Teaching Physiotherapy during the Initial Stages of the COVID-19 Pandemic: What Did We Learn?

Abstract

The onset of the COVID-19 pandemic in March 2020 resulted in a rapid shift to online learning for physiotherapy education in Australia and around the world. This Sydney-based qualitative study explored the reflections of physiotherapy educators and leaders involved in delivering physiotherapy programs with the aim of gaining insight into what happened to physiotherapy education during the initial stages of the pandemic and what lessons were learnt that will inform future physiotherapy education. Many pedagogical challenges were identified including the need to rapidly shift content online whilst still meeting competency requirements, how to effectively engage students, and the challenges of teaching and assessing practical psychomotor skills. The benefits of the rapid shift were the upskilling of educators, innovations in teaching and resources, and recognising that some aspects of physiotherapy education were improved by the change. Overall educators and leaders felt time was needed to effectively design physiotherapy content to fit different delivery modes and it was important some aspects of physiotherapy education should continue to be taught in-person. Future physiotherapy education is likely to be a combination of in-person and online delivery and lessons learnt from this time need to be incorporated into physiotherapy programs to achieve the best educational outcomes.

1. Introduction

The onset of the COVID-19 pandemic in early 2020 affected more than 80% of the world’s student population in over 150 countries [1] and necessitated a rapid switch from in-person to online learning for most universities [2,3]. For Sydney-based tertiary physiotherapy schools, this switch to online learning occurred almost overnight at the end of March 2020 as Australia went into the first period of lockdown. World Health Organisation (WHO) recommendations and public health orders meant all Australian university teaching was delivered in an online-only mode for the remainder of semester one (through to June 2020) and either in an online only or hybrid mode for semester two (July to December 2020). In 2021, both these modes were utilised again in response to the ongoing restrictions of the pandemic which became more severe from June 2021 with another period of lockdown in Sydney.

Physiotherapy is a practical “hands-on” profession and physiotherapy education utilises a performance-based learning approach where the emphasis is placed on role modelling, communication, and the development of practical skills [4]. Historically, physiotherapy education has involved large contact hours with the majority of tutorials being delivered in-person to allow students to gain instruction, practice, receive feedback, and gain competency in the many psychomotor skills [5] required to be a physiotherapist, and to meet the national governing body standards [6]. The pedagogy behind traditional physiotherapy programs is based on solid education theory and frameworks [7] backed by years of research and refinement. In pre-pandemic times, this had included the increased use of digital and online technologies through blended learning to augment physiotherapy education [8]. Blended learning incorporates some content being delivered in-person and some content delivered remotely, either synchronously or asynchronously [8]. Learning management systems (LMS) were utilised to store and access content to enhance student learning and were seen as an adjunct to physiotherapy education rather than replacing in-person learning [4].

The switch to an online-only format that occurred in early 2020 was unprecedented in physiotherapy education [4,9,10]. The new online-only format meant classes had to be taught live online (synchronously) via online platforms such as Zoom and Microsoft Teams [11], or through recordings designed for online learning (asynchronously). Courses developed for online education usually take considerable time to develop. Much of this time is spent incorporating the best pedagogy into syllabus design, devising ways to engage students, and developing high quality audio-visual materials and assessments [8]. In response to the sudden lockdown, academics had to rapidly adapt their lesson plans to fit the new online delivery format with the greatest challenge being how to teach and assess psychomotor skills remotely [12] whilst still maintaining student competency [10]. The initial rapid change was seen as an emergency response made under extreme circumstances [13,14] rather than something that was well planned. It was a ‘reactive’ response rather than a ‘proactive’ development. Irrespective of whether they had a formal education qualification [12], the educators and leaders of physiotherapy programs lacked the skills, resources, or knowledge to design and deliver pedagogically sound online education experiences in such a short timeframe [5].

