Academic Exchange Quarterly Fall 2010 ISSN 1096-1453 Volume 14, Issue 3
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Tele-rehabilitation Assisted Clinical Education
Trisha Parsons, School of Rehabilitation Therapy, Queen’s University, Canada
Kathleen Norman, School of Rehabilitation Therapy, Queen’s University, Canada
Parsons, PhD, is an Assistant Professor in the Physical Therapy Program, and Norman, PhD, is an Associate Professor and the Physical Therapy Program Chair at Queen’s University.
A pilot study was conducted to determine the feasibility and value of delivering faculty moderated, “case workshops” between small groups (5-8 students each) of Queen’s University MScPT Students while they were on a clinical placement. These workshops were delivered by multi-point video-conferencing using the existing telemedicine infra-structure (Ontario Telemedicine Network; OTN).
The ultimate goal of the Master’s of Science Physical Therapy (MScPT) Program at Queen’s University is to prepare individuals to undertake the roles of a Physical Therapist in Canada. The MScPT program curriculum is structured into on-campus academic (6-12 week) blocks and clinical placements (6-week blocks). For the clinical placements, students are supervised by a registered physiotherapist at each of a variety of sites. The majority of the sites are health care facilities within a catchment area so large that students may be as much as 500 km apart.
Problem-based learning (PBL) is a valid model for the education of physical therapy students as it reflects clinical practice and serves as a model for life-long learning (Saarinen-Rahiika & Binkley 1998; Solomon 2005). During academic blocks, students often receive assignments which center on hypothetical case studies. These case studies serve as learning objects which, with the help of a facilitator, learning teams use to discuss key issues related to assessment, interpretation, and/or treatment planning. In general, this form of learning is well-received by students as it reflects clinical practice (Gibson et al 2010). However, given the geographical spread of our catchment area, and the fact that many students are on placements on their own, there has been little opportunity to test the value of using PBL of actual patient cases in real-time during a PT clinical placement.
The value of such an activity is suggested by the anecdotal and empirical success of higher student to supervisor ratio placements, also known as the collaborative placement model (Triggs & Shepherd 1996; Currens & Bithell 2003; Lekkas et al 2007). In these environments, a single clinical instructor at a regional site is responsible for the supervision of two or more student PTs. Often these students are allowed to collaborate on the analysis of assessment findings and on the development of treatment plans. Furthermore, Cole & Wessel (2008) reported, that according to physiotherapy students who were on an introductory placement that the clinical instructors who, amongst other attributes, provided students with time to seek out information and for reflection were amongst those who greatly enhanced their placement experience. It is our hypothesis that this would further be enhanced by a peer support. Despite the advantages of the collaborative placement model, a number of barriers exist to its wider implementation. First, not all clinical instructors are comfortable with supervising more than one student at a time. Second, some facilities are unable to accommodate larger groups of students during a single placement for reasons such as workspace or ability to absorb caseloads at the end of the placement. As such, many students find themselves without peer in their clinical placement sites.
In recent years, technology advancements have afforded greater video-conferencing infrastructure amongst health care sites. The Ontario Telemedicine Network is a non-profit agency whose mandate is the delivery of health care services and education across our province. Due to these advancements it is possible to connect MScPT students into “virtual learning teams” during their clinical placements. In these learning teams, students are able to meet in real-time, and with the help of a faculty moderator, workshop their patient cases. Such interaction is proposed to enhance the development of clinical reasoning skills through peer support, increased time for reflective practice, and shared experience.
This paper will describe one method by which pre-licensure health care students on clinical fieldwork placements could be connected across distance. The objectives of this paper are to describe the education model that was used in this teaching initiative, to outline the logistics associated with using the existing telemedicine infrastructure in our region and to present preliminary feedback received from Second year MScPT students who participated in the Fall 2009 case workshops.
A pilot project was performed during the fall term of 2009 involving Queen’s University MScPT students while they were on clinical placements.
The primary objectives of this project were to:
a) Determine the feasibility to deliver faculty-moderated, multi-point video-conferences using existing infrastructure (Ontario Telemedicine Network; OTN).
b) Determine the value of a moderated, case workshop during physical therapy clinical placement as perceived by the students themselves.
A mixed quantitative and qualitative method was selected to address these objectives. These methods were approved by the Queen’s University Health Sciences Research Ethics Board.
Queen’s University MScPT students were recruited to participate in this study in the fall term of their second year. Given that it was a pilot project, a sample of convenience was utilized based on students’ placement sites relative to the location of existing video-conferencing infrastructure. Students were recruited to four learning teams during this placement block, which is the third of five placement blocks in the students’ program. Each placement site either had OTN equipment on site or within a reasonable commuting distance (<30 minutes). Furthermore, each student’s participation in the project had to receive the support of the student’s clinical instructor.
