Clinical education is an important aspect of most medical and allied health professions because it plays a fundamental role in shaping the students’ approach towards future professional practice. Its role in physiotherapy education cannot be over-emphasized as it equips students with the competencies, skills, and confidence necessary for clinical practice. The student learning environment and clinician teaching attributes are determinants of effective clinical education and need to be regularly assessed in any clinical setting.
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). The clinical education phase is the stage in student training during which direct patient care is experienced (Odole et al., 2014). During this phase of learning, clinical instructors who are specialists in the different areas of physiotherapy share their knowledge and professional expertise with the students, as well as give direct clinical supervision in various areas of study using the best teaching strategies in a good learning environment. Several authors agree that 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). Earlier years in clinical education were focused on basic scientific and medical knowledge while clinical teaching, which consists mostly of bedside demonstration, was incorporated during the later phase of the programme (Bench, 1999). 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).
However, there are three variations of physiotherapy clinical education organisation. The first is the internal version which is no longer in existence and 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 and in which student’s affiliation experiences takes place in free-standing hospitals, clinics, and centers. Also prevalent in the 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). The clinical experience acquired by students during the clinical education phase of their programme may be 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, and if such experience is impacted in an optimal educational environment.
In addition, clinical learning experience thus 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 real problems (Demiroren et al., 2008). Clinical learning is therefore an important part of education for physiotherapy students as it is a key determinant of curriculum and a silent index of the behaviour of both the students and teachers (Demiroren et al., 2008). However, obtaining feedback from students on their clinician’s teaching attributes and 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 carried out in other health professions to evaluate clinical students’ perception of their learning environment and clinician’s teaching attributes (Aruzuman et al., 2010; Demiroren et al., 2008).
There is a paucity of literature on physiotherapy students’ perception of their clinical learning environment and clinicians teaching attributes in Nigeria. Oyeyemi et al carried out a study on Nigerian physiotherapy students’ perception of their clinicians’ teaching attributes (Oyeyemi et al., 2012), while Odole et al. (2014) carried out another study on physiotherapy student perception of their clinical learning environment at the University of Ibadan, Nigeria. However, there is still a dearth of knowledge on the perception of 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, student’s 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 inpatient care. Therefore, this study investigated physiotherapy student’s perception of their clinical learning environment and clinicians’ teaching attributes in Nigeria.
Design: This study utilized a cross-sectional research design.
Subject selection: Two hundred and fifty-eight (258) undergraduate physiotherapy students from the 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: 4th and 5th-year students who are in their clinical phase of training and who were available and willing to participate. A convenience sampling technique was utilized to select the participants.
Instrument for data collection
Questionnaire: Section A and B was self-structured and assessed the socio-demographic characteristics of the participants and clinical instructors respectively.
Section C contained the McGill Clinical Teacher Evaluation Tool (CTE). 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. The tool was reported to have a reliability of 0.73.
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.The DREEM has been reported to have a high level of internal consistency with the overall Cronbach’s alpha coefficient being more than 0.7 (Dimoliatis et al., 2010; Hammond et al, 2012). It was also reported to have a high level of stability with a test-retest correlation coefficient of more than 0.8 (Dimoliatis et al., 2010).
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 before data collection. The data base of all the 4th and 5th 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. Also, further notification was given to the students through their class representatives. All the students who were interested, willing and available were recruited. All the procedures were explained to the participants and confidentially assured. The questionnaires were distributed to all the participants that met the selection criteria. They were asked to fill in the appropriate responses. The questionnaires were distributed and collected in the class room of the participants.
Descriptive statistics of mean, standard deviation and percentages was used to summarise the data. Mann Whitney U test was used to determine the difference in the students perception of their clinical learning environment and clinicians teaching attributes based on institution of learning and level of study. Mann Whitney U test was also used to determine the difference in the student’s perception of their clinicians teaching attributes based on clinical instructors gender. Kruskal Wallis test was used to determine the difference in the student’s perception of their clinicians teaching attributes based on their last clinical posting unit and highest educational level of the instructors. All data were analysed using statistical package for the social science (SPSS version 21.0). Alpha level was set at 0.05.
