Theme 1: Facility Safety Culture
Safety culture is influenced by the values, attitudes, and behaviors of every team member, as well as the presence of and adherence to policies and procedures that prevent error from reaching the patient. The student experiences provide insight into the safety culture of various clinical sites, highlighting orientation and onboarding procedures, error response systems, and overall perceived culture of safety.
Variability of Orientation
Variability of orientation and onboarding processes was evident in both phase 1 and phase 2 data collection. In the survey, 37% of students reported receiving a formal orientation involving facility-wide and/or physical therapy–specific areas, 59% reported informal orientation, and 3% reported no orientation. Informal orientation was more common in inpatient settings, whereas formal orientation was more common in outpatient settings. Many focus group students reported that orientation was minimal or untimely with orientation occurring as late as week 6 of 10. Others described that orientation was presented as unimportant or “just something we had to get done.” The students described downstream implications of not receiving formal orientation, especially to emergency procedures and protocols. Students described being anxious that an emergency might occur and that they would be unprepared to respond:
I eventually got orientation to emergency procedures, but not at the beginning. I feel fortunate I didn't have any of those situations because in this setting, emergencies happen a lot because of the patient population. I feel fortunate I didn't have to call a code or rapid response. That was in my nightmares.
Variability in Error Reporting
Error reporting systems and response to error also varied widely. Thirty-one percent of survey respondents were not aware of a method for reporting error within their clinical setting. More students were aware of error reporting processes in outpatient settings (88%) versus other clinical settings (36%). Forty-three percent of students reported an error during their clinical experience, either to their CI or through a formal reporting system or incident report, with no difference found by setting. Thirty-five percent of those who had reported an error were unaware of any resulting action or investigation after the report, also with no difference based on setting.
Consistent with the survey data, the focus group participants discussed a number of patient safety events, with similar variability in both whether reporting occurred and the ensuing follow-up process:
Throughout the entire time, there were a series of unfortunate events or incidents…I don't think they did a formal write up because it was the nature of the schools. I was bitten numerous times. I had children try to run away. Escape the building.
I had a patient fall about 2 hours after I worked with him, so I got to experience the entire hospital protocol for after a patient fall… the charge nurse gathers everyone and gets a basic timeline of what was going on…Then they have a team that is specifically for quality… they did a root cause analysis…with myself, the occupational therapist, my CI, the inpatient therapy supervisor, a nurse who was working with that patient that day and her supervisor. I got the impression that I was being blamed for this patient's fall even though it had been 2 hours since I had worked with him. I got that impression when I offered up something that could have happened better after the fall…the nurse kind of jumped on that, and I feel she was really targeting me because I was a student and I was leaving. The woman running it (the root cause analysis) had a slide in giant type “This is not about blame.” Great in theory. It opened my eyes to teamwork in a hospital and how it seems like everyone is on the same team until something goes bad then it's very quickly CYA and department versus department type of thing.
Perception of Culture of Safety
Regardless of experiences with risk and actual patient safety events, most focus group participants identified their clinical sites as having a “Culture of Safety.”6 One student stated: “I think the therapy department was more of a culture of safety… pretty much patient safety, patient safety. Above all else.” Another student said, “I never heard anybody say 'Oh, that therapist made a mistake.' Or 'She should have been next to her' (after a patient fell)…it was more like how can we prevent this from happening in the future.” A third physical therapy student had the following insight:
I don't think it was either (Culture of Safety or Culture of Blame). Everyone was doing what they thought was right. There wasn't a lot of communication between the rehab team and the nursing team and the CNA team. It was just everyone do your job and hopefully we'll make it through the day. It wasn't really advocating for safety or pointing fingers.
Presence of Authority Gradients
The presence of authority gradients emerged during the focus groups as a key aspect of safety culture and a potential contributing factor to error. An authority gradient is defined as “the balance of decision-making power or the steepness of command hierarchy in a given situation.”35 Research shows it can be difficult for students to ask questions or speak up against the decisions or actions of those who they perceive to be superior,36 a concern if a student identifies that the decisions or actions of others are putting a patient at risk, but does not speak up. During the focus groups, the students described variable experiences with authority gradients. Some felt very supported by their CI: “I felt I was able to bring up things that I was comfortable with or was not comfortable with.” Other student described a different experience:
The most stress would revolve around the CI…at the beginning he was very intimidating. Beyond just questioning me and questioning what I was doing…more like “mansplaining.” He did it with me and the patients…. lecturing, but in a very condescending and kind of an intimidating way.
