evaluation of physiotherapy clinical educational models: comparing 1:1, 2:1 and 3:1 placements

Physiotherapy August 2003/vol 89/no 8

Professional articles

Introduction and BackgroundClinical education is a core element ofphysiotherapy education where studentsgain experience and knowledge of thepractice setting. ‘Practice-based learningforms an indispensable and integral partof the learning process. Learning gainedin practice settings is vital to students’educational and professional develop-ment’ (CSP&CPSM, 2002).

In the practice setting, students workclosely with a clinical educator for theduration of the placement. Clinicaleducators are senior, qualified, practisingphysiotherapists whose role is to super-vise, facilitate and assess students’learning while they are on placement(Moore et al, 1997).

The learning experience may occur in avariety of practice settings wherephysiotherapists are employed, includingacute hospital wards or community-basedrehabilitation units, where therapists workwithin multi-disciplinary teams in contrastto uni-professional outpatient physio-therapy settings where physiotherapistswork predominantly with members oftheir own profession.

A mandatory requirement of all UK-based physiotherapy degree courses is the need for students to complete succ-essfully a minimum of 1,000 hours ofclinical/fieldwork education before beinggranted a licence to practise and elig-ibility for membership of The Chart-ered Society of Physiotherapy. There are

Evaluation of PhysiotherapyClinical Educational Models Comparing 1:1, 2:1 and 3:1 placements

Summary Nationally there is an increasing problem of clinical placement shortages for physiotherapywhich is likely to become worse with the implementation of Government National Health Service plans.The purpose of this study was to compare experiences of clinical educators and students using threedifferent clinical placement models.

Method Eight clinical educators volunteered to experience 1:1, 2:1 and 3:1 placement models; 48 third-year physiotherapy students volunteered to attend these placements. Data were collected byface-to-face interviews with educators and students at the end of each placement. Departmentmanagers and visiting tutors were also interviewed when all the placements were completed. All interviews were recorded on audiotape, transcribed verbatim and assessed for accuracy. The data were analysed thematically using NVIVO software and assessed for reliability and validity.

Results Themes emerged that had an effect on the success of a placement. These included the time the educator spent with individual students, size of department, number of patients and availability ofaccommodation. The experiences of the interviewees suggest that each of the models has advantagesand disadvantages, but they all provide valuable learning opportunities. The results indicate that thesuccess of any placement model depends heavily on how the placement is planned.

Conclusion It is evident from the findings that all three models investigated have a place inphysiotherapy clinical education. The 2:1 and 3:1 models provide different learning opportunities fromthe 1:1, but are no less important; they can now be promoted in the clinical setting with more evidenceto support their use. If implemented these models will contribute to increasing placement numberswhile still maintaining high quality learning environments for the students and rewarding experiencesfor the educators.

Key WordsCollaborative learning, peer learning, clinical education models.

by Ann MooreJane MorrisVictoria CrouchMarion Martin

489

Moore, A, Morris, J,Crouch, V andMartin, M (2003).‘Evaluation ofphysiotherapy clinicaleducational models:Comparing 1:1, 2:1and 3:1 placements’,Physiotherapy, 89, 8,489-501.


490

significant parallels between the physio-therapy model and that of other healthprofessions, for example occupationaltherapy.

Challenges of ShortagesThe need for higher education inst-itutions to access enough clinical place-ments continues to present a challengefor all those involved in allied healthprofessional courses, with providers ofphysiotherapy courses currently facingacute problems (Roberts, 2001; Walker,2001). Evidence from recent studies(Huddleston and Standring, 1998;Maxwell, 1995) suggests that staff short-ages among placement providers and a strong historical adherence to thetraditional 1:1 placement model havecontributed to the dearth of availableplacements.

While physiotherapy student numbershave gradually increased during the lastdecade there is currently a shortage ofsenior qualified practitioners, withrecruitment and retention issues seen ascontributing to this shortage. In theNational Health Service Plan (DoH,2000), the government set out its aim toincrease the number of student trainingplaces for physiotherapists, along withother health professionals, in order toincrease the physiotherapy workforce overthe next five to ten years. The success ofthis proposal will depend on the ability ofphysiotherapy higher education providersto access enough clinical placements toaccommodate the additional students. If the National Health Service Plan is tofulfil its target numbers for physiotherapy,a substantial number of additional place-ments must be found within the nextdecade.

Rationale for the StudyThe Chartered Society of Physiotherapy iscontinuing to explore ways of increasingplacement numbers while at the sametime striving to maintain or improve thestandard of learning experiences forstudents and the rewards for clinicaleducators. So far as the professional bodyis concerned the stakes are high.

