One Reply to “Peer review (Michael Rowe) – Physiotherapy students’ perception of their clinical learning environment and clinician teaching attributes in Nigeria”

1. RESPONSES TO REVIEWERS COMMENT

   1. Complete, coherent, and well-organized presentation: The article is presented well for the most part, although there are some minor grammatical errors remaining. I have made suggestions below that may help with clarifying some of the issues with presentation.

   Authors’ comment: The grammatical errors which were pointed out have been addressed.

   2. Sufficient explanation of the significance of the problem: There isn’t a clear link between the problem that the study purports to address (i.e. improving learning outcomes) and the findings of the study. The authors can do more to create a stronger link between student perceptions of clinical learning placements and clinical teachers, and improvements to the curriculum (and therefore, to learning outcomes).

   Authors’ comment: The introduction section has been revised in the following areas to address this issue.

   Paragraph 4, line 5-9: “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)”

   This was replaced with “As a result, the clinical experience acquired by students during the clinical education phase of their programme and the learning outcomes 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)”.

   Paragraph 4, line 12-16: “Paragraph 4, line 12-16: “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”.

   This was replaced with ”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 outcomes”.

   Paragraph 5: “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 an integral component of curriculum and a silent index of both students’ and teachers’ behaviour (Demiroren et al., 2008). As such, the student’s ability to gain clinical exposure, knowledge and skills which is in line with the stipulated clinical learning standards in the curricula may be influenced by the clinicians teaching attributes and the clinical learning environment. 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 ……………”

   This was replaced with “Curricula in programmes that educate future practitioners in health care professions are strongly affected by the requirements of professional associations, regulatory agencies and approval boards. As such, planning and structuring the clinical learning programmes of students in accordance with the overarching curriculum is seldom a linear process. Clinical learning is an important part of the curricula in physiotherapy programmes, as it is in most health-related professions (Buccieri et al, 2013; McCallum et al, 2013). This experience provides 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 an integral component of the curriculum and a silent index of both students’ and teachers’ behaviour (Demiroren et al., 2008). As such, the student’s ability to gain clinical exposure, knowledge and skills which is in line with the stipulated clinical learning standards in the curricula may be influenced by the clinicians teaching attributes and the clinical learning environment. 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…………………”

   Paragraph 5: “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”

   This was replaced with “However, obtaining feedback from students regarding their clinician’s teaching attributes and their clinical learning environment is an important aspect of health care because it provides a useful basis for modifying and improving the quality of teaching and the suitability of the learning environment, thereby improving learning outcomes”

   Paragraph 6, Last paragraph, line 10-13: “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”

   This was replaced with “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 to meet the required standards in the curriculum”

   Paragraph 6, line 13: “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 to meet the required standards in the curriculum”.

   This was replaced with “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 to meet the required standards in the curriculum and to improve learning outcomes”.

   learning environment increases students’ attention and focus, promotes meaningful learning experiences, encourages higher levels of student performance, and motivates students to practice higher-level critical thinking skills. Active learning will increase the focus and retention of the curriculum, resulting in an exciting learning environment.

   Students in health care education programs at universities complete practicums in a clinical learning environment in addition to attending academic classes. occupational therapy (Rodger, Fitzgerald, Davila, Millar & Allison, 2011), dietetics (Dietitians of Canada, n.d.), radiation therapy (Leaver, 2012),

   The clinical environment should be carefully selected, accepted by nurse tutors, and prearranged to be capable of transforming nursing students into competent nursing practitioners [8, 9]; this is dependent on factors such as curriculum design, cost effectiveness, and relationship with specific health facilities [10].

   3. Clear demonstration of the relevance to the field (beyond the case presented): If the authors can strengthen the link between student perceptions and improved curricula with practical suggestions, this article will have relevance for other physiotherapy educators.

   Authors’ comment: This has been addressed in the introduction section.

