Factors influencing the quality of student learning on practice placements

© 2007 The Author Journal compilation © 2007 Blackwell Publishing Ltd.

Learning in Health and Social Care

,

6

, 4, 213–219

Original article

Blackwell Publishing Ltd

Factors influencing the quality of student learning on practice placements

Jenny

Morris

EdD MSc

BA

GradDipPhys

DipTP

CertEd(FE)

*

Lecturer in Physiotherapy, School of Health Professions and Rehabilitation Sciences, University of Southampton, Highfield, Southampton SO17 1BJ, UK

Abstract

Practice/clinical placements are central to learning in healthcare programmes, and

optimizing learning during placements is important. However, little literature exists on

physiotherapy students’ practice placement experiences. That which has been published

presents a picture of both positive and negative experiences.

The topic was addressed within a larger longitudinal study into the learning experiences

of students from non-traditional backgrounds undertaking a 4-year part-time

physiotherapy programme. Seventeen students from the 2000 cohort participated in the

qualitative phenomenographic study. The study met institutional ethical requirements

and participants’ gave written informed consent. Within the individual semi-structured

interviews undertaken in the final year, participants were asked to identify the aspects of

their practice placements which had least and most facilitated their learning.

Data were analysed using a phenomenographic approach, which identifies variation in

the ways in which people experience phenomena. The iterative process began with

identification of interview responses from verbatim transcriptions of the interviews, and

ended with a set of categories of description which, together, captured the full set of

participants’ responses. Representative quotations illustrated the nature and scope of each

category of description and provided evidence regarding the rigour of the data analysis

process.

Some categories were identified as both positive and negative, for example direct

involvement with patients, educator–student interaction, with the degree and nature of

context deciding on the direction of participants’ perceptions. Factors relating to

placement organization were also found to have both positive and negative influences on

learning. Effective communication is proposed as a means to addressing the negative

aspects identified.

This study provides useful information on participant’s perceptions of the quality of

their clinical placement experiences. However, the research base on this important topic

continues to be small, and further research is needed on physiotherapy students from both

traditional and non-traditional backgrounds.

Keywords

physiotherapy, practice/

clinical placement

learning, students’

experiences

*Corresponding author. Tel. 023 80592569 (work); fax: 023 80595301; e-mail: [email protected]

214 J. Morris

© 2007 The AuthorJournal compilation © 2007 Blackwell Publishing Ltd.

Introduction and literature review

High-quality learning which can be taken forward

and used effectively has been recognized as imperative

in graduates in the health professions, in order for

them to successfully meet the challenges of ever-

changing work environments and the requirements

for continuing professional development and lifelong

learning (Department of Health 2000). Research has

identified that the characteristics of the learning

environment which students experience has a

powerful effect on the nature and quality of their

learning (Biggs 2003; Ramsden 2003).

Learning on practice placements is argued to be

the most important element of vocational healthcare

programmes because it is the learning environment

which most closely resembles the work-place and

the realities of clinical practice (Sanford, Stratford

& Solomon 1993). Practice placements form a

substantial part of the learning experiences of physio-

therapy students and it is important that students’

experiences while on placement enable them to

optimize their learning and performance (Penman

& Oliver 2004). As part of standard quality procedures,

physiotherapy students complete evaluation forms

at the end of each practice placement (Chartered

Society of Physiotherapy 2003). These are used to

inform staff at both the higher education institution

and the practice placement of students’ perceptions

of the extent to which their academic preparation

and the placement experience enabled them to

achieve the learning objectives.

Research into the design and utility of practice

placement evaluation forms has been published (e.g.

Copeland & Hewson 2000; Stachura, Garven & Reed

2000). However, the responses on these forms are

normally processed and held internally and there is

a dearth of published literature on students’ feedback.

In addition, the forms tend to request procedural

feedback, for example rating of statements like ‘The

placement assisted my learning’ (Penman & Oliver

2004) or ‘Stimulates me to learn independently’

(Copeland & Hewson 2000), and do not identify or

explore the elements of the placement experience which

inform the responses to statements like these ones.

Literature exists on the characteristics which

students perceive to be important in their practice

placement educators (e.g. Cross 1995). However,

electronic and manual searching of the medical,

nursing and health profession literature identified

only one, rather dated, study in physiotherapy which

explored students’ actual experiences on practice

placements. The qualitative study by Harris & Naylor

(1992) involved 23 final-year students who completed

a diary and a questionnaire. Five of the participants

were also interviewed. No information was included

on the questions asked in the questionnaire or at

interview, or what participants were asked to record

in their diaries. Positive experiences identified were

patient contact, discussions with educators and sup-

ported self-directed learning opportunities. Negative

experiences were absence of teaching/observation

sessions, students being seen as ‘another pair of hands’,

and insufficient supervision and feedback. It is pos-

sible that the findings could have been influenced by

whether the students’ performance on placement

had already been assessed or not. However, the authors

did not identify whether data were collected before

or after students had completed their placement.