During the last decade physiotherapyhas predominantly adopted the 1:1 modelof clinical education, where one studentworks with one educator, as the acceptedway of educating students within theclinical learning environment. However,

this model is not based on soundevidence. There is a growing body ofliterature that supports the use ofcollaborative or multiple placementmodels (where two or more studentslearn together with one educator). Thesemodels are felt to embrace soundeducational concepts based on thetheoretical principles of adult learning,using peer review and peer support.Studies both nationally and inter-nationally have investigated the use ofcollaborative models in the clinicaleducation of physiotherapy and otherprofessions (Huddleston, 1999a, b;Ladyshewsky, 1995; Martin and Edwards,1998; McAllister et al, 1997).

There is also evidence from supportingliterature on clinical placement models,which highlights students’ and educators’perceptions of factors contributing to‘good’ and ‘bad’ placement experiences(Fosnaught, 1996; Huddleston, 1999a, b;Ladyshewsky, 1993; Reynolds, 1996;Tiberius and Gaiptman, 1985; Zavadak etal, 1995). The majority of this work wasundertaken outside the UK.

The University of Brighton, like mostother higher education institutions at thetime this research was instigated in 1999,was having difficulty accessing enoughplacements for all its pre-registrationphysiotherapy students. Many of thereasons for this difficulty are related to the shortage of clinical educators(Huddleston and Standring, 1998). Sinceeducators are key to the development andmaintenance of clinical education it wastherefore thought vital in this study togather the views of educators on the useof collaborative models and the projectwas therefore designed to focus mainly onthe experiences of clinical educators.

In recognition of the current placementshortages, the expectation of an ongoingcrisis in placement availability, andevidence in the literature about theefficacy of 2:1 and 3:1 models, it wasthought timely to carry out a local projectexploring the use of collaborativeplacement models in clinical education.The Clinical Research Centre for HealthProfessions therefore put forward aproposal to carry out a study to the localNational Health Service EducationConsortium and the resultant project wasa joint initiative between the University ofBrighton and the Sussex National HealthService Education Consortium.


491Research report

Aims 1. To determine how different models of

clinical education (1:1, 2:1 and 3:1)impact on the quality of education forstudents and the quality of experiencefor educators.

2. To contribute to the development ofclinical education frameworks.

Method A qualitative approach was adopted forthe study as it was felt that it would enablethe views and perceptions (Robson, 1994)of educators and students based on theirexperiences of the 1:1, 2:1 and 3:1placement models to be explored.

In recognition that the key peopleinvolved in any clinical educationexperience are the educators andstudents (Moore et al, 1997) and in orderto evaluate the three models of placementit was felt important for data to becollected from both educators andstudents as they would not only haveexperienced the different placementmodels but would also be influenced bythe quality of the placement experience.

However, as the literature indicated,clinical educators’ previous preference forthe traditional 1:1 placement model hasbeen an obstacle to the adoption of otherratio models (Huddleston and Standring,1998; Martin and Edwards, 1998; Walker,2001). The project team, guided by therecent research evidence and the views of the project steering group (whichconsisted of educators, senior managersand representatives from the educationconsortium) recognised the importanceof focusing the study principally on theexperience of the clinical educators.

ParticipantsEight physiotherapy clinical educatorsvolunteered to experience 1:1, 2:1 and 3:1placement models, and 48 third-yearphysiotherapy students agreed to attendthese placements over a six-month period.

As the eight physiotherapy clinicaleducators formed the key focus of thestudy it was felt essential for them toexperience all three of the placementmodels. Where possible educators wererandomly allocated to placement modelsin an attempt to counterbalance anyorder effects. The study was conductedduring the third and final year of thecourse when the physiotherapy studentsundertake the majority of their placement

experience. It was felt essential that theeducational balance for each individualstudent should be maintained andtherefore due to time constraints and theavailability of placement sites offering the required core practice experience,student participants did not experienceall the placement models.

Although Hicks (1999) suggested thatorder effects cannot be eliminated totallythe research team is aware that theconstraints mentioned above preventedorder effects from being more fullyaddressed in the study design andrecognises this as one of the limitations of the study.

Managers and Visiting Tutors The research officer (VC) contacted thedepartmental managers of the clinicaleducators from each study site and invitedthem to take part in the study. Managersof four physiotherapy educators agreed tobe interviewed. Time constraints prohib-ited the remaining managers from part-icipating in the study. Four tutors fromthe University of Brighton Physiotherapydivision who normally visited the studysites were also asked to participate in thestudy.

Before the start of the study ethicsapproval was given by the School ofHealth Professions Ethics Panel, Uni-versity of Birmingham.

Preparation of EducatorsAll educators and managers who hadvolunteered to take part in the study wereinvited to an afternoon preparatoryworkshop organised by the project team.During this workshop the aims andpurpose of the study were identified andsuggested ways of facilitating learningwith more than one student in thepractice setting were explored. The needfor preparing educators for use of theseclinical education models was highlightedby Ladyshewsky (1993).