   4. Original contribution to the topic of physiotherapy education: While this is a local study in two Nigerian institutions, the lessons learned could be useful to other contexts.

   5. Compelling presentation of the problem within a theoretical framework (where appropriate): There is room for improvement in the introduction, especially with respect to connecting the findings of the study to the practical issue of curriculum reform. The authors might consider looking for a curriculum development framework that includes ‘student perception’ as a relevant variable to consider, and then integrate it into this article.

   Authors’ comment: This has been addressed in paragraph 5 of the Introduction section.

   Paragraph 5: “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”

   This was replaced with “However, obtaining feedback from students regarding their clinician’s teaching attributes and their clinical learning environment is vital because it provides a useful basis for modifying and improving the quality of teaching and the suitability of the learning environment, thereby improving learning outcomes. More so, students reportedly play a vital role in curriculum planning (Huppatz,1996). Students, based on their own experiences can provide feedback on student resources and facilities. Students’ involvement and their ideas will enable educators to develop a student friendly curriculum thereby improving learning outcomes. Consequently, feedback from students could be used as a guide during the curriculum reform process, which entails reviewing and updating the curriculum to prepare students for a fast-changing world and recent healthcare advancements. Several studies have been…….”

   6. Establishment of a relationship between the problem and other relevant literature: The authors can do more to link this study to the wider literature on curriculum development. Even though this isn’t made explicit in the article, the premise is that student perceptions of various parts of the programme are important for further developing the curriculum, with the aim of enhancing student learning outcomes. This connection between the existing literature and what this study sets out to achieve, can be strengthened. In addition, the use of citations to support claims made in the discussion is poor. The authors could do more to use existing research to justify some of the explanations provided for the findings of this study.

   Authors comment: The study has been linked to curriculum development and learning outcomes in paragraph 5 and 6 of the Introduction section.

   Authors comment: Citations have been used to justify some of the explanations provided for the findings of this study in the following areas.

   Discussion paragraph 2, line 1-4: “More so, the students in the current study had significant differences in the 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 in the current study”

   This was replaced with “More so, the students in the current study had significant differences in the perceptions of their learning environment based on their level of study. Despite the fact that the transition between the theoretical and the clinical phase is reportedly the most stressful period of undergraduate medical education (Morrison et al, 2001; Radcliffe, 2003), the fourth-year students had higher mean scores in the rating of their clinical environment than the fifth-year students in the current study”.

   Discussion paragraph 2, line 10-14: “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 pre-clinical to the clinical phase of training. Students who have recently moved from preclinical to clinical training may be unfamiliar with the system”.

   This was replaced with “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 pre-clinical to the clinical phase of training. Furthermore, though transiting from pre-clinical to clinical training has been reported as an exciting phase of learning for students due to changes in context and responsibilities (Morrison, 2001; Artherley, 2019), it has been described as a challenging process. Students who have recently moved from preclinical to clinical training may be unfamiliar with the system”.

   Discussion, paragraph 3: “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 was replaced with “It was observed among the study participants that “clinicians’ interest in helping students to learn’ had the highest rating based on the McGills CTE tool, while ’emphasizing concepts rather than factual recall’ had the lowest rating.”

   Discussion, paragraph 3: “It was observed among the study participants that “clinicians’ interest in helping students to learn’ had the highest rating 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). In their study, they reported that the ‘clinicians interest in helping students learn’ had the highest mean score among physiotherapy students in Nigeria. Clinical teachers are central to the successful education of medical graduates.”

