Perception of peer physical examination in two Australian osteopathy programs
The aim of the present study was to explore perceptions of first year osteopathy students
at two Australian universities about PPE. Overall, students in the present study were
willing to examine, and have examined all body regions listed in the questionnaire.
This is consistent with results of another study 12] and within the 5 % range of students unwilling to participate in PPE identified by
Power and Center 26]. The only region where this value was larger was for students from VU who indicated
an unwillingness to examine the groin of a peer, or have their groin examined, in
some cases, regardless of peer biological gender. Students in the present study were
less apprehensive about PPE and perceived it as a professional experience, as did
those in the study reported by Consorti et al. 3]. The findings of the present study, for the first time, reinforce the anecdotal experiences
of the authors with the application of PPE in osteopathy.
The concept of PPE in osteopathy education extends beyond the rehearsal and development
of physical examination skills to include the application of osteopathic manipulative
therapy (OMT) and other manual therapy techniques. The World Health Organisation 14]Benchmarks for Training in Osteopathy requires programs to graduate students with:
competency in the palpatory and clinical skills necessary to diagnose dysfunction
in the aforementioned systems and tissues of the body, with an emphasis on osteopathic
diagnosis;
competency in a broad range of skills of OMT;
proficiency in physical examination and the interpretation of relevant tests and data,
including diagnostic imaging and laboratory results.
Achieving these benchmarks requires substantial time practising these skills on peers
in the classroom. In the context of the present study, over the 12-week teaching period,
students spent approximately 50 h in a PPE environment. By the completion of their
program of study they will have spent approximately 300 h developing their practical
skills in the classroom and 1000 h with actual patients in a student teaching clinic.
It is anticipated, as Rees et al. 27] suggested, that the positive perceptions of PPE identified in this study will remain
throughout the entire program. Exposure to the living body early in a students’ training
is likely to have a significant influence on the relative ease that students will
have with ‘therapeutically touching’ a patient in their clinical training years, and
contribute to the development of professional attitudes towards patients 28]. The practice of osteopathy in Australia is focused on the management of musculoskeletal
complaints 13]. Therefore there is little need to learn, or be able to practise, examination of
sensitive areas like the breast and genitals 29] which are beyond the scope of practice of osteopaths in Australia. Consequently,
these regions were not included in the EFS questionnaire.
To be able to develop the manual therapy skills to become a registered osteopath in
Australia, students undertake carefully scaffolded and supervised practice throughout
their course. Students require full information about what is expected of them before
they enrol and explanations about the benefits of participating in PPE need to be
made clear 4], 30]. However, some students may not wish to participate in a particular PPE activity,
or may place conditions on their participation 5]. Alternative learning pathways such as practising on standardised patients or on
family members need to be made available 16]. One of the challenges for educators is to design activities that meet the required
learning outcomes while respecting the right of students to refrain from participating.
In the history of both osteopathy teaching programs, few challenged have been reported,
most being resolved by allowing students to practise initially with someone with whom
they feel comfortable (e.g. a student of their own choosing, or a family member or
friend), before practising with other students who can provide a wide variety of body
types, and personal and medical histories.
No national or international guidelines could be located to guide good practice in
PPE and practising treatment techniques on peers. The University of Queensland Medical
School 31] called for development of such guidelines in medicine. In osteopathy and other health
sciences, guidelines for good practice are likely to include:
obtaining informed consent from students before they participate in PPE 4], 30];
telling students what to expect in practical classes before they commence their courses
6], 30], 32];
facilitating discussions about ethical, cultural and professional issues associated
with PPE (e.g. therapeutic touch vs sexual touch; body image; age, gender, cultural
influences on willingness to participate in PPE);
allowing students to choose who they practise with; and
offering alternatives to students who choose not to participate 16].
Demographic influences on PPE
The EFS questionnaire asks students to indicate which areas of the body they would
not be willing to examine on a peer or have examined by a peer. Numerous authors have
reported that students are more willing to examine, rather than be examined by, a
peer 11], 33], 34], and this appeared to be consistent with the present study. Students entering an
osteopathy program are likely to be aware that their course will include a substantial
amount of time devoted to learning clinical assessments and manual therapy skills
3]. Such an assertion is supported by the PPEQ responses in the present study where
students were likely to agree or strongly agree with the items at T1, with either an increase in the median value, or at least with
the value remaining high, at T2. Medium to large effect sizes were noted for PPEQ
items 1 to 12. The changes in items 1 to 12 from T1 to T2 may reflect ‘reasoned or
rationalized changes’ 35] in the students’ perceptions following participation in PPE activities.
The last four PPEQ items relate to the application of PPE in osteopathy education.
