A profile of physiotherapy clinical education.

Abstract

The purpose of the study was to examine clinical education placement data to generate a profile of providers and examine the students' exposure to health care and educational factors during clinical education. A retrospective audit of clinical placement rosters was undertaken for 3 calendar years (2001-2003). Data were analysed overall and by clinical school for sites and placements, public or private sector and type of placement. Over the 3-year period, 209 sites provided 3475 clinical placements, with the number of placements increasing from 1066 placements in 2001 to 1133 in 2002 and to 1276 in 2003. Overall, 72.2% of placements were located in metropolitan Sydney. The proportion from regional providers increased over the 3 years from 11.8% to 15.1%. Overall 85.8% of placements were delivered by public providers. The profile indicated that a considerable number of clinical sites were utilised with an emphasis on large public hospitals. The challenge for curriculum development is to reduce the clinical education demands on current providers while ensuring graduates meet entry-level standards of physiotherapy.

Full text

Page 1

38Australian Health Review February 2009 Vol 33 No 1
Health Professional Education
Aust Health Rev ISSN: 0156-5788 1 Feb-
ruary 2009 33 1 38-46
©Aust Health Rev 2009 www.aushealthre-
view.com.au
Health Professional Education
clinical school for sites and placements, public or
private sector and type of placement. Over the 3-
year period, 209 sites provided 3475 clinical
placements, with the number of placements
increasing from 1066 placements in 2001 to 1133
in 2002 and to 1276 in 2003. Overall, 72.2% of
placements were located in metropolitan Sydney.
The proportion from regional providers increased
over the 3 years from 11.8% to 15.1%. Overall
85.8% of placements were delivered by public
providers. The profile indicated that a considera-
ble number of clinical sites were utilised with an
emphasis on large public hospitals. The challenge
for curriculum development is to reduce the clini-
cal education demands on current providers while
ensuring graduates meet entry-level standards of
physiotherapy.
Abstract
The purpose of the study was to examine clinical
education placement data to generate a profile of
providers and examine the students’ exposure to
health care and educational factors during clinical
education. A retrospective audit of clinical place-
ment rosters was undertaken for 3 calendar years
(2001–2003). Data were analysed overall and by
Aust Health Rev 2009: 33(1): 38–46
PHYSIOTHERAPY EDUCATION programs aim to
equip graduates with the required knowledge,
skills and attributes to work safely and compe-
tently as physiotherapists. In addition, Australian
physiotherapy education programs must comply
with Standards for accreditation of physiotherapy
education programs at the level of higher education
awards and the Australian standards for physiother-
apy.1 Clinical education is an integral part of
physiotherapy programs and is reliant on strong
relationships with clinical providers in a variety of
health care settings.
The challenge of securing sufficient high-qual-
ity clinical education placements to meet the
Catherine M Dean, BAppSc(Phty), MA, PhD, Senior
Lecturer
Angela M Stark, BAppSc(Phty), MAppSc,
GradCertEdStudies, Lecturer
Carolyn A Gates, BAppSc(Phty), MAppSc, Physiotherapy
Practicum Coordinator
Sharon A Czerniec, BAppSc(Phty), MHlthSc, Lecturer
Cheryl L Hobbs, HScD, MAppSc, P&OT, Inter-professional
Learning Co-ordinator
Discipline of Physiotherapy, Faculty of Health Sciences, The
University of Sydney, Lidcombe, NSW.
Lisa D Bullock, BExSc&Rehab(Hons), MPT, Physiotherapist
Narromine Physiotherapy and Sports Injury Clinic,
Narromine, NSW.
Ilka Kolodziej, BAppSc(Phty)(Hons), Data Manager
NHMRC Clinical Trials Centre, The University of Sydney,
Sydney, NSW.
Correspondence: Dr Catherine M Dean, Discipline of
Physiotherapy, Faculty of Health Sciences, The University of
Sydney, PO Box 170, Lidcombe, NSW 1825.
c.dean@usyd.edu.au
A profile of physiotherapy clinical education
Catherine M Dean, Angela M Stark, Carolyn A Gates, Sharon A Czerniec,
Cheryl L Hobbs, Lisa D Bullock and Ilka Kolodziej
What is known about the topic?
Clinical education is an integral part of
physiotherapy programs and is reliant on major
contributions and strong relationships with clinical
providers in health care settings. Health care and
educational environments have been changing over
the last decade, and securing sufficient high-quality
clinical education placements to meet the needs of
physiotherapy students is increasingly difficult.
What does this paper add?
This study establishes a profile of clinical education
providers for one of the largest educational institutions
training physiotherapists. From 2001–2003 the
demand increased by 210 placements (16.5%). The
major providers were large public hospitals who
provided 85.8% of placements. It was found that
aside from experience in the private sector the
students had a wide range of exposure to a variety of
clinical sites, locations and health care sectors.
What are the implications for practitioners?
The study highlights that graduates not only meet
entry-level standards but also have exposure to a
range of health care and educational factors.
However, the contribution of the private sector in
physiotherapy clinical education needs to increase.

