PHYSIOTHERAPY CANADA

Yeldon et al. Exploring the Experience of Discussing Student Performance at the Mid- and Final Points of the Clinical Internship 241 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 Clinical education is a vital component of preparing the form has two Summative Comments sections in which students to enter the physiotherapy (PT) profession.1 the CI notes a student’s overall strengths and areas need- Throughout their clinical education, students are assessed ing improvement. on their ability to perform the required clinical skills and behaviours necessary for competent PT practice. Sum- Feedback is a necessary and interactive process, and mative performance assessments include a standardized it can benefit both the CI and the student within and assessment tool, completed by a clinical instructor (CI), beyond the realm of teaching and learning. For students, which is then sent to the director of clinical education receiving accurate and timely feedback helps them de- or academic coordinator of clinical education at a stu- velop their clinical practice and directs their attention to dent’s university. Formative performance assessments certain skills and behaviours.4 It can also contribute include the student’s self-assessment, completed using to increased motivation and self-esteem.10–12 Feedback the same standardized tool. Exchanging both completed aims to provide learners with insight into their perfor- assessment tools facilitates an important discussion of mance, and it ideally occurs both informally and formally.4 performance assessment between the CI and the student. Informal feedback includes on-the-spot comments and general conversation about performance, both of which Performance assessment discussions between the stu- are crucial to a student’s clinical learning experience.4 dent and the CI are used to structure the clinical expe- Formal feedback is defined as a planned and intentional rience, outline performance expectations, and evaluate process.13 The ACP is a tool for exchanging formal feed- instructional effects.2,3 The CI’s assessment identifies back. the student’s strengths and areas for improvement, motivates the student, promotes learning, and assesses CIs believe that verbal feedback exchanged between the transfer of knowledge.3 For students, these discus- the CI and student can enhance their own communica- sions serve to outline expectations and define goals. The tion and interpersonal skills while also fostering a sense importance of establishing these goals extends past the of personal satisfaction.10,14 In addition, a study explor- current internship into future placements and entry into ing the perceptions of CIs using the PT–CPI found that clinical practice. the comments were considered the most useful part of the assessment because they initiated a conversation BACKGROUND between the CIs and their students.2 This demonstrates Clinical internships give PT students opportunities to that there are multiple methods of feedback delivery— such as verbal, written, formal, and informal—that can make connections among academic knowledge, course- be valuable to furthering student and CI learning. For work, and clinical practice. These experiences engage the purpose of this study, we defined a valuable perfor- them in a real-life learning process that includes acquir- mance assessment discussion as one that motivates the ing and improving specific skill sets.4 Internships are student and promotes learning by identifying areas of equally as important for providing an opportunity for strength and areas needing improvement, outlines perfor- professional socialization, a term used to describe the mance expectations, and assesses the transfer of knowl- practice of gaining a better understanding of the culture edge from classroom to practice. of a profession, its values and attitudes, and its accepted behaviours.5,6 Thus, clinical education experiences are Clynes and Raftery4 examined the performance assess- foundational because they require students to go beyond ment discussions that took place between nursing stu- applying classroom knowledge in a clinical setting and dents and their preceptors, and they identified the effec- gain a practical and comprehensive understanding of tive delivery of feedback as a multi-factorial process. the PT profession.4 First, it was helpful for a CI to have an understanding of how a student was likely to respond to feedback. This In 2014, a standardized tool called the Canadian Phys- required the CI to assess the nature of the relationship iotherapy Assessment of Clinical Performance (ACP) was between him or her and the student. Second, setting up developed, and it is now being implemented in PT pro- a conducive physical environment was a significant part grammes across Canada to replace the American-based of the process. The authors concluded that feedback Physical Therapist Clinical Performance Instrument (PT– ‘‘should be given in a quiet, private environment [and CPI).7–10 During all internships, a student and a CI are that] an informal room layout will promote a two-way required to independently complete and then review an discussion of the student’s performances and should ACP on two occasions: at the internship’s midpoint and foster openness and honesty.’’4(p.408) The exchange should at its end. The ACP is organized into seven roles, each of be structured in a way that required the student to share which includes one or more key competencies outlined his or her self-assessment first because this would give by the Essential Competency Profile for Physiotherapists the CI an opportunity to assess the student’s ability in Canada.9 Each role includes a brief description, one to evaluate his or her own performance.15 Finally, the or many key competencies, and enabling competencies. CI should allocate sufficient time for discussion and A rating scale follows each key competency, and at the clarification. end of each role is a Comments section. The last page of

242 Physiotherapy Canada, Volume 70, Number 3 Table 1 Example of CI Coding Spreadsheet Quote from participant FG Interpretation/code(s) https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 ‘‘I think the summative comments in the end are the gist of it; that’s the stuff in CI-FG4 Summative comments are a beneficial, important part of my opinion that makes everything come together ’cause that’s where you can the discussion. point out all the specific issues. You can write it out in your own words, instead of A summary of the assessment in the CI’s own words it being guided. The guide reminds you of the things you need to focus on, but the A section not bound by the language or format of the tool end gives you the time to focus in with your own words.’’ The tool serves as a reminder. CI ¼ clinical instructor; FG ¼ focus group. PURPOSE Data collection The PT literature has limited research examining the We chose to conduct face-to-face, semi-structured essential features, challenges, and benefits of a perfor- FGs to explore the students’ and CIs’ experiences of the mance assessment discussion from the perspectives of mid- and final clinical performance discussions. Face- students and CIs. The purpose of this study was to ex- to-face FGs would provide an opportunity to draw out plore students’ and CIs’ experiences discussing clinical multiple viewpoints in a single session, and using open- performance at the mid- and final points of a clinical ended questions would allow unprompted exchanges internship. The objectives were to (1) identify why perfor- between the participants to occur. The goal was to create mance assessment discussions are valuable, (2) explore an open environment in which participants felt comfort- the role of each participant throughout the discussion, able expressing their ideas.16 (3) identify the challenges associated with these dis- cussions, and (4) explore the effect of the standardized Two investigators facilitated the student FGs, and two assessment tool on the discussion. After our analysis other investigators facilitated the CI FGs. A standard dis- of the data, we propose recommendations that could cussion guide was developed for each type of FG using help to promote a valuable performance assessment the four objectives of the study; it consisted of nine discussion. open-ended questions with appropriate probes to encour- age exchange among the participants. Each FG was audio METHODS recorded and then transcribed verbatim by one investi- gator in the research group. Study design This study used a qualitative descriptive design, con- Data analysis We used an inductive thematic analysis to analyze the sisting of student and CI focus groups (FGs) in the Greater Toronto Area from January to June 2016. This FG data; this type of approach is suitable for topics lack- study was approved by the Research Ethics Board of ing extensive literature and therefore applied to this the University of Toronto, and informed consent was study.17,18 Five investigators (JY, RW, JL, GA, SSG) partici- obtained from all participants. pated in a step-wise paper-and-pencil coding process that consisted of identifying the emerging ideas, assign- Participants ing codes, and discussing the overarching themes (see All students (excluding the student investigators) en- Table 1). The coding spreadsheet and themes were then used to determine patterns, agreements, and contradic- rolled in the Master of Science in Physical Therapy tions in the data. (MScPT) programme at the University of Toronto who had completed three of five caseload-carrying intern- RESULTS ships were eligible to participate. A minimum of three We conducted four student FGs consisting of 4 stu- internships was a selection requirement because students would be familiar with these discussions and would have dents each for a total sample of 16 students. We also different experiences to draw from. CIs were considered facilitated four CI FGs at four diverse practice sites: three eligible if they were registered physiotherapists in the FGs consisted of 3 CIs, and one FG consisted of 4 CIs for University of Toronto catchment area and had super- a total sample of 13 CIs. All students had used the ACP vised MScPT students between January 2015 and January three times before participating in the FG. Six CIs had 2016, when the ACP was used. To achieve diversity in the supervised between 1 and 5 students, and 5 CIs had sample, four different practice settings were selected for supervised more than 15 students. All CIs had used the the CI FGs: a hospital serving a pediatric population; an ACP at least once. The results of the data analysis are acute care hospital and a rehabilitation hospital, both presented below, organized into the four main objectives serving an adult population; and a private practice clinic. of the study.

Yeldon et al. Exploring the Experience of Discussing Student Performance at the Mid- and Final Points of the Clinical Internship 243 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 Why are performance assessment discussions valuable? (CI-FG4), ‘‘reaffirm the student is on the right track’’ (CI- FG1), ‘‘make a plan moving forward’’ (CI-FG2), and ‘‘set Students the expectations for the second half of the internship’’ Students in all FGs agreed that performance assess- (CI-FG3). The discussion at the end of the internship was used to ‘‘give them suggestions when they’re moving ment discussions gave them more specific feedback about on to their next placements’’ (CI-FG2), comment on and clarification of the comments written by the CIs. whether the student was able to apply the feedback, and ‘‘[CIs] don’t always have time to sit down and write out caution students that ‘‘they are not going to walk away the examples, so the discussion is always much more from the placement knowing everything’’ (CI-FG2). Two in-depth than the comments’’ (student [S]-FG1). Students CIs stated that the discussions at mid-term and final recognized that constructive criticism from their CIs was were very similar. more helpful; however, they also appreciated positive feedback because it provided encouragement. One stu- Importance of the environment dent stated, ‘‘For me it goes a long way when my CI All FGs discussed the importance of having face-to- includes some positive feedback; it goes a long way for the student’s confidence’’ (S-FG3). Students expressed face performance assessment discussions in a quiet and the value of receiving constructive and tangible feedback, private space. The students and CIs believed that meet- as described by this participant. ‘‘The CI came prepared ing face-to-face provided an opportunity to clarify issues with a lot of thoughtful comments and constructive [feed- and allowed the participants to interpret body language back] and came up with things that I didn’t even think of, and tone. These face-to-face conversations helped to strengths and areas for improvement. . . . I took a lot more build a more personal relationship and prepare students away from that discussion’’ (S-FG3). for professional practice. ‘‘Our whole job is face-to-face; why would that be any different with our student?’’ (CI- Students in all FGs stressed that the value of perfor- FG1) mance assessment discussions depended on factors that had occurred before a discussion took place, such as What are the roles of the student and the clinical instructor? adequate preparation and ongoing communication and feedback. For example, ‘‘I think it [the discussion] goes Students’ perspective much better when you have had small bits of communi- Six participants in the student FGs reported that their cation throughout and you get feedback prior to those two dates’’ (S-FG3). role was to remain open minded to feedback and to honestly reflect on their performance. They believed it Clinical instructors was important for them to advocate for their performance All CIs agreed that performance assessment discus- if there was a discrepancy between their ratings and those of the CI. They also thought it was their role to come up sions facilitated the students’ learning and increased with tangible methods to improve on identified weak- their confidence. ‘‘Conversations are always valuable for nesses. ‘‘I think that, as a student, it is our role to reflect students; they seem to really appreciate the feedback on our performance and try to be specific on things we they’re given as long as it’s constructive’’ (CI-FG2). Two think we did well and things we think we need to im- CIs also mentioned that these discussions were valuable prove on’’ (S-FG2). because they prompted them to reflect on their roles as instructors and experts. The CIs spoke about valuable The students believed it was the role of CIs to lead the discussions being a dynamic two-way exchange that discussion, communicate their expectations, and give enhanced the student–CI relationship. A discussion was feedback with concrete examples. Six students considered also considered valuable if a student came away with a CIs to be the experts and expected the CIs to be honest clear understanding of expectations and had engaged in and to give them guidance on how to implement the a process of goal setting. feedback delivered by the CI. ‘‘I feel like the CI is in the driver’s seat for most of the discussion because they are These discussions provide them with direction and guid- the expert; they have a better idea, I feel, of where I ance. They should have a really good idea of what their should be in my progress rather than myself’’ (S-FG2). areas of improvement are. . . . You want to add to their Four students mentioned that they found it valuable confidence in their areas of strengths but also give them when their CI made an effort to discuss performance a plan or direction for moving forward regarding their every day. weaknesses, whether it’s at midterm or final. (CI-FG2) So I think the role of the CI is to talk daily and weekly Some CIs explained that the mid-term and final dis- with the student. It feels good for the student to know cussions had different benefits, while others said the where they are at because it is hard to make improve- conversations were very similar. We found that the CIs ments when weeks have gone by, but if you are told in used the mid-term discussion to provide ‘‘guidance on the first or second week, then that [informal discussions] where to go next and the things that have been lacking’’ becomes a good tool. (S-FG2)

244 Physiotherapy Canada, Volume 70, Number 3 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 Clinical instructors’ perspective you see yourself one way and your CI sees you differ- The CIs stated that their role was to guide the discus- ently; it’s a little bit awkward if there is inconsistency.’’ One student mentioned that it affected the content of sion and provide students with direction for learning. the discussion as well. ‘‘If I saw that I was higher or Five CIs indicated that an important role of the student lower, it kind of altered how I talked about my own was to maintain an open dialogue and to ask for clarifi- scoring, so for me sometimes the conversation wasn’t as cation throughout the conversation, if needed. They also fluid’’ (S-FG1). This challenge was mitigated, however, mentioned that reviewing both ACP forms at the same by consistent feedback before the discussion, according time helped ensure a dynamic two-way conversation to one student. ‘‘[The discussion can be] challenging if and often instilled a sense of confidence in the student. you’re not getting feedback day to day; the experience CIs should use this opportunity to reflect on their own for me has been, like, constant feedback from the CI, so performance as educators. the mid-term or final isn’t as big of a surprise’’ (S-FG3). It’s nice to be able to go over [a student’s evaluation] and Both the students and the CIs agreed that conversa- self-reflect; it almost happens simultaneously. I find that tions were challenging if there was a difference in the as I’m talking to the student, I’m like, ‘‘You did really amount of preparedness. As described by a student in well, and I would have liked to have given you more FG1, ‘‘If they [my CI] wrote a lot and I didn’t write a lot, opportunities.’’ (CI-FG2) it would make it pretty awkward in that they were doing most of the talking.’’ One CI in each FG reported that the What are the challenging aspects of these discussions? timeline for these discussions was in itself a challenge: Both the students and the CIs identified several factors When an internship lasted only 5 weeks, the brief time frame leading up to the mid-term (2.5 weeks) made it that made these discussions challenging. Three students difficult for them to comprehensively assess and discuss reported feeling anxious and nervous beforehand, and each aspect of the students’ performance outlined in the four other students thought that these discussions had ACP. an awkward and emotional component throughout and ‘‘especially at the mid-term.’’ Likewise, two CIs stated How does the assessment tool affect the discussion? that they often found it challenging to give their students The ACP was considered to be a useful instrument for negative feedback. The power differential between stu- dents and CIs was mentioned by two students and per- prompting CIs to discuss all aspects of professional com- ceived as a challenge to the discussion. As one student petency, whether or not they were directly related to the described, ‘‘There is a power differential a bit and I clinical setting. Ten CIs frequently spoke about how the don’t think it’s specific to the ACP, more the discussion’’ ACP had helped focus a discussion, provided flow, and (S-FG1). developed a conversation with good structure. ‘‘It [ACP] helps focus our discussion on the various components Four students indicated that the CI’s role as the clinical of the ACP and gives you a nice breakdown of different expert and leader of the discussion made it difficult for areas’’ (CI-FG2). Five students reported that the enabling them to give their CI feedback and advocate for them- competencies under each key competency directed and selves. One student stated, ‘‘It’s really hard to speak up added to the conversation. for myself, at mid-term, telling them that they are wrong about something if you disagree’’ (S-FG1). Two students I found it very helpful to focus on different things. So for admitted to ranking themselves lower to avoid appearing ‘‘A,’’ whatever the subheading was, she [the CI] would overconfident and having to justify their ranking; another make a remark about a patient or an example. That was student said, ‘‘I tailor my comments to what my CI will valuable because we went through each subheading in- say’’ (S-FG3). Five CIs commented on some students stead of one overarching comment. (S-FG2) taking ‘‘a very passive role’’ (CI-FG4) in these feedback conversations. The students’ feelings of awkwardness In contrast, two CIs reported that the ACP could re- were also reflected in the story told by one CI in FG1. ‘‘I strict the conversation because they perceived it to be did mine [ACP evaluation] first, and we went to do hers, too theoretical and detailed. ‘‘I am just better at giving and she was more like, ‘Oh, I don’t care about mine’; she the student feedback on a day-to-day basis, [instead of] didn’t want to self-evaluate as much because she had sitting there trying to mould this tool to what I want to given herself such a low score.’’ say’’ (CI-FG3). For some students, the rating scale presented a chal- The ACP incorporates many opportunities for com- lenge when there was a discrepancy between their own ments to be written throughout it. Students emphasized score and that of the CI or, as one student put it, ‘‘show- how important it was for CIs to provide specific examples ing up to your evaluation on a completely different page for reflection and give thorough comments to guide a as your CI’’ (S-FG4). Students in FG2 said that this chal- discussion. One student explained, ‘‘When the CI uses lenge related more to the mid-term discussion than to examples in the comments, the discussion has more the final. ‘‘The discussion is awkward at the mid-term if depth’’ (S-FG1). Four CIs stated that the Comments

Yeldon et al. Exploring the Experience of Discussing Student Performance at the Mid- and Final Points of the Clinical Internship 245 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 section contributed to the conversation by triggering is important to highlight its implications.24 When their memories and providing clarification. As one CI put it, CI avoided addressing sensitive issues throughout the ‘‘The comments throughout [the ACP] help facilitate the placement and during the feedback discussion, the stu- discussion so that we don’t just sit together and say, dents described the feedback as less valuable. In addition, ‘You’re good at this, not good at that.’ We build a discus- although the students appreciated praise, they recognized sion around it’’ (CI-FG2). that it could go only so far to increase confidence and build rapport.4,25,26 Furthermore, the literature on feed- We found mixed opinions regarding the importance back has suggested that uncritical, positive feedback of the Summative Comments section, which is the last directed at performance rather than effort does not serve page of the ACP form. Although this section is meant to to inspire further achievement.4,27 be used for emphasizing or entering comments that have not already been mentioned, we found that it was often Throughout our analysis, we found that the students used to summarize the feedback and to give general and educators engaged in distinct behaviours that could comments to a student or CI. Eight students stated that hinder or facilitate the exchange of feedback during the summative comments served to end the conversa- these discussions.19 On one hand, students perceived tion on a positive note and provide ‘‘a better picture of the CIs who had written limited or broad comments as you as an overall clinician’’ (S-FG1). Both the students being unprepared and stated that it made the discussion and the CIs reported that the summative comments ‘‘robotic’’ and awkward. On the other hand, students weighed more heavily during the mid-term conversation perceived the CIs who had booked a private space for because they led to setting goals for the remainder of the the discussion and prepared comments that were honest, internship. However, five students and two CIs thought specific, tangible, and directly related to clinical practice that this part of the assessment tool was a repetition of as being invested in the discussion and the students’ previous comments and added no value to the discussion. learning experience. For their part, the CIs recognized that performance assessment discussions were difficult DISCUSSION for the students. They stated that a conversation was Our results suggest that a valuable discussion occurred negatively affected when students did not come prepared with comments or questions. It was also a challenge when when both parties came prepared to exchange construc- students did not accurately evaluate their own perfor- tive and positive feedback, engaged in an ongoing pro- mance or did not contribute to the conversation by cess of self-reflection, and built rapport through their sharing their concerns or expectations. The literature interactions. Performance assessment discussions provide has explained that these behaviours may be attributed an opportunity for formal feedback. Formal feedback to a student’s focusing on the educator’s summative discussions are a component of the clinical education assessment rather than on the learning process.19 experience and, as such, are shaped by the interaction among the learner, the educator, and the clinical setting.19 Given that the ACP includes several rating scales, dis- When this interaction creates a positive learning climate, parities between the student and CI assessments were it promotes both awareness and discovery, thus enhanc- visually apparent, and this could lead to a conversation ing the clinical experience.20 It is also in this environ- that predominantly focused on the rating scales. Ongoing ment that optimal performance discussions can take informal dialogue between a student and a CI decreased place. These conversations can provide meaningful feed- the likelihood of significant discrepancies in the assess- back, strengthen the student–CI relationship, and engage ment forms. On the basis of the data, it appears that a learner in an ongoing and cumulative learning process a valuable and motivating discussion was more likely that contributes to professional development. to occur when both parties presented comparable ACP assessments of a student’s performance. The students Feedback is powerful and CIs consistently emphasized how important ongoing Our findings support those in the feedback literature communication was for preparing students and reducing their anxiety about formal feedback. Drawing on our in which some educators have reported a level of unease findings, we propose that it is important to recognize with the process of giving their students constructive that the nature of the relationship throughout the intern- feedback and that students were somewhat apprehen- ship can promote or hinder the exchange of feedback at sive about these conversations.4,21,22 We found that both the mid-term and final evaluations. parties were aware that this exchange of feedback was highly beneficial and were thus willing to persevere through The relationship is important the unease.4 Intentionally avoiding sensitive issues, such The best educational relationships promote co-learn- as areas in which a student needs to improve, not only hinders the student’s learning experience but also puts ing and occur in an environment that encourages open the educational relationship at risk of remaining super- dialogue.20,28,29 Students and CIs must recognize their ficial and unable to address important issues.23 This shared responsibility and assume their individual roles phenomenon is known as vanishing feedback, and it in the educational relationship because this fosters a

