Satisfaction Trends in Undergraduate Physiotherapy Education

Professional articles

Satisfaction Trends in Undergraduate Physiotherapy Education Summary The present study explores the effects of physiotherapy student characteristics on satisfaction with their learning and teaching and performance in assessment. It examines the influences on students’ performance and contentment of their sex, disability, ethnicity, age, academic level and term, mode of study and entry qualification. It also investigates the relationship between student satisfaction and performance in terms of module grades. Survey data from 300 questionnaires completed by students attending nine physiotherapy modules and undertaking the BSc in physiotherapy at a British university were analysed. The research tool was reliable and student satisfaction levels were generally high with most of the nine physiotherapy modules examined. The study found no significant differences in performance in relation to disability, ethnicity, academic term, or full-time and part-time study modes. However, women performed significantly better than men, and there was a stepwise age gradient in accomplishments, with older people achieving better grades than younger students. Similarly, level 3 students scored higher than level 1 participants, and those with a prior degree entry qualification achieved higher grades than those with A-level or equivalent entries. For some of the demographic and educational-related parameters under study, there was a positive and parallel relation between total student satisfaction score and their module grades, and a similar one between the percentage of satisfied students attending a module and the mean overall grade achieved in the module. However, these relations were of small magnitude. On the basis of the findings and their probable explanations, it seems that age, sex and education are important predictors of achievement, since mature women with a prior degree performed better than traditionally aged males with A-level entries. The findings also highlight the importance of undertaking further research on developing and measuring satisfaction markers, where such indicators could act as advanced ‘radars’, alerting educators to areas and programmes requiring attention.

171 Key Words Physiotherapy, higher education, student satisfaction, attributes, demographic and academic influences. by Walid El Ansari

Introduction Over the last two decades physiotherapy education has changed significantly throughout the world. Through the transfer of programmes from colleges and hospitals, where they were predominately ‘vocational’, to universities, physiotherapy education has assumed applied sciences and clinical sciences frameworks (Hunt et al, 1998). In 1993 physiotherapy became an all-graduate profession (Titchen, 1992) and a popular degree at various centres in the British Isles, lasting three or four years, where qualifications range from an honours to an unclassified degree (Maxwell, 1995). Its popularity was due to the fact that it became a degree course together with a licence to practise with no further training, a professional qualification, a career and status that a diploma course did not attract (Green and Waterfield, 1997). In the meantime, quality has become a key issue everywhere: within the World Health Organisation (WHO, 1983), in the National Health Service (Griffiths, 1983), in the caring professions (Ellis, 1988), and in higher education (Chapple and Murphy, 1996; Harris et al, 1998). There is an acute focus on the quality of learning and teaching (Law, 2000), where customer information is being used to encompass quality in education. Hence, professional accountability in the quality of learning and teaching (NCIHE, 1997), the relevance of teaching programmes (Lim, 1999) and the attendant improvements in quality performance (Ho and Wearn, 1996) have come to the fore. Few studies have specifically examined the education of physiotherapists, whether at undergraduate (Maxwell et al, 1991) or postgraduate level (Beeston et al, 1998), notwithstanding the fact that in 1995 there were about 39,000 undergraduate students (Green and WaterPhysiotherapy March 2003/vol 89/no 3

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El Ansari, W (2003). ‘Satisfaction trends in undergraduate physiotherapy education’, Physiotherapy, 89, 3, 171-185.

field, 1997) and currently there are about 25 physiotherapy MSc courses listed in the UK (CSP, 1996; Gosling, 1997). However, the Chartered Society of Physiotherapy, which is regulating an emergent graduate profession (Holey, 1993), now has considerable control of pre-registration physiotherapy education (Maxwell, 1995), and has fostered access and continuing professional development links with higher education (Beeston et al, 1998). There seems little literature that simultaneously examines the influences of the demographic and educational-related characteristics of physiotherapy students on their academic per formance and satisfaction with their learning and teaching experiences. This is despite the fact that for studies focusing on allied health professions students’ satisfaction, sex (Kinsella et al, 1999; Nahas et al, 1999), disability (Martin et al, 1998), ethnicity (El Ansari, 2002a) and age bracket (Ofori, 2000) have all been documented as important variables warranting examination. Similarly, academic level (Kerridge and Mathews, 1998), mode of study (Ford et al, 1995; Lee et al, 1999) and the qualification aim (El Ansari, 2002b) have also been recognised as predictors of students’ performance and satisfaction. In relation to physiotherapy, more frequently, a narrower scope of one or two student related variables are investigated, usually in isolation from other critical dimensions of satisfaction (El Ansari et al, 2002). For instance Schultz et al (1988) evaluated a course in Australia using a student questionnaire with a view to assessing its value and identifying the most effective methods of teaching. Likewise, other studies surveyed the link between physiotherapy students’ admission criteria and previous academic study in relation to their progression through their courses and final degree classification (Kerr, 1985; Green and Waterfield, 1997). In evaluations of quality, students are one of the most used sources of data (Pozo-Munoz et al, 2000), and surveys are one of the most used research designs (Coffey and Gibbs, 2001). Both are frequently employed methods for evaluating effectiveness of learning programmes. The survey is a practical method of evaluating the different educational aspects, and results are useful as evidence when surveys of different

