Chapter 15: Physiotherapy
Melanie K. Farlie; Michael Storr; and Narelle Dalwood
Uncertainty in Physiotherapy
Numerous sources of uncertainty within physiotherapy (in some contexts referred to as physical therapy) have been described. Uncertainty may stem from the environment within which physiotherapy practice occurs and ranges from diagnostic uncertainty to uncertainty regarding the evidence base of physiotherapy practice or ethical issues. Physiotherapists interviewed during the COVID-19 pandemic reported many sources of uncertainty during that time and described this uncertainty as ‘navigating uncharted waters’ (Ditwiler et al., 2021, p. 4). Uncertainty about the COVID-19 virus was amplified by a lack of evidence or clinical guidelines, changes to work tasks, and the scope of physiotherapy practice. For example, at the onset of the pandemic, physiotherapists needed to navigate the conflict between healthcare system restrictions and individuals’ access to care in the United States of America (Ditwiler et al., 2021; Swisher, 2021) and globally (Sturm et al., 2023). Environmental uncertainty also led to ethical uncertainty when decisions needed to be made in unprecedented circumstances (Swisher, 2021).
Practice uncertainty in physiotherapy may also be related to diagnoses and available research evidence. Diagnostic uncertainty in physiotherapy has been defined as ‘the subjective perception of an inability to provide an accurate explanation of the patient’s health problem’ (Bhise et al., 2018, p.103). Physiotherapists have described diagnostic uncertainty as uncomfortable, awkward, and, overwhelming (Almond et al., 2021). Many physiotherapists express feelings of anger, distress, frustration, and anxiety when recalling their experiences of diagnostic uncertainty (Almond et al., 2021; Costa et al., 2022; Hartholt et al., 2020). For example, Danish physiotherapists reported feeling uncertain about their ability to detect sinister pathology using ‘red flag’ screening methods and linked their diagnostic uncertainty to the unclear definitions of red flags and the individualised approaches to red-flag screening within the profession. They said they managed uncertainty by relying on ‘gut feeling’ to resolve a diagnosis rather than using a ‘clear-cut’ standardised approach (Budtz et al., 2022). Screening for ‘yellow flags’ (psychological factors such as anxiety or stress that may affect a person’s health) has also been described as a source of uncertainty for physiotherapists and may lead them to respond with disengagement by altogether avoiding such screening (Stearns et al., 2021).
Priorities to Prepare Learners for Uncertainty in Physiotherapy
Physiotherapists deliver healthcare services to ‘individuals and populations to develop, maintain and restore maximum movement and functional ability throughout the lifespan’ (World Physiotherapy, 2019, p. 1). World Physiotherapy (2021) revised its education framework in 2021, highlighting the ‘need for education which supports the development of physiotherapists who are adaptable and comfortable with change and uncertainty’ (p. 5). Over the last century, the profession has evolved from a predominance of passive therapies, such as massage, to the use of active therapies, such as therapeutic exercise (Australian Physiotherapy Association, 2024). Physiotherapy research has evolved alongside the profession to develop an increasing evidence base underpinning the profession’s practice. World Physiotherapy (2021) has established a competency standard that requires physiotherapists to ‘develop strategies to manage ambiguity, uncertainty, change, and stress to develop resilience and to manage physical, emotional, and mental well-being’ (p. 6). Moreover, it has set an expectation that education programs will prepare graduates for ‘the complexities and uncertainties of the [sic] future practice in any given context’ (p. 26).
Experiences of uncertainty impact how physiotherapists practise. For example, diagnostic uncertainty may lead to variations in clinical practice and guideline adherence that can adversely impact patient care. Physiotherapy educators need to help learners recognise uncertainty and reflect on how the emotions accompanying uncertainty may impact their practice behaviour. Educators can achieve this by guiding learners to reflect on their experiences of uncertainty. Learners should be prompted to identify and moderate those emotional or cognitive responses to uncertainty that have the potential to impair their clinical judgement.
Educators can challenge learners to engage in increasingly sophisticated reflective practice. At the outset of a physiotherapy degree, learners are unlikely to fully appreciate the profession’s scope of practice. They are often unaware that physiotherapy careers span clinical areas such as neurological, musculoskeletal, and cardiorespiratory conditions and include settings such as hospitals, private practice, and primary healthcare. The practice of reflection is critical in the development of learners’ professional identity, including learning to manage uncertainty, and commencing with longitudinal reflective practice activities can help learners develop the skills needed to navigate uncertainty they will encounter in their physiotherapy career.
Fostering Uncertainty Tolerance in Physiotherapy Learners
Physiotherapy education must equip graduates with the ‘agency students need to navigate uncertain and changing futures’ (Barradell, 2017, p. 440). Topics recommended for teaching pre-registration physiotherapists to manage practice uncertainty include reflective practice, recognising and accepting uncertainty and provoked emotions, and communicating uncertainty in clinical encounters (Almond et al., 2021; Costa et al., 2022; Jensen & Richert, 2005; Peterson et al., 2023). It has also been suggested that preparing physiotherapy students for future uncertainties should include teaching ethical and professional practice through a professional curriculum that promotes evidence-informed practice (Edwards et al., 2011; Fay et al., 2019; Markee & Sebelski, 2022; Swisher, 2021).