246 Physiotherapy Canada, Volume 70, Number 3 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 sense of partnership. According to Va˚gstøl and Skøien,20 lower [on the rating scale], it kind of altered how I talked PT students acknowledged that mutual respect and trust about my own scoring’’ (S-FG 1). Another student ex- were the essence of the student–educator relationship. plained, ‘‘I hear them say a comment, and I feel like I This was a feeling echoed by the students in the current need to change [my response]. I feel like I don’t get to study when they described the CI as someone ‘‘you can say, ‘No, I think I am good at that’’’ (S-FG1). have these [difficult] conversations with.’’ The inherent emotional complexity of performance In our analysis, the CIs were aware of the significant assessment discussions was not overlooked by the CIs, role they played in shaping students’ attitudes about and they commented on their role in setting the tone of themselves, and they stated that conveying a sense of these discussions. For example, reassurance and recognition to their students was an important objective of performance discussions. Accord- I try to still go back to that ‘‘You will get there,’’ that over- ing to Gillespie,28 an effective educator appreciated his all ending message is, ‘‘We’re here to support you and not or her students’ current level of knowledge and contribu- just tell you what you’re doing wrong’’ and giving them tions to patient care and framed their areas requiring im- the chance to address anything. Just being open. (CI-FG4) provement as potential for learning. This in turn allowed the students to feel safe and supported as they took Another CI expressed a similar sentiment. ‘‘I think risks and solved problems in new learning situations.28 a key conversation that I always have with students is Hutchinson30 argued that providing a sense of belong- letting them know that they are not going to walk away ing and demonstrating behaviours that build students’ from the placement knowing everything’’ (CI-FG2). In self-esteem instills a sense of self-actualization, allowing both these cases, the CI used his or her position as the learners to reach their full potential. Va˚gstøl and Skøien30 expert to mitigate the students’ stress or disappointment also suggested that students who feel respected and and reassure them of the bigger picture—that clinical recognized express a greater level of confidence and con- internships are learning opportunities and that CIs are trol over the challenges they encounter in clinical work. experts who use their skills to support and guide that One student in our study summarized this idea well. learning. I think that providing gentle constructive criticism is the Ongoing learning and professional socialization CI’s role, when they provide you with room for improve- In our study, the CIs consistently stressed the impor- ment, but they do so in a non-judgmental way. They should understand that, as students, we are here to learn; tance of the student learning process remaining ongoing we want to do better. (S-FG2) and cumulative. They stated that conversations at the mid- and final points of an internship were good oppor- The CIs appreciated it when students made a genuine tunities to remind students that clinical education ex- effort to actively listen to their feedback, asked questions tended beyond acquiring technical skills. One CI referred to clarify it, and collaborated with them to come up with to it this way: ‘‘It’s based on putting different pieces strategies to apply it. These efforts showed that the stu- together; it’s not about how to range, how to percuss, dents were invested in the learning process. Being invested that’s not what we are as professionals. It’s putting could also include giving the CIs feedback on their teach- all that together’’ (CI-FG2). This example reflects the ing because CIs are also continuing to learn and self- attitude that achieving independent professional practice reflect. The CIs thought that formal discussions with is not only about performing skills correctly but also their students helped them build a better relationship about gaining important skills such as critical thinking, with them. self-reflection, and understanding the PT profession as a whole. The structure of the ACP outlines the key com- Consistent with previous literature, our results indicated petencies, which CIs use as a prompt to address each that some students thought that formal feedback conversa- role and its relevance to the current clinical setting.9 tions with their CI were emotional experiences.19 ‘‘I think When students reflect on each role, it allows them to either way it is an emotional experience, whether it be better understand that entry-level practice encompasses good or bad, because you are invested in it’’ (S-FG3). both a clinical and a professional knowledge base.6 Part This emotional component was described as awkward of the transition from student to clinician is a process of when there were significant discrepancies in the students’ socialization and integration into the profession, during and CIs’ performance assessments or expectations. When which students gain an understanding of its values, atti- this happened, students were more likely to assume the tudes, and culture.5,6 role of attentive listener and view the CI as the expert diagnostician.19 In the case of performance assessment In a study by Molloy,19 used feedback sessions to dis- discussions, students who take on the role of passive close aspects of their own clinical practice and to teach listener contribute to the conversation less frequently, students about the community of knowledge they were less meaningfully, or both. We found two examples of entering. CIs who shared their knowledge and provided this. One student stated, ‘‘If I saw that I was higher or feedback by linking clinical performance with professional competency encouraged students to develop expectations

Yeldon et al. Exploring the Experience of Discussing Student Performance at the Mid- and Final Points of the Clinical Internship 247 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 of themselves as members of the profession.19,28 We found 2. Both the student and the CI should invest in the dis- evidence that students considered their identity during a cussion by being prepared, honest, and open minded. placement not only as students but also as members of the profession. For example, one student stated, ‘‘[These 3. There should be ongoing communication during discussions] help facilitate our growth as practitioners, the internship, before the discussion, to mitigate any to kind of help us not only in our clinical skills but in feelings of apprehension and anxiety about these that reflective piece, [our] growth and ways to improve’’ formal feedback sessions. (S-FG4). 4. Both reinforcing and corrective feedback should be According to Molloy,19 to encourage students to take tangible, specific, encouraging, and supported by on the role of junior colleague rather than only that of examples. It should provide learners with a clear student or learner, it was helpful if educators disclosed understanding of their strengths and areas needing the difficulties they themselves had experienced. The improvement. author reported that self-disclosure had a positive im- pact on the learning climate because it conveyed empathy Used together, these recommendations should promote and encouragement and normalized the students’ diffi- a valuable, dynamic exchange that shares meaningful feed- culties.19 One student in our study commented on how back and encourages co-learning and a sense of partner- she appreciated a sense of empathy from her CI. ‘‘Just ship between students and clinical educators. Moreover, making them aware that it [the discussion] can be these recommendations should contribute to the social- stressful for students, so [they should] keep that in ization of students into the PT profession. mind’’ (S-FG4). KEY MESSAGES Our study had a few limitations. First, although we acquired rich data from 29 participants from a variety of What is already known on this topic practice settings, our sampling pool included only stu- Clinical internships are important opportunities for dents from the University of Toronto programme and CIs from facilities in the Greater Toronto Area. Second, students to practice and apply classroom knowledge and the participating students and investigators were all improve their clinical skill sets in a real-life environment. enrolled in the MScPT class of 2016. To mitigate this Giving feedback on a student’s performance is a neces- important limitation, the students and CIs were given sary and interactive process that occurs both formally the option of anonymously recording any additional and informally throughout the student’s clinical intern- thoughts not verbalized during the FG on a separate ship. Effective feedback can increase motivation and sheet of paper distributed to all participants beforehand. self-esteem and enhance communication skills for both Investigators did not call on any participant who chose a student and a clinical instructor (CI). The performance not to answer a question or probe. Participants were assessment discussions that occur at the mid- and final also reminded that they could withdraw from the study points of clinical internships are instances of formal at any point without penalty. feedback, and they help structure the clinical experience, outline performance expectations, and assess instruc- Finally, convenience sampling for both the student tional effects. and CI FGs may have introduced a bias: Students may have chosen to participate because they had constructive What this study adds feedback to offer during an FG, and CIs may have chosen This article explores the unique challenges and bene- to participate because they were invested in clinical edu- cation, and their opinions may not represent the views of fits of formal face-to-face performance assessment discus- all CIs. sions. Valuable discussions take place in a quiet, private space; require preparation; and include meaningful feed- CONCLUSION back. The emotional component of these discussions This study aimed to explore the experiences of stu- continues to be a challenge because these conversations involve a process of self-evaluation and the exchange dents and CIs while discussing the assessment of the of constructive feedback. However, when performance students’ clinical performance at the mid- and final assessment discussions occur in a positive learning points of their clinical internship using the ACP. On the climate, they strengthen the student–CI relationship and basis of our study’s results, we provide four key recom- prepare students for ongoing learning and entry into mendations as a framework for promoting a valuable physiotherapy practice. performance assessment discussion. REFERENCES 1. The discussion should occur in a conducive environ- ment (e.g., a quiet and private space) to enhance 1. Canadian Physiotherapy Association. Position statement: clinical open, two-way dialogue. education of physiotherapy students. Ottawa: The Association; 2008 [cited 2016 June 20]. Available from: https://www.physiotherapy.ca/ getmedia/3b256d44-e16f-4350-b74f-49e4721b7dec/Clinical- Education-of-Physiotherapy-Students_en.pdf.aspx.

248 Physiotherapy Canada, Volume 70, Number 3 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 2. Creaser G. An exploration of clinical instructors’ experiences and 16. Kitzinger J. Qualitative research. Introducing focus groups. BMJ. perceptions of the physical therapy clinical performance instrument 1995;311(7000):299–302. https://doi.org/10.1136/bmj.311.7000.299. [dissertation]. Halifax (NS): Mount Saint Vincent University; 2006. Medline:7633241 3. Vendrely A. Student assessment methods in physical therapy 17. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res education: an overview and literature review. J Phys Ther Educ. Psychol. 2006;3(2):77–101. https://doi.org/10.1191/ 2003;16(2):64–9. 1478088706qp063oa. 4. Clynes MP, Raftery SE. Feedback: an essential element of student 18. Hsieh HF, Shannon SE. Three approaches to qualitative content learning in clinical practice. Nurse Educ Pract. 2008;8(6):405–11. analysis. Qual Health Res. 2005;15(9):1277–88. https://doi.org/ https://doi.org/10.1016/j.nepr.2008.02.003. Medline:18372216 10.1177/1049732305276687. Medline:16204405 5. Payton O. Psychosocial aspects of clinical practice. New York: 19. Molloy E. Insights into the formal feedback culture in physiotherapy Churchill Livingston; 1986. clinical education. In: Delany C, Molloy E, editors. Clinical education in the health professions: an educator’s guide. Melbourne (VIC): 6. Bartlett DJ, Lucy SD, Bisbee L, et al. Understanding the professional Elsevier; 2009. p. 131–8. socialization of Canadian physical therapy students: a qualitative investigation. Physiother Can. 2009;61(1):15–25. https://doi.org/ 20. Va˚gstøl U, Skøien A. A learning climate for discovery and awareness: 10.3138/physio.61.1.15. Medline:20145748 physiotherapy students’ perspective on learning and supervision in practice. Adv Physiother. 2011;13(2):71–8. https://doi.org/10.3109/ 7. Mori B, Brooks D, Norman KE, et al. Development of the Canadian 14038196.2011.565797. Physiotherapy Assessment of Clinical Performance: A new tool to assess physiotherapy students’ performance in clinical education. 21. Ende J, Pomerantz A, Erickson F. Preceptors’ strategies for correcting Physiother Can. 2015;67(3):281–9. https://doi.org/10.3138/ptc.2014- residents in an ambulatory care medicine setting: a qualitative 29E. Medline:26839459 analysis. Acad Med. 1995;70(3):224–9. https://doi.org/10.1097/ 00001888-199503000-00014. Medline:7873011 8. Mori B, Norman KE, Brooks D, et al. Canadian Physiotherapy Assessment of Clinical Performance: face and content validity. 22. Higgs J, Richardson B, Abrandt Dahlgren M. Developing practice Physiother Can. 2016;68(1):64–72. https://doi.org/10.3138/ptc.2015- knowledge for health professionals. Edinburgh: Butterworth- 35E. Medline:27504050 Heinemann; 2004. 9. Mori B, Norman KE, Brooks D, et al. Evidence of reliability, validity 23. Dohrenwend A. Serving up the feedback sandwich. Fam Pract and practicality for the Canadian Physiotherapy Assessment of Manag. 2002;9(10):43–6. Medline:12469676. Clinical Performance. Physiother Can. 2016;68(2):156–69. https:// doi.org/10.3138/ptc.2014-43E. Medline:27909363 24. Ende J. Feedback in clinical medical education. JAMA. 1983;250(6):777–81. https://doi.org/10.1001/ 10. American Physical Therapy Association. Physical Therapist Clinical jama.1983.03340060055026. Medline:6876333 Performance Instrument (PT CPI). Alexandria (VA): The Association; 2016 [cited 2016 June 20]. Available from: http://www.apta.org/ 25. Mulholland S, Derdall M, Roy B. The student’s perspective on what PTCPI/. makes an exceptional practice placement educator. Br J Occup Ther. 2006;69(12):567–71. https://doi.org/10.1177/030802260606901206. 11. Atkins S, Williams A. Registered nurses’ experiences of mentoring undergraduate nursing students. J Adv Nurs. 1995;21(5):1006–15. 26. Conn JJ. What can clinical teachers learn from Harry Potter and the https://doi.org/10.1046/j.1365-2648.1995.21051006.x. Philosopher’s Stone? Med Educ. 2002;36(12):1176–81. https:// Medline:7601984 doi.org/10.1046/j.1365-2923.2002.01376.x. Medline:12472752 12. Begley CM, White P. Irish nursing students’ changing self-esteem 27. Dweck CS. The perils and promises of praise. In: Ryan K, Cooper JM, and fear of negative evaluation during their preregistration editors. Kaleidoscope: contemporary and classic readings in programme. J Adv Nurs. 2003;42(4):390–401. https://doi.org/ education. 13th ed. Belmont (CA): Cengage Learning; 2007. p. 57–64. 10.1046/j.1365-2648.2003.02631.x. Medline:12752884 28. Gillespie M. Student–teacher connection in clinical nursing 13. Branch WT Jr, Paranjape A. Feedback and reflection: teaching education. J Adv Nurs. 2002;37(6):566–76. https://doi.org/10.1046/ methods for clinical settings. Acad Med. 2002;77(12 Pt 1):1185–8. j.1365-2648.2002.02131.x. Medline:11879421 https://doi.org/10.1097/00001888-200212000-00005. Medline:12480619 29. Gillespie M. Student-teacher connection: a place of possibility. J Adv Nurs. 2005;52(2):211–9. https://doi.org/10.1111/j.1365- 14. Allen C. Peers and partners: a stakeholder evaluation of 2648.2005.03581.x. Medline:16164482 preceptorship in mental health nursing. Nurse Res. 2002;9(3):68–84. https://doi.org/10.7748/nr2002.04.9.3.68.c6190. Medline:11985149 30. Hutchinson L. Educational environment. BMJ. 2003;326(7393):810– 2. https://doi.org/10.1136/bmj.326.7393.810. Medline:12689981 15. Pugh BJ. Managing your academic career—feedback in clinical teaching. Nurse Educ. 1992;17(1):5–7. https://doi.org/10.1097/ 00006223-199201000-00008. Medline:1732872

Clinician’s Commentary on Yeldon et al.1 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 Yeldon and colleagues1 conducted a qualitative study to ex- A strong educational alliance can develop when students plore the discussion of student clinical performance arising out consider CIs to be credible because of their expert knowledge of completion of the Canadian Physiotherapy Assessment of and their desire to teach.2 It can be strengthened if students Clinical Performance (ACP). They set out to explore the value, perceive that CIs have a positive attitude toward them and are roles, and challenges of the discussion as well as the structure genuinely interested in their professional development and provided by the ACP. personal identity. CIs can make a point of asking students about their career aspirations and learning about their past clinical The study points out that an important function of the ACP and life experiences. Although an optimal clinical environment is that it provides focus and flow for the feedback conversation can facilitate an open, two-way discussion, the development of at the mid- and final points of an internship. Some clinical in- an educational alliance (or the lack thereof) sets the tone of the structors (CIs) thought that it was repetitive and too theoretical, discussion long before it actually occurs. and they preferred to give daily feedback. However, the ACP is structured in such a way as to ensure that the discussion Another interesting finding is that some Cis considered com- touches on all the physiotherapy competencies, and its struc- pleting the ACP to be a professional development activity. A tured approach brings to the discussion the additional benefit commonly identified barrier to taking on students for an intern- of clarity. A discrepancy often exists between the feedback ship is the perception that it increases the workload4 and that that students think they have received and the feedback that the time required to complete an assessment and then review it educators think they have provided.2 Verbal feedback can be with a student contributes to this workload. However, hosting a difficult for students to process and retain in the moment student prompted CIs to evaluate their practice as a form of because the clinical environment can be complex, filled with professional development,4 and Yeldon and colleagues1 report stimuli and other distractions.2 The ACP serves as a record of that this professional development extended to completing the this feedback discussion, and it enables students to review the ACP. Some of the CIs stated that the evaluation prompted them written feedback later, on their own time. to reflect on their role as instructors and clinicians. To effec- tively evaluate a student’s performance and formulate com- Moreover, the ACP’s structure supports the physical therapy ments, CIs must be able to identify the competence required to curriculum. The clinical environment is a place where the edu- be effective in their own practice. Thus, physiotherapists may cation being provided shifts from faculty, who have detailed think of completing the ACP as an opportunity to reflect on knowledge of the curriculum, to clinical educators, who may their own practice as a form of professional development. have more practical knowledge.3 CIs may emphasize different competencies on the basis of their area of practice and past expe- In the current Canadian climate, where finding sufficient riences; thus, the ACP provides an important template for ensur- clinical internships can be challenging, the study serves two ing that each CI discusses the required clinical competencies. purposes for those considering taking on a student. First, it gives CIs an excellent opportunity to reflect on their practice as a Another important finding from the study is that the form of professional development. Second, it supports CIs in environment and the prior relationship between the CI and the developing the skills necessary to be effective—namely, it is an student can influence a session. A quiet environment, free of investment in the student–instructor relationship, or educational distraction, can set the tone for an open discussion, and both alliance, and it can set the tone for an open and meaningful the students and the CIs stated that the students should come mid-term and final discussion. into it with an open mind. However, students and CIs also thought that a discrepancy in the assessment between a CI Jaimie Coleman, BPHE, MScPT, MHM(c) and a student can have a negative impact on the discussion: Academic Coordinator of Clinical Education, Students’ participation tends to decrease, and they become passive recipients of the feedback. They may even alter their Department of Physical Therapy, comments to match those of the CI. Yet Yeldon and colleagues1 University of Toronto, Toronto; noted that the students valued a two-way discussion to clarify [email protected]. and advocate for their performance, and the CIs valued it to determine students’ self-assessment of their performance. REFERENCES Another interesting finding was that a discrepancy between 1. Yeldon J, Wilson R, Laferrie`re J, et al. Let’s talk about the talk: a student’s and a CI’s assessment could be mitigated by their Exploring the experience of discussing student performance at the prior relationship. In fact, the ACP discussion could strengthen mid- and final points of the clinical internship. Physiother Can. 2018 an already positive relationship. The student–CI relationship 70(3):240–48. https://doi.org/10.3138/ptc.2016-96. is a concept known in medical education as the educational alliance, defined as ‘‘a collaborative framework underpinning 2. Telio S, Regehr G, Ajjawi R. Feedback and the educational alliance: the supportive educational relationship required to facilitate feed- examining credibility judgements and their consequences. Med back impact and the development of self-regulated learning.’’3(p541) Educ. 2016;50(9):933–42. https://doi.org/10.1111/medu.13063. Telio and colleagues2 have stated that a strong educational Medline:27562893 alliance can lead to a more open discussion, one in which stu- dents feel comfortable sharing their thoughts. More important, 3. Murdoch-Eaton D, Bowen L. Feedback mapping—the curricular students are more receptive to the feedback they receive and cornerstone of an ‘‘educational alliance.’’ Med Teach. more likely to incorporate it into their behaviour. 249

250 Physiotherapy Canada, Volume 70, Number 3 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 2017;39(5):540–7. https://doi.org/10.1080/0142159X.2017.1297892. Medline:28281849 4. Hall M, Manns P, Beaupre L. To supervise or not to supervise a physical therapist student: a national survey of Canadian physical therapists. J Phys Ther Educ. 2015;29(3):58–67. https://doi.org/ 10.1097/00001416-201529030-00008. DOI:10.3138/ptc.2016-96-cc

https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 EDUCATION Physiotherapists’ and Physiotherapy Students’ Perspectives on the Use of Mobile or Wearable Technology in Their Practice Jenna Blumenthal, MASc; Andrea Wilkinson, PhD; Mark Chignell, PhD ABSTRACT Purpose: Although extensive research has been carried out on the determinants of mobile or wearable health care technology (mHealth), as well as on its acceptance by patients and other health care providers, very little research has been done on physiotherapists’ perspectives on the use of mHealth in their current or future practice. The aims of this study were to (1) explore the attitudes of physiotherapists toward mHealth using a modified technology acceptance model questionnaire, (2) understand the applications and delivery paradigms that are most desirable, and (3) assess the content validity of the questionnaire. Method: The questionnaire was administered online. Participants (n ¼ 76) were recruited using snowball and convenience sampling. Data were analyzed using factor analysis and partial least-squares path modelling. Results: Results indicate that perceived usefulness and perceived ease of use were related to early adoptive behaviour among participants. We found no evidence that age, gender, experience, or practice setting influenced early adoptive behaviour. Participants demonstrated favourable attitudes toward mHealth tools in clinical practice. Conclusions: This article provides initial insights into factors that are likely to be significant determinants of adoption of mHealth among physiotherapists. Further work, including qualitative research, will help to identify personal and institutional factors that will improve the acceptance of mHealth. Key Words: health care surveys; mobile phone; technology assessment, health. RE´ SUME´ Objectif : meˆ me si des recherches approfondies ont porte´ sur les de´ terminants de la technologie de sante´ mobile et portable (sante´ mobile) et sur leur acceptation par les patients et les professionnels de la sante´ , rares sont celles qui traitent des perspectives des physiothe´ rapeutes a` l’e´ gard de l’utilisation de la sante´ mobile dans leur pratique actuelle et future. La pre´ sente e´ tude visait a` 1) explorer les attitudes des physiothe´ rapeutes a` l’e´ gard de la sante´ mobile au moyen d’un mode` le d’acceptation technologique modifie´ , 2) comprendre les applications et les paradigmes de prestation les plus souhaitables et 3) e´ valuer la validite´ du contenu du questionnaire. Me´ thodologie : les chercheurs ont publie´ le questionnaire en ligne. Ils ont recrute´ les sujets (n ¼ 76) par e´ chantillonnage en boule de neige et par e´ chantillonnage de commodite´ . Ils ont analyse´ les donne´ es a` l’aide d’une analyse des facteurs et d’un mode` le de re´ gression des moindres carre´ s partiels. Re´ sultats : d’apre` s les re´ sultats, la perception de l’utilite´ et de la facilite´ d’utilisation de´ pend du comportement d’adoption rapide des participants. Aucune donne´ e n’indique que l’aˆ ge, le sexe, l’expe´ rience ou le lieu de pratique influe sur un comportement d’adoption rapide. Les participants avaient des attitudes favorables envers les outils de sante´ mobile en pratique clinique. Conclusion : le pre´ sent article donne des points de vue initiaux sur les facteurs susceptibles d’eˆ tre des de´ terminants importants de l’adoption de la sante´ mobile par les physiothe´ rapeutes. D’autres travaux, y compris des recherches qualitatives, contribueront a` de´ terminer les facteurs personnels et institutionnels qui favoriseront l’acceptation de la sante´ mobile. The focus of the health care system is shifting from tions to support functional recovery for patients affected delivering expensive acute care to integrating preventive by injury, illness, and disease.3 programmes and complex chronic management into the community.1 At the same time, the development and To date, the most prolific application of mobile or adoption of consumer-grade technology has been expe- wearable health care technology (mHealth) is in monitor- dited by the increasing computing power and plunging ing the type, quantity, and quality of everyday activities.4–9 cost of electronics,2 fostering a surge of innovative applica- Inexpensive and unobtrusive wireless sensors, combined with Internet-based communications and sophisticated From the Department of Mechanical and Industrial Engineering, Faculty of Engineering, University of Toronto, Toronto. Correspondence to: Jenna Blumenthal, Department of Mechanical and Industrial Engineering, Faculty of Engineering, University of Toronto, 5 King’s College Rd., Toronto, ON M5S 3G8; [email protected]. Contributors: All authors designed the study; or collected, analyzed, or interpreted the data; and drafted or critically revised the article and approved the final draft. Competing Interests: The first author was supported by the Canadian Institutes of Health Research, and the second and third authors are recipients of a Networks of Centres of Excellence AGE-WELL grant. Acknowledgements: The authors acknowledge Tammy Sieminowski, Brenda Elliott, and Heather Kwok at Bridgepoint Sinai Health System for their work in devel- oping the questionnaire, and they thank the participants for contributing to this study. Physiotherapy Canada 2018; 70(3);251–261; doi:10.3138/ptc.2016-100.e 251

