A clinical assessment tool used for physiotherapy students--is it reliable?

Educational institutions providing professional programs such as physiotherapy must provide high-quality student assessment procedures. To ensure that assessment is consistent, assessment tools should have an acceptable level of reliability. There is a paucity of research evaluating the reliability of clinical assessment tools used for physiotherapy students. This study evaluated the inter- and intrarater reliability of an assessment tool used for physiotherapy students during a clinical placement. Five clinical educators and one academic participated in the study. Each rater independently marked 22 student written assessments that had been completed by students after viewing a videotaped patient physiotherapy assessment. The raters repeated the marking process 7 weeks later, with the assessments provided in a randomised order. The interrater reliability (Intraclass Correlation Coefficient) for the total scores was 0.32, representing a poor level of reliability. A high level of intrarater reliability (percentage agreement) was found for the clinical educators, with a difference in section scores of one mark or less on 93.4% of occasions. Further research should be undertaken to reevaluate the reliability of this clinical assessment tool following training. The reliability of clinical assessment tools used in other areas of physiotherapy education should be formally measured rather than assumed.     

Relationship between quality of training programs and internists’ subsequent practice performance

The influence of the quality of physicians’ medical school and residency training programs on subsequent practice performance has not been explored in depth. In this study, program directors and medical educators rated a large number of medical schools and residency programs based on their perceptions of the quality of each program's faculty, curriculum, program graduates, and national reputation. Performance of graduates of these programs was compared from among practicing board‐certified internists in three states who volunteered to undergo assessment. Methods to evaluate physician‐subjects included written evaluations of the subjects completed by professional associates and a written examination to measure medical knowledge and clinical decision making. The perceived quality of residency training programs was found to be weakly related to the physicians’ performance, as assessed by these measures. Differences were found in examination performance and in ratings by peer physicians of selected clinical skills, humanistic qualities, and communication skills. Perceived quality of medical schools did not appear in these analyses to be related to practice performance.     

An exploration of undergraduate nursing and physiotherapy students’ views regarding education for patient handling

Aims and objectives. To ascertain the views of undergraduate student nurses and physiotherapists regarding their education in patient handling. Background. Musculo‐skeletal injuries are an important cause of staff sickness absence and attrition from the nursing profession and are a recognised problem within the physiotherapy profession. Nurses and physiotherapists are at risk of musculo‐skeletal injuries as a result of their role in assisting patients with movement. Methods. A questionnaire survey was undertaken of undergraduate nursing and physiotherapy students (n = 371) at one university. Results. Most students agreed that university teaching about moving and handling prepared them for clinical practice (64%). Over a third reported that they had never undertaken a written moving and handling risk assessment in clinical practice (38%). Almost half of the sample (40%) admitted undertaking unsafe moving and handling activities. Half (50%) also stated that they would rather ‘fit’ into the team than challenge unsafe practice. Almost a third (29%) stated that they had begun to experience pain since becoming a student. There were significant differences between nursing and physiotherapy students. Physiotherapy students were more likely to report being supervised when moving and handling and reported being more assertive about adhering to safe practice. Conclusions. The well‐being of both nursing and physiotherapy undergraduate students is threatened when students undertake work placements in clinical settings. University‐based education in safe patient handling, though important, can be undermined by workplace settings where unsafe practices occur. Collaboration is needed between university educators, managers and practice‐based mentors to support students to maintain safe approaches to moving and handling patients. Relevance to clinical practice. A third of students reported developing pain since becoming a healthcare student. Students entering their professions already injured may leave the workforce owing to poor physical well‐being. It is vital that the clinical workplace supports safe systems of working.     

Factors shaping e‐feedback utilization following electronic Objective Structured Clinical Examinations

The development of student‐practitioners' practical clinical skills is essential in health professional education. Objective Structured Clinical Examinations are central to the assessment of students performing clinical procedures on simulated patients (actors). While feedback is considered core to learning providing timely, individualised student OSCE feedback is difficult. This study explored the perceptions of students about the multiple factors which shape the utility of e‐feedback following an electronic Objective Structured Clinical Examinations, which utilized iPad and specialised software. The e‐feedback was trialled in four courses within occupational therapy and physiotherapy pre‐professional programs with a cohort of 204 students. Evaluation of student perceptions about feedback was collected using two surveys and eight focus groups. This data showed three factors shaped perceptions of the utility of e‐ Objective Structured Clinical Examinations feedback: 1) timely accessibility within one day of the assessment, 2) feedback demonstrating examiners' academic literacy and 3) feedback orientated to ways of improving future performance of clinical skills. The study found training in the provision of feedback using IPads and software is needed for examiners to ensure e‐feedback meets students' needs for specific, future‐oriented e‐feedback and institutional requirements for justification of grades.     

