Learning pathways during clinical placement of physiotherapy students: a Malaysian experience of using learning contracts and reflective diaries

Purpose: Learning contracts and reflective diaries are educational tools that have been recently introduced to physiotherapy students from Malaysia during clinical education. It is unclear how students perceive the experience of using a learning contract and reflective diary. This study explores the learning pathways of the students after using a learning contract and a reflective diary for the first time in their clinical placement. Methods: A total of 26 final-year physiotherapy students completed a learning contract and a reflective diary during clinical placements. Two researchers explored the data qualitatively by the thematic content analysis method using NVivo. Results: A total of four and six main learning themes were identified from the data of the students through a learning contract and reflective diary. Conclusion: These learning themes reflected the views of the students about what they have considered to be important learning pathways during their clinical placements. They give valuable insights into the experiences and opinions of students during their clinical education process, which should be useful for enhancing teaching and learning methods in physiotherapy education.


INTRODUCTION
Reflective diaries and learning contracts are popular educa tional tools commonly used in Western countries by the vari ous health professions. However, such tools are not very com mon nor as popular among students and academicians from Malaysia. Reflective practice is a vital component in health care professional education [1]. Writing reflective diaries is strongly recommended for students in their clinical placement. It is a powerful method for students to express their emotions based on good and bad experiences during practice [2,3]. Fur thermore, students are prompted to share their learning mo ments through writing, discovering themselves deeply by look ing through their own written reflections [4]. In writing re flective diaries, the students pick up selfreflective assessment skills during their clinical posting to develop their critical think ing by identifying their own limitations, reflecting upon learn ing incidents, and thereby creating changes among themselves [5]. A learning contract also serves as a guide for the students to choose a specific learning task at their clinical placement and focus on learning it. Thus, students are able to set their in dividualized learning goals with a learning contract [6]. There fore, a learning contract and reflective diaries are valuable cli nical educational tools in physiotherapy practice.
Although these learning tools have been widely acknowl edged by researchers, we are keen to capture the perspective of students towards their learning pathway during clinical place ment using these tools. The main focus of this study was to answer the question of how the students perceive using clini cal education tools such as a learning contract and reflective diary during their clinical placements. The present study aimed http://jeehp.org J Educ Eval Health Prof 2013, 10: 6 • http://dx.doi.org/10.3352/jeehp.2013. 10.6 to understand the learning pathways of physiotherapy students during their clinical placement using these clinical education tools. The findings derived through this current study might provide information on the experience of the students and their learning pathways using reflective practice and learning contracts at their clinical placement. Such information might be beneficial to new students in preparing themselves mental ly and physically in their learning pathway using these educa tional tools.

Study design
A qualitative design using a phenomenological approach was applied. This approach aimed to generate a description of experiences of participants as phenomena [7].

Sample
A purposive sample of 26 final year physiotherapy students who underwent clinical placement in a government hospital participated in this study. This sample consisted of 22 females and 4 males with a mean age of 22.5 years (SD, 0.58; range, 21 to 23 years). The purposive sampling was chosen in this study in order to capture the true reflections of the study participants who had significant knowledge and experience of going thr ough the process of using a learning contract and reflective diary. This sampling method was chosen to elicit the true ex periences of the participants and to prevent data pollution and biases.

Ethical considerations
Permission for this study was obtained from the Ethics Com mittee of a government university. The students signed inform ed consent prior to the study. All of the research materials were handled exclusively by the first researcher and no student names were associated with any final written materials.

Data collection
All of the subjects had a familiarization session on the utili zation of a learning contract and reflective diaries during their studies in Year 3, Semester 2. The format of the learning con tract and structured questions in the reflective diaries was in troduced. Some examples were given to facilitate students in preparing their learning goals and promoting better reflective diary writing. The students were arranged for a 12week clini cal posting in a government hospital in the first semester of the 4th year of a physiotherapy undergraduate program. They were asked to complete their learning contract with individu alized learning objectives after discussion with their clinical educators on the first day of clinical placement. They were re quested to complete the diaries at the end of the 12week clin ical placement. All of the learning contracts and reflective dia ries were collected the day after the end of the 12 weeks of cli nical placement.