By mid-2020, there were a number of publications in health education offering tips and tricks to get by for educators [15]; however, research into the effects of the pandemic on physiotherapy education was largely focussed on the student experience [4,8,9,10]. During the latter part of 2020, one study investigated the lessons learnt delivering manual therapy education in physiotherapy from the educators’ perspective [16], describing innovative ways manual therapy skills had been taught and evaluated online, such as online instruction and video review and feedback of performance. The authors felt that COVID-19 had provided an opportunity to review the modes of manual therapy education and while these novel methods had some benefits they did not substitute completely for in-person instruction [16]. Another study explored more broadly the perceptions of physiotherapy educators who had transitioned to online learning [17], noting the challenges and opportunities that arose during the pandemic and highlighting the uniqueness of the physiotherapy curricula with so many psychomotor skills. Our study adds further weight to these findings by investigating the perspective of both the leaders of physiotherapy programs as well as the educators delivering them.

Physiotherapy education faced challenges combining theoretical and practical learning practices through the delivery of an entirely online curriculum during repeated periods of lockdown. It is still not known how online learning has changed the approaches to teaching and pedagogies in physiotherapy education, and in particular understanding what worked well during that period. Given that there may be a need for future online delivery of education and it is unlikely physiotherapy education in Australia will ever go back to the way it was, it is an important time to reflect on the experiences of physiotherapy educators and leaders and the educational implications of this transition. By acknowledging their experiences during the early stages of the pandemic, information from this study will improve the planning of physiotherapy education and learning experience for physiotherapy students in the future. Therefore, the aim of this study was to gain insight into what happened to physiotherapy education during the initial stages of the pandemic and what lessons were learnt to inform future physiotherapy education.

2. Materials and Methods

2.1. Design

A phenomenological qualitative study utilising focus groups was conducted in July 2021. Physiotherapy educators and leaders at the five universities running physiotherapy programs in metropolitan Sydney were invited to participate via an email from the researchers to the heads of department at each institution. Participants were included if they were either: a physiotherapy educator (permanent or casual) of any level of experience who taught at least four hours of online content during pandemic restrictions in 2020, or a program leader who was responsible for the running of a physiotherapy program or managing clinical placements, for one of the Sydney physiotherapy programs in 2020. All participants provided informed consent to participate in the study. This study was approved by the University of Sydney Human Research Ethics Committee (protocol number 2021/173).

Prior to being allocated to a focus group, consenting participants completed a brief online questionnaire via REDCap [18] which detailed basic demographics (gender, age), type and level of employment, years of teaching experience, previous online teaching experience, and hours taught online during 2020. Answers from this questionnaire were used to allocate participants to the educator or leader focus groups.

The semi-structured interview guide (Figure 1) used in the focus groups probed the participants’ experiences of the rapid change to online learning in 2020. The questions covered both the challenges and negative aspects, as well as the benefits and positive aspects of the rapid transition. Four focus groups (one with leaders and three with educators) were held online via Zoom videoconferencing (Zoom Video Communications Inc., San Jose, CA, USA). All focus groups were moderated by the same researcher (SD), who has a background in physiotherapy education but was not involved in teaching into or leading a physiotherapy program in 2020. A second researcher (JB) assisted with focus groups and took field notes. An iterative approach was used across focus groups, such that questions were initially broad, and as the groups progressed questions became more focussed to allow participants to elaborate on their experiences and lessons learnt. The sessions were audio recorded and the ‘Otter’ App [19] was used for initial transcription; transcripts were then deidentified and the initial transcription checked against the recording and field notes. From the transcription, a summary of the key findings from the focus groups was circulated to the participants for member checking.

2.2. Data Analysis

Descriptive statistics of participant characteristics were collected via the online questionnaire. Focus group data were analysed using the principles of thematic analysis [20]. The first two transcripts were read and coded line by line by two researchers (JB, SD) to identify key concepts and codes. The coding tree was revised following discussion with the wider research team, which comprised experienced academics who have expertise in adult learning approaches or have taught into the physiotherapy course for more than five years. The revised coding tree was then used to code the remaining focus groups with brief discussion after the coding of each new focus group. Codes were compared and categories formed by grouping codes that expressed related concepts across the focus groups. The categories were then examined for common clusters of similar issues and organised into sub-themes. Sub-themes were explored in relation to the categories and brought together to identify higher order themes that represented the data’s main ideas [20]. Discussions with the wider research team at each stage of the analysis resulted in revisions of the themes and sub-themes and resolved any issues emerging from the data. A summary of the final analysis was provided to the participants for member checking and to provide further comment.