No significant difference between T1 and T2 was observed for these items (items 13
to 16). Students from both institutions potentially saw PPE as an integral part of
their osteopathy education before entering the course, similar to the medical students
reported by Chang and Power 12]. Previous studies have found that students’ negative perceptions of PPE may be related
to experiences with tutors and classmates. It is hypothesised that the tutors and
lecturers of students in the present study may have created a supportive learning
environment that contributed to the increase in median values for these items. Such
supportive environments incorporate appropriate feedback from lecturers/tutors and
peers. Chang and Power 12] found that receiving feedback from peers was a key positive feature of PPE. In the
present study, females were less likely to agree with item 15 In performing PPE I (will) get useful feedback from my colleagues about my skill at both T1 and T2, however, these OR’s were small.
Biological gender
Consistent with findings from other authors is the greater willingness to examine,
or be examined by, a peer of the same biological gender 33]. In the present study, there were no significant differences between the pre- and
post-test EFS responses. Work by Rees 32] suggested that female students ‘… may also be more likely than males to fear critical
and teasing comments…’ (p. 801) and this could account for the less positive perception
of feedback from peers in PPE activities. Although both teaching programs aim to incorporate
peer feedback as part of the classroom environment where PPE is employed, it may be
that further work is required to reinforce this, along with specific training for
lecturers and tutors on feedback skills.
Females were also more likely to feel uncomfortable with getting undressed for PPE
activities at T1 and T2 although this influence of biological gender was reduced at
T2. This result is consistent with the discussion by Rees 32] who used a feminist theory lens to highlight the potential for body image issues
to play a role in PPE. Of note is that females were still significantly more likely
to feel embarrassed if disrobed in their practical skills class at T2, even though
they had experienced 12 weeks of the learning environment and could arguably be more
comfortable participating in it. This result highlights the ongoing need to consider
body image wherever PPE is employed, including incorporating information about body
image in the curriculum before and during the use of PPE, as well as reinforcing the
need to demonstrate appropriate draping 6], 36]. Discussions about body image could form part of students’ introduction to PPE.
Age
Rees et al. 5] previously demonstrated that older students are less comfortable with PPE. In the
present study age was not associated with an unwillingness to examine, or be examined
by, a peer 12], 33], 34]. Results from the EFS for age were not significant in the binomial logistic regression
models for willingness to examine, or have examined, specific body regions. However,
with regard to the PPEQ items, the responses from students aged over 20 were in many
cases likely to differ from their peers aged 18–19 years. Most of the OR’s for the
PPEQ items were small to moderate, suggesting age is likely to influence a students’
perception of PPE, albeit minimally. Items 8, 9 and 10 were significant for age at
T2 but not at T1, and all of these items were those that evaluated whether the student
felt comfortable with PPE (Additional file 2). Older students were less likely to agree with these items at T2 suggesting their
perception may have become more negative after participating in PPE activities. The
only exception was item 11 I (will) feel comfortable when PPE is performed on me by a colleague of the opposite
sex than mine. Age was not significant for this item at T1 or T2 suggesting that age is unlikely
to influence perception of PPE if performed by a colleague of the opposite biological
gender.
The apparently conflicting results from our two questionnaires could be related to
sample size: only a small number of people reported feeling uncomfortable examining,
or having examined, most regions, most commonly the pelvis. Alternatively, the results
may simply reflect the different purposes of the two questionnaires: the EFS targets
students’ perceptions about PPE of specific body regions. The PPEQ on the other hand
draws out responses to the wider learning environment for PPE and students’ level
of comfort in it. This global willingness to engage in PPE is not elicited from the
EFS.
Religion
In the EFS, practising a religion was not significant in the binomial logistic regression
models for willingness to examine, or have examined, specific body regions. From the
PPEQ data, students who reported practising a religion were initially concerned about
being of ‘sexual interest’ to their peers and tutors, however this influence was not
present at T2. Those students practising a religion were also more likely to agree
with item 12 related to inappropriateness of performing PPE on future colleagues.
Again, this influence was not present at T2. These initial perceptions may be influenced
by their limited knowledge of PPE at T1. Further, the classes where PPE is employed
may be conducted in a professional, sensitive manner, and the students will have experienced
this by the time they completed the questionnaires at T2. PPE activities are also
taught by both male and female tutors at the two institutions in the present study,
and this may reduce the influence of tutor biological gender on student concerns about
PPE 32].
A previous study 5] suggested that practising a religion influenced willingness to examine the groin
or feet of a peer – this was not the case in the present study, according to EFS data.
The current data did not include details of particular religions practised by student(s)
and did not explore whether specific religious beliefs accounted for the results 27]. Further, it would be interesting to explore students’ understanding at T1 of what
each of the EFS body regions meant to them given that a small number of students indicated
this was a body region that they felt uncomfortable examining, having examined, or
both. For example, examination of the groin and anterior hip are closely related in
a musculoskeletal examination, and the use of the term ‘groin’ may have a particular
meaning for an individual, albeit the EFS explicitly states ‘no genital exposure’.
The femoral triangle, anterior hip, and chest (excluding breast tissue) are the only
potentially sensitive regions of the body that are examined by students in Australian
osteopathy programs.