The exemplar activities in this chapter demonstrate educational strategies for use in a physiotherapy curriculum that introduce the concept of and stimulate learners to consider practice uncertainty, teach skills for managing this uncertainty, and embed ethical and professional behaviour in physiotherapy practice. The strategies also equip learners with the reflective practice and communication skills necessary to navigate the inevitable uncertainties within their future health professions careers. The complexity of the activities can increase through a four-year course.
Exemplar Activity 1: Longitudinal Reflective Practice
Activity Origin
This program of activities related to longitudinal reflective practice was developed, implemented, and evaluated in the Department of Physiotherapy at Monash University, Melbourne. Learners undertaking physiotherapy training at Monash University have differing levels of exposure to the practice of physiotherapy before entering the course (moderator: subject proficiency). Learners embark on the course directly from secondary school education or via graduate entry programs after completing an undergraduate degree.
Sources of Uncertainty
Reflective skills have been identified as a critical element in successfully navigating uncertainty (Stephens et al., 2022). We propose that by undertaking structured and purposeful reflective tasks, students develop skills and strategies for dealing with the uncertainty they will encounter during their professional careers (moderator: reflective learning). The longitudinal practice of reflection provides learners with an opportunity to contemplate and manage the uncertainty associated with developing and maintaining their professional identity. Physiotherapists are expected to practise ‘as reflective practitioners, self-directed learners … and engage in critical reflection … throughout their career’ (Physiotherapy Board of Australia & Physiotherapy Board of New Zealand, 2024, p. 20).
Physiotherapy research commonly reports the use of frameworks that scaffold reflective skills, such as those developed by David and Alice Kolb (Kolb & Kolb, 2013) and Gibbs (1981, 1988), with written reflection most likely to be used in education contexts (Ziebart & MacDermid, 2019). This activity, which is delivered across the first year of the course (moderator: low subject proficiency), aims to scaffold reflective practice skill development (moderator: reflective learning) by providing learners with structured reflective questions that unfold across the year (moderator: scaffolding uncertainty), thus following their transition from course commencement to later preclinical stages in their professional identity development.
Facilitator Guide
In the authors’ context, reflections in the early years of the physiotherapy course are typically formative tasks that are compulsory but ungraded (moderator: open pedagogy). They may be submitted in various formats, such as written, video, other visual, or audio, to allow students to explore reflective practice in different ways (moderator: flexible assessments). Educators review all reflections and provide group feedback (moderators: expert guidance, anonymity). This strategy keeps the feedback workload manageable for educators, prevents students from feeling judged on their reflections (moderator: pastoral care), and helps mitigate the risks of submissions becoming depersonalised and students submitting content that they feel will get them ‘good marks’ rather than personally meaningful content (moderator: merit-minded). Feedback provided after each reflection is a summary statement to all students highlighting the shared themes identified by educators. The statement may also suggest how students can deal with common issues raised in the reflections or how to strengthen reflective practice skills (moderator: reflective practice). Although written feedback is provided in summary form, reviewing all reflections is necessary, allowing staff to identify individuals who may be struggling or to flag areas of concern. These are followed up directly in person (moderator: pastoral care).
Facilitating the longitudinal reflective practice activity requires commitment from the education team across a defined period, such as a semester, an entire year, or multiple years. The number of educators needed depends on how many students contribute and how frequently reflections are submitted and reviewed. To keep the load manageable for both learners and educators, the quality of the reflections rather than their length is emphasised in learner instructions and educator training.
Learners also analyse their reflective practice as part of the educational strategy (moderator: capacity for reflection). They submit reflections and then review them later in the semester, submitting reflections on the earlier reflections, to identify how their reflective practice skills have developed. This gives students insights into their development over time and highlights areas for reflection skill improvement. Educators review the reflections and provide summary feedback to the cohort about the quality of the insights about their reflective practice. This creates an asynchronous dialogue with students, who contribute to the feedback conversation.
The chapter authors find the areas in which learners struggle most commonly are in adopting an appropriate writing style (i.e., navigating between a formal, ‘academic’ and an informal, personal reflective style) and being reflective rather than descriptive – or, if using Driscoll’s model (Driscoll & Teh, 2001), not concentrating enough on the so what? and now what? and focussing too much on the what? reflection elements. These areas can be strengthened via the summary written feedback, which may also include some simple worked examples, and via increased familiarity and practice gained through performing targeted activities and exercises.
The activities described below are elements of a purposefully planned, vertically integrated personal and professional development theme. The curriculum allows students to develop and enhance their reflective practice skills by focusing on contemporaneous content and events. The activities link to the skills required to manage uncertainties from course commencement to graduation. Thus, the activities described are delivered at opposite ends of the course and demonstrate how reflective practice skills can be progressed with increasingly sophisticated curriculum content. This allows students to apply reflective practice skills to navigate uncertainty relevant to their stage of learning (moderator: scaffolding uncertainty). The activities also share an underlying theme of transition (moderator: subject proficiency). Example 1 is delivered when students enter the physiotherapy program (and, for some, university study). It was designed to allow students to formally apply reflective practice skills as they are introduced into the curriculum. The tasks are also carefully scheduled at critical points in the semester and provide teaching staff with important feedback on overall cohort performance while allowing targeted support to be offered to struggling students. Example 2 is delivered at the transition point when students graduate from the program and enter the professional workforce.