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student groups (Jayawickramarajah, 1992) and modules are pooled and interpreted. Within the sphere of physiotherapy, surveys of students have been employed in exploring their perceptions in relation to their taught interpersonal and communication skills (Schultz et al, 1988) and their undergraduate rural education (Butler and Sheppard, 1999). Similarly, surveys have been used to examine physiotherapy students’ occupational prestige (Whitfield et al, 1996; Turner, 2001), or for the evaluation of their clinical experiences (Clifford, 1992) and the factors influencing their uptake of physiotherapy MSc courses (Beeston et al, 1998). There is an increased emphasis on the monitoring of the quality of learning and teaching in higher education (Chapple and Murphy, 1996). Likewise, institutional effectiveness could be gauged by way of students’ satisfaction with their educational experiences (Cameron, 1981). Collectively, these considerations along with the paucity of research focusing specifically on the contentment of physiotherapy students with their learning encounters formed the underpinnings of the present study. Aims of the Study This study formed part of a wider survey into student satisfaction at the School of Health Care of a British University in the United Kingdom (El Ansari, 2002a, b). The questionnaire survey explored the factors that influence student satisfaction with their educational experiences. The four aims of this study were to: ■ Describe the general level of students’ satisfaction with their educational experiences. ■ Investigate the effects of four demographic variables (sex, disability, ethnicity and age) on physiotherapy students’ performance and perceptions of satisfaction with their learning. ■ Investigate the influence of four education-related parameters (academic level, academic term, mode of study and entry qualification) on physiotherapy students’ performance and levels of contentment. ■ Test the hypothesis that mean student satisfaction is related to the mean module grade (performance) for nine physiotherapy modules.

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Design and Method The Survey: Modules and respondents The nine modules collectively contributed to the three-year BSc course in physiotherapy. These modules can be categorised into three clusters. The first cluster had to do with human performance and comprised the first four modules, addressing either movement (modules 1, 2 and 3) or physiological (module 4) perspectives. The second cluster dealt with dysfunctions and embraced two modules representing the management of vascular/cardiorespiratory (module 5) or neurological (module 6) dysfunctions. The third cluster included another three modules focusing on physiotherapy practice, whether as an introductory content (module 7), within specific groups and contexts (module 8) or as integrative study (module 9). Most modules contributed 7%-11% of the sample except module 3 which comprised 20.3% of the completed questionnaires. Three hundred questionnaires were completed. Women comprised the majority (78%) of the sample, and about 1.4% of students reported a disability. Nearly all participants (98%) were fulltime students and of ‘white’ ethnicity (97.6%). Mean student age was 22.2 years (range 18-45 years). Less than one quarter (21.7%) of the students were traditionally aged students (< 21 years) while about half (43.3%) were mature (21-25 years) and more than one-third (35%) were older mature students (> 25 years). In connection with academic levels, level 2 has only been recently introduced at the university where the study was implemented. Levels 1 and 3 are defined respectively as levels of per formance expected from notional first- and thirdyear undergraduates in higher education. Accordingly the sample comprised level 1 (62.2%) and level 3 (37.8%) participants. Slightly less than one-quarter (21.7%) of respondents attended term 1 modules, while 43% and 35% attended term 2 and 3 modules respectively. As regards entry qualifications, most respondents (85.1%) had A-levels, ASlevel which is taken by students normally at the end of their first year of the sixth form (worth half an A-level), Access qualification, and Scottish highers (Scotland's equivalent to A-levels). Less than 1% had either GCSE or O-level

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qualifications generally taken by 15/16 year olds at secondary school, or subdegree qualifications which are quantitatively and/or qualitatively different from qualifications which are either wholly or partly at higher education level but which are not degrees, eg HNC, HND, CertHE or DipHE (usually one or two years of a degree course respectively). Finally 13.5% had first degrees, eg bachelor of arts (BA) or science (BSc). As the numbers of respondents who had GCSE/O-level or subdegree qualifications were fewer than 2%, they were excluded from the analysis related to the entry qualification. All the modules examined in this study were pre-registration modules, and the qualification aim for all students was a BSc degree in physiotherapy. Questionnaire A cross-sectional quantitative survey (Polit and Hungler, 1995) was undertaken employing a one-page questionnaire. Besides the demographic characteristics (age, sex, ethnicity and disability) and the academic related information (full- or part-time mode of study, academic term, module code, registration number) the 18 questionnaire items were close-ended questions scored on 5-point scales where 1 = ‘positive perception’ and 5 = ‘negative perception’ (see appendix). The 18 questions addressed several themes related to the quality of learning and teaching of the modules under investigation. Twelve items were from Kerridge and Mathews (1998) augmented by another six questions that were added to capture other important parameters. For instance, the modules’ stimulation of independent thinking and usefulness to students’ careers (Jowett et al, 1992); the modules’ demands in terms of the amount of work required (Briggs, 1972; Orr, 1990); teaching styles (Hounsell et al, 1997); and the theory/practice gap (Cash, 2000). In order to capture a wide view of the domain (Churchill, 1979, page 67), other issues that were also included were the integration of the module’s distinctive elements into a meaningful whole and the intellectual stimulation of the module. Collectively, the research tool covered the major areas of student attitude in relation to module administration, module content, perception of module