3. Results

3.1. Characteristics of Participants

Twenty-one physiotherapists from three institutions participated in this study. There were seventeen educators and four physiotherapy leaders, with a range of teaching experience (<1 to >15 years) and type of employment (casual n = 2, fixed term n = 4, and continuing n = 15). Sixty-seven percent of participants (n = 14) had 5 years or more teaching experience with only one participant (4.8%) having taught less than one year. The majority (81% 17/21) of the participants were female. The mean number of hours taught online during 2020 was 59.5 (SD 38.4) and 67% (14/21) of participants had neither taught synchronous online classes nor delivered any asynchronous online content prior to the pandemic.

3.2. Focus Groups

Two main themes emerged from the focus group data concerning the pedagogical aspects of participants’ experiences teaching into or managing physiotherapy programs: issues related to the balance of maintaining the standards of practice and academic progression and issues relating to navigating online teaching under resource constraints. Each of these had their own subthemes. Figure 2 summarises the themes, subthemes, categories, and how all of these contributed to the overall lessons learnt.

Theme 1: Balance of maintaining standards of physiotherapy practices and academic progression.

• Maintaining public safety and academic governance.

To ensure timely academic progression students were initially required to learn entirely online, with some aspects of their courses delayed or deferred. Each institution differed in what aspects were delayed or deferred; however, all educators and leaders of programs felt strongly that professional standards could not be compromised and found this difficult in the absence of an in-person approach. Most felt that they had done their best to maintain these standards.

“That challenge of trying to make sure you’re meeting the professional standards of graduates from the University of having had the adequate hands on manual type skills” (FG1).

There was also acknowledgement of the challenges involved in successfully assessing students in the online format. Learning objectives for each subject are mapped to the standards of practice; therefore, the assessments set the standard of competency in that subject. Most theoretical content was examined online but most practical skills assessments were either deferred or modified, and academics found it difficult to determine which aspects of practical exams needed to be deferred. As one participant recounted:

“one of our big decisions was about the prac[tical] exam, and as a team we ended up deciding that we weren’t happy for the students to get through our unit until we’ve actually seen them with their practical skills” (FG3).

Some participants welcomed the opportunity to be creative with other types of assessments and in some cases the new assessment was an improvement on the previous version; “so we changed assessment and made it a video assignment, and it’s so much better” (FG3).

Participants talked about the problem of flow-on effects and consequences for students with decisions that involved postponing or deferring practical exams. Such decisions were not taken lightly as participants had to balance the need to progress students during online learning while maintaining the standards of professional practice. This was particularly true for those programs that included international students.

“I definitely lost a lot of sleep over that decision, I was very stressed about it, and it has had a lot of unintended consequences now…we’re still trying to work out ways that we can get them to finish and be through the unit” (FG3).

• Rapid transition of learning materials.

Participants in all focus groups discussed how the teaching materials and pedagogy of the programs needed to be changed rapidly and the impact of those rapid changes on some of the core elements of physiotherapy programs including practical skills, clinical reasoning, and communication.

There was a very sudden and unexpected need to shift in-person teaching material to an online platform with a background of “pressure from the university for us to rapidly prepare these materials so that they are suitable online” (FG2). Some academics were only given one weekend to move content online, with one reporting “I think we were changing content, up to an hour before the first class started” (FG2). There was acknowledgement that a lot of work was involved in getting everything online in such a short timeframe and deciding what to prioritise and what to delay. However, because the changes were required to be made within very tight deadlines it meant that there was neither the time nor the resources to effectively plan how lessons could be adapted to ensure learning materials supported the attainment of learning outcomes. Many participants agreed “it all just happened too quickly there wasn’t time to plan it well” (FG2).