252 Physiotherapy Canada, Volume 70, Number 3 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 signal processing and event-detection algorithms, have In the research reported in this article, we consider a driven the growth of both clinical and consumer use of simplified TAM model that examines early adopter (EA) tools to monitor fitness and general wellness.4 Clinical behaviour as a proxy for BI, along with the predictive providers can harness such technological advances to power of PU and PEOU for EA. This reduced model ex- gather biometric data, engage patients in activity, im- cludes actual behaviour, as well as any explicit intention prove communication, and increase efficiency in their to immediately implement technology,27 because of the practice.10 low levels of current use of mHealth in physiotherapists’ daily practice. To clarify and contextualize the assessment There is a natural fit between current, emerging instrument, we also examine therapists’ willingness to im- mHealth technologies and the scope of physiotherapy plement mHealth tools in common clinical practice. practice.11 Although it is not meant to take the place of therapist-to-patient interaction, mHealth can provide OBJECTIVE OF THIS ARTICLE tools to collect reliable outcome measures of vital signs, The research we report in this article seeks to under- monitor data outside the clinical visit, provide feedback on posture and body mechanics, supply educational material, stand the attitudes of physiotherapists toward mHealth and engage patients with motivational prompts.12 and the use of technology in their practice. Our interest was in the possible barriers to adopting mHealth technol- Despite a growing body of academic research and ogy, which might explain its relatively slow adoption. To considerable commercial interest, physiotherapists have understand attitudes and possible barriers, we developed not shown a corresponding integration of mHealth tools a questionnaire based on the TAM and administered it to into their day-to-day practice.10 Thus, although mHealth, a sample of training and practicing physiotherapists. We and the increasing use of technology in rehabilitation then carried out an online survey to evaluate the ques- research, may ultimately improve practice, understanding tionnaire’s content validity. the barriers to adoption and improving acceptance is needed. Once the technologies are ready for adoption, METHODS a thorough investigation of the impact of mHealth on patient outcomes should be carried out. One reason Questionnaire design for the slow adoption of mHealth by physiotherapists Initial questionnaire items were derived from previously thus far may be a mismatch between their technological preferences and current offerings. Although some re- published instruments and modified to suit the context of search has been carried out on patient attitudes toward mHealth technology in physiotherapy practice.18,25,28,29 We technology in rehabilitation,13 a gap exists in determin- identified articles describing previous instruments by ing the factors that may influence physiotherapists’ will- means of searches that were conducted in both the ingness to use or recommend new technologies. Although PubMed and the Google Scholar databases. Breadth was there has been some research in this area,14 the literature provided by using a disjunctive search strategy, in which is often specific to a single application or limited to physi- relevant articles were defined as having any one of the cians.15–20 Gaining an insight into the experiences, atti- following terms: TAM, technology in health, uptake of tudes, and opinions of physiotherapists may encourage technology, technology in physical therapy, uptake of the development of mHealth products and services that technology in physical therapy, or mobile technology in are more widely accepted. health. Because our goal was not to generate every possibly relevant construct or questionnaire item but rather to in- CONCEPTUAL MODEL FOR UNDERSTANDING ACCEPTANCE clude a comprehensive and representative set of measures, AND ADOPTION OF MHEALTH we reviewed the titles and abstracts to narrow down the large number of articles returned in the search to a smaller The inconsistent adoption of mHealth21 has high- set that listed relevant questionnaire instruments. lighted the need for theories that can predict and explain attitudes toward, and the eventual intention to use, The questionnaire’s face validity and comprehensibility technology in health care. The Technology Acceptance was evaluated by a panel of experts in fields relevant to Model (TAM)22 is a popular framework that has been technology acceptance, usability research, medicine, and used frequently across a range of industries, including physiotherapy, who filtered and refined the set of ques- health care.23 In the Venkatesh and Davis version, the tions. The panel consisted of one physician working TAM consisted of perceived usefulness (PU), perceived in neuro-rehabilitation, two physiotherapists working in ease of use (PEOU), behavioural intention to use (BI), the neuro-rehabilitation unit of a rehabilitation hospital, and usage behaviour.24 PU and PEOU have been found one expert in human factors and technology assessment, to be the strongest determinants of BI, and PEOU has a and one PhD in psychology with expertise in the design direct effect on PU.25 of health care environments. The preliminary question- naire was then pilot tested among 12 physiotherapists Several studies have suggested that the TAM needs to at Bridgepoint Active Healthcare, a complex care facility be extended to improve its explanation of behaviour relat- in Toronto. Our research ethics protocol was approved ing to the acceptance of technology in health care.18,23–26 by the institutional review boards at both Mount Sinai

Blumenthal et al. Physiotherapists’ and Physiotherapy Students’ Perspectives on the Use of Mobile or Wearable Technology in Their Practice 253 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 Figure 1 Simplified framework for the 12 Technology Acceptance Participants and conditions Model items in the questionnaire. After the questionnaire was refined, it was distributed mHealth ¼ mobile or wearable health care technology. to practicing physiotherapists and physiotherapy stu- Hospital and the University of Toronto. Both quantita- dents online using the Typeform platform (Typeform, tive (Cronbach’s a and inter-item correlation analysis) Barcelona, Spain). The questionnaire link was advertised and qualitative feedback were used to revise the ques- through e-mail and Twitter, through Ontario’s profes- tionnaire before we sent it out for wider distribution. sional physiotherapy organizations, and through the Domain experts then further reviewed the questionnaire administrative heads of professional physiotherapy degree to ensure that it was well structured and that there was programmes at Ontario universities. When they com- no excessive redundancy among the questions. pleted the questionnaire, all participants were entered into a drawing to win a $50 Amazon gift card. The in- The final version of the questionnaire, the Physio- stitutional review board at the University of Toronto therapy Mobile Acceptance Questionnaire (PTMAQ), con- approved the protocol. Participants were informed that sists of a set of demographic items relevant to the use of submitting the survey implied informed consent. In the personal technology, along with 30 questions derived presentation of the results, the term physical therapist using the method described previously. The 30 questions refers both to practicing physical therapists and to stu- consist of 12 modified TAM items and 18 items relating dents who were training to be physical therapists, unless to clinical variables for which mHealth technology could otherwise noted. be recommended (see the Appendix). After consulting with several academically appointed physiotherapy pro- Methods of analysis fessionals, the clinical variables we used were (1) overall Other than the demographic information, data were activity level, (2) balance, (3) gait speed, (4) gait quality, (5) cognitive status, and (6) pain level. We chose these collected using a five-point Likert scale, on which 1 ¼ clinical variables because they are broad, commonly strongly disagree, 2 ¼ disagree, 3 ¼ neutral, 4 ¼ agree, assessed, and incorporate measures for which various and 5 ¼ strongly agree. Principal components analysis technology solutions have already been found.30–33 Each (PCA) was used to explore the underlying factor struc- clinical variable had three variants: one covering mea- ture and reliability, and the internal reliability of the surement at a single point in time, one covering longitu- resulting factors was assessed by means of Cronbach’s a dinal measurement, and one dealing with practice items and inter-item correlation.34 Demographic group differ- carried out by patients. ences with respect to the components were evaluated using analyses of variance, and post hoc analysis was In the PTMAQ’s final configuration, the 12 TAM items carried out using Tukey–Kramer adjustments to account in the questionnaire were based on a simplified frame- for multiple comparisons. All data analyses were performed work, in which we examined the effect of PU and PEOU using R statistical software (R Foundation for Statistical on EA and the effect of PEOU on PU (see Figure 1). We Computing, Vienna, Austria). also examined the extent to which accepting technology in the use of clinical tools could be explained by an indi- To examine the appropriateness of the modified TAM vidual’s EA behaviour. model for our data set, partial least-squares path model- ling (PLS-PM) was used.35 PLS-PM is an approach to In accordance with previous practice for the TAM, structural equation modelling that allows researchers including its formulation by Venkatesh and Davis,24 the to represent latent constructs, observations, and their PU questions in our questionnaire were framed positively, relationship in a single statistical model.36–38 Using the as were the intention to use–EA questions. However, we PTMAQ, observations were collected on the latent con- chose to frame the PEOU questions negatively so that structs of interest. Factor analysis was then used to we could collect a conservative estimate of how usable create a revised set of constructs based on the correla- physical therapists find mobile or wearable technology tions among the question items that were observed (MWT) to be. in our sample. The significance of path coefficients was assessed using two-tailed t-tests; associated p-values were reported along with b values. RESULTS Descriptive statistics A total of 76 completed surveys were submitted. Be- cause we used a network recruitment strategy,39 whereby participants were encouraged to share the survey with colleagues, the exact number of surveys sent out is not known. There were 120 unique visits to the survey

254 Physiotherapy Canada, Volume 70, Number 3 Table 1 Demographic Attributes of the Participants (KMO) measure verified the sampling adequacy for the analysis: KMO ¼ 0.79, whereby a value of more than https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 Category and attribute No. (%) of participants 0.80 is classified as ‘‘meritorious.’’40(p.35) Bartlett’s test of (n ¼ 76) sphericity (w2561 ¼ 2,245.7; p < .001) indicated that corre- lations between items were sufficiently large for PCA. An Age, y 27 (35.5) initial analysis was run to obtain eigenvalues for each <25 26 (34.2) component in the data. After examining the scree plot 25–34 13 (17.1) and eigenvalues, we retained six components, which ex- 35–44 5 (6.6) plained 68% of the total variance. Item reliability analysis 45–54 5 (6.6) was then carried out using Cronbach’s a as the criterion; b55 this enabled us to create scales based on the items 27 (35.5) that loaded on each of the factors.41 For each factor, Gender 48 (63.2) items were removed if removing them did not reduce Male 1 (1.3) Cronbach’s a.42 Female Prefer not to disclose 32 (42.1) Table 2 shows the factor loadings after item removal 6 (7.9) and rotation. To assist in interpreting the table, we Highest education completed 36 (47.4) ordered the components to match the order of the items Undergraduate degree 1 (1.3) in the questionnaire as closely as possible. Items were College degree 1 (1.3) considered relevant to a factor if their loadings were Master’s degree greater than 0.6.43 On the basis of the item loadings, PhD 46 (60.5) component 1 represents PU (specifically as it relates to Other 4 (5.3) usefulness, patient engagement, and communication of 5 (6.6) progress), component 2 represents EA behaviour and Years in practice 10 (13.2) receptiveness to using emerging mHealth, and compo- 0 (student) 11 (14.5) nent 3 represents PEOU (reverse-scored). For the clinical 1–4 variables, the factor analysis aggregated the clinical mea- 5–10 18 (23.7) sures on three components: Component 4 relates to gait 11–20 5 (6.6) speed, component 5 relates to gait quality and balance, >20 20 (26.3) and component 6 relates to the non-biomechanical mea- 2 (2.6) sures of pain and cognitive status. The reliability of the Primary practice setting 31 (40.8) components, as estimated with Cronbach’s a, were all Private above the recommended 0.7 threshold. The average inter- Acute care hospital 75 (98.7) item correlation ranged from 0.48 to 0.79, suggesting that Rehab hospital 1 (1.3) the internal consistency was high, with the possibility of Home-based care some redundancy between items.44 n/a 46 (60.5) 30 (39.5) Descriptive statistics for the questionnaire responses Own a smartphone? (mean, SD, and correlation of the item with the com- Yes 1 (1.3) ponent, corrected for item overlap and scale reliability) No 4 (5.3) are shown in Table 3, ordered by the factors on which 6 (7.9) they load. Again, the components are ordered as closely Wear (or have worn) a wearable tracking device? 30 (39.5) as possible to the items in the questionnaire. Yes 7 (9.2) No Structural model assessment Once we determined that the measurement model was Type of mHealth device used Activity tracker satisfactory, we used the PLS-PM technique to examine Pedometer the relationships between the components. Figure 2 Smartphone (embedded sensors) presents the path coefficients (referring to the structural Watch or band relationship among the tested variables) that were esti- Multiple devices mated in the analysis. Note that in the figure, each participant’s component score is the mean of the scores n/a ¼ not applicable. obtained for the items listed under that component in Table 3. The data indicate that PU had a reasonably website (completion rate ¼ 63%; average time to com- strong effect on EA (b ¼ 0.46; p < 0.001), but the hypo- plete ¼ 9 min, 20 s). Table 1 shows the demographic thesis that PEOU had a direct effect on EA was not sup- attributes of the participants. Although 46 of the partici- ported (b ¼ 0.14; p ¼ 0.20). We did find that PEOU had a pants were physiotherapy students, participants had a moderate effect on PU (b ¼ 0.24; p ¼ 0.041) and that EA relatively broad range of ages and years of experience. All the students had completed at least 1 year of their graduate degree programme and likely had practicum experience in various care settings (as some of them noted; see Table 1). Evaluating the measurement instrument PCA, followed by orthogonal rotation (varimax), was conducted on the initial items from the non-demographic data to reduce the dimensionality of the data and identify an underlying factor structure. The Kaiser–Meyer–Olkin

Blumenthal et al. Physiotherapists’ and Physiotherapy Students’ Perspectives on the Use of Mobile or Wearable Technology in Their Practice 255 Table 2 Factor Loadings and Reliability Analysis Component and item Loading https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 Usefulness in engagement and communication PU3 0.71* 0.23 À0.08 0.25 À0.05 0.21 0.16 0.24 À0.12 0.10 0.06 PU1 0.69* 0.03 0.05 0.53 0.23 0.23 0.01 0.07 0.01 À0.01 ACTIVITY3 0.63* 0.16 0.85* 0.10 0.09 0.02 PU2 0.62* 0.72* À0.01 0.01 0.21 0.14 0.64* 0.04 À0.09 0.02 Early adoptive behaviour 0.05 0.23 0.01 À0.05 0.11 EA1 0.07 0.32 0.83* 0.10 0.10 À0.04 À0.16 0.79* À0.09 0.22 EA2 0.28 0.67* 0.16 0.06 0.18 0.33 EA3 0.42 À0.01 0.04 0.35 0.08 0.00 0.81* 0.22 0.29 Perceived difficulty of using MWT 0.14 0.06 0.78* 0.29 0.78* 0.85* PEOU2† 0.12 0.11 0.10 0.81* 0.24 0.08 0.03 0.09 0.67* 0.37 PEOU1† 0.01 0.31 0.04 0.14 0.81* 0.33 0.06 0.04 0.12 0.81* 0.18 PEOU3† 0.01 0.02 0.07 0.30 0.75 0.23 0.11 0.07 0.23 0.25 Clinical usefulness: gait speed 0.28 0.23 0.07 0.11 0.31 0.73* GAITSPEED1 0.04 0.08 À0.01 0.00 0.25 0.75* 0.07 À0.06 0.07 0.18 0.81* GAITSPEED2 0.12 0.05 0.08 0.16 0.77* 0.03 0.16 0.21 0.23 0.80* GAITSPEED3 0.25 À0.04 0.18 0.18 0.72* 0.27 0.15 5.55 Clinical usefulness: balance and gait quality 2.77 16.3 4.78 8.1 2.63 3.13 0.94 14.0 BALANCE1 À0.01 0.75 7.7 9.2 0.72 0.91 0.51 0.74 0.92 0.62 BALANCE2 0.06 0.49 0.79 BALANCE3 0.17 GAITQUAL1 0.09 GAITQUAL2 0.14 GAITQUAL3 0.17 Clinical usefulness: non-biomechanical measures COG1 0.04 COG2 0.01 COG3 0.08 PAIN1 0.06 PAIN2 0.13 PAIN3 0.24 Other Eigenvalue 4.38 % of variance 12.9 Cronbach’s a 0.75 Average inter-item correlation 0.48 Note: Items without significant factor loadings have been removed. PTMAQ items are abbreviated to improve readability. Numerals are used to indicate the following: 1 refers to objective measurement of the variable, 2 refers to longitudinal measurement of the variable over time, and 3 refers to encouragement of practice carried out by patients. *Factor loading >0.6. † Item was reverse-scored for analysis. PU ¼ perceived usefulness; ACTIVITY ¼ activity level; EA ¼ early adopter; MWT ¼ mobile or wearable technology; PEOU ¼ perceived ease of use; COG ¼ cognitive status; PAIN ¼ pain level; PTMAQ ¼ Physiotherapy Mobile Acceptance Questionnaire. was related to the clinical components identified during average variance extracted were all above the recom- factor analysis. The effect of EA on the likelihood of mended 50%.45 GoF was 0.28, indicating the model’s recommending an mHealth device for both gait speed reasonable predictive power. (b ¼ 0.32; p ¼ 0.006) and gait quality and balance (b ¼ 0.31; p ¼ .008) was statistically significant, and the non- Individual differences in technology acceptance biomechanical construct (pain–cognitive status) exhibited Composite scores for each component were obtained a near-significant trend (b ¼ 0.22; p ¼ 0.07). by averaging the items within the component. Univariate The overall quality of the structural model was analyses of variance were then carried out to see how the evaluated by R2, the coefficient of determination; the component scores varied across the different levels of redundancy index; and GoF. The average redundancy the demographic variables. Because this was an explora- indicated that PU and PEOU explained 31% of the vari- tory analysis, directional hypotheses were not formulated, ability in the EA indicators. The average redundancy and two-tailed tests of significance were used for the post and R2 values for the three clinical measures were also hoc pairwise comparisons (independent-samples z-tests) less than 0.10. However, the average communalities and that were carried out for the components that had a

256 Physiotherapy Canada, Volume 70, Number 3 Table 3 Components, Items, and Descriptive Statistics Component and item Mean Correlation (SD) (r b) https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 Usefulness in engagement and communication PU3 MWT may help my patients stay engaged during the rehabilitation process (especially outside our 4.11 (0.73) 0.78 face-to-face sessions). 4.17 (0.79) 0.91 4.47 (0.64) 0.51 PU1 I would find it interesting to use mobile or wearable technology to monitor my patient’s progress (e.g., using a FitBit 4.04 (0.72) 0.55 to assess their daily activity levels). 4.17 (0.88) 0.74 4.00 (0.80) 0.70 ACTIVITY3 I would recommend a MWT to my patient if it encouraged my patient to increase their overall activity level (within or 4.22 (0.64) 0.59 outside our one-on-one sessions). 2.30 (0.80) 0.74 2.72 (0.87) 0.67 PU2 Mobile or wearable technology may provide me with a way to communicate my patient’s progress more clearly. 2.43 (1.06) 0.58 4.17 (0.84) 0.88 Early adoptive behaviour 4.24 (0.80) 0.93 4.17 (0.88) 0.82 EA1 I would be willing to try out a new MWT in my practice before it had been clinically validated. 4.29 (0.80) 0.86 EA2 In the future, I would be likely to test or try out a new MWT with my patients. 4.29 (0.78) 0.88 4.28 (0.93) 0.78 EA3 I would be willing to use a new MWT if I received appropriate training. 4.21 (0.87) 0.87 4.25 (0.84) 0.90 Perceived difficulty of using MWT 4.26 (0.89) 0.88 PEOU2 I expect learning how to use a new MWT that was specifically designed for physiotherapy will be quite difficult (e.g., 3.59 (0.93) 0.72 a device that provides feedback on my patient’s balance). 3.64 (0.86) 0.81 PEOU1 I expect using a MWT in my practice will take a lot of extra time (e.g., a wearable tool that collects data about my 3.72 (0.89) 0.83 patient’s gait). 4.03 (0.93) 0.83 4.08 (0.90) 0.85 PEOU3 I expect it will take significant additional training before I am comfortable using a MWT in my practice. 4.12 (0.73) 0.78 Clinical usefulness: gait speed GAITSPEED1 I would recommend a MWT to my patient if it gave me a more objective measurement of my patient’s gait speed. GAITSPEED2 I would recommend a MWT to my patient if it gave me a longitudinal measurement of my patient’s gait speed over time. GAITSPEED3 I would recommend a MWT to my patient if it encouraged my patient to practice exercises to improve their gait speed (within or outside our one-on-one sessions). Clinical usefulness: balance and gait quality BALANCE1 I would recommend my patient use a [MWT] if it gave me a more objective measurement of my patient’s balance. BALANCE2 I would recommend my patient use a [MWT] if it gave me a longitudinal measurement of my patient’s balance over time. BALANCE3 I would recommend my patient use a [MWT] if it encouraged my patient to practice exercises to improve their balance (within or outside our one-on-one sessions). GAITQUAL1 I would recommend my patient use a [MWT] if it gave me a more objective measurement of my patient’s gait quality. GAITQUAL2 I would recommend my patient use a [MWT] if it gave me a longitudinal measurement of my patient’s gait quality over time. GAITQUAL3 I would recommend my patient use a [MWT] if it encouraged my patient to practice exercises to improve their gait quality (within or outside our one-on-one sessions). Clinical usefulness: non-biomechanical measures COG1 I would recommend my patient use a [MWT] if it gave me a more objective measurement of my patient’s cognitive status (e.g., by having them answer a questionnaire or perform an assessment like the Stroop task). COG2 I would recommend my patient use a [MWT] if it gave me a longitudinal measurement of my patient’s cognitive status over time (e.g., by having them repeatedly answer a questionnaire or perform an assessment like the Stroop task). COG3 I would recommend my patient use a [MWT] if it encouraged my patient to practice exercises to improve their cognitive status (e.g., through guided meditation or a cognitive-strengthening game). PAIN1 I would recommend my patient use a [MWT] if it gave me a more objective measurement of my patient’s pain level (e.g., by having them answer a questionnaire electronically). PAIN2 I would recommend my patient use a [MWT] if it gave me a longitudinal measurement of my patient’s pain level over time. PAIN3 I would recommend my patient use a [MWT] if it encouraged my patient to practice exercises to mediate their pain level. Note: PTMAQ items are abbreviated to improve readability. Numerals are used to indicate the following: 1 refers to objective measurement of the variable, 2 refers to longitudinal measurement of the variable over time, and 3 refers to encouragement of practice carried out by patients. r b ¼ correlation of item with mean score for the construct items (as shown in this table); PU ¼ perceived usefulness; MWT ¼ mobile or wearable technology; ACTIVITY ¼ activity level; EA ¼ early adopter; PEOU ¼ perceived ease of use; COG ¼ cognitive status; PAIN ¼ pain level; PTMAQ ¼ Physiotherapy Mobile Acceptance Questionnaire.