Activity
Example 1: First Year
Early in the first year of the course, learners start with theoretical instruction through an interactive online module that outlines the what?, how?, and why? of reflective practice and formal models of reflection, such as those described by Gibbs (1988) and Driscoll (Driscoll & Teh, 2001). Students put this content into practice via a mandatory but ungraded multipart written reflective portfolio. Given their lack of clinical professional experience at this point, students are asked to submit written reflections on relevant contemporaneous themes:
Transition In Week 4, students reflect on their transition into the physiotherapy program from school, other studies, or the workplace.
Participation In Week 8, students reflect on how well they engage in class, apply to their study, and incorporate improvement plans (as needed).
Performance In Week 11, after submitting short, clinical, skill-based video tasks, students reflect on their performance and identify their development across the semester, along with ongoing strategies for improvement.
These early tasks allow students to develop critical reflection skills by reflecting on the uncertainty associated with their first experiences of studying physiotherapy (moderator: low subject proficiency). These tasks use a format relevant to their stage of education (moderator: scaffolding uncertainty). As students progress through the program, tasks are focussed more on the performance of new and increasingly complex clinical skills (albeit not yet in a clinical setting) (moderator: uncertainty dress rehearsal), with reflection on performance not only guided by teaching staff but also encouraged through a same-level peer-to-peer approach (moderator: diverse teamwork), facilitated by the provision of purposefully developed performance checklists acting as structured feedback tools (moderator: expert guidance). One of the tasks is a video-based self-reflection on clinical skills that continues across the program’s first two years and is further enhanced by staff identifying and posting (with consent) ‘clips of the week’ that exemplify a high-performance standard (moderator: expert guidance). Students are asked to view both their submission(s) and the ‘clips of the week’ and to reflect on what they did well, what their peers did well, areas for improvement, and strategies for ongoing development (moderator: capacity for reflection). The feedback received through this process helps to allay uncertainty associated with self-appraisal of performance.
Other first-year activities that support a longitudinal approach to reflective practice are integrated into the whole program. For example, a ‘reflection station’ is introduced after an objective structured clinical examination activity, which prompts students to write a reflection on their performance (moderator: capacity for reflection). This is combined with written examiner feedback to promote self-awareness of communication, clinical skill performance, and general examination management and to help students identify strategies for improvement (moderator: expert guidance). In later years of the program, students receive a structured, written learning needs form, which is used in discussions with clinical educators while on placement(s). At the end of clinical placement blocks, small-group debrief sessions are facilitated by student coordinators on clinical sites to promote reflective practice in authentic workplace settings, modelling the clinical supervision practices those students will transition into as new graduates (moderators: uncertainty dress rehearsal, career value).
Example 2: Final Year
Reflective practice across the course culminates in a significant written summative essay at the end of the final year (moderator: high subject proficiency). The essay brings together critical elements of reflective practice, as described by McLeod et al. (2015, p. 144), by asking students to ‘pay attention to what is occurring in practice’ and ‘thoughtfully consider the impact of personal, cultural and social assumptions on experiences’.
Students choose a topic based on an experience from a final-year clinical placement on which to write 3500 words. The topic may be clinical or non-clinical but must relate to physiotherapy practice (moderator: career value) and should be explored from multiple angles. The essay needs to include an integrated synthesis of research evidence gathered through a rapid review of relevant information sources, including (but not limited to) conversations held with patients and clinicians during clinical placements. The rapid review findings should then be compared with the students’ observed experience. Finally, students must reflect on factors that contributed to their observed experience (positively or negatively) and discuss implications for their future practice (moderators: uncertainty dress rehearsal, career value). This task was designed to replicate some of the complexities of professional practice when a clinician must bring together the domains of ‘propositional knowledge’, ‘professional craft knowledge’, and ‘personal knowledge’, as suggested by Higgs et al. (2008). It represents the significant development in reflective sophistication that students can achieve compared to some of the relatively simple and prescriptive yet important tasks they undertake at the start of their studies (moderator: subject mastery).
Impact
These activities have been evaluated experientially and play a crucial role in developing skills assessed across the physiotherapy curriculum, through objective structured clinical examinations in the campus-based years; through clinical placements in later years, as part of the assessment of physiotherapy practice (Dalton et al., 2011); and through the Example 2 activity. The last of these is a formally graded written piece in which students demonstrate the syntheses of their reflective practice skills developed in previous years. It has prompted student-led exploration of themes such as workplace professionalism, patient confidentiality, informed consent, and, most commonly, the importance of continuing professional development and staying current with emerging knowledge for practising clinicians. These themes are further explored in a workshop format during the students’ final classes, providing additional opportunities to discuss the critical elements of clinical practice that students have identified in their reflections and the importance of embedding reflection into their professional careers.
Adaptations and Summary
The activities fit into a more extensive theme of personal and professional development, for which students undertake various tasks that draw from and link with the broader curriculum. As the structure and content of the broader curriculum have changed and adapted, so have the related reflective practice tasks. Adaptations have included increased use of technology, such as video reviews; modification of tasks to focus more on pastoral care during the pandemic; and responses to economic impacts on the wider educational institution (i.e., reshaping tasks to decrease marker burden while maintaining desired learning outcomes).