Author Walid El Ansari PhD MB BCh MSc(PHM) Dip(Ped) DTM&H PGCert(HE) is a senior lecturer in the School of Health and Social Care, Oxford Brookes University. This article was received on April 12, 2002, and accepted on August 20, 2002. Address for Correspondence Dr Walid El Ansari, Public and Community Health, School of Health and Social Care, Oxford Brookes University, Heritage Gate, Sandringham House, Sandy Lane West, Oxford OX4 6LB. E-mail: walid.ansari@brookes. ac.uk Acknowledgements The author would like to thank the staff and students of the School of Health Care at the university where the research was implemented for their participation and generous contribution of information about the modules. Special thanks go to Julie Poulton of the Systems Unit for data retrieval and linkage, and to Professor Terence Davis and Dr Diane Pearson for constructive comments on earlier drafts of the paper.

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team, university resources, module assessment procedure, and module relevance. Attention was paid to both the design (Moser and Kalton, 1971) and the order and balance of questions (Bourque and Fielder, 1995). Analysis Participants’ responses to the 18 items under investigation were not normally distributed (Kolmogorov-Smirnov tests for all items were significant, indicating that the distributions of responses to the questions were significantly different from normal distributions) (Field, 2000, page 48). Accordingly the Mann-Whitney U test (two-independent-samples test) was employed to examine students’ satisfaction with the modules when the variable was binary (eg sex, disability and ethnicity). Similarly, the Kruskal-Wallis test (for several independent samples) was used when the comparison was between more than two groups (eg age bracket and academic term). Each parameter was examined in turn, and the percentages of participants in the comparison groups reporting favourably (choosing either the 1 or 2 option out of a five-point scale where 1 = ‘positive perception’ and 5 = ‘negative perception’) were calculated. The module grades were the actual grades that students attained in the modules under investigation. They were normally distributed (KolmogorovSmirnov test of normality was nonsignificant) (Field, 2000, page 48), hence when comparing the module grades, independent samples t-test and one-way analysis of variance were employed when the comparison was between two or more groups respectively. As an indicator of internal consistency, Cronbach’s alpha coefficient (Cronbach, 1951) was calculated for the 18 items of the questionnaire, and values greater than 0.7 taken as indicating good reliability (Nunnally, 1978). In order to explore the relation between students’ satisfaction and their grades two independent analyses were undertaken. First to capture the richness in variability of student responses, a total score was computed for each student by summing the responses across all questions. Students’ total scores were then correlated to their grades employing Pearson’s correlation coefficient. Physiotherapy March 2003/vol 89/no 3

Secondly, the mean percentage of students reporting satisfaction for each of the nine modules was correlated to the mean grade for the module also employing Pearson’s correlation coefficient. For all tests, significance level was set at P < 0.05. Results Satisfaction with Aspects of Learning and Teaching In relation to the first aim of the study, the percentage of students satisfied with aspects of their learning experience was computed across the nine modules. A 50% cut-off level in percentages of students was arbitrarily adopted, below which the satisfaction level with a particular aspect of the course was seen as requiring attention. Accordingly, for the first cluster of modules, modules 1, 2 and 3 depicted a good mean overall level of satisfaction (68.7%) across all aspects of teaching and learning. In some of these modules, the satisfaction levels fell under 50% only in relation to one or two of five aspects: the smooth running of as well as the setting of the module at the level of students’ skills and knowledge; the quantity of work required for the modules and the feedback to students in relation to their assessed work; and the integration of module elements into a meaningful whole. Module 4, on the other hand, exhibited low mean satisfaction, where about 80% of aspects of the learning experience generated less than 50% satisfaction. In spite of this, participants were content with the availability of information about the module and the appropriately sized seminar groups, and felt that the module was seen to be of direct use in their professional careers. In connection with the second module cluster, modules 5 and 6 both showed high (80%) mean levels of satisfaction. For both modules the satisfaction level fell below 50% only in relation to the availability of required references and reading material in the library. With regard to the third module cluster, modules 7, 8 and 9 indicated a high (70%) mean level of satisfaction. For some of the modules comprising this cluster, the satisfaction levels fell under 50% only in relation to one or two of the following four aspects: feedback to students while preparing assignments;

