What students say to be ready for acute care: Implications for preceptors

Student readiness for clinical education experiences is an important variable for clinical preceptors. Readiness has been reported from the viewpoints of clinicians, academic faculty, clinical preceptors, employers and novice graduate physical therapists. Perspectives from physical and occupational therapy students could better prepare preceptors in the acute care setting.

groups within physical therapy practice have also published essential competencies to ensure that graduates are ready for specific practice areas or populations.For the acute care practice, the Core Competencies for Entry-Level Practice in Acute Care Physical Therapy further clarified expectations to prepare future physical therapists for the acute care practice. 4,55][6][7][8] Critical behaviours for health care providers in acute care include making complex decisions for a variety of patients and communicating effectively with a diverse health care team.[6][7][8][9] Acute care clinical education experiences have been reported to have the highest incidence of both remediation and failure for physical therapy students. 10][12][13] Health profession students from disciplines such as nursing, occupational therapy and physical therapy report their perceived readiness as well as clinical preceptor approach being key determinants in clinical experience success. 14,157][18] More specifically, the Acute Care Confidence Survey is a more setting specific tool developed to measure a physical therapy student's degree of readiness for the acute care setting.This reliable tool allows students to rate their selfconfidence related to skills, knowledge and behaviours deemed important to the setting based on expert consensus.Outcomes from this tool have provided insights on student confidence in delivering physical therapy services during clinical experiences in acute care, with findings that students whom report higher confidence on some subsections of the tool had a higher performance during their acute care clinical experience. 19,20ile the literature points to a need to better prepare students for the acute care setting, our understanding of the factors that contribute to students' perceived readiness for this setting is unknown.
Relying on expert consensus alone to address performance gaps may be problematic because a comprehensive learning needs assessment should include not only normative competencies but also the felt needs of the students. 21Regardless of approach, knowledgeto-practice gaps in the clinical performance of students in acute care may continue to be present, and learning opportunities may be missed if the lived experiences of students are not fully considered.Therefore, the purpose of our study was to explore readiness for the acute care setting from the perspectives of physical therapy (PT) and occupational therapy (OT) students during their acute care clinical education experiences.

| METHODS
After obtaining Institutional Review Board approval at Mayo Clinic (IRB #19-012337), we used the Consolidated Criteria for Reporting Qualitative Research (COREQ) to guide the study. 22Collectively, two of the study researchers (MH and HO) had over 35 years of clinical student teaching experience.One of the researchers (AR) was an experienced qualitative researcher and trained the other researchers in qualitative methods including how to conduct focus group interviews.
Inclusion criteria for participation were occupational and physical therapy students that were completing a terminal clinical experience in acute care and receiving their graduate education from an accredited occupational or physical therapy programme.Three pilot focus group interviews were conducted with nine occupational and physical therapy students (three students in each focus group).The purpose of the pilot was to trial, evaluate and refine the survey content, interview guide and all research procedures (interview methods, audiovisual recording, transcription, member-checking and coding framework).
The pilot phase informed modifications needed for the remainder of the study, including the order of questions in the survey and probing questions needed during the interview phase.It also served as a means to finalise coding strategies between researchers.
Audio and visual recordings of the interviews were used to collect the data.In addition, two researchers were present during interviews: one conducting the interview and the other taking field notes in real time.Additional field notes were compiled while viewing the audiovisual recordings including documentation of non-verbal communication such as head nodding or hand gestures by students.For example, if one student provided a description statement and another student nodded in agreement, this was documented in the fieldnotes.After interview completion, we completed transcription.As a method of member checking, written transcripts of the audiovisual recording were provided to participants for comment and/or correction.All participants approved transcription as accurate.
Thematic analysis was conducted following the approach described by Braun and Clarke. 23We used a two-stage iterative process of thematic inquiry to systematically generate an inductive, grounded theory about student readiness for full-time acute care clinical experiences in PT and OT.First, we aligned with the study theoretical framework, using an initial coding process that consisted of individual researchers reading, reflecting on text and highlighting frequently cited words throughout the interview.For example, commonly cited words or phrases such as 'flexible', 'adaptable', 'communication', 'knowing labs and vital values' and 'having multiple plans' were identified and highlighted by individual researchers.Secondly, we wrote brief summary narratives of our initial interpretations of each whole interview.Third, we individually reviewed the transcript data line-by-line and tracked our changes in Microsoft Word using a combination of word-based, linguistic and pawing techniques such as colour-coding key words or word repetition and circling metaphors, transitions (pauses, use of 'now' or 'then') and connectors (because, since, as a result, if, then, rather than, instead of, before, after, next, never, not).Finally, we triangulated our individual and combined responses to identify key initial and final themes in the student responses (Figure 1).
Contributing to the trustworthiness of our study, during the pilot phase, researchers individually reflected on the research question to gain awareness of their own biases and assumptions.Researchers asked and answered the question 'What does student readiness in acute care mean to me and why?' Bias checking through reflective journaling continued to be performed by researchers throughout each phase of the study.In addition to the aforementioned triangulation and member checking, we made efforts to reduce thematic redundancy by combining concepts into larger categories with subthemes.

