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Teaching and Learning Forum 2010 [ Refereed papers ]
Teaching and learning in postgraduate manual therapy education: Perspectives on clinical supervision

Rebecca J. Crawford, Peter J. Fazey and Kevin P. Singer
Centre for Musculoskeletal Studies, School of Surgery, The University of Western Australia

Clinical teaching of postgraduate manual therapy students in the patient-care setting represents a complex teaching and learning environment that is not well documented in the literature. The opportunity for students to practically apply new class-taught knowledge and skills to real patients is important for the successful delivery of education common to all health professions. High priority is placed on affording the time and resources to do so. The clinical supervisor (CS) is the primary teacher tasked with facilitating active learning in this highly individualised environment. CSs are generally not formally educated in teaching and instead rely on previous experience and informal guidance to shape their practice. The trend toward collaborative and interactive teaching appears to be gathering momentum in medical education. This exploratory descriptive study surveyed ten past or present CSs associated with the Masters of Manual Therapy (MMT) program at The University of Western Australia (UWA). The aim was to provide a framework for comparison to the experience and practice within other health disciplines, and to inform future MMT staff development opportunities. Perceptions of desirable qualities, skills and teaching strategies were canvassed in participants. Survey results were discussed by the current MMT CSs as an internal development initiative. The results of this study provide a basis for future professional development of clinical supervisors in postgraduate manual therapy.


Introduction

Clinical teaching is a core element of medical and allied health education and involves teaching and learning focussed on, and directly involving, actual patients (Crosbie et al., 2002; Jarski, Kulig, & Olson, 1989; Moore, Morris, Crouch, & Martin, 2003; Spencer, 2003). The supervisor-student-patient triumvirate represents a complex teaching and learning environment toward which considerable time, resources and importance are directed by all stakeholders (Cross, 1995; Giles, Wetherbee, & Johnson, 2003; Jarski et al., 1989; Vaughn & Baker, 2001). Manual therapy education relies on effective clinical teaching for the successful delivery of course aims and objectives (Fazey & Singer, 2009). The skills of patient assessment, clinical reasoning and decision making, treatment application, empathy and professionalism, are all integrated into this single educational setting (Fazey & Singer, 2004; Spencer, 2003). Learners are generally motivated by the relevance to their professional practice and the opportunity to apply their laboratory-taught manual skills to real patients with symptomology (Lake & Ryan, 2004a; Spencer, 2003). Clinical teachers therefore assume an influential and integral role in the professional development of medical and allied health students (Cross, 1995; Ettinger, 1991; Giles et al., 2003; Spencer, 2003).

Despite the vital contribution that clinical supervision plays in postgraduate medical and allied health education, it remains one of the least investigated, developed or discussed aspects of clinical teaching (Kilminster & Jolly, 2000). No literature was identified that investigates the CS's role in teaching and learning specifically in postgraduate manual therapy. Aligned literature provides guidelines for the clinical teaching of junior doctors (Lake & Ryan, 2004a; Spencer, 2003), undergraduate physiotherapy (Crosbie et al., 2002; Cross, 1995; Giles et al., 2003; Jarski et al., 1989; Ladyshewsky, 2000; Moore et al., 2003; Stiller, Lynch, Phillips, & Lambert, 2004) and other allied health students (Mullholland, Derdall, & Roy, 2006; Scanlan, 2001), with potential application to postgraduate manual therapy education. Literature discussing teaching and learning aspects of the clinical reasoning process in allied health exist (Christensen, Jones, Edwards, & Higgs, 2008; Edwards, Jones, Carr, Braunack-Mayer, & Jensen, 2004; Jones, 1992; Ladyshewsky & Jones, 2008; May, Greasley, Reeve, & Withers, 2008; McAllister & Whiteford, 2008; Round, 1999; Ryan & Higgs, 2008). These provide valuable insights for postgraduate manual therapy educators who are tasked with facilitating improved clinical reasoning in their students.

Australian and UWA context

Australian physiotherapy is recognised as a world leader in musculoskeletal education and clinical research, which may have contributed to the increasing numbers of international students committing to Masters clinical programs in Australia (Jull & O'Sullivan, 2006). Like similar degrees nationally and internationally, prerequisites for the MMT course at UWA are the completion of an entry-level qualification in Physiotherapy, and a level of musculoskeletal clinical experience which is assessed for suitability on application. The result is an intercultural student group comprising postgraduate professionals with institutionally accepted clinical competencies and decision-making credibility.