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Australian Health Review February 2009 Vol 33 No 1 39
Health Professional Education
needs of physiotherapy students is global.2-5 Con-
tributing to the challenge are the dramatically
changing health and education environments
worldwide.6 In Australia, there has been a shift
toward community-based care and self-manage-
ment, rather than extended hospital care,7 and a
rapid expansion in the number of physiotherapy
programs.8 The challenge of securing clinical
placements has grown in New South Wales over
the last decade, with the number of universities
offering physiotherapy programs increasing from
one to three and a national shortage of physio-
therapists in 9 of the last 10 years.9
The University of Sydney’s physiotherapy clini-
cal education program uses a mixture of models of
clinical education with variable ratios of students
to educators, ranging from 6:1 to 1:1. This is a
reflection of tradition and pragmatism where
delivery of clinical education needs to be flexible
to match the complexity of providers and health
care delivery. While a recent systematic review10
found that no model of clinical education was
superior, it was noted that there was a paucity of
high-quality research. Descriptive studies, such as
this study, provide information which can
enhance the design of high-quality research to
improve the evidence base for clinical education.
Clinical site variety, location and health care
sector are health care factors, and learning group
size is an educational factor of clinical programs
that can vary among students. Clinical site variety
and location may influence students’ future career
choices. At The University of Sydney, we aim for
students to attend a different clinical site for each
placement, to give students exposure to different
workplaces. While this aim places burdens on the
provider to orientate students and accommodate
the settling-in period, we feel that wide exposure
better prepares graduates for the workforce. In
addition, given that the NSW health system cur-
rently has an allocation system for new physio-
therapy graduates, students report anecdotally
that greater exposure to clinical sites assists them
to rank their allocation preferences.
Location is also varied. We aim to provide stu-
dents with experience in metropolitan Sydney and
in regional and rural NSW. We know that rural and
regional providers are essential to our clinical edu-
cation program to ensure that we meet the number
of placements required. Students are informed on
enrolment that they will be required to undertake
at least one placement in a rural and/or regional
setting. The strategy of exposing students to a
variety of sites and locations was designed not only
to give students an insight into health delivery in
different settings and sites but also to allow them to
contemplate different sites and locations when
considering future work options. While it is known
there has been a national shortage of physiothera-
pists in Australia for 9 out of the last 10 years, the
shortage has been worst in rural areas.9 Exposure
to the rural setting may also help alleviate the rural
workforce shortage.
In Australia, a significant proportion of health
care is provided in the private sector.11 In NSW,
58.6% of registered physiotherapists work in the
private health care sector.12 We aim to provide
students with experiences in the private sector,
however, given only 14% of clinical placements
are provided by the private sector, it is unlikely all
students will have an experience in this sector.
Learning group size is an educational factor
which is also varied. Our students complete place-
ments in groups ranging from one (ie, alone) to
six. In the absence of clear data about which
model of clinical education is superior,10 we aim to
provide students with experiences of different
learning group sizes. Grouping students allows for
the utilisation of peer learning, collaborative learn-
ing and teamwork,3,6 whereas being on a place-
ment without others gives the students
opportunity to develop independence and auton-
omy, which are also important professional
attributes.
Exposure to these four factors is limited by two
constraints. The first constraint is mandatory
adherence to the prescribed curriculum in terms
of type of placement (eg, neurology placement),
which has been designed to ensure graduates
meet all entry-level standards for physiotherapy.
The second constraint is the availability of place-
ments offered by clinical providers.
The purpose of this study was to examine
clinical education placements for The University