| Study participants
We used purposive, convenience sampling to identify student occupational and physical therapists who were completing a full-time (i.e., 12-week duration) acute care clinical education or fieldwork experience at a large medical institution.Students were eligible to participate in the study if they were in good academic standing (i.e., had met the minimal standards for their given programme) within an accredited entry-level occupational or physical therapy programme; currently completing a terminal, full-time clinical or fieldwork experience in acute care at the time of the study; participating in a collaborative model clinical or fieldwork experience at the time of the study; were able to attend a 60-minute focus group interview session; and agreed to review an interview transcript for accuracy.Exclusion criteria for participation included academic probation, current participation in a traditional (1:1) clinical or fieldwork model and being unable or unwilling to review an interview transcript for accuracy.
Rolling recruitment and data collection occurred until data saturation was achieved.All participants signed a document of informed consent.
The participants were 21 physical or occupational therapy students who were completing their 12-week, full-time acute care clinical education experiences at a hospital within a collaborative (i.e., 3:1) supervision model.The students were assigned an experienced preceptor to supervise the delivery of therapy services to populations having orthopaedic, cardiopulmonary, oncology or general medicine conditions.The majority of the participants were students from Midwest regional physical or occupational therapy programmes in the United States (Table 1).

| Procedure
Rolling recruitment occurred until data saturation was achieved.Subjects provided oral consent using a scripted oral consent form and were given time to discuss or ask questions related to study participation during the first week of their clinical or fieldwork experience.
During Week 6 of their clinical experience, we had students complete a one-time questionnaire as well as the one-time virtual focus group interview.We conducted virtual focus group interviews with groups of three students using a semi-structured interview guide.The guide included four primary questions: Initial codes to themes.Note: The process of coding was an individual and collaborative process among researchers.First, frequently cited words were highlighted from transcripts, reflected upon, then compared among researchers, and finally, codes and subthemes were generated.and re-direction to the topic.We chose a group interview method because discussion among group members could prompt recall and deeper elaboration of experiences.
We completed and recorded all interviews on our institution's secure virtual network after clinical hours.We divided roles during the interview process, with one researcher facilitating the interview while another took field notes.We created written transcripts of the interviews based upon the audiovisual recordings and provided them to participants for comment and/or correction.All participants approved the transcriptions as accurate prior to concluding their clinical experience.There were no changes noted by participants regarding their comments.
In addition to a focus group interview, students completed a onetime questionnaire that included demographic questions as well as learner characteristic scales that considered students cognitive load (i.e., Cognitive Load Index), growth mindset (i.e., Revised Implicit Theory of Intelligence Scale) and self-efficacy (i.e., New General Self-Efficiency Scale).[26] 3 | FINDINGS

| Learner characteristics
Overall, the results of the learner characteristic scales indicated the students had a high cognitive load due to the complexity of patients in the acute care environment, had a minimally fixed mindset, and exhibited high self-efficacy.The results of the Cognitive Load Index indicated 14 of the students (67%) believed significant mental effort was required to care for acute care patients.Furthermore, all students reported the full-time clinical or fieldwork experience helped them understand their role as an occupational or physical therapy practitioner.Eighteen of the students (86%) rated themselves as having a growth mindset.However, scores ranged from 1.00 to 4.13 with 1 of the 21 students having a fixed mindset.Furthermore, 14 of the students (67%) had high self-efficacy.The mean score on the New General Self-Efficiency Scale was 4.15 with a range of 3.38 to 4.75.