Assessment of undergraduate physiotherapist clinical performance: investigation of educator inter-rater reliability

Objectives

To investigate the inter-rater reliability of physiotherapy educators in awarding clinical placement marks to undergraduate students using a standardised clinical placement assessment form.

Design

Inter-rater reliability study performed over five undergraduate physiotherapy clinical placements.

Setting

Five clinical sites associated with a BSc undergraduate physiotherapy programme.

Participants

Second and final year physiotherapy students who were on clinical placements (n = 86 paired assessments). Two physiotherapy educators (a practice tutor and a practice educator), equally involved in supervising the students over the placement period, marked each student blindly at the end of the placement.

Outcome measure

Marking was performed using a standardised clinical placement assessment form and guidelines. This form was developed by physiotherapy educators, and utilised previously published work in the area.

Results

Eighty-six paired assessment marks were analysed. Practice educators and practice tutors agreed on grades on 74% of occasions. The mean difference in marks (maximum of 100) between educators was −0.5 (95% confidence interval −1.1 to 0.2), and using the limits of agreement method, the results suggested that where two raters mark a student at the end of a clinical placement, the raters will be within 6.2 marks of each other on 95% of occasions. The intraclass correlation coefficient (ICC) for the overall mark was 0.84, indicating almost perfect agreement. Subsections of the form also had substantial agreement (patient management ICC, 0.75; professional development ICC, 0.75; organisation and management ICC, 0.81).

Conclusion

Physiotherapy educators demonstrated a high level of reliability in the assessment and marking of undergraduate physiotherapy student performance using a standardised clinical assessment form. This was evident over several sites and specialities.     

Protocol‐based care: the standardisation of decision‐making?

Aim. To explore how protocol‐based care affects clinical decision‐making. Background. In the context of evidence‐based practice, protocol‐based care is a mechanism for facilitating the standardisation of care and streamlining decision‐making through rationalising the information with which to make judgements and ultimately decisions. However, whether protocol‐based care does, in the reality of practice, standardise decision‐making is unknown. This paper reports on a study that explored the impact of protocol‐based care on nurses’ decision‐making. Design. Theoretically informed by realistic evaluation and the promoting action on research implementation in health services framework, a case study design using ethnographic methods was used. Two sites were purposively sampled; a diabetic and endocrine unit and a cardiac medical unit. Methods. Within each site, data collection included observation, postobservation semi‐structured interviews with staff and patients, field notes, feedback sessions and document review. Data were inductively and thematically analysed. Results. Decisions made by nurses in both sites were varied according to many different and interacting factors. While several standardised care approaches were available for use, in reality, a variety of information sources informed decision‐making. The primary approach to knowledge exchange and acquisition was person‐to‐person; decision‐making was a social activity. Rarely were standardised care approaches obviously referred to; nurses described following a mental flowchart, not necessarily linked to a particular guideline or protocol. When standardised care approaches were used, it was reported that they were used flexibly and particularised. Conclusions. While the logic of protocol‐based care is algorithmic, in the reality of clinical practice, other sources of information supported nurses’ decision‐making process. This has significant implications for the political goal of standardisation. Relevance to clinical practice. The successful implementation and judicious use of tools such as protocols and guidelines will likely be dependant on approaches that facilitate the development of nurses’ decision‐making processes in parallel to paying attention to the influence of context.     