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references and reading material availability in the library; appropriateness of the assessment methods; and whether the module made students look at their professions differently. Reliability Table 1 shows the number of completed questionnaires, Cronbach’s alpha, and mean students’ grades in relation to the nine physiotherapy modules and four demographic and four educationalrelated parameters under study. Cronbach’s alpha displayed values greater than 0.7 (except in one instance) indicating good reliability (Nunnally, 1978). Influence of Demographic and Educational-related Variables In relation to the second and third aims of the study, table 1 suggests that although the mean grade across all the modules was 56.7%, students’ grades differed significantly across the modules, reaching a mean high of 67.6% for module 8 and a mean low of 53.6% for module 3. There were no differences in mean grades in connection with ethnicity, academic term and study mode, and although nondisabled students performed better than their disabled colleagues, the difference was not statistically significant. Across the nine physiotherapy modules, women performed significantly better than men, and there was a stepwise age gradient in accomplishments, where the older age groups achieved better grades than the younger ones. Similarly, level 3 students scored higher than their level 1 counterparts, and participants with a prior degree entry qualification achieved higher grades than those with A-level or equivalent entry. An analysis of the percentages of students who reported satisfaction with 18 aspects of their learning experience by the eight demographic and educationalrelated parameters under study was then undertaken (data not presented). Three distinct categories emerged: ■ The first category of low differences comprised those parameters that exhibited significant differences in 0-3 of the 18 items under study. Four parameters fell into this category. There were no differences in satisfaction with the physiotherapy

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Table 1: Nine physiotherapy modules: Number of completed questionnaires, percentage of whole sample, Cronbach’s alpha, and mean students’ grades N (% Standard- Mean of whole ised item grade sample) alpha* (%)

Nine modules

Mean grade (SD) Range

(9.34)

Mean grades differences (P)

300 (N/A)

0.84

56.7

32-88

N/A

Cluster 1 Module1 Module 2 Module 3 Module 4

33 34 61 32

(11) (11.3) (20.3) (10.7)

0.83 0.76 0.86 0.69

54.5 55.4 53.6 55.8

(7.2) (8.1) (9.2) (10.8)

39-68 37-72 32-74 39-72

Cluster 2 Module 5 Module 6

32 (10.7) 31 (10.3)

0.75 0.78

56.8 57.4

(8.6) (7.0)

39-76 45-74

Cluster 3 Module 7 Module 8 Module 9

33 (11) 24 (8) 20 (6.7)

0.90 0.71 0.79

57.2 67.6 56

(8.2) (11.1) (7.2)

44-78 51-88 42-71

65 (21.7) 234 (78.3)

0.86 0.83

53.5 57.5

(11.1) (8.7)

37-88 32-88

0.004

4 (1.4) 279 (98.6)

N/A 0.84

48 56.9

(6.98) 42-58 (9.4) 32-88

NS (0.059)

288 (97.6) 7 (2.4)

0.84 0.89

56.6 61

(9.3) (5.0)

32-88 55-67

159 (53.9) 79 (26.8) 57 (19.3)

0.85 0.83 0.79

54.7 57.7 60.8

(8.5) (8.7) (10.9)

32-80 39-88 39-88

< 0.001

65 (21.7) 130 (43.3) 105 (35.0)

0.77 0.86 0.84

55.7 55.8 58.4

(8.0) (9.0) (10.3)

39-76 32-74 32-88

NS

176 (62.2) 107 (37.8)

0.87 0.77

55 59.3

(8.7) (9.6)

32-78 39-88

< 0.001

294 (98) 6 (2)

0.84 0.89

56.7 59

(9.4) (1.4)

32-88 58-60

NS

239 (86.3) 38 (13.7)

0.85 0.77

56.3 60.8

(8.7) (11.5)

32-88 39-88

0.005

Module Clustera

< 0.001

Sexb Men Women Disabilityb Disabled Not disabled Ethnicityb White Others

NS

Age bracketa < 21 years 21-25 years > 25 years Academic terma One Two Three Academic levelb One Three Study modeb Full-time Part-time Entry qualificationb A/AS level or equivalent Degree

* Alpha computed for the 18 items of the questionnaire; N/A = not applicable; SD = standard deviation; NS not significant; a b One-way ANOVA test; Independent samples t-test

modules according to disability status, and for the dimensions of ethnicity, mode of study and entry qualifications, each showed differences in only 3 (16%) of the items under investigation. ■ The second category of intermediate differences encompassed the parameters that exhibited significant discrepancies in 6-7 items out of the 18 questions. Two parameters fell into this Physiotherapy March 2003/vol 89/no 3

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100

Men

Women

75

50

25 Module ran smoothly

Increased my interest

Assessment methods

Correct assumptions about my knowledge

Library resources

Information available

Fig 1: Percentage satisfaction with learning and teaching parameters by sex – significant differences

100

< 21 years

21-25 years

> 25 years

75

50

25 Opportunities Material well Thought Information Helpful to ask questions presented provoking available feedback

Amount of module work

Module's elements integrate

Fig 2: Percentage satisfaction with learning and teaching parameters by age bracket – significant differences