Some students experienced a very strong hierarchy involving physicians and within the larger health care team. For example, one student stated:
There was definitely a hierarchy…we had a patient that we were pretty sure had a stress fracture in his femur…But we had to keep him for at least 4–6 weeks instead of just referring him immediately, because it had to be known to the physicians that PT tried and failed. I asked my CI “if we are pretty sure it's a stress fracture, why aren't we just going to send him to imaging?” It was more like we need to play this a certain way so that everyone is happy type thing. I was like oh, interesting…
Another student reflected on how she overcame the perceived authority gradients with her clinical setting:
It actually worked out well because it was kind of a culture of the PT's didn't talk to the physicians. There was a hierarchy sort of situation. I didn't really know that and on my second day I was like “Hi Dr. (Smith).” And she was like “who are you?” “Just a PT student but I have some questions.” She was like “OK, I like questions.”
Theme 2: Communication Methods and Frequency
Communication in complex environments, with multiple providers and a mix of written and verbal communication can, if not done well, increase the likelihood of error and patient harm.37 Thirty-nine percent of survey respondents reported always or frequently communicating with team members outside of the immediate rehabilitation team (team members such as physicians, pharmacists, psychologists, and nurses), while 36% reported rarely or never communicating with these individuals. A significant 79% of students in outpatient settings reported always or frequently communicating with other team members compared to 14% in inpatient settings and 18% in other settings. Twenty-six percent of all respondents reported primarily written communication to communicate with other team members while 29% reported primarily verbal communication, and 45% reported using both written and verbal communication.
Communication with rehabilitation team members (Physical Therapist Assistants, aides, Occupational Therapists, Occupational Therapy Assistants) was more frequent than the broader team. Seventy-eight percent of respondents in all settings and 100% of students in outpatient settings reported they had communicated always or frequently with other rehabilitation team members. Only 5% of overall respondents reported rarely or never communicating with the rehabilitation team. Two percent of all survey respondents reported primarily written communication, 48% primarily verbal communication, and 50% both.
While paper documentation was still present, many sites used electronic or a combination of paper and electronic documentation. The survey showed that 67% of students had used all electronic health records within their clinical setting, 31% had used part paper/part electronic, and 2% had used all paper documentation, with no significant difference found between settings. Seventy-one percent of those using electronic health records reported a personal login, 26% were required to use their CI's login, and 3% were unable to access the medical record. A statistically significant number (64%) in other settings were required to use their CIs' login. Availability of the medical record was good overall, with 94% of students reporting that they were always or frequently able to access the chart.
Challenges with documenting, co-signing of notes, and documentation systems was the most prevalent topic in the focus groups. Examples of challenges given by the participating students included:
The stereotype of school systems not documenting well held very true. Every therapist had a different way of doing it. A lot of them would wait and do them in bulk like weeks later… I don't really know why, I wouldn't have done it that way. I documented right after each session, and a lot of times I would keep extra more detailed notes for myself. On numerous occasions they would ask me for more details because they knew I was keeping track.
As far as a standard for charting, there was none. And there were some computer issues… if she changed something in the flow chart, it would erase part of the note that I had put in so we had to deal with that. If I entered charges, the note would get erased so she just basically had me do the text part, and she handled everything else from there on my notes.
They had a habit sometimes of documenting using public Wi-Fi and I'm embarrassed to say that I didn't think that was an issue at the time. I was just following my CIs lead. It didn't happen super regularly but I would say maybe 3 times a week we would end up documenting like at Starbucks using their Wi-Fi.
Theme 3: Widespread Clinical Education/Clinical Instructor Variability
Highly variable supervision of students was a theme repeated throughout the survey and focus group discussions. Sixty-one percent of survey respondents reported having had 1 CI, 31% had 2 CIs, 8% had 3 CIs, and 5% had more than 3 CIs, with no difference between settings. Seventy-eight percent of students were supervised by someone other than their CI at some point during their rotation. As noted above, the students were expected to independently manage a 75% caseload by the end of the 10 weeks. Five percent of students reported little to no supervision throughout their rotation, 87% reported a decrease in supervision over time, and 8% reported extensive supervision with little independence in decision making across the experience. Eighty-nine percent of students reported their CI was always or frequently available as needed. The following examples from the focus groups represent this variability:
My CI was with me the whole time. Not in an overbearing away. A great amount of supervision that slowly progressed into independence towards the end… She was pretty good at letting me take the reins. I think she knew I wasn't going to hurt anyone.
