Forensics: A Community Clinical Education Pilot Project
Hopkins-Rosseel, Diana
Background and Purpose. Physical therapists (PTs) have been providing services to inmates both inside and outside penal institutions for over 2 decades. The key issue in rehabilitation services in penal institutions is ensuring the practitioner has a sound understanding of the unique culture and environment of the patient population. This population is growing, and there is an increasing need for physical therapy services, yet PTs are either unaware of the opportunities or are concerned about the inherent risks of working with this population. In an effort to meet the growing societal need for physical rehabilitation of inmates while broadening the clinical experiences for PT students and enhancing their professional opportunities, a descriptive pilot project was undertaken to investigate the feasibility of student placements in Canadian federal correctional facilities. Case Description. The forensics pilot project was undertaken as one often community pilot projects developed by the Ontario Council for University Programs in the Rehabilitation Sciences to enhance clinical education for students in the rehabilitation disciplines. Four PT student volunteers were selected to undertake a 2:1 supervision model, 5-week clinical placement at one of two penitentiaries. The students underwent special training, had an extensive preplacement orientation, and attended weekly debriefing sessions. Outcome measures included preplacement and postplacement reflection questions, student journals, exit questionnaires (given to both students and clinical instructors [CIs]), weekly debriefing sessions, Queen’s University midterm and final student clinical performance instruments and site evaluation forms, and a midterm telephone interview. Outcomes. It was demonstrated that implementation of student forensic clinical placements is feasible and that the benefits of the learning experience far outweighed the risks and limitations of the placement. Students performed well clinically while demonstrating significant changes in professional attributes and generic behaviors. Discussion. The academic coordinator of clinical education (ACCE), both CIs, and all four students concurred that the placement of PT students in penal institutions is a “value added” experience for the students demanding more flexible, innovative treatment approaches and more sensitive interpersonal communication and interaction skills. Student prejudices and biases brought into the placement were replaced by more open-minded, thoughtful, and impartial qualities.
Recommendations include establishing forensic placements for intermediate and senior students, expanding the preplacement orientation, and developing advanced forensic placement handbooks.
Key Words: Collaborative clinical education, Correctional facilities, Forensics, Health care, Penal institution, Physical therapy clinical education.
BACKGROUND AND PURPOSE
PTs have been providing services to inmates both Inside and outside penal institutions for over 2 decades in contract positions.1 They have been recognized by Corrections Canada and Institutional physicians and nurses as a valuable health care resource (Judi Laprade, PhD, faculty of Health Sciences, School of Rehabilitation Therapy, Queen’s University; personal communication). In penal institutions, PTs and physicians work in concert to examine and manage inmate injuries and disabilities. In addition, it has been suggested that the availability of physical therapy services has allowed staff physicians to reduce the volume or dosage of pain medication administered to inmates (Cathy Closs, Chief of Health Services, Kingston Penitentiary, Kingston, Ontario, Canada; personal communication). The key issue in rehabilitation health care services In penal institutions is that the practitioner must have a sound understanding of the unique culture and environment of the patient population. In such settings, PTs are obligated to optimize treatment outcomes despite the potential immediate personal risk or environmental limitations. Unfortunately, the inherent difficulties and unique risks of these particular work sites have prompted many health care professionals and their training institutions to generally overlook the health care needs of the populace housed in penal institutions. In order for these biases to change, health care providers need an opportunity to study and understand correctional practices and penal culture.2 It is generally not recognized that penal institutions have policies and procedures specifically designed to minimize dangers for health care providers.
Within penal institutions there are many rules and regulations (both official and culturally specific to the institution) to know and follow in order to gain access to the inmates and to avoid personal danger. The values, beliefs, and norms of health care providers must he synthesized with those of law enforcement and correctional institutions in order to promote collaboration and service provision.2 Despite the need for and the existence of PTs in this venue, students have not traditionally received clinical training in penitentiaries.
The past decade has shown a dramatic increase in the number of inmates in correctional facilities and burgeoning demographic diversity among people incarcerated throughout North America.1 Before the upsurge in jail populations, incarcerated people were almost exclusively young and male.1,3 Longer mandatory sentences and restrictive release policies have meant a concurrent increase in the need for special care for older people.1 Another demographic change is the increased number of female inmates in prison who require gender-specific health care services.1 The Increase in prison populations and their growing demographic diversity have prompted a remodeling of correctional health services and the training of health care providers in order to adequately address the health care needs of inmates. A review of the literature demonstrates a lack of health care student training programs involving interaction with inmates.4 There appears to be a particular deficit in addressing the issue in the curriculum as well as in placement offerings for students at correctional facilities. This omission may be detrimental to both the physical therapy profession and the prison population.