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40Australian Health Review February 2009 Vol 33 No 1
Health Professional Education
of Sydney to generate a profile of clinical educa-
tion providers in 3 calendar years and determine
how successful the placement allocation is in
providing undergraduate students with wide
exposure to clinical sites, locations, health care
sectors and learning group sizes. Generating such
a profile provides information about clinical edu-
cation, enables identification of inequities in clin-
ical education provision across the health care
system and can guide the development of future
physiotherapy clinical education curricula.
Methods
Organisation of clinical education
The University of Sydney, which is located in
New South Wales, Australia, is among the largest
providers of physiotherapy education worldwide.
There are two entry-level programs for physio-
therapy: a 4-year undergraduate bachelor degree
and a 2-year graduate-entry masters degree. Both
programs have integrated academic and clinical
components.
In 1998, the University of Sydney implemented
a “clinical schools” model. The clinical education
program is organised into five clinical schools.
Each school covers a geographic region of Sydney
as well as regional and rural areas. The five schools
are Central, Northern, Southeastern, Southwestern
and Western. Clinical providers are allocated to a
clinical school based on geographic regions and
students are allocated to a school based on a
preferential ballot. Each clinical school has a clini-
cal coordinator and administrative support pro-
vided by the university, however direct student
supervision is provided by clinical educators work-
ing in the health care settings. Each clinical school
has a steering committee, made up of the providers
and the university clinical coordinator, to facilitate
placement and support of students and educators.
The Clinical Education Advisory Committee over-
sees the development and implementation of the
clinical education program. Members of this com-
mittee include academics, clinical educators, phys-
iotherapy managers and students. The
membership of the Clinical Education Advisory
Committee reflects the strong collaboration
between key stakeholders in development and
implementation of clinical education.
Each year between 2001 and 2003, undergrad-
uate students completed six full-time clinical
placements totalling 29 weeks. The undergradu-
ate and graduate programs run concurrently so
that in any calendar year there are 29 weeks of
clinical education organised in six placement
periods. In the period studied, all students com-
pleted a general placement, a cardiopulmonary, a
neurology and two musculoskeletal placements.
The undergraduate students had an additional
elective placement.
Data collection
A retrospective audit of the clinical education
placement rosters generated from a Microsoft
Access database (Microsoft Corporation, Red-
mond, Wash, USA) was undertaken for 3 calendar
years (2001–2003) which included data from both
entry-level programs and for three cohorts of
undergraduate students between 1998 and 2003
(cohort 1, 1998–2001 [195 students]; cohort 2,
1999–2002 [159 students]; cohort 3, 2000–2003
[193 students]). Data from the three cohorts were
pooled, resulting in a total of 547 undergraduate
students who completed six full-time clinical edu-
cation placements. Any inconsistencies in the data-
set were identified and corrected by reviewing
student assessment records which confirmed the
details of the clinical education placements.
Data analysis
Data were analysed overall and by clinical
school for 2001, 2002 and 2003 for the number
of providers and placements, location of provid-
ers, health care sector (public or private), type
of placement and learning group size. A small
number of placements were provided interstate
or overseas and these placements were analysed
separately. Number of providers was defined as
the number of clinical sites, whereas placement
was defined as the number of student place-
ments. For example, one site may provide 65
placements in a year, made up of 20 neurology
placements, 30 musculoskeletal, 12 cardiopul-
monary and 3 elective placements. Provider