Term 1

100

Term 2

Term 3

75

50

25 s s t t s k k k n g le ds ed es io as s or ac yle rce ka am ab kin nt ho er o lat loo sion ff st db te ou ail vo et ew nt es t stion rese u e s l i v e s o e l e t m a u a y b p ti e t pr lf tim ren rofe st n yr n m od ni qu ell ea ls fu en io ht ar e p ing ra d lp dg fm w at rtu ua Diff br se sm le h ug e i t e l o s o a l m c u L o H a e t p r ac i e h s w re l r n p o s l c T od f e Te O A no te In ou M In at K n I m M A ly

th

oo

sm

Fig 3: Percentage satisfaction with learning and teaching parameters by academic term – significant differences

Level 1

100

Level 3

75

50

25 s s t t s k k n g le rk ds ed es io as s ac yle rce ka am ab kin nt ho er wo o lat loo sion ff st db te ou ail vo et e nt es t stion rese u e s l i v e s o e l e t u r a y b p ti e tm lf tim ren rofe sta n yr n m od tp ni qu ell ea ls fu en io ar e p ing ra d gh lp m dg fm w at rtu ua Diff br se s le h u e i t e l o s o a l m c u L o H r ac ia se w nt lle cre Opp Th od fo er Te As no te In ou M In at K n I M Am ly

th

oo

sm

Fig 4: Percentage satisfaction with learning and teaching parameters by academic level – significant differences

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category: sex and age bracket each displayed differences in 6 and 7 (33% and 39% respectively) of the questionnaire items. Figures 1 and 2 depict these differences. ■ Finally the third category of high differences included the dimensions that demonstrated significant discrepancies in 14 of the 18 items. Two parameters fell into this category: academic term and academic level each displayed differences in 14 (78%) of the items that the study examined. Figures 3 and 4 depict these differences for academic term and academic level respectively. Is Student Satisfaction Related to Module Grades? In relation to the fourth aim of the study, part A of table 2 shows the relation between students’ total satisfaction score

and their mean grades. The correlation is weak, and the negative sign confirmed the parallel relation between satisfaction and grades; a decrease in total satisfaction score (lower scores indicate higher satisfaction) was accompanied with an increase in grades. Although this finding suggested the value of satisfaction in relation to performance, the relation did not reach statistical significance. Part B of table 2 shows the relation between percentage of students reporting satisfaction per module and the mean module grade for each of the nine physiotherapy modules under investigation. The association between the percentage of satisfied students in a module and the mean module grades was again a weak one, and the positive sign confirmed the parallel relation between percentage of satisfied students attending a module and the mean grade achieved in

Table 2: Relation of student satisfaction to module grades by total students’ scores, percentage of students reporting satisfaction per module and student parameters A. By total scores of students across all modules

Total student satisfaction score (M)

Mean grade (%)

38.49

56.68

% of students satisfied (M)

Mean grade (%)

73.4 63.4 69.5 36.3 78.8 80.1 74.6 70.4 63.5

54.5 55.4 53.6 55.8 56.8 57.4 57.2 67.6 56

B. By % of students reporting satisfaction per module Module 1 Module 2 Module 3 Module 4 Module 5 Module 6 Module 7 Module 8 Module 9 C. By study parameters

No of questionnaire items with significant satisfaction differences (N)

Trend of the differences

Satisfaction

Correlation

Weak correlation (–0.07) Non-significant (P = 0.26) Correlation

Weak correlation (0.14) Non-significant (P = 0.71)

Significance of difference in grades

Grades

Sex

6

Women > men

Women > men

Significant

Disability

0

No trend

Non-disabled > disabled

Non-significant

Ethnicity

3

White > other

Other > white

Non-significant

Age bracket

7

No trend

Stepwise increase with age

Significant

Academic term

14

No trend

Stepwise increase with academic term

Non-significant

Academic level

14

Level 3 > level 1

Level 3 > level 1

Significant

Study mode

3

Full time > part time

Part time > full time

Non-significant

Entry qualification

3

A-level > degree

Degree > A-level

Significant

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the module. An increase in the number of satisfied students was accompanied by an increase in the mean module grade. Once more, this finding suggested the value of satisfaction in relation to performance, yet again the relation did not reach statistical significance. An exploration of how satisfaction was related to performance for the various parameters under study was then undertaken. Part C of table 2 displays the number of questionnaire items with significant satisfaction differences between the comparison groups for each of the eight demographic and educational-related parameters under investigation. It also shows, generally for each dimension, whether there were any stable trends in relation to satisfaction and module grades. The table suggested no particular trends for the relation between satisfaction and module grades. Different trend categories were however noted. Table 3 clarifies the relation trends between levels of student satisfaction and their performance in terms of module grades for each of the eight student characteristics. It should be noted that

Table 3: Satisfaction and performance (module grades) trends in relation to eight student characteristics: Directions and significance Direction of Trend No direction

Same direction

Grade differences significant Age bracket: No Sex: Women more satisfaction trend in satisfied and performed relation to age bracket, better than men but stepwise increase in grades with age Academic level: Level 3 students more satisfied and performed better than level 1 participants Grade differences non-significant Disability: No satisfaction trend in relation to disability status, but non-disabled students performed better than disabled participants Academic term: No satisfaction trend in relation to academic term, but stepwise increase in grades with academic term