Although the nature of participant’s responses in the

Harris and Naylor study suggests that their experiences

could have impacted on their learning, this was not

identified as the primary purpose of the investigation.

Taken together, the issues outlined above justify

investigating students’ practice placement experi-

ences, with a focus on their learning. The aim of the

research presented in this paper was to identify and

explore students’ perceptions of the aspects of their

practice placement experiences which had best and

least facilitated their learning.

Method

Setting

This topic was investigated within a large longitudinal

study into the learning experiences of students

undertaking a 4-year part-time undergraduate

physiotherapy programme in the UK.

Sample

Seventeen of the 23 students from the 2000 cohort

participated in the study. Fourteen participants

Student learning on clinical placements 215


were female and three male. Their age on entry to

the programme ranged from 19 to 51 years (mean

29 years). Their academic backgrounds ranged from

school-leaver qualifications, through a range of

subdegree entry qualifications, to first degrees. The

participants were all experienced physiotherapy or

rehabilitation assistants who were continuing their

employment when not attending college. The study

design met the ethical requirements of the educational

institution, and participants gave informed consent

at the start of the study.

Procedure

As the focus of the study was on participants’

experiences, a qualitative approach was used in

order to obtain rich data which would provide an in-

depth picture (Frankel & Devers 2000). Data were

collected via individual semi-structured interviews

which were tape recorded. In semi-structured

interviews, questions have a focus, but are open-

ended. This encourages respondents to talk around

the issue under consideration and also gives the

interviewer the opportunity to explore responses

and seek elaboration (Payne & Payne 2004). The

students’ learning on practice placements was

investigated within the fifth of five interviews which

explored a number of factors which could influence

their learning, for example motivation and curriculum

design. The interviews took place at different times

across the 4-year programme. The final interviews

were undertaken towards the end of the participant’s

final year of study after they had successfully

completed all seven of their practice placements.

Within this 40- to 45-minute interview, they were

asked the following two questions:

1

Looking back, which aspects of your clinical

placements do you think have best facilitated your

learning?

2

Which aspects of the placements do you think

have least facilitated your learning?

Although not involved in the students’ clinical

placements, the fact that the interviewer was one of

the participants’ tutors could have influenced their

responses in the interviews. The potential impact of

this power imbalance on participants’ responses was

an issue which needed to be addressed. Busier &

Pigeon (1999) argue that the nature and effects of

the researcher–participant relationship must be

openly addressed in order to identify its potential

effects on the outcomes, particularly if the interview

questions are context-based, as was the case in this

study. A number of measures were taken to address

the issue. The possibility of participant’s responses

being influenced by the fact that the interviewer was

one of their tutors was raised overtly before the

study began. The core ethos of the programme, that

staff aimed to provide optimal learning experiences

for the students, was restated, and the students were

encouraged to be open in their responses. In addition,

at an operational level, a statement that their parti-

cipation or withdrawal from the study would have no

effect on their experiences and performance on the

programme was included in both the covering letter

and consent form. In addition, participants were

assured of their anonymity throughout the under-

taking and reporting of the study and that nothing

they said could be traced back to them individually.

Data analysis

The tape recordings were transcribed verbatim.

The data were analysed using a phenomenographic

approach, a methodology widely used in research

into student learning. Its focus is on identifying

variation in the ways in which people experience

phenomena (Marton & Booth 1997). The approach

involves study, not of the individual separate from

a phenomenon, but focuses specifically on the

interaction and relationship between the individual

and the phenomenon under consideration (Marton

& Booth 1997; Trigwell 1997), in this case, the

students’ experiences of different aspects of the

physiotherapy programme.

Phenomenographic analysis involves thematic

analysis whose end result is a number of ‘categories

of description’ which, together, form a single ‘outcome

space’ or set of themes (Marton & Booth 1997). The

analysis involved a staged, iterative process which

began with identification of responses relevant to

the question under consideration (Trigwell 1997).

Preliminary possible categories were identified and

then reviewed with reference to the quotations which

embodied the responses from all the transcripts.

216 J. Morris


The quotations were pooled and scrutinized in

order to identify group responses with the same

meaning. These were then separated from others

with different meanings and compared with the

proposed categories of description. As described by

Marton & Booth (1997), the iterative process was

complete when all the quotations had been correctly

allocated to the smallest number of clearly defined

groups which, together, captured the full range of

responses. A final name for each category of descrip-

tion was confirmed and the final outcome space for

each question compiled. The quotations which

formed the categories are used both to illustrate

them and to provide evidence for reliability and

validity of the findings.

Results

Thirteen of the original participants took part in the

final set of interviews, 11 females and 2 males.