Exemplar Activity 2: Peer Simulation
Activity Origin
Simulation in health professions education is well documented as a way of developing professional practice skills (Bienstock & Heuer, 2022; Cook et al., 2018). One form of this is peer simulation, in which student peers are trained to portray roles, including that of the patient, in hypothetical scenarios (Dalwood et al., 2020). (It is also referred to as destabilisation in cultural literacy pedagogy; see Chapter 7.) Peer simulation can positively impact students’ communication and empathy development (Dalwood et al., 2020). In the Department of Physiotherapy at Monash University, students undertake peer simulation tasks over nine weeks in the third year, before commencing their intensive clinical placement blocks. The pre-clinical peer simulation sessions focus on applying assessment, treatment, communication, clinical reasoning, and decision-making skills to realistic clinical scenarios. The students then undertake a final peer simulation in the weeks before their course completion (moderator: high subject mastery), which uses the now-familiar format to introduce more complex and unanticipated scenarios.
Sources of Uncertainty
The final simulation experience was designed to allow students to encounter realistic professional, ethico-legal, and interpersonal conflict uncertainties by taking on the role of a new graduate physiotherapist in a complex situation (moderator: uncertainty dress rehearsal). The scenario was developed to stimulate reflection (moderator: reflective learning) and conversation about challenging and unexpected experiences that new graduate physiotherapists may encounter. The sources of uncertainty in this activity are twofold. Firstly, the patient (Akira) presents with an unexpected new injury. Secondly, the consultation turns to ethico-legal issues, a departure from what students experienced in prior simulations. However, to the students playing the role of the new graduate physiotherapist, the simulation preparation materials (patient notes from previous physiotherapy appointments) look the same as those used in the simulations undertaken earlier in the course (moderators: scaffolding uncertainty, high subject proficiency), which were for standard assessments and treatments. It is not until the simulation commences that they realise the scenario is unlike those they experienced before.
Students playing the role of the physiotherapist enter the treatment space expecting to treat 17-year-old Akira’s knee injury. They must adapt quickly when they realise that Akira has a new injury and that an unexpected additional person is present: Akira’s parent Rae. The student playing the parent role is instructed beforehand to ‘take over’ the consultation, speaking for Akira. The physiotherapist needs to determine how to restore the situation as a patient-centred consultation while also managing Rae’s apparent frustration and anger and Akira’s relative silence in the interaction. The physiotherapist also becomes aware that the parent inaccurately believes that the new injury will be included with the initial WorkCover compensable injury and should be added to the pre-existing claim. At this point in the scenario, the physiotherapist must try to navigate the ethico-legal issues at play.
Facilitator Guide
In the scenario, one student plays the role of 17-year-old Akira; another, Akira’s parent Rae; and a third, a new graduate physiotherapist. Akira has seen a physiotherapist twice previously in a private practice setting for a compensable, work-related injury to their knee. Akira’s parent is unexpectedly present at this follow-up consultation. The physiotherapist is seeing Akira for the first time and is initially unaware that they have a new ankle injury, sustained while out at a nightclub on the weekend. This injury has no relationship to the original compensable injury; however, Rae demands that the physiotherapist add the new injury to the existing compensable claim. The new graduate must navigate the ethical dilemma posed by the parent’s request to commit fraud before addressing physical injury management (moderator: uncertainty dress rehearsal). For an overview of the roles in this activity, please click on each element in the accordion.
The learning objectives for this simulation are listed below; they are quoted from the key competencies within the Australian and Aotearoa New Zealand physiotherapy practice thresholds (the competency numbers are included for reference). After this activity, it is expected that students will be able to:
1.1 plan and implement an efficient, effective, culturally responsive and client-centred physiotherapy assessment
1.2 involve the client and relevant others in the planning and implementation of safe and effective physiotherapy using evidence-based practice to inform decision-making
1.3 review the continuation of physiotherapy and facilitate the client’s optimal participation in their everyday life
1.4 advocate for clients and their rights to health care
2.1 comply with legal, professional, ethical and other relevant standards, codes and guidelines
2.2 make and act on informed and appropriate decisions about acceptable professional and ethical behaviours
…
3.1 use clear, accurate, sensitive and effective communication to support the development of trust and rapport in professional relationships with the client and relevant others
…
3.3 deal effectively with actual and potential conflict in a proactive and constructive manner
…
4.5 recognise situations that are outside their scope of expertise or competence and take appropriate and timely action
5.1 engage in an inclusive, collaborative, consultative, culturally responsive and client-centred model of practice
…
6.1 use education to empower themselves and others
6.2 seek opportunities to lead the education of others, including physiotherapy students, as appropriate, within the physiotherapy setting. (Physiotherapy Board of Australia & Physiotherapy Board of New Zealand, 2015, pp. 13–14)
Activity
The scenario comprises three roles played by students (moderator: uncertainty dress rehearsal). Students are placed in groups of three (moderator: diverse teams), the groups are distributed across the available rooms, and multiple simulations take place concurrently. The setting is a private practice; each group requires an area representing a treatment space, in which are a treatment plinth and a chair. In the authors’ context, up to 10 groups are allocated to a single room, a minimum of two tutors are present in each room of students, and the lead educator oversees the entire activity in a coordinating role. The phases and activities for educators and students are outlined in Table 15.1.