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Opposite direction

Entry qualification: A-level participants more satisfied but lower grades than degree students

Study mode: Full-time students more satisfied but lower grades than part-time respondents Ethnicity: ‘White’ students more satisfied but lower grades than ‘other’ ethnicity students

the various categories of the table were not premised on the 18 items of the questionnaire, but only on items that displayed significant differences between the various levels of each demographic or educational related parameter (range 0 for disability to 14 items for academic term and academic level). Five categories emerged: ■ No satisfaction trend, significant increase in grades: eg age bracket. ■ No satisfaction trend, non-significant increase in grades: eg disability and academic term. ■ Trend in the same direction, increase in satisfaction associated with significant increase in grades: eg sex and academic level. ■ Trend in the opposite direction, increase in satisfaction associated with significant decrease in grades: eg entry qualification. ■ Trend in the opposite direction, increase in satisfaction associated with non-significant decrease in grades: eg study mode and ethnicity. Discussion The results presented an overview of physiotherapy students’ satisfaction levels with nine modules at a British university in the UK. In order to prepare physiotherapy students optimally for their future, educators must attend to issues of both content and process of learning, identifying what is required for their graduates and how it is best achieved (Hunt et al, 1998). By responding to the challenge of change, educational methods can complement service developments (Holey, 1993). The questionnaire was found to be reliable and Cronbach’s alpha reliability coefficients by the various units of analyses under investigation were in most cases in the range of 0.7-0.9, indicating good to excellent reliability. Other authors, examining various health professionals’ attitudes, have reported similar values (Swenson and Kleinbaum, 1984; Harrison et al, 1991; Björkström and Hamrin, 2001). The nine physiotherapy modules under investigation generally indicated good student satisfaction levels. Here two points need to be considered. The first is that the study employed a conservative

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measure of contentment, reporting respondents who were actively satisfied (choosing only the 1 or 2 options of a five-point scale, where 1 = ‘positive perception’ and 5 = ‘negative perception’). In adopting a stringent measure of satisfaction that did not include those who were in the middle of the scale (ie choosing the 3 option of the five-point scale ‘neither satisfied nor dissatisfied’), the reported satisfaction levels are indicative of positive satisfaction only. The second point is that a 50% cut off level in percentages of students was arbitrarily adopted, below which the satisfaction level with a particular aspect of the course was seen as requiring attention. As fail grades in most institutions are those which fall below 40%, it would have been sensible to adopt a parallel 40% cut-off level in percentages of dissatisfied students to declare that a module required attention. However, as quality issues and student satisfaction are of critical importance to the university, the study favoured a more scrupulous approach to measuring satisfaction. Even with such rigorous appraisal gauges, most of the modules had a narrow range of one to four aspects (out of 18 items) where satisfaction levels fell below 50% of the respondents. For three modules, low contentment was reported with only one aspect of the learning experience. Such findings are reassuring for the institution and reflect the ongoing drive aimed at improving the quality of the learning experience of students. An important feature is that module 4 could benefit from more attention due to respondents’ low satisfaction levels. However, a point that needs to be taken in consideration is that this characteristic is not unique to the university where the study was implemented, but rather has to do with the subject matter of physiology, a broad subject with multiple core areas. For instance, Vaz et al (1996) called for the need for more formative assessment of core areas within the physiology curriculum, and stated that review exercises following the completion of major lecture series were an important formative tool both for students and teachers. They help the knowledge and understanding of students without incurring academic penalty, allowing for rapid remedial action. This supports

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Curzon’s (1990) obser vations that periodic revisions enhance assimilation, consolidation and retention of the subject matter. The learning of physiology using selfstudy has been advocated (Villani, 1996), though lecturing continues to be the favoured way of teaching undergraduate physiology (Laidlaw, 1988). An advantage of self-study is that students who ask questions have first tried to understand the material for themselves, consequently teaching time is not spent only on presenting information, but there is greater interaction and conceptual discussion (Villani, 1996). Because the classroom focus changes from teacher-centred to student-centred activities, students display more enthusiasm for learning (Jones and Kember, 1994). Hence accommodating students’ diverse learning styles is important (Griggs et al, 1994). Likewise, in Spain, Escanero et al (1995) reported that there was no uniformity in the organisation of physiology lessons, and called for a reduction of theoretical programmes of physiology and an increase in practical learning. In this study, women were more satisfied and performed significantly better than men. This is in agreement with Kevern et al (1999) who, examining pre-registration diploma students, reported that mature women performed well overall. However, differences in degree performance of men and women have proved highly controversial in recent years (Hoskins et al, 1997). Rudd (1994) examined degree results of all UK universities over a 12-year period and concluded that there were no sex differences in performance. Similarly, Kerridge and Mathews (1998), looking at marketing students, also found no sex influences on satisfaction ratings. The study also indicated that level 3 students were more satisfied and performed better than level 1 part-icipants. This finding contrasts with Kerridge and Mathews (1998) who reported that the perceptions of level 3 students were more negative than those of level 1 students in relation to 25% of the aspects of the modules that they investigated. However, students’ orient-ations, their values, perceptions and ex-pectations change during education for the health professions (Pleasance and Sweeney, 1994; Vanhanen and Janhonen, 2000).