Data Collection MethodsFace-to-face semi-structured interviewswere held at the end of each placementfor both educators and students. Thismethod of data collection was consideredto offer a flexible approach and wouldenable participant responses to befollowed-up by the researcher (Bell,2000).

In addition a focus group interview was

Authors

Professor Ann MoorePhD FCSP CertEdILTM is director ofthe Clinical ResearchCentre for HealthProfessions, Universityof Brighton.

Mrs Jane Morris MAMCSP PGCert ILTMand Ms MarionMartin MA(Ed) BADipCOT are seniorlecturers in theSchool of HealthProfessions, Universityof Brighton.

Mrs Victoria CrouchBSc MCSP was aresearch officer at theUniversity of Brightonuntil September 2001.

The project wasfunded by SussexEducationConsortium.

This article wasreceived byPhysiotherapy onFebruary 25, 2002,and accepted on May 6, 2003.

Address forCorrespondence

Professor Ann Moore,Director, ClinicalResearch Centre forHealth Professions,University ofBrighton, Aldro House, 49 Darley Road,Eastbourne, East Sussex BN20 7UR.


492

conducted with student participants at theend of the placement period, when issuesthat arose following the initial dataanalysis could be explored (Vaughan et al,1996). A synopsis of the broad interviewtopics for both educator and studentinterviews is included in table 1.

Data Collection ProcessBefore the start of data collection, allparticipants who had agreed to take part in the study were sent a detailedinformation sheet outlining the aims andpurpose of the study and highlightinghow issues of confidentiality and anony-mity would be addressed.

All interviews were pre-arranged andconducted in a private room and werecarried out on placement sites withinNational Health Service trusts. Permissionfrom each departmental manager wassought in advance of each interview.Before each interview was conducted thepurpose of the study was fully explained,participants were assured that they wouldbe free to leave the study at any time and a consent form was completed. Allinterviews were conducted by the researchofficer and were recorded on audiotape.

Clinical educators were interviewedseparately. Students who were exper-iencing 2:1 and 3:1 placements wereinterviewed in their pairs or in threes asappropriate. At the end of each interview,time was allowed for any students to makeadditional comments on an individualbasis in a private area if they wished to doso. Each interview with clinical educatorsand students lasted between 30 and 50minutes or until saturation occurred.

Visiting tutors were interviewed in two

groups and these interviews took placeonce all the placements had been com-pleted and were carried out in a privateroom at the host university.

Managers were interviewed individuallyonce all the placements within their trustshad been completed. It was felt importantto investigate the effects of hosting thedifferent models on the home depart-ment and to determine if adoption of thedifferent models raised any other issuesfor the education institutions that had notalready been identified.

The physiotherapy placement special-ties were outpatients with general pract-itioner clinics, outpatients (hospitalbased), hydrotherapy, respiratory includ-ing an intensive care unit, acute elderlycare and amputees. All three models wereused for all specialties.

To improve the consistency of the datacollection the researcher receivedfeedback from educators and studentsfollowing a series of pilot interviews,which enabled the structure of theinterview to be adjusted before the start ofthe main data collection. Of the maininterviews 10% were also observed by twoexperienced qualitative researchers, inorder to provide the research officer with feedback on her interview skills(Appleton, 1995).

Data AnalysisEach audio-tape of the interviews waslistened to several times by the researchofficer before being transcribed verbatimby a professional transcriber and assessedfor accuracy by the research officer. Eachtranscript was then read through severaltimes by the research officer enabling‘meanings of sentences or phrases toemerge’ (Stockhausen and Kawashima,2002) before the data were coded andanalysed thematically using a qualitativeanalysis package, NVIVO version 1.0software (QSR International, Australia).Copies of the original transcripts werereserved to enable the research officer torefer back to the appropriate section onthe transcript, ensuring that the contextof the interviewees’ comments wasretained during the analysis process(Appleton, 1995). A random 10% sampleof transcripts from the original interviewswith both students and educators wasreturned to participants to enable them tocheck for accuracy. No issues of accuracyarose.

Table 1: Synopsis of the broad interview topics covered for bothclinical educators and students

Interview topics for clinical educators Interview topics for students

Previous experience of different Previous experience of differentmodels of placement education models of placement education

Student support Learning from each other

Provision of student feedback Student feedback

Student learning Other opportunities offered by the different models

Student competition Student competition

Time spent for supervision Time for individual supervision

Time spent for discussion Time for discussion

Advantages and disadvantages of Advantages and disadvantages of the placement model the placement model

Learning opportunities


493Research report

Issues of Reliability and ValidityThe main themes from the interviewswere taken to both educators and stud-ents at the initial analysis stage to verifythe credibility of the analysis. Return visitsby the research officer to participantsenabled the meanings emerging from thedata to be explained and interpretationsestablished (Hammell et al, 2000).Colleagues who were not involved in themain data analysis analysed a randomsample of the data to check the applic-ability and ‘truth value’ of the analysisprocess (Appleton, 1995; Burnard, 1991;Glaser and Strauss, 1967).

