Community-based primary healthcare training for physiotherapy: Students’ perceptions of a learning platform

Background South Africa is faced with an overburdened public healthcare system and physiotherapists need to be equipped to address these challenges. Community-based primary healthcare clinical training (CBPHCT) offers physiotherapy students with learning opportunities to develop core competencies in order to address the needs of a disparate healthcare system. Objectives To explore the experiences of physiotherapy students participating in a CBPHCT platform. Method An explorative qualitative approach was adopted, using focus group discussions with final year physiotherapy students exposed to a year of CBPHCT. Data from the focus groups were transcribed and analysed using content analysis. Results Four overarching themes were identified: prerequisite community-based primary healthcare competencies, positive factors associated with CBPHCT, negative factors associated with CBPHCT and recommendations. Conclusion The CBPHCT experience was seen to present challenges to, and have benefits for, physiotherapy students. The students felt that communication between stakeholders, such as academic staff and hospital personnel, could be developed, while the lack of resources, such as Internet access, posed a barrier to learning. Students felt core competencies, such as professionalism of caring, were influenced by their exposure to the clinical personnel. Furthermore, they saw themselves as health advocates and felt there was mutual benefit from engagement with communities during their clinical placements. Recommendations included a review of physiotherapy curricula to prepare students for CBPHCT. Clinical implications Community-based primary healthcare clinical training provides learning opportunities for undergraduate physiotherapy students to develop core competencies, such as health advocacy, necessary to address the unique needs of a disparate South African healthcare system.


Introduction
Possible outcomes of CBPHCT include underserved facilities gaining healthcare from healthcare students as well as the supporting tertiary structures. It is also beneficial for the health science student who has the opportunity to develop core competencies and skills through clinical exposure in a primary healthcare setting (Taukobong 2004).
In 2017, the Kwazulu-Natal Department of Health and the provincial tertiary health science training facilities embarked on a drive to introduce CBPHCT into the health sciences curricula . The physiotherapy discipline answered the call in 2017 and embarked on the implementation of this novel approach into clinical training. The CBPHCT platform included six extra-clinical training facilities in rural and peri-urban communities, in addition to the existing four urban clinical training hospitals in the eThekwini district. The facilities provided final year physiotherapy students with clinical exposure to neurology, cardiopulmonary, neuro-musculoskeletal conditions and community-based rehabilitation. Each physiotherapy student spent 5 weeks at four of the clinics, two of which were the newly introduced rural/peri-urban facilities, and two of the urban facilities that were used prior to the new CBPHCT approach. Because of the novelty of the new clinical training platform, and the lack of a model to guide clinical training, a group of researchers embarked on a project to develop an integrated model for CBPHCT across the disciplines in the health sciences . The aim of this study was specifically to explore the perceptions of final year undergraduate physiotherapy students about CBPHCT so that their insights could be incorporated into the integrated model for CBPHCT in health sciences at the same university.