I was working with a different therapist each day of the week so I worked with 5 different therapists…I liked working with the other therapists more than my designated CI. They all had different backgrounds so I think that led to a breadth of knowledge.
She could not help herself and jump in. She couldn't just let it go. I mentioned I need to struggle. This is how I'm going to learn. You helped me too soon. I never got that because she just couldn't let it go.
First week I was with my CIs a little bit more. Into the second week and the third week, it was pretty autonomous. I would just come in and get my schedule and treat patients. My CIs would say if you had questions come find me. Sometimes I could find them, sometimes I couldn't. Because they were busy. Some days I felt it was good I was learning, they trust me, but at other times I felt more like an employee than a student.
My CI gave me my own schedule. At the beginning, she would see people and I would see people but the director told her she isn't allowed to do that and bill separately. So she stopped doing that. She basically picked up projects around the clinic. I usually got there a half hour before she did to kind of plan my day, and she would text me when she got to the front door. She would say OK I'm here you can start treating, then I would not see her until I was done. Then she could cosign my notes.
The relationship between the CI and student was described by the focus group participants as a very important factor in the level of supervision given and the overall student experience:
I think my CI was laid back but not in so much of a way that she wasn't giving me direction. She was easy to talk to. Maybe it was that my learning style matched her teaching style. It was very easy to learn from her. I told her at the beginning I wanted her feedback, and she gave it to me. But not in a way that made me feel like a bad student or bad PT. We had a very good relationship.
I just knew they were all talking about me. That is where my discomfort came from…I felt very misunderstood and very characterized…I went into the situation with an open mind and an open heart, and because I didn't fit what she wanted, and she even in a conversation compared me to her other students she had had in a negative way. I felt very picked on in a way. It was awful.
The experience level and comfort level with serving as a CI was expressed as a contributor to the overall CI–student relationship. Focus group students described wide variation in experience level and comfort of the CI, from a first-time CI to a CI who had had many PT students.
Theme 4: Dual Identity as Student and Clinician
The survey and focus group data highlight the students' identity as both student and clinician as they worked alongside licensed physical therapists. Students bring their own unique set of personal factors that are different than other staff members. They begin to gain more autonomy and independence but require continuous oversight and evaluation.
“Cognitive dissonance” has been used to describe the presence of a major difference between what students learn in the classroom and what they encounter during clinical experiences.38 Some students in the focus groups described experiences consistent with this phenomenon:
I was surprised, not much of the rehab staff monitored vitals… I think there was an assumption that (because) nursing comes around every 2 hours and takes vitals, they'll pick up on something; but in education, we had vitals drilled into us, especially monitoring exercise response for patient encounters.
The (Root Cause Analysis after a fall) didn't operate like how we saw it in IPED… …it was definitely NOT what we experienced, where everyone is hoping for the better. The larger picture.
Many students advocated for themselves to maximize learning opportunities or to address challenges in feedback and supervision. This advocacy allowed the students to reconcile the cognitive dissonance between what they had learned and what they were experiencing. The results of this self-advocacy varied, with some students experiencing lasting change, and others having less success. A student provided the following example of self-advocacy:
When she (CI) introduced me to the (documentation) system, she literally said like “You could literally write 3 words and it would be fine.” I was like, ok well I'm not doing that. I hope it's not inconvenient for you to have to check, but I'm going to practice documentation.
The survey and focus group results also highlight student discomfort and conflict when faced with speaking up and advocating for patient safety. Students may have been concerned about potentially being evaluated poorly or making their clinical experience more difficult. While 100% of survey respondents stated that they would report an error to their CI if one occurred, 19% reported that they thought reporting an error would adversely impact their clinical experience or that they did not know if reporting an error would negatively impact their experience. The focus group participants expressed feeling unsafe and conflicted when faced with questionable decision making by their supervising physical therapist and sometimes by the larger team. The participants identified concerning examples of patient safety events and, in these situations, advocated for the patient. However, none of the students formally reported these errors and safety issues through a facility process:
One patient's BP (Blood Pressure) was out of control all the time. One time I saw her, her BP wasn't getting picked up by the automatic cuff so I was taking it manually. It was 70 over 40…I told my CI. They were like, just strap an abdominal binder on her and see what happens. So I didn't feel very safe. And the problem persisted for a few days. I even brought it up to the PA, and the nurses and they were like, “I don't know what was going on with it.” She was in there going through dialysis so they weren't really concerned about it. She did have a heart attack a week later. But when I was working with her, we didn't have any adverse event happen. And I was definitely on the more cautious side than I think some of the other staff would have been in that was a situation. I felt unsafe.