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Australian Health Review February 2009 Vol 33 No 1 41
Health Professional Education
location was classified as Metropolitan (defined
as providers located in greater metropolitan
Sydney), Regional (defined as large cities out-
side Sydney and including the Central Coast,
Hunter and Illawarra regions as well as the
interstate and overseas large cities) or Rural
(defined as locations not classified as Metropol-
itan or Regional). Providers were classified as
private or public according to funding source.
Where there was a mix of funding (ie, charitable
organisations and support groups) the provider
was classified as private. Type of placement was
classified according to the curriculum as gen-
eral, musculoskeletal, cardiopulmonary, neurol-
ogy and elective. Common electives included
paediatrics, private practice, sleep disorders,
rehabilitation, pain clinics, Indigenous health,
rural health and occupational health. The data
were analysed descriptively using Microsoft
Excel software (Microsoft Corporation, Red-
mond, Wash, USA).
Ethical approval was not sought for this project
as the audit involved the review of publicly
available placement rosters and the clinical pro-
viders agreed to the project.
Results
Over the 3 calendar years, 3475 placements were
provided by 209 different clinical sites, with a
maximum of 170 clinical sites used in any single
year. Over the 3-year period the demand
increased by 210 placements (16.5%) from 1066
in 2001 to 1133 in 2002 and to 1276 in 2003.
Almost all undergraduate students (99.1%)
went to four or more different sites for their six
placements, with 47.9% attending a different
clinical site for every single placement. The
majority of students completed at least four met-
ropolitan Sydney placements (84%), with a small
number undertaking all six placements in metro-
politan Sydney (4.9%). One or more rural NSW
1 Number of placements in each type of location
No. of students (%)
No. of placements Metropolitan Sydney Regional NSWRural NSW InterstateOverseas
None
1
2
3
4
5
6
1 (0.2%)
5 (0.9%)
20 (3.7%)
61 (11.2%)
162 (29.6%)
271 (49.5%)
27 (4.9%)
327 (59.8%)
113 (20.6%)
75 (13.7%)
23 (4.2%)
6 (1.1%)
3 (0.6%)
0 (0)
170 (31.1%)
320 (58.5%)
51 (9.3%)
5 (0.9%)
1 (0.2%)
0 (0)
0 (0)
506 (92.5%)
38 (6.9%)
3 (0.6%)
0 (0)
0 (0)
0 (0)
0 (0)
510 (93.2%)
37 (6.8%)
0 (0)
0 (0)
0 (0)
0 (0)
0 (0)
2 Type of placement in each location for 2001, 2002 and 2003
2001 20022003
Metropolitan Rural RegionalMetropolitan Rural Regional Metropolitan Rural Regional
Cardiopulmonary
Elective
General
Musculoskeletal
Neurology
Total
146
128
134
238
123
769
3 21
23
25
37
20
126
145
139
157
239
153
833
6 22
24
35
56
12
149
171
168
141
274
153
907
11
25
30
86
24
176
29
21
28
77
38
193
29
45
67
27
15
36
79
15
171151

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42Australian Health Review February 2009 Vol 33 No 1
Health Professional Education
placements were completed by 68.9% of stu-
dents. Regional NSW placements were under-
taken by a total of 39.8% of students, whereas
interstate and overseas placements made up only
a small percentage (7.5% and 6.8% respectively).
Results for location of placements are summarised
in Box 1.
Over the 3-year period, metropolitan clinical
sites provided 2509 placements (72.2 %). Both
metropolitan and regional sites increased the
number of placements over the 3-year period,
whereas the rural sites had a decrease of place-
ments in 2002, which were regained in 2003. The
proportional contribution from regional providers
increased from 11.8% in 2001 to 15.1% in 2003.
Rural sites were more likely to provide muscu-
loskeletal and general placements, whereas
regional and metropolitan sites provided the
range of placements, with at least twice as many
musculoskeletal placements compared with the
other type of placements (Box 2).
The public health sector provided 2982 place-
ments (85.8%) over the 3-year period, and the
554 cardiopulmonary placements were provided
exclusively by the public sector (Box 3). Over
time, the private sector provided more place-
ments, the number rising from 135 (12.7%) in
2001 to 204 (16.0%) in 2003 (Box 3). The
private sector predominantly provided elective
(213) and musculoskeletal (178) placements
(Box 3). The vast majority of undergraduate
students (99.6%) attended three or more of their
placements in publicly funded sites, and 43.9%
attended all of their placements in the public
sector. The private sector provided placements to
a total of 56.1% of students, of whom only
17.2% completed more than one placement in
the private sector.
The analysis of individual clinical school data
illustrated that the Western and Southeastern
clinical schools provided the most, and South-
western school the fewest, placements. Seven
4 Learning group sizes experienced by students during clinical placements
No. of students (%) per learning group
No. of placements123456
None
1
2
3
4
5
6
152 (27.8%)
258 (47.2%)
99 (18.1%)
34 (5.9%)
4 (0.7%)
0 (0)
0 (0)
32 (5.9%)
122 (22.3%)
155 (28.3%)
138 (25.2%)
64 (11.7%)
32 (5.9%)
4 (0.7%)
337 (61.6%)
175 (32.0%)
32 (5.9%)
3 (0.5%)
0 (0)
0 (0)
0 (0)
140 (25.6%)
181 (33.1%)
110 (20.1%)
69 (12.6%)
40 (7.3%)
7 (1.3%)
0 (0)
405 (74.0%)
139 (25.4%)
2 (0.4%)
1 (0.2%)
0 (0)
0 (0)
0 (0)
367 (67.1%)
141 (25.8%)
33 (6.0%)
5 (0.9%)
1 (0.2%)
0 (0)
0 (0)
3 Type of placement in the public and private sectors for 2001, 2002 and 2003
2001 20022003
Type of placement PublicPrivatePublic Private PublicPrivate
Cardiopulmonary
Elective
General
Musculoskeletal
Neurology
Total
170
109
195
297
160
931
0 173
119
201
315
171
979
0 211
131
176
363
191
1072
0
71 59
27
59
9
83
23
74
24
9
45
10
135154204