Materials and methods
Using an explorative qualitative approach (Baxter & Jack 2008), the perceptions of physiotherapy students participating in the CBPHCT offered at a tertiary institution were explored. Focus group discussions were the primary method of enquiry. This approach allowed for a comprehensive understanding of the experiences of students accessing the clinical training (Wildemuth 2016). The study was located at the University of KwaZulu-Natal. A purposive sample of final year physiotherapy students, who were exposed to the training for a year, was used to gain insight into their experiences of the new clinical training approach (Onwuegbuzie et al. 2009). The sample comprised both male and female students of varying ages and ethnicities representative of all the rural and urban clinical sites to achieve maximum variation. The power influences of interviewer-interviewee relations were managed by electing a part-time staff member (part of the research team) who was not involved in final year clinical training to conduct the interviews together with a staff member from the student academic support services.
Four focus group discussions were conducted by the first author and observed by a senior academic at the university, who is experienced in qualitative methodology (Gill et al. 2008). The discussions were conducted in a meeting room in the physiotherapy department and lasted between 45 and 60 min. Informed consent and biographical information were obtained from the students and they were made aware that they could withdraw from the study at any point. No incentives were offered to participate in the study (Gill et al. 2008). A focus group guide developed by the authors was used as a basis for understanding students' experiences during their clinical placements. The questions included perceptions of being the pioneers of the CBPHCT at the institution, experiences of the four mandatory clinical training sites attended by students in the year and also explored relationships on the CBPHCT platform including peer support. Facilitators and barriers as they emerged were also probed. Students were also asked about their perceptions of the teaching and learning approaches to CBPCHT, as well as their recommendations for an approach to teaching and learning on the CBPHCT platform.
Discussions were conducted in English, which was the preferred language of the students, and were recorded using a digital voice recorder. Data were collected until no new information emerged from the discussion. The recordings were transcribed verbatim immediately after the focus group discussions. The observer, an academic development officer who is part of the student support service, documented nonverbal cues to contribute to the credibility of the verbally expressed data. Then, conventional thematic data analysis was conducted by using an inductive approach (Vaismoradi, Turunen & Bondas 2014). Consensus was reached following reading, analysis and in-depth discussions among the coauthors of the study. This process ensured the dependability of the data. The themes and subthemes that emerged were sent back to students for verification of the results as a means of member checking to enhance the confirmability of the data (Morse et al. 2002). Detailed, rich descriptions further contributed to the transferability and credibility of the data (Creswell & Miller 2000).

Ethical consideration
Ethical clearance was obtained from the Humanities and Social Sciences Research Ethics Committee of the University of KwaZulu-Natal (ethical clearance number: HSS/0576/018M).

Findings
There were 39 female and 10 male physiotherapy students who participated in the study. Of the students, 47 were aged between 20 and 25 years and two were aged between 26 and 30 years. Of the students, 28 were black South Africans, 17 were of Indian descent and 4 were white South Africans. Four overarching themes were identified from the focus group discussions: prerequisite competencies for CBPHCT, positive factors associated with CBPHCT, negative factors associated with CBPHCT and recommendations, which are discussed next.
Theme 1, prerequisite competencies for CBPHCT, was made up of five categories: community respect, cultural sensitivity, language competency, health advocacy and professionalism. The students learnt the importance of community respect and to be culturally sensitive, as well as the need to improve their language competency during their community-based primary healthcare clinical training. Physiotherapy students embraced their role as health advocates and felt that the training influenced their professional approach to care. Theme 2, positive factors associated with CBPHCT, with the subtheme benefits of the clinical training platform, included three categories: personal development, clinical support and independent learning. The support offered by clinicians in this study, through tutorials and mock examinations, enhanced the clinical training. The rural placements challenged students to develop their independent learning skills.
Theme 3, negative factors associated with CBPHCT, included four subthemes: logistical factors with six categories (poor infrastructure, online learning access, lack of consumables and equipment, accommodation challenges, administrative challenges and transport problems), curriculum gaps with three categories (theoretical gaps, assessment and theory into practice), collaborative influence on learning with four categories (academic and clinician dynamics, student and clinician partnership, peer relationships and poor multidisciplinary team work) and obstacles to clinical training platform with three categories (lack of knowledge, lack of supervision and inadequate specialised exposure).
Theme 4, recommendations, included three categories: personal development, clinical support and independent learning. Physiotherapy students in this study recommended that the infrastructure needs to be improved. They felt that access to computers, printers and Wi-Fi would facilitate their learning. Furthermore, physiotherapy students believed that improved accommodation at the rural and peri-urban placements would enhance their CBPHCT experience. Table 1 shows relevant quotes, categories and themes. Pseudonyms are used when quoting the students.

