical to clinical training may be unfamiliar with the system. In most cases, adequate support is provided in some institutions in terms of transportation and clinical orientation programmes so as to get these students acquainted with the environment and ensure a smooth transitioning. Thus, the perception of the learning environment tends to decrease as the students advance in their years of study when they get more familiar with the clinical environment. On the other hand, this finding contradicts the study by Till et al. (2004) in which fourth-year students rated their clinical environment lower than their final years. The authors reported that students in their fourth year required more assistance in transiting from their preclinical to the clinical year of study but had inadequate support from their institution.
Clinicians’ teaching attributes
It was observed that clinicians’ interest in helping students to learn’ had the highest rate of agreement based on the McGills CTE tool, while ’emphasizing concepts rather than factual recall’ had the lowest rating. This is in agreement with the findings of Oyeyemi et al. (2012). They reported that the ‘clinicians interest in helping students learn’ had the highest mean score amongst physiotherapy students in Nigeria.
There was no significant difference in students’ perception of their clinician’s teaching attributes based on their institution and level of study. However, students from NAU rated their clinicians higher than UNN students. This may have been noted in NAU students because of a wide range of contact with different clinicians who have different specialties during their SIWES programme. Fifth-year students rated their clinical teachers higher than fourth-year students. This may be attributed to their increased number of contact with their clinical instructors as well as a higher level of clinical exposure in several clinical posting units compared to the fourth-year students.
The results also showed that students had a higher rating of exercise-immunology-instructors followed by instructors in the neurology unit. This could be attributed to the style of teaching adopted in these clinical posting units which involve majorly practical teaching sessions. The students also had a higher rating of male instructors compared to females despite no significant differences in the ratings of clinical instructors’ attributes based on gender. This may be linked to the male to female ratio of clinical instructors in the hospitals utilised for this study. These hospitals had more male instructors compared to female instructors.
In addition, clinicians with an MSc degree had the highest rating followed by clinicians with BSc degrees and those with Ph.D. This may have occurred because clinical students in these institutions have lesser contact with clinical instructors who have obtained their Ph.D. degrees. The majority of these clinical instructors head clinical posting units and may not always be available to students.
Regular evaluation of clinical instructors teaching attributes and students’ clinical learning environments should be advocated so as to improve student learning outcomes and ensure readiness for professional practice after training. There should be a revised harmonised curriculum for the clinical posting experience of students outlining the minimum standards of clinical exposure a student should have during clinical education. This should form part of the requirement for accreditation of clinical departments. Seminars and workshops on clinical skill acquisition should be regularly organised for clinical instructors in the health sector to improve their teaching abilities.
Limitations of the study: Poor compliance on the part of some students.
Conflict of Interest Statement
The authors declare that there is no conflict of interest.
|Less than 16||0||0|
|Greater than 30||4||1.6|
|Year of study|
|Last unit in clinical posting|
|Intensive Care Unit||31||12.1|
|Obstetrics and Gynaecology||28||10.8|
Key: N= Number of participants, UNN= University of Nigeria, NAU= Nnamdi Azikiwe University.
|Highest Educational level|
|Specialty of clinical instructor|
|Obstetrics and Gynaecology||33||12.7|
|Level of Study|
Key: * significant at p<0.05, UNN=University of Nigeria, NAU=Nnamdi Azikiwe University, N= Number of participants.
|My clinician is :|
|-Interested in helping students to learn||4.25||0.82|
|-Emphasizes problem solving approach rather than solution per se||4.13||0.80|
|-Encourages students to ask questions||4.07||0.90|
|-Deals with colleagues and staff members in a friendly manner||4.01||0.83|
|-Encourages students to think||4.00||0.97|
|-Dependability of attendance is good||4.00||0.84|
|-Provides feedback and direction to students||3.95||0.93|
|-Encourages students to take responsibility of their own learning||3.93||0.83|
|-Is enthusiastic and understanding||3.92||2.81|
|-Inspires confidence in his/her knowledge of the subject||3.90||1.05|
|-Provides opportunities for discussion with students||3.88||1.05|
|-Display good judgments in decision making||3.88||0.96|
|-Emphasizes clinical skills, not lab test for patient management||3.88||0.95|
|-Presents divergent viewpoints for contrast and comparison||3.87||1.00|
|-Is usually readily available for discussion||3.85||1.01|
|-Attitudes to patients fit my concept of professional||3.84||1.03|
|-Invites comments rather than providing all answers||3.83||1.10|
|-Conveys enjoyment of associating with and his/her colleague||3.82||0.92|
|-Is clear and understanding in his/her explanation||3.79||0.93|
|-Is usually well prepared for teaching sessions||3.76||1.02|
|-Teaching is suited to the level of student sophistication||3.76||1.01|
|-Poses problem for students to solve||3.75||1.07|
|-Is interested in the social and psychological aspects of illness||3.72||1.05|
|-Occasionally challenging points presented in texts and journals||3.66||1.00|
|-Emphasizes concept rather than factual recall||3.64||1.05|
Key: X=Mean, SD= Standard deviation
|N||Mean Rank||Z||p value|
|Level of Study|
Key: UNN=University of Nigeria, NAU=Nnamdi Azikiwe University
|O and G||28||123.75|
Key: p is significant at 0.05
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