Some participants felt there may be longer term implications from successfully getting material online so quickly and teaching in that format at the start of the pandemic. There was a sense that “the willingness staff had in terms of trying to adapt their material and their units of study for the pandemic has now come back and backfired on them” (FG4) because there is pressure to continue to teach in this online format even though staff may feel it is not pedagogically the best way to present aspects of the course. It was felt that there was an assumption by some institutions that “this is the way you will continue because you did it last year, under duress and extreme circumstance, but because you’ve done it once, then we expect that you’ll be doing it on an ongoing basis” (FG4).

Physiotherapy degrees comprise a high proportion of practical skills and the rapid transition to online learning affected both the timing and delivery of these. Practical skills delivery is reported under the delivery theme. The timing of skills meant they were either not taught in that year, reduced in number, delayed, or taught in concentrated bursts during or at the end of semesters when in-person teaching was permitted with each scenario bringing their own challenges. Some educators felt the biggest challenge was not being able to do any in-person practical skills, especially with first year students or the students who were just starting practical skill-based subjects. Other educators reported it was harder when students were brought in for intensive periods of skills practice. For example, “all of the practical skills sessions are crammed into a single session and trying to teach practical hands on skills in this single session was so stressful both to me and to the students” (FG2). One of the positives of missing in-person practical skills, however, was that more time than normal was dedicated to clinical reasoning activities and some educators felt that “the students had better clinical reasoning skills coming out of our unit than what our normal students would” (FG2). Finally, a number of educators made reference to the importance of good communication skills in physiotherapy, pointing out it was difficult to teach effectively online and it is “not the same communication skill you do online versus the face-to-face” (FG2).

• Challenging experience for students.

Many participants expressed concern about student engagement with online learning and the impact it would have on different year groups and types of students. As the students themselves were not interviewed for this study, the concerns expressed are the views of the academics and their perceptions of the potential impacts on students.

Engagement was seen as a major challenge for educators on a number of fronts. Importantly, educators found it difficult to gauge the level of student engagement in the online environment. Educators also did not feel as if they knew their students as well online compared face-to-face teaching. “I thought god I don’t know these students at all, I don’t know if they’re understanding the content, I don’t know if they’ve looked at the content much” (FG3). It was particularly difficult to keep track of students online and identify those who may not understand or had fallen behind with the content. One participant referred to the ‘silent lurkers’ who might be identified during in-person teaching but could easily hide in the online space. The lack of visual feedback and body language contributed to this and meant “you just don’t have the same number of clues to pick up” (FG1). This was felt to be a problem in online classes generally but was particularly evident in classes where students had their videos turned off and could not be seen.

Interestingly, some educators also described how they were less engaged with their own content because they were not seeing the students in person. “I felt disengaged because I wasn’t seeing the students as regularly, so, there may have just been a perception that they weren’t as engaged” (FG2). Some educators discussed the need to work harder to make their material more engaging as they were receiving less feedback from the students, which limited their ability to adapt their style of delivery. There was a sense that in the online format “we had to be more engaging in the way we present our material, so that they’re interesting to listen to” (FG2). Finally, as students came back for some practical classes later in the year the positive was that some academics felt that engagement was higher than usual. “I think they’ve actually been more engaged in pracs for us because they were just happy to be… doing stuff, rather than being online” (FG3).

There was an overall perception that some year groups and student types were more negatively impacted by online learning than others. Students in their first year of study might have found it harder to meet and connect with their year group online and this may have affected their ability to adapt to the change in the online format. Educators noticed “there wasn’t as much collegiality…they just didn’t know each other as well so that then impacts the belonging to the course [and] also impacts their ability to study” (FG2). On the flip side, one educator felt the impact was greater on those students in second and third years who were more aware of what they were missing out on. “The first years…knew no different, whereas the second years and third years have struggled a bit more I think because they knew what they were missing out on” (FG2). In terms of student type, they felt that the higher achieving students were better able to cope with the disruption and change in format, although online examinations in some subjects might have helped some lower performing students to advance through. “I think that the online exams did help the bottom end of students who probably wouldn’t have gotten through normally to just bolster their marks and shuttle through” (FG3). Similarly, it was felt that students who were shy or could not have their cameras turned on may have found the online format difficult and this may have affected their performance.