Discussion
The perceptions of physiotherapy students about the CBPHCT approach offered at the university who participated in this study are discussed under the four core themes and framed by contemporary literature.
The prerequisite competencies for community-based primary healthcare assumes that community-based primary healthcare competencies are embedded in community respect, cultural sensitivity, language competency, health advocacy and professionalism. South African universities promote graduate competencies to prepare their undergraduate students for professional practice upon completion of their degree.
The framework that guides the training of health science students in this study setting espouses seven key roles: practitioner, communicator, collaborator, leader, scholar,  Govender et al. 2018). The core competencies align with the perceived competencies that physiotherapy students in this study identified after their exposure to the CBPHCT model. Future healthcare professionals, such as physiotherapists, need to develop social responsibility and professional attributes that make them community leaders and innovators. Mlambo et al. (2018) suggested that decentralised clinical training, such as the CBPHCT, offers an opportunity for health science students to learn these competencies and become socially responsive during their undergraduate clinical training.
The community respect experienced by the students in this study facilitated their learning experience. This finding is supported by Mabuza et al. (2013), where the students were deemed vital members of the healthcare team by the community, and where it was acknowledged that communities were key to educating prospective healthcare professionals . In a study regarding community-based education, health science students in South Africa agreed that exposure to diverse communities facilitated the development of students' cultural awareness and sensitivity. Focusing on language competency, physiotherapy students felt motivated to improve their local language skills. In their 2013 study exploring clinical training with physiotherapy undergraduate students at a South African tertiary institution, Mostert-Wentzel and colleagues believed that understanding local languages facilitates the relationship between health science students and the community (Mostert-Wentzel, Frantz & Van Rooijen 2013).
The students indeed have perceived CBPHCT positively. This is evident from the positive factors associated with CBPHCT. This core phenomenon subsumes the benefits to the clinical training platform and asserts that personal development, clinician support and independent learning are facilitators of the CBPHCT platform.
Physiotherapy students in our study stated that they had grown on both a personal and a professional level. Two studies at South African universities, focusing on undergraduate physiotherapy students, concurred that students develop personally and professionally during their clinical placements (Ernstzen, Statham & Hanekom 2014;Talib et al. 2017). Respondents in this study stated that the clinicians at the rural and peri-urban facilities engaged more, and offered more support as supervisors, than the clinicians at the urban sites. Naidoo and Van Wyk (2016) expressed the opinion that health science students developed their clinical skills through observing their mentors. They found themselves having to be creative and resourceful in poorly resourced environments and took responsibility for their learning. Ernstzen et al. (2014) and Taukobong (2004) found that the challenges at rural clinics facilitated physiotherapy students to think laterally and develop their clinical reasoning skills.
In spite of the benefits perceived by physiotherapy students, there were still some negative factors associated with CBPHCT, which included logistical factors, collaborative influence on learning, obstacles to clinical training platforms and curriculum gaps. Logistical factors included the categories of poor infrastructure, online learning access, lack of consumables and equipment, accommodation challenges, administrative challenges and transport problems. The physiotherapy students stated that the poor infrastructure and lack of resources influenced their learning. In a similar South African study, Ernstzen et al. (2014) opined that limited infrastructure can have both negative and positive effects on clinical learning of undergraduate physiotherapy students. A recurring challenge for our students was inadequate Internet access during their rural and peri-urban placements.
In Talib et al.'s (2017) study, with medical students in sub-Saharan Africa, learning was hindered because of limited resources in the learning environment, such as Internet access. Although limited resources will present challenges in poor-and middle-income countries like South Africa, these obstacles encourage students to be creative and solve problems (Ernstzen et al. 2014).
Collaborative influences on learning encompassed academic and clinician dynamics, student and clinician partnerships, and peer relationships. Physiotherapy students believed that the partnership between the academic staff at the university and the staff at the CBPHCT sites was crucial for the success of learning in this model. In a similar study conducted prior to the adoption of CBPHCT, students reiterated that poor communication between the university and clinical training sites can be an obstacle to optimal learning ). Diab and Flack (2013) also attest that universities should not only train the clinicians supervising health science students but also provide them with ongoing support. The physiotherapy students voiced that clinicians employed at the urban facilities were unwilling to offer supervision or assist them with their teaching and learning. The relationship between the student and clinician is critical and the clinicians need to be approachable and dynamic to enable a favourable learning environment (Ernstzen, Bitzer & Grimmer-Somers 2010). The physiotherapy students expressed dissatisfaction about the multidisciplinary teamwork, especially at the urban clinics. They stated that the doctors did not acknowledge their role. In Mostert-Wentzel et al.'s (2013) study, physiotherapy students stated that doctors lacked awareness of physiotherapy and/or insight into allied health professions. Multidisciplinary teamwork (MDT) is very important if seamless healthcare is to be offered and the issue of collaboration should be explored further, especially regarding CBPHCT Ernstzen et al. 2014).
A lack of perceived knowledge, lack of supervision and inadequate specialised exposure posed barriers to the clinical training platform. Some physiotherapy students felt unprepared to practise independently and stated that they did not have adequate knowledge. They said that they lacked supervision and exposure to specialised areas of practice, such as neurology and paediatrics. In a similar South African study, an explorative review of physiotherapists doing their community service found that the respondents agreed with these sentiments, but in retrospect, once they had experienced independent practice, found the undergraduate training adequate .
What is adequate supervision for physiotherapy undergraduate students? This is a relevant question, yet there is little in the literature which provides an answer. A recent systematic review by Lekkas et al. (2007) concluded that no model of clinical education is superior to any other. Taukobong (2004) reported that students require suitable supervision to enable a positive learning environment. The lack of specialisation is echoed in previous studies by Ramklass (2013) and Chetty et al. (2018), and these shortcomings need to be addressed in order to facilitate the preparedness of physiotherapy students prior to clinical training.
The curriculum gaps included assessment and theory into practice gaps. Physiotherapy students felt that they needed more input from the academic staff at the university in the form of tutorials and Skype sessions.
Our respondents stated that they were unable to complete assessments because of the demands of patient care placed on them. In Ernstzen et al.'s (2014) study, physiotherapy students agreed that the demands of heavy workloads encroached on assessment time and therefore affected clinical learning. Our physiotherapy students said that the current programme of clinical exposure should begin earlier in the curriculum, and not in level 3, in order to better integrate theory into practice. Talberg and Scott (2014), assessing a physiotherapy undergraduate programme in South Africa, noted that undergraduate students struggle to integrate theory into practice. Introducing clinical education earlier in the programme could alleviate this problem.
Finally, the recommendations included improved communication, increased clinical supervision and improved infrastructure. The physiotherapy students stated that communication needs to improve between academic and clinical staff in order to improve learning. Mabuza et al. (2013), in a study of health science students, highlighted the impact of poor communication in hindering clinical training. Students suggest that, prior to clinical placements, university staff should ascertain from clinical supervisors whether they are willing to supervise students. Physiotherapy students in Ernstzen et al.'s (2010) study on the perspectives of physiotherapy students and clinical teachers regarding best clinical teaching and learning reported that they learnt through observation and that their personal clinical reasoning developed as the clinical supervisors shared their clinical reasoning with them. Ernstzen et al.'s study validated the powerful role of clinical supervisors in the teaching and learning of physiotherapy students.

