THE WINSTON CHURCHILL MEMORIAL TRUST OF AUSTRALIA
Report by Sarah Anderson 2008 Churchill Fellow
The Dame Joyce Daws Churchill Fellowship to study education in Prosthetics and Orthotics
I understand that the Churchill Trust may publish this Report, either in hard copy or on the Internet or both and consent to such publication.
I indemnify the Churchill Trust against any loss, costs or damages it may suffer arising out of any claim or proceedings made against the Trust in respect of or arising out of the publication of any Report submitted to the Trust and which the Trust places on a website for access over the internet.
I also warrant that my Final Report is original and does not infringe the copyright of any person, or contain anything which is, or the incorporation of which into the Final Report is actionable for defamation, a breach of any privacy law or obligation, breach of confidence, contempt of court, passing –off or contravention of any other private right or of any law.
Introduction
The Dame Joyce Daws Fellowship enabled me travel to observe and participate in Prosthetic and Orthotic (P&O) education programs world wide. I attended P&O educational programs in Hong Kong, Germany, Sweden, Scotland, England, Chicago and Atlanta. The programs ranged in their level of education from Diploma to Bachelor, Masters and Post Graduate levels of education. This report summarises the observations and findings regarding P&O education internationally that have come about as a result of my Fellowship.
I would like to thank the Winston Churchill Memorial Trust and in particular the late Dame Joyce Daws for sponsoring this Fellowship and for the wonderful opportunity to learn from other institutions and observe Prosthetics and Orthotics teaching internationally.
I would like to pass on my many thanks to those who took time to meet with me throughout the course of the Fellowship. Gratitude must go to those who generously assisted me during my travels, particularly: Mr. MS Wong, Mr. Andre Muller, Mr. Simon Ramstrand, Mrs. Sandra Sexton, Mrs. Sarah Deans, Mr. Joe Wilkenson, Dr. Stefanie Fatone and Mr. Christopher Hovorka.
I would also like to thank Mr Rowan English, members of the National Centre for Prosthetics and Orthotics and LaTrobe University for their support in extending my knowledge and understanding of the role education plays in Prosthetics and Orthotics, along with my referees for supporting my application. Lastly, I would like to thank Rob and our families whose support enabled me to undertake such a wonderful opportunity with no concerns about walking the dog amongst many other things.
Participating in teaching at the National Centre for Prosthetics and Orthotics, The University of Strathclyde, Glasgow Scotland.
Executive Summary Sarah Anderson Prosthetist/Orthotist Associate Lecturer Sarah.Anderson@Latrobe.edu.au (03) 9479 1662
National Center for Prosthetics and Orthotics
Room 444
Health Science Building 4 LaTrobe University Bundoora 3086 VIC Program Description
Travel for this fellowship was undertaken between the 23rd of September and the 4th of
November 2008. The purpose of this Fellowship was to investigate different P&O educational programs. I visited a variety of Universities, other educational institutions, manufacturers and community based rehabilitation centres and observed and participated in the P&O programs. I also attended a number of courses and scientific meetings in the course of my travels that were beneficial in gaining further insights in education and new technologies in P&O.
Highlights
Attending the Annual International Society of Prosthetics and Orthotics Hong Kong Chapter Scientific Meeting
Otto Bock Germany, attending a portion of the Helix Hip Disarticulation course
Visiting Strathyclde University, gaining in-depth overview of the new 4 year Bachelor 5 years Master course, and observing educational aspects of the course in detail
Visiting Jonkoping University, developing an understanding of the detailed and in-depth teaching of Clinical Gait Analysis
Visiting the P&O Research Laboratory based at Northwestern University and gaining an insight to the extensive research program
Visiting Georgia University of Technology and observing the new P&O Master course
Developing an understanding of the high esteem that the course at LaTrobe University is held in internationally.
Recommendations, Major Lessons and Conclusions
To ensure education at the National Center for Prosthetics and Orthotics (NCPO) remains at the current high level internationally, the following aspects require consideration:
Establishment of Post graduate courses to enable current clinicians to improve and maintain clinical and technical skills
Encourage graduates to develop skills in both fields, Prosthetics and Orthotics.
Continue to develop links with universities overseas to allow specialized teaching and co teaching units across units with experts in the relevant field.