   This was replaced with “It was observed among the study participants that “clinicians’ interest in helping students to learn’ had the highest rating 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). In their study, they reported that the “clinicians’ interest in helping students learn” had the highest mean score among physiotherapy students in Nigeria. Clinical instructors are critical to the success of medical students’ training. A study carried out by Dahlstrom (2005) found that clinicians are motivated to teach medical students because of the desire to help students become good health professionals. Most clinicians in their study were motivated to teach because of inspiration from senior mentors, their involvement in the development of upcoming health professionals and the opportunity to highlight an area of speciality. These reasons, as indicated in prior research, may not be different from the reason why clinicians in the current study had a high rating in “clinicians’ interest in helping students to learn”

   Discussion, paragraph 4: “There was no significant difference in students’ perception of their clinician’s teaching attributes based on their institution and level of study in the current study. However, students from NAU rated their clinicians higher than UNN students. This may have been noted in NAU students because of the wide range of contact with different clinicians in different specialties in various hospital settings during their SIWES programme”

   This was replaced with “There was no significant difference in students’ perception of their clinician’s teaching attributes based on their institution and level of study in the current study. However, students from NAU rated their clinicians higher than UNN students. This may have been noted in NAU students because of the wide range of contact with different clinicians in different specialties in various hospital settings during their SIWES programme. As a result of their interactions with these clinicians, these students may have been exposed to a variety of clinical cases. This observation supports the findings of a previous study that stated that exposing students to a variety of clinical cases can help them learn more effectively (Lofmark et al, 2001). Another previous study reported that exposure of students to high experiences that are associated with proper feedback is positively associated with their performance in end rotation clinical examinations. Thus, apart from enhanced learning and performance, the findings of these previous studies may positively affect the students’ ratings of their clinicians.”

   Discussion, last paragraph: “In addition, clinicians with an MSc degree had the highest rating followed by clinicians with BSc degrees and then 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.”

   This was replaced with “In addition, clinicians with an MSc degree had the highest rating followed by clinicians with BSc degrees and then those with Ph.D. Clinical instructors with M.Sc. degrees may have had more up-to-date knowledge, skills, clinical competence, and enthusiasm for instruction than clinical instructors with B.Sc. degrees, which might explain why this occurred. These have been noted as important characteristics of a good and effective clinical instructor (Jahan et al., 2008; Sutkin et al, 2008). Also, clinical instructors with Ph.D. degrees were perhaps rated lowest because clinical students in these institutions may have had lesser contact with them because most of them are in charge of clinical posting units and are not always available to students.”

   7. Appropriate research design and method: The study design is appropriate, although the analysis of data (and the meaning of the analysis outputs) could be explained more clearly.

   Authors revision: “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”

   This was replaced with “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 the clinical instructors’ gender. The Kruskal Wallis test was used to determine the difference in student’s perception of their clinician’s teaching attributes based on the last clinical posting unit they attended and the highest educational level of the instructors. All data were analysed using the statistical package for social science (SPSS version 21.0). Alpha level was set at p < 0.05. 8. Accurate and useful interpretation: For me, this was the least effective part of the article. I had difficulty connecting the findings of the study to it’s relevance to a broader community of physiotherapy educators. What is the value of reading this article, if you’re not an educator based at either of these institutions in Nigeria? The authors can do more to demonstrate the utility of these findings for a wider audience.

   Authors comment: This has been addressed with the changes made in the discussion and conclusion section.

   9. Sound argument and analysis: See my comments below for guidance on how the argument and analysis could be improved.

   10. Effective conclusion about the implications for physiotherapy education, research, and/or practice: The conclusion in its current form is more like a list of recommendations. However, these recommendations don’t flow clearly from the study findings. I had little confidence in the reasons provided for the findings (because of the limited connection to existing research) and so couldn’t take the recommendations seriously. The conclusion section should be primarily a summary of the findings of this study, and recommendations could certainly be included, but only after having been thoroughly discussed in the previous section.

   Authors comment: The conclusion has been revised.

   —
   Additional feedback for the author

   Authors comment: Other areas of the results and discussion were revised for clarity.