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Australian Health Review February 2009 Vol 33 No 1 43
Health Professional Education
public hospitals provided over 100 placements
each in the 3-year period. One public hospital
consistently provided the most placements, pro-
viding 306 placements over the 3-year period,
which was 8.8% of the total placements.
Learning group sizes ranged from students
attending placements on their own to being in a
group with five other students (Box 4). The
majority (94.1%) of students experienced at least
one placement in a pair, 72.2% attended at least
one placement alone and 74.4% had at least one
placement in a group of four. Group sizes of
three, five or six students were less common.
There were differences between the five clinical
schools in terms of the four factors: clinical site
variety, location, health care sector and learning
group size (Box 5).
The percentage of students attending a different
site for each of the six placements varied from
77.9% for the Northern School to 16.7% for the
Central School. The percentage of students expe-
riencing a rural setting varied from 89.7% for the
Western School to 34.5% for the Northern
School. Over 12.0% of the students in the West-
ern and Central Schools went rural for two or
more placements. The percentage of students
experiencing a regional setting ranged from
90.3% for the Northern School to 9.3% for the
Central School. Over 40.0% of students from the
Northern and Southwestern schools experienced
a regional setting on two or more placements.
Students were more likely to experience the
private sector if they were from the Northern
School and least likely if they were from the
Southwestern and Southeastern Schools. Work-
ing in pairs (groups of two) was the most com-
mon learning group size for all schools except the
Central School, whose most common group size
was 4. A high percentage (74.3%) of students
from the Southeastern school experienced the
maximum group size of six.
Discussion
This descriptive study provides useful informa-
tion for physiotherapy clinical education and
curriculum design. Over the 3-year period, an
additional 210 clinical placements were needed.
5 Individual clinical school analysis: percentage of students experiencing each
characteristic
Clinical school
Characteristic Central NorthernSoutheastern SouthwesternWestern
Different clinical
sites
4 sites, 26.9%
5 sites, 52.8%
6 sites, 16.7%
Metro, 100.0%
Rural, 85.2%
Regional, 9.3%
Rural 2+, 12.0%
Regional 2+, 0.0
Public, 100.0%
Private, 50.9%
4 students, 97.2% 2 students, 100.0% 2 students, 91.2% 2 students, 99.1%
2 students, 87.0% 1 student, 88.5%
1 student, 63.9%4 students, 51.3%
4 sites, 0.9%
5 sites, 21.2%
6 sites, 77.9%
Metro, 100.0%
Rural, 34.5%
Regional, 90.3%
Rural 2+, 4.4%
Regional 2+, 53.1% Regional 2+, 1.8% Regional 2+, 42.5% Regional 2+, 0.0
Public, 100.0% Public, 100.0%
Private, 81.4%Private, 46.9%
4 sites, 12.4%
5 sites, 54.0%
6 sites, 32.7%
Metro, 100.0%
Rural, 74.3%
Regional, 15.9%
Rural 2+, 1.8%
4 sites, 3.8%
5 sites, 30.2%
6 sites, 66.0%
Metro, 99.1%
Rural, 72.3%
Regional, 78.3%
Rural 2+, 6.6%
4 sites, 17.8%
5 sites, 36.4%
6 sites, 45.8%
Metro, 100.0%
Rural, 89.7%
Regional, 6.5%
Rural 2+, 28.0%
Location
Health care
sector
Public, 100.0%
Private, 47.2%
Public, 100.0%
Private, 53.3%
2 students, 93.5%
1 student, 84.1%
4 students, 67.3%
Learning group
size (top 3)
4 students, 86.7% 4 students, 69.8%
6 students, 74.3% 1 student, 60.4%
2+=two or more placements.