In an effort to meet the growing societal need for physical rehabilitation of inmates while broadening the clinical experiences for PT students and enhancing their professional opportunities, a pilot project was undertaken to Investigate the feasibility of student placements in federal correctional facilities (Corrections Canada). The pilot project took place in Kingston, Ontario, Canada, with Queen’s University School of Rehabilitation Therapy students. This was an ideal location because the Kingston region houses five federal correctional institutions which are geographically accessible to the university and the project participants. The pilot was designed with the intention of providing students with the opportunity to develop and refine their clinical ability while concurrently acquiring the skills vital to competence in the forensic field. Objectives of the pilot project included the identification of particular challenges unique to this client base and the development of workable solutions.
The forensics pilot project was undertaken as one of ten community pilot projects developed by members of the Ontario Council for University Programs in the Rehabilitation Sciences (OCUPRS) as a component of a one-time $1.03 million Ontario Ministry of Health (MOH) grant awarded in 1995 (Figure). The purpose of the grant was to support projects leading to the improvement of clinical education for students in the rehabilitation disciplines of speech pathology, audiology, occupational therapy, and physical therapy. The projects were divided into five major categories: community pilot projects, models of supervision, underscored areas, clinical educational resources, and technological support. These five primary fields were further divided into 15 subdivisions. The project described in this article was part of the subdivision dubbed “New Frontiers” under the community pilot projects category (Figure). The specific objective of the community pilot projects component, of which the forensics pilot project was a part, was to develop clinical placement activities in community organizations.
CASE DESCRIPTION
Forensic clinical placements were arranged to take place at the multiple-security level Penitentiary for Women (PW) and (he medium-security level Collins Bay Penitentiary (CBP), both in Kingston. A project coordinator was hired to oversee placement logistics, including administration and project data collection. The project coordinator was a registered PT with 3 years of forensic physical therapy experience and was employed hy the PW at the time of the project. The project coordinator also served as the clinical instructor (CI) for the PW site, while a second CI supervised students at the CBP site. The Queen’s University School of Rchahilitative Therapy’s academic coordinator of clinical education (ACCE), a representative from Corrections Canada, the project coordinator, and the CBP CI collectively assessed the sites for the following characteristics: (1) suitability (eg, gender requirements, geographic location, and PT services for inmates), (2) administrative feasibility (eg, available supervision, management, cooperation, scheduling limitations), (3) costs, and (4) risk level.
Once appropriate sites for the placements were secured and project administration and support personnel were established, the availability of these unique placement opportunities was announced to students. Students were informed of the scope of the placement, and volunteers were recruited. From a PT student population of 76 (36 junior-level students and 40 intermediate students), 9 individuals expressed an interest in the pilot project. From this group, 3 intermediate students and a junior were chosen to participate based on specific selection criteria. Institutional restrictions required the placement of female students in the PW; similarly, there was an expressed preference for male students at CBP. Other selection criteria included the strength of the student’s academic performance background. The candidates accepted by the ACCE were required to possess a minimum B+ (75%+) academic standing. They also were expected to possess the following personal qualities: (1) a professional level of maturity, (2) intuitiveness, (3) good communication skills, (4) good listening skills, and (5) an excellent capacity for collaboration. These criteria reflected the following assumptions of the ACCF,: The student’s potential for increased anxiety due to anticipation of risk suggested a need for a high level of student maturity; the potential volatility of the client population required that the students avoid miscommunication or interpretation to minimize any potential risk; the logistical barriers of a penal institution would demand collaboration of all parties to ensure efficient and effective provision of care; and, in order to minimize confounding factors such as limited student capacity that could mask pilot outcomes, students of higher academic standing should be a priority.
After selection, the students received an orientation from the project coordinator covering topics ranging from the facility’s organizational chart to sign-in and emergency procedures. In accordance with correctional institution standard procedure, the students were subject to preplacement criminal record checks. They were also required to sign consent/waiver forms. In addition, students were given the opportunity to participate in a full tour of all the living facilities of the prisons, including medium, maximum, and segregation/protective custody areas, in order to acclimatize them to the inmates’ living environment. Visits to other correctional facilities, such as the Bath Institution (medium-security facility for men) and Kingston Penitentiary (maximum-security facility for men), were also offered to those interested in au alternative experience. The students at the PW went on medical rounds with the ward nurse to the segregation/protective custody regions, giving them the opportunity to discuss medical treatment of inmates with a professional from a different health care discipline. All policies regarding interaction with guards, health care staff, and inmates were reviewed carefully with the selected student candidates. Certain rules and regulations had to be followed by the students in the program. A handbook provided to the students explained many of the procedures that would be unique to the penal environment (Appendix 1).