The placement types represented a variety of areas of physical therapy practice (based on the patient populations) as well as contexts of health care delivery (inpatient, outpatient, community). Many of these placements were categorized by their clinical instructors as being “mixed” and/or “variety”, which meant students provided care for patients across traditional classifications and/or in a variety of settings within a single placement.
Based on the placement offers received for the placement block in question, the following “Interest Groups” were established: Musculoskeletal, Adult Neurology, Cardiorespiratory, and Pediatrics.
Students met via multi-point video-conferencing in order to “workshop” patient cases with each other under the guidance of a faculty moderator. Students were scheduled to meet once a week for four weeks of the six-week placement via OTN video-conferencing. Each meeting lasted one hour. The first meeting was used to orient the group to the learning objectives of the workshops and to the video-conferencing technology. The remaining meetings each had a topic theme: 1. Assessment Planning, 2. Interpretation of Assessment Findings and Goal Setting and, 3. Treatment Planning & Informed Consent. The role of the faculty moderator was to help guide the discussion, to serve as content expert and to direct students, as appropriate, to necessary resources.
OTN is an independent, non-profit organization which is funded by the Provincial Government of Ontario. The OTN mandate is to deliver health-related services and education (health-professional and patient) using two-way videoconferencing and tele-diagnostic systems (www.otn.ca). Currently more than 3000 health care professionals deliver services through the OTN at more than 925 sites across the province. Member sites include Ministry of Health and Long-Term Care funded agencies (including, but not limited to, hospitals, Community Care Access Centers, and Family Health Teams).
Student Demographics, video-conference experience and education information:
In order to provide descriptors of our informant sample, students were asked to complete a questionnaire on general demographic information, prior video-conferencing experience and clinical experiences to date.
Case Workshop Questionnaire:
Following each of the three sessions that were Case Workshops, student participants were asked to complete an on-line questionnaire in order to obtain their feedback on the session. The questionnaire was a 12-item survey. Participants rated their responses on a 5-point Likert Scale (Strongly Disagree, Disagree, Neutral, Agree, and Strongly Agree). A text box at the end of the questionnaire allowed for additional open-ended comments. Following each Case Workshop the faculty moderator forwarded a link to the Survey and a reminder note to prompt their completion.
Participant gender, prior video-conferencing experience, confidence using video-conferencing technology and other questionnaire responses were summarized by frequency counts.
Twenty-six student participants were recruited to this pilot project. Four interest groups were created and are described in Table 1. The participants were 26±4 and were predominantly female. Prior to participating in the case workshops, 15 of the participants reported having previous video-conferencing experience, and only 3 reported having prior experience using an OTN platform. Only 7 participants identified being either “confident” or “very confident” using video-conference; the remaining participants were either unsure (n=11), unconfident (n=6), or very unconfident (n=1) with using the technology (Figure 1).
With the exception of the musculoskeletal interest group, which experienced unforeseen conflicts with the Case Workshop schedule, all remaining groups completed four video-conference sessions, of which the latter three were case workshops. At each session, two or three participants presented a case study to the group for subsequent discussion.
The survey response rate over all sessions was 74%. The results from the survey responses for a single case workshop with the highest response rate (21 out of 26 participants; 84% response rate) are summarized in Figure 2. All of the respondents (100%) either “agreed” or “strongly agreed” that the case workshops enhanced their learning while they were on their clinical placement and that overall they were satisfied with the session. Only one respondent indicated that the video component of the communication was not satisfactory and only one participant identified not having had enough time to prepare for the workshop. Two respondents indicated that they did not have enough time for discussion in the workshop. Responses to the statement “This session has reduced my sense of isolation” were mixed: approximately half the participants “agreed” or “strongly agreed” with this statement, and the other half were either “neutral” or “disagreed” with it. This finding is consistent with the fact that only 7 participants were geographically isolated on their placement.
This pilot project established that a faculty-moderated, case workshop for small groups of MScPT students using existing video-conference infrastructure (i.e., OTN) was feasible within our context. Furthermore, survey results from the participants indicated that there was unanimous opinion that participation in the case workshop enhanced their learning while on clinical placement and that all participants were satisfied with the workshop. The survey responses were underscored by a number of student comments, which elaborated on their perceived value of the sessions. One student commented that, “I enjoyed discussing other student’s cases because it gave me insight into how others would treat a condition.” And another that, “It was great to receive feedback from everyone about my case, which was particularly good because it has helped my treatment of that patient greatly.” Finally,
Fantastic session and fantastic learning experience going through the cases, understanding why we see certain observations and what precautions we should keep in mind with certain equipment (especially since we have never seen these in school before!)