Table 15.1: Phases in a Peer Simulation Activity for Educators and Learners
| Pre-Briefing (20 or 30 mins) |
Simulation (30 or 40 mins) |
Debriefing (45 mins) |
|
|---|---|---|---|
| Educators | The lead educator coordinates arrival, group, role, and preparation room designations. Tutors are spread across the preparation rooms. |
The lead educator oversees all simulations. Tutors supervise several simulations in action and play the role of the senior colleague where required. |
The lead educator facilitates a debriefing session. Tutors provide feedback on their role as the senior colleague and feedforward strategies for new graduate practice. |
| Learners | Students prepare for their respective roles. In each group of three, one prepares for the new graduate physiotherapist, one for the patient, and one for the parent. | Students act out the simulation as directed in their instructions. | Students undertake small- and whole-group reflection activities and discussions with tutors and the lead educator. |
Ideally, the tutors staffing this simulation should have clinical experience to coach the students on realistic portrayals of the patient and parent roles during the preparation time. Additionally, the tutors must be able to carry out authentic interactions as the senior colleague of the new graduate physiotherapist, to help them navigate the complexities of the interaction, but only if called upon (moderator: expert guidance). The lead educator also requires debriefing facilitation skills.
Tutor Preparation
To prepare for the simulation, tutors receive written information one to two weeks before the session. They also have access to the role portrayal information that the learners will be given on the day.
Before the simulation, the coordinating educator allocates students to groups and roles (moderator: setting clear roles). For role preparation, there should be one or two educators for each group of students. Tutor input should be available for any questions about interpreting the notes (moderator: expert guidance).
Tutor Instructions
The patient is Akira, a 17-year-old apprentice plumber, attending physiotherapy at an outpatient clinic for a Grade 1 medial ligament sprain of the right knee, sustained in a workplace accident. They now have a new ankle injury, sustained while inebriated on Saturday night. Rae, Akira’s parent, is also attending the appointment and will request that the new graduate physiotherapist put the new injury through on the WorkCover claim and add a request to the claim for funding for natural supplements. Students will be portraying the roles of the new graduate physiotherapist, Akira, and Rae. Those portraying the physiotherapist will have read notes from the patient’s previous two physiotherapy treatment sessions for their knee and will have been instructed to provide appropriate intervention to Akira to ‘manage their presenting issues’. They will be unaware both of the new injury and that Rae will be present.
Student Preparation
Details about the roles are not released to students before the session, to protect the simulation’s integrity and to maintain the unexpected element in the consultation. Two rooms are required for role preparation. In one room, students with the role of the new graduate physiotherapist read through the patient’s previous physiotherapy treatment notes, preparing for what they anticipate will be a standard follow-up appointment for the work-related knee injury. In the other room, students with the roles of the patient (Akira) and the patient’s parent (Rae) prepare using a script, video (see Video 15.1 and read the transcript), tutor training, and guided rehearsal. Students have 20 minutes to learn their roles.
Video 15.1 Akira and Rae in the Waiting Room © Monash University is licensed under a Creative Commons Attribution-NonCommercial 4.0 license
New Graduate Physiotherapist Role Instructions
You are a new graduate physiotherapist working in a busy private practice. There is also a senior physiotherapist on this premises available for advice if required. You are seeing Akira, a 17-year-old apprentice plumber. Ten days ago, they sustained a Grade 1 medial ligament sprain of their right knee in a fall on an uneven worksite. WorkCover has approved funding for the treatment of the injury. Akira has been seen twice (Days 1 and 5 post-injury) by another physiotherapist at the clinic. Akira has arrived for their third scheduled appointment.
Read the physiotherapy notes from Akira’s previous two appointments, then provide an appropriate intervention to Akira to manage their presenting issues.
Patient Role Instructions
You are Akira, a 17-year-old apprentice plumber, and you sustained a Grade 1 medial ligament sprain of your right knee 10 days ago at work, when you were carrying pipes across an uneven worksite, and you fell and twisted your knee awkwardly. You saw a physiotherapist on Days 1 and 5 post-injury, and your knee injury has been progressing well (decreased pain and swelling, walking with a slight limp only). WorkCover has approved funding for the treatment of your knee injury, and you have been doing light, modified duties at work (helping the boss’s partner with invoices, accounts, and stock ordering, mostly seated, minimal walking or weight-bearing required).
It is Monday, and you are attending your next scheduled appointment, which is at the same clinic but with a different physiotherapist from the one you saw previously. However, you now have an additional injury: on Saturday night, you were out partying and fell over in the street, severely twisting your left ankle, but you continued to walk and dance. Now, the ankle is extremely painful, but your right knee is okay. You are limping heavily, have significant bruising over the lateral surface of your ankle, and all ankle movements are painful.
Your parent (Rae) is attending the appointment with you. They are very keen to have this new injury added to your WorkCover claim and for the physiotherapist to request funding for natural supplements to aid the healing process. Your parent is irate about the injury to your ankle over the weekend and is in a terrible mood. You are embarrassed to have them accompany you to this appointment, but to avoid provoking them further, you are going along with the plan.
Parent Role Instructions
You are the parent of 17-year-old Akira, who sustained a grade one medial ligament sprain of their right knee ten days ago at work. Akira is an apprentice plumber, and the injury happened when they were carrying pipes across an uneven worksite, and they fell and twisted their knee awkwardly. Akira saw the physio on day one and day five post-injury (without you), and their knee injury was progressing well – decreased pain and swelling, walking with a slight limp only. WorkCover has approved funding for treating Akira’s knee injury. They have been doing light, modified duties at work – helping the boss’ partner with the invoices, accounts and stock ordering– mostly seated, minimal walking/weight bearing required.