   Results, paragraph 2: “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)”

   This was replaced with “The majority of the students (N=189; 73.2%) perceived their learning environment to have “more positive than negative features”. Out of the remaining, 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). The mean scores of the remaining domains consisted of “students’ academic self-perception” (23.86±5.45), “students’ perception of teachers” (26.21±6.30) and “students’ perception of atmosphere” (24.02±10.38). There was a significant difference in students’ perception of the learning environment based on the institution (p = 0.037) and the level of study (p = 0.031) (see Table 3)”

   Results, paragraph 3: “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)”

   This was replaced with “Table 4 presents the student rating of their clinical instructors’ teaching attributes using the McGill CTE tool. The clinicians were rated highest in “interested in helping students to learn”(4.25 ± 0.82) and lowest in “emphasises concept rather than factual recall” (3.64 ± 1.05). There was no significant difference in the students’ perception of their clinicians’ teaching attributes based on the institution and level of study (Table 5)”

   Discussion, paragraph 6: “The results of the current study also showed that students had a higher rating of exercise-immunology clinical 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.”

   This was replaced with “The results of the current study also showed that students had a higher rating of exercise-immunology clinical instructors followed by instructors in the neurology unit. This could be due to the fact that this clinical posting unit was recently established as a sole unit in the physiotherapy departments of these two institutions. As a result, clinical instructors in this unit may devote more time and effort to endearing students to this area of physiotherapy. Students may have rated the clinical instructors in the unit higher as a result of this”.

   Conclusion

   Authors comment: “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.”

   This was replaced with “A significant difference was observed in the students’ perception of their learning environment based on the institution and the level of study. There was no significant difference in the students’ perception of clinicians’ teaching attributes based on the institution and level of study. There was no significant difference in students’ perception of their clinicians’ teaching attributes based on the students’ last unit in clinical posting, clinical instructors’ gender and highest educational qualification. Regular evaluation of the clinical instructors’ teaching attributes and students’ clinical learning environments should be advocated. This can form the basis for the investigation of the quality of teaching and the nature of the clinical environment to ensure the desired learning outcomes are attained and that students are ready for professional practice after training. In addition, this could aid educational administrators in recognising underlying problems that limit medical students’ learning experiences, thereby increasing the quality of medical education and clinical care. A unified curriculum for students’ clinical posting experience could be developed, outlining the clinical learning standards and the students’ learning outcomes so as to ensure uniformity in students’ clinical exposure. 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 sensitise and keep them informed on the latest advances in health care and in clinical teaching. This will enable students to have better learning outcomes.”

   Abstract

   > assessed regularly
   I wonder if ‘evaluated’ would be more accurate since you’re not assessing the quality of students’ feedback but rather evaluating it. Later in the article you talk about ‘evaluation’ and not ‘assessment’.

   Authors revision: “Feedback from students regarding their clinical learning environment and clinicians teaching attributes should be assessed regularly ……”

   This was replaced with “Feedback from students regarding their clinical learning environment and clinicians teaching attributes should be evaluated regularly ……”

   > it
   It’s not clear what you mean by ‘it’ here. Is ‘it’ the students’ feedback, or is ‘it’ the clinical learning environment and instructors? This sentence should be rephrased to make it clear how ‘it’ affects the outcomes of learning.

   Authors revision: “Feedback from students regarding their clinical learning environment and clinicians teaching attributes should be evaluated regularly to monitor the students’ outcome of learning, the readiness for professional practice, and the level of satisfaction with the profession”

   This was replaced with “Feedback from students regarding their clinical learning environment and clinicians teaching attributes should be evaluated regularly to monitor the students’ learning experiences which can affect learning outcomes, the readiness for professional practice, and the level of satisfaction with the profession.

   > determine
   This is different to saying that you’re ‘assessing’ (or evaluating) student feedback. I suggest changing to “To evaluate physiotherapy students”

   Authors revision: “Aim: “To determine physiotherapy students’ perception of their clinical learning environment…………”

   This was replaced with “To evaluate physiotherapy students’ perception of their clinical learning environment…………”

   > based on clinical instructors’ gender
   This is very specific and should be justified earlier in the abstract. Why do you think it’s important to determine differences in student perceptions of clinical instructors’ teaching attributes based on their (the instructors’) gender?