Point‐of‐Care Ultrasound Education

This article reviews the current technology, literature, teaching models, and methods associated with simulation‐based point‐of‐care ultrasound training. Patient simulation appears particularly well suited for learning point‐of‐care ultrasound, which is a required core competency for emergency medicine and other specialties. Work hour limitations have reduced the opportunities for clinical practice, and simulation enables practicing a skill multiple times before it may be used on patients. Ultrasound simulators can be categorized into 2 groups: low and high fidelity. Low‐fidelity simulators are usually static simulators, meaning that they have nonchanging anatomic examples for sonographic practice. Advantages are that the model may be reused over time, and some simulators can be homemade. High‐fidelity simulators are usually high‐tech and frequently consist of many computer‐generated cases of virtual sonographic anatomy that can be scanned with a mock probe. This type of equipment is produced commercially and is more expensive. High‐fidelity simulators provide students with an active and safe learning environment and make a reproducible standardized assessment of many different ultrasound cases possible. The advantages and disadvantages of using low‐ versus high‐fidelity simulators are reviewed. An additional concept used in simulation‐based ultrasound training is blended learning. Blended learning may include face‐to‐face or online learning often in combination with a learning management system. Increasingly, with simulation and Web‐based learning technologies, tools are now available to medical educators for the standardization of both ultrasound skills training and competency assessment.     

An evaluation of a framework for facilitating and assessing physiotherapy students' reflection on practice

Reflective practice is promoted in the health care professions as a developmental process leading to competent and effective practice, although the link between reflection and enhancement of physiotherapy practice remains speculative and conjectural. This article provides evidence that reflection can influence developing practice based on the evaluation of a reflective framework for students on clinical placement. The evaluation explored, in depth, students' experiences and perceptions of its benefits and limitations. Thematic analysis of response data from five focus groups (n = 43) representing three student cohorts resolved significant outcomes-related themes: personal insight, linking reflection to the physiotherapy process, and learning and personal change. Process-related themes focused on strengths and weaknesses of the framework and associated issues. Evidence supports the effectiveness of the framework in facilitating reflection and in linking reflection to higher order cognitive processes such as gaining new insights and understandings, facilitation of systematic enquiry, problem solving, and decision making. Feedback from students indicated that the experience was meaningful and valuable in preparation for practice because they were guided to question themselves and could see the relevance and value of that for their practice. We recommend that educators consider this approach to facilitating reflection in physiotherapy undergraduate education.     

Clinical supervision as an interaction between the clinical educator and the student

The interaction between clinical educators and students is regarded as the strongest element in developing expertise and in forming students' professional identity in clinical education. Although clinical education has been studied in physiotherapy, the natural interaction between clinical educators and students has remained unanalyzed. The aim of this study was to examine how supervised learning sessions during patient treatment were constructed. The focus was on the forms of interaction between clinical educators and students in natural contexts. By videotaping 12 natural patient treatment sessions, which simultaneously comprised part of the clinical education of physiotherapy students, and by using qualitative discourse analysis, three supervision discourses emerged from the data: "directing the interaction," "making limited room for the student," and "encouraging the student's participation." This study revealed that clinical educators have a dominant role in constructing supervised learning sessions during patient treatment. Depending on how the interaction is constructed, it is possible to support or prevent student participation in decision making as well as to promote or reject the rehearsal of critical thinking or self-directed learning among students. This study highlighted the importance of interactional skills in supervision practices. More research into constructing learning sessions in clinical education is needed.     

Effects of an educational programme on shared decision‐making among Korean nurses

This study was conducted to examine the effects of an educational programme on shared decision‐making on end‐of‐life care performance, moral sensitivity and attitude towards shared decision‐making among Korean nurses. A quasi‐experimental study with a non‐equivalent control group pretest–posttest design was used. Forty‐one clinical nurses were recruited as participants from two different university hospitals located in Daegu, Korea. Twenty nurses in the control group received no intervention, and 21 nurses in the experimental group received the educational programme on shared decision‐making. Data were collected with a questionnaire covering end‐of‐life care performance, moral sensitivity and attitude towards shared decision‐making. Analysis of the data was done with the chi‐square test, t‐test and Fisher's exact test using SPSS/Win 17.0 (SPSS, Inc., Chicago, IL, USA). The experimental group showed significantly higher scores in moral sensitivity and attitude towards shared decision‐making after the intervention compared with the control group. This study suggests that the educational programme on shared decision‐making was effective in increasing the moral sensitivity and attitude towards shared decision‐making among Korean nurses.     

Teaching invasive perinatal procedures: assessment of a high fidelity simulator-based curriculum.