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Mature participants of the older age groups achieved better grades than traditional students, where there was a stepwise age gradient in accomplishments. Although some studies (Woodley, 1984) might have suggested otherwise, recent studies have tended to show a slight advantage for mature students (Hartley and Lapping, 1992; Hartley et al, 1993; Richardson, 1994, 1995; Ofori, 2000; El Ansari, 2002a). Similarly, Kevern et al (1999) found that mature students performed better than younger participants and Houltram (1996) indicated an important trend in the rise of mature pre-registration students. Mature students are often exceptionally motivated, work hard and per form well (Hoskins et al, 1997). At the university where the study was implemented, mature (21-25 years) and older mature (> 25 years) physiotherapy students comprised about 80% of the sample, which is higher than the 67% reported by Green and Water field (1997) in relation to 16 physiotherapy programmes in the UK and the Republic of Ireland. This could have implications for the institution, since mature students come from a variety of backgrounds, such as Access, first degree and those with equivalent overseas qualifications. The study findings indicated that participants with a prior degree entry qualification achieved higher grades than those with A-level or equivalent entries. Hoskins et al (1997) reported prior qualification to be a weak predictor of performance, and similarly Ofori (2000) found no performance differences based on prior qualifications. However a critical difference with this study is that both those authors were examining non-degree qualifications as entry criteria (eg Access, O-levels, BTEC, GCSE, etc). This is not the case with the comparisons that were undertaken in this investigation, where Alevel entries were compared to degree entries. The study findings also suggested that both groups of A-level and degree entry participants were performing well (table 1), in support of Green and Waterfield (1997) who stated that for 1990/91, A-level and first-degree students comprised a high proportion of students who attained a first-class honours physiotherapy degree. For physiotherapy undergraduate edPhysiotherapy March 2003/vol 89/no 3

ucation, there appears to be no baseline or set of criteria for admission against which prospective students can measure themselves. This might cause difficulties when deciding which mode of pre-entry study will make applicants more acceptable to the majority of physiotherapy programmes (Green and Waterfield, 1997). For this study’s sample, less than 2% had either GCSE/O-level qualifications or sub-degree qualification (eg HNC, HND, CertHE or DipHE). This is despite the fact that the profession recognises that physiotherapy would be better able to serve and represent clients if it broadened its admission profile (Green and Waterfield, 1997). In this study the 13.5% of students who had a degree qualification on entry to the programme were performing better than those with A-levels. This is in support of other authors (Green and Waterfield, 1997), who found that students who already have a first degree make up a relatively small percentages of most physiotherapy programme intakes, but are well represented in the higher bands of degree classification. Given that Kevern et al (1999) reported that participants with modest qualifications did less well, we may infer that a prior degree before undertaking physiotherapy study would add to students’ capacity in terms of motivation, learning, assimilation, consolidation and performance. In testing the relation between student satisfaction and module grades, two pieces of evidence emerged. The first was on the individual students’ level: the parallel relation between total students’ satisfaction scores (low scores indicate higher satisfaction) and their module grades, where increased satisfaction was accompanied with an increase in grades. The second was on a collective level: the parallel relation between the percentage of satisfied students attending a module and the mean overall grade achieved in the module. The greater the proportion of satisfied students on a module, the higher the mean module grade that was accomplished. These two pieces of evidence suggested the value of satisfaction in relation to performance at both the individual and collective levels. Indeed satisfaction could be a useful early warning sign of how students are likely to perform on a particular module. Such signs need to be actively sought by health

Research report

professions educators and, when feasible, measured and acted upon. However, in connection with students’ demographic and educational-related characteristics, the relation between satisfaction and performance was not very clear. At times satisfaction and performance were significantly parallel, thus confirming the above findings (eg sex and academic level). At other instances, the relation took no particular direction (eg age, disability and academic term), or was inverse (eg entry qualification, study mode and ethnicity). Additional research in this area, perhaps with larger sample sizes, might help further the understanding of how student characteristics positively or negatively interact with the satisfaction-per formance equation. A closer examination of such interactions would aid in confirming or refuting some of the findings emerging from this investigation. The limitations of this study are that the sample of modules came from one university and did not include any clinical modules. The questionnaire was designed to examine the theory-based and practical modules rather than the clinical placements and other skills. Hence caution must be exercised in reviewing and generalising the findings. Conclusion For physiotherapy education to equip graduates to work within and contribute to a radically changing service, students need to be enabled to reach a certain level of competency (Holey, 1993). With 300 questionnaires completed in this study, it provides insights into physiotherapy education. The research tool has been shown to be reliable, and the study has indicated that the profiles of physiotherapy students at the university where the study was undertaken are diverse and that some of the demographic and educational student characteristics play a part in determining satisfaction and performance. Employing rigorous appraisal gauges, student satisfaction levels were generally