   Authors revision: “Feedback from students regarding their clinical learning environment and clinicians teaching attributes should be evaluated regularly as these could affect learning experiences, learning outcomes, the readiness for professional practice, and the level of satisfaction with the profession”.

   This was replaced with “Feedback from students regarding their clinical learning environment and clinicians teaching attributes should be evaluated regularly as these could affect learning experiences, learning outcomes, the readiness for professional practice, and the level of satisfaction with the profession. Differences may exist in this feedback from students based on their institution, level of study, and characteristics of the clinical instructor”

   > Perception of the students’ learning environment resulted in more positive compared to negative features.
   This sentence isn’t clear.

   Authors revision: This has been revised for clarity in the abstract and the main manuscript.

   Abstract: “Perception of the students’ learning environment resulted in more positive compared to negative features”

   This was replaced with “The students perceived their learning environment to be “more positive than negative”.

   > perception of learning
   You should try to differentiate the names of your categories from the rest of the sentence. You could do this by using italics for the category names, or capitalising them, or placing them in single quotes.

   Authors revision: This has been addressed. The students perceived their learning environment to be “more positive than negative”. The highest-rated domain in the DREEM questionnaire was “perception of learning”, while the lowest was “social perception”. The highest-rated attribute for clinicians in the McGill CTE tool was “clinical interest in helping students to learn”, while the lowest was “emphasises concept rather than factual recall“.

   > ‘Clinical interest in helping students to learn’
   Here you’ve used capitalisation and single quotes to name the category. I suggest using only one of these options, and ensuring that you’re consistent in how you do this throughout the article.

   Authors comment: This has been addressed.

   > Emphasizes
   Use UK/English spelling throughout the article. In this case, you should use “Emphasises” i.e. “s”, not “z”.

   Authors comment: This has been addressed in the entire manuscript.

   > regular evaluation of the clinical instructors’ attributes
   Your study didn’t evaluate the actual attributes; you evaluated student perceptions of the attributes. Please make sure that you are clear in terms of what you actually did and what you say you did.

   Authors revision: This has been addressed. “There is a need for regular evaluation of the clinical instructors’ attributes, and the clinical learning environment……………..”

   This was replaced with “There is a need for regular evaluation of students’ perception of their clinicans’ attributes and the clinical learning environment………..”

   > in order to monitor students’ learning outcomes and to ensure readiness for professional practice
   I think it’s a stretch to say that this is something that your study can say anything about. You didn’t formally establish a link from student perceptions of various concepts to the monitoring of outcomes and readiness for practice.

   Authors revision: This has been addressed in the introduction and conclusion of the abstract.

   Introduction/background

   > emphasized
   UK spelling should be used throughout the article.

   Authors comment: This has been addressed in the manuscript.

   > practice
   I’m not sure that this first paragraph adds much value to the article. The second paragraph could also serve as a suitable opening for the article.

   Authors revision: The first and second paragraph in the introduction has been revised.

   > Clinical education is a core component of physiotherapy professional training
   You don’t have to argue for why clinical training is important; everyone reading this article already accepts the value of clinical placement and education in that environment. I suggest that this introduction should try to focus on the core concepts of the study i.e. student perceptions, clinical learning environments, and clinical teachers. What is the minimum amount of information you need to provide to ensure that the reader is comfortable with the concepts you’re going to explore in the article?

   Authors revision: The first and second paragraph in the introduction has been revised. These core concepts have been incorporated.

   Paragraph 1 and 2 of Introduction: “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)……”

   This was replaced with “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). Clinical education can only be effective in a conducive learning environment and with clinicians who have good teaching attributes to ensure enhanced learning experiences and outcomes. In physiotherapy professional training, clinical education involves the assimilation of attitudes, values, and behaviours that define a physiotherapy professional (Delany & Bragge, 2009). Its role in physiotherapy education cannot be over-emphasized as it equips students with the competencies, skills, and confidence necessary for clinical practice thereby enhancing learning outcomes. During this phase of student learning, direct patient care is experienced (Odole et al., 2014)…….”.