You are attending Akira’s next appointment on Monday. However, Akira now has an additional injury – on Saturday night, they were out partying and fell over in the street, severely twisting their left ankle. They did not feel much pain on Saturday night due to the amount of alcohol they had consumed and continued to walk and dance. Their left ankle is now very painful – their right knee is okay, fortunately. They are limping heavily and have significant bruising over the lateral surface of the ankle. All ankle movements are extremely painful. You are attending the appointment with them as you are angry and frustrated with Akira. Things are tight financially, and you want to ensure the physiotherapist includes treatment for this new injury on the existing WorkCover claim. The way you see it, if it wasn’t for Akira having hurt their knee at work in the first place, they might not have twisted their ankle on Saturday night. You also want the physiotherapist to add the cost of the natural supplements you have purchased to speed up Akira’s recovery to their WorkCover claim. The physio doesn’t know anything about the new injury yet (they think Akira is coming unaccompanied for a review appointment for their knee).
Simulation
The simulation begins with the students portraying Akira and Rae as seated in the treatment space when the student, who is playing the role of the new graduate physiotherapist, enters. Each simulation unfolds in an unscripted and uncertain manner, and thus varies from delivery to delivery (moderator: open pedagogy). However, the execution of this simulation is consistent with the nature of simulations used more widely in health professions education (Dalwood et al. 2020).
Following the 20 minutes of preparation, the simulation runs for 40 minutes. However, within the hour of the preparation and simulation, there is potential for flexibility with timings. Students accustomed to peer simulation will be adequately skilled at getting into character with 20 minutes of preparation, but for those with less experience, a longer preparation time of 30 minutes could be made available, to provide more rehearsal time for patients and parents, followed by a shorter simulation time, of 30 minutes. Relative accuracy in the portrayals of the patient and parent, and staying in character, is critical to the success of this (and any) peer simulation session, so timing adjustments are warranted to ensure this.
Students are prompted during the preparation time that tutors playing the role of senior colleagues will be in the room during the simulation and available for questions, consultation, or advice (moderator: expert guidance). During the simulation, these senior colleagues are visible at all times to the physiotherapist, may introduce themselves to Akira and Rae, and may also check in with the physiotherapist to see how they are doing and whether they require any assistance.
Debriefing
Immediately following the simulation, students and educators gather in a debriefing room away from the simulation space. The students should sit in their simulation groups of three. The lead educator runs the post-simulation debriefing. Students are reminded that debriefing should be safe and non-judgemental (moderator: psychological safety) and are asked to abide by the following principles during the session:
- Keep to the question asked.
- Answer based on your learning only (i.e., not on what you learned about your peers’ skills).
- Consider the perspectives of the patient, parent, and physiotherapist.
The lead educator divides the simulation learning objectives (competencies listed above) between the students who work in self-selected groups. The debrief then begins. It includes three components, each lasting 15 minutes:
- Students discuss whether they achieved their allocated learning objectives in their simulation. They need to decide what went well in this regard, what didn’t go well, and the reasons for these outcomes. They should also note two key points that arise during their discussion (moderators: reflective learning, capacity for reflection).
- Each small group presents the outcomes of their discussion to the whole group.
- Tutors give feedback on their role as senior colleague (moderator: expert guidance), highlighting to students the value and importance of asking questions and seeking assistance if unsure (moderator: career value). Tutors also provide feedforward strategies for asking questions (e.g., stating what the new graduate already knows or are thinking about the case and being transparent about which aspect they require assistance with).
Impact
An experiential evaluation of this activity was conducted, and in debriefing sessions with students, three main sources of uncertainty for learners were identified, which are outlined, with subthemes, in the accordion.
Adaptations and Summary
This activity incorporates several authentic elements associated with clinical practice in a simulation scenario that presents learners with the experience of uncertain situations they may encounter as healthcare professionals in their first year of practice. It provides educators with confidence that learners have gained critical competencies before they graduate. Learners who have participated in this activity have demonstrated that they can successfully navigate complex scenarios and related uncertainty to manage authentic clinical contexts.
The scenario used in this simulation was based on a real patient case and was developed by the education team and peer reviewed by a private practice clinician for accuracy. It could be adapted to different physiotherapy or health professions contexts by using other real-life scenarios that present health professions students with unanticipated interpersonal and ethico-legal challenges.
Conclusion
This chapter presents two activities that apply to physiotherapy education but are also applicable across health professions. The use of reflection in a longitudinal manner with accompanying theoretical models, templates, and structures which are adapted as students develop their reflection skills can be used to support the professional identity development of students across health professions education contexts. Similarly, the use of peer simulation early in a health professions curriculum to develop assessment and management skills allows educators to revisit the format at the end of the curriculum to introduce scenarios that deliberately expose students before they graduate to uncertainties they are likely to encounter in real-world practice. This prepares health professions students for their transition to practice by equipping them with the critical reflection and practice competencies they need to navigate the uncertainty inherent in a health professions career.