298 questionnaires were distributed for the study. Out of this, 258 were returned giving a return rate of 87%. Table 1 shows the socio-demographic characteristics of the students while table 2 presents the profile of clinical instructors.
Clinical learning environment
Majority of the students 189(73.2%) perceived their learning environment to have more positive than negative features. Forty-eight of the participants [48(18.6%)] perceived their learning environment to have plenty of problems while 21(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). Others are: 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 learning environment based on institution and level of study (See table 3).
Clinicians teaching attributes
Table 4 presents the order of agreement of students 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, students rated clinical instructors in 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).
Also, there was no significant difference in students rating of their clinical instructors attributes based on highest educational qualification (p = 0.533). Clinicians with M.Sc were rated higher (mean rank: 130.48) than clinicians with B.Sc (mean rank: 116.56) while clinicians with 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 reported 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 attributed to the recurrent advances in the health sector which makes every department faced with the struggle of meeting up with the required standard to ensure that the clinical learning environment is conducive for the students. The significant difference observed between the two institutions (UNN and NAU) in the rating of their clinical environment may be likely due to the difference in the curriculum in the two institutions. Students in NAU rated their clinical environment higher than students in UNN. In the course of this study, the researchers observed that the curriculum in NAU is arranged in such a way that the students undergo Student Industrial Work Experience Scheme (SIWES) postings regularly which gives them the opportunity to visit other teaching hospitals or special homes with physiotherapy services outside their state. This is not obtainable in UNN where they carry out their clinical postings within the hospitals situated in their state, thereby making the students only conversant with the clinical conditions prone to this area.
However, students had different perceptions of their learning environment based on their level of study. The 4th year students rated their clinical environment higher than the 5th year students. This was consistent with a similar study which reported that students’ year of study influenced the perception of their learning environment (Riquelme et al., 2009). This may be attributed to the zeal to learn and explore new ground associated with transiting from preclinical to clinical years of study. In most cases, the students are excited and not yet too familiar with the system. Adequate support is also provided in terms of transportation and clinical orientation programmes organised by the department to sensitise the students and make them acquainted to the environment. This is aimed at making students transition from the preclinical to the clinical phase of their programme easier. 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. However, this finding contradicts the findings of Till et al. (2004) in which the 4th years rated their clinical environment lower than their final years. They reported that students in their fourth year require more assistance in transiting from their preclinical to cliical year of study but are faced with inadequate support. For students in their fifth year, this was of less concern, probably because before transitioning to the fifth year they must have learned the means to access support when they need it.
Clinicians’ teaching attribute
It was observed that the clinician’s interest in helping students to learn’ had the highest rate of agreement based on the McGills CTE tool while ’emphasizing concept rather than factual recall’ had the lowest rating. This was 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 by 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 resulted from 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 4th-year students. This may be attributed to the level of exposure and contact the 5th year have gained within their rounds in different clinical posting units compared to the fourth year.
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 mostly practical teaching sessions. The students also had a higher rating of male instructors compared to females even though no significant difference in the rating of clinical instructors’ attributes based on gender was recorded. 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 unlike 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.
Limitations of the study: Poor compliance on the part of some students.
Regular evaluation of clinical instructors and the clinical learning environment of students should be encouraged to boost the outcome of learning of students and ensure readiness for professional practice after training. There should be a revised harmonised curriculum for the clinical posting experience of students spelling out the basic 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 boost their teaching skills.
|Less than 16||0 (0.0)|
|Greater than 30||4 (1.6)|
|Year of study|
|4th year||145 (56.2)|
|5th year||113 (43.8)|
|Last Unit in clinical posting|
|Intensive care unit||31 (12.1)|
|Obstetrics and Gynaecology||28 (10.8)|
|Exercise Immunology||6 (2.4)|
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 ≤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 subject||3.90||1.05|
|-Provides opportunity 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 view points 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 social and psychological aspect of illness||3.72||1.05|
|-Occasionally challenge 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
|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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