   > Benner et al,
   Please review the APA guidelines for citation formatting and ensure that your usage is consistent throughout the article.

   Authors revision: This has been addressed in the entire manuscript.

   > Generally
   It feels like this paragraph is a distraction and doesn’t add much to the overall article. I get that it’s providing a basic overview of different approaches to clinical training but the reader doesn’t need to know the other systems in order to understand this article. Maybe a single sentence describing how Nigerian clinical supervision takes place would be enough?

   Authors revision: This has been addressed in the introduction section.

   > with medical dysfunctions
   Unnecessary to include.

   Authors revision: This has been expunged.

   > 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).
   You’ve made this point several times in the article already. I’m not sure you need to keep repeating it.

   Authors comment: This has been addressed

   > Medical Students’ Perception of the Clinical Learning Environment
   Shouldn’t be capitalised.

   Authors revision: This has been changed to lower case letters.

   > Different Phases of Medical Education
   Don’t capitalise.

   Authors revision: This has been changed to lower case letters.

   > Ghana
   Would it be worthwhile summarising the key findings of these studies? Without knowing what the authors found, there’s little value in including this list of papers. Perhaps you could summarise the main outcome of the studies collectively, rather than simply listing the authors and titles.

   > Nigerian Universities
   Is this the name of an institution? It’s not clear. If not, consider rephrasing.

   Authors comment: This has been revised for clarity

   > Oyeyemi et al
   Review APA for correct formatting of in-text citations.

   Authors comment: This has been addressed

   > have been reported to have an enormous impact on the outcome of learning
   Who made this claim and what is the nature of this impact? Considering the pivotal role that the claim plays in the article, it should be clearly cited and explained in some detail earlier in the introduction.

   Authors comment: This has been addressed in the third paragraph of the introduction.

   > 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.

   Authors revision: “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” This was replaced with

   “In addition, students’ opinion on their clinicians’ teaching attributes and the clinical learning environment needs to be constantly evaluated to ensure their learning experience is in line with the requirement of the curriculum, the desired outcome and recent innovations in health care”

   Authors revision: “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” This was replaced with “In addition, students’ opinion on their clinicians’ teaching attributes and the clinical learning environment needs to be constantly evaluated to ensure their learning experience is in line with the requirement of the curriculum, the desired outcome and recent innovations in health care”

   >I don’t recall seeing any evidence for this claim earlier in the introduction. Please justify it with some form of evidence because it’s a strong claim to make and is central to your main argument.

   Authors comment: This has been incorporated in the Introduction

   Methods

   > cross-sectional research design
   It’s often useful to explain briefly what this is and why you chose this design.

   Authors revision: “This study utilised a cross-sectional research design because it is an observational study in which information will be obtained from the participants at a particular point in time.”

   > Section A and B
   Of what? A self-designed questionnaire? It’s not clear what these sections are referring to.

   Authors revision: “Section A and B of the questionnaire included self-administered questions which were used to collect information on the socio-demographic characteristics of the participants and clinical instructors, respectively”.

   > self-structured questions
   What is a ‘self-structured question’?

   Authors comment: This has been expunged.

   > assessed
   “…was used to collect sociodemographic characteristics…”

   Authors comment: This has been addressed.

   > contained
   “…included…” may be more suitable.

   Authors comment: This has been addressed.

   > physical therapy
   Be consistent in how you name the profession. You can use either “physical therapy” or “physiotherapy” but not both.

   Authors comment: This has been addressed.

   > is rated on
   “…uses a 5 point…”

   Authors comment: This has been addressed.

   > assessed
   “…evaluated…”

   Authors comment: This has been addressed.

   > 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).
   It’s reasonable to direct the reader to the relevant source for more detailed information, especially for a commonly used tool like the DREEM. It’s not a problem for this detail to be included here but it does take up more space than necessary, and the reader can easily find this information on their own.