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high with the nine physiotherapy modules that were examined. Age, sex, and education were important predictors of achievement, where mature women with a prior degree performed better than traditionally aged men with A-level entries. Although these three variables are all important, the significance of previous higher education experience in terms of a prior degree suggests it would be preferable to recruit students with a first degree above students with other qualifications. Furthermore, academic level also influenced progress, and nondisabled students performed better than disabled participants, with the differences being short of statistical significance (P = 0.059). The relation of student satisfaction to performance in terms of module grades shows no clear trends. An understanding of how student characteristics positively interact with or negatively impact on the satisfaction-performance equation is still speculative and warrants further research. Nevertheless, the evidence of two parallel relations between students’ satisfaction and their module grades, and between the percentage of satisfied students attending a module and the mean overall grade achieved in the module, highlighted the importance of measuring satisfaction markers. Such indicators could act as advanced ‘radars’ alerting educators to areas and programmes requiring attention. Whenever real answers are sought on effectiveness of educational programmes a careful examination of the evidence of accomplishments of the process and outcomes is required. In addition, the expectations and experiences of students need to be highlighted in order to develop strategies to meet such hopes. The institution holds student satisfaction as important, and the findings of this investigation will inform physiotherapy education, curriculum design, preparation and relevance of teaching materials in order to respond to the quality assurance imperatives of learning and teaching in higher education.

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Hoskins, S L, Newstead, S E and Dennis, I (1997). ‘Degree performance as a function of age, sex, prior qualifications and discipline studied’, Assessment and Evaluation in Higher Education, 22, 317-328.

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Key Messages ■ Student satisfaction is an important aspect of the quality assurance imperatives of learning and teaching in higher education. ■ Student satisfaction levels were generally high with the most of the nine physiotherapy modules that were examined. ■ There were no significant differences in student performance in relation to disability status, ethnicity, academic term, or full-time and part-time study modes. ■ Mature women with a prior degree performed significantly better than traditionally aged men with A-level entries.

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■ Satisfaction and performance were sometimes significantly linked (eg sex and academic level). At other instances, the relation took no particular direction (eg age bracket, disability and academic term). Sometimes, the relation was inverse (eg entry qualification, study mode and ethnicity). ■ Further research is required to explore how student characteristics positively interact with or negatively impact on the satisfaction performance equation.

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Appendix: Student perception of module questionnaire Please complete all questions. All responses will be treated in strictest confidence.

This questionnaire is designed to evaluate the quality of individual modules offered at the university. You may be asked to complete, if you wish to do so, more than one of these questionnaires during your study programme. Using the numbers as a scale (ignore values) between the pairs of statements listed below, please circle the response that is nearest to your view. 1.

This module ran smoothly

1

2

3

4

5

This module did not run smoothly

2.

The teaching of this module has increased my interest in the subject

1

2

3

4

5

The teaching of this module has not increased my interest in the subject

3.

The module team provided sufficient opportunity for me to ask questions and give opinions

1

2

3

4

5

The module team did not provide sufficient opportunity for me to ask questions and give opinions

4.

The material was well presented

1

2

3

4

5

The material was not well presented

5.

The module was thought provoking

1

2

3

4

5

The module was not thought provoking

6.

The module’s assessment method was appropriate

1

2

3

4

5

The module’s assessment method was not appropriate

7.

The module team displayed good knowledge of the subject

1

2

3

4

5

The module team did not display good knowledge of the subject

8.

The module team incorrectly assumed the level of skills and knowledge I already had

5

4

3

2

1

The module team correctly assumed the level of skills and knowledge I already had

9.

Information (assessment schedule and reading lists) was not made available at the beginning of module

5

4

3

2

1

Information (assessment schedule and reading lists) was made available at the beginning of module

10. I did not receive helpful feedback while preparing my assignment/ assessment

5

4

3

2

1

I received helpful feedback while preparing my assignment/assessment

11. The seminar groups were too big for everyone to contribute

5

4

3

2

1

The seminar groups were small enough for everyone to contribute

12. The references I needed for this module were not available in the library

5

4

3

2

1

The references I needed for this module were available in the library

13. The amount of work demanded for this module was greater than I could give to a single/double module

5

4

3

2

1

The amount of work demanded for this module was appropriate and manageable

14. The module is made of distinctive elements and these do not integrate into a meaningful whole for me

5

4

3

2

1

The module is made of distinctive elements and these integrate into a meaningful whole for me

15. The module was intellectually stimulating 1

2

3

4

5

The module was not intellectually stimulating

16. I do not expect anything I have learnt on 5 this module to be of direct use to me in my career

4

3

2

1

I expect some things I have learnt on this module to be of direct use to me in my career

17. Things I learnt on this module will cause 1 me to look at my profession in a different way for the rest of my life

2

3

4

5

None of the things I learnt on this module will cause me to look at my profession in a different way for the rest of my life

18. The teaching staff’s styles on this module 1 were clear/informative and stimulated me to think independently

2

3

4

5

The teaching staff’s styles on this module were not clear/informative and did not stimulate me to think independently

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