MMT students are adult learners from diverse national origins, who are all working professionals with various educational, experiential and personal backgrounds. They represent a mixed group of learners whose differences require a level of accommodation by teachers and co-ordinators in the delivery of course content. Complementing teaching and learning styles of clinical supervisors and students to facilitate the best learner-centred andragogic environment, can present planning difficulties for a clinical course coordinator (Lake & Ryan, 2004a; Vaughn & Baker, 2001; Vaughn, Gonzalez Del Rey, & Baker, 2001).

Clinical supervisors (CSs) on the MMT course are employed by UWA as designated clinical educators (DCE) to teach and facilitate student learning in the patient-care setting. They do not have their own caseload however accept the responsibility for appropriate patient management. The DCE model is preferred over shared teaching responsibilities in undergraduate physiotherapy education in Australia (Stiller et al., 2004). MMT CSs are typically more experienced, postgraduate-qualified musculoskeletal physiotherapists, who have a recent knowledge of the course program and objectives or aims. Like their counterparts in medical and other allied health education (Giles et al., 2003; Spencer, 2003; Vaughn & Baker, 2001), no formalised teaching qualification is required for the role.

Study aims

The primary aim of this study was to better appreciate the opinions and values towards teaching, of CSs associated with the MMT program at UWA. An intention was to contribute to the limited literature exploring the role and experience of clinical supervision in postgraduate physiotherapy education. Whether common themes existed with undergraduate physiotherapy or other health professions education was of interest. Comparisons were made to understand the approaches adopted by medicine and other allied health professions, and to broadly acknowledge potential for inter-professional methods sharing in clinical education. Additionally, compiled survey responses were intended to inform future collegiate discussion and subsequent development of internal departmental learning opportunities.

As with treating a patient with manual therapy, there is no absolute right way to achieve teaching and learning outcomes in a changing clinical setting. Diverse survey responses were anticipated given the highly individualised CS environment. General agreement with education literature in other health professions was predicted.

Methodology

Ten past and/or present clinical supervisors for the MMT program at UWA were surveyed to establish their educational and clinical supervision backgrounds. The purpose-designed survey (Appendix I) included demographic questions in order to establish the education backgrounds of the group, while qualitative responses were required in answer to questions addressing perceptions of clinical supervision. Clarifications of responses were sought (by the first author) from each subject via telephone or face-to-face meeting as needed. Descriptive statistics were used to present the demographic data. Responses regarding desirable and undesirable CS qualities were ranked according to their reported frequency. Similar descriptors, as judged through content analysis (by first author) as representing common themes, were combined for data processing. Similar adjectives and themes were grouped as one quality (like rigid and inflexible). Listed qualities were sorted into one of four skills domains: andragogic, communication, interpersonal and professional, using the work of Cross (1995) as a basis. Participants' teaching influences and strategies were also ranked according to their reported frequency.

Related literature was sourced via Medline and CINAHL using 'clinical teaching' 'clinical supervision' or 'clinical education' as search terms, in addition to a review of known expert literature and opinion.

As a departmental staff development opportunity, survey results were summarised (by the first author) and presented to facilitate peer discussion at a meeting of five current supervisors, the clinical coordinator, and MMT program Head. Based on the outcomes of this investigation, a strategy to provide additional internal teaching and learning development opportunities for MMT staff was proposed.

Results

All but one supervisor had more than ten years clinical experience as a physiotherapist (mean 17.0, SD 7.5 yrs). Half each received their postgraduate manual therapy qualification either less than, or more than ten years earlier (mean 12.2, SD 8.2 yrs). Those with less than ten years since completing their postgraduate manual therapy qualification all completed their MMT degree at UWA. Years of postgraduate clinical supervision experience ranged between 2 and 14 (mean 5.2, SD 3.4 yrs). The CSs surveyed had no formal qualification in teaching. Four (of 10) had attended one or more teaching and learning-based professional development courses. One participant was a member of an educator's special interest group within the Australian Physiotherapy Association. All participants discussed teaching and learning expectations both as a group and individually with their students.

When subjects were asked to list five desirable and five undesirable clinical supervisor qualities, their responses were diverse. The most frequently reported desirable qualities were 'good communicator', 'open-minded/flexible' and 'patient/tolerant', representing skills in the communication, andragogic and interpersonal domains, respectively (Table 1). The most frequently rated undesirable qualities considered the least favoured for effective clinical supervision were 'under attentive/offhanded', and 'domineering/authoritarian', representing skills in the interpersonal and andragogic domains, respectively (Table 1).