Findings and DiscussionThe experience of the intervieweessuggests that each of the models hasadvantages and disadvantages but allprovide valuable learning opportunities.Most of the clinical educators interviewedfor the study preferred the 2:1 model.The key themes that emerged from thefindings were:

■ Peer support.■ Peer learning opportunities.■ Time available for facilitating learning.■ Integration into the department.■ Placement planning.■ Potential problems.

The findings are considered below andto facilitate comparison they are alsosummarised in table 2 (Cresswell, 1998).

Peer SupportThe value of support from a fellowstudent was a key theme and is supportedin similar studies (Zavadak et al, 1995;Baldry Currens, 2000).

All students who participated in thestudy felt that there was value in havinganother student experiencing the place-ment with them. In 2:1 and 3:1 placementmodels students automatically assumedthe role of ‘supporter’ contributing to thesafety, belonging and self-esteem of eachother. In contrast to the 1:1 model wherethe educator was often solely responsiblefor providing student support as well asfacilitating student learning, the 2:1 and3:1 models appeared to shift some of theresponsibility for basic support from the educator to the students, allowingeducators more opportunity to concen-trate on fulfilling the students’ additionallearning needs. This finding is supported

in the literature (Best and Rose, 1996;Tiberius and Gaiptman, 1985)

One of the main disadvantages of the1:1 model was the lack of peer supportexperienced by students who were aloneon placements. This situation was exac-erbated if they were also living alone inaccommodation for the whole duration ofthe placement. The following commentsillustrate the isolation felt and thepotential disadvantage to the student’slearning experience:

‘Our student is very lonely in theaccommodation at the moment, whichis a problem at times, and it’s nice tohave someone else to talk over ideaswith you on your level.’ Educator 3

‘I feel disadvantaged by the fact thatkind of here, it’s in the middle ofnowhere and I do feel really isolated.’Student 3

In contrast the 2:1 and 3:1 models ofclinical education provided students with peer support, a key advantage ofcollaborative placement models. Studentswere reassured by the fact that a fellowstudent was finding areas of their practiceequally challenging. The sentiments ‘it’snice to be with someone who’s in thesame boat’, or ‘at the same level’ or ‘inthe same situation’ were frequentlyechoed by students on the 2:1 and 3:1models. The peer support provided was also an advantage recognised by educ-ators in both the 2:1 and 3:1 models asone typical comment from an educatorsuggests:

‘I think they get loads of supportfrom each other.’ Educator 2

The support offered by fellow studentswas highly valued and at times associatedwith an increase in confidence whichpromoted student learning, as the foll-owing quotations illustrate:

‘It’s probably less intimidating maybebecause you can go together and say,hang on we don’t remember how touse this … so I suppose it gives youmore support and confidence to ask.’Student 5

‘It definitely encourages them to bemore forthright, it gives them moreconfidence than with just the one, sojust that process they learn.’ Educator 1

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1:1

2:1

3:1


495Research report

Some educators felt that the increasedconfidence observed in students on 2:1and 3:1 placements encouraged them toquestion their educators’ practice morereadily. Educators regarded this asultimately beneficial to their own practice,perceiving that their own clinical reas-oning and professional practice wasenhanced by the questions generated bymore than one student. One educator ona 2:1 placement suggested:

‘They tend to have slightly moreconfidence to question you whileyou’re doing things, which is no badthing from my point of view. Keeps youon your toes. Makes you think aboutwhat you’re doing.’ Educator 7

Another educator echoed the positivebenefits and rewards of having more thanone student on placement:

‘It’s much more stimulating andmuch more rewarding, much moresatisfying as an educator.’ Educator 3

One student on a 3:1 placement exper-ienced feelings of isolation, however,because the other two students were closefriends. While it is fully recognised thatthis is a finding from only one placementin a small study, previous research hasindicated that an awareness of groupdynamics by both educators and studentsduring multiple placement models mayhelp to facilitate the learning experience(Jowett et al, 1999).

Inextricably linked to peer support werepeer learning opportunities, which havebeen acknowledged to be a major featureof multiple placement models and greatlyvalued by both educators and students(Baldry Currens, 2000; Zavadak et al,1995). Educators and students alikebelieved that the absence of peer learningopportunities was a major disadvantage ofthe 1:1 placement model.