…we decided the patient needed a chair alarm. He was kind of impulsive and unsafe. We looked a long time for a working chair alarm. And she (the PT) said it's really hard to find a working one. We'll just use one that doesn't work. I don't understand why you would use one that doesn't work. She said it was more for principle. I don't really think that's how an alarm works, but we used it, and I felt really uncomfortable with it, and I told her, “I don't think this is going to help this patient be safer if we just put his pad under him.” He wasn't going to follow the rules. I told the CNA and the Nurse, “We put this chair alarm under him but it's not going to work, so I know you are busy but if you happen to walk by, can you make sure he's OK?” I think he did end up falling a couple of days later. It really made me feel unsafe in that instance. This is clearly not going to work. Why are we doing it? Why didn't we have better methods?
I worked with this gentleman, and I knew he “desatted” after 10 feet of walking into the lower 70's and upper 60's. So he required multiple minutes of rest. But the PT that day walked him like 200 feet. She was like “he's a (certain insurance) patient, we don't have time to wait. We need to walk him as much as we can in his 30 minute session.” But I was like he is going to desat(urate). He can't do that. He was definitely turning blue. His eyes were like rolling back. I said “we need to stop.” She was like “no it's OK.” And I said “NO it's not OK,” so I told him to sit down and rest…we need to check his pulse ox and he was like 61 or something. She was like “It's OK, we'll just start again.” I was like “NO it is not okay.” I felt like that was super unsafe.
Theme 5: Student Stress
Student stress was identified as a theme in both the survey and the focus groups. On the survey, 19% of respondents reported no scheduled breaks or lunch during the day, and all but 2 students reported doing paperwork during lunch. Student reported stress levels on the survey varied, with 14% reporting very high or high stress levels, 61% moderate, and 25% low or very low. In focus groups, students reported various sources of stress, including many examples already listed in themes 1–4, including lack of sufficient orientation, difficult CI–student relationships, and cognitive dissonance as a student and clinician. Other sources of stress included interpersonal relationships, emotional reaction to vulnerable patient population, and/or few breaks:
There were a lot of interpersonal relationships that weren't really healthy for learning and just kind of negative. That part of it was really stressful. I was really quick to get out of there every day.
I would be hammered with questions in the car. Bathroom breaks were few and far between…. It was definitely a situation where I didn't think I could speak up for myself and say, can we stop because it was just so very intense. Like we have to go, we have to go.
There were a few times where emotionally it was very stressful. And this is something that I was concerned about going into it. Because I know myself and I get attached to people. It's a very vulnerable population… As (their life story) came out throughout my sessions there were a few really hard experiences… there was this one child in particular…I couldn't go to sleep at night…
Poor sleep quality and quantity can adversely impact performance in health care professionals.39 Despite varying sources of stress, these students did not describe fatigue and lack of sleep as an issue. On the survey, 67% of students reported always or frequently getting enough sleep to feel rested and prepared for clinic, while 8% reported that this occurred rarely or never. One student remarked that while she was attending classes and had assignment and deadlines, she tended to get less sleep than during her clinical experience.
DISCUSSION AND CONCLUSION
This study broadly explored DPT student experiences with patient safety during clinical education by examining seven previously published major domains of patient safety contributory factors (Figure 1).8-10 The quantitative survey revealed the existence of potential factors that could contribute to error while a student is caring for a patient. While some of these factors were found to be different depending on setting (Tables 1 and 2), many were prevalent regardless of setting or patient population. Thematic analysis using both quantitative and qualitative data resulted in five major themes that further highlight potential contributing factors.