Ensure that course material that covers ischial containment, preimpregnated materials and high end componentry is included in the LaTrobe Undergraduate program
Utilise open laboratories to maintain quality teaching that requires high staff-student ratios whilst allowing academic time to be allocated to other teaching and research. Implementation and Dissemination
Fellowship Program
23rd -27th September, Hong Kong, China
Hong Kong Polytechnic University, Department of Health Technology and Informatics Attendance at Hong Kong Annual Scientific Meeting
28th September – 2nd October, Frankfurt, Duderstadt and Dusseldorf, Germany
Otto Bock Health Care Group, Duderstadt Bundesfachschule (BUFA), Dortmond
2nd – 9th October, Jonkoping Sweden
Jonkoping University, School of Prosthetics and Orthotics, Jonkoping
9th -16th October, Glasgow and Edinburgh, Scotland
Strathclyde University, National Center for Prosthetics and Orthotics, Glasgow SMART center, community based rehabilitation, Edinburgh
16th-23rd October, Manchester, England
University of Salford School of Health Care Professions, Salford
23rd- 28th October, Chicago, United States of America
North Western University Prosthetics Research Laboratory and Rehabilitation Engineering Research Program
28th-30th October, Georgia, Atlanta, United States of America
Georgia University of Technology
30th October – 3rd November
Main Body
P & O as a ‘profession’ is relatively new, over the last 25 years it has developed from a system of trade/apprentice to a clinical health care sector profession. As such, education in Prosthetics and Orthotics is an exceptionally varied process around the world. Variables such as schooling, funding, resource availability, environment, and the development level of a country all affect the way in which education in P&O is administered, taught and, thus, the resultant level of education of graduates.
The categorisation of educational programs into the three different levels by the International society of P & O proves useful in assessing where courses and graduates sit within educational frameworks.
A Category I course should result in a graduate who has the ability to make a sound clinical decision about the prescription of a device for a client. Following a thorough assessment, and taking in to consideration medical, biomechanical and lifestyle factors, the clinician has the ability to manufacture this device assessing its fit and function. This is usually a University Bachelor or coursework Master level education.
A Category II course is more technically focused. It requires more technical work and less clinical decision making. This is often a diploma level or pre-university course. A Category III course is a technical course where the student has been trained to build and make devices but not in the clinical aspects of fitting, modifying and assessing clients. These technicians normally work along side a Category I or II Clinician.
The educational programs I visited during my fellowship mostly fell within the Category I standard. The variations that come from different systems of education within the different countries result in some course being classified as University programs whilst others were administered by external groups. Below is a rough summary of the different levels of education available in the countries I visited.
Education levels in the NCPO and the programs visited through the fellowship
Australia: National Center for Prosthetics and Orthotics at LaTrobe University (the only course available). 3.5 Year Bachelor degree, with Master and PhD programs
Hong Kong: 4 Year Bachelor of Biomedical Science, (P&O is taken as an elective within the course) Master and PhD programs can also be taken
Sweden: Jonkoping University 3 Year Bachelor Program (although this is a 3 year program is it the equivalent number of weeks of a 4 year program in Australian or the UK)
Germany: There are a number of pathways both which involve a 3 year apprenticeship system and one year at BUFA this can be combined with a new university degree that has been established.
USA: The course here range from 6 month diplomas, 3 year undergraduate programs to 2 year Masters Programs (all course by 2012 will need to be masters programs to gain accreditation).
United Kingdom: University of Salford, England 4 year Bachelor program
United Kingdom: University of Strathclyde, Scotland, 4 year Bachelor, 5 Year Master Programs
Funding
Funding was the biggest concern for the majority of P & O programs. P&O courses are expensive to run, reasons such as the high cost of materials, small class size requirements, high staff to student ratios and constantly evolving technologies all result in significantly high program costs. Students must gain exposure to the most current componentry and technology that is available, ensuring that the student can competently use this technology once graduated. Schools identified that having enough of this componentry and keeping it up to date causes massive financial strain, and in some cases, is not possible. Different institutions overcame funding hurdles in differing ways. Sponsorship through inviting manufactures to donate equipment or to come and teach are two methods used. Nonetheless, teaching staff did specify that it is important that these sessions do not become ‘sales pitches’ but are balanced and remain educational. Teaching the theoretical science behind the devices or materials and have a model for students to try was another concept used. When technologies such as large pieces of machinery or highly specialized computer systems were discussed usually schools make a choice and invest in one device gaining sponsorship through the companies that supply these.