OBJECTIVE: Learning curves pose a difficult problem in the teaching of technical skills: how do you teach procedural skills without compromising patients' health? A simulator-based curriculum has been designed to minimize the risks to patients undergoing amniocentesis by shifting the learning curve away from patients and into the laboratory. This study evaluated the effectiveness of a high-fidelity simulator-based curriculum in improving the performance of amniocentesis by obstetric trainees. DESIGN: Thirty trainees received a course on the practice of amniocentesis. The curriculum consisted of a lecture, a syllabus, and a hands-on training session with the simulator. Pre- and post-training performance were evaluated with two rating scales. Training and performance evaluation were completed using the same simulator. The effectiveness of the simulator-based workshop and the effect of year of training were assessed using a two-way analysis of variance. RESULTS: Performance scores improved from a mean score of 55% to 94% using checklist scoring and from 57% to 88% using global ratings. The two-way analysis of variance revealed a significant effect of training (F1,60 = 43.57; P < 0.001) accounting for 45% of the variance in scores, and a significant effect of experience level (F2,60 = 9.16; P < 0.001) accounting for 25% of the variance in scores. CONCLUSIONS: A comprehensive curriculum based on a high-fidelity simulator was effective at improving skills demonstrated on the simulator. The challenge remains to establish that skills acquired on a simulator are transferable to the clinical setting.     

Implementation of evidence‐based practice by nurses working in community settings and their strategies to mentor student nurses to develop evidence‐based practice: A qualitative study

The aim of the study was to explore how community nurses apply the best available evidence to their practice, and how they mentor student nurses to conceptualize and implement evidence‐based practice in community settings. In the UK, the expansion of health‐care provision in the community has supported the development of highly skilled community nurses. However, there is limited literature regarding the strategies used by community nurses to implement evidence‐based practice and mentor student nurses to conceptualize evidence‐based practice in community placements. An exploratory qualitative approach applying inductive reasoning to focus group data was used. As a result, nurses working for a community NHS Foundation Trust in South England with a mentor qualification were invited to participate in one of the seven focus groups, 33 nurses participated. Data were analyzed with thematic analysis. The themes discussed in this paper are: ‘our practice is evidence‐based’ as guidelines and policies provided structure, but occasionally stifled autonomous clinical decision‐making, and ‘time’ as a barrier and facilitator to mentoring student nurses in community settings. In conclusion, nurses need to develop the ability to incorporate patients' needs and wishes within evidence‐based care. Time was a facilitator for some community mentors, but protected time is required to complete the necessary practice documentation of student nurses.     

Practical concerns of educators assessing reflections of physiotherapy students

Abstract

Background: Reflection has become an accepted element of physiotherapy education. Reflection is a cognitive, emotional, and embodied activity that remains largely invisible as individuals undertake their professional work. The use of reflection has been related to a number of positive benefits for practitioners such as to develop their capacity for self-assessment and critique, to challenge their existing knowledge base, to engage in lifelong learning, to make sense of their experiences, and to improve decision making.

Objectives: Although there is an extensive debate in the wider reflection literature about assessing reflection, this has yet to be applied to physiotherapy and developed as a discourse held by the members of the profession.

Major findings: The current body of physiotherapy literature does not offer educators realistic tools to deal with the practical concerns and hands-on educational decisions they face when assessing reflection. The findings from physiotherapy research investigating how reflection is practiced and assessed in physiotherapy implies a need to engage in a dialogue as a profession about teaching and assessing reflective practice.

Conclusion: This paper concludes that the assessment of reflection is complex and difficult and explains the practical concerns of educators. Physiotherapy educators are faced with rethinking how reflection is assessed to carefully consider the intentions of reflection in their assessment design and the impact of assessment on how reflection is learnt and practiced.     

Characteristics and processes of physiotherapy clinical decision making: a study of acute care cardiorespiratory physiotherapy