Queen’s University PT student placements consist of six 5-week, full-time blocks. This configuration represented the first logistical challenge for the pilot project, as the penal institutions in this project employed PTs on a part-time basis, thereby restricting the students’ forensic placements to a part-time basis as well. The forensic placement took place over 2 half-days per week over a 5-week period. An additional half-day was used for conferencing between the project coordinator and the four students. Consequently, concurrent part-time nonforensic placements had to be arranged for the students. Although physical therapy in penal institutions covers a wide variety of interventions, traditionally the majority of treatment is orthopedic in nature. Thus, all four students’ nonpenal case-loads were arranged to be in the area of orthopedics. The four students were paired with a second CI at a nonpenal site, providing the students with Queen’s University’s mandatory standard total of 40 hours per week of clinical practice.
It was preferred that a minimum of four students participate in this pilot project. However, limited suitable penal sites were available at that time. As a solution to this problem (as well as to decrease any student anxiety due to working in the penal environment), the two-students-to-one-CI clinical education model was used. This model can increase productivity without additional cost, promote peer collaboration and professional socialization, and encourage student independence and self-directed learning.5-8 The PT students were paired in the 2:1 supervision model at one of the two sites in Kingston: female students in the PW (n=2, both intermediate) and male students at CBP (n=2, 1 junior/1 intermediate) for a total of 4 student participants. The CI provided an essential link between the students and their patients at all times. Initially, the CI, being more familiar with the social climate in the institution and more at ease with the inmates, provided a significant proportion of patient assessment and intervention while assisting both students and inmates with the socialization process. As students and their patients developed an appropriate rapport and level of trust, and when the CI judged that they were practicing safely, the students were given the opportunity to examine and manage patients with greater independence. However, at no time throughout the 5-week placement were any students alone with an inmate. Follow-up discussions were encouraged at all times with the student individually or between the two students and the therapist as a group. In this particular placement, the 2:1 model was initially believed to have an advantage over a 1:1 model in that it provided an inherent coping mechanism for the initial anxieties of students. In addition, it was to provide students with the opportunity to play multiple roles, including primary care practitioner, professional observer, and collaborator.5-8 The latter two roles required the development of debriefing, feedback, and collective clinical problem-solving skills, promoting and reinforcing valuable professional attributes.
EVALUATION
Ontario Institute of Studies In Education (OISE) consultants and the project coordinator performed the forcnsics pilot project evaluation concurrently with the other nine OCUPRS community pilol projects. Outcome measures included: prcplaccment reflection questions, postplacement reflection questions, student journals, exit questionnaires (given to both students and CIs), weekly Cl debriefing sessions, standard Queen’s University midterm and final student clinical performance instruments and site evaluation forms, and a midterm telephone interview with students. Table 1 outlines the process of evaluation used hy both the Cl and student throughout this placement.
Preplacement questions. The pieplaccment questionnaires given to both students and CIs to complete before entering their placement allowed cvaluators to assess what biases and preconceptions the participants possessed approaching their forensic placements. all of the questions were of an open-ended nature. These questions were:
* The reasons I think the forensic placement will be different from my other placements are:
* The reasons why I think being involved in the forensic placement pilot will be a good experience are:
* I have prepared myself for this placement by:
* The things I want to achieve during this placement are:
Postplacement questions. The postplacement reflection questions given to both students and CIs were designed to examine whether learning objectives were met, what opportunities or problems arose, whether or not the participants found their experience satisfying, and what suggestions the participants had. The postplacement reflection questionnaires consisted of six open-ended questions where students were generally asked what they learned, what was positive, what was negative, and how things could he improved. The postplacemcnt open-ended questions were:
* The forensic placement pilot has been a good placement experience because:
* The following things presented added challenges during the forensic placement pilot:
* I believe the collaborative model should be used for future students because:
* I believe the collaborative model should not be used for future students because:
* I would recommend the following changes to the forensic placement project if it is to be used again in the future:
* Other things 1 would like you to know about my experience during the forensic placement pilot arc:
Student journals. Students were directed by the OISE consultants to use their journals in two ways. First, they were directed to describe how well their practicum arrangements were working out, rather than to evaluate their own progress. This allowed the students an informal daily outlet to record their thoughts and feelings about the placement logistics. Second, students were instructed to make a detailed chronological list of their activities by the hour, to be recorded every second or third day. Comments in the student journals were read to search for trends over time. Similarities among the comments of the students were noted. There was no specific system for coding or pattern analysis used for this documentation.
Exit questionnaires. The exit questionnaire given to each student differed considerably from the other evaluations because it consisted of 55 primarily close-ended questions and five open-ended questions, with only a selection of standard responses available. A few examples of the fixed-response questions follow:
How satisfied were you with each of (lie following aspects of your placement?