References
Almond, A., Zou, Y., & Forbes, R. (2021). Navigating diagnostic uncertainty in musculoskeletal practice: The perspectives and experiences of new graduate physiotherapists. Musculoskeletal Science and Practice, 52, Article 102354. https://doi.org/10.1016/j.msksp.2021.102354
Australian Physiotherapy Association. (2024). We’ve been a profession for over 110 years. https://australian.physio/aboutus/our-history
Barradell, S. (2017). Moving forth: Imagining physiotherapy education differently. Physiotherapy Theory & Practice, 33(6), 439–447. https://doi.org/10.1080/09593985.2017.1323361
Bhise, V., Rajan, S. S., Sittig, D. F., Morgan, R. O., Chaudhary, P., & Singh, H. (2018). Defining and measuring diagnostic uncertainty in medicine: A systematic review. Journal of General Internal Medicine, 33(1), 103–115. https://doi.org/10.1007/s11606-017-4164-1
Bienstock, J., & Heuer, A. (2022). A review on the evolution of simulation-based training to help build a safer future. Medicine, 101(25), Article e29503. https://doi.org/10.1097/md.0000000000029503
Budtz, C. R., Rønn-Smidt, H., Thomsen, J. N., Hansen, R. P., & Christiansen, D. H. (2022). Primary care physical therapists’ experiences when screening for serious pathologies among their patients: A qualitative study. PTJ: Physical Therapy & Rehabilitation Journal, 102(5), Article pzac026. https://doi.org/10.1093/ptj/pzac026
Cook, D. A., Andersen, D. K., Combes, J. R., Feldman, D. L., & Sachdeva, A. K. (2018). The value proposition of simulation-based education. Surgery, 163(4), 944–949. https://doi.org/10.1016/j.surg.2017.11.008
Costa, N., Mescouto, K., Dillon, M., Olson, R., Butler, P., Forbes, R., & Setchell, J. (2022). The ubiquity of uncertainty in low back pain care. Social Science & Medicine, 313, Article 115422. https://doi.org/10.1016/j.socscimed.2022.115422
Dalton, M., Davidson, M., & Keating, J. (2011). The Assessment of Physiotherapy Practice (APP) is a valid measure of professional competence of physiotherapy students: A cross-sectional study with Rasch analysis. Journal of Physiotherapy, 57(4), 239–246. https://doi.org/10.1016/S1836-9553(11)70054-6
Dalwood, N., Bowles, K. A., Williams, C., Morgan, P., Pritchard, S., & Blackstock, F. (2020). Students as patients: A systematic review of peer simulation in health care professional education. Medical Education, 54(5), 387–399. https://doi.org/10.1111/medu.14058
Ditwiler, R. E., Swisher, L. L., & Hardwick, D. D. (2021). Professional and ethical issues in United States acute care physical therapists treating patients with COVID-19: Stress, walls, and uncertainty. PTJ: Physical Therapy & Rehabilitation Journal, 101(8), Article pzab122. https://doi.org/10.1093/ptj/pzab122
Driscoll, J., & Teh, B. (2001). The potential of reflective practice to develop individual orthopaedic nurse practitioners and their practice. Journal of Orthopaedic Nursing, 5(2), 95–103. https://doi.org/10.1054/joon.2001.0150
Edwards, I., Wickford, J., Adel, A. A., & Thoren, J. (2011). Living a moral professional life amidst uncertainty: Ethics for an Afghan physical therapy curriculum. Advances in Physiotherapy, 13(1), 26–33. https://doi.org/10.3109/14038196.2010.483015
Fay, D., Bordenave, L. M., & Wilkinson, T. (2019). Virtual grand rounds: A curricular model for translating evidence-based practice from the classroom to the clinic. Journal of Physical Therapy Education, 33(4), 289–297. https://doi.org/10.1097/JTE.0000000000000098
Gibbs, G. (1981). Teaching students to learn: A student-centred approach. Open University Press.
Gibbs, G. (1988). Learning by doing: A guide to teaching and learning methods. Oxford Brooks University.
Hartholt, E., Vuoskoski, P., & Hebron, C. (2020). Physiotherapists’ lived experiences of decision making in therapeutic encounters with persons suffering from whiplash-associated disorder: A hermeneutic phenomenological study. Musculoskeletal Care, 18(4), 519–526. https://doi.org/10.1002/msc.1496
Higgs, J., Jones, M. A., Loftus, S., & Christensen, N. (2008). Clinical reasoning in the health professions (3rd ed.). Elsevier.