Limitations
While the results of this study may be transferable to other contexts, they are not generalisable. The perceptions of physiotherapy students about CBPHCT are specific to their own experiences at one university and thus cannot be generalised to the broader population of South African physiotherapy students. Furthermore, although reflexivity was taken into account, the authors note the potential for internal bias in the interpretation of the findings because of their positions at the institution.

Recommendations
Future studies exploring the collaboration between clinical educators and undergraduate students in this context need to be conducted in order to provide insights into and recommendations for improving partnerships.
Furthermore, a review of the undergraduate curriculum is important to include community-based clinical training.

Conclusion
Improved approaches to clinical training for healthcare professionals, such as physiotherapists, in resource-poor countries like South Africa are needed to address the healthcare needs of the country. The CBPHCT platform introduced at a tertiary level allows students to be exposed to rural and underserviced communities during their clinical training. This study explored the experiences of final year physiotherapy students who participated in the recently introduced CBPHCT at the University of KwaZulu-Natal. Physiotherapy students experienced challenges during their CBPHCT placements, such as curriculum gaps, lack of adequate communication between stakeholders and limited resources. However, the benefits they derived included developing more competence in areas such as health advocacy and improved professionalism. The physiotherapy students experienced personal and professional growth and felt that they were contributing to the communities they engaged with during their clinical placements. The CBPHCT approach was seen as a feasible method to address various needs of undergraduate health science training while providing care at a primary healthcare level.