A: The opportunities you had to leam or practice new skills and knowledge
B: The variety of client experience/caseload
C: Your working conditions
The answer choices for each of the above questions were: (a) very satisfied, (b) somewhat satisfied, (c) somewhat dissatisfied, and (d) very dissatisfied.
D: The amount of contact with your supervisor
E: The time you had to work in teams
The answer choices for each of the above questions were: (a) far too much, (b) somewhat too much, (c) about right, (d) somewhat too little, and (e) far too little.
A few examples of the open-ended questions follow:
A: Do you have any suggestions as to how the placement could have been improved?
B: The forensic pilot has been a good placement experience because…
C: Other things I would like you to know about my experience during the forensic pilot arc…
The responses to the exit questionnaires were analyzed using SPSS/PC+ 7.5* for IBM PC.9 For the forensic data (n=4), a simple, nonparametric cross-tabulation was performed to provide descriptive trends in the data.
Weekly CI debriefing sessions. The weekly meetings gave the student participants an opportunity to be proactive, defining the placement challenges, discussing common experiences and problems, and devising solutions. In addition, a single follow-up meeting with Joint Chiefs of Staff, Corrections Canada, was held to give participants the opportunity to voice concerns to corrections administration and to debrief Corrections Canada on the progress of the project and the results of the placements. Preliminary review of the input and feedback highlighted several issues unique to this genre of placement, including both benefits and challenges arising from forensics.
Midterm and dual student clinical performance Instruments and site evaluation forms. At midterm (2 ½ weeks) and at the end of the placement, standard Queen’s University student clinical performance and site evaluation tools were used to measure the students’ clinical competency, the CIs’ performance, and the site’s attributes. The Queen’s University student clinical performance evaluation, as completed by the CIs, is a normative tool and is not criterion referenced. The tool did undergo a pilot study to evaluate its performance (Diana Hopkins-Rosscel, Kurian Asha; unpublished research; 1998). It was demonstrated in the pilot study that the tool had construct and content validity and was reliable. The evaluation tool, as depicted in Appendix 2, has 56 parameters queried over the seven broad categories of assessment, treatment planning, treatment applications, caseload management, relationship between theory and practice, communication skills, and professional behavior. Using a 5-point scale for each question (in which 1 indicates excellence and 5 denotes a failing grade), each CI is responsible for completing midterm and final student evaluations. The form also provides space for CI comments, which are mandatory if the grade is either 4 or 5.
Conversely, site evaluations are used by the students to grade the CI and their clinic, using the same 5-polnt scale. These evaluations were repeated at the end of the placement as well. Of note are the implications of using a normative-referenced evaluation tool. Although a full discussion of normative-referenced versus criterion-referenced evaluation is beyond the scope of this article, comparing students with a theoretical or known peer group versus a delineated “gold standard” in a new environment limits the validity of the evaluation process for the initial group(s) of students. This form of evaluation does not indicate how competent a student’s clinical performance is in relation to the demands of the profession, because it is solely scored in relation to his or her peers.10 In this case, it was imperative to stipulate the goals and objectives of the placement and of expected clinical performance standards clearly at the outset. This was a relatively simple task in the context of orthopedic clinical skills but more difficult in terms of expected generic behaviors (eg, communication skills, professional behavior, interpersonal skills, problem solving, and integration of theory and practice).
Midterm telephone Interview. Structured midterm telephone interviews with Ae students procured information beyond that obtained in the questionnaires and evaluations and provided clarification on any issues or suggestions for changes in the forensic placement itself. These telephone interviews consisted of a few short open-ended questions about the general aspects of the placement and the progress of students.
OUTCOMES (H1)
It is important to note that the project was exploratory and descriptive in nature and was conducted with only four students. Therefore, it is impossible to draw any statistical significance from the data available. However, trends noticed in outcomes have been explained in the results.
Preplacement questions. In their prcplacement reflection questions, students admitted to being apprehensive and anxious, but each student was prepared to enter his or her placement with an open mind to learn. Students demonstrated an awareness of being part of a pilot project and how that expanded their role in the forensic placement from being just a learner to being an acute observer and cvaluator. One student wrote, “I will be dealing with a patient population that will be totally different than any other I have worked with. The environment mat I’ll be in will be one that most people wouldn’t get to experience.” Though students did acknowledge the uniqueness of the clinical setting, none of the students expressed how they would personally prepare themselves for the placement beyond reviewing clinical skills and practices.
