Preparing the foundations for video-based practice-placement support: establishing the role from a students’ perspective

Currently, many placement-based health programme students within the UK are supported through face-to-face visits from university staff. Whilst cited in literature as being of value, the face-to-face nature of this contact is not supported. Alternatives including video-based communications methods offer the potential for cost effective, environmentally responsible support. However, in order to establish the fitness for purpose of alternative approaches, the content and purpose of current support needs to be understood. This project aimed to investigate student perceptions of the ideal content and purpose of clinical support visits, and alternatives to the current face-to-face approach. Fifty-six Physiotherapy undergraduate students responded to questionnaires with a further nine participating in a follow-up focus group. Participants emphasised the value of the visit in guiding learning, ensuring progression and resolving arising issues, and highlighted concerns over alternative approaches. Focus group participants discussed the importance of personal and professional confidence in directing requirements for support, and went on to propose a menu of options for methods of communication. Whilst limited in some applications, video technologies may be one of the options. Overall, however, this project supports the need for consideration of individualised learning journeys within curriculum planning.

This project builds upon an earlier pilot project (Taylor 2009) that investigated the feasibility of using video-based communications for supportive dialogue between practice-based students, clinical educators and academic staff.Whilst experiencing a number of logistical issues, the project demonstrated the potential for this form of student support and highlighted participants' positive perceptions of the process.However, questions of fitness for purpose of the medium and the true value of the clinical visit perceived by students and clinical staff were raised.In order to evaluate fitness for purpose of alternatives to face-to-face contact, it was necessary first to understand the student experience and identify the activities that would need to be facilitated via an alternative means.

Student support
Support for students whilst undertaking placement-based learning is advocated throughout the literature (Andrews et al. 2005;Hutchings, Williamson, and Humphreys 2005;Levett-Jones and Bourgeois 2011).However, little literature exists on how to support such a period of practice (Neill and Mulholland 2003).Whilst visits to students within placement may be the ''norm'' in many institutions, there is the question as to whether or not face-to-face placement visits offer value for money (Martin 2005).
Both Burns and Patterson (2005) and Martin (2005) discuss the value of clinical visits for the purpose of focusing the learning experience, balancing the needs of the students with those of the service and patients and offering an opportunity for seeking clarification or information.Whilst acknowledging that the insights and knowledge of the tutor are vital to the student-placement experience, these authors leave the face-to-face nature of clinical visits largely unexplored.Hence, though the importance of the tutor in facilitating relationships is not in question, the methods by which this is achieved needs further exploration.

Institutional perspective
Whilst affirming that a student-centred approach to placement support is paramount, Henderson, Heel, and Twentyman (2007) also discuss the benefits of clinical visits in building and maintaining partnerships between clinical and educational institutions.Their research has focused upon the development of specific roles for this purpose, leading to a more streamlined, collaborative and structured approach.Their findings support earlier studies (Gore and Mitchell 1992;Martin 2005;Swinehart and Meyers 1993) that suggest clinical visits aid in cementing working relationships, ensuring placement quality and maintaining academic staff contact with ''coal face'' changes in policy.Whilst raising important points, the author questions whether trying to fulfil so many roles within a placement visit may overcomplicate what is essentially a student-support process.By focusing placement visits upon the student experience, alternatives to face-to-face methods are easier to evaluate for fitness for purpose.

Student perception
Unfortunately, few studies specifically address student perceptions of the value of the clinical visit.Thus, it is questioned whether, to date, students have been appropriately involved in planning for change.Gillespie (1997) undertook research into the perceptions of Occupational Therapy students regarding the value of clinical visits during a 3 year undergraduate programme.Findings of the study highlighted students' perceptions of value in supporting and recognising them during placement periods, and in providing the opportunity to address issues arising in a timely manner.However, the age of the study raises questions of validity within current institutional student-support structures.
Literature suggests value of the clinical visit in facilitating support and communication and in cementing institutional partnerships.However, the face-toface nature of current practice lacks a clear evidence base, and apparent confusion over the purpose of clinical visiting further limits the potential of research into alternative approaches.Whilst an earlier project has supported using video-based communications for this purpose, there is a need to further consider the student voice in planning and to clearly identify the purpose and role that this medium may be asked to fulfil.

The project
This study focuses upon mid-placement support for undergraduate physiotherapy students.However, as clinical visits are common in many other programmes and institutions, this study may be of interest to a wider audience.

Aim
To evaluate the perceptions of student participants regarding the value, purpose, ideal content and delivery of clinical visits.

Objectives
The objectives of the study were as follows: . To establish participant perceptions of the purpose of the clinical visit. .To identify ideal visit content from the participant perspective. .To investigate participant opinion regarding alternative methods of providing support during placement periods.