When asked to rank the six influences on their clinical supervision style, subjects responded that their clinical supervisor(s) when they were a student was the strongest influence. A proportion of participants (4/10) indicated that their negative experience as a student provided motivation for them not to repeat similar behaviours as a teacher. The ranked order of all six influences for the group is presented in Table 2. Several subjects (5/10) responded that collegiate discussion was ranked low due to a lack of opportunity for such an activity, however acknowledged a need for such. In addition to the outlined influences, three participants identified other influencing factors that included: published clinical reasoning literature, their own emotional intelligence in perceiving a students needs, previous experiences in teaching, and a process of self-evaluation.

Table 1: Desirable and undesirable qualities required for effective clinical supervision

DesirableDomain* Freq.UndesirableDomain*Freq.
Good communicatorC7Domineering/AuthoritarianI7
Open-minded/FlexibleA6Under-attentive/OffhandedA6
Patient/TolerantI6Rigid/InflexibleI5
Challenging/EngagingA5DisrespectfulI5
Collaborative/ConstructiveA4ArrogantI4
Clinically competentP4Poor communicatorC4
RespectfulI3InexperiencedP3
ConfidentI3Poor course knowledgeA3
KnowledgeableP3Pre-emptive/ImpatientI3
Passionate/EnthusiasticI2InsensitiveI2
ApproachableI2UnapproachableI2
EmpatheticI2Poor time managementA2
EncouragingI1SarcasticI1
HumorousI1Low confidenceI1
OrganisedA1Poor detail attentionA1



RudeI1
*A=Andragogic skills; C=Communication skills; I=Interpersonal skills; P=Professional skills.

Table 2: Ranked importance of influences on MMT clinical supervision.


MedianSumMean
Clinical supervisor2232.1
Students2.5242.6
Patients2.5323.0
Site and resources4.5414.0
Peer discussion4.5424.3
Supervisor manual5485.0

Expert-novice mentoring ranked as subjects' (9/10) most valuable teaching strategy. Verbal case reporting to the supervisor, and small group peer discussion, ranked second and third, respectively. Verbal case-reporting to student peers, and in front of the patient, were considered the least useful teaching strategies alongside buddying. Table 3 reveals the ranked order of value for 11 teaching strategies employed by ten MMT clinical supervisors.

Table 3: Teaching strategies ranked in order of importance (1=most valued; 11=least valued).


MedianSumMean
Expert-novice mentoring1.0131.6
Verbal case reporting: supervisor2.0313.9
Small group peer discussion4.0405.0
Peer observation5.0637.9
Skills demonstration: patient6.0698.6
Skills demonstration: student6.5708.8
Summarised session learning7.0556.9
Unclear point for elaboration7.0698.6
Verbal case report: students9.09111.4
Verbal case report: patient9.08110.1
Buddying9.5789.8

Discussion

No clinical supervisor in this study had formal teaching qualifications. This is common to clinical teachers within medical and allied health occupations where more importance seems o be placed on the expertise of the clinician or their workplace superiority (Giles et al., 2003; Spencer, 2003; Vaughn & Baker, 2001). Undergraduate physiotherapy students surveyed in a recent study did not relate effective clinical supervision to those with formal qualifications in teaching (Morren, Gordon, & Sawyer, 2008). Years of experience have been more positively associated with effective undergraduate physiotherapy teaching behaviours than teaching credentials (Wetherbee, Nordrum, & Giles, 2008). Perhaps given the clinical focus of workplace based teaching in the health professions, formal teaching qualifications are not a prerequisite for CSs in medicine and allied health.

Undergraduate and postgraduate physiotherapy students are adult learners, and therefore generic adult learning principles apply to them both. By the same rationale, teaching strategies commonly employed in other adult learning environments, and particularly those in health-based professions, should have relevance. Engagement of the learner is considered a crucial aspect of the adult medical education, wherein motivation and perception of relevance are influencing factors of success (Hutchinson, 2003; Lake & Ryan, 2004a; Spencer, 2003). Involvement of the student in setting their own learning objectives based on their educational expectations is an established strategy in promoting a rewarding experience (Kilminster & Jolly, 2000; Lake & Ryan, 2004a; Spencer, 2003). Clinical supervisors in the present study all reported discussing learning expectations and objectives with their students, suggesting an alignment with andragogic models.