Peer Learning OpportunitiesStudents and educators felt that one keyadvantage of the 2:1 and 3:1 models wasthe fact that students were able to discussand explore issues with each other, which facilitated learning that by its very nature appeared to be more active.In both the 2:1 and 3:1 models, peerlearning opportunities enabled studentsto share ideas, solve problems andexperience clinical reasoning together,which it was felt promoted self-directed

learning. Through group discussionstudents were able to identify issues ofimportance to them, to question eachother and to learn from each other’sexperience (Martin and Edwards, 1998;Tiberius and Gaiptman, 1985; Zavadak etal, 1995). There is also evidence thatclinical competence, patient assessment,treatment planning, implementation oftreatment and professional behaviour canbe enhanced by discussion with peers(DeClute and Ladyshewsky, 1993;Fosnaught, 1996).

There were opportunities during coll-aborative placements for students toobserve each other working with patients,valuing the subsequent feedback theyreceived from their colleagues following atreatment session with a patient, a findingalso reported by Zavadak et al (1995).Both educators and students reported thebenefits of students working togetherwhen treating patients, with one studenttaking the lead and the other adoptingthe role of assistant. As a result of thispractice it was felt that students’communication and team skills weredeveloped and their ability to delegateresponsibilities enhanced.

The following quote illustrates the valueof peer learning:

‘It’s supportive, you’ve got someoneelse to talk through ideas with, andyou can learn together. I did loads oflearning, we had student time to go off and practise with each other, whichwas really good. You can learn fromhow the other person is with patients,watching each other. We sort ofremember different things and then by talking it through you can learnfrom each other.’ Student 4

Educators also appreciated the advan-tage of demonstrating and practisingtreatment techniques within the 2:1 and3:1 models when there was always some-one to act as a model. Students highlyvalued the opportunity of practisingtechniques together. This was felt to be a particularly successful strategy forreinforcing learning, when peer practicefollowed tutorial sessions in physiotherapyoutpatient and hydrotherapy settings, anadvantage noted previously by Fosnaught(1996). Educators found that preparationfor and delivery of teaching sessions was more rewarding when more than one student was on placement, as oneeducator indicated:


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‘I think perhaps I have demonstratedmore during a 2:1 because it’s mucheasier to say "come on, let’s go throughthis" … rather than trying to findanother member of staff to be amodel.’ Educator 2

Of particular note is a findingsupported by Tiberius and Gaiptman(1985) that students participating ineither the 2:1 and 3:1 models questionedtheir educators in a more focused andcomplex manner. Students initiallydiscussed more simple questions withtheir peers and began problem-solvingtogether before consulting their educ-ators. A good example of this studentpractice was described by one of theeducators:

‘One student was coming to me withsuch basic questions [1:1 model].Because I think they would sort ofcheck with the other students first [2:1and 3:1 models] … they came to mewith a group of questions … which wasmuch easier for me to support themwith…. It was taking in wider ideas andconcepts, which from my point of viewis much easier and much morerewarding to teach.’ Educator 5

Time Essentially in the 1:1 model more timewas available for the educator to spendwith each student and this was seen to bean asset valued by both educators andstudents. It allowed students andeducators to observe each other withpatients, which facilitated discussionbetween the educator and student andpromoted feedback on student progress.Reflecting on a 1:1 placement oneeducator observed:

‘I have still quite a fair caseload myselfand the student can observe that andsee how I can manage.’ Educator 1

This advantage was strongly echoed bystudents on 1:1 placements. Typicalcomments were:

‘It’s ideal. You’ve got somebody’scomplete attention and so they cantake their time to look at your writtenand verbal communication skills andthey can observe you with differentgroups perhaps.’ Student 2

‘I am mainly with my supervisor onthe ward and so I do have a lot offeedback.’ Student 2

Time was also deemed to be an essentialfactor in the development of relationshipsbetween students and educators, enablingthem to get to know each other and tobuild a relationship. It was noted by manyof the educators and students on 1:1placements that when the educator andlearner established a collaborativerelationship the learning experience was apositive one, a finding consistentlysupported in the literature (Emery, 1984;Jarski et al, 1990; Neville and French,1991; Ramsden and Dervitz, 1972).

As the previous findings have suggested,the main advantages of the 1:1 modelappear to have been associated with theamount of time that students spent withtheir educator. Some educators wereconcerned however that the 1:1placement model might result in studentsbecoming too dependent on theireducator, a disadvantage of the 1:1 modelhighlighted in previous research byHuddleston and Standring (1998).

One of the disadvantages of both the2:1 and the 3:1 models was that studentsspent less time with their educators on anindividual basis. This disadvantage wasparticularly evident in the 3:1 modelwhere most educators divided their timebetween the three students. Students andeducators questioned whether enoughtime had been made available to identifyindividual students’ strengths andweaknesses and for feedback, which formessential components of any learningexperience (Moore et al, 1997).