   Authors revision: The source has been included

   “Section D of the questionnaire contained the Dundee ready environment evaluation measure (DREEM). This was used to evaluate the physiotherapy students’ perception of their clinical learning environment. It consists of five sub-domains with a total of 50 questions (Miles et al., 2012)………………………..”

   > that
   “…who…”

   Authors comment: This has been addressed.

   > The students were asked to complete all the questions honestly.
   We can safely assume that students were expected to answer honestly. This sentence could be removed.

   Authors comment: This has been expunged.

   > was also used to determine the difference in the student’s perception of their clinician’s teaching attributes based on clinical instructors’ gender.
   Why do you emphasise this component? There is nothing in your introduction to indicate that this variable (i.e. gender) is relevant for your study question. I think it would be useful for you to explain why this particular variable is important to investigate.

   Authors comment: Apart from the students’ perception of their learning environment and clinicians’ teaching attributes which was the main focus of this study, this study also sought to determine the differences in these perceptions based on the institution and level of study of the student. Also, differences in the rating of the clinicians’ attributes were determined based on the last clinical posting unit of the students, the clinicians’ gender, and the clinicians’ highest level of education.

   Results

   > Table 1 shows the socio-demographic characteristics of the students while Table 2 presents the profile of the clinical instructors.
   At this point I’m wondering where you’re presenting cross-tabulated data e.g. participants with variable X were more likely to respond in this way to question Y.

   > plenty of problems
   Do you have any sense of what these problems might be? Simply knowing that almost 20% of the students perceive there to be “plenty of problems” isn’t very useful, without knowing what they are.

   Authors comment: The “plenty of problems” mentioned is a reflection of the participant’s scores obtained on the DREEM questionnaire which are 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. The citation for this questionnaire has bn included in the study.

   > domains of DREEM
   I see some of them listed below but it may be difficult for the reader to understand what you mean when you say that the highest mean on a certain domain is X.

   Authors revision: The mean score of the various domains of DREEM showed that the domain on “students’ perception of learning” had the highest mean score (30.95±6.52) while the domain on “students’ social perception” had the lowest mean score (16.36±5.43).

   The clinicians were rated highest in “interested in helping students to learn” with a mean score of 4.25 ± 0.82 and lowest in “emphasises concept rather than factual recall” with a mean score of 3.64 ± 1.05.

   > least
   “…lowest…”

   This has been addressed.

   Discussion

   > to have more positive than negative features
   Is it relevant that there are “more” or “less” positive/negative features? What we really need to know are how important the relative value of each feature is. For example, a negative feature might be that there isn’t enough space to properly learn. While a positive feature might be that there is parking space for students. These are not equivalent and one is way more important for learning than the other. A simple tally of “how many” doesn’t tell the reader the important part of the story. Is it possible to add any of this detail?

   Authors comment: This has been discussed elaborately.

   > 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.
   This would benefit from a citation in support of the claim.

   Authors comment: This has been addressed: These findings are 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 pre-clinical to the clinical phase of training. Furthermore, though transiting from pre-clinical to clinical training has been reported as an exciting phase of learning for students due to changes in context and responsibilities (Artherley et al., 2019; Morrison & Moffat, 2001), it has been described as a challenging process (Malau-Aduli, 2020).

   > may be unfamiliar with the system
   Which system?

   Authors comment: This has been further explained and backed up with citations

   > They reported that the ‘clinicians interest in helping students learn’ had the highest mean score amongst physiotherapy students in Nigeria
   Your discussion would benefit from some description of what this all means for the reader or interested physiotherapy educator. How can the reader use the results of your study to make changes in their own programme?

   Authors comment: This has been addressed

   > 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.
   It would really strengthen your article if you provided citations in support of the rationales you provide for your findings. Yes, it may be because of what you suggest. But it also may not. A citation in support would give the reader more confidence that your explanation is valid.