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44Australian Health Review February 2009 Vol 33 No 1
Health Professional Education
During the audit period the curricula for the
entry-level programs did not change, and this
increase in placements resulted from increased
student intake, particularly the graduate-entry
masters program.
Need for additional placement sites
Although meeting the demand for placements in
the period audited, the continuing yearly
increase in clinical placement requirements is
not sustainable for the providers.13,14 The clini-
cal school data enables planning for further
placement development. For example, the Cen-
tral clinical school should increase elective
placements, whereas the Southwestern school
needs to further develop all types of placements.
Information about inequities between clinical
schools has also been utilised by the Clinical
Education Advisory Committee in its role to
oversee the development and implementation of
clinical education.
This study demonstrates that the vast majority
of clinical education provision is undertaken by
the public sector, particularly hospitals. While the
private sector increased its contribution over the
3-year period, its average contribution was only
14%. Given that in 2001 58.6% of registered
physiotherapists in NSW worked in the private
sector,12 the contribution from the private sector
is inadequate. This challenge has also been docu-
mented in medicine.15 Barriers to increased pri-
vate involvement need to be identified and
solutions developed and implemented.
While the public sector provides 85.8% of
clinical education, there were inequities between
public hospitals. For example one site provided
306 placements over the 3-year period while two
other similarly sized hospitals provided 101 and
80 placements respectively. The hospitals more
likely to take a greater number of placements
appeared to be those with designated clinical
educator positions. Such positions allow a physi-
otherapist to take 4–6 students at one time.
During placement periods, these designated clini-
cal educators’ primary role is educating students.
Given the location of The University of Sydney,
not surprisingly all but one student completed at
least one placement in metropolitan Sydney.
Placements in Sydney are preferred by students as
they impose the lowest financial burden. Rural
placements are included in an attempt to help
with the well known shortage of health care
workers in rural areas.9 While the majority of
students gained experience working in a rural
area at least once, there remained a small percent-
age who attended regional sites instead or who
remained in metropolitan sites for all clinical
placements. The main reasons for this were the
relatively small number of offers by rural sites and
students applying for “special consideration” to
stay in metropolitan Sydney for specific,
approved reasons (eg, family illness, primary
carer duties or elite-level sporting commitments).
Need for placement sites representative of
the Australian health care system
Our finding that most clinical education takes
place in large public hospitals is at odds with the
changes in Australian health care. It is recognised
that there has been a policy shift toward commu-
nity-based care and self-management rather than
extended hospital care.6 If students undertake the
majority of their clinical education in large public
hospitals they may be ill-prepared for the work-
force, with a mismatch between their skills and
experience and Australian health care. Develop-
ment of physiotherapy clinical education place-
ments in both public and private community-
based health care settings is essential. The shift of
health care from the public to the private sector,
and the associated challenges for clinical educa-
tion programs, has been recognised not only in
specialist circles but also within the mainstream
national broadsheets.8,15
The changes in Australian health care have
implications not only for the educational institu-
tions in the delivery and development of curricula
but also for the regulatory authority, the Austral-
ian Physiotherapy Council, which accredits
entry-level programs. The requirement that edu-
cational institutions must demonstrate that their
graduates meet the Australian Standards for Phys-
iotherapy in all key areas of physiotherapy
(including musculoskeletal, neurology, cardiopul-