Finally, there was a sense that the students were very understanding in the beginning but as the pandemic and online learning continued there was an increase in demands and expectations from the students.

“In the very beginning, yes you did have a lot of students very understanding and they’re just happy that there is a class….I think it changes throughout the time but I agree in the beginning, they were very supportive of the fact that you will all try to work so hard” (FG1). As time went on participants noticed an increased level of dissatisfaction from some students that the content “isn’t well delivered or it isn’t well planned [and] there’s too much content” (FG2). There was also the sense that some students felt extra classes needed to be run in order for them to receive value for money for their degrees.

Theme 2: Navigating online teaching under resource constraints.

The second theme was navigating online teaching under resource constraints and this covers the challenges and benefits of online delivery of the physiotherapy programs.

• Challenges of online delivery.

The delivery of lectures and tutorials went to a fully online format in late March 2020 and at least part of all the physiotherapy courses have remained in that format since then. Key challenges of an online format of delivery described by participants included: being time consuming, requiring significant upskilling, and relying heavily on technology. Furthermore, some practical skills were not able to be delivered online due to equipment requirements and safety implications. Finally, some academics found it even more challenging when a hybrid format of teaching was introduced later on in the pandemic.

There was consensus that the rapid switch to online delivery was incredibly time consuming and required significant upskilling. Participants said that the recording of lectures required more effort and editing to correct mistakes so that they were perfect which was not expected if the same lectures were delivered in-person. Similarly, some participants realised that existing tutorial materials were not going to work in the online format, “so that meant that we had to develop a whole heap of new content” (FG3) which not only took time but required creative thinking. Most had never really taught online before and were not familiar with the multiple platforms and videoconferencing software that were available. As one participant explained;

“it was just very difficult because it wasn’t just having to pivot everything on to online it was learning new platforms and even just working out how you’re going to record your videos and upload your videos, all of that took a lot of time and I don’t think that that was accounted for, really in the hours that we took” (FG1).

Initially there was not the time or resources to receive training in how to use all the various platforms so educators who found the technology challenging relied on those educators who were already skilled in how to effectively use the platforms. Whilst they recognised this increased other people’s workloads, many commented how grateful they were for that assistance.

Practical skills education was either delivered online only or in limited bursts of in-person teaching during 2020. Many educators described the challenges of teaching and giving feedback about practical skills remotely or the constraints to teaching practical skills once students were allowed back on campus. Some of these were subject-specific and related directly to infection control issues, such as the specialised equipment needed or the specific techniques being taught. For example, “teaching cardio was very, very difficult. You are not allowed to cough, you are not allowed to touch each other, you have to maintain social distancing” (FG3). Other participants commented on the challenges of having enough time to effectively practice the skills when they were condensed into fewer in-person sessions and felt there was not “enough time to practice all the skills in our tutorial sessions” (FG2).

Participants commented that there was a heavy reliance on technology and internet connectivity for the smooth running of lectures and tutorials. The rapid switch to online education meant there was not time to adequately set up for this and often connectivity issues were out of their control. Many educators were teaching from home and sharing bandwidth with other members of their family and similarly “some students had their videos off because they just didn’t have the bandwidth to be able to have video on so it was a really difficult thing for a lot of them” (FG2). The various online platforms and features (such as Zoom and Teams) were seen as both enablers and barriers to engaging students in synchronous teaching. Negatives included the educator only able to see the faces of a few students at a time making it difficult to keep track of them, and it was likely difficult for students to have multiple tabs open concurrently when they were working on smaller devices or with a single screen. As one participant pointed out;

“I don’t know how the students are managing, they have like four or five windows all open at the same time…I suspect if …you’re on a little phone or a tiny iPad… then I think it would be difficult for students” (FG3).