Study design
This study was undertaken as an evaluative phase (Robson 2002) of a larger Action Research cycle, which aimed to evaluate alternative, non-direct forms of contact with students during practice placements.Reason and Bradbury (2001, p. 1) describe action research as, '' . . .a participatory, democratic process concerned with developing practical knowing . . .seeking to bring together action and reflection, theory and practice, in participation with others, in the pursuit of practical solutions . . ..''This methodology has been successfully used in similar practice areas (Henderson, Heel, and Twentyman 2007) where action research has been advocated as a means of exploring issues through collaborative critical reflection, thereby ''empowering each other to take actions to achieve the set goal agreed upon . . .''(Kemmis 2007).As this study aims to establish changes to practice, involvement of, and ''buy in'' by, stakeholders are essential in ensuring engagement with change.As face-to-face placement visits may no longer be feasible within financial, time and environmental constraints faced by institutions, the perceptions of key stakeholders in the process are vital in establishing a legitimate alternative approach which does not compromise quality.
Year 2 and 3 students undertaking the Undergraduate Physiotherapy degree were approached as participants as being representative of those Physiotherapy students with the most placement experience.With large numbers of students in each year (Year 3 048; Year 2052), initial questionnaires facilitated data collection from a large sample with a subsequent focus group used to clarify and explore issues in more depth (Robson 2002).Ethical approval was gained, and fully informed consent was received from all participants prior to data collection.Guarantees of confidentiality, anonymity of questionnaires, freedom of refusal to either participate or withdraw from participation and the freedom to refuse to discuss particular questions were given to all participants.

Questionnaires
Table 1 outlines the development, distribution and data analysis methods used when issuing questionnaires to the study sample.Care was taken to reduce potential bias in Table 1.Questionnaire design and distribution.

Questionnaire development
Questionnaires aimed to investigate the perceived purpose of clinical visits, the current and ideal content of these visits and the potential to support students in alternative formats Pilot The questionnaire was piloted with five students and three staff members (not involved in the overall study), for validity and clarity prior to use Likert scale responses indicating agreement or otherwise, with suggestions for alternative approaches to successful (student is progressing well and passing the placement) and failing placements (student is at risk of not passing the placement at the final assessment) accordance with guidance on the wording and structure of questionnaires (Bowling 2002;Ruane 2005).

Focus groups
A focus group was used to follow up on questionnaire results.Participants from both year groups were asked to indicate interest in participating, with a volunteer sample of nine participants taking part as a result.Table 2 outlines the approach to this focus group.
Limitations of this project included the potential for bias created through researcher involvement in the focus group.However, as an insider researcher (Senge 1998) and placements coordinator for Physiotherapy, the author had considerable prior understanding of the complexities associated with the support of Physiotherapy students during placement learning.This was felt to offer more advantages than disadvantages to progression of discussions.Care was taken to ensure that the researcher remained neutral whilst facilitating discussions, offering no opinion and avoiding the use of leading questions (Buckingham and Saunders 2004).

Data analysis
Differences in distribution between Year 2 and Year 3 students are felt to account for the difference in questionnaire return rates (Year 2082% response, Year 3 027% response).Whilst raising issues of bias associated with non-respondents (Buckingham and Saunders 2004), comparison of responses from Year 2 and 3 students did not suggest marked differences in trends, though individual sections of the questionnaire were not statistically compared.
Questionnaire data were entered on to a Microsoft Excel spread sheet with qualitative comments also listed on a separate worksheet.Excel was used to analyse the data, producing descriptive statistics (see Figures 1Á5 and Table 4).Questionnaire results were also subject to thematic analysis and were used to inform focus group discussion; major themes arising included the following: . Concerns over changing from a face-to-face to alternative form of placement support. .Differences between successful and failing placements and the impact upon alternatives to face-to-face support methods. .Content areas perceived to be important for mid-placement support.
These were used to initiate exploration of unclear issues and majority opinions within the focus group.The focus group transcript was subject to manual thematic analysis, and participants unanimously agreed that the themes generated were a true reflection of discussion.

Results
Results arising from data analysis have been grouped with reference to project outcomes: alternatives to current placement contact; visit content and purpose of visits.Each of these areas is discussed below.

Alternatives to current face-to-face mid-placement contact
Students were asked to consider alternatives to the current mid-placement, face-toface visit from a member of the academic team, for both successful and failing placements.Results for this area are shown in Figures 1Á5.
Overall, there appeared to be a split in opinions relating to altering practice for successful placements.On average, 57% of the student responses were either positive  or unsure about alteration of practice to: attending university-based meetings; communication via telephone; communication via email; communication via video link or attendance at a drop in session.However, this average was reduced to 41% when considering the failing placement.