Postplaccrneut questions. In the poslplacc- ment reflection questions, students unanimously indicated that the forensic placement was an enlightening experience that allowed them to practice their clinical skills and participate in a unique work environment. One student commented, “I learned a great deal of clinical and life skills.” The institutional rules regarding clinician-inmate interaction and discourse quickly taught students appropriate professional behavior, and a majority of the student participants felt the forensics experience helped develop their maturity as human beings as well, as shown by the following comments:
The life experiences of the inmates was so vastly different than my own, I learned as much from their approaches to their surroundings as I did from the physiotherapy aspects of care.
I learned to listen rather than judge.. .and that most things are not necessarily what they appear to be.
I am still shocked by my naivete!
Students indicated that the ongoing interaction with inmates allowed them to become better communicators and counselors because the institutional protocols gave them interaction guidelines and that the time they spent in the correctional facility gave them insight into the institutional culture of their clients. The creation of such a positive learning environment was largely due to the actions of the on-sitc CI and the informed support of the correctional service staff, as acknowledged by the students in their reflections.
[The Cl] took a lot of time to teach us new skills.
It was obvious from the “Forensic Placement Physiotherapy Student Handbook” and the open reception we received from the prison staff that [the CI] worked hard to prepare for us and to pave the way for our placement.
Students also reported that the group reflection process itself was favorable, commenting that it provided an excellent opportunity to express successes and frustrations and to develop solutions to challenges.
Student journals.In practice, the student journals functioned primarily as nonstructured outlets for students. Students reported in their journals that they were initially apprehensive about entering the penal institution and had some misgivings about their ability to treat inmates without preconceived notions and emotions regarding their criminal activities. Students reflected that, particularly at the start of the placement, the inleraclion and the socialization with the client population, institutional nurses, and guards was something that they had difficulty adjusting to. One student noted that she was “a little ‘shaken up’ by the whole security process.” Unique attendance policies used by the institution also caused friction because they regulated inmate appearance in the clinic, frustrating students, who felt that their clinical learning opportunities were being limited. Students observed that inmates tended to cancel without prior notice or they had conflicting appointments that prevented consistent attendance, most commonly due to unexplained security issues. The students commented:
…missed appointments would be so much less frustrating if they were cancellations rather than “no-shows” and if the staff didn ‘t always use the “veil of confidentiality” of “it is a matter of security” as the reason for the patient’s absence. Also, conliln they tell us when the lockdown happens and not wait for us to call and see why the patient is absent?
I did wish that physio [physical therapy] treatments took priority over other, non-health-related appointments.
Any misgivings articulated by students generally revolved around issues of time and space. Students raised concerns in their journals regarding the many restrictive security issues that they initially felt depreciated the value of their placement, including inmate procurement of clinic passes, the limited and controlled issuance of rehabilitation aids, and the disclosure of medical information to the inmate. Students reported that their current caseload was limited by: (1) restricted contact hours allotted with the patient, (2) physical space and equipment availability in the clinic, and (?) the regulated schedule of the prison. For example, 11 am is the time for “head count,” when all inmates must return to their respective cells. Two students expressed concern in their journals about the quality of treatment they could provide under the time constraints that were placed on them, for security reasons, when treating inmates. They commented that “it is hard to practice the skills when there are only a few hours of clinical time a week.” The physical therapy clinic was also a matter of concern for students at both placement sites because they were both large, singleroom facilities, necessitating treatment of a single inmate by the CI and the two students concurrently. “Hands-on” clinical experience was documented by students to be restricted, as only one patient could be treated at a time in such a confined clinical environment.
As students progressed in their forensic placements, their journal entries began Io adopt a more positive tone. Students indicated that once the orientation was over mid they became accustomed to the policies and the procedures of their respective penal institutions, it became easier for them to focus on the details of clinical practice. As one student commented:
I spent so much time ivorrying about or fig- uring out how to go about simple tasks like making an appointment or get t ing into the health clinic area that I almost forgot I was there to learn Io do physio [physical therapy]. Now that stuff doesn’t bother me much anymore. I can concentrate on clinical skills.
Students often indicated surprise in their journals at finding their initial prejudices and expectations of the prison environment and inmates to be inaccurate, as indicated by the following statement:
Before coming, I think we though/we were being brave to volunteer for the placement and were curious about the “bad guys, ” almost a morbid curiosity. I am embarrassed by that now. I am thinking about being a volunteer with the John Howard Society [a national inmate advocacy association].
By the end of their placements, all four students demonstrated an appreciation for the experience and felt that, despite the clinical limitations, they were better professionals and better human beings for having practiced in a forensic setting. The apprehension of earlier journal entries gave way to more contemplative and appreciative comments in later entries. One student’s journal concluded by stating:
These inmates are, first and foremost, human beings, and they should be treated as such. I [am not In the position] to judge them or carry out their punishment. I went in to practice what I have been trained, and continue to train, to do.