The outcome space for each question is presented

in Tables 1 and 2. Each quotation is followed by an

anonymous participant code, for example S3.

Representative quotations which capture the scope

of responses which informed each category of descrip-

tion are included. In each table, two groups of factors

were identified: those relevant to the placement itself

(internal), and external factors which influenced

learning on the placement (external).

Discussion

As a number of categories of description were

common to both outcome spaces, rather than

considering each table separately, the internal and

external factors found will each be discussed in

relation to both positive and negative findings.

Internal factors

The factor which led to responses being perceived

either as positive or negative was that of degree. For

example, in the ‘Direct involvement with patients’

categories, participants valued direct hands-on

work with patients. For example,

The hands-on, definitely the hands-on ... (S3). (Table 1)

In contrast, participants felt that their learning

opportunities were restricted when they did not

have such opportunities, for example,

Table 1 Clinical placement experiences which best facilitated learning

Categories of description Representative quotations

Internal

Direct involvement with patients ‘The hands-on, definitely the hands-on ...’ (S3)

‘... developing clinical reasoning ...’ (S14)

‘... being given responsibility and a caseload.’ (S16)

Educator–student interaction ‘I need to watch first and take it in and then do it myself ’ (S7)

‘... I think it’s important, you need that feedback from your clinical educator.’ (S11)

‘... if you get the right clinical educator ... I just think you can learn so much from a good

clinical educator ....’ (S17)

Interaction with junior clinicians ‘Working with other juniors ... because they’re closer to your level so you just feel like

you can ask them and you know they’re not marking you as well so it probably makes

things a bit easier.’ (S15)

Employment experience ‘... the communication skills allow you to be learning ... just ask that question ...’ (S2)

External

Placement variety ‘... the variety of placements ... working with the different clinical educators’ (S12)

‘... I work in continuing care, so going into general hospitals has been great for me.

I loved the ward work and getting that whole experience.’ (S17)



You can’t really learn much through in-service training...

I think I would have benefited from having more patients ...

(S5) (Table 2),

In the ‘Educator–student interaction’ category,

the value of this interaction was recognized, only if

its nature was perceived to influence their learning.

For example,

I need to watch first and take it in and then do it myself.

(S7) (Table 1)

... I’m terrible if someone’s stood over me, watching me.

(S16) (Table 2)

The results also identified that students’ prior

experiences could either have positive or negative

influences on their learning. For example,

... the communications skills (learned from employment

experience) allow you to be learning ... just ask that

question ... (S2) (Table 1)

... you’ve done something in your job and you think it

works and then you go to another place and you think

‘Well, actually, my way’s better, but you don’t want to start

treading on their toes or anything like that ... that can be

quite negative.’ (S10) (Table 2)

In this investigation, past experiences identified by

respondents are related to their employment roles.

This characteristic does not necessarily imply that

this finding would not be relevant to the wider

student population who do not have such experience.

It is possible that similar issues could also have

arisen from experience gained on earlier practice

placements, but the limited literature on this topic

prevents drawing any conclusions.

Several of the findings from this investigation

were also identified by Harris & Naylor (1992),

including the presence of some issues as both positive

and negative, for example the nature of educator–

student interactions. In both studies, too, the extent

of involvement with patients was an issue, with direct

hands-on experience being seen as positive in general,

but excessive or unsupported responsibility as

negative. In Harris and Naylor’s study, negative per-

ceptions regarding direct involvement with patients

were attributed to staff shortages and/or excessive

work-loads. Staff shortages were also identified as

one of the negative factors in the current study:

... if they weren’t so short staffed I could have learned so

much more. (S2) (Table 2 ‘Educator–student interaction’)

Table 2 Clinical placement experiences which least facilitated learning

Categories of description Representative quotations

Internal

Expectations and responsibility ‘... instead of being an educational placement ... it was like “You’re nearly qualified,

this is what you need to be doing, if you can’t then you shouldn’t be doing this’.’ (S8)

Educator–student interaction ‘... if they weren’t so short staffed I could have learned so much more.’ (S2)

‘... I’m terrible if someone’s stood over me, watching me.’ (S16)

‘... when you don’t get feedback really.’ (S11)

Direct involvement with patients ‘You can’t really learn much through in-service training....I think I would have

benefited from having more patients....’ (S5)

Employment experience ‘... you’ve done something in your job and you think it works and then you go to

another place and you think ‘Well, actually, my way’s better’, but you don’t want to

start treading on their toes or anything like that....that can be quite negative.’ (S10)

External

External pressures ‘... the travelling was absolutely killing.’ (S7)

‘The dissertation and the last placement ... instead of going home and thinking

“I need to be reading round this subject”... I was thinking “I need to be writing”.