Institution-based education programs in medicine aim to develop faculty competencies where teaching within the clinical setting is a significant focus (Lake & Ryan, 2004a; Spencer, 2003). The 'Teaching on the Run - Teaching Tips' series developed within the Education Centre of the Faculty of Medicine, Dentistry and Health Sciences at The University of Western Australia, is a nationally recognised program aimed at educating clinical teachers within the medical profession (Lake, 2009). The program has also been adapted for nursing, midwifery, occupational therapy and speech pathology (Lake, 2009). The suitability of a similar program for educating the teaching staff on the MMT course may be a valuable consideration.

The present findings agreed with Cross (1995) who revealed that physiotherapy clinical supervisors and students rated good communication and interpersonal skills higher than knowledge or professional competence of the clinical teacher. Although Cross (1995) investigated clinical teaching within undergraduate programs, the results of the present study suggest common teaching perceptions within physiotherapy clinical education at whatever tertiary level. Similarly, good communication and interpersonal skills have also been identified by patients as qualities comprising a good physiotherapist (Potter, Gordon, & Hamer, 2003). Clearly an emphasis on superior communication and interpersonal skills exists within the education and practice of physiotherapy. Discussing specific educational methods on how best to develop these generic skills is beyond the scope of this paper.

Desirable and undesirable qualities identified by the ten clinical supervisors in this study appear to have commonality to previous studies assessing student and teacher perceptions in physiotherapy education (Cross, 1995; Jarski et al., 1989). The most frequently reported desirable skills were in the communication, andragogic and interpersonal domains (Table 1) and occurred more often than professional skill qualities. The predominance of most frequently reported undesirable qualities were in the interpersonal domain, which is in general agreement with the study by Jarski et al (1989) where perceptions of clinical students and instructors from physiotherapy and physician assistant programs were assessed. This may indicate that good communication skills facilitate teaching in the clinical environment, while good interpersonal skills alone may not.

The primary influence on the clinical teachers surveyed in this study was reported to be the clinical supervision they received themselves as a student. This appears consistent with studies in various health professions where clinical teaching has been reported to be primarily learned on the job through observation of others and aspects of trial and error (Jarski et al., 1989; Scanlan, 2001; Spencer, 2003). This may add further weight to the need for supporting CSs in developing their teaching and supervisory skills.

The finding that an expert-novice mentoring strategy was most favoured is not surprising and is in agreement with earlier studies investigating clinical education models in physiotherapy (Moore et al., 2003; Page & Ross, 2004). On closer inspection of the rankings outlined in Table 3, the preferred methods appear to indicate a more traditional mode of delivery where teacher-centred pedagogic instruction predominates. Lower ranked strategies like 'unclear point', 'student peer reporting' and 'buddying' represent collaborative and cooperative teaching strategies with an interactive learner-focus. As adult professionals, students of the MMT program require involvement and an element of self-direction at this stage in their education. According to the 'staged self-directed learning model' outlined by Grow (1991), these necessitate a motivator/facilitator or delegator teaching style, respectively (Grow, 1991). A move toward andragogy for these students appears reasonable (Delahaye, Limerick, & Hearn, 1994).

The MMT program encourages collaborative peer learning (Fazey & Singer, 2004), while success with reciprocal peer coaching (RPC) has been reported for physiotherapy education (Ladyshewsky, 2000; Ladyshewsky & Jones, 2008). Despite this, the group of clinical supervisors surveyed in the present study rated 'buddying' as their least favoured teaching strategy. This finding may relate to individual interpretations of the term itself, and/or its perceived priority alongside the other alternatives given (Table 3). It may also be a reflection of the diverse backgrounds of the student group, toward which paired learning may not be possible or appropriate. RPC generally assumes students are at a complementary stage of learning (Ladyshewsky, 2000), which may not be the case in the MMT student group of diverse postgraduate professionals. One might however argue that MMT students are more homogenous than an undergraduate cohort given their common and specific area of clinical practice. This aspect of the present study may signal an importance in providing MMT staff development opportunities where adult learning principles and collaborative teaching methods are described and outlined.

Teaching methods like the "one-minute teacher" (Furney et al., 2001) or "SNAPPS" (Wolpaw, Wolpaw, & Papp, 2003) as outlined by Lake & Ryan (2004) relating to medical education, are arguably providing a contemporary framework to teaching strategies already in use (Lake & Ryan, 2004b). These methods may provide a structure for education in manual therapy, within which specific techniques may be explored. It is widely accepted across health professions that clinical teaching represents a unique environment requiring individual tailoring to suit both teachers and learners (Cross, 1995; Fazey & Singer, 2004; Jarski et al., 1989; Kaufman, 2003; Lake & Ryan, 2004a; Spencer, 2003; Vaughn & Baker, 2001; Wolpaw et al., 2003). A structured education for clinical supervisors in physiotherapy to help them in their role as teachers may be of benefit (Moore et al., 2003; Neville & French, 1991). Specific teaching strategies used to deliver education according to these frameworks are somewhat dependent on the creativity and innovation of individual teachers according to their given environment. This aspect itself highlights a potential opportunity for intra- and inter-professional information sharing when clinical patient-care settings require diverse yet fundamentally common teaching strategies and approaches (Lake, 2009).