Previous course involving PPE
Having previously undertaken a course that involved PPE influenced responses to item
3 I will feel embarrassed if I am undressed for PPE in front of my group of colleagues at T1, and item 5 I am concerned of being a possible object of sexual interest during PPE at T2. In both instances students were less likely to agree with these two items.
This suggests that students who have had previous exposure to PPE are less likely
to feel embarrassed, and highlights the importance of providing sufficient information
to students before they start their course so that they know exactly what to expect
in practical classes, a sentiment commonly called for in the PPE literature 6], 30], 32].
Born outside Australia
Being born in Australia influenced responses to a number of PPEQ items, albeit the
95 % confidence intervals for these OR’s were large. Item 3 I will feel embarrassed if I am undressed for PPE in front of my group of colleagues, item 5 I am concerned of being a possible object of sexual interest during PPE, and item 7 I am concerned of experiencing possible sexual interest for my teacher or tutor during
PPE were influenced by whether a student was born overseas at both T1 and T2. Those students
who were not born in Australia were more likely to agree with these items. It is not
possible to isolate these responses to particular countries from the data collected.
Therefore feeling embarrassed about being disrobed and possible perception of sexual
interest may relate to social influence (non-Anglo Saxon background) 27], 30].
Statistical considerations
The internal consistency of the PPEQ was evaluated using two approaches: Cronbach’s
alpha and McDonald’s omega 23]. Authors have argued that Cronbach’s alpha may not provide an accurate indication
of internal consistency, and McDonald’s omega may be a better option 24], 37], 38]. The PPEQ internal consistency was very good when using alpha, but borderline when
using omega. Given the questionnaire has only been used in one other study 3], further work to investigate the psychometric properties of the PPEQ is required.
McLachlan et al. 35] have asked authors investigating longitudinal changes in PPE perceptions to provide
support for the pre-post differences obtained. In the present study this is provided
by the reporting of effect sizes, something that the majority of PPE studies have
not done. Many of the effect sizes in the present study are interpreted as medium
19], suggesting that there is likely to be a change pre to post participation in PPE
activities but larger participant numbers are required to confirm the results.
Limitations
The limitations of this study include its limited longitudinal nature (only a 12 week
teaching period) and the fact that not all body regions had been examined by the students
before the conclusion of the study period. Further, the study was conducted in two
Australian teaching programs with a single cohort, therefore the generalisability
to other non-United States osteopathy programs, and other Australian osteopathy student
cohorts is limited. Matched data were only available for 105 students. It is possible
that some students were not able to complete the questionnaire at either T1 or T2
due to an absence, or had withdrawn from the teaching program prior to completing
the questionnaires at T2. The ratio of respondents was approximately 4.5:1 for VU
and SCU and this may have influenced some of the results, however it would be difficult
to control given the substantial differences in cohort sizes at the two institutions.
Only quantitative data were collected in the present study, and the addition of a
qualitative component may shed further light on some of the issues faced by osteopathy
students when entering a program of study that emphasises PPE. In particular, previous
studies have highlighted the issue of harming, or being harmed by a peer during PPE
5], 7], 33], something which is not captured in either questionnaire employed in the present
study. The application of manual therapy techniques carries a very small risk of an
adverse reaction 39], so fear of harm may be a valid concern. How the results of the present study relate
to the practice of OMT and other treatment techniques would require further investigation.
This is particularly relevant as students in osteopathic programs in Australia will
be required to practise manual techniques on some body areas that students in the
present study were either unwilling to examine, or have examined on themselves. This
is an avenue for further work in osteopathy and other manual therapy professions.
Direct comparisons with the Consorti et al. 3] study at item level are not possible as detailed data from the previous study were
not available. Such comparisons in future studies will enable a deeper understanding
of the quantitative data derived from the PPEQ. The results of the present study also
highlight a potential issue with the PPEQ in that it may be subject to a ceiling effect
and not necessarily sensitive enough to detect a change in student perceptions. This
may have been reinforced in the present study as the analysis was undertaken using
the ordinal data generated by the responses to the PPEQ, rather than making the assumption
that the underlying data were interval in nature, and subsequently using parametric
inferential statistics 18]. The use of these statistics may have yielded different results, however it may have
also provided a less accurate indication about pre-post differences. Another factor
that influences the interpretation of the PPEQ data is the large 95 % confidence intervals
for some of the demographic variables (Additional file 2). In some cases these were quite substantial and suggest that further work is required
to confirm if these demographic variables do in fact have a significant influence
on the PPEQ responses.
Only one student reported not speaking English at home in the present study. Therefore
it is not possible to describe its influence on perception of PPE. It is also possible
that other unmeasured factors influence a students’ perception of PPE. The learning
environment, interpersonal experiences with the class tutors and peers, learning approach,
personality, body image, and motivations for learning could all influence students’
perceptions of PPE. These require exploration in future research. Rees 32] also suggested that tutor biological gender is an avenue for further research and
will be considered in future studies.