Blumenthal et al. Physiotherapists’ and Physiotherapy Students’ Perspectives on the Use of Mobile or Wearable Technology in Their Practice 257 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 Figure 2 Path coefficients estimated by the analysis. Dotted line they involved the clinical variables. ‘‘Encouraging overall indicates the relationship was non-significant activity’’ was grouped with the PU factor, balance and *p < 0.05. gait quality were combined into a single factor, and † p < 0.01. cognitive status and pain level were combined into a ‡p < 0.001. single factor. Note that the first two activity questions are not reported in Tables 2 or 3 because they were not significant relationship with a demographic variable. We associated with any of the six derived factors used to used z-tests because the degrees of freedom were greater formulate the revised components. than 70 for comparison and, with this relatively high number, the t-distribution asymptotes to a z-distribution. As shown in Figure 2, PU was found to be the strongest driver of BI, with the impact of PEOU on BI being largely For the post hoc tests, levels of significance were indirect (as a supplementary effect on PU). PU and PEOU interpreted on the basis of a Bonferroni-adjusted p-value. jointly explained 31% of the variability in EA behaviour. There was a significant main effect for primary setting of Although this indicates that a significant portion of the practice on component 6 (pain level–cognitive status; variability is attributable to the TAM constructs, it is F3,41 ¼ 5.20; p ¼ 0.002). That effect was found to be due likely that constructs outside the TAM (and not assessed to a significant difference between private practice and in this study) also influence the physiotherapists’ EA rehabilitation hospital (z ¼ 3.34; p ¼ 0.001). Participants behaviour with respect to mHealth and their practice. BI in the hospital had a more favourable attitude toward was significantly related to willingness to recommend MWT. We also found a significant main effect for owning MWT in the context of gait speed and in the context of a wearable tracking device on gait speed (F1,73 ¼ 6.15; gait quality and balance, but the relationship of BI to p ¼ 0.008), with participants who owned a tracking pain and cognitive status was weaker. device being more favourable toward use of MWT. We found no other significant effects of age, gender, experi- This study has several limitations. First, the transfera- ence, student status, practice setting, or personal technol- bility of its findings is limited by the small sample of ogy use on any other constructs. Physical therapists rated participants, who were predominantly from Ontario. MWT as a better prospect for use with both gait speed Second, the sample included a relatively large proportion (z ¼ 2.7; p ¼ .007) and gait quality and balance (z ¼ 3.25; of students. Third, we found limited variation in the data p ¼ .001) than for use with the non-biomechanical (pain collected, suggesting congruent perspectives among our level–cognitive status) components. sample. However, this convergence in opinion may have occurred because participants in an online survey are DISCUSSION more likely to be comfortable with using information We found no evidence to suggest that age, gender, technology, and have more interest in its use, than physiotherapists in general. years of experience, practice setting, or personal tech- nology use were predictors of early adoptive behaviour. In formulating the 18 items associated with the clinical This contrasts with the popular notion that acceptance variables in Section III of the questionnaire, we chose to of emerging technology is much greater among the group the items under the six clinical variables. Alterna- (digital native) generation, who have grown up in the tively, these 18 items could have been organized so that age of ubiquitous Internet and mobile connectivity. In the six clinical variables were nested under the goals particular, although our sample had a high proportion of for each clinical variable (more objective measurement, students (46 of 76), we found no significant differences better longitudinal data, more practice). That alternative between students and non-students on any of the mea- instrument would have had 6 items on more objective sured constructs or in personal technology use. measurement (1 for each of the six clinical variables), 6 items on better longitudinal data, and 6 items on Exploratory factor analysis indicated the presence of more practice. It may be of interest in future research to six factors, which mirrored, to a large extent, the concep- examine whether the responses to Section III change, tual structure of the questionnaire that we had developed. depending on whether questions are grouped by the six When variations in the conceptual structure occurred, clinical variables or by the three goals (more objective measurement, better longitudinal data, more practice). Future qualitative studies can build on this work to better illuminate the barriers and facilitators that exist in specific environments and institution types. Our expe- rience suggests that future studies should include a demonstration of existing tools or prototypes to better determine technology acceptance factors. Other recom- mendations for future research are to revise the ques- tionnaire to include other (non-TAM) possible drivers

258 Physiotherapy Canada, Volume 70, Number 3 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 of EA and to administer the revised questionnaire to a outcomes, will need to be demonstrated before particular broader (e.g., international) and larger sample. The ques- technological solutions will be adopted. One other caveat tionnaire could also be modified by researchers develop- from this survey is that ratings were generally lower for ing rehabilitation technologies (by changing the word- PU (as can be seen in the lower mean ratings for PEOU ing appropriately for the rehabilitation technologies of items in Table 3) than for the other components. Conse- interest) so that they can assess whether potential end quently, suitable training initiatives may need to accom- users are ready to use their target devices or technologies. pany the rollout of any new MWT tools for physical therapists. Anyone administering this questionnaire in the future should also consider distributing it using methods other KEY MESSAGES than an online survey to avoid the possibility that the results will be biased toward the views of technology What is already known on this topic enthusiasts. Alternative data collection strategies might Mobile or wearable technology (MWT) is making sig- involve distributing the survey within organizations that include a large number of physiotherapists and at phys- nificant inroads in the consumer space and advanced iotherapy conferences. research, but it is not necessarily widely implemented in the day-to-day practice of physical therapists. Previous CONCLUSIONS questionnaires and usability studies have provided per- This study highlights the importance of understanding spectives on specific technologies, which are useful in that context but limited in scope. physiotherapists’ attitudes and perceptions of mHealth in clinical practice. As key stakeholders, physiotherapists What this study adds determine the appropriateness of interventions by com- This study demonstrates that a previously validated bining clinical reasoning with the needs and preferences of their patients.46 Their acceptance of, or resistance to, framework of technology acceptance is appropriate in emerging technologies will have a significant impact on exploring physiotherapists’ attitudes toward incorporat- the adoption of these tools, and it will likely have an im- ing MWT into their practice. 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Trials. 2014;15:399. 20. Bergmann JHM, McGregor AH. Body-worn sensor design: what do https://doi.org/10.1186/1745-6215-15-399. Medline:25322807 patients and clinicians want? Ann Biomed Eng. 2011;39(9):2299–312. 40. Kaiser HF. An index of factorial simplicity. Psychometrika. https://doi.org/10.1007/s10439-011-0339-9. Medline:21674260 1974;39(1):31–6. https://doi.org/10.1007/BF02291575. 41. Spector PE. Summated rating scale construction: an introduction. 21. North F, Chaudhry R. Apple HealthKit and health app: patient Thousand Oaks (CA): Sage Publications; 1992. https://doi.org/ uptake and barriers in primary care. Telemed J E Health. 10.4135/9781412986038. 2016;22(7):608–13. https://doi.org/10.1089/tmj.2015.0106. Medline:27172297 22. Davis FD. Perceived ease of use, and user acceptance of information technology. Manage Inf Syst Q. 1989;13(3):319–40. https://doi.org/ 10.2307/249008. 23. Holden RJ, Karsh B-T. The technology acceptance model: its past and its future in health care. 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260 Physiotherapy Canada, Volume 70, Number 3 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 42. Zwick WR, Velicer WF. Comparison of five rules for determining the 45. Sanchez G. PLS path modeling with R [Internet]. Berkeley (CA): number of components to retain. Psychol Bull. 1986;99(3):432–42. Trowchez Editions; 2013 [cited 2016 Aug 29]. Available from: http:// https://doi.org/10.1037/0033-2909.99.3.432. www.gastonsanchez.com/PLS_Path_Modeling_with_R.pdf. 43. Matsunaga M. How to factor-analyze your data right: do’s, don’ts, 46. Tatla SK, Shirzad N, Lohse KR, et al. Therapists’ perceptions of social and how-to’s. Int J Psychol Res (Medellin). 2010;3(1):97–110. https:// media and video game technologies in upper limb rehabilitation. doi.org/10.21500/20112084.854. JMIR Serious Games. 2015;3(1):e2. https://doi.org/10.2196/ games.3401. Medline:25759148 44. Clark L, Watson D. Construct validity: basic issues in objective scale development. Psychol Assess. 1995;7(3):309–19. https://doi.org/ 10.1037/1040-3590.7.3.309. APPENDIX 8. Do you use any third-party applications (that you have downloaded onto your smartphone)? Physiotherapy Mobile Acceptance Questionnaire (PTMAQ) j Yes j No Section I—Demographics and Personal Technology Use 1. Age 9. Do you wear or have you ever worn a wearable track- ing device (pedometer, FitBit, Apple Watch, etc.)? j <25 j Yes j 25–34 j No j 35–44 j If yes, what type? ______________________________ j 45–54 j 55þ Section II—Modified Technology Acceptance Model (TAM) 2. Gender Items j Male j Female Response scale: strongly disagree, disagree, neutral, j Prefer not to disclose agree, strongly agree. (The component–item abbrevia- 3. Education level tion appears in parentheses after the item.) j Undergraduate degree j College degree Perceived usefulness j Master’s degree 1. Mobile or wearable technology can promote engage- j PhD j Other _________________ ment between the health care provider and patient or 4. Number of years in profession caregiver. j 0 (student) 2. Mobile or wearable technology may provide me with j 1–4 a way to communicate my patient’s progress more j 5–10 clearly. (PU2) j 11–20 3. I would find it useful to use mobile or wearable tech- j >20 nology to monitor my patient’s progress (e.g., using a 5. Area of specialization FitBit to assess their daily activity levels). (PU1) j ___________________________ 4. Mobile or wearable technology may help my patients 6. Primary setting of practice stay engaged during the rehabilitation process j Private (especially outside our face-to-face sessions). (PU3) j Hospital j Acute care Perceived ease of use j Long-term care 5. I expect using a mobile or wearable device in my j Home care 7. Do you own a smartphone device? (defined as a practice will take a lot of extra time (e.g., a wearable mobile phone that has a touch screen, can access tool that collects data about my patient’s gait). the Internet, and can run third-party apps) (PEOU1) j Yes 6. I expect it will take significant additional training j No before I am comfortable using a mobile or wearable j If yes, what type (iPhone, Android, etc.)? device in my practice. (PEOU3) 7. I expect learning how to use a new mobile or wearable ______________________________ device that was specifically designed for physiotherapy will be quite difficult (e.g., a device that provides feedback on my patient’s balance). (PEOU2)

Blumenthal et al. Physiotherapists’ and Physiotherapy Students’ Perspectives on the Use of Mobile or Wearable Technology in Their Practice 261 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 8. I expect it will be difficult to teach or coach my patients 20. I would recommend my patient use a wearable on the use of a new mobile or wearable device (e.g., a device if it gave me a longitudinal measurement of mobile application that displays instructional videos my patient’s gait speed over time. (GAITSPEED2) on exercises and allows the patient to track their progress). 21. I would recommend my patient use a wearable device if it encouraged my patient to practice Intention to use/early adopter exercises to improve their gait speed (within or 9. I would be willing to try out a new mobile or wear- outside of our one-on-one sessions). (GAITSPEED3) able technology in my practice before it had been clinically validated. (EA1) 22. I would recommend my patient use a wearable device if it gave me a more objective measurement 10. In the future, I would be likely to test or try out new of my patient’s gait quality. (GAITQUAL1) mobile or wearable technology with my patients. (EA2) 23. I would recommend my patient use a wearable device if it gave me a longitudinal measurement of 11. I would be willing to use a new mobile or wearable my patient’s gait quality over time. (GAITQUAL2) technology if I received appropriate training. (EA3) 24. I would recommend my patient use a wearable 12. In the future, if my patient wore a sensor that auto- device if it encouraged my patient to practice exer- matically collected information about their health or cises to improve their gait quality (within or outside well-being, I would refer to the data to understand of our one-on-one sessions). (GAITQUAL3) how my patient is responding to treatment. 25. I would recommend my patient use a mobile device Section III—Likelihood of Recommending an mHealth Tool if it gave me a more objective measurement of my for Specific Clinical Purposes patient’s cognitive status (e.g., by having them 13. I would recommend my patient use a wearable answer a questionnaire or perform an assessment like the Stroop task). (COG1) device if it gave me a more objective measurement of my patient’s overall activity level. 26. I would recommend my patient use a mobile device 14. I would recommend my patient use a wearable if it gave me a longitudinal measurement of my device if it gave me a longitudinal measurement of patient’s cognitive status over time (e.g., by having my patient’s overall activity level over time. them repeatedly answer a questionnaire or perform 15. I would recommend my patient use a wearable an assessment like the Stroop task). (COG2) device if it encouraged my patient to increase their overall activity level (within or outside of our 27. I would recommend my patient use a mobile device one-on-one sessions). (ACTIVITY3) if it encouraged my patient to practice exercises to 16. I would recommend my patient use a wearable improve their cognitive status (e.g., through guided device if it gave me a more objective measurement meditation or a cognitive-strengthening game). of my patient’s balance. (BALANCE1) (COG3) 17. I would recommend my patient use a wearable device if it gave me a longitudinal measurement of 28. I would recommend my patient use a mobile device my patient’s balance over time. (BALANCE2) if it gave me a more objective measurement of my 18. I would recommend my patient use a wearable patient’s pain level (e.g., by having them answer a device if it encouraged my patient to practice questionnaire electronically). (PAIN1) exercises to improve their balance (within or outside of our one-on-one sessions). (BALANCE3) 29. I would recommend my patient use a mobile device 19. I would recommend my patient use a wearable if it gave me a longitudinal measurement of my device if it gave me a more objective measurement patient’s pain level over time (e.g., by having them of my patient’s gait speed. (GAITSPEED1) repeatedly answer a questionnaire electronically). (PAIN2) 30. I would recommend my patient use a mobile device if it encouraged my patient to practice exercises to mediate their pain level. (PAIN3)

https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 EDUCATION Simulation Experiences in Canadian Physiotherapy Programmes: A Description of Current Practices Meaghan Melling, BSc, MSc, MScPT;* Mujeeb Duranai, BSc, MScPT;* Blair Pellow, BSc, MScPT;* Bryant Lam, BMSc, MScPT;* Yoojin Kim, BSc, MScPT;* Lindsay Beavers, BSc, MPT;*† Erin Miller, BHSc, MScPT, MHM;*† Sharon Switzer-McIntyre, BPE, BScPT, MEd, PhD*† ABSTRACT Purpose: Although health care professional education programmes around the world are increasingly using sophisticated simulation technology, the scope of simulation use in Canadian physiotherapy programmes is currently undefined. The current study explores the definitions of simulation, its current use, and the perceived benefits and barriers in Canadian entry-to-practice physiotherapy programmes. Method: Using a qualitative, descriptive study approach, we contacted Canadian physiotherapy programmes to identify faculty members with simulation experience. Using a semi-structured interview format, we asked participants to discuss their perspectives of simulation in their physiotherapy programmes. Interviews were audio recorded, transcribed, and analyzed for themes. Results: Of 13 eligible Canadian physiotherapy programmes, participants from 8 were interviewed. The interviews revealed three major themes: (1) variability in the definition of fidelity in simulation, (2) variability in simulation use, and (3) the benefits of and barriers to the use of simulation. Conclusions: Variability in the definition of fidelity in simulation among Canadian physiotherapy programmes is consistent with the current literature, highlighting a spectrum of complexity from low fidelity to high fidelity. Physiotherapy programmes are using a variety of simulations, with the aim of creating a bridge from theoretical knowledge to clinical practice. This study describes the starting point for characterizing simulation implementation in Canadian physiotherapy programmes and reflects the diversity that exists across the country. Key Words: education; high fidelity simulation training; patient simulation; qualitative research. RE´ SUME´ Objectif : autour du monde, les programmes de formation des professionnels de la sante´ font de plus en plus appel a` une technologie de simulation raffine´ e. On ne connaıˆt pas l’ampleur de l’utilisation de la simulation dans les programmes canadiens de physiothe´ rapie. La pre´ sente e´ tude porte sur les de´ finitions de la simulation, son utilisation actuelle et les avantages et obstacles perc¸ us a` son utilisation dans les programmes canadiens de physiothe´ rapie de base. Me´ thodologie : les chercheurs ont utilise´ une approche descriptive et qualitative. Ils ont pris contact avec les programmes canadiens de physiothe´ rapie pour savoir quels professeurs avaient de l’expe´ rience en simulation. Au moyen d’entrevues semi-structure´ es, ils ont demande´ aux participants de parler de leurs perspectives de la simulation au sein de leurs programmes de physiothe´ rapie. Ils ont enregistre´ les entrevues sur bande sonore, les ont transcrites et analyse´ es pour en de´ gager les the` mes. Re´ sultats : au sein des treize programmes canadiens de physiothe´ rapie admissibles, les participants de huit d’entre eux ont e´ te´ interviewe´ s. Les entrevues ont fait ressortir trois the` mes majeurs : 1) la variabilite´ de la de´ finition de fide´ lite´ de la simulation, 2) la variabilite´ dans l’utilisation de la simulation et 3) les bienfaits et les obstacles lie´ s a` l’utilisation de la simulation. Conclusions : la variabilite´ de la de´ finition de fide´ lite´ de la simulation dans les programmes canadiens de physiothe´ rapie correspond aux constatations des publications actuelles, ce qui fait ressortir un spectre de complexite´ qui passe de la faible fide´ lite´ a` la haute fide´ lite´ . Les programmes de physiothe´ rapie font appel a` diverses simulations afin de cre´ er un pont entre les connaissances the´ oriques et la pratique clinique. La pre´ sente e´ tude de´ crit le point de de´ part pour caracte´ riser l’adoption de la simulation dans les programmes canadiens de la physiothe´ rapie et refle` te la diversite´ au pays. Simulation is defined as any educational aid that using standardized patients (an individual trained to mimics a clinical scenario to facilitate experiential learn- portray a patient in a clinical situation) and part-task ing.1 In the health care setting, simulation ranges from trainers (artificial anatomical sections of a body) to using From the: *Department of Physical Therapy; †Ontario Internationally Educated Physical Therapy Bridging Program, University of Toronto, Toronto. Correspondence to: Meaghan Melling, Department of Physical Therapy, University of Toronto, 160–500 University Ave., Toronto, ON M5G 1V7; [email protected]. Contributors: All authors designed the study; or collected, analyzed, or interpreted the data; and drafted or critically revised the article and approved the final draft. Competing Interests: None declared. This research was funded by the Ontario Internationally Educated Physical Therapy Bridging Program at the University of Toronto. Acknowledgements: This research was completed in partial fulfillment of the requirements for an MScPT degree at the University of Toronto. The authors acknowledge Marina Bastawrous for her assistance in this research. Physiotherapy Canada 2018; 70(3);262–271; doi:10.3138/ptc.2017-11.e 262

Melling et al. Simulation Experiences in Canadian Physiotherapy Programmes: A Description of Current Practices 263 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 interactive, sophisticated manikins.2–4 Health care educa- lation in health professional educational programmes. tion incorporates simulation to develop students’ clinical Thus, with more technologically advanced and sophisti- skills by providing repetitive learning opportunities in a cated manikins being integrated into health care edu- controlled environment.5 cation curricula, it is beneficial to explore the current perceptions of high fidelity and low fidelity to gain a Although the implementation of simulation has been better understanding of how these terms are being used well documented in medicine and nursing, the physio- to frame simulation use in physiotherapy education. therapy education literature has underrepresented the topic.6,7 The body of physiotherapy-specific literature Given the gaps in the literature described here, this that does exist has described simulation as a vital learn- study explores the definition of, perceived benefits and ing tool for addressing the specific learning objectives barriers associated with, and use of simulation in entry- included in physiotherapy curricula. The one systematic to-practice physiotherapy programmes across Canada. review conducted reported a variety of types and uses of This study also provides an in-depth look at simulation simulation in physiotherapy programmes, ranging from experiences in physiotherapy education through the lens computer simulation education to using simulation in of the educators, an area that has not previously been interprofessional events.8 explored. Studies have shown that simulation-based education METHODS improves self- and preceptor-reported independence, clin- ical reasoning, and judgement in physiotherapy students Study design during their clinical placements.9,10 Through simulation, This study used a qualitative, descriptive methodology students consolidate knowledge and develop competencies in clinical skills.11 Simulated scenarios also address non- using individual semi-structured interviews. The study technical skills (e.g., interpersonal skills, manners, pro- used collected individual narratives and thematic analysis fessionalism, teaching ability), and patients describe these to provide descriptive insights into simulation use in skills as vital qualities when recalling good experiences Canadian physiotherapy programmes.23 with physiotherapists.12 Many components of the essen- tial competencies outlined by the Essential Competency Recruitment and sample Profile for Physiotherapists in Canada are addressed using Research was conducted in the Department of Physical simulation.13,14 Furthermore, simulation has been shown to be an excellent learning tool for cardiorespiratory and Therapy at the University of Toronto, and the study pro- acute care techniques including tracheal suctioning and tocol was approved by the University of Toronto Health oxygen titration, both of which are high-risk activities for Sciences Research Ethics Board. Canadian physiotherapy Canadian physiotherapists.14–16 These findings support programmes were the targeted population. Members of the use of simulation as an adjunct to learning in physio- the Canadian Council of Physiotherapy University Pro- therapy education. grams were contacted by e-mail and asked to delegate a participant from their programme who met the study’s Australia, the United Kingdom, and the United States inclusion and exclusion criteria. are the primary nations, to date, conducting research on the use of simulation in physiotherapy; no current litera- Inclusion and exclusion criteria ture has explored the use of simulation in physiotherapy To be included in this study, participants must first programmes in Canada.15,17–19 Given the variation that exists in the scope of physiotherapy practice in Canada have been involved in simulation in one of the following compared with other countries, exploring simulation capacities: (1) they had taught using simulation, (2) they in the context of the Canadian physiotherapy education had administrative experience with simulation, or (3) system is warranted.20 they had overseen simulation. In addition, they needed the ability to be interviewed in English and had to have In addition to the absence of studies exploring simu- been deemed the most appropriate individual for the lation use in Canadian physiotherapy education, there is study by the chair of their physiotherapy programme, a lack of consistency about the fidelity of the technique.6 based on the study objective outlined in our initial e-mail Simulation is often divided into high fidelity and low invitation. We excluded participants if they were current fidelity; however, even here, the terminology is incon- master’s-level, entry-to-practice physiotherapy or bridg- sistent, and definitions vary throughout the literature. ing programme students, working in a physiotherapy pro- High-fidelity simulation is most often defined in terms gramme conducted in French, or both. of using sophisticated, computer-driven technology, but it is also defined by the believability of a scenario.3,21,22 In Canada, 10 entry-to-practice physiotherapy pro- Low-fidelity simulation is often framed as using lower grammes and three bridging programmes for inter- levels of technology such as part-task trainers, standar- nationally educated physiotherapists are conducted in dized patients, and role playing.4 This variation in defini- English. Bridging programmes were included in this study tions impedes the discussion of how to implement simu- because they also educate pre-licensed physiotherapists. We required all participants to provide computer-based written consent via e-mail to participate.