The range of technologies taught was interesting, with some of the more high-end aspects being taught in a practical manner in only a few of the programs. This includes clinical gait analysis and Computer Aided Design. Schools that tended to have high research outputs and graduate students tended to be the schools that were able to attract funding or grants for these pieces of equipment.
Small Courses
Staff-student ratios are a common thread that many programs identified as being raised as issues outside the schools. However, all programs agreed that high staff student ratios in P&O are a requirement for safe and efficient learning. The NCPO had the highest student numbers of any of the programs visited and one of the lowest numbers of staff. Class sizes ranged from 10 to 32 per year over courses ranging from 2-4 years when compared with the NCPO whose class sizes range from 28 to 39 per year over 4 years. The reasons for keeping numbers around this level were: accessing volunteer patients, physical space restrictions (OHS, machinery etc), staff supervision in practical sessions and so forth.
As a result of these high staff student ratios teaching loads were identified as being high in comparison to other courses. One programs way of overcoming aspects of the high teaching hours required along with high staff student ratios was to have open laboratories. This involved students being given demonstrations of procedures but then using their own time, within set timeframes, to complete these tasks. These demonstrations were combined with detailed notes to assist students, it was suggested that videoing the demonstration for students to review during this open lab time would further assist students learning. These sessions were supervised by technical staff, thus relieving teaching staff for other teaching or research time. Closed circuit television was used to ensure that there was supervision in all areas of the laboratories at all times to assist with overcoming Occupational Health and Safety issues that may arise. Other ways of ensuring that there was sufficient time for students to undertake practical teaching and gain further access to patients was to hold classes in traditionally ‘non-teaching’ times, after 5.30 pm and over holiday periods. The draw back of this solution, however, is that teaching staff would be still required and hence this can actually result in greater teaching time being required of those staff members.
Access to Patients
Due to the practical nature of Prosthetics and Orthotics it remains imperative for students to have access to volunteer patients. This enables students to gain experience
in real clinical work. Students observe, assess and develop an understanding of patient’s needs and associated pathologies. Programs that have a large numbers of volunteers were programs that had clinical facilities (functioning clinics) attached to the schools. Other programs pay patients to attend classes along with reimbursement for travel costs, they did indicate that this can be a costly procedure for projects requiring 3 or more volunteer attendances. Some programs use one or two volunteers for the whole group, which they indicated was not particularly time efficient nor was students learning as substantial as having multiple volunteers with differing residuum’s, medical and biomechanical factors.
Teaching Mediums
A number of schools have utilised on-line, case based learning and problem based learning as a means of delivering education. The innovative way that programs are using these differing modes is positive. Programs that did not necessarily have access to hardware where are able to use software and specifically constructed ‘patient’ files to enable students to manipulate data and understand the technology. All without actually having direct access to the clinical technology and hardware requirements.
Discussions between one specific program and the NCPO are now underway to co-teach some units in an online environment utilising skills within both programs. The main method of teaching observed was still through a traditional lecture, tutorial and practical teaching medium. However, it appears that this is evolving with the introduction of new technologies, both in P&O and higher education teaching. It is clear that some programs have embraced changes in technology, to a greater extent than others.
The use of case based learning and problem based learning methods clearly enhance students learning within certain aspects of P&O teaching. From talking to these students it was evident that the level of knowledge and understanding they had developed as a result of this learning method was superior to that of a student who had only be exposed to the theoretical method of teaching. Thus, the need for practical hands on methods of education in P&O is important in the development of a course if it is to have high international standing.
It was further identified that in order these specific methods of education to work effectively staff required education on how to utilise such teaching methods and develop appropriate cases. This ensures that the learning objectives of a particular concept or subject can be met through case and problem based methods of education. Facilitation of groups was important especially when introducing the concepts of these different styles of learning. Students needed spaces to work together in a face to face environment with access to all the information (contained on university intranets or online learning environments) available. It was highlighted that some students find changing to this style of learning difficult. As enquiry based learning is due to be implemented into the new NCPO curriculum it will be important to consider some of these issues to a greater degree when designing enquiries.
Staff Education
The international need for academic P&O staff with Master and PhD Qualifications to teach within education institutions is high. Education of students is changing especially in a number of the European schools with the introduction of the principles of the Bologna Declaration and across the United States of America. The American
European and other countries P&O programs when the American Masters programs commence. It is important that the Australian school maintains its staff to ensure the new curriculum can be appropriately staffed and we have sufficient staff with high level education to supervise other high level research students.