Exit questionnaires. The exit questionnaires contained 25 close-ended questions designed to gauge student satisfaction with what they were able to leam from their placements, with three additional spaces open for learning outcomes achieved that were unique to a particular student (Table 2). Of the 2$ closed-ended questions, only 13 questions were deemed to be applicable by all 4 students in this pilot project. Of the 13 questions unanimously deemed applicable, the students responded with satisfaction on all learning aspects except three: learning diagnostic skills, learning how to develop a plan of intervention, and learning self-management skills. In the three areas of difference, it was the same student who differed from the other students, a trend that was consistent throughout the exit questionnaires and postplacement evaluation.
In all of the postplacement assessments, students emphasized a desire for more ch’ent contact, greater autonomy, and generally longer placements. The five exit questions regarding the frequency of peer and CI interaction revealed a significant lack of one-on-one time (Tables 2 and 3). all of the students indicated that one-on-one time with their CI was rare and that similar infrequent one-on-one interaction existed in relation to their placement peer. The exit questionnaires illustrated that most interaction was done within the group setting, which became the dominant mode of interaction due to confined physical space of the clinics. This type of environment also left no room for students to be on their own. However, when responding to exit questions related to time, all the students generally indicated that the time spent with their peers, with their supervisors, or on their own was about right. Consequently, in response to questions that asked for suggestions on how to improve the placement, all of the students indicated a need for more space, not necessarily more Cl or peer contact time. Students indicated that the physical environment in the clinic itself was too crowded, with the Cl and two students being assigned to a single room. In response, one student suggested that a 1:1 supervision model would be better for this type of placement, thereby freeing up physical space and creating a more focused supervisor-student interaction within the same time frame.
Weekly CI debriefing sessions. Students reported that the group reflection process Itself was favorable, commenting that it provided an excellent opportunity to express successes and frustrations and to develop solutions to challenges collaboratively. Students also suggested in their journal entries that the process of acclimatization was aided significantly by the team meetings they participated in with the CI and the other on-site student. As one student commented, “[Team meeting] times are essential to the placement because it helps us to figure out the environment and provides a forum to work off some stress.”
Midterm and final student clinical performance instrument and site evaluation forms. The Queen’s University midterm and final student clinical performance and site evaluations demonstrated that forensic placements can be equal to any conventional placement site, as no indication was given by either CIs or students as to any site-specific hindrance to clinical practice. All students involved in the pilot project passed their placement evaluations and gave their CIs favorable site evaluations. One senior student was critical of the overall placement, but did not find the experience value-less. The one difficulty that was indicated as serious was regarding the basic clinical competence of the junior student. The junior student did not have any previous clinical orthopedic experience and thus felt limited by the placement, as noted by both the junior student and Cl in their evaluations (Appendix 2).
Midterm telephone interview. The chal lenges and recommendations students made in regard to their forensic placements, which were articulated in the postphicement reflection questionnaires, were also expressed in the midterm telephone interviews. Though there was a great deal of positive feedback regarding the general aspects of the forensics pilot project, the students put forward challenges they felt should he addressed. In particular, the students indicated a desire for key logistical changes to be enacted in order to increase the total placement value: decreasing the time to enter the facility, decreasing the numbers of cancellations due to sanctioning of inmates, making changes in the geographical space and equipment, and not dividing their time between two placement sites and types. Much of the criticism of the placement came as a result of the limited “hands-on” clinical care time with this particular patient population.
Three of the four students expressed overall satisfaction with the forensic placements and considered the placements to be a suitable alternative to conventional placements. The remaining student was dissatisfied with the placement’s overall suitability. The same three students were asked seven close-ended questions regarding the placement’s suitability; in all but three instances, their responses were positive. The exit questionnaires reflected unanimous approval of the suitability of the placements to provide opportunities to learn new skills, access to resources (additional placements and CIs), and satisfactory working conditions.
When asked for suggestions in the exit questionnaires, the students recommended that It might be more effective to run the forensic placements as year-round, “intramural” or part-time placements. This change would allow for greater institutional socialization, increased clinical practice, and a more diverse caseload. It would also address another student concern, because the students would not be switching between placements continuously. Students did not react favorably to dividing their time between the forensic placement and a conventional placement because it did not allow for in-depth treatment at cither placement, congruency in the type of cases examined, or continuity in patient care and learning.
All four students also indicated a high degree of satisfaction with the preplacement orientation that they received. In their exit questionnaire responses, students unanimously praised the usefulness of their orientation in presenting clearly the policies, procedures, and basic expectations. Students also had positive responses toward the variety of their clients, the people involved at the institution, and the opportunity to work within such a unique environment.