(S16)

Placement organization ‘J – So the time gap between your learning and the time you had the relevant

placement (was too large)? S – Yes.’ (S14)

218 J. Morris


The importance of facilitating rather than inhibit-

ing learning on practice placements posits that

the negative aspects of these elements need to be

addressed. A possible solution is use of open and

effective ongoing communication between practice

educators and students, an approach supported by

Cross (1995) and Whitcombe (2001). This would

allow for clarification of what students’ existing

strengths and current needs are, and identification

of the opportunities and constraints within the

placement environment. Students and educators

could then agree strategies which would optimize

learning opportunities while minimizing negative

elements, with ongoing review allowing for evalua-

tion of the practical implementation of these

strategies. One means of facilitating such communi-

cation is use of a learning agreement/contract on

practice placements, a mechanism used on a number

of nursing and health profession programmes,

including physiotherapy (Whitcombe 2001). Learn-

ing contracts involve identification of the learning

objectives relevant to each student, based on discussion

and agreement between them and their placement

educator. If undertaken by both people, this would

help establish useful communication and enable it to

continue, as it should form the basis of review of

experience and performance. In addition to optimiz-

ing the student’s learning experiences, the outcomes of

open communication could enable the student to con-

currently make a useful contribution in the workplace.

Communication also forms the basis of the two

categories of description identified in the current

study which were not also found by Harris & Naylor

(1992). ‘Interaction with junior clinicians’ was

perceived to be a positive influence for learning. For

example,

Working with other juniors ... because they’re closer to

your level so you just feel like you can ask them and you

know they’re not marking you as well so it probably

makes things a bit easier. (S15) (Table 1)

In contrast, participants found unrealistic expectations

of placement educators to be problematic. For example,

... instead of being an educational placement ... it was like

‘You’re nearly qualified, this is what you need to be doing,

if you can’t then you shouldn’t be doing this.’ (S8)

(Table 2 ‘Expectations and responsibility’).

External factors

Influences on students’ learning identified in the

study were not confined to the placement experience

itself. In both tables, placement organization was also

identified as a factor. Experience gained in a variety

of settings was regarded positively. For example,

... the variety of placements ... working with different

clinical educators ... (S12) (Table 1 ‘Placement variety’).

However, location of placements could be pro-

blematic. For example,

... the travelling was absolutely killing ... (S7) (Table 2

‘External pressures’)

R – So the time gap between your learning and the time

you had the relevant placement? S – Yes. (S14) (Table 2

‘Placement organization’).

The findings of long travelling distances and

temporal distance between relevant teaching in the

academic setting and practice experience may not be

surprising. The difficulties which practice placement

coordinators experience with shortages of placements

are well known in physiotherapy and may have con-

tributed to such negative experiences. Identification

of these negative factors and their potential impact

on learning confirms that the issue of placement

availability warrants ongoing consideration, despite

the challenges involved.

General

The similarity in findings between the current study

and those reported by Harris and Naylor suggests

that, despite the fact that their study did not focus

specifically on student learning, students’ responses

were related to the impact on their learning. The

close agreement between the results in the two

studies undertaken over a decade apart identifies the

consistency of students’ learning needs. At the same

time, however, the lack of evidence of change in the

negative aspects over time suggests a continued need

for these issues to be addressed.

Although the findings of this study were sup-

ported by the literature, a number of methodological

issues need to be considered when evaluating the

utility of the results. The small sample size, and



unusual background of participants, that is that they

were all experienced clinical assistants, challenge

generalizability of the findings. The identification

by participants of both negative and positive

experiences in the interviews suggests that the power

imbalance between the researcher and students

did not influence their responses However, the

possible effects on participants’ responses of power

relationships implicit in the fact that the inter-

viewer was one of the students’ tutors should not

be ignored when evaluating the findings. Another

factor which could have influenced participants’

responses also needs to be borne in mind. The

participants had completed their clinical place-

ments before the final set of interviews took place.

However, they had not yet completed their studies

and, although they had been assured that honest

responses were being sought, some might have

felt inhibited.

Conclusion

This study explored the factors which best and

least facilitated physiotherapy students’ learning on

practice placements. Positive and negative issues

relating to both the organization of placements and

placement experiences themselves were identified.

The findings supported the importance of effective

ongoing communication between students and

practice educators regarding the extent and nature

of both hands-on experience of students with

patients and of educator availability and involvement.

An associated need to take account of student’s prior

experiences was also identified. In addition,

placement arrangements were found to influence

learning,

More, and larger, studies including students from

traditional as well as non-traditional backgrounds

are needed into this important aspect of physiotherapy

education, in order to build up a more complete

picture. In the interim, the high levels of agreement,

over time, between the limited research which has

been undertaken, supports the need to address

aspects of practice placement experiences perceived

to inhibit students’ learning.

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Factors influencing the quality of student learning on practice placements

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