Focus group
Participants were asked to consider their reasons for preferences/concerns over potential alternative formats of placement support.The group was split between those who were confident in their skills and progress and those who were not.Table 3 shows how opinions differed between participants in the two year groups.Participant perceptions echoed the researcher's professional experience that students confident in their clinical skills were often happier with less direct contact and support from the University.
Lengthy discussions focused upon the differing requirements of successful and failing placements.Three participants stated that during a successful placement, any contact, including telephone, email or video link, that provided a ''prompt to undertake paperwork'' was enough.Three participants strongly felt that this was not the case and that, being unsure of their own skills; a face-to-face visit provided an appropriate level of ''hand-holding''.The remaining three participants were unsure regarding this issue.One participant commented that: I'm not a very confident person and as you know, I like to make sure that what I'm doing is right . . . the visit from the tutor is really important and I would not like to not have it . . .I need to know that I'm doing ok and the more people who tell me the better.
Participants concluded that students had individual support needs that depended upon progress within the placement, the relationship with the educator and their own levels of personal confidence: I think that's right . . .I'm not confident so I like someone to hold my hand . . . it might be a pain and I know that I can be . . .but it makes me feel better to know that someone I know is coming to see me.
Another participant agreed, stating that: I agree, there are some students who aren't comfortable with placements or aren't very confident people . . .I'm happy with a phone call, but I'm quite confident and I suppose that if I weren't, I would prefer to see someone than chat with them on the phone. . .it's not so personal.Further discussions concluded that a student's level of confidence in both themselves and in their placement were the primary influence on support needs.On prompting, no one could define what a face-to-face visit provided that a video-based or telephone call could not.A participant commented that: I don't know, it's like . . .easier to get a hug from a person, it would be a bit weird if you needed a hug from a TV screen.
The participants were asked whether they had ever needed or received a hug and all stated that they had not: But it's the thought that they might that might help. . .you can't get a tissue over the phone.
The study findings strongly indicate a requirement to consider individual need when planning for changes in methods of support.Previous research into the use of videobased support has involved primarily confident volunteers (Taylor 2009) who highlighted positive experiences with the process.Their experiences may reflect the discussions outlined above.However, it is also questioned whether perceptions may be altered with familiarity and exposure to an alternative practice.This is discussed further in the discussion section of this paper.

Visit content
Students were asked to rank suggested areas for visit content in order of their perceived importance, results from this question are shown in Table 4. Support for emerging issues (n 030) and learning and continuing professional development (CPD) (n 027) appeared high on the participants' preferred content list.Whilst supportive dialogue could arguably be conducted through any audio or audio-visual medium, the involvement of written work in CPD development may pose a problem for non-direct support methods.In addition, support for arising placement issues may involve sensitive or emotive elements.Thus, further investigation is needed into the ability of any alternative support method to fulfil this role.

Purpose of visits
On being asked to define the purpose of clinical visits, participants demonstrated clear understanding of the wider role in overall student support with answers such as, ''to facilitate learning'', ''check that the learning opportunities are at the right level'', '' . . . to deal with any issues that come up . ..,'' ''to help solve any conflicts between the student and educator''.
This again raises questions about the ability of alternative formats of communication to meet these needs.

Discussion
The findings of this study highlight a number of factors influencing participant perceptions of the support process, and identify areas of content perceived to be important within clinical visits.These findings are considered in the context of planning for change in the section below.

Risk
Whilst this study aimed to evaluate the potential for a range of non-direct support methods, arising issues indicate limitations of non-visual approaches.Focus group discussions advocated consideration of individual student need rather than a ''one size fits all'' approach.However, one student discussed the desire to ''hide any problems'' and the ease of doing this via telephone.Supported by the researcher's experience with some students, where non-verbal cues have been the only indication of arising problems, this statement suggests a potential risk with non-direct support for vulnerable individuals.Whilst non-verbal communication alters as a result of power relationships, social behaviour and cultural (Moukheiber et al. 2010;Slessor, Phillips, and Bull 2010), the combined availability of non-verbal and verbal cues via video link may offer a lower risk option than audio only media such as the telephone or email.