Data analysis
Data analysis was done using thematic content analysis. The process of data analysis was adapted from Burnard [8]. First, the first researcher went through the data and recorded a pre liminary general message from students. The data were ana lyzed further by the first researcher to identify similarities and differences between the messages. The messages were then unitized into phrases or sentences relating to specific topics. Then, a code was assigned to a text chunk of any size that rep resented a single theme or issue of relevance by using NVivo (QSR International Pty Ltd., Doncaster, VIC, Australia) soft ware. Phrases or sentences formed through the reflective dia ries and learning contracts of the students were categorized under specific codes. Similar codes were collapsed into fewer, broader themes, and the final theme list emerged. The final theme list was shared with additional researchers to validate the first coding scheme created. Doubts and problems con cerning the definitions of themes and coding results were dis cussed and resolved within the research team [9]. General agree ment in the coding process was reached and verbatim extracts were taken from the text to illustrate the content of each final study theme. The triangulation method was adopted, as the final data were crosschecked among the researchers and with the informants to ensure the credibility of the research.

RESULTS
A total of 26 final year physiotherapy students who under went clinical placement in a government hospital participated in this study. This sample consisted of 22 females and 4 males with a mean age of 22.5 years (SD, 0.58; range, 21 to 23 years). The students demonstrated 4 common themes in their learn ing contract, while 6 themes were extracted through the anal ysis of their reflective diaries. All of the details are as discussed below. Analysis of the learning contract demonstrated the fol lowing 4 common themes by students during the clinical place ment: 1) to apply theory to practice, 2) to improve communi cation skills, 3) to achieve selfdevelopment, and 4) adaptation to the clinical environment. A summary of the themes and subthemes is shown in Fig. 1.

To apply theory into practice
The students were encouraged to identify their own learn ing needs through utilization of a learning contract in their http://jeehp.org To apply theories, knowledge, and clinical reasoning in the cases that I got. (Student P) To apply assessment and treatment techniques. (Student X) Some students were able to recognize their weaknesses spe cifically and therefore more focused objectives were generated through their learning contracts. Subthemes extracted through main objectives are listed as assessment skills, clinical reason ing, and treatment skills, as described below.
Subtheme 1: assessment skills. Good assessment skills are important for students to identify problems in patients, pre paring a treatment plan accordingly to ensure effective chang es happen during the physiotherapy sessions. Our findings showed that students were keen to sharpen their assessment skills during their clinical placement.
To practice full assessment toward every case. (Student H) To be able to perform a nerve tension test. (Student L) To improve cardiorespiratory assessment skills. (Student Y) Subtheme 2: clinical reasoning. Undergraduate physiothera py students are required to possess the ability to analyze re sults of assessment, develop a hypothesis and prepare a treat ment plan accordingly. Therefore, students in this study focus ed a great deal on applying evidencebased practice to their learning contracts. Some of the experiences that supported the need for clinical reasoning in the learning pathway of the students are presented below: To

To improve communication skills
Giving instructions in a proper and understandable man ner is very important for gaining compliance in patients and carers during assessment and treatment sessions. Interaction with other healthcare members is also vital for better perfor mance in an interdisciplinary system of hospitals. Clinical set tings provide the best opportunity for students to deal with different characteristics of patients in the hospital. Thus, stu dents in this study demonstrated their eagerness to sharpen their communication skills during clinical placement. The opinions of students collectively support the need for com munication skills, as demonstrated below: To

To achieve self-development
Final year students in this study were trying to prepare them selves to work in the society by fulfilling their objectives in their learning contracts, which stressed achieving higher perfor mance physically and mentally. For example, they wished to improve their confidence level and time management skill as demonstrated below: To be able to manage my time better in treating every pa tient. (Student Q) To be able to finish all assessment and treatment within 1 hour. (Student C) To build confidence while approaching patients and care  givers. (Student B)

Adaptation to the clinical environment
Familiarization with the working environment was men tioned by students as well. It improves the efficiency of work while it enables work to be performed safely.
To be able to get familiar with the setting in medical wards such as types of oxygen masks, arterial lines, and central lines. (Student P)

Analysis of the reflective diaries
Analysis of the reflective diaries has shown 6 common themes with subthemes described in Fig. 2.