| Themes
In order to be ready for full-time acute clinical experiences, students reported needs categorised within four major themes: (1) mindset and willingness; (2) knowledge and experience; (3) communication and collaboration; and (4) planning and prioritising.For each of the major themes, there were three to four subthemes (Table 2).Some subthemes included multiple domains of personal readiness: affective, cognitive and psychomotor.
The first major theme was the need for students to adopt the mindset and willingness to take responsibility for their own learning.Within this theme, students expressed the need to be flexible; growth-oriented; and be an active, engaged learner.Students recognised they were 'here to learn', and they needed to be open to challenges and be willing to try and to push themselves out of their current comfort zones.They also recognised they needed to take action on feedback and learn from their mistakes.Furthermore, students reported that, in order to be successful, they needed to think on their feet and problem-solve 'in the moment' to many unexpected situations and unforeseen changes.
The second major theme was the need for students to have had at least some acute care focused educational preparation.Within this theme, students expressed the need for foundational knowledge from which to make decisions in acute care (such as vital signs, lab values  The fourth major theme was the need for students to be able to plan and prioritise to ensure that therapy services were delivered in a safe, efficient and effective manner.Within this theme, students expressed the need to prioritise safety and function; create plans A, B and C; and facilitate optimal discharge planning.Student described creating a plan A, B, C as having multiple treatment plans or therapeutic activities articulated prior to arriving to the patients room for a given day.Each of these plans was to account for modifications that can occur in acute care due to patients medical acuity and prognoses, preferences or desire, and medical setting cultural considerations (i.e., timing or procedure schedule for a given day, a medical change or symptom arises during session, grading of therapy activities).Students expressed that a different approach to patient care was needed in acute care (e.g., functional mobility and self-care management focus for discharge) compared with outpatient settings (e.g., diagnosis and pain management focus).Within this acute care approach, the emerging and changing status of their patients required students to continually modify their plan of care, team communications and discharge recommendations.Students felt inadequately prepared to plan and prioritize effectively when their patient's medical status was complex or when their medical prognosis was uncertain (Table 3).

If your clinical instructor
gives you feedback about something, put in the work.
Being ready for acute care is really being prepared to be flexible.

Communication & collaboration
Á 'Being able to determine when another care team member needs to be updated, or called on for assistance, when managing a patient'.-Student3 Á 'I went in and the family and the patient were all on the same page because we all had the same goal in mind that the patient wanted to get out.And we wanted the patient to get out as safely as possible'.-Student5 Á 'Like one of my patients, I made a discharge recommendation that was different than the service's plan.And then I got a direct page and had to answer the call from the primary service and defend my position and explain why I chose that.I think something like that could be a helpful, helpful thing to practice.Our orientation was really good at highlighting the key things that we need to know.
Family and the patient were all on the same page because we all had the same goal in mind that the patient wanted to get out.And we wanted the patient to get out as safely as possible.
Being ready for acute care means understanding how the acute care goals are going to be different from other settings.
You really have to have different options of things that you can do during your session.

| DISCUSSION
][6][7][8][9][10] Our study described physical and occupational therapy students' perspectives on readiness for completing a full-time acute care clinical education experience in hospitals with a variety of units (i.e., orthopaedic, medical, oncology, transplant and cardiopulmonary).
Our findings suggest that clinical preceptors played an important role in facilitating student readiness for participating in the delivery of physical or occupational therapy rehabilitation services in a fastpaced, complex, hospital setting.Four major themes were identified among the student voices regarding their perceived needs to be ready for a full-time acute care clinical experience.