There were also mixed views about the potential impacts on students of having all the lectures online. Some participants felt that it made “the student a bit lazy so they don’t need to really participate” (FG2) and if they did not keep up with watching the lectures each week content would accumulate and the students would fall behind. Conversely some participants felt “when the lectures went online, students were engaged with them a lot more” (FG3) because when it was online “they structured their day a little bit better” (FG2).

As 2020 progressed, some in-person classes resumed and most universities moved to a hybrid format of teaching with either synchronous or asynchronous online lectures and a mix of online and in-person tutorials. Interestingly for some participants this hybrid model was seen as more difficult than online only.

“By semester two we had a hybrid of online and face-to-face and I almost found that more challenging, because we were trying to deliver all of the theoretical content online and get all of the practical skills sessions crammed into a single session” (FG2).

• Benefits of online delivery

Many academics and leaders felt there were benefits from the rapid change to delivering physiotherapy content online, including some positive changes to teaching that could be carried forward. These included having an upskilled workforce, innovations in teaching practical skills, resource development, and continued use of team teaching.

Overall the upskilling of academics was seen as a major positive and the forced need to upskill might have expedited changes and improvements to physiotherapy education more broadly. As educators became more comfortable with the technology, they were able to use some of the features to foster increased participation and engagement of students. For example, one participant commented;

“I found that there was some good online, like the zoom functions that we could make use of quite well…and we could force basically all of the students to vote or to get to engage…and I don’t think we would have been able to do that, even if we had the classes face-to-face” (FG2).

Many educators talked of innovations of teaching practical skills remotely, including getting students to practice “a technique on their family member while we gave feedback online” (FG2), making videos of themselves performing practical techniques, using simulated patient scenarios and virtual case studies and creating a virtual clinical practicum. This was summed up by “it was good for me to be forced to look at a different way of teaching something that I thought was not possible to be taught that way” (FG2).

In terms of resources some participants mentioned the benefit of using existing resources like videos and pre-recorded lectures, and many talked about how the resources they developed in the early parts of 2020 could be used in their ongoing teaching: “some of the resources… that we’ve developed, have been extremely useful for our ongoing teaching and hopefully might make things a bit easier this time” (FG1). Similarly, it was felt the extra work done at the start of the pandemic like re-recording lectures and creating online learning activities may have saved time later for some academics in subsequent semesters. Finally, some institutions already had a team-teaching model in place prior to COVID but for those institutions that did not this was seen as a major positive to come out of the switch to online learning and transition back to face-to-face teaching. Those who mentioned team teaching all said they found it enjoyable. The other positives of team teaching were “having someone else there as a bit of a backup” (FG2), for “students to see how healthcare professionals interact with each other” and the students having access to “both tutors being able to give their thoughts on something as well” (FG2).

3.3. Lessons Learnt

The main lessons learnt from the rapid switch to online learning in 2020 were consistent across the four focus groups. All felt that adequate time was needed to effectively design the online components of physiotherapy programs; they questioned some of their existing practices and there were some areas of physiotherapy education that were important to be delivered in-person and not online. In the rush to get everything online so quickly, there was no time to consider the underlying pedagogy behind the changes to teaching content and delivery, and the lack of planning was viewed both as a “missed opportunity” (FG2), as well as causing difficulty in some cases to revert to more pedagogically sound methods. “Now it comes to the issue when we want to revert back with some of those units to say well, you know, we want to present them in the way that’s that we think is pedagogically more sound” (FG4) but “the assumption was, this is the way you will continue because you did it last year” (FG4). One of the major positives of being forced to move content online was that it forced participants to question their existing practices, be open to new ways of doing things and realising that change could bring improvement. As one educator commented;

“I think that it made you question why you taught, the way that you did, and sometimes you just did it because that’s how you’ve always done it. And because you had to change or adapt your style of teaching, in some ways you realize actually that wasn’t inferior, actually that could be better and a better way to do something” (FG1).