The students, in their text comments, also highlighted the supportive benefit of the sessions. One participant commented that,
I presented my case study in this session and it was enough just to have the support of classmates (and professor) when dealing with a significantly challenging case. It made me feel like I was doing an OK job!
Yet another commented on how the conferences helped them to deal with challenging issues faced by care-givers,
It was good to talk about some of the ‘tough’ situations we face...eg. Death. These situations are not addressed in the classroom so it is nice to discuss them among classmates and learn from their experiences.
For some students, the case workshops acted to reduce their sense of isolation while on placement. In the words of one participant, “These sessions were helpful both for brainstorming challenging cases and for reminding me I'm not alone out here.” Another student compared it to a previous placement where they did have peers available physically on-site,
It reminds me of being in [placement site name] and having everyone who I could talk to at lunch about different cases. I find that this is better because at lunch I can't usually talk to other students so it's nice to get information about what they have learned on placement.
Although, many participants reported that their sense of isolation was reduced by participation, this was matched by those students who were not alone on placement. As another student put it “I am unsure about the isolation question....it assumes that I feel isolated to begin with, which I do not.” It is interesting to note that even students who were not isolated on their placement, (i.e., they had other peer members on site) reported that this experience was of value to them.
Overall, the learning curve for the technology appeared to be minimal. Approximately 60% of the participants had previous experience with video-conferencing, including web-based platforms such as Skype or Netmeeting. However, only three participants identified having prior experience using OTN video-conferencing systems. Furthermore, only 28% of the respondents identified themselves as being “confident” or “very confident” using video-conferencing. This would seem to highlight that, with very minimal orientation, these participants were able to successfully use the OTN systems. In one student’s words,
It was already set up for us when entering the room and therefore it was quite straight forward and easy. It didn't take much time to get use [sic] to the audio and visual delays. It was easy to get use [sic] to the system and to the idea of using mute and hand signals to coordinate who was talking.
This ease of use was counterbalanced by an administrative overhead to reserve the equipment at each regional site, to register the multi-point video-conference on the OTN Bridge (for an automated start), and to co-ordinate with the regional support personnel (Information technology and/or telemedicine co-ordinators) to ensure that the equipment is set-up and turned on for each conference. Furthermore, unlike other forms of multi-point video-conferencing, OTN platforms were made available at no cost to our participants. That is, the costs associated with the video-conferencing were absorbed by the respective institutions themselves. It is unclear if the participants would have had a different cost-benefit appraisal if these conferences required a fee to participate.
Finally, the success of these groups may rely heavily on the strengths of the group moderator. Although the survey responses suggests an overall satisfaction with the moderator’s ability to keep the discussion on track during the workshop, text comments from some students highlight that certain skills were valued in their moderators. As one student commented,
….I think the success will be determined by the abilities of the moderator to keep the conversations going. There were definitely times when there seemed to be these awkward silences but were minimized by the ability of the moderator to jump in and re-direct the session or pose a new question in initiate conversation [sic].
In conclusion we achieved our purpose of connecting MScPT students via multi-point video-conferencing to support their learning while they were on clinical placements. Students responded positively, experiencing no significant problems with the technology. Only some report having reduced isolation reflective of the fact that not all of the students were in remote settings. Moderator skill-set, as perceived by the students, contributed to the success of the workshop.
Results from this pilot project support the value and feasibility of this model in principle. It will be important to investigate further the sustainability of this model and the value of this resource to students at all levels in PT education. This educational initiative could also serve as a model for other health care professions, either pre- or post-registration/licensure.
Sincerest thanks are extended to Pete Fowler and Dr. Gene Dagnone in the School of Medicine at Queen’s University for providing access to and technical support using their video-conferencing equipment; to Shelley Huffman, Regional OTN Manager, for assistance in developing the network of contacts required for the project; to Trish Lundstrom, the telemedicine co-ordinator at Kingston General Hospital, and Allan Zahara, the Regional Education Manager for OTN, for their assistance in setting up and delivering a training session for the faculty moderators; to Randy Booth and Paula Mooney, Academic Co-ordinators of Clinical Education (ACCE) at Queen’s University, for their assistance liaising with clinical instructors at our participants’ placement sites. Finally, this project would not have been possible without the support and generosity of the telemedicine co-ordinators, clinical instructors, and associated administrative personnel at each of the participant sites.
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