Apply theory to practice
In the diaries, the students shared their handson experien ces during the clinical placement, recalling the incidents that happened throughout the period. Furthermore, they shared their happiness in applying new assessment skills such as wo men's health assessment in patients.
It was the first time I performed a vaginal examination. It was a really good experience for me. (Student I) I studied women's health for quite some time but never had the opportunity to apply them in a clinical situation. Today, I learned and performed a vaginal examination and perineometer measurement for the first time! (Stu dent H) I had a chance to improve and become more familiar with the surgical case assessment. (Student Y)

Self-evaluation
Of all the reflective diaries, selfevaluation became part of the common events during students' reflection upon their cli nical experience. Two main subthemes were generated in the analysis, which were 1) selfdevelopment and 2) recognizing weaknesses and limitations.
Subtheme 1: self-development. The students were aware of their development during the clinical placement. Improve ment in their confidence level was mentioned by the students in their reflective diaries. They also recognized their own ca pability in managing their learning as well as the patients' con ditions.
The new knowledge made me enjoy the learning so much. I will face the situation with more confidence in the future. (Student G) I have to be more independent and take initiative to ask for cases or discuss them with clinical supervisors. I will try to see different types of cases and always get back to cli nical supervisors for their opinions.(Student D) Subtheme 2: recognizing weaknesses and limitations. The stu dents had undergone the process of identifying personal inad equacies in clinical placement through their reflective diaries. Culture shock and lack of medical knowledge were the main issues in the reflections of students as demonstrated below: I was fearful and kept thinking of any contraindications in managing the patient. I was hesitant to provide treatments. Overall, I took more than 1 hour to complete the whole session. (Student C) Basically, I have little experience in those areas of attach ment. I have had no chance to perform objective assess ment for women's health cases before due to the restric tions in different hospitals. That's why I am not confident in managing those cases. (Student Q)

Therapist-patient communication
Good communication skills are vital to improving the un derstanding of patients about their own condition and deliv ering clear instructions to patients. Compliance of patients to wards physiotherapy treatment may be increased through pro per patient and carer education. Students in this study reflect ed on problems faced during an interactive session with pa tients and the approaches they had used to solve the difficul ties. The students showed a positive attitude in achieving im provement of their communication skills.
The most difficult task is to give instruction in performing pelvic floor exercises, especially to the elderly. I have to be creative during the explanation of incontinence and tea ching the exercises. Besides, I need to do it in the simplest way so that my patients will be able to understand the ex ercises and their benefits. (Student U) I learned to approach patients in a proper way so that he/ she can understand me and follow my instructions. (Stu dent Z) In dealing with an elderly patient, I need more patience towards them. They get tired and give up easily, having more difficulty in expressing their feelings compared to younger patients. It is hard for them to obey my commands when carrying out exercises. I learnt that we need to be  more patient and give them more encouragement when dealing with them. (Student P)

Coping with responsibility
The findings demonstrated that finalyear physiotherapy students were striving to cope with their responsibility as fu ture physiotherapists. The process of improvement was aided by various strategies of learning such as group discussion and knowledge sharing with colleagues. The effort of students was shown in the reflective diaries of students as displayed below:

Effectiveness of clinical educator
Undeniably, clinical educators play a major role in assisting students' development in this profession. Adequate supervi sion and guidance of good clinical educators encourages stu dents to achieve better performance academically and clini cally. Students showed their gratitude towards clinical educa tors who aided them along the clinical placement. Positive feed back was seen through their reflective diaries.
With the guidance from clinical educators, I was able to take my first

Facing reality despite expectations
Different hospitals with various settings and workforces af fected the students' learning events. Students' high expecta tions toward their learning environment may have been in congruence with what they wish to observe and practice. The students showed their disappointment in reflective diaries as demonstrated below: Mostly medical cases were given when I was posted in the surgical area. (Student U)