Background and Purpose . Physiotherapists have been increasingly interested in investigating physiotherapy clinical reasoning and decision‐making processes. Cardiorespiratory physiotherapy has received little attention within this increasing body of research. This study aimed to investigate characteristics and processes of cardiorespiratory physiotherapy decision making and to contribute to the broader understanding of physiotherapy reasoning and decision making. Methods . Fourteen cardiorespiratory physiotherapists took part in the study. Qualitative research methods were used, guided by a philosophical hermeneutic approach. Participants were observed undertaking their usual daily patient care activities and were later interviewed about their decision making. In‐depth, iterative hermeneutic strategies were used to interpret the texts created by these processes to identify the nature and processes of decision making. Results . Clinical decision making in cardiorespiratory physiotherapy is focused on making decisions about the nature of patients' problems, physiotherapeutic intervention and interaction, and evaluation of effectiveness of actions. Cardiorespiratory physiotherapy decisions varied in their difficulty according to the attributes of the decisions. The variable nature of decisions influenced the reasoning processes used. Clinical decision making involved complex reasoning processes that were cyclic, evolving and flexible in nature, with interdependence and interrelation between the different foci of clinical decision making. Clinical decision making was also found to be a social and collaborative process. Conclusions . This study contributes to the body of literature on physiotherapy reasoning and decision making by revealing details about the characteristics and processes of cardiorespiratory physiotherapy decision making. This research can be used to shape the education of beginning practitioners and provide practicing physiotherapists with a basis for critical appraisal of their decision making. Copyright © 2008 John Wiley & Sons, Ltd.     

Dealing with verbal abuse: evaluation of the efficacy of a workshop for student nurses.

Verbal abuse is a problem that can confront all health care professionals in their day to day practice. Studies into abuse of professionals have emphasised the stressful effects of non-physical violence and have shown that it is often the most inexperienced members of various professions who are in the 'front line' of such attacks. The group of staff particularly at risk are student nurses (HSC 1987). This paper presents an evaluative study of a workshop devised to help student nurses to deal with verbal abuse (Wondrak 1989). Psychiatric nursing students were studied from two intakes into a training course. A simulated situation of an interview with a verbally abusive patient was video taped and assessment was made by independent raters of each subjects ability to deal with the situation. 14 of the subjects then attended a verbal abuse workshop and when re-tested, their ability to deal with abuse was compared with those 15 student nurses who did not attend a workshop. The findings are encouraging, indicating that there is a significant change in the experimental group on a number of variables, related to both practical and emotional aspects of dealing with abuse. Thus the efficacy of the short workshop in improving ability to deal with verbal abuse was demonstrated.     

Kennedy Axis V: Clinimetric properties assessed by mental health nurses

The Kennedy Axis V is a routine outcome measurement instrument which can assist the assessment of the short‐term risk for violence and other adverse patient outcomes. The purpose of this study was to evaluate the interrater reliability and clinical utility of the instrument when used by mental health nurses in daily care of patients with mental illness. This cross‐sectional study was conducted in inpatient and outpatient adult psychiatric care units and in one adolescent inpatient unit at a university hospital in the Netherlands. Interrater reliability was measured based on the independent scores of two different nurses for the same patients. The clinical utility of the instrument was evaluated by means of a clinical utility questionnaire. To gain a deeper understanding of rating difficulties at the adolescent unit, additional data were collected in two focus group interviews. The overall results revealed a substantial level of agreement between nurses (intraclass correlation coefficient and Pearson 0.79). Some rating challenges were identified, including difficulties with scoring the instrument and using tailor‐made interventions related to the scores. These challenges can be resolved using refined training and implementation strategies. When the Kennedy Axis V is accompanied by a solid implementation strategy in adult mental health care, the instrument can be used for short‐term risk assessment and thereby contribute in efforts to reduce violence, suicide, self‐harm, severe self‐neglect, and enhanced objectivity in clinical decision‐making.     

Tabletop exercises in the nursing classroom: An introduction for nurse educators

A long‐standing gap exists between graduate and newly licensed nurse abilities and employer expectations. The National League of Nursing has charged nurse educators to address health and welfare through innovative learning to improve student decision‐making for patient care. How, then, can a nurse educator link education to practice, innovate learning, and improve student decision‐making for patient care? One option is to use tabletop exercises in the nursing classroom. The tabletop exercise provides a structure for participants to use available knowledge for decision‐making to identify or use a process in context. Though often include disaster scenarios and common in disaster education, these exercises have broad healthcare applications to link education to practice. Tabletop exercises are an active, low‐stress, high‐impact learning strategy carried out in the classroom with students sitting at desks or tables. In an exercise, there is a scenario, a facilitator, participants, and for the given circumstance, an objective, and participants solve an identified problem by making decisions. The after‐exercise discussion identifies exercise outcomes. Remediation occurs for identified gaps. This article introduces what tabletop exercises are, provides educator considerations for developing a nursing classroom exercise, and influences to implementing the exercise and its outcomes.