DISCUSSION
The purpose of the pilot project was to describe and evaluate the implementation of this unique type of placement. It was acknowledged at the outset that despite the small sample size, the insights derived from the project could be valuable to the future development of clinical education, student learning opportunities, and the provision of PT services in correctional facilities. The physical therapy forensic placements represented a considerable challenge, as with most pilot projects, due to the absence of a reference model. From the beginning, it was recognized that the small, nonrandom sample of student volunteers would limit the strength and generalizabilily of the results of the pilot project. There were also the challenges and difficulties that arose during the unique pilot project that, despite extensive planning, consultations, and preplacement site assessments, still came as a surprise. Adjustments were made immediately or noted for the future. However, all the stakeholders agreed that the overall experience was valuable and worth pursuing further because the benefits far outweighed the limitations caused by the challenges and difficulties of the work environment.
The use of a small, nonrandom sample of student subjects and the absence of a control group represented the primary confounding factors to the analysis of the project data. In addition, although OISE analyzed the forensics exit questionnaire data using SPSS, the data were combined with all the community projects and therefore made the results inapplicable to either the unique population or environment of the forensic placement. However, these data were not lost; the data were analyzed by hand by the project evaluators and combined with the wide variety of other evaluation tools used to highlight obvious trends and project outcomes, ‘flic use of a variety of different evaluation tools and formats in the face of such a small sample size proved to be one of the successes of this pilot project, evaluators were in contact widi, and had responses from, all of the different stakeholders before, during, and after the project, and in a variety of forms. This allowed project evaluators to make accurate assessments and address any concerns or challenges mat arose Imm tile forensic pilot project.
Evaluation tools such as the student journals revealed that students were concerned about the spatial and temporal limitations caused by the unique nature of the institution and its part-time physical therapy clinic. Student frustrations about the limited amount of hands-on clinical time they were being given were coupled with expressed desire for more challenging caseloads and greater autonomy. Generally, a majority of the challenges arose from the limitations imposed by the unique environment (for example, restrictions due to personal safety concerns, the nonavailability of equipment for inmate use, and security “shutdowns” because of inmate unrest, which can be isolated to a portion of the prison or involve the entire facility). However, it has been the experience of the Queen’s University School of Rehabilitation Physical Therapy Program that these student concerns tend to be the same for conventional placements. Students have consistently experienced a desire for more challenging caseloads, greater autonomy, and more hands-on time. These sentiments were also consistent with a majority of students in the OISE statist!cal analysis of all the community placements. Yet, in comparison with conventional placements, the forensic placements did have limits that decreased the hands-on practice, so initiatives were taken by the CIs and the project coordinator to compensate for any real or perceived losses of clinical practice. The CIs granted students their own patients, conscientiously shared treatment or evaluation with the students, and assigned projects each week to balance out the decreased client contact. In addition, students had a clinic or hospital placement that they attended for half of their placement time in the orthopedics discipline.
Ultimately, the forensic activities that the students participated in allowed them to develop innovative, intuitive, and flexible assessment and treatment skills. By the end of their placement, the students uniformly regarded their patients with a more understanding attitude, as noted by the cvaluators and the students themselves. In one example, a student at the beginning of the project expressed selfdoubt about being able tu handle the treatment of inmates who had committed “heinous crimes.” This same student, a senior student, had also responded negatively toward the forensic placement in journal entries, preplacement questionnaire, and exit questionnaire, in stark contrast to the other students. The student commented, “1 constantly fight the feeling that these people don’t deserve our services.” Yet despite this, the student made a determined attempt to keep an open mind while treating patients. By the end of the placement, the student admitted that this experience had clearly helped him/her to develop a more flexible professional attitude and avoid personal judgments in treating patients. This student stated:
It was a turning point for me when an inmate I worked and socialized with in the [armedforces] was here. As far as I can tell, it was circumstances rather than moral character that put [the inmate] here. I started to be less closed-minded that day.
The student learned a valuable lesson, one that emphasizes the value of the forensic placement as ail opportunity to groom socially conscious and caring PT practitioners.