| Implication for preceptors
Students reported that the clinical learning environment, orientation process, scaffolding of patient conditions and role responsibilities contributed to their readiness for delivering occupational or physical therapy services in acute care.There were some suggestions provided by students to better prepare them for acute care practice, especially for situations when the patient discharge plan differed between patient desire versus what was recommended by student as well as when medical prognosis for patients abruptly worsened.On the basis of these descriptions shared by the students in our study, we suggest that in order to further facilitate and support student readiness in acute care, students need preceptors who can (1) model flexibility, (2) foster communication that promotes holistic clinical reasoning, (3) provide a formal clinical orientation and (4) facilitate the transfer of professional authority to the student.
First, students reported their own flexibility was critical to readiness in the acute care environment due to the complexity of the environment, the policies and procedures, team interactions and the unpredictability and medical instability of their patients.The students in our study reported having clinical preceptors who modeled flexibility and adaptability facilitated their ability to demonstrate the same characteristics.Clinical preceptors highly value these characteristics in students as well and have reported these were among the important characteristics for students to possess for successful clinical education experiences. 27cond, students reported their readiness was fostered by clinical preceptors who exhibited excellent verbal communication skills.For example, students reported that routinely communicating with the clinical preceptor before a patient session helped them develop a framework with which to predict and plan for multiple elements of the patient encounter including communication strategies, prioritised examination, patient education and intervention needs and individualised discharge considerations.Without preceptor guidance, inexperienced students may fail to consider the patients' life context, previously reported as an essential component of discharge planning in acute care. 28In addition, preceptors have a role in helping students identify, navigate and reflect on challenging patient encounters or medical factors such as a patient's change in prognosis, difficult behaviours and threats to the therapeutic relationship between patient and student.
Third, students reported their readiness was facilitated by having a formal orientation process.An organized orientation process allowed students to grow in their confidence and autonomy in patient care while still being supervised by an experienced clinical preceptor.Students described an ideal orientation as one which included identification of practice resources and equipment, discussion of specific clinical expectations, review of critical safety processes and procedures, and an understanding of the culture of the facility.Students have previously emphasized that a formal clinical orientation process that included emergency procedures and protocols was critical to their ability to confidently maintain patient safety in the acute care setting. 29nally, students reported their readiness was facilitated by clinical preceptors who gradually transferred professional authority to them over the course of the clinical experience.Students in the clinical setting have been described as transitioning from having the role of 'observing learner' to a 'jointly responsible co-clinician' and finally to an 'individually accountable lead clinician'. 30The students in our study reported this was a difficult transition.They lacked confidence in taking a lead role and speaking with professional authority as an interprofessional team member due to their inexperience.Students and clinical instructors have previously reported this as a specific area where improvement is needed to prepare students for the acute care setting. 29,31Having preceptors facilitate team communication strategies using frameworks such as the Situation-Background-Assessment-Recommendation (SBAR) tool or Acknowledge, Introduce, Duration, Explanation, and Thank You (AIDET) may support student confidence in their interprofessional communication skills in the acute care setting. 32,33her inexperienced medical trainees have also reported initial difficulty with exerting professional authority and that their relationship with their preceptor was fundamental to their ability to transition from 'observing learner' to 'individually accountable lead clinician' (Brown et al.).Because preceptors are initially in the position of power, they need to explicitly invite the student to share that space and move towards a gradual transfer of professional responsibility to the student until they become the lead clinician.Students voiced appreciation for preceptors who clearly communicated expectations and utilized an intentional scaffolding approach to help them develop their professional authority.Example of scaffolding techniques included 'See one, do one, teach one' and 'Be the aide, next co-treat with me, now be the lead'.Students also reported that their growth in professional confidence was fostered by preceptors who strategically built up the students' confidence with patients who had similar diagnoses or conditions before expanding the diversity or complexity of patient cases.

| Future considerations
We do not know the degree to which students who completed clinical experiences at other acute care facilities would agree that these factors are important for readiness for the acute care setting.We also do not know if these factors might also be considered by students to be