Practical application of video media
Consideration of the ability of video media to fulfil the placement support role has been easier with a clearer understanding of students' support needs.For example, in preparation for CPD discussion, students are asked to prepare and then share with the tutor, relevant materials utilising PowerPoint software would facilitate sharing of this material via video-mediated technology.Alternatives might include the use of Google Docs or Microsoft Office Live applications which enable individuals to collaborate, review and amend written materials via technology, in ''real time'', thus enabling discussion and amendment of placement paperwork in electronic form.However, installation of software across geographically and organisationally diverse locations, combined with the necessity to upload or scan materials, may make this overly complex.
It may also be possible to use hardware such as smartphones to photograph and then forward written work for review, whilst also conversing via video link.Whilst this process is laborious and does not allow for ''real time'' correction of documents, it may provide an easy alternative access, providing network or Wi-Fi connections are viable.

Benefits of video-based support
A requirement to work with written materials may limit non-direct support methods on the grounds of perceived reduction in quality of experience.However, for failing students requiring multiple visits or those attending extremely distant placements, the use of video-based support may offer an attractive and cost-effective alternative to face-to-face.Consideration needs to be given, though, to use of the medium within difficult or emotive situations.

Emotional support
As concerns over non face-to-face contact had been substantial, focus group participants were asked to explore this in more depth.Whilst unable to identify specific threats of non-direct support, the focus group emphasised concerns over difficulties with emotional dialogue.This was supported by a further study comparing video and face-to-face conversations in which concerns over the quality of one-to-one support via video link were raised (Taylor 2011).Kappas and Kra ¨mer (2011) discuss the limitations of video-based media in meeting the emotional needs of interpersonal interaction, identifying changes in interaction as a result of video mediation and an impact upon accurate utilisation of non-verbal cues.However, they also discuss adaptation of individuals and development of coping strategies with exposure to the medium.This supports the need for further research into placement application following familiarisation with the medium.

The student voice
Focus group discussions moved beyond the objectives of the study to discuss the students' views on an ideal approach to placement support.This ''tangent'' provided valuable insight and supports the value of focus group methodology within this study.Focus group participants proposed a ''menu'' of communication options consisting of an initial consultation via telephone between the clinical educator, academic tutor and student, used to assess progress of the placement and the student's needs, followed by an agreed upon method of mid-placement support.Choice would be between telephone, email, face-to-face and video-based communications.Whilst agreement with this proposal was unanimous, one participant clarified that face-to-face contact would be given if desired, with no expectation to vary the format.
Whilst literature tends to focus on the institutional value of visiting students in practice settings (Gore and Mitchell 1992;Martin 2005;Swinehart and Meyers 1993) this project also supports this in the context of the student voice.In an increasingly consumer-led environment, student voice has become stronger in driving policy and practice (Higher Education Academy 2010).The study findings, however, do not support the broad introduction of alternatives to face-to-face placement contact.The importance of individualised learning in guiding education in health (Krackov 2011) is recognised, and careful consideration of individual need within financial constraints is recommended when proposing any change to practice.

Conclusion
This study has explored student perceptions of practice-placement support and the potential for alternatives to current approaches.Questionnaires focused on identifying the purpose and content of mid-placement contact.Participants perceived importance of placement support in motivating, supporting and developing learning, progressing CPD and addressing arising issues.As such, non-direct approaches need to be able to meet these requirements.Potential methods of sharing placement documentation whilst engaging with video-mediated dialogue are discussed.
Participants expressed concerns over non-direct support for emotional situations and went on to propose a menu of options for support, tailored to the needs of the individual.Discussion highlighted the potential for video-mediated communications to vulnerable students to reduce the risks of providing support via audio only media.The need for further study into the role of familiarisation with technologies, in enabling successful implementation, is proposed.
Educators are under increasing pressure to implement technology into curricula and a ''one size fits all'' approach is common.Whilst change is often at the system rather than the local level (Hartley 2010), it is essential to consider individualised learning if institutions are to maintain quality whilst also adhering to economic drivers.Ultimately, in a time of increasing university fees the student voice has to be balanced with a sound evidence base for practice if institutions are to remain credible.

Figure 4 .
Figure 4. To communicate with an academic member of staff via email only.

Table 2 .
Focus group details.Figure 1.To attend university for half a day, approximately half way through the placement.Figure 2. To communicate with an academic member of staff via the telephone only.
Clinical Skills Centre of the school duration Á 1 hour 15 minutes Data collection Focus group content recorded for transcription.Researcher took notes re: key emerging themes and points raised (Kumar 2005, p. 124).Figure 3. To communicate with the visiting tutor via a video link approximately half way through the placement (with training provided prior to the link).

Table 3 .
Division of opinion within the focus group regarding levels of confidence in clinical skills.

Table 4 .
A table indicating participant responses to a question asking them to rank proposed clinical visit content in order of perceived importance to them (highlighted areas indicate greatest number of responses in each category).