264 Physiotherapy Canada, Volume 70, Number 3 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 Data collection as associate director and programme administrator, clin- Five members of our research team (MM, MD, BP, BL, ical placement coordinator, and professor. Of the partic- ipants who identified holding a teaching position, 75% YK) developed a semi-structured interview guide with were involved in the cardiorespiratory or acute care units open-ended questions (reproduced in the Appendix). of their programmes. The participants’ experience using The aim was to discuss the participants’ perspectives on simulation ranged from 3 to 20 years. how high-fidelity simulation and low-fidelity simulation are defined, how simulation is used in their programmes, From the interviews, we identified three major themes what their goals are in using simulation, and the per- in the data: (1) a variability in the definition of fidelity in ceived benefits and challenges of using simulation. One simulation, (2) a variability in simulation use, and (3) of three investigators (MM, MD, BP), accompanied by the benefits of and barriers to simulation use. one of two note takers (BL, YK) interviewed participants by telephone. We verbally administered a demographic Theme 1: variability in the definition of fidelity in simulation questionnaire administered at the end of the interviews To gauge how simulation is defined in Canadian to provide context for the participants’ perspectives. Each interview was audio recorded, professionally tran- physiotherapy programmes, we asked participants to pro- scribed, and reviewed by one of the five investigators vide examples of how they implemented both high- and (MM, MD, BP, BL, YK) to ensure accuracy. Any names low-fidelity simulation in their institution. The majority in the transcripts were de-identified using a numeric associated high-fidelity simulation with manikins of vary- code after we had developed the master code list and ing types. This included higher technology manikins, the master identifier list. which connect to monitors and computers, as well as full-body, non-responsive manikins with no embedded Data analysis computer technology. The most common example partic- Five investigators (MM, MD, BP, BL, YK) analyzed the ipants provided of low-fidelity simulation was the use of standardized patients, such as patients from the commu- data using the six steps of thematic analysis outlined by nity, students role playing with one another, and persons Braun and Clarke.23 Each transcript was coded by two hired and trained to emulate specific conditions and investigators individually, and then, as a group, the in- patient responses. Two participants also defined using vestigators reviewed each coded transcript to ensure part-task trainers as low-fidelity simulation. consistency in analysis. The investigators listened to the audio recordings and critically examined the transcripts We did not give participants definitions of high- and to identify and make notes on the tone of the participants’ low-fidelity simulation, and several were uncertain of answers, become familiar with the data, and check for how to define them. After some probing, some qualified errors in transcription. The same five investigators de- their responses by saying that their interpretation of the veloped a codebook to determine the preliminary topics term fidelity was based on the extent of technology used. discussed, and open coding was conducted. We used NVivo, version 9 (QSR International, Doncaster, Victoria, So, I’m using low-fidelity synonymously with the term low Australia), during the coding process to manage the data. technology. . . . However, you can have a low-technology The five investigators organized the codes into categories and very high-fidelity situation. For example, our task that enabled them to develop themes, which were re- trainers you can feel the carina when you go down to viewed by all investigators (MM, MD, BP, BL, YK, LB, suction and you can feel the resistance as it’s passing EM, SSM) to ensure that they were robust and distinct. through the oropharynx, so those are high-fidelity, very All the investigators participated in refining and finaliz- real believable feelings that you have as you’re learning ing the themes to convey a clear, concise message.23 how to suction a patient. (Participant 5) RESULTS A few participants commented on that the perceived risk of the simulated scenario contributed to their inter- Participants’ demographics pretation of fidelity. Of the possible 13 entry-to-practice or internationally My impression was like high and low fidelity was more educated bridging Canadian physiotherapy programmes about the risks involved for the students dealing with conducted in English, 8 participated in this study. Eight that particular patient. . . . I don’t think it is about sophis- separate individuals participated in the interviews, 2 ticated or not sophisticated. . . . I really don’t know because from bridging programmes and 6 from master’s-level high-fidelity could also mean that you know it’s authentic, entry-to-practice programmes. The participating bridging representation of like what the real thing would [be] like. programmes were associated with two universities partic- (Participant 2) ipating as entry-to-practice programmes and may have had access to similar resources. Most participants held The perceived risk was reported as consisting of mul- multiple positions in their respective programmes, such tiple factors, including the inherent risk of the specific skill being performed (e.g., suctioning vs. interviewing) and the perceived safety of the simulated environment

Melling et al. Simulation Experiences in Canadian Physiotherapy Programmes: A Description of Current Practices 265 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 (e.g., the presence vs. absence of a supervisor to assist if her programme did not use any form of manikin for sim- necessary). ulation, despite the fact that she had reported having access to a simulation center. However, her department Several participants also commented that the degree was researching how it could use manikins in the cardi- of complexity guided their interpretation. orespiratory component of its curriculum or in an inter- professional capacity. In my definition, I thought it was just around the com- plexity of the interaction and almost from the technolog- Area of practice ical side. So, there’s a lot of resources and technology and The majority of schools described using manikin sim- cost that goes into the high fidelity, like a simulation lab. (Participant 7) ulation exclusively for acute care scenarios, cardiorespira- tory scenarios, or both. Participants considered simula- Thus, interestingly, participants used varying degrees tion to be an appropriate learning tool in these settings of technology, scenario risk, and complexity to deter- because of the added complexity of the scenarios and mine their criteria for fidelity. The degree of complexity the ability to use technology to manipulate them. related to numerous features of the simulated scenario, including the setup of the simulated environment (e.g., Manikins . . . are hooked up to monitors, and we can adjust a hospital setting vs. the institution’s clinical skills lab), everything from breathing, coughing, crying, you know, the demands of the scenario itself (e.g., reproducing a temperature, blood pressure, like everything that you would single psychomotor skill vs. multiple technical and non- find in a real regular hospital. It’s really like a real hospital technical skills, with responses from the simulator), the surgical room, or hospital bedroom. (Participant 2) complexity of the technology involved, and the overall perceived authenticity of the scenario. These simulated scenarios were typically presented near the beginning of a programme to provide early ex- Theme 2: variability in simulation use posure to the rapidly changing environments and com- mon acute care skills (e.g., tracheal suctioning, heart Equipment and lung auscultation, and mobilization with multiple We also asked participants to identify the simulation lines) required of physiotherapists. Some participants reported wanting to incorporate the use of manikins for equipment that was used in their programme’s curriculum. simulation into the orthopedic curricula in the future; Most commonly used were manikins, part-task trainers, however, standardized patients were used most often and standardized patients. Different simulation equipment for students to assess patients’ strength, range, and served varying purposes at each institution. For example, mobility. When discussing the neurological curricula, the majority of universities most often used manikins most participants reported recruiting standardized patients, and part-task trainers to promote the acquisition of tech- or real patients from the community, to be part of sce- nical skills (e.g., auscultation, tensoring limbs, acute care narios because certain characteristics of neurological mobilization, and tracheal suctioning), whereas they used conditions, such as spasticity, were difficult to capture standardized patients more often for non-technical skills using manikins. acquisition (e.g., communication, collaboration, and pro- fessionalism). Several participants also said they used Technical skills acquisition standardized patients for basic assessment and treatment All schools reported using simulation to facilitate planning; for objective, structured clinical examinations; and to prepare for the Physiotherapy Competency Exami- students’ acquisition of technical skills. Auscultation of nation. In addition, one participant used online cases to breath sounds and tracheal suctioning were skills identi- simulate real-world scenarios and combine decision fied by all the participants, and the majority used mani- making with technical skill. kins and part-task trainers for this purpose. Additional skills used in simulated settings included early mobiliza- The majority of participants had off-site access to tion in the acute care setting, measuring and interpreting manikins at teaching hospitals and multi-faculty simulation vital signs, oxygen titration, and tensor wrapping of limbs. centers. These centers used a combination of standardized patients and manikins for simulation at inter-professional We usually use [manikins] in terms of looking at different events, ranging from a single event in the physiotherapy vital signs so you get them to practise taking heart rates, programme to extracurricular student courses available blood pressure, respiratory rate and some transfers and every week. In addition to involving physiotherapy stu- suctioning, so usually it’s just to work on those psycho- dents, these scenarios included students from the faculties motor skills. (Participant 8) of medicine, nursing, occupational therapy, midwifery, pharmacy, social work, dentistry, and speech-language Some schools reported using simulation to emulate pathology. Several participants also reported that their acute clinical settings, playing out unpredictable scenarios programmes had on-site access to computerized manikin to help students acquire the clinical skills necessary in a simulation equipment. One participant indicated that cardiorespiratory environment. These scenarios ranged

266 Physiotherapy Canada, Volume 70, Number 3 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 from practising basic technical skills on a manikin to It kind of bridges what they learned I guess in their multi-component scenarios requiring physiotherapy as- lectures and maybe in their labs—put it into the context sessment, treatment, and decision making. Standardized of a clinical application with a patient that feels a little patients were also used for technical clinical skills acqui- bit I think more engaged than just reading, ‘‘Ms. Smith is sition in areas such as performing joint range of motion, a 49-year-old blah-blah-blah.’’ (Participant 7) manual muscle testing, ambulation, gait aid training, and basic assessment skills. I can change the manikins to have . . . altered vital signs that you may see in . . . people that are sick, or elderly Non-technical skills acquisition patients, or people after surgery . . . [who have an] irregular The majority of participants emphasized using simula- pulse, arrhythmias, weak pulse—things that they might not be feeling on themselves. . . . They’re not going to be tion in general for non-technical skills acquisition, specif- treating healthy . . . 23-year-old people. They’re going to ically communication, collaboration, and professionalism. be treating people [who] are elderly and sick. [Simulation is] . . . sort of that bridge from practice to sort of a . . . real It helps with some of that communication, some of those situation. (Participant 8) ‘‘non-technical’’ skills, so that’s a beautiful thing about simulation. Simulation can run the gamut from just pure The majority of participants stated that using simula- psychomotor task acquisition skills all the way to, I would tion enabled students to acquire psychomotor skills and argue, non-technical skills, collaboration, communication, gain confidence in performing them. Simulation also team functioning, etcetera. (Participant 5) allowed students to develop problem-solving skills. A few participants reported that students developed other The majority of participants also reported using simu- skills such as improved self-reflection on their perform- lation to develop students’ communication skills and ances; interviewing and assessment skills; and collabora- improve their interactions with patients and families. tion or communication with patients, peers, and health Many participants reported that they used complex, care professionals. Several participants also identified inter-professional simulations, as mentioned earlier, with increased student confidence in their lecture material: both manikins and standardized patients to carry out ‘‘I think there is some benefit to practising their skills in collaborative and communicative learning objectives with a more realistic environment than on a classmate and other health care professionals. just gives them a little bit more confidence I guess before they go on placement’’ (Participant 4). Debriefing session All participants described having a debriefing session The benefits of specific types of simulation were also mentioned. Standardized patients were more often when a simulated scenario finished, and several thought effective for students’ acquisition of interpersonal skills. it was one of the most important components of using Participants consistently reported that manikins were simulation. more useful for providing a safe environment for high-risk skills acquisition and creating more realistic scenarios. I really felt strongly about having that debriefing as most of the learning occurs at that point. (Participant 1) [Using manikins for simulation] is much more realistic, and it also allows it [to be performed] in a very safe envi- That’s a really important part of the simulation that ronment where they can practise these skills without we have the debrief and people can talk about it. . . . It’s hurting anybody. If they have red flags or do something really meant to be a learning environment, not a puni- dangerous, at least it is done in a learning setting where tive environment or a stressful evaluation environment. no one is getting injured. . . . It’s a really great step before (Participant 8) they are actually going on to their clinical placements and working with real people, real patients. (Participant 1) Despite the value of the debriefing component, there was some variability in how it took place. Debriefing A few participants also said that manikins could pro- sessions could consist of summative or formative feed- vide a replacement for experiences that students may back; delayed (post-simulation scenario) or immediate not encounter in clinical placement (e.g., tracheal suc- (during simulation scenario) feedback; and feedback re- tioning and oxygen titration). Many participants added ceived from peers, from clinical facilitators, or through that they wanted to include computerized manikins self-reflection. Half the participants also reported record- in future initiatives on the basis of the benefits we have ing videos that students could watch to reflect on their described. own simulation experience. The barriers described by participants to implement- Theme 3: benefits and barriers associated with using simulation ing simulation were similar, whether they were referring Participants identified a variety of benefits of and to manikins or standardized patients. All the participants identified logistics as a major barrier—for example, organ- barriers to implementing simulation in their physio- izing students, staff, and volunteers; creating time in a busy therapy programmes. All reported that simulation pro- physiotherapy curriculum; and coordinating with other vided increased authenticity and stimulated students to faculties to use shared facilities were added tasks. ‘‘There develop clinical reasoning and integrate their lecture material into clinical practice.

Melling et al. Simulation Experiences in Canadian Physiotherapy Programmes: A Description of Current Practices 267 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 is [sic] eight different rooms acting every 8 minutes or 10 Uses of simulation minutes at the same time, you know switching actors, In general, simulation is consistently used as a tool to switching rooms and all that. It takes a lot of coordina- tors within the sim center’’ (Participant 2). bridge the gap between didactic lectures and physio- therapy clinical practice. Many of the reported purposes The time commitment required to train personnel to of using simulation correlated with the eventual objective run the simulation scenarios was also mentioned as a of ensuring acquisition of skills outlined in the Essential barrier by the majority of participants. Half included the Competency Profile for Physiotherapists in Canada.13 Par- cost of training personnel as a barrier to implementing ticipants explicitly described the physiotherapist roles of simulation. communicator, collaborator, and professional as those that students should learn when performing simulated Well, it’s not only training, but it is the actual hours that activities. they spend, the whole activity has to be accounted for with our time, it’s the actors’ time, it’s the actual session Separating the uses of simulation by fidelity also has time, all the coordinators within the sim center because it interesting implications for student education. The most doesn’t just take the actors, it takes the whole team of co- frequently stated objective for using low-fidelity simula- ordination, coordinating all these activities. (Participant 2) tion was for students to acquire non-technical skills, whereas the objective for using high-fidelity simulation Few participants identified the cost of initial purchase was for students to practise procedural, high-risk skills. or the maintenance of computerized manikins as a Identifying high-fidelity scenarios as useful specifically barrier to using simulation. The cost of renting space for the safe practice of high-risk skills is consistent with to run scenarios and store equipment were also rarely the main uses of manikins reported in the literature.1,25 mentioned. Furthermore, participants described using both types of simulation to target distinct student learning objectives. DISCUSSION Although most participants used manikins solely for the purpose of procedural motor skills acquisition, some Definition of fidelity reported using standardized patients and manikins in Following most of the current literature on simula- the same scenario. It is important to consider opportunities to create scenarios that combine both types of simulation. tion, we began this study by defining fidelity as being based on technology.3,21 Our hypothesis equated high- Creating mixed-fidelity scenarios by combining mani- fidelity simulation with computerized manikins and low- kins and standardized patients could integrate the per- fidelity simulation with less sophisticated, part-task ceived benefits of low- and high-fidelity simulation, trainers and standardized patients. Participants reported allowing students to simultaneously learn technical and a variety of definitions, some based on technology; most, non-technical skills. For example, a station could require however, included complexity or authenticity in their a student to auscultate a manikin for breath sounds definition. For example, participants reported that com- while having to interact appropriately with a distraught plex scenarios involved authentic emulation of clinical family member, all under the additional pressure from environments, applying high-risk skills, more complex other health care team members of having to make deci- technology, and stressful dynamic scenarios. sions. Studies have also shown that mixed-fidelity sce- narios, in a medical and paramedical student population, Placing these components under the umbrella term highlight incompetency in learner-specific skills and iden- of complexity increases the scope of the term fidelity tify skills that need to be further developed.26,27 in simulation and lays a promising foundation for im- proving future communication and clinical practice in Many participants cited using high-fidelity manikins Canadian physiotherapy programmes. Numerous coun- for inter-professional practice to increase students’ ex- tries are increasingly integrating high-fidelity manikins posure to collaboration and communication with other into physiotherapy and other health care professional pro- health care faculties. The current body of literature grammes to promote numerous benefits to students.6,24 has documented inter-professional simulation events, Ensuring a clear definition of fidelity across our physio- which include physiotherapists, physiotherapy students, therapy programmes represents a critical first step in or both.28–31 King and colleagues29 explored using mixed- promoting a common platform of conversation and, fidelity simulation (manikin and standardized patient), eventually, standardization of the implementation of sim- as well as only standardized patients, for physiotherapy, ulation. In Canadian physiotherapy education, fidelity in registered nursing, and respiratory therapy students in simulation could be defined using a gradient of complex- a hospital scenario in which a patient was in respira- ity, ranging from high-fidelity scenarios using dynamic tory distress. Students’ responses were similar in both components, authentic tasks, and intricate technology scenarios; they felt nervous and realized that they needed to low-fidelity scenarios using standardized patients in to develop their communication skills and knowledge informal environments.

268 Physiotherapy Canada, Volume 70, Number 3 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 of the scope of practice among professions in real-life physiotherapy students are unable to acquire during clin- scenarios. If the goal of inter-professional simulation is ical placements17,33—primarily cardiorespiratory practice to enable students to gain confidence in their communi- and higher risk activities, such as tracheal suctioning cation and collaboration skills, the fidelity of the simula- and oxygen administration. One study indicated that some tion (manikin vs. standardized patient) may not be an high-fidelity scenarios caused more psychological stress essential element to consider. However, if it is included than clinical placements and may have had a negative specifically in a physiotherapy curriculum, a mixed-fidelity impact on physiotherapy students’ education;34 how- scenario may be more beneficial because it targets stu- ever, that study used third-year undergraduate physio- dents’ technical and non-technical skills development. therapy students in Australia, some of whom had only 3 days of exposure to an acute care environment. The Another consistent comment of the participants about researchers suggested that a gradual increase in student low- and high-fidelity simulation is the presence of a stress during realistic simulation scenarios would mediate post-scenario debriefing session, although the timing, the transition to clinical placement. Despite a handful of method, and specific goals of the session varied. There studies citing caution with high-fidelity simulation, the is agreement in the literature that encouraging feedback body of research is positive, reporting numerous benefits and holding debriefing sessions are key methods of over low-fidelity simulation, including reliable formative maximizing the learning benefits of simulation.5,19 A study assessment, improved skills acquisition, and student conducted by Day and colleagues15 showed that clinical confidence.4,27,35 observation of students’ tracheal suctioning performance was improved, as was their knowledge retention, when Because of the variation in implementation described, sessions were followed up with tailored, performance- there may be a need to standardize when and how simu- based feedback. Debriefing guides, such as the Debrief- lation, especially high-fidelity simulation, is used in ing Assessment for Simulation in Healthcare, can also Canadian physiotherapy curricula. Standardization across help instructors introduce a standardized debriefing physiotherapy programmes—bringing each curriculum session into physiotherapy student simulations.32 Further up to the same level of simulation practice—may come research is necessary, however, before making specific at a cost; however, it could give pre-licensed physio- recommendations for implementing debriefing sessions therapy students across the country equal opportunities in physiotherapy simulation education in Canada. to develop the skills necessary to become competent, safe, and successful physiotherapists. Implementing simulation Overall, the reported benefits and barriers associated This study had several limitations. The first was that we recruited participants from only English-language with implementing simulation in this study reflect the programmes because the interviewers were not bilingual. published literature. The benefits named by the partici- There are 15 physiotherapy schools in Canada; 10 pro- pants were similar to the collection from a review com- grammes are conducted in English, and 5 are conducted paring student inter-professional (high-fidelity) simulation in French. In addition, there are 4 physiotherapy bridging education experiences.31 The overlapping benefits included programmes for internationally educated physiothera- a realistic, yet safe environment for high-stress situations, pists, 3 conducted in English and 1 in French. This may opportunities to develop communication, and feedback have reduced the richness of data. A second limitation from the experience. was that some individuals interviewed did not think they were the best person to speak about the day-to-day Regardless of the type of simulation used, low fidelity use of simulation (e.g., Participant 2 stated, ‘‘I am less or high fidelity, the barriers identified by participants familiar with those because I don’t participate in high- are similar. The most common barriers are scheduling or low-fidelity simulation with manikins; it would be and logistics, followed by the cost of training personnel. more the professor who works in the cardiorespiratory Palaganas and colleagues30 discussed the challenges of unit’’), and this may also have reduced the richness of simulation in inter-professional health care education the data. Nevertheless, we decided to retain this indi- programmes; they included scheduling, time, and educat- vidual in this study because she fit the inclusion criteria ing staff. Because many programmes have mainly off-site of having administrative involvement with simulation in access to equipment, the added challenge of coordinating that physiotherapy programme. with other faculties to use their training facilities may overshadow cost as a barrier to high-fidelity implementa- CONCLUSION tion. Future research is needed to further investigate why Simulation in Canadian physiotherapy education has programmes may be under-using high-fidelity simulation given participants’ reports of the increased benefits for received minimal attention in the peer-reviewed litera- student education. ture. This study describes current practices of simulation in physiotherapy programmes in the country, specifically Research, undertaken primarily in Australia, has docu- how programme representatives defined high-fidelity mented a steady progression toward using high-fidelity versus low-fidelity simulation, the perceived benefits simulation to supplement the competency in skills that

Melling et al. Simulation Experiences in Canadian Physiotherapy Programmes: A Description of Current Practices 269 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 and barriers associated with using simulation, and how 3. Maran NJ, Glavin RJ. Low- to high-fidelity simulation - a continuum their respective curricula integrated simulation. On the of medical education? Med Educ. 2003;37(Suppl 1):22–8 http:// basis of this study, simulation, in a variety of forms, is dx.doi.org/10.1046/j.1365-2923.37.s1.9.x. Medline:14641635 currently integrated into Canadian physiotherapy edu- cation programmes conducted in English. Although 4. Ryall T, Judd BK, Gordon CJ. Simulation-based assessments in participants used a variety of definitions to categorize health professional education: a systematic review. J Multidiscip the fidelity of the simulation, these results provide a Healthc. 2016;9:69–82. Medline:26955280 unique opportunity to define fidelity in terms of the complexity of a scenario. 5. McGaghie WC, Issenberg SB, Petrusa ER, et al. A critical review of simulation-based medical education research: 2003-2009. Med This study also serves as the starting point for charac- Educ. 2010;44(1):50–63 http://dx.doi.org/10.1111/j.1365- terizing simulation use in physiotherapy programmes in 2923.2009.03547.x. Medline:20078756 Canada. The results reflect the diversity that exists across the country in the use of simulation with respect to 6. Issenberg SB, Scalese RJ. Simulation in health care education. curriculum implementation, the equipment used, the Perspect Biol Med. 2008;51(1):31–46. Medline:18192764 targets for skills acquisition, the importance of debrief- ing, and the perceived benefits and costs of using high 7. McGaghie WC, Issenberg SB, Barsuk JH, et al. A critical review of versus low fidelity. We recommend that Canadian physio- simulation-based mastery learning with translational outcomes. therapy programmes and governing regulatory bodies Med Educ. 2014;48(4):375–85 http://dx.doi.org/10.1111/ convene to examine the effectiveness and unique stu- medu.12391. Medline:24606621 dent learning outcomes and behaviors achieved from high-fidelity versus low-fidelity simulation. This would 8. Mori B, Carnahan H, Herold J. Use of simulation learning aid in developing optimal recommendations and standard- experiences in physical therapy entry-to-practice curricula: a ization for the future use of simulation in physiotherapy systematic review. Physiother Can. 2015;67(2):194–202 http:// curricula. dx.doi.org/10.3138/ptc.2014-40E. Medline:25931672 KEY MESSAGES 9. Babyar SR, Pivko S, Rosen E. Pedagogical tools to develop clinical reasoning: physical therapy students’ perspective. J Allied Health. What is already known about this topic 2010;39(3):e97–104. Medline:21174014 Simulation in health care education is widely docu- 10. Cahalin LP, Markowski A, Hickey M, et al. A cardiopulmonary mented and used in numerous countries, especially in the instructor’s perspective on a standardized patient experience: fields of medicine and nursing, and it has been shown to implications for cardiopulmonary physical therapy education. have a positive impact on student skills acquisition. Pres- Cardiopulm Phys Ther J. 2011;22(3):21–30. Medline:21886477 ently, there is a gap in the literature regarding the use of simulation in Canadian physiotherapy programmes. 11. Yeung E, Dubrowski A, Carnahan H. Simulation-augmented education in the rehabilitation professions: A scoping review. Int J What this study adds Ther Rehabil. 2013;20(5):228–36. http://dx.doi.org/10.12968/ Canadian physiotherapy programmes are using both ijtr.2013.20.5.228. high- and low-fidelity simulation to bridge students’ 12. 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Melling et al. Simulation Experiences in Canadian Physiotherapy Programmes: A Description of Current Practices 271 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 APPENDIX 5. Can you describe any challenges, if any, with imple- Interview guide: Semi-structured questions menting simulation in the physiotherapy curriculum 1. Can you tell me about your role in the physiotherapy in your programme? programme? Probing Questions Probing Questions e How long have you been involved in the e Can you provide us with an example? curriculum? e Why do you feel this is a challenge? e Can you elaborate on the type of students you e How have you met this challenge? interact with? e Can you describe the structure of the physio- 6. Can you give an example of how low-fidelity therapy curriculum at your school? simulation is used in your programme? 2. Can you describe an example of how you use simulation in your physiotherapy programme? Probing Questions Probing Questions e Why do you describe this as low fidelity? e What is it used for? By whom? e How often do you use this? e Where is it used in the curriculum? e Why is it used? e In what capacity is it used? For example, open e Who implements this? labs, teaching. e When do you use this? e How much and/or how often? e Where is this used? e Do you have any other examples of how it’s used in your programme? 7. Can you give an example of how high-fidelity 3. You’ve described several examples of using simula- simulation is used in your programme? tion in your programme; what is your overall goal for using this as a teaching strategy? Probing Questions e Why do you describe this as high fidelity? 4. Can you describe the benefits of using simulation, e How often do you use this? if any, in the physiotherapy curriculum in your e Why is it used? programme? e Who implements this? Probing Questions e When do you use this? e Can you provide us with an example? e Where is this used? e Why do you feel this is a benefit? 8. Is there anything you would like to add about the use of simulation in your programme that hasn’t already been covered? 9. Is there anything else in general you would like to add that you feel is important to capture?