   Authors comment: This has been addressed: However, students from NAU rated their clinicians higher than UNN students. This may have been noted among NAU students because of the wide range of contact with different clinicians in different specialties in various hospital settings during their SIWES programme. As a result of their interactions with these clinicians, these students also may have been exposed to a variety of clinical cases, thereby leading to a higher rating of their clinicians. This observation supports the findings of a previous study which stated that exposing students to a variety of clinical cases can help them learn more effectively (Lofmark et al., 2001). Another previous study reported that exposure of students to high experiences which are associated with proper feedback is positively associated with their performance in end rotation clinical examinations (Chateenany, 1996).

   > This may be attributed to their increased number of contact with their clinical instructors
   Same here. It may be because of what you describe but it may also be something else entirely. Without a citation to support your claim, the reader can’t have much confidence in your explanation.

   > This could be attributed to the style of teaching adopted in these clinical posting units which involve majorly practical teaching sessions
   Again, a citation would be great here.
   Authors comment: This has been addressed

   > These hospitals had more male instructors compared to female instructors.
   How does this explain the fact that participants rated male teachers more positively? Citation needed.

   Authors comment: This has been revised and citations included: “The students also had a higher rating of male instructors compared to females though there was no significant difference in the students ratings of their clinical instructors’ based on the instructors gender. Likewise in previous studies, though in other medical professions, students rated their male instructors higher. Male physicians were rated higher on trustworthiness, competence, and professionalism compared to female physicians in a study by Ladha (2017). In addition, Morgan et al. (2016) and Fasiotto et al. (2018) observed that female instructors were rated lower than males by medical students and residents respectively. Therefore, there seems to be gender bias in students’ rating of their instructors”

   Conclusion

   > so as to improve student learning outcomes and ensure readiness for professional practice after training
   What you’ve presented in the results and discussion doesn’t actually provide any guidance around how knowing this information can improve learning outcomes. If you want to make this claim in your conclusion, you really should discuss how your findings can be used in this way. What, in practical terms, can the reader do with your findings in order to improve learning outcomes?

   > 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.
   Again, it’s not clear to me how your findings lead you to this conclusion. And, what do you mean when you say “harmonised curriculum”?

   > Seminars and workshops on clinical skill acquisition should be regularly organised for clinical instructors in the health sector to improve their teaching abilities.
   Your conclusion doesn’t actually discuss the findings of this study. You seem to be making recommendations in the conclusion that don’t clearly stem from your results and discussion. This paragraph should only present the conclusions from this study. And recommendations should be supported in the discussion through appropriate citation.

   Authors comment: The conclusion has been revised to address these points.

   > Poor compliance on the part of some students.
   This isn’t a limitation. If students chose not to complete your survey, there are many other reasons for why that might be true. For example, the survey may have been confusing, or distributed at a busy time of year, or the rationale for completing it may not have been explained. My point is, you can’t blame your participants when things don’t work out as you had hoped.

   Authors comment: This has been expunged as a limitation of the study.

   Table layout and presentation
   > UNN
   Write these out in full.
   > Less
   “Younger…”
   > 15.0
   Remove the decimal place when the first number after the point is 0.
   > Greater
   “Older…”
   > Marital status

   Authors comment: This has been addressed.

   >Why present this information if you’re not going to link responses to these variables. For example, It might be interesting to know if married participants perceptions of feedback based on the gender of the clinical teacher is different to the perceptions of unmarried participants. The same question can be asked of the gender of participants. There’s little value in including sociodemographic information that isn’t tied to some other variable.

   Authors comment: This was expunged because there were not linked to other variables in the course of this study

   > Key: N= Number of participants, UNN= University of Nigeria, NAU= Nnamdi Azikiwe University.
   Not necessary to include. All readers will know what the “N” stands for. And there’s enough space in the table to write the institution names in full.
   Authors comment: This has been addressed

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