Finally, participants across all four focus groups felt strongly there were some aspects of physiotherapy education that were not suitable to remain online. This centred around the importance of in-person practical and communication-skills education which was viewed as “critical and cannot be replaced” (FG2). Both educators and leaders felt it was important to draw “the line about where we wouldn’t budge on” (FG1) in future education planning and design.

4. Discussion

The rapid transition to online learning in 2020 due to the COVID-19 pandemic provided an opportunity to test the feasibility of the online delivery of practical hands-on courses such as physiotherapy. However, it was one that was made due to pragmatic reasons rather than being pedagogically informed. Therefore, unlike previous literature that examines the impact of online learning where online learning was well planned, given the appropriate time to develop, and implemented as an informed choice, the rapid transition to online learning as a result of the pandemic was quite different. No-one had been in this situation before and the educators had to employ more of a reactive rather than a pro-active approach. This was compounded by the direct impact of the public health orders at the time, such as lockdown restrictions and the need to social distance.

The physiotherapy educators and leaders interviewed for this study found this rapid transition to online learning both challenging and rewarding and identified some areas that remain ongoing concerns in physiotherapy education. The main challenges identified were adapting the content into an online format quickly to ensure teaching was continuous and that student competency was not compromised, engaging students in an online format, knowing how to teach and effectively assess practical skills, and deciding what content could stay online and what was critical to be taught in-person. The rewards identified included upskilling and the learning of technology that otherwise may not have happened, utilizing the benefits of team teaching, and realising that some teaching practices could in fact be improved by changing the ways things had been done in the past. The greatest ongoing concern was how to teach and assess psychomotor skills online. The authors acknowledge these challenges, rewards, and ongoing concerns would be well recognised by physiotherapy educators worldwide and are in line with recent physiotherapy research [16,17]; however, it is vital to document them as not every program has the same autonomy over decision making and it is important university decision-makers are also aware and can provide adequate support.

In terms of content-related aspects, the greatest challenge reported was the ability to teach and assess psychomotor skills online. Repetition and feedback of hands-on skills are required for psychomotor skills learning [16]. The teaching of practical skills during the pandemic was either deferred entirely until in-person learning was possible, or educators developed creative and alternative solutions for teaching them online. These included the live feedback of skills, watching and critiquing skills of videos with peer and student feedback, and students videoing themselves demonstrating techniques at home. The successful use of these techniques has been reported in the teaching of physiotherapy and similar health science psychomotor skills during the early stages of the pandemic [5,12,16,17]; however, the ongoing impact of these education techniques remains to be determined and has not been well tested in physiotherapy education broadly. The idea of frontloading theory online with targeted in-person practical sessions has already been suggested as the way of the future in physiotherapy education [8]. In the current study, hybrid or blended learning modes of delivery were seen as a positive, but many educators also reported the challenges and pressure of covering practical skills in limited in-person sessions. The pandemic has challenged the notion that psychomotor skills cannot be taught online; however, notwithstanding new and as-yet unimagined technologies, educators do not envisage it to be possible or appropriate to teach psychomotor and clinical skills solely online in the current sociotechnical context.

It was also clear from our study and supported elsewhere in the physiotherapy literature [21,22] that the online-only format may have had an impact on the non-content focussed aspects of physiotherapy education, such as student engagement, how students learn, and their sense of belonging to a course or cohort. It was perceived the online environment suited some students but was to the detriment of others. Educators felt it was more difficult to gauge student engagement and tailor learning activities in an online-only format, and in the future it will be necessary to adapt the online learning environment to cater for students with different learning styles and needs. A recent Australian study [22] investigated both student and academic perspectives of the impact of online learning on the sense of belonging of first year health sciences students to their course. Students’ sense of belonging and ability to engage in their courses were directly impacted by the difficulties they experienced forming relationships between staff and other students in the online medium [22]. These findings and those of our study indicate the potential flow-on impact of this period of online-only education to the students’ professional behaviour and identity and warrants a longitudinal study on students and educators to investigate this. Similarly, the technology and connectivity issues experienced by educators and perceived to be experienced by students may have impacted on their learning. Whilst the online medium affords the opportunity to reach more students, this will only be useful if there are not technology and connectivity problems. Student equity and access issues have been exacerbated in Australian higher education, and indeed the world, due to the COVID-19 pandemic [23] and need to be a consideration in the planning of future physiotherapy education programs.