Clinician’s Commentary on Melling et al.1 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 Take a minute. Think back to the most memorable moment of fidelity, we should think in terms of realism relevant to the you had as a learner in your physiotherapy programme— learning objectives. We want a learner to buy into the realism whether it was feeling overwhelmed by taking a history from a of the scenario, whether it is physical, conceptual, or emotional. difficult patient, feeling excited when hearing the benefits of a As the field of simulation has already grappled with fidelity and cardiorespiratory treatment on a chest assessment, or feeling produced other terms—functional task alignment and suspen- concerned when palpating an abnormality while examining a sion of disbelief—perhaps the efforts put into defining fidelity patient. Physiotherapy is a profession based on clinical reason- could be better used to consider how learning objectives are ing, hands-on skills, and patient–family interactions. For each aligned with the modality of training and evaluating those of these moments, simulation-based training that provides ex- modalities to ensure that the learning objectives have been met. periential learning could be an ideal modality as it can integrate all these skills. HOW ARE PEOPLE DESIGNING AND BEING TRAINED TO DELIVER SIMULATION-BASED TRAINING? I have had the benefit of reading Melling and colleagues’1 article through two different lenses: first, that of a critical care Melling and colleagues1 conducted high-level interviews that physiotherapist with 10 years of experience and, second, as an explored the use of differing simulation technology in physio- educator who joined the simulation world a year ago. Research therapy, although they did not ask how simulation helped to im- in simulation has typically occurred in the nursing and medical prove physiotherapy training and assessment. To focus more fields. Melling and colleagues thought they needed to shed light on the latter, it would be useful to understand how physio- on the currently limited reports on the value of simulation to therapy educators are using simulation to create an educational physiotherapy programmes in Canada. Their findings are similar experience—specifically, how they design, implement, and to those of other studies on simulation, which have found varia- evaluate their sessions. For example, are sessions designed as tion in how the term fidelity was defined as well as how simula- peer-to-peer training? ‘‘See one, teach one, do one’’? Case-based tion was implemented and what barriers and benefits there were versus deliberate- or mastery-skill training? How many facilitators in using it. For me, the article raises two questions: What is this are there? How are facilitators trained? work a starting point for? Where do we go from here? Although one element of design, debriefing, was deemed DO WE NEED TO DEFINE THE TERM FIDELITY? to be important across all programmes, in my experience as a simulation educator, debriefing can be a difficult skill to From my work as a simulation educator, Melling and collea- develop. I would be curious to know whether clinicians and gues’1 findings that fidelity is not clearly defined and that it educators taking part in simulation have been taught to debrief varies widely across programmes was not a surprise because effectively. PEARLS (Promoting Excellence and Reflective Learn- this term has been a source of debate in the simulation world ing in Simulation) is one debriefing framework that is widely for years. Interestingly, Hamstra and colleagues2 suggested that used; it offers a blended approach that accounts for the ex- we abandon the term fidelity altogether.2 Those authors took perience of the facilitator, the insights of the learner, the time issue with the idea of fidelity because it was ‘‘defined as the available to debrief, and the session objectives.3 The skill of degree to which a simulator looks, feels, and acts like a human debriefing differs from that of providing feedback, and, as a patient . . . emphasiz[ing] technological advances and physical clinician, I believe it would be valuable for not only those in- resemblance over principles of educational effectiveness.’’2(p387) volved in simulation but also those providing clinical placements In other words, simulation educators’ focus should be less on for students. the nice, shiny, wireless manikin and more on meeting the objectives of the students’ education and optimizing learning WHERE DO WE GO FROM HERE? transfer to clinical practice. The article provides an excellent overview of how simulation Instead of fidelity, Hamstra and colleagues2 recommended is used in physiotherapy programmes. As a simulation educator, using the term functional task alignment—that is, aligning the I recommend that those interested in using simulation as a simulation task with the clinical task to enhance transfer to training modality or researching its effectiveness, need to: clinical application. Let us use tracheal suctioning as an example. If the objective were for the student to provide the appropriate 1. Study how simulation enhances learning transfer and how technique and identify the carina or an obstruction, one would that transfer can affect other domains, such as patient care choose a simulator that could best mimic what that would feel and safety; like in real life—whether it were a manikin, a pig’s trachea, or a polystyrene foam cup. Regardless of the simulator, the educa- 2. Examine how well educators who develop simulation scenarios tional effectiveness is seen to be the same, especially if the or programmes understand best practices in simulation, there- learners are engaged, able to suspend their disbelief, and buy by ensuring that their learners and their patients derive the into the simulation. most value from the experience; When designing simulation scenarios for educational pur- 3. Learn what resources are available across local and affiliated poses, one should focus on ensuring that a scenario meets spe- centres to optimize how we support teaching for learners as cific objectives (technical, non-technical, or both), and, instead well as for new graduates and colleagues engaged in con- tinuing education and lifelong learning; and 272

Clinician’s Commentary on Melling et al. 273 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 4. Integrate ourselves into an existing simulation community of REFERENCES practice so that we leverage existing evidence and learn from and with like-minded individuals. 1. Melling M, Duranai M, Pellow B, et al. Simulation experiences in Canadian physiotherapy programmes: a description of current Christine Le´ger, MScPT practices. Physiother Can. 2018;70(3):262–71. https://doi.org/ Simulation Educator and Physiotherapist, 10.3138/ptc.2017-11.e. St. Michael’s Hospital, Toronto; 2. Hamstra SJ, Brydges R, Hatala R, et al. Reconsidering fidelity in [email protected]. simulation-based training. Acad Med. 2014;89(3):387–92. https:// doi.org/10.1097/ACM.0000000000000130. Medline:24448038 3. Eppich W, Cheng A. Promoting Excellence and Reflective Learning in Simulation (PEARLS): development and rationale for a blended approach to health care simulation debriefing. Simul Healthc. 2015;10(2):106–15. https://doi.org/10.1097/SIH.0000000000000072. Medline:25710312 DOI:10.3138/ptc.2017-11-cc

https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 EDUCATION Variation in the Geographic Distribution of Physiotherapy Student Clinical Placements in Rural Saskatchewan Tayyab I. Shah, PhD;* Stephan Milosavljevic, PhD, PT;* Peggy L. Proctor, BSc(PT);* Arlis M. McQuarrie, BPT, BA;* Cathy Cuddington, BSc(PT);* Brenna Bath, BSc(PT), MSc, PhD*† ABSTRACT Purpose: Rural and remote Saskatchewan has a shortage of physiotherapists. Positive student experiences in rural and remote communities may influence whether graduates choose to work in these settings. The intention of the first full-time, 4-week clinical placement (CP) in the Master of Physical Therapy programme at the University of Saskatchewan is to provide clinical experiences in rural settings outside Saskatoon and Regina. This study examines the geographic distribution of and yearly variation in these CPs to determine whether this stated intent is being realized. Method: We analyzed the locations of physiotherapy student CPs from 2008 to 2016 using geospatial mapping. Results: Spatial patterning using mapping identified variability in the number of rural placements in geographical regions in Saskatchewan over a 9-year period. An average of 75% of CP experiences occurred in rural locations outside the two major cities in Saskatchewan between 2008 and 2016 (ranging from 58% in 2015 to 84% in 2009). Conclusions: The goal of providing all University of Saskatchewan physiotherapy students with a rural experience for their first CP is not being met. Securing more CPs in rural settings may have a positive impact on recruitment of physiotherapists to these communities. Key Words: education; health services accessibility; rural health. RE´ SUME´ Objectif : on observe une pe´ nurie de physiothe´ rapeutes dans les re´ gions rurales et e´ loigne´ es de la Saskatchewan. Les expe´ riences positives des e´ tudiants en milieu rural ou e´ loigne´ peuvent influer sur leur choix d’y travailler a` la fin de leurs e´ tudes. Le premier stage clinique (SC) de quatre semaines a` temps plein a` la maıˆtrise en physiothe´ rapie de l’universite´ de la Saskatchewan vise a` offrir des expe´ riences cliniques en milieu rural a` l’exte´ rieur de Saskatoon et de Regina. La pre´ sente e´ tude porte sur la re´ partition ge´ ographique et les variations annuelles de ces SC pour de´ terminer si cette intention exprime´ e se re´ alise. Me´ thodologie : les auteurs ont analyse´ les lieux ou` les e´ tudiants en physiothe´ rapie ont fait leur SC entre 2008 et 2016 au moyen d’une cartographie ge´ ospatiale. Re´ sultats : la mode´ lisation spatiale par cartographie a contribue´ a` e´ tablir la variabilite´ du nombre de stages en milieu rural dans les re´ gions ge´ ographiques de la Saskatchewan sur une pe´ riode de neuf ans. En moyenne, 75 % des expe´ riences de SC se sont produites dans des milieux ruraux situe´ s hors des deux grandes villes de la Saskatchewan entre 2008 et 2016 (entre 58 % en 2015 et 84 % en 2009). Conclusions : l’objectif d’offrir une expe´ rience en milieu rural a` tous les e´ tudiants en physiothe´ rapie de l’universite´ de la Saskatchewan lors de leur premier SC n’est pas respecte´ . L’obtention d’un plus grand nombre de SC en milieu rural pourrait avoir un effet positif sur le recrutement de physiothe´ rapeutes dans ces localite´ s. Recruiting and retaining health care providers in rural Canada, are poorly distributed in rural areas, particularly areas is a continuous challenge for health system planners, compared with population health needs.6,8 For example, decision makers, and health care professional training 36% of Saskatchewan’s population lives in a rural area, programmes. People living in rural and remote parts whereas only 11% of the province’s physiotherapists of Canada have poorer health, shorter life expectancy, indicate a primary employment location in a rural or re- and higher rates of disability than urban dwellers,1,2 and mote community; however, physiotherapists who travel rural residents may have reduced access to health care to provide services at secondary or other rural locations services, including physiotherapy.3–7 Physiotherapy serv- are not necessarily represented in prior research examin- ices, like many other primary health care services in ing rural physiotherapy service delivery.8 From the: *School of Rehabilitation Science; †Canadian Centre for Health and Safety in Agriculture, University of Saskatchewan, Saskatoon, Sask. Correspondence to: Brenna Bath, School of Rehabilitation Science, University of Saskatchewan, 104 Clinic Pl., Saskatoon, SK S7N 2Z4; [email protected]. Contributors: All authors designed the study; or collected, analyzed, or interpreted the data; and drafted or critically revised the article and approved the final draft. Competing Interests: None declared. Funding support was provided by the College of Medicine at the University of Saskatchewan and the Saskatchewan Health Research Foundation. Acknowledgements: The authors thank Brenda Pollock for research coordination support. Physiotherapy Canada 2018; 70(3);274–279; doi:10.3138/ptc.2017-10.e 274

Shah et al. Variation in the Geographic Distribution of Physiotherapy Student Clinical Placements in Rural Saskatchewan 275 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 Clinical placements (CPs) are a critical component of the two metropolitan areas of Saskatoon and Regina. health science training programmes. They have a direct Each year, we canvass clinical sites in rural, regional, bearing on students’ ability to integrate theory into prac- and remote communities in an attempt to secure a CPII tice, work effectively, function in a variety of roles and placement for each student in his or her first CP; we then diverse practice settings, and, ultimately, help students confirm the placement schedule on the basis of the rural confront many of the challenges and issues related to placement capacity for that year. Students who cannot patient care.9 Several recent studies of the CPs of phy- be placed in a rural setting for CPII are placed in one of siotherapy and other health professional students have the two major urban centres. observed that, when they are carried out in rural and remote locations, they are associated with a greater We collected information about the CPII placement likelihood of the students practicing in a rural or remote schedule and a list of health care facilities and centres community after they graduate.10–18 For example, Boehm that have accepted CPII students from the U of S MPT and colleagues17 and Johnston and colleagues18 reported Clinical Education Unit. First, we captured a set of that recruiting students to, and retaining them in, a geographic coordinates for all health care facilities and regional and remote workforce was significantly related centres using different spatial data sources, such as to their rural and remote educational experiences. A Statistics Canada’s geographic layers (e.g., census sub- systematic review conducted in 2016 also determined division, municipality), Google Maps, and so forth. We that rural exposure strategies had a positive effect on then aggregated the CPII data at the community or census dental students’ and graduates’ intention to practice in subdivision level to obtain yearly placement counts, and a rural area.19 A separate challenge, however, is identify- we then assigned these aggregated data to the community ing suitable health care centres with qualified profes- locations for mapping purposes. We applied a geospatial sionals willing to supervise students for CPs in rural and mapping technique to visualize the spatial distribution remote settings. of CPII data by year and created a bar graph to plot 9 years worth of data (2008–2016) at the community level The University of Saskatchewan (U of S) is 1 of 15 using ArcGIS Desktop software (version 10.5.1; ESRI, universities in Canada offering a professional Master Redlands, CA). The CPII data for Saskatoon and Regina of Physical Therapy (MPT) degree (or equivalent) at the were not included in the mapping. entry-to-practice level. Clinical Practice Two (CPII) is a month-long CP that is one of six full-time CPs embedded We used the metropolitan influence zone (MIZ) classi- in our programme. The goal of CPII is for MPT students fication layer to distinguish among urban and four types to obtain clinical experience in ‘‘rural, regional, and remote of rural community. We prepared the MIZ classifications Saskatchewan centres outside of Regina or Saskatoon.’’20 for statistical analysis purposes and assigned them to Having CPs in rural locations is an integral part of fulfill- census subdivisions (CSDs) outside urban centers after ing the MPT programme’s commitment to addressing considering the percentage of the CSDs’ resident em- the physiotherapy workforce requirements of the rural ployed labour force who commuted to work in the cores and remote communities across Saskatchewan. In addi- of urban census metropolitan areas or census agglomera- tion, because it is the sole post-secondary programme tions. The following MIZ classifications were used: strong for physiotherapists in a geographically large province, it MIZ, at least 30% commuters; moderate MIZ, at least 5% has an institutional mandate to distribute the resources commuters but less than 30%; weak MIZ, more than involved in training physiotherapists throughout the 0% commuters but less than 5%; and no MIZ, none of province. the CSD’s residents commuted.21 We incorporated the Saskatchewan Health Region boundary layer into the The purpose of this study was to examine the geo- mapping as a background layer. The U of S’s Research graphic (spatial) distribution of and yearly variation in Ethics Board deemed this project to be programme CPs for physiotherapy students in rural, regional, and evaluation and thus exempted it from ethical review. remote Saskatchewan centres outside the cities of Regina and Saskatoon. These findings will help to identify and RESULTS target potential health care centres (and clinical preceptors) The results obtained from the geospatial analysis and that have historically not supervised physiotherapy stu- dents and have the potential to increase CP capacity in mapping are presented in Figure 1. Figure 1 shows the rural locations. yearly variation in CPII data at the community level, overlaid with the geographical groupings of a 2011 census METHODS layer for Saskatchewan based on the MIZ classification. In this descriptive study, we used geospatial mapping In total, 353 CPs occurred in Saskatchewan during the 9 years from 2008 to 2016, with an average of 40 place- techniques to examine the distribution of and yearly ments per year, and 75.0% of these placements occurred variation in CPs for physiotherapy students at the U of in rural areas outside Regina and Saskatoon (see Figure 2 S. Given the intent of CPII, our goal is to place all 40 and Table 1). Of the 262 CPII placements that occurred students from the first-year MPT cohort in CPs outside outside Regina and Saskatoon (n ¼ 94 placements), 168

https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 276 Physiotherapy Canada, Volume 70, Number 3 Figure 1 Results of geospatial analysis and mapping.

Shah et al. Variation in the Geographic Distribution of Physiotherapy Student Clinical Placements in Rural Saskatchewan 277 Table 1 Summary of MPT CPII Placements by Health Region CP count by geographic area https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 Health region Rural Urban Overall Saskatoon 15 50 65 Prairie North 52 – 52 Regina Qu’Appelle 7 44 51 Cypress 44 – 44 Sunrise 29 – 29 Sun Country 29 – 29 Five Hills 27 – 27 Prince Albert Parkland 23 – 23 Kelsey Trail 16 – 16 Heartland 13 – 13 Keewatin Yatthe´ 4 – 4 Other 3 – 3 Total (overall) 262 94 356 Figure 2 Yearly comparison of MPT CPII by area (rural and urban MPT ¼ Master of Physical Therapy; CPII ¼ Clinical Placement Two. areas). MPT ¼ Master of Physical Therapy; CPII ¼ Clinical Placement Two. Many factors may have influenced the variability in rural placements for physiotherapy students during 2008– occurred in 10 municipalities classified as strong MIZ, 20 2016. The distribution of registered physiotherapists in 7 municipalities classified as moderate MIZ, 70 in 15 practicing in Saskatchewan is a key consideration when municipalities classified as weak MIZ, and 1 municipality examining student placements because they are the pro- classified as no MIZ. Three CPII placements occurred fessionals who serve as preceptors, thereby making CPs in the areas outside Saskatchewan. Figure 2 shows the possible. There is an apparent mismatch between where number (and percentage) of placements over the 9-year physiotherapists work and population distribution and period that occurred in rural, regional, and remote areas needs, and this mismatch is greater in certain health outside Regina and Saskatoon. regions in Saskatchewan.8,22 Heartland Health Region, for example, has fewer than 2.0 physiotherapists per We found that an average 75.0% of CPII placements 10,000 population, whereas Saskatoon Health Region occurred in rural, regional, and remote settings outside has more than three times that number.8 The low pro- Regina and Saskatoon between 2008 and 2016, ranging portion of registered physiotherapists in the Heartland from 57.5% (23) in 2015 to 84.2% (34) in 2009. During Health Region is mirrored in the low number of CPs these 9 years, CPII placements occurred in 33 com- secured in this region over the 9-year period. An increased munities and 52 health care facilities and centres outside number of physiotherapists working in rural and remote Regina and Saskatoon (Figure 1)—4 in Swift Current and Saskatchewan will likely lead to more CP opportunities 3 each in Moose Jaw, North Battleford, Prince Albert, for students in these regions. Weyburn, and Estevan. CPII occurred just once in 9 communities and only twice in 6 communities. Successfully recruiting and retaining physiotherapists is one way to improve access to physiotherapy services DISCUSSION in underserved rural and remote areas, and providing Providing rural and remote placement opportunities more CP opportunities in rural and remote communities may have a positive effect on the recruitment of for physiotherapy students may increase the likelihood new physical therapy graduates to these settings. Winn, that the students will consider employment in a rural or Chisholm, and Hummelbrunner (2014) conducted a remote location after graduation or contribute to other survey of rehabilitation professionals living and working models of care that improve access to underserved rural in northern Ontario to assess the factors linked to re- communities. The intent of CPII, in particular, is to pro- cruitment and retention, and they identified the fact vide students with a CP opportunity outside Saskatoon that both rural or remote educational experiences and and Regina, if possible. In Saskatchewan, Saskatoon and rural or remote origin were important recruitment factors.15 Regina are the only metropolitan centres with popula- Similar results have been found in other disciplines. For tions larger than 100,000 (246,376 and 215,106, respec- example, a study investigating factors that may affect the tively, in 2016). For the purposes of our programme, recruitment and retention of physicians in rural com- smaller urban centres such as Yorkton (population 16,041 munities reported that, besides physician characteristics, in 2016) and Weyburn (population 10,870 in 2016) are considered rural.