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Australian Health Review February 2009 Vol 33 No 1 45
Health Professional Education
monary and electrophysical agents across all ages
and from acute and community contexts)1 has
effectively driven the division of placements into
neurology, musculoskeletal and cardiopulmonary
physiotherapy. However, such placements are at
odds with how current health care is delivered
and also the professional roles of physiotherapists
today. Ongoing and open dialogue between the
Australian Physiotherapy Council and educa-
tional institutions guided by health providers is
necessary to ensure curriculum development is
reflective of current health care. It may be more
prudent to align placements with health care
delivery — that is, divide placements into acute
care, rehabilitation, ambulatory care and commu-
nity health. Subsequent to this study, curriculum
development along these lines has been imple-
mented.
With a national shortage of physiotherapists,9
the challenge for the profession is to reduce the
clinical education demands on current providers
while ensuring graduates meet entry-level stand-
ards and match current health care practices. An
increased contribution from the private sector is
warranted as well as development of placements
in community heath care. Alternatively, there may
be solutions within curriculum development,
with the reduction of placements utilising tech-
nologies such as telehealth,16 virtual reality17 and
patient simulations.18 There may also be efficien-
cies to be gained by utilising interprofessional
placements.19 High-quality research is needed
that evaluates the effect of different technologies
and simulated learning environments on profes-
sional competency and cost effectiveness.
Our study indicates that most students gained
experience in learning groups of variable sizes.
The group size offered is dependent on the
clinical provider and frequently reflective of their
staffing and space resources. Larger learning
groups (4–6 students) are exclusively provided by
large public hospitals with designated clinical
educators, whereas private providers and other
public facilities without designated educator posi-
tions typically offer placements for 1–2 students.
We argue that a variety of learning group sizes is
beneficial. Working in pairs allows for collabora-
tive learning and peer support,3 whereas larger
groups allow for teamwork. Teamwork is an
essential skill for physiotherapy graduates, as
health care delivery has become increasingly
interprofessional.20 Physiotherapists need to
work well in health care teams and need to be
able to interact with a range of clients and
colleagues.6 With 85.8% of all placements pro-
vided by the public sector and the majority
provided by large public hospitals we are confi-
dent that the clinical education program exposes
students to multidisciplinary teams in a number
of placements. Placements with only one student
may also be beneficial, as increasing numbers of
new graduates take up positions in settings where
they are forced to make critical clinical decisions
without a network of support from senior physio-
therapists.8 Placements without other students
may assist students to develop confidence, inde-
pendence and autonomy.
Limitations
The major limitation of this study is that it was a
descriptive study examining data retrospectively
from only one Australian educational institution.
However it provides useful background informa-
tion for the design of future studies. For example,
it may be useful to set up targets for private sector
involvement, implement strategies for its contri-
bution and to monitor providers regularly as a
means of addressing the inequity between the
public and private sectors. Examination of the
relationships between exposure to the different
factors and student and graduate employer satis-
faction, and graduate work choices is needed. In
the area of curriculum development, study of the
effect of learning-group size on clinical perform-
ance is also warranted.
Implications
The audit was useful in establishing a profile of
clinical education providers and describing the
variation in placement experiences between clini-
cal schools. The information highlighted inequi-
ties between public and private health care
sectors in clinical education. The information can

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46Australian Health Review February 2009 Vol 33 No 1
Health Professional Education
also be used to drive curriculum developments to
ensure clinical education programs match current
health care practice. This study demonstrated
that we need more clinical education providers,
particularly providers outside the public hospital
system. Given the importance of clinical educa-
tion and the challenges in providing it, further
work is urgently needed.
Acknowledgements
We would like to acknowledge all the clinical educators
who provided clinical placements to our students and
also Associate Professor Louise Ada for her valuable
comments on the manuscript.
Competing interests
The authors declare that they have no competing interests.
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(Received 29/11/07, revised 13/04/08, accepted 16/09/08)
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