Jensen, G. M., & Richert, A. E. (2005). Reflection on the teaching of ethics in physical therapist education: Integrating cases, theory, and learning. Journal of Physical Therapy Education, 19(3), 78–85. https://doi.org/10.1097/00001416-200510000-00011
Kolb, A. Y., & Kolb, D. A. (2013). The Kolb learning style inventory 4.0: A comprehensive guide to the theory, psychometrics, research on validity and educational applications. Experience Based Learning Systems. https://learningfromexperience.com/downloads/research-library/the-kolb-learning-style-inventory-4-0.pdf
Markee, M., & Sebelski, C. (2022). Preparing for the future: A practice-based approach for entrepreneurship education in health professions. Journal of Allied Health, 51(3), 172–179. https://www.ingentaconnect.com/contentone/asahp/jah/2022/00000051/00000003/art00003
McLeod, G., Barr, J., & Welch, A. (2015). Best practice for teaching and learning strategies to facilitate student reflection in pre-registration health professional education: An integrative review. Creative Education, 6(4), 440–454. https://doi.org/10.4236/ce.2015.64044
Peterson, S., Miciak, M., Kleiner, M., Woolf, J., & Davenport, T. (2023). Drawing a ‘perfect circle’: How clinicians can become better communicators. Journal of Orthopaedic & Sports Physical Therapy, 53(10), 579–584. https://doi.org/10.2519/jospt.2023.11917
Physiotherapy Board of Australia & Physiotherapy Board of New Zealand. (2015). Physiotherapy practice thresholds in Australia and Aotearoa New Zealand. Australian Physiotherapy Council. https://webarchive.nla.gov.au/awa/20170216194045/https://physiocouncil.com.au/media/1020/physiotherapy-board-physiotherapy-practice-thresholds-in-australia-and-aotearoa-new-zealand-6.pdf
Physiotherapy Board of Australia & Physiotherapy Board of New Zealand. (2024). Physiotherapy practice thresholds in Australia and Aotearoa New Zealand. Australian Physiotherapy Council. https://cdn.physiocouncil.com.au/assets/volumes/downloads/Physiotherapy-Board-Physiotherapy-practice-thresholds-in-Australia-and-Aotearoa-New-Zealand.PDF
Stearns, Z. R., Carvalho, M. L., Beneciuk, J. M., & Lentz, T. A. (2021). Screening for yellow flags in orthopaedic physical therapy: A clinical framework. Journal of Orthopaedic and Sports Physical Therapy, 51(9), 459–469. https://doi.org/10.2519/jospt.2021.10570
Stephens, G. C., Sarkar, M., & Lazarus, M. D. (2022). Medical student experiences of uncertainty tolerance moderators: A longitudinal qualitative study. Frontiers in Medicine, 9, Article 864141. https://doi.org/10.3389/fmed.2022.864141
Sturm, A., Edwards, I., Fryer, C. E., & Roth, R. (2023). (Almost) 50 shades of an ethical situation – International physiotherapists’ experiences of everyday ethics: A qualitative analysis. Physiotherapy Theory and Practice, 39(2), 351–368. https://doi.org/10.1080/09593985.2021.2015812
Swisher, L. L. (2021). 23rd Pauline Cerasoli lecture educating for professionalism: The science of caring. The art of healing. Journal of Physical Therapy Education, 35(4), 260–269. https://doi.org/10.1097/JTE.0000000000000201
World Physiotherapy. (2019). Description of physiotherapy: Policy statement. https://world.physio/sites/default/files/2020-07/PS-2019-Description-of-physical-therapy.pdf
World Physiotherapy. (2021). Physiotherapist education framework. https://world.physio/sites/default/files/2021-07/Physiotherapist-education-framework-FINAL.pdf
Ziebart, C., & MacDermid, J. C. (2019). Reflective practice in physical therapy: A scoping review. Physical Therapy, 99(8), 1056–1068. https://doi.org/10.1093/ptj/pzz049
Looking back on an experience or scenario and exploring the thoughts, feelings and actions taken with the purpose of learning from the experience, so that learnings may be applied to future scenarios. May aid in the development of uncertainty tolerance.
A simulation activity where student peers are trained to portray roles, including the patient role, during simulated scenarios.
About the authors
name: Melanie Farlie, BPhysio, PGCPhysio, GCHPE, PhD FHEA, FANZAHPE, APA Titled Research Physiotherapist
institution: Monash University
website: https://research.monash.edu/en/persons/melanie-farlie
Melanie is a Senior Lecturer in the Department of Physiotherapy, and Education Research Fellow in the Monash Centre for Scholarship in Health Education (MCSHE), in the Faculty of Medicine, Nursing and Health Sciences at Monash University, Victoria, Australia. Balance exercise prescription was the topic of her PhD, and Dr Farlie has led the development and validation of the world’s first objective measure of balance exercise intensity: the Balance Intensity Scale. Dr. Farlie is regularly engaged to deliver her innovative and interactive scale training workshops to health professionals nationally and internationally.Her research interests include: support for clinical educators and students in workplace settings and the development of evidence informed clinical reasoning skills for exercise prescription.
Looking back on an experience or scenario and exploring the thoughts, feelings and actions taken with the purpose of learning from the experience, so that learnings may be applied to future scenarios. May aid in the development of uncertainty tolerance.
A simulation activity where student peers are trained to portray roles, including the patient role, during simulated scenarios.
name: Michael Storr, BPhysio, MEd
institution: Monash University
website: https://research.monash.edu/en/persons/michael-storr/publications/
Michael is a Physiotherapist, Associate Professor (Education Focused) and Course Director of the Bachelor of Physiotherapy (Honours) program in the Department of Physiotherapy in the Faculty of Medicine, Nursing and Health Sciences at Monash University, Victoria, Australia. He is a passionate educator with a strong interest in student engagement and has previously been awarded the Dean’s Award for Excellence in Education and received a Vice Chancellor’s Citation for Outstanding Contribution to Student Learning.
Looking back on an experience or scenario and exploring the thoughts, feelings and actions taken with the purpose of learning from the experience, so that learnings may be applied to future scenarios. May aid in the development of uncertainty tolerance.
A simulation activity where student peers are trained to portray roles, including the patient role, during simulated scenarios.
name: Narelle Dalwood, B.App.Sc (Physio), Grad Dip Neuroscience
institution: Monash University
website: https://research.monash.edu/en/persons/narelle-dalwood
Narelle is a Neurological Physiotherapist and Senior Lecturer in the Department of Physiotherapy in the Faculty of Medicine, Nursing and Health Sciences at Monash University, Victoria, Australia. Her research focuses on the use of peers to portray the patient role during simulation based learning in physiotherapy education.
Looking back on an experience or scenario and exploring the thoughts, feelings and actions taken with the purpose of learning from the experience, so that learnings may be applied to future scenarios. May aid in the development of uncertainty tolerance.
A simulation activity where student peers are trained to portray roles, including the patient role, during simulated scenarios.