‘I don’t think I’ve been able to givefeedback as often as I’d like.’ Educator 6

‘I don’t think the educator has spentenough time with us to know what ourweaknesses and our strengths are to beable to tell us to go away and readsomething up.’ Student 32

The amount of time available in the 3:1model was also felt to impact on therelationship between the educators andstudents as it took longer for them toform a relationship because each studenthad less time with the educator, as illus-trated by the following quotation:

‘It takes longer to get to know them Ithink because you have less time withthem whereas with one or even twoyou get to know them fairly early on inthe placement.’ Educator 6


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Although the lack of available time wasmore obvious in the 3:1 model, in some1:1 models the time available foreducators to facilitate student learninghad been substantially reduced becausesome educators retained a heavy caseload.If educators maintained their normalcaseload and failed to time-table sessionsfor meeting their students, there waslimited time for observation anddiscussion resulting in students report-ing a less than satisfactory learningexperience. Students and educators allagreed that it was important for educatorsto spend time with each student on aregular basis to enable practice to beobserved, feedback to be exchanged andstudent progress monitored. Individualtime was also considered to be essentialfor discussion, problem-solving andreflection promoting the development ofclinical reasoning skills (Higgs, 1992).Thisfinding was particularly evident wheneducators worked across specialty areas,for example outpatients and painmanagement, or had additional man-agerial responsibilities.

Integration into the DepartmentDuring 1:1 placements students appearedto integrate well into the department as awhole, resulting in students feeling morerelaxed and seeking help if required fromother team members. Students on 2:1placements also felt less intimidatedduring the integration process becausethey were together, as one highlighted:

‘It’s a bit less scary in the staff roomisn’t it at lunchtime?’ Student 4

In contrast some students reportedfeeling less integrated into the depart-ment during 3:1 placements:

‘I think the other staff members inthe department don’t make such aneffort with you as well, if there arethree if you they think you’re OKsitting in a corner talking to each other.They don’t actually start conversationswith you as much as I think they wouldif you were on your own. So that’s oneof the main disadvantages I think.’Student 25

The above finding supports previousresearch by Jowett et al (1999) whichfound that physiotherapy students on a4:1 collaborative placement model feltless integrated within a department as

they tended to stay in their group atlunchtime rather than mixing with otherstaff.

Placement PlanningMost educators and students experiencingthe 2:1and 3:1 model emphasised theneed for adequate preparation before thestart of the placement. All educatorsinterviewed agreed that when adoptingthe 2:1 and 3:1 placement models theyhad to be more organised in terms ofplacement planning before the studentsarrived. Some educators recognised theimportance of reducing their caseloadand ensuring that enough provision wasmade for student tutorials during the 2:1and 3:1 placements. However, someeducators were reluctant to reduce theirown patient caseload, perceiving thatsatisfaction in their professional roledepended on direct contact with patients.As a result the 3:1 model was lessrewarding for all concerned. Other ward-based educators in a rehabilitation unitfor older people were unable to reducetheir workload, which also made the 3:1model more challenging.

Previous research into multipleplacement models has consistentlyemphasised the need for careful planningand due reduction of the educator’scaseload, which should normally beshared between the student group(Ladyshewsky, 1995; Jowett et al, 1999;Baldry Currens, 2000; CSP, 2002).Students considered placements to havebeen planned effectively when theeducators had reduced their ownworkload enough to spend more timewith individual students or the studentgroup. Moore et al (1997) recognised the planning stage as a key element of any good learning experience, whileLadyshewsky (1993, 1995) highlights theimportance of educators delegating partof their workload to meet student needsin a 2:1 placement model.

Linked to planning and forwardthinking was the need to considerphysical space and patient numbers,particularly on 3:1 placements. Too littlespace on some placements was achallenge. A lack of enough desk or officespace within a physiotherapy departmentresulted in students being ‘housed’elsewhere and this exacerbated theproblem of lack of integration within the department. Too few patients also


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challenged some educators who wereconcerned about the level of the students’‘hands on’ experience during 3:1placements. Students and educators whotook part in a placement where therewere not enough patients or limitedopportunities for patient contact due totime constraints felt that the learning wasless than satisfactory. Several of theplacement sites which hosted 2:1 or 3:1placement models encountered ashortage of patients which led todissatisfaction by both educators andstudents. The shortage was particularlyapparent in a 3:1 hydrotherapy placementwhere limited pool time curtailed thenumbers of patients who could beaccommodated. On an acute respiratoryplacement a shortage of patients was alsoa limiting factor of the 3:1 model.