278 Physiotherapy Canada, Volume 70, Number 3 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 ‘‘training environment and a rural training curriculum KEY MESSAGES are important factors’’23(p.12) related to attracting physi- cians to rural practice locations. According to a recent What is already known on this topic systematic review using meta-analysis to assess the im- The distribution of physiotherapists in rural and remote pact of strategies on the intention of dental students and graduates to practice in rural areas, both the recruit- communities relative to urban settings is inequitable. ment of dental students from rural backgrounds and Inconsistent and inadequate rural student placement clinical rotations in rural areas appeared to be effective opportunities have also been noted in other health care strategies for tackling the shortage and uneven distribu- professions in Canada and elsewhere in the world. tion of dentists in rural areas.19 Having a positive clinical placement (CP) experience in a rural or remote setting is associated with a greater Our findings should be considered in light of the likelihood of choosing to work in such a community. following limitations. First, we did not analyze CPs that occurred outside of CPII. In the MPT programme, stu- What this study adds dents complete six full-time placements (a total of 29 In a programme in which the first full-time CP is weeks) during the programme; thus, those students who do not secure a rural placement in CPII may secure one intended to take place in a rural setting, the number of later in the programme. This means that although the CPs secured in rural settings has varied over the years number of rural placements in CPII may be decreasing and has not been evenly distributed across Saskatchewan. overall, students may have the opportunity to complete These findings support the need to increase opportunities one in a subsequent CP. In addition, examining only the for physiotherapy students in rural and remote settings, primary location of CPII may not have captured models and doing this may ultimately increase recruitment of of care in which physiotherapists (and students) travel to MPT graduates to underserved communities. provide services to rural and remote communities. REFERENCES Second, we accounted only for the geographic location of a placement; we did not evaluate whether the place- 1. Mitton C, Dionne F, Masucci L, et al. Innovations in health service ment was a positive experience. We do know, however, organization and delivery in northern rural and remote regions: a from physiotherapy student feedback collected after every review of the literature. Int J Circumpolar Health. 2011;70(5):460–72. CP over many years that students’ experiences are, in https://doi.org/10.3402/ijch.v70i5.17859. Medline:22030009 general, overwhelmingly positive. Having a positive ex- perience in a rural or remote community is a motivator 2. Romanow RJ. Building on values: the future of health care in Canada to seek employment in this setting.10,24,25 [Internet]. Saskatoon: Commission on the Future of Health Care in Canada; 2002 [cited 2015 Aug 5]. Available from: http:// CONCLUSION publications.gc.ca/collections/Collection/CP32-85-2002E.pdf. The goal of giving all University of Saskatchewan 3. Landry MD, Ricketts TC, Fraher E, et al. Physical therapy health physiotherapy students a rural experience for their first human resource ratios: a comparative analysis of the United States CP is not being met. Securing more CPs in rural settings and Canada. Phys Ther. 2009;89(2):149–61. https://doi.org/10.2522/ may have a positive impact on recruitment of physio- ptj.20080075. Medline:19131399 therapists to these communities. Further research is needed to explore the factors involved in Saskatchewan 4. Wilson RD, Lewis SA, Murray PK. Trends in the rehabilitation physiotherapists’ decision making regarding their career therapist workforce in underserved areas: 1980-2000. J Rural Health. choices. In addition to having a rural CP, other factors 2009;25(1):26–32. https://doi.org/10.1111/j.1748-0361.2009.00195.x. may include demographic characteristics, financial in- Medline:19166558 centive programmes for relocation, access to support and mentorship, and other various market and labour 5. Gupta N, Castillo-Laborde C, Landry MD. Health-related drivers. Effectively addressing the shortage and uneven rehabilitation services: assessing the global supply of and need for distribution of physiotherapists in rural and remote human resources. BMC Health Serv Res. 2011;11(1):276. https:// communities in Saskatchewan will require provincial doi.org/10.1186/1472-6963-11-276. Medline:22004560 policymakers and health system managers to take a comprehensive approach, one that must be supported 6. Roots RK, Li LC. Recruitment and retention of occupational by both the provincial professional and regulatory bodies therapists and physiotherapists in rural regions: a meta-synthesis. and the physiotherapy educational programme at the BMC Health Serv Res. 2013;13(1):59. https://doi.org/10.1186/1472- University of Saskatchewan. This study may serve as 6963-13-59. Medline:23402304 a template for examining student placement training opportunities in other parts of Canada or beyond with 7. Laurent S. Rural Canada—access to health care. Ottawa: similar workforce distribution challenges. Parliamentary Research Branch (Economics Division);2002. 8. Bath B, Gabrush J, Fritzler R, et al. Mapping the physiotherapy profession in Saskatchewan: examining rural versus urban practice patterns. Physiother Can. 2015;67(3):221–31. https://doi.org/ 10.3138/ptc.2014-53. Medline:26839448 9. Norman KE, Booth R, Chisholm B, et al. Physiotherapists and physiotherapy student placements across regions in Ontario: a descriptive comparison. Physiother Can. 2013;65(1):64–73. https:// doi.org/10.3138/ptc.2011-63. Medline:24381384 10. Roberts C, Daly M, Kumar K, et al. A longitudinal integrated placement and medical students’ intentions to practise rurally. Med Educ. 2012;46(2):179–91. https://doi.org/10.1111/j.1365- 2923.2011.04102.x. Medline:22239332 11. Shires L, Allen P, Cheek C, et al. Regional universities and rural clinical schools contribute to rural medical workforce, a cohort

Shah et al. Variation in the Geographic Distribution of Physiotherapy Student Clinical Placements in Rural Saskatchewan 279 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 study of 2002 to 2013 graduates. Rural Remote Health. across settings. Aust J Rural Health. 2017;25(2):85–93. https:// 2015;15(3):3219. https://www.rrh.org.au. Medline:26245841 doi.org/10.1111/ajr.12302. Medline:27184770 12. Walker J, DeWitt D, Pallant J, et al. Rural origin plus a rural clinical 19. Suphanchaimat R, Cetthakrikul N, Dalliston A, et al. The impact of school placement is a significant predictor of medical students’ rural-exposure strategies on the intention of dental students and intentions to practice rurally: a multi-university study. Rural Remote dental graduates to practice in rural areas: a systematic review and Health. 2012; 12:1908. Medline:22239835. meta-analysis. Adv Med Educ Pract. 2016;7:623–33. https://doi.org/ 13. Courtney M, Edwards H, Smith S, et al. The impact of rural clinical 10.2147/AMEP.S116699. Medline:27822134 placement on student nurses’ employment intentions. Collegian. 20. School of Physical Therapy. Expectations of P.T. students: PTH 2002;9(1):12–8. https://doi.org/10.1016/S1322-7696(08)60039-6. 852.4—clinical practice 2 [Internet]. Saskatoon: College of Medicine, Medline:11893112 University of Saskatchewan; 2015 [cited 2015 Nov 19]. Available 14. McAllister L, McEwen E, Williams V, et al. Rural attachments for from: https://medicine.usask.ca/documents/physical-therapy/ students in the health professions: are they worthwhile? Aust J Rural ClinPrac2Expectations2015.pdf. Health. 1998;6(4):194–201. https://doi.org/10.1111/j.1440- 21. Statistics Canada. Census metropolitan influenced zone (MIZ) 1584.1998.tb00312.x. Medline:9919076 [Internet]. Ottawa: Statistics Canada; 2015 [cited 2017 June 3]. 15. Winn CS, Chisholm BA, Hummelbrunner JA. Factors affecting Available from: http://www12.statcan.gc.ca/census-recensement/ recruitment and retention of rehabilitation professionals in 2011/ref/dict/geo010-eng.cfm. Northern Ontario, Canada: a cross-sectional study. Rural Remote 22. McFadden B, Jones McGrath K, Lowe T, et al. Examining the supply Health. 2014;14:2619. Medline:24717094 of and demand for physiotherapy in Saskatchewan: the relationship 16. Winn CS, Chisholm BA, Hummelbrunner JA, et al. Impact of the between where physiotherapists work and population health need. Northern Studies Stream and Rehabilitation Studies programs on Physiother Can. 2016;68(4):335–45. https://doi.org/10.3138/ recruitment and retention to rural and remote practice: 2002–2010. ptc.2015-70. Medline:27904233 Rural Remote Health. 2015;15(2):3126. Medline:26163882. 23. Bosco C, Oandasan I. Review of family medicine within rural and 17. Boehm J, Cordier R, Thomas Y, et al. The first year experience of remote Canada: education, practice, and policy. Mississauga, ON: occupational therapy students at an Australian regional university: College of Family Physicians of Canada; 2016. promoting student retention and developing a regional and remote 24. Lea J, Cruickshank M, Paliadelis P, et al. The lure of the bush: do workforce. Aust J Rural Health. 2017;25(1):22–7. https://doi.org/ rural placements influence student nurses to seek employment in 10.1111/ajr.12252. Medline:26684041 rural settings? Collegian. 2008;15(2):77–82. https://doi.org/10.1016/ 18. Johnston C, Newstead C, Sanderson M, et al. The changing j.colegn.2008.02.004. Medline:18567479 landscape of physiotherapy student clinical placements: an 25. Roots R. The importance of clinical placements in emerging models exploration of geographical distribution and student performance of practice. Physiother Practice. 2016. 6:10–5.

EXERCISE PRESCRIPTION https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 Facilitators of and Barriers to Providing Access to Community-Based Exercise Programmes for Adults with Post-Stroke Aphasia from the Perspective of Programme Representatives Meredith Fairbairn, BSc, MScPT, PT, CSCS;* Emily Wicks, BHSc, MScPT, PT;* Sabrina Ait-Ouali, BSc.HK, MScPT, PT;* Olivia Drodge, B.Kin.(Hons), MScPT, PT;* Dina Brooks, PhD, PT;*† Maria Huijbregts, PhD, PT;*‡ Diane Blonski, MSc, MScPT, PT § ABSTRACT Purpose: Individuals with post-stroke aphasia (PSA) engage in inadequate levels of physical activity (PA), hindering physical and psychosocial recovery. The purpose of this study was to identify the extent to which community-based exercise programmes (CBEPs) in the Greater Toronto Area (GTA) are accessible to adults living with PSA and the characteristics of such programmes from the perspective of CBEP representatives. Methods: A cross- sectional, Web-based survey was administered to representatives of CBEPs open to adults post-stroke in the GTA to identify the CBEPs’ relevant character- istics and perceived facilitators of and barriers to accessibility. Results: A total of 17 eligible CBEP representatives completed the survey, for a response rate of 32%. The most commonly used exercise instructors were personal trainers (8; 47%). Of the 17 eligible CBEP representatives, 10 (59%) identified a lack of qualified personnel as the main barrier to providing access to adults with PSA. Verbal strategies were among the most commonly used methods of communication with adults with PSA (16; 94%), and written material was the least used (5; 29%). Conclusion: Understanding the common facilitators of and barriers to providing adults with PSA access to CBEPs will assist programme developers to improve the accessibility of CBEPs and facilitate PA in this population. Key Words: aphasia; community participation; exercise; health services accessibility; stroke. RE´ SUME´ Objectif : les personnes souffrant d’aphasie apre` s un accident vasculaire ce´ re´ bral (AAVC) ne font pas assez d’activite´ physique (AP), ce qui nuit a` leur re´ tablissement physique et psychosocial. La pre´ sente e´ tude visait a` de´ terminer l’accessibilite´ des programmes d’exercices communautaires (PEC) du Grand Toronto (GT) pour les adultes atteints d’un AAVC, ainsi que les caracte´ ristiques de ces programmes selon des repre´ sentants de PEC. Me´ thodologie : les repre´ sentants des PEC ouverts aux adultes apre` s un AVC du GT ont rec¸ u un sondage transversal en ligne pour connaıˆtre les caracte´ ristiques des PEC ainsi que les incitatifs et les obstacles perc¸ us a` l’accessibilite´ . Re´ sultats : au total, 17 repre´ sentants des PEC admissibles ont rempli le sondage, ce qui constitue un taux de re´ ponse de 32 %. Les moniteurs d’exercices les plus sollicite´ s e´ taient des entraıˆneurs personnels (8, 47 %). Parmi les 17 repre´ sentants des PEC admissibles, dix (59 %) soulignaient la pe´ nurie de personnel qualifie´ comme le principal obstacle a` l’acce` s pour les adultes atteints d’AAVC. Les strate´ gies verbales e´ taient les modes de communication les plus utilise´ s aupre` s des adultes atteints d’AAVC (16, 94 %), et les documents e´ crits e´ taient les moins utilise´ s (5, 29 %). Conclusion : s’ils comprennent les incitatifs et les obstacles courants a` l’acce` s aux PEC pour les adultes atteints d’AAVC, les de´ veloppeurs de programmes seront mieux en mesure d’ame´ liorer l’accessibilite´ des PEC et de favoriser l’AP au sein de cette population. In Canada, approximately 40,000–50,000 strokes occur tion and services. Being involved in long-term physical each year,1 with aphasia being diagnosed in one-third of activity (PA), which is known to improve mobility, func- cases.2 Aphasia is a language impairment that affects tion, and fitness levels in adults post-stroke,4 is very im- one’s ability to produce or comprehend written language, portant for this population. However, the level of partici- spoken language, or both.3 These communication chal- pation in PA among adults with post-stroke aphasia lenges make it difficult for individuals to access informa- (PSA) is substantially lower than that in the general From the: *Department of Physical Therapy; †Faculty of Medicine, University of Toronto; ‡Family Service Toronto, Toronto; §Early Intervention Services of York Region – Children’s Treatment Network, Markham, Ont. Correspondence to: Maria Huijbregts, Family Service Toronto, 202–128A Sterling Rd., Toronto, ON M6R 2B7; [email protected]. Contributors: All authors designed the study; collected, analyzed, and interpreted the data; drafted or critically revised the article; and approved the final draft. Competing Interests: None declared. Acknowledgements: We gratefully acknowledge the community-based exercise programme representatives who participated in this study as well as those who helped pilot test the survey. Physiotherapy Canada 2018; 70(3);280–288; doi:10.3138/ptc.2016-103 280

Fairbairn et al. Facilitators of and Barriers to Community-Based Exercise Programmes for Adults with Post-Stroke Aphasia 281 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 stroke population.4,5 Although community-based exercise sonnel.27 Programme-specific barriers include a lack of programmes (CBEPs) are an appropriate service to miti- trained personnel,4,28 conversation at an inappropriate gate this situation, research has found that personal and level of complexity, and limited strategies for ensuring environmental barriers limit accessibility for adults with participants’ comprehension.28 These factors have not been PSA.6,7 evaluated from the perspective of CBEP representatives. Although evidence exists of the lack of CBEPs for Strategies for improving participation in PA have been stroke survivors,8 little research has been conducted spe- identified from the perspective of those affected by PSA; cifically on adults with PSA.9 Exploring this topic further these include appropriately trained staff, public awareness can provide information about the barriers associated of CBEPs, active advertising, and exercise programmes with adapting CBEPs to individuals with PSA, and it can tailored to people with both physical and communicative inform strategies for increasing the accessibility of these disabilities.9 Although some CBEPs have put these strat- programmes. To obtain an understanding of this issue in egies in place, barriers to accessibility remain. To better the Greater Toronto Area (GTA), we surveyed representa- inform the development of future interventions at a tives of CBEPs that are open to individuals post-stroke.9 programme level, evidence is needed regarding CBEPs’ current level of accessibility, as well as the strategies Various physical impairments1 related to walking, and barriers perceived by CBEP representatives, because balance, and cardiovascular capabilities may be the these may be contributing to inadequate levels of PA in sequelae of stroke.10 Compared with stroke survivors adults with PSA. without aphasia, those with PSA experience additional communication barriers, which have been associated The purpose of this study was to identify the extent to with diminished functional recovery and quality of life which CBEPs in the GTA are accessible to adults living (QOL).9,11–14 Engaging in PA is an important strategy for with PSA, as well as the characteristics of such pro- mitigating post-stroke–related complications such as grammes. Our specific objectives were to identify the impaired gait and balance.9,15 In addition, PA has been existence and characteristics of CBEPs that are open to found to positively influence psychosocial outcomes, in- adults with PSA in the GTA, evaluate the extent to which cluding self-efficacy, social interaction, and QOL.16 In- relevant information is collected on their participants, adequate long-term PA has been linked to accelerated and identify the perceived facilitators of, strategies for, functional decline in individuals with stroke17,18 and has and barriers to promoting access to their services for subsequently reduced successful reintegration into the adults with PSA. This information will fill the current community.19,20 Despite these well-established findings, gaps in the literature about the availability and nature of adults with PSA do not participate in adequate levels of existing CBEPs for adults with PSA, and it may inform PA.5,21,22 CBEP representatives who are setting up future pro- grammes to increase the access to and frequency of PA A CBEP, specifically structured to maintain or improve in this typically sedentary population.4 physical functioning and promote health and well-being using various physical activities, is an effective strategy METHODS for promoting PA for adults with PSA.4 Although giving individuals the opportunity to engage in PA, CBEPs also Study design create an opportunity for social interaction and increased We administered a cross-sectional, Web-based survey self-efficacy,22 both of which may facilitate community reintegration for those with aphasia.14,23,24 The GTA is to representatives of CBEPs in the GTA that are open to significantly lacking in CBEPs that offer fitness pro- adults post-stroke. We used a modified Dillman approach, grammes for adults post-stroke,8 however, and whether which uses personalized and repeated follow-up re- any aphasia-accessible CBEPs exist there remains un- minders by telephone and subsequent e-mail at set inter- known. To ameliorate health outcomes in this popula- vals29 to maximize the response rate. The University of tion, it is imperative to determine the accessibility of Toronto Research Ethics Board approved the study pro- CBEPs for adults with PSA. tocol. We used the Checklist for Reporting Results of Internet E-Surveys checklist30 for quality reporting of Myriad barriers to engaging in PA have been identi- the results of the study. fied for adults with PSA,9,14,25 and they have been cate- gorized as personal,6,7 communicative, procedural, and Recruitment environmental issues.9 For example, most existing edu- Representatives of CBEPs in the GTA that are open cational and promotional material developed for this population appears to be inaccessible because the level to adults post-stroke, including administrative staff and of language and readability is too high, making it difficult programme instructors, were eligible to participate in for these individuals to understand that CBEPs exist and the study. Sites included hospitals, rehabilitation cen- how important they are.13,26 Environmental barriers in- tres, community centres, and not-for-profit and private clude transportation, programme cost, and policies such programmes. Participation in the survey was voluntary, as the inability to attend a CBEP without support per- and consent was implied by submitting a completed questionnaire.

282 Physiotherapy Canada, Volume 70, Number 3 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 Commencing in September 2015, we identified CBEPs non-normally distributed data. We categorized the re- by means of a Web-based search, using the search terms sponses that were entered into text boxes by content community, exercise, stroke, rehab, aphasia, GTA, and analysis. We used the code 999 to account for missing network in varying combinations. We identified other data and the code 1111 for questions that were not appli- potential participants by sending e-mails to staff in cable to particular respondents. different stroke networks in the GTA as well as to those involved in stroke programming or research. RESULTS In January 2016, we contacted possible eligible partic- Response rates and participants ipants, using a scripted telephone call to ensure stan- Of the 53 CBEP representatives contacted by tele- dardization, requesting that they provide a valid e-mail address and participate in the Web-based questionnaire. phone, we were unable to reach 13, 6 declined to partic- Within 1 day of receiving consent, we sent participants a ipate, and 3 were ineligible to participate. This left 31 follow-up e-mail detailing the purpose of the study and eligible representatives who agreed to participate in this including a link to the questionnaire. We subsequently study and to whom we sent the Web-based question- sent two reminder telephone calls and follow-up e-mails, naire. Eight possible participants refused at our follow-up, with a link to the questionnaire, at weekly intervals. and six did not respond at all, resulting in 17 completed Within a week of the submission deadline, we sent final surveys, for a final response rate of 32% (see Figure 1). thank you e-mails. We identified all 17 participating CBEPs as being open to adults with PSA. Survey instrument We used Fluid Surveys (Fluidware, Ottawa, ON) to Characteristics of CBEPs and information collected on characteristics of exercise participants create a Web-based questionnaire. The final 51-item ques- tionnaire (reproduced in the online Appendix) included Of the 17 CBEP representatives who completed the domains pertaining to eligibility, programme setting, questionnaire, the majority were with community centres and programme representative and programme partici- (11; 65%; see Table 1). Of these, 9 (53%) required a pant characteristics. The questionnaire was pilot tested referral, with 7 of the 9 (78%) requiring referral by a phy- by two physical therapists using convenience sampling sician; 13 (77%) CBEPs required a fee for participation. to obtain feedback. Both physical therapists were regis- Various activities were provided by the CBEPs; balance tered with the College of Physiotherapists of Ontario and activities were reported most frequently (16; 94%; see had a comprehensive understanding of working with the Table 1). Personal trainers (8; 47%) were the most com- neurological population. Additional pilot testing by one monly employed programme providers, and the least CBEP representative, recruited through a co-investigator, commonly employed were physical therapists (1; 6%; evaluated the ease of use and readability of the question- see Figure 2). The average number of staff employed, in naire, resulting in minor modifications. We used a com- an entire facility, was 4 (SD 2), and the average number bination of nominal, ordinal, and ratio scales to collect of exercise participants throughout the entire cycle of a the data. If a participant answered ‘‘no’’ to any of the programme was 20 (SD 16; see Table 1). The estimated four eligibility questions, the survey was terminated. average number of participants with PSA, however, was only 4 (SD 3). Data analysis We exported data from Fluid Surveys into a file in MS The CBEPs gathered information from participants on aphasia-related (14; 82%), hearing (12; 71%), memory Excel 2013 (Microsoft Corp., Redmond, WA) and imported (10; 59%), and visual (12; 71%) difficulties. On-site physical the data into the IBM SPSS Statistics, version 19.0 (IBM assessment data on balance (8; 47%), strength (6; 35%), Corporation, Armonk, NY) and produced descriptive endurance (7; 41%), and functional activities (4; 24%) statistics. For all items with categorical response scales, were also collected, as were the type (5; 29%) and severity we summarized the data using frequencies and percen- (8; 47%) of the PSA. tages. For enhanced clarity and ease of reporting, we used a 5-point Likert scale, but we collapsed the response Extent of openness to adults living with post-stroke aphasia options strongly agree and agree into agree and the Of the 17 CBEPs, 6 (35%) reported being targeted to response options strongly disagree and disagree into disagree; a final response option was neutral. Similarly, adults post-stroke, and all the CBEPs reported being open we collapsed the response options of all of the time, to adults with PSA. Only 4 (24%) publicly advertised their most of the time, and some of the time into used and the openness to adults with PSA. A total of 14 (82%) CBEPs response option none of the time into not used. For items incorporated general exclusion criteria into their admis- with ratio response scales, we summarized the data using sion process (e.g., physical, communicative, or cognitive means, standard deviations, and ranges, where appro- ability; age or financial requirements), and 4 (24%) re- priate, as well as medians and interquartile ranges for quired specific inclusion criteria for people with PSA:

Fairbairn et al. Facilitators of and Barriers to Community-Based Exercise Programmes for Adults with Post-Stroke Aphasia 283 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 Figure 1 Recruitment flow diagram. CBEP ¼ community-based exercise programmes. Three (75%) required a caregiver to be present if an indi- strategies, verbal communication was the method used vidual with PSA was not deemed physically independent, most often (16; 94%), and pictures was the method used and 1 (25%) required a caregiver to be present at all least often (5; 29%). A total of 16 (94%) CBEPs used times. In addition, 7 (41%) CBEPs reported having specific verbal communication; simplified instructions; provided requirements, depending on the severity of aphasia; 2 extra time; used repetition, rephrasing, or both; and (12%) and 5 (29%) required a caregiver to be present for demonstrated exercises as instructional methods (see adults with moderate and severe aphasia, respectively. Figure 3). Strategies for facilitating accessibility for adults with Perceived barriers to providing access to CBEPs to adults with post-stroke aphasia post-stroke aphasia The strategies used by the CBEPs to facilitate accessi- Of the barriers to programme accessibility that were bility for adults with PSA included using various available identified, a lack of qualified personnel with aphasia- services, methods of advertising, aphasia-specific train- specific training was reported most consistently (10; 59%), ing, and exercise implementation strategies (see Table 2). followed by a lack of appropriate equipment (e.g., exercise Transportation was identified as the most frequent service equipment or other adaptive communication aids; 8; 47%; available (14; 82%). More important, only 1 CBEP (6%) see Table 3). Other important barriers included cost, lack reported publicly promoting its openness to adults with of human resources, lack of knowledge about how to PSA specifically using written and electronic means as improve communicative accessibility (7; 41%), and low well as using its affiliations with other organizations. demand for programme services from adults with PSA. Also, staff at 7 CBEPs (41%) had received aphasia-specific training; communication-based training was identified Although the majority (15; 88%) of the CBEP represen- as the type of training most frequently received (5; 71%). tatives said that the accessibility of CBEPs to adults with Of the communication-related exercise implementation PSA was important, 2 (12%) did not agree. Similarly, 14 (82%) participants reported that they were confident in

284 Physiotherapy Canada, Volume 70, Number 3 Table 1 Characteristics of CBEPs Open to People Post-Stroke (n ¼ 17) pictures were the least used methods. This highlights a gap between what is believed to be an effective strategy https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 Characteristic No. (%) of and evidence-based practice. participants* There is a lack of information regarding available and Area in GTA 10 (58.8) accessible CBEPs for adults with disabilities.33 Blonski Toronto 7 (41.2) and colleagues9 obtained suggestions from adults with Outside Toronto PSA for improving access to CBEPs, and they found that 11 (64.7) actively advertising the openness of CBEPs was an im- Type 2 (11.8) portant aspect of accessibility that should be addressed. Community centre 2 (11.8) Despite this result, we found that four (24%) CBEPs Not-for-profit 1 (5.9) surveyed publicly advertised openness to adults with Outpatient 1 (5.9) PSA and only one (6%) publicly advertised such openness Private using written or electronic means. This is an important Registered charity 16 (94.1) consideration for people with PSA, but it is also important 15 (88.2) from the perspective of meeting the legal requirements Activity 9 (52.9) defined in the Accessibility for Ontarians with Disabilities Balance 8 (47.1) Act, which set out to develop, implement, and enforce Resistance training 6 (35.3) accessibility standards by identifying and removing phys- Aquatics 4 (23.5) ical, architectural, informational or communicational, Treadmill attitudinal, technological, and procedural barriers.34 More- Cycling 19.5 (16.3) over, this finding appears to identify a lack of understand- Yoga 3.71 (3.14) ing of communicative accessibility and the critical role 4.35 (2.45) that accessible marketing and promotion play in en- No. of participants and staff, mean (SD) hancing access and participation rates for those with Participants 8 (10) communication impairments. Using nonverbal forms of Participants with PSA 20 (16) advertising,9 such as electronic or paper-based strategies, Administrative and programme staff 60 (10) should be considered because persons with PSA have been found to be more receptive to information they Time, median (IQR) see in written media.34,35 No. of years programme has existed Sessions per cycle Furthermore, adults with PSA have reported that they Session duration, min cannot attend CBEPs if support personnel are not avail- able to accompany them.8 Similarly, we found that seven Note: Percentages may not total 100 because of rounding. (41%) CBEPs required some form of caregiver accom- *Unless otherwise indicated. paniment, depending on the severity of the aphasia, a CBEP ¼ community-based exercise programme; GTA ¼ Greater Toronto Area; result that demonstrates a substantial barrier that adults PSA ¼ post-stroke aphasia; IQR ¼ interquartile range. with PSA face when accessing CBEPs. To mitigate the re- quirement for accompaniment, CBEPs should consider their communication with adults with PSA; the re- increasing the number of aphasia-trained staff to provide mainder were either neutral (2; 12%) or disagreed (1; 6%). guidance, including support personnel or trained volun- teers, one-on-one attention, and modifying the exercises DISCUSSION AND FUTURE DIRECTIONS they provide; all of these suggestions would enable We conducted this study to describe the openness of adults with PSA of all severities to participate unaccom- panied in their programmes. CBEPs in the GTA to accepting adults with PSA and to explore CBEP representatives’ perceptions of facilitators The qualifications of the CBEP instructors varied across of and barriers to providing these services. Although the the programmes surveyed. We found that the most com- influence of these determinants has been assessed from monly employed instructors were personal trainers, and the perspective of adults with PSA,9 our study is the first the least commonly employed were physical therapists. to examine them from the perspective of programme Similarly, Fullerton and colleagues8 found that fitness representatives. Our findings indicate that all the CBEPs facilities that were open to adults post-stroke predomi- surveyed were open to adults with PSA and that the nantly employed personal trainers. The evidence shows majority used personal trainers as exercise instructors. that fitness instructors do not have adequate knowledge Interestingly enough, we found that the main perceived about how to effectively adapt and deliver exercise pro- barrier to providing access was the lack of health care grammes to individuals with disabilities.7,8,33 Salbach professionals with training in communicating with adults and colleagues36 suggested that fitness certification pro- with PSA. The majority of CBEP representatives stated grammes were typically short and did not provide the that providing transportation services to exercise partici- expertise necessary to instruct adults with neurological pants was a strategy for enhancing access. Although this strategy helped mitigate the physical barriers, it did not at all target the communicative accessibility necessary for people with PSA. To address this, verbal communica- tion was among the most commonly used communica- tion strategies; however, it was not reported to be the most effective.9,31,32 Conversely, written material and

Fairbairn et al. Facilitators of and Barriers to Community-Based Exercise Programmes for Adults with Post-Stroke Aphasia 285 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 Figure 2 Distribution of health care professionals involved in delivering exercise at the community-based exercise programmes. Table 2 Strategies Used by the CBEPs to Increase Accessibility for with PSA; however, 41% reported not knowing how to Adults with PSA (n ¼ 17) improve their programme’s accessibility. This finding suggests that the accessibility of CBEPs to adults with Strategy No. (%) of PSA might be improved if their representatives were respondents more aware of what strategies could be implemented to promote accessibility. Thus, further education and col- Transportation 14 (82.4) laboration among health care professionals is needed Free parking 8 (47.1) to create programmes that will provide education for Reminder calls or e-mails 4 (23.5) individuals running CBEPs. Web-based services 2 (11.8) Flexible scheduling 2 (11.8) The literature consistently encourages the use of sup- Other (child care, volunteers, rural satellite programmes) 3 (17.6) ported conversation for adults with PSA, including the use of pictographs,9,35,37 as a method of facilitating com- CBEP ¼ community-based exercise programme; PSA ¼ post-stroke aphasia. munication and promoting accessibility in social and community exercise contexts. However, the current conditions. Therefore, although personal trainers may study found that 94% of the CBEPs used verbal methods have a wide variation of training and certifications, they as the most frequent communication strategy and written may not have the appropriate depth of knowledge to material and pictures as the least frequent (29%). Increas- effectively serve the needs of adults post-stroke. In sup- ing awareness of the importance of nonverbal and alter- port of the Canadian Best Practice Recommendations for native methods of communication, and integrating these Stroke Care,32 all health care providers in a community- methods into CBEPs, could promote the accessibility of based setting should be trained and capable of interact- these programmes to adults with PSA.34,35 Aphasia-friendly ing with adults with communicative impairments such materials, assistive technologies, and staff trained in con- as aphasia. A possible strategy for delivering the best versing with adults with PSA may also help to eliminate possible exercise programme to participants with neuro- barriers and facilitate access to CBEPs. logical and communicative conditions would be for health care providers with expertise in both exercise Our study had several limitations. First, although we delivery and communication strategies to give regular made rigorous attempts to develop a comprehensive list training, in the form of seminars or workshops, to fitness of CBEPs in the GTA, we cannot guarantee that those instructors in the appropriate exercise and communica- that participated were representative. Second, we were tion adaptations.36 unable to reach all 53 CBEPs. Of the 31 we successfully contacted, we received responses from only 17. Although Of the CBEP representatives surveyed, 88% agreed this response rate (32%) appears to be significantly that it was important that CBEPs be accessible to adults higher than other studies of similar design,38 it is based

286 Physiotherapy Canada, Volume 70, Number 3 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 Figure 3 Communication strategies used by CBEPs to facilitate participation by adults with PSA. CBEPs ¼ community-based exercise programmes; PSA ¼ post-stroke aphasia; AAC ¼ augmentative and alternative communication. Table 3 CBEP Representatives’ Perceived Barriers to Providing Access to friendly early after stroke. Future studies should also Adults with PSA (n ¼ 17) explore the best staff complement and training needed to deliver effective CBEPs to adults with PSA as well as No. (%) of respondents the best possible marketing strategies. Barrier or limitation Agree Neutral Disagree CONCLUSION All the CBEPs surveyed were open to admitting adults Lack of qualified personnel 10 (58.8) 1 (5.9) 6 (35.3) Lack of appropriate equipment 8 (47.1) 3 (17.6) 6 (35.3) with PSA, and they generally employed personal trainers Cost 7 (41.2) 3 (17.6) 7 (41.2) as exercise instructors. However, the lack of qualified Lack of human resources 7 (41.2) 4 (23.5) 4 (23.5) personnel to work and communicate with adults with Lack of knowledge of how to 7 (41.2) 3 (17.6) 7 (41.2) PSA was frequently identified as a barrier to providing improve accessibility access. Furthermore, the majority of CBEPs reported Low demand 7 (41.2) 2 (11.8) 8 (47.1) not knowing how to implement appropriate strategies to Exercise-related time limitation improve accessibility. Providing transportation services 6 (35.3) 4 (23.5) 7 (41.2) was the most common strategy used to provide access Implementation 4 (23.5) 4 (23.5) 9 (53.0) to adults with PSA, but it did not address the unique Prescription communication-related accessibility issues of those with PSA. Contrary to the literature that suggests that written CBEP ¼ community-based exercise programme; PSA ¼ post-stroke aphasia. material is the most effective method of communica- tion,9,35,37 we found that verbal strategies were reported only on the 31 CBEPs. It is imperative to consider that most often. This demonstrates a discrepancy between these findings may not be generalizable to the CBEPs suggested best practices and the actual strategies used that did not complete our questionnaire or to all CBEPs at the programme level. Understanding the common located in the GTA. For example, all 17 respondents re- barriers to and facilitators of providing access to adults ported being open to people with aphasia; it is possible with PSA may help inform programme procedures and that those who did not respond are not open to people attempts to improve the accessibility for and participa- with aphasia and should be further investigated. Last, tion of adults with PSA in CBEPs, ultimately facilitating although these findings demonstrate the extent to which their involvement in adequate levels of PA. CBEPs in the GTA are accessible to adults with PSA, as well as the characteristics of such programmes, they KEY MESSAGES do not evaluate the effectiveness or quality of these programmes. What is already known on this topic Individuals with post-stroke aphasia (PSA) face multiple Because this study examined only CBEPs in the GTA, a wider examination of CBEPs across Canada may further barriers when attempting to participate in community- advance strategies for improving accessibility for adults based exercise programmes (CBEPs). These barriers have with PSA. Future research should explore ways to increase awareness of the availability of CBEPs that are aphasia-

Fairbairn et al. Facilitators of and Barriers to Community-Based Exercise Programmes for Adults with Post-Stroke Aphasia 287 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 been categorized as personal, communicative, procedural, 10. Michael KM, Allen JK, Macko RF. Reduced ambulatory activity after and environmental.9 Adults with aphasia report that com- stroke: the role of balance, gait, and cardiovascular fitness. Arch municative inaccessibility is a significant barrier to their Phys Med Rehabil. 2005;86(8):1552–6. https://doi.org/10.1016/ engaging in CBEPs27 and that initiating and arranging j.apmr.2004.12.026. Medline:16084807 participation opportunities are themselves a challenge.28 11. Worrall L, Holland A. Editorial: quality of life in aphasia. What this study adds Aphasiology. 2003;17(4):329–332. https://doi.org/10.1080/ This study examined the underlying determinants of 02687030244000699. Medline:27005901 CBEP accessibility for adults with PSA from the perspec- 12. Hubanks L, Kuyken W. Quality of life assessment: an annotated tive of the programme representatives. The findings bibliography. Geneva: World Health Organization; 1994. identified a gap between the strategies commonly used by CBEPs and those recommended in the literature. 13. Cruice M, Worrall L, Hickson L, et al. Finding a focus for quality of Understanding the accessibility barriers faced by adults life with aphasia: Social and emotional health, and psychological with PSA will provide guidance to CBEP developers and well-being. Aphasiology. 2003;17(4):333–53. https://doi.org/10.1080/ organizers in developing appropriate strategies for promot- 02687030244000707. ing accessibility to those with PSA. Employing physical therapists or other personnel with dedicated aphasia- 14. Law J, Huby G, Irving AM, et al. Reconciling the perspective of specific training may mitigate the prevalent communi- practitioner and service user: findings from the Aphasia in Scotland cation and movement barriers, thereby facilitating this study. Int J Lang Commun Disord. 2010;45(5):551–60. https:// typically sedentary population’s participation in physical doi.org/10.3109/13682820903308509. Medline:19886848 activity through participation in CBEPs. Augmenting awareness of the importance of non-verbal and alterna- 15. Saunders DH, Greig CA, Mead GE, et al. Physical fitness training for tive methods of communication, and integrating these stroke patients. Cochrane Database Syst Rev. 2009;(4):CD003316. methods into CBEPs, could further promote accessibility Medline:19821305. to adults with PSA. 16. Carin-Levy G, Kendall M, Young A, et al. 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https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 EXERCISE PRESCRIPTION ‘‘A Learned Soul to Guide Me’’: The Voices of Those Living with Kidney Disease Inform Physical Activity Programming Trisha L. Parsons, PhD, PT;* Clara Bohm, MPH, MD;† Katherine Poser, RN, BScN, MNEd* ABSTRACT Purpose: The purpose of this study was to (a) confirm the barriers to and facilitators of physical activity (PA) among persons living with chronic kidney disease (CKD) in Ontario and (b) inform the design of a Kidney Foundation of Canada Active Living for Life programme for persons living with CKD. Method: Adults living with CKD in Ontario were invited to participate in a cross-sectional survey investigating opinions about and needs for PA programming. The 32-item survey contained four sections: programme delivery preferences, current PA behaviour, determinants of PA, and demographics. Data were summarized using descriptive statistics and thematic coding. Results: A total of 63 respondents participated. They had a mean age of 56 (SD 16) years, were 50% female, and were 54% Caucasian; 66% had some post-secondary education. The most commonly reported total weekly PA was 90 minutes (range 0–1,050 minutes). Most respondents (84%) did not regularly perform strength training, and 73% reported having an interest in participating in a PA programme. Conclusion: Individuals living with CKD require resources to support and maintain a physically active lifestyle. We identified a diversity of needs, and they require a flexible and individualized inter-professional strategy that is responsive to the episodic changes in health status common in this population. Key Words: community surveys; exercise; kidney diseases. RE´ SUME´ Objectif : la pre´ sente e´ tude visait a` a) confirmer les obstacles et les incitatifs a` l’activite´ physique (AP) chez les personnes atteintes d’une ne´ phropathie chronique (NPC) en Ontario et b) e´ tayer la conception du programme Une vie active pour la vie de la Fondation canadienne du rein pour les personnes atteintes d’une NPC. Me´ thodologie : des adultes de l’Ontario atteints d’une NPC ont e´ te´ invite´ s a` participer a` un sondage transversal sur leurs avis et leurs besoins lie´ s aux programmes d’AP. Le sondage de 32 questions e´ tait divise´ en quatre parties : pre´ fe´ rences quant a` la prestation du programme, comporte- ments actuels en matie` re d’AP, de´ terminants de l’AP et de´ mographie. Les chercheurs ont re´ sume´ les donne´ es a` l’aide de statistiques descriptives et de codes the´ matiques. Re´ sultats : au total, 63 re´ pondants ont participe´ . Ils avaient un aˆ ge moyen de 56 ans (E´ T de 16 ans), 50 % e´ taient des femmes, 54 % e´ taient blancs et 66 % avaient une certaine e´ ducation postsecondaire. L’AP physique hebdomadaire totale la plus de´ clare´ e e´ tait de 90 minutes (plage de 0 a` 1 050 minutes). La plupart des re´ pondants (84 %) ne faisaient pas d’entraıˆnement musculaire re´ gulier, et 73 % se sont dit inte´ resse´ s a` participer a` un programme d’AP. Conclusion : les personnes atteintes d’une NPC ont besoin de ressources pour maintenir un mode de vie actif. Les chercheurs ont repe´ re´ une diversite´ de besoins et la ne´ cessite´ d’une strate´ gie interprofessionnelle personnalise´ e qui tient compte des changements e´ pisodiques de l’e´ tat de sante´ , courants dans cette population. Chronic kidney disease (CKD) carries with it several Studies examining the barriers to and facilitators of multi-system consequences, which can lead to impair- PA and exercise among persons living with CKD have ments of ‘‘physical function, cognitive function, emo- primarily focused on those living with end-stage kidney tional functioning and quality of life.’’1(p.305) The presence disease. For example, Delgado and Johansen8 studied of complex comorbidity in CKD, particularly as patients patient-perceived barriers to engaging in 30 minutes age, can contribute to a heavy self-management burden.2 of moderate-intensity PA among a cohort of 100 hemo- Evidence supports the use of therapeutic exercise and dialysis patients from a single dialysis unit in the United physical activity (PA) to improve several these negative States. They identified 25 barriers to PA, with degrees consequences.3–7 of endorsement ranging from 1% (amputation) to 67% From the: *School of Rehabilitation Therapy, Queen’s University, Kingston, Ont.; †Health Sciences Centre-Nephrology, Winnipeg, Man. Correspondence to: Dr. Trisha L. Parsons, School of Rehabilitation Therapy, Queen’s University, 31 George St., Louise D. Acton Building, Clinical Education Centre Room 208, Kingston, ON K7L 3N6; [email protected]. Competing Interests: None declared. This study was funded by the Ontario Sport and Recreation Communities Fund (2014–2016). Acknowledgements: The authors acknowledge Sarah Hart and members of the Kidney Foundation of Canada’s Active Living Program’s Steering Committee for their contributions to the successful completion of this project. Physiotherapy Canada 2018; 70(3);289–295; doi:10.3138/ptc.2017-01.ep 289

290 Physiotherapy Canada, Volume 70, Number 3 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 (fatigue on dialysis days). They also determined that ‘‘exercise vital sign’’ was used to capture the proportion fatigue, lack of motivation, and shortness of breath were of respondents who were not meeting PA guidelines commonly reported by patients in this dialysis unit, (150–300 min/wk of moderate-intensity exercise).19 We although only lack of motivation and shortness of breath asked respondents to identify the number of minutes were associated with the measured levels of PA. How- per day (in 10 min intervals) they performed moderate- ever, that study did not comment on possible other intensity exercise and the number of days per week they factors that might facilitate or enable PA. Furthermore, performed it. We also asked participants to report the because the perception of benefits, drawbacks, and degree to which they had access to exercise equipment, facilitators is linked to the level of PA referenced, these other programmes that supported their PA in their local barriers and facilitators may vary, depending on the communities, and any information or support they had nature of PA defined, geographical location, and disease already received from their nephrology team. status (before dialysis vs. dialysis). In section 3, we asked the participants to identify Calls to action have included exercise prescription to their information needs, both as open-text prompts and promote PA among persons living with CKD.9–12 How- as closed checklists of 13 predefined topics related to ever, high-quality evidence about how to best promote PA and CKD (including balancing exercise and fatigue, PA, either in the CKD population or in other populations, developing a plan for PA, and balancing PA with a fear is lacking.13–15 This lack of evidence may account, in of falls). We asked participants to indicate the physical part, for the observed gap in PA promotion programmes activities that they were interested in trying out or resum- targeted to persons living with CKD in Canada.16 ing. Additional items questioned their preferred travel distance (multiple choice, giving predefined distances), The Kidney Foundation of Canada (KFOC) proposed to personal goals for PA participation (open text), and address this lack of programming by creating a physical whether they would like to participate with a partner or literacy programme for persons living with CKD in spouse (multiple choice: yes, no, or unsure). Ontario.17 Called the Active Living for Life (KFOC-ALFL) programme, its intended goal was to help support people In section 4, we asked the respondents to answer four living with CKD to lead more active lives. To inform the questions about a predefined level of at least 20 minutes development of the format (education, exercise) and of PA, performed three days a week at a moderate inten- content of the KFOC-ALFL, we conducted a patient sity.20 We chose this level of PA because it is the lowest needs assessment survey with the following objectives: level of PA recommended in the American College of (1) to confirm that previously reported barriers to and Sports Medicine Guidelines for Exercise in Renal Disease21 facilitators of PA participation among persons living and would represent a starting level of PA. In reference to with CKD were valid in the local context in which the this level of PA, we asked survey participants to identify KFOC-ALFL was to be piloted and (2) to inform the the benefits, drawbacks, and facilitators of and barriers design of the content and delivery of, and evaluation to performing the defined behaviour. The survey was strategies for, the KFOC-ALFL. pilot tested by three patient experience advisors serving on the KFOC-ALFL’s Steering Committee. We incorporated METHODS their feedback into the final version of the survey. Study design Participants This was a prospective, cross-sectional, voluntary survey We invited people living with CKD in Ontario to of Ontario residents living with CKD. participate in the survey. To be included in the study, participants had to be aged older than 18 years, be com- Survey instrument munity dwelling, have a current diagnosis of any stage of The principal investigator (TLP) developed a 32-item CKD, be fluent in English, and reside in Ontario. Recruit- ment for participation used two strategies: online and survey in consultation with the KFOC-ALFL Advisory partnering with nephrology programmes in cities previ- Committee. This committee consisted of patient experi- ously selected to pilot the KFOC-ALFL programme. The ence advisors, researchers, exercise professionals, and first recruitment strategy was to place an advertisement clinicians. The survey was based on a previous instru- on the website of the Ontario branch of the KFOC; the ment developed by TLP and is grounded in the theory ad included a link to the online version of the survey of planned behaviour.18 It was divided into four sections: and the contact information of the KFOC-ALFL staff (1) demographics (9 items), (2) current PA (9 items), (3) coordinator if an individual preferred to complete the programme delivery preferences (10 items), and (4) psy- survey in paper format. We also shared the online survey chosocial determinants of PA (4 items). Section 1 included link through the Facebook page of KFOC’s Ontario open-text items to determine respondents’ age, gender, branch. The second strategy was to recruit participants ethnicity, preferred language, employment status, and through the nephrology programmes of sites identified highest education achieved. to participate in the pilot programme. We gave these Section 2 contained items to assess respondents’ cur- rent level of weekly PA, including strength training. The