Interaction between the CI and each student, as well as between the two students, was an integral part of the success of the 2:1 model, deemed essential by the ACCE and the CIs in the initial stages in this type of setting. By emphasizing cooperation instead of competition, the students in this 2:1 model would equally benefit from the experiences, insights, and knowledge of each other in the peer support group system,5 thereby alleviating the anxiety of operating in such an environment. However, us the placements progressed, and as students became comfortable with their presence in the penal institutions, the 2:1 model became restrictive because the students no longer needed the support it provided. In order to prepare the students for this new setting and address any apprehensions, without the supportive structure of the 2:1 model, care must he taken to provide as much detailed orientation and information as possible prior to the actual contact with inmates. A background survey of the correctional institution-its practices, personnel, procedures, and history-therefore, should be integrated with materials and teaching of clinical practices for that setting. Students must be made aware that they are supposed to be developing their clinical skills concurrently with their ability to understand, accept, and adapt to the cultural and physical environments of (he correctional institution. The institutional health care staff was crucial in creating positive learning environments in which individual and group feedback was encouraged, along with the clinical guidance. This allowed the four students to develop the appropriate communication skills and techniques of professional rapport with inmates. The four students involved in the pilot project and the two CIs were committed to weekly group meetings that provided a support network and a forum to exchange their ideas, feelings, experiences, and opinions. This was an important support mechanism, capable of making a 1:1 model viable if expanded, because it provided students with the opportunity to reevaluate and direct their own learning.
CONCLUSIONS
The placement of undergraduate PT students in penal institutions presents the university, the student, the institution, and the CI with significant, new challenges. However, it is a viable option for clinical education and provides the PT student with valuable insights and competencies that are unique to this placement environment. The results of the multiple evaluation tools demonstrated concurrence among the CIs, the ACCEs, and the students on the value of forensic clinical placements. These participants agreed that neither the personal risks nor the limited clinical time outweighed the overall benefits of the placement. The CIs, the ACCEs, and the students agreed that this was a beneScial exercise, a truly value-added experience for the students. The placement effectively demonstrated the depth and breadth of clinical practice opportunities and helped develop more sensitive interpersonal communication skills as well as decrease the persona] biases of the students. Students developed more flexible, innovative treatments and learned to work within a unique environment. However, in order to increase the value of forensic; ax a learning experience, two things must occur. First, the development and expansion of this placement should be pursued. second, with the expansion of the model, more research needs to be done to verify the results of this project. Site-imposed confounding factors such as security and part-time therapy, could, and did, affect the forensic placements, despite the support network and orientation efforts. However, these environmental difficulties and those as experienced by the junior student were minor and could be resolved at the time or in the future in most instances.
further forensic placements should be pursued in order to give students the opportunity to develop their skills in such unique clinical settings. Concurrently, physical therapy schools must conductmore evaluation and analysis of forensic placements in order to verify the value of such placements to students and the profession.
In the establishment of forensics placements, where site and caseload or content dictates, a 1:1 supervisory model should be implemented along with the continued or expanded use of group meetings. The preplacement orientation should be expanded to include a greater frequency of preplacement visits and a more in-depth review of the penal culture and institutional procedures. It is also strongly recommended mat a forensic placement student handbook be developed and presented to students as a comprehensive reference manual, covering all aspects of this genre of placement as produced by mis pilot project, and adaptable enough for use in future forensic placements. Finally, all students involved in forensic placements should be intermediate-level students or higher and have previous orthopedic experience.
*SPSS Inc, 233 S Wacker Dr, Chicago, IL 60606.
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10. Yu B. Clinical Competence and the Tools Used to Assess It in Undergraduate Physiotherapy Students. A project submitted to the School of Rehabilitation Therapy, Queen’s University, Kingston, Ontario, Canada, in partial fulfillment of the requirements for the degree of Bachelor of Science in Physiotherapy. 1996.
Diana Hopkins-Kosseel, BSc(PT), DEC, MSc(Rehab)
Ravinder Panwar, BA(Hons)
Judi Laprade, PhD
Diana Hopkins-Rosseel is associate professor, School of Rehabilitation Therapy, Faculty of Health Sciences, Queen’s University, Louise D Acton Bldg, 31 George St, Kingston, Ontario, Canada K7L 3N6 (hopkinsd@post.queensu.ca). She was an academic coordinator of clinical education (ACCE) in the School of Rehabilitation Therapy for 8 years. Address all correspondence to Diana Hopkins-Rosseel.
Ravinder fanwar was an ACCE research associate working with Diana Hopkins-Rosseel in the School of Rehabilitation Therapy at Queen’s University. he is currently a public school teacher with the Peel District School Board in Mississauga, Ontario, Canada
(rav_panwar@hotmail.com).
Judi Laprade is assistant professor, Hong Kong Polytechnic University, Hung Horn, Kowloon, Hong Kong (rslaprad@polyu.edu.bk). Laprade worked as a physical therapist for 8 years in a variety of settings, including a correctional institution, private practice, and specialized clinics for women’s health. She held academic appointments at Queen ‘s University and the University of Toronto prior to joining Hong Kong Polytechnic in 2001.
This project was supported by a grant from the Ontario Council of University Programs in Rehabilitation Sciences, Toronto, Ontario, Canada.
Received June 11, 2001, and accepted May 30, 2003.
Copyright Journal of Physical Therapy Education Spring 2004
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