Potential ProblemsThe final theme that emerged from thedata resulted from the concern expressedby educators and students that therecould be personality clashes, competitionbetween students, or differences instudent competency which might impacton the learning experience. However, noevidence suggested that these problemshad occurred during this study and they were therefore categorised by theresearch officer as ‘potential problems’.

The most commonly cited concern thatall the educators and students raised inrespect of 2:1 and 3:1 placement modelswere personality clashes between thestudents, closely linked to the possibilityof competition between students. Theeducator was felt to have a role inmanaging these differences and issues ofcompetition, which potentially could giverise to difficulties. One student said:

‘I think if you are with anotherstudent who is quite competitive thenit might become an issue. But then it isalso dependent on the clinical educatorand how they deal with having twostudents…. I think if they were startingto compete, you might have to sort ofre-think your ideas.’ Student 6

Other potential problems that weresolely highlighted by the educators werethe ability to manage students onplacement together who demonstratedvery different levels of competence, andthe ability of weaker students to hide theirinadequacies when in a pair.

‘Luckily for me, most of my studentsthat I’ve had in pairs have been on apar with each other. I think thedifficulty might come where you’ve got two extremes. One who is very,very competent, super competent, and one who is a little below the average would be, then I think it would be a disadvantage for themboth possibly.’ Educator 8

Managers’ and Tutors’ CommentsManagers and visiting tutors interviewedechoed the comments made by educatorsand students but also made someadditional observations regarding themodels. Some of the managers inter-viewed commented that increasednumbers of students on placement withintheir department might have a positiveinfluence on future physiotherapyrecruitment within their trust.

Although visiting tutors felt thatincreased numbers of 2:1 and 3:1placements might make visiting moreefficient, of significance was theirobservation that sudden cancellation of3:1 placements may have a detrimentalimpact on the management of a clinicaleducation programme as three additionalplacements would have to be found.

DiscussionThe study findings demonstrate that allthree models evaluated have valuableadvantages for both students andeducators engaged in clinical education.Student and educator participants in thestudy all agreed that certain factors,identified below, are deemed to beessential in determining a successfullearning experience irrespective of theclinical model of education which wasbeing undertaken.

It was essential to the success of theplacement that:■ The placement was well planned.■ Enough time was made available for

the educator to meet individualstudents regularly throughout theplacement.

■ Sufficient patients were available foreach student.

It was interesting to note that all thoseplacements investigated in the study thatwere considered by students to be wellplanned were deemed to be successfulregardless of the model of clinicaleducation that was being used.


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Facilitation of LearningEducators who experienced 2:1 and 3:1placement models felt motivated toprepare more thoroughly for theirteaching sessions as they found groupteaching more challenging at times as well as more rewarding. In addition, thestudent group appeared more confidentand more likely to ask questions prom-oting discussion, which enhanced teamskill development (Fosnaught, 1996). As aresult a more active approach to learningwas facilitated (Boud, 1988; Martin andEdwards, 1998). Group discussion wasalso felt to encourage problem solvingwhich provided the educator with greaterinsight into students’ strengths andweaknesses (Zavadak et al, 1995).

It was evident from the findings that the 2:1 model encompassed all of theadvantages of peer support and peerlearning highlighted previously. Studentsand educators expressed more advantageswith the 2:1 than the 1:1 and 3:1 modelsand far fewer disadvantages. Many of theeducators reported that the 2:1 model wasno more stressful than the 1:1, and oftenwas less stressful, a finding also noted byTriggs Nemshick and Shepard (1996).

The 3:1 model In the 3:1 model the advantages anddisadvantages were evenly balanced. Thestudents benefited from peer support andpeer learning opportunities but spent lessindividual time with their educator. Third-year physiotherapy students who hadprevious clinical experience benefitedfrom sharing experiences with their peers.

Of note is one particular disadvantageof the 3:1 model, namely the potentialinability of educators to spend enoughtime with each student to ensure thattheir progress was monitored effectively.This finding could impact on the ability ofthe educators to meet individual studentneeds and to assess individual studentprogress accurately. It is thereforeessential when planning to implement a3:1 model that clinical educators areenabled to reduce their workload enoughto make time available to fulfil their roleas both facilitator and assessor of studentlearning.

Limitations of the StudyDue to the relatively short time availablefor the project it was impossible for allstudents to experience all the placement

models and this was seen as a limitation ofthe study. Time constraints also made itimpossible for all the clinical educators toattend a focus group at the end of theplacement period, which may havelimited the study findings. The researchteam would also have valued theopportunity to gather data from com-munity practice settings but no educatorsfrom community sites volunteered toparticipate in the study.

ConclusionOverall the 2:1 placement model app-eared to be the most successful of thoseinvestigated in this study although it is notideal in all situations. The findings fromthis small-scale study have indicated thateach clinical educator should considerthe learning opportunities that they can offer students and plan placementsaccordingly.