Limitations

Participants were asked to identify five qualities each that represented desirable and undesirable clinical supervisor traits. This broad and qualitative exploratory approach encouraged an exhaustive list in which there was scope for different interpretations and a potentially varied command of English by respondents. As indicated in the methods, the first author (RJC) condensed the descriptors list from those originally provided by the ten clinical supervisors. This approach may have subsumed qualities whose intended meaning differed from that perceived by the supervisor who completed the survey. This was in part mitigated by follow-up clarification sought by the first author as needed. The grouping of qualities relied heavily on the interpretation of the authors, representing further potential for variability.

Although all authors contributed to the construction of the survey adding to the face validity of the instrument, it was primarily devised by the first author and is therefore influenced by her experience and interest in the subject. This may be particularly problematic when required responses were qualitative beliefs or feelings. Similarly, the clinical supervision influences and teaching strategies lists were devised by a single author (RJC) and were therefore based on her experience and interpretation of the relevant literature. The finding that three subjects added other influences to the supervisor influences list suggests that the provided list was not adequate to fully appreciate the group's motivations. Only one respondent suggested a further teaching strategy over the list of 11 provided. This potentially indicates that the provided list for teaching strategies was adequate in encompassing the teaching strategies used by this select subject group.

Future directions

The majority of literature discussing clinical supervision for Physiotherapy relates to teaching at undergraduate/entry-level. Although there are obvious material similarities between undergraduate and postgraduate teaching within the same discipline, it may be necessary to consider the influence on teaching that an already autonomous qualified professional might have despite their being a student.

Perceptions of a postgraduate manual therapy student group have not been assessed in order to add additional information. This may represent a topic requiring further investigation wherein the results of this study provide a basis for comparison.

Results of this survey have been employed to initiate a forum between clinical teaching staff on the MMT program. Follow-up meetings and group email exchange are intended to provide structure for teaching and learning-themed collegiate discussion. A strategy for delivering additional internal teaching and learning development opportunities for MMT staff has been proposed.

The potential scope for inter-professional discussion regarding specific teaching strategies as they are applied to existing, particularly medicine-based frameworks, indicate an opportunity for educators within differing professions to learn from each other.

Conclusions

Clinical supervisors for the Masters of Manual therapy program at the University of Western Australia have no formal teaching qualifications, which is common to medicine and other allied health professions. Good communication is perceived by clinical supervisors as the most desirable quality as a teacher, with interpersonal skills ranking high in both desirable and undesirable lists. Clinical supervisors in manual therapy described their primary influence on clinical teaching to be their own experiences as a student. Expert-novice mentoring rated the most valuable teaching strategy with buddying as the least utilised. Further investigation is necessary to better appreciate aspects of teaching and learning within postgraduate manual therapy education.

Acknowledgments

The authors would like to acknowledge the valuable critiques and ideas provided by Dr Lee Partridge and Dr Margaret Potter in the construction of this paper.

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Appendix

[ SURVEY: Clinical Supervision: UWA Masters of Manual Therapy (MMT) Programme ]

This is contained in the file [crawford-appendix.pdf], PDF format, 96 kB

Authors: Rebecca J. Crawford, Peter J. Fazey and Kevin P. Singer, Centre for Musculoskeletal Studies, School of Surgery, The University of Western Australia. Email: crawfr04@student@uwa.edu.au

Please cite as: Crawford, R. J., Fazey, P. J. & Singer, K. P. (2010). Teaching and learning in postgraduate manual therapy education: Perspectives on clinical supervision. In Educating for sustainability. Proceedings of the 19th Annual Teaching Learning Forum, 28-29 January 2010. Perth: Edith Cowan University. http://otl.curtin.edu.au/tlf/tlf2010/refereed/crawford.html

Copyright 2010 Rebecca J. Crawford, Peter J. Fazey and Kevin P. Singer. The authors assign to the TL Forum and not for profit educational institutions a non-exclusive licence to reproduce this article for personal use or for institutional teaching and learning purposes, in any format, provided that the article is used and cited in accordance with the usual academic conventions.


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