DISCUSSION
All the 26 respondents were considered in the results. No data was excluded during the analysis of the learning contracts and reflective diaries of the students. There was no issue of a difference of opinion between the 2 researchers during the process of theme extraction. This study explored the learning pathway of finalyear students through learning contracts and reflective diaries. Students identified several issues that were important to clinical practice through personal perceptions such as the application of theory to practice, a concern for communication skills, reflection on positive and negative ex periences, and effectiveness of clinical educators throughout the clinical placement. The analysis of the learning contracts provides information on the common learning goals of the students while the reflective diaries of the students generate a summary of practical experiences from the clinical placement. The results demonstrated the process of transition in the per formance of students from the academic to the clinical setting. The learning contracts and reflective diaries were useful clini cal teaching tools. The findings of the current study supported the fact that the students benefitted from these clinical teach ing tools in their clinical placement as reported in past studies [10,11].
The results showed that the students focused much on their application of theory during their clinical placement. In this study, through analysis of learning contracts, specific skills such as assessment skills, treatment skills, and evidencebased practices were experienced by students as key learning path ways within their learning process. Past studies of contract learning in nursing education also demonstrated that the ma jority of the students agreed that a learning contract enable them to relate and apply theory to practice, improving their nursing skills after the clinical placement [10]. Similar opin ions were given by physiotherapy students in this study who had been exposed to the benefits of a learning contract during the familiarization session prior to the beginning of clinical placement. Our findings showed that students were keen to obtain the same benefits by using this learning tool. Most of the students are aware of the importance of minimizing theo rypractice gaps by applying theories to practice during clini cal placement. Thus, students demonstrated their individual ized learning goals in the learning contract to ensure that tar gets were achieved at the end of clinical placement.
The students shared a number of clinical experiences, which ranged from their first experience on selective assessment skills until the end in their difficulty faced during treatment in writ ing reflective diaries. The findings revealed that students had undergone a process of selfevaluation during reflection on their positive and negative experiences. They mentioned their http://jeehp.org J Educ Eval Health Prof 2013, 10: 6 • http://dx.doi.org/10.3352/jeehp.2013. 10.6 strengths and weaknesses in clinical events during the place ment. While recognizing selfweaknesses, such as low confi dence level and poor clinical reasoning skills, students showed their ability to make changes in themselves with plans and suggestions. Students in this study also shared their happiness with the success of coping with their responsibilities as phys iotherapy students. The findings are consistent with the re search of Cooper et al. [11] on final year nursing students. The authors found that their students reflected both positive and negative characteristics in themselves while dealing with dif ferent patients. The study demonstrated the development of maturity among nursing students in their leaning process, as these students were able to synthesize the importance of and responsibility for a given clinical task. William et al. [12] ob served the learning process of students in clinical placement with reflective practice in his study. His results showed the emotional response of students meeting with unfamiliar or new learning events, followed by development of coping strat egies, evaluation of learning outcomes, and an increase in their confidence level with successful events. In the current study, the students showed a similarly positive attitude in facing their limitations and improved with reflection on the good and bad points among them.
Similar findings regarding the interaction of students with patients and supervisors were found by Larin et al. [13]. A pre vious study of reflective diaries of students revealed students' awareness of the therapistpatient relationship, learning to lis ten to their patients' needs, and recognizing the importance of patient education and care. The results of this study showed that the topic of communication was stressed by students in their learning contract and reflective diaries. Students strived to obtain patient compliance during the treatment process through effective communication skills. Besides, students men tioned that the proper manner of explanation of the disease process in patients and exercise instructions would help to re duce anxiety in patients. In this study, the students also stressed effective communication skills as a key factor for communi cating with clinical educators to achieve more advanced learn ing of professional skills. The experience of students in the clinical placement was greatly influenced by the clinical edu cators [14,15]. The students in this study shared good experi ences of learning with the clinical educators in the clinical placement. The students felt that their confidence level in ma naging patients increased with support from clinical educa tors. The students frequently mentioned the clinical educators during their reflective diary writing. Identifying effectiveness in clinical educators can improve the quality of clinical educa tion, which aids the positive development of key learning path ways in students.
The main weakness of the qualitative study is that it is not possible to make quantitative predictions. However, the strength of this research is that this study provides an understanding and description of students' personal experiences of using these clinical education tools and their reflection of how learning takes place individually in a clinical atmosphere. Another stren gth is that this study showed a sequential pattern of learning pathways as exemplified by the students in a naturalistic set ting using these clinical education tools. Such information might help academics and clinical educators to monitor the students over the domains of clinical learning and clinical skills identified by the participants of the current study. Al though learning pathways and a reflective diary were used in other parts of the world, the natural setting in which these learning tools are implemented may have an influence on the efficacy of these tools. Any such influence could be considered new knowledge pertaining to that particular naturalistic set ting and such knowledge holds high importance for success ful implementation of these teaching methods in a clinical en vironment. In this regard, the current study findings are claim ed to have value and importance for academics and clinical educators from Malaysia. Hence, the findings of the current study cannot be neglected, and it should certainly be of inter est to any academics or clinical educators who look forward to evidence of efficacy in implementing learning contracts and reflective diaries with Malaysians.
In conclusion, learning contracts and reflective diaries were shown to be effective clinical educational tools for physiother apy students. A major benefit in this study was that the stu dents were being encouraged to develop independent learning methods. The students successfully identified their individual learning needs while recognizing the value of their clinical ex periences through reflection. Therefore, both of these learning tools should be considered an integral part of professional practice in physiotherapy education.