The study also shows that the 1:1 modelof clinical education does not alwaysoptimise students’ learning opportunities.In placement areas where it is consideredto be the most appropriate model it maybe possible for more than one educator tooffer a student placement, at the sametime ensuring that students can benefitfrom some peer support.

It is evident from the findings that allthree models investigated have a place inphysiotherapy clinical education. The 2:1and 3:1 models facilitate peer learningopportunities that the 1:1 model cannotboast. The 2:1 and 3:1 models can now bepromoted in clinical settings with moreevidence to support their use. Ifimplemented, the 2:1 and 3:1 models willcontribute to increasing placementnumbers while still maintaining, andpossibly improving, the quality of learningexperiences for the students and therewards for the educators.

Because of the similarity of models ofplacement education in some otherhealth professions it is likely that therewill be parallel advantages and disad-vantages.

RecommendationsHigher education institutions shouldcontinue to inform students and clinicaleducators of the potential positivelearning opportunities of peer learningand other benefits associated with 2:1 and3:1 models.

Clinical educators should be encour-


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aged to consider their local learningenvironments to enable them todetermine which placement models areappropriate, taking into account internalresource availability, patient through-putand accommodation availability.

As this was a relatively small-scale studythere is limited capacity for the inform-

ation to be generalised to a larger pop-ulation of educators and students.Ongoing research into different modelsof clinical education is essential andfuture research should focus on practice-based education in community learningenvironments.

References

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Baldry Currens, J (2000). ‘An evaluation ofthree clinical placement models forundergraduate physiotherapy students. Reporton Phase 11 of the Clinical Education Project’,University of East London.

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Best, D and Rose, M (1996). QualitySupervision: Theory and practice for clinicalsupervisors, Saunders, London.

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Chartered Society of Physiotherapy (2002).‘Guidelines for implementing (multiple)models in physiotherapy practice placements’,Information Paper CE1, CSP, London.

Chartered Society of Physiotherapy and theCouncil for Professions Supplementary toMedicine (2002). Curriculum Framework forQualifying Physiotherapy Programmes, CSP,London.

Cresswell, M (1998). Qualitative Inquiry andResearch Design, Sage, London.

DeClute, J and Ladyshewsky, R (1993).‘Enhancing clinical competence using acollaborative clinical education model’,Physical Therapy, 73, 10, 683-689.

Department of Health (2000). The NationalHealth Service Plan: A plan for investment, a planfor reform, DoH, London.

Emery, M (1984). ‘Effectiveness of the clinicalinstructor: Students’ perspective’, PhysicalTherapy, 64, 7, 1079-83.

Fosnaught, M (1996). ‘Collaborative learning:The 3:1 model’, PT-Magazine of PhysicalTherapy, 4, 10, 56-62, 64.

Glaser, B G and Strauss, A L (1967). TheDiscovery of Grounded Theory, Aldine, New York.

Hamell, K W, Carpenter, C and Dyck, I (2000).Using Qualitative Research: A practicalintroduction for occupational and physicaltherapists, Churchill Livingstone, Edinburgh.

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Higgs, J (1992). ‘Managing clinical education:The educator-manager and the self-directedlearner’, Physiotherapy, 78, 11, 822-828.

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Key Messages

■ The 2:1 placement model appears toencompass all of the advantages ofpeer support and peer learning,which is supported by the literature.

■ Educators indicate that this module isno more stressful than the 1:1 modeland all models have their place inclinical education, but detailedplanning of the experience is essentialfor success.

Martin. M and Edwards. L (1998). ‘Peerlearning on fieldwork placements’, BritishJournal of Occupational Therapy, 61, 6, 249-252.

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Ramsden, E L and Dervitz, H L (1972).‘Clinical education: Interpersonal foundation’,Physical Therapy, 52, 10, 1060-65.

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Roberts, G W (2001). ‘Fieldwork education:Challenges and opportunities’, OccupationalTherapy News, April.

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Tiberius, R and Gaiptman, B (1985). ‘Thesupervisor-student ratio: 1:1 versus 1:2’,Canadian Journal of Occupational Therapy, 52, 4,179-183.

Triggs Nemshick, M and Shepard, K (1996).‘Physical therapy clinical education in a 2:1student-instructor education model’, Physical Therapy, 76, 9, 968-983.

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Walker, A (2001). ‘Meeting the clinicaleducation challenge’, Physiotherapy Frontline, 7,13, 6-7.

Zavadak, K H, Dolnack, C K, Polich, S and Van Volkenburg, M (1995). ‘Collaborativemodels’, PT-Magazine of Physical Therapy, 3, 2, 46-54.

evaluation of physiotherapy clinical educational models: comparing 1:1, 2:1 and 3:1 placements

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