It is important to learn from the initial stages of the pandemic and whether any of the changes to the pedagogy and delivery that were made should be retained to improve the future student experience [10]. The overall lessons learnt from the rapid switch to online learning can help inform this. It is well known that time is needed to effectively design good educational programs; however, this was simply not possible in the early stages of the pandemic. Similarly, the fact that some educators questioned their existing practices and felt aspects of their teaching had improved is part of good physiotherapy educational practice; however, the pandemic forced this to happen and expedited changes that may have taken years to eventuate. Finally, the fact that the educators and leaders felt they needed to draw a line on where they would not budge reflected the institutional pressures to keep aspects of the programs online, even after the initial lockdown periods had passed. It is clear some aspects of the program worked well online but that others, such as teaching communication skills and teaching and assessing hands-on practical skills unique to physiotherapy curricula really need to revert back to pre-pandemic in-person approaches. Moving forward, support from university executives will be vital to provide time as well as economic, technical, and organisation support, including professional learning, to managers and academic staff to achieve the best educational outcomes [9]. Strong institutional support has been seen as essential in getting through the pandemic in other health care disciplines such as nursing [24].

The pandemic has potentially expedited a new era where traditional courses that were mostly delivered via in-person methods can be also delivered via online platforms. All of the educators and leaders interviewed felt that a combination of online and in-person physiotherapy education would continue in the future regardless of the status of the pandemic. Further research is needed to determine the long-term impacts of the forced online-only learning for this COVID cohort of physiotherapy students and how they are managing their skills in the workplace.

This study was a chance for educators and leaders to reflect on their experiences of teaching or leading physiotherapy programs at the start of and during the pandemic; however, there were some aspects of this study that may have influenced the perceptions of the participants. Firstly, the fact they were reporting on experiences at the institutions they were employed at may have affected their responses. Secondly some participants only taught a small number of hours online, primarily theoretical lecture content and not practical tutorial content. Thirdly, participants’ individual personal situations during the pandemic (such as home-schooling children whilst working from home) may have influenced their views on teaching. A limitation of this study is that only participants from three of the five Sydney-based physiotherapy schools participated and the majority were from one institution. Thus, the experiences of these academics may not be generalizable to other physiotherapy programs in Australia or internationally. Furthermore, the area of clinical education was not explored and is something that needs investigation in the future. Since the moderator and technical support person in each focus group was from the same profession, there is the possibility of biased answers in the focus groups [25]; however, the moderator had only taught one lecture at the time of the focus group and the clear themes that emerged from all four focus groups suggests this was not the case. Finally, the results of this paper reflect a time in the pandemic when educators just had to do their best to keep teaching rather than focus on the pedagogy behind what they were doing and have been interpreted in that context. Clearly the associated challenges in physiotherapy education with potential future lockdowns and in some countries requirements to keep aspects of physiotherapy education online require further attention and investigation.

5. Conclusions

The COVID-19 pandemic forced a change in the delivery of physiotherapy education without the time to plan it effectively. Physiotherapy educators and leaders felt there were some aspects of online learning that may be effective and should remain part of physiotherapy education in the future; however, some aspects of physiotherapy programs, including psychomotor and communication skills, cannot be taught effectively in an online-only platform and should be taught in-person. Future physiotherapy education is likely to be a combination of in-person and online delivery and lessons learnt from this time need to be incorporated into physiotherapy programs to achieve the best educational outcomes.