( 1 )
What does 'being ready' for acute care mean to you?; (2) Describe a specific situation or time where you were ready for your role in acute care; (3) Describe a specific situation or time where you were not ready for your role in acute care; and (4) What have you done that was most helpful in being ready or prepared in your role as an occupational or physical therapy student?Follow-up questions were used to prompt elaboration, clarification, summarisation and equipment); a variety of experiential learning methods; prior acute care clinical experience; and a culture of learning in the clinical environment.Students expressed the culture of learning was best facilitated by the student's clinical preceptor and included providing a formal comprehensive orientation process, grading the student's transitions from observation to collaboration to mentored independence and providing positive and constructive feedback.
theme was the need for students to be able to effectively communicate and collaborate with others.Within this theme, students expressed the need to use others as clinical resources; develop therapeutic alliance with patients, families and team members; and communicate with appropriate professional authority.Students recognised that specific individuals were necessary to help them navigate cultural and contextual factors surrounding their role in delivering therapy services in the acute care setting, especially their clinical preceptor.They highlighted the importance of being active teammates and building and maintaining alliances with the multidisciplinary team through frequent collaboration and communication.Students felt inadequately prepared to collaborate and communicate effectively when there was disagreement with the team about a discharge plan or when they were assigned to care for patients experiencing cognitive impairment or poor prognosis.

T A B L E 3
Student comments associated with themes.Theme Associated student quote Mindset & willingness Á '… being willing to learn and being comfortable not knowing what everything is and knowing that you have the capacity to grow into the role'.-Student 1 Á 'You have to be willing to put in the work.If your clinical instructor gives you feedback about something, put in the work … it has to be an active learning process … it can't just be a passive learning process'.-Student17 Á '… being ready for acute care is really being prepared to be flexible … that was the biggest thing … you really have to be prepared to be flexible throughout your day just because things change so quickly'.-Student20 Knowledge & experience Á 'We watched one, then did one on our own … I felt more ready afterwards because I'd seen how the flow of it can go, and what needs to be said, and what can happen after the conversation'.-Student 2 Á 'Our orientation was really good at highlighting the key things that we need to know'.-Student 9 Á 'How to chart review and understand medical aspects … and then apply physical therapy to that'.-Student 13 important for readiness in other types of patient care settings.Future studies could include surveying a national sample of physical therapy and occupational therapy students from other programmes who completed acute care clinical experiences at other facilities to determine the degree to which a larger sample of students would rate the importance of these factors in their own readiness for acute care.Focus group interviews could also be conducted with students completing clinical experiences in other settings to determine factors that contribute to readiness among varying settings.Being that this study focused on perspectives among who were in good academic standing at the time of the study, further research may examine student perspectives on clinical preparation and considerations among who may be having academic or performance difficulties surrounding their clinical experience.Furthermore, facilitating focus groups with clinical preceptors in acute care regarding readiness may further enhance an understanding of readiness surrounding clinical education for rehabilitation students in acute care.5 | CONCLUSION Physical and occupational therapy students need to be ready to manage-under appropriate supervision-the multifaceted learning environment and patient demands presented in acute care.Rehabilitation students' perception regarding readiness for a full-time acute care clinical education experience considered affective, environmental, communication and preceptor factors.Preceptors can support rehabilitation students' readiness for delivering rehabilitation services by the following methods: (1) modeling flexibility, (2) fostering communication that promotes holistic clinical reasoning, (3) providing a formal clinical site orientation and (4) facilitating the transfer of professional authority to the student.ETHICAL APPROVAL Institutional Review Board approval was obtained at Mayo Clinic (IRB #19-012337).
Being ready for acute care means understanding how the acute care goals are going to be different from other settings: focusing on patient safety and what safe discharge to where ever they are planning to discharge, and really understanding that difference in what you want to focus on'.-Student 9 Á 'I spent a lot of the morning preparing for this patient through talking to the care team about their needs for discharge and how everyone else is contributing to planning for this person'.-Student13 Á 'So, you really have to have different options of things that you can do during your session, and in your overall schedule for your day.If one patient that you are planning to see doesn't work out, you to be able to think "what other patient could I potentially see?" to still be productive'.-Student16