Many of the themes identified in this paper have been studied in relation to patient safety by other health care professions and health care students. These themes include documentation and communication,40-44 onboarding and orientation,45,46 cognitive dissonance,47 student stress,48 sleep loss and fatigue,39,49,50 and authority gradients.51,52 Themes such as clinical education variability,53 cognitive dissonance,38,54 ethical and legal violations,55 CI experience,56,57 and CI/student relationship58 have been explored by physical therapy researchers, but they have been framed primarily as challenges to educating students. To our knowledge, this is the first paper to explore these issues as risks to the patients that physical therapists are entrusted to treat. The factors and themes identified in this paper highlight areas that need to be further investigated to reduce the risk of patient harm when physical therapy students treat patients.
The focus groups revealed alarming situations that placed patients at significant risk of harm and, at first glance, seem to be intentional decisions rather than mistakes. However, by analyzing each situation further, contributing system factors can be identified. For example, one student described that her CI encouraged her to use a nonfunctioning chair alarm because she was unable to find a working one, a Work/Care Environment issue. Another student described that a physical therapist maximized walking even in the presence of unsafe physiological signs. This decision appears to be in part due to a certain payer contract limiting the volume of treatment, a Management/Organizational and External Factor. It is likely that other contributing factors (Staff Factors, Task/Technology Factors) were present and combined to increase risk of patient harm beyond any single factor in isolation. While students were present in these scenarios, some of the system conditions would have increased risk of patient harm whether a student was present or not.
Other factors identified in this paper are more specific to the students themselves. Even in the most well-run, safety-focused facilities, the introduction of a new individual into the team environment has the potential to disrupt normal everyday processes. A student can bring many attributes that may positively influence patient care; however, facilities should consider how the addition of a student changes communication, flow, and expectations, and develop processes to ensure that the presence of a student does not make the system more vulnerable to patient safety events.
Several focus group students described experiencing tension, inner conflict, and emotional stress as they received conflicting messages about what it means to be a “good physical therapist”38,54 and how to act in unsafe situations. Students are straddling the world of academics and clinical practice, and they can struggle to sort out the frequent contrast between the academic curriculum and clinical reality.47,54,59 Early practice experiences can “cultivate, expand, and deepen understandings of the importance of ethical thought and action (first touched on in academic environments) or diminish them and render such curricular content 'useless,' 'impractical,' and 'unrealistic' in the student's view.”60 In our study, students experienced dissonance between their level of concern in unsafe situations and their supervisors' reactions as well as between what they learned in school about error reporting and actual management of patient safety events in the clinical setting. While most students expressed a commitment to prioritize safety, the students observed that some physical therapists work in environments with financial, business, and ethical pressures that do not support safe and ethical practice.55,60 It can be argued that even though the students are learning about patient safety and culture of safety in school, if they do not see a culture of safety prioritized in clinical settings, they may learn that taking active steps to reduce the risk of future error is unrealistic or unimportant.
Several potential challenges should be acknowledged. While this study was not a part of an academic course, the primary author was a faculty member in the academic program in which the participants are students. No course, grade, or other assessment was linked to participation in either phase. A sample of convenience was used, and the exploratory nature of the study limits its generalizability. However, students stated that most of these clinical sites accept students from multiple physical therapy programs, and they are in fact fairly “typical” clinical sites. Several of the sites with the most alarming stories were reported by previous students to have provided excellent experiences. Sampling bias is also possible because individuals with “stories to tell” may have been more likely to volunteer for the focus groups. The described experiences could lead to an overestimation of prevalence compared to the overall population. A mixed methods model design was used to try to reflect a wider variety of experiences, and the authors feel that was accomplished with the high survey response rate. While this project explored the experiences of students, the experiences of their clinical instructors are not reflected. It is possible that the students may have been naive to the bigger picture of their clinical sites because they were not fully acculturated into the site and therefore may have a different description of specific experiences than their CI or other staff.
There are opportunities for academic institutions to better partner with clinical sites to enhance overall educational excellence and to reduce variability in clinical education. Better partnerships may mitigate patient safety risk when a student is present in a clinical environment. However, our results suggest underlying system issues existed prior to the introduction of the student. Therefore, we recommend that facilities closely examine their safety culture and potentially adopt a more systems focused approach to quality and safety. This paper identifies many issues that have the potential to increase risk of patient injury within physical therapy practice. Each of these issues requires further study to determine prevalence and to further investigate their impact on the safety of patients, both individually and in aggregate.
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Patient safety; Physical therapy education; Clinical education; Risk factors
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