Graduates
Continuing to educate graduates with post graduate courses and scientific meetings ensures that clinicians working in the field are well informed of current treatment processes and technological advances. Current clinicians are also able to inform teaching staff of other factors that are changing within the specific health system such as funding systems, patient demographics etc.
Many courses overseas educate students in either Prosthetics or Orthotics or when students first graduate they are forced to specialise in one of the two fields. This seems to divide the profession significantly to the extent that the departments are not collocated on hospital campuses. The benefits of having clinicians able to work across both fields are vast along with having departments located together. Clinicians are able to provide sick and leave cover for other members of their departments, many people requiring prosthetics services also require orthotic services. The benefit of being able to have these be delivered together along with the decreased administration, and machinery requirements assists in keeping what is already a very small profession united.
Conclusions
The most positive finding that has come out of my fellowship is my understanding of the high standard the NCPO course and the level of esteem my fellow academics hold the NCPO course in. While there remains room for improvement in many aspects of the NCPO course the international standing and recognition given to the Australian course is positive.
As a means to increase funding many programs are increasing both domestic and international student numbers, thus, increasing revenue along with approaching government and health departments to assist with funding. The NCPO’s standing as an international educator ensures we are in good stead to continue to attract these students. A number of health departments fund aspects of the programs as the need for P&Os in the health system is high. In the next 10 to 15 years with the aging population and increase in chronic diseases it has be predicted that there will be a significant shortfall of allied health professionals both across Australia and Internationally. This shortage is expected to be a major issue within the P&O profession and has been recognised both within and external to universities internationally. Accordingly, the majority of institutions are examining means to increase student numbers. This is something that has been highlighted to the Australian professional body and will again be discussed at the next P&O scientific meeting.
The need to have high staff student ratios is something that has been acknowledged along with the importance of staffing programs appropriately to ensure that research and other activities can be undertaken. If research output is increased and time is allocated for this the application for further research funding can be made and this may enable new and emerging technologies to be available for teaching programs.
The use of web based teaching units to complement teaching is starting to be introduced and programs that have introduced these have had similar findings to the current NCPO findings. Student enjoy having some aspects of Self Directed Learning available on line however full subject teaching online does not necessarily result in positive learning outcomes for students or to satisfaction with the learning process. Case based learning will continue to be investigated within the new curriculum at the NCPO and collaboration in teaching between programs is being further developed
Maintaining education of clinicians working in the field is important and encouraging new graduates to work across both prosthetics and orthotics leads to well rounded clinicians who can cover all aspects of prosthetic and orthotic management
Recommendations
There are a number of recommendations that have been made in this report regarding the current course at the NCPO. It is important that the NCPO provides students with an education that is thorough and covers all important aspects of clinical Prosthetics and Orthotics. This will ensure that graduates and clinicians working in the field are able to offer people with disabilities the optimal solution to their mobility or functional problem.
1. Ensure graduates are skilled in both Prosthetics and Orthotics
By encouraging students to apply for positions that enable both Prosthetics and Orthotics to be practiced and highlighting the importance of this through out their studies ensures students have an understanding of the importance of acquiring skills in both areas.
2. Utilise alternative teaching methods, Enquiry/Problem/Cased based learning along with other concepts such as open laboratories.
By taking an active role in the curriculum building process I am developing units that utilise different methods of teaching. The use of open laboratories will be discussed within the curriculum development process.
3. Continue to develop ties with other institutions to enable delivery of education with a variety of experts in differing fields.
We are currently discussing providing teaching between institutions in a number of areas where the NCPO either has high level or low level skills. I am planning on having one of these subjects established for the 3rd or
4th year program in 2011.
4. Include newer technologies in the undergraduate program
Through the teaching above some of these newer technologies will be included into the curriculum along with having developed greater ties with some manufacturers to allow students to experience some of these technologies. There is also room in the new curriculum to include other technologies that are emerging.
5. Deliver post graduate courses to clinicians
As a member of the ISPO executive I am aware that there have been discussions regarding running instructional courses for clinicians for some time, the last course was run in 2004. This concept is being further developed by the Science and Education committee of ISPO Australia. This information gained in the fellowship will be disseminated in a number of ways. I am applying to present some of the findings of the fellowship at the next International Society of Prosthetics and Orthotics Australian National Member Society conference in Brisbane in 2009 along with the International Scientific Meeting in Leipzig, Germany in 2010. Discussions amongst colleagues regarding some of these findings have already begun and aspects have been incorporated into the new curriculum process.
