Internationalisation Of The Curriculum:
Aims before review
Aims after review
To provide opportunities for students to:
To develop academic and professional language and communication skills relevant to studying and practicing physiotherapy cross-culturally.
Objectives before review
Objectives after review
On completion of this course, the student should be able to :
On completion of this course, the student should be able to:
Students were involved in some entirely new activities in the 'culture and communication' stream. For example, whereas previous classes on understanding various explanatory models regarding health involved readings followed by group discussion, this year, in addition to class discussion, students interviewed a friend not involved in health care to discover their beliefs about health and whether these beliefs differed to their own. Previous classes that centred on culture specific interview and teaching skills were replaced with discussions on what culture is, the significance in understanding it and how cultural competence is developed. Sessions on interview and teaching skills then centred on the ability to recognise difference in language and communication and how to form strategies to cope with these differences. Students also attended a physiotherapy clinic as a patient themselves allowing them to reflect on culture differences and 'power dynamics' in the client/therapist relationship. Some very specific classes were run encouraging students to reflect on cultural differences in both verbal and non-verbal communication and the value judgments that can often be associated with these differences.
The written professional communication stream was augmented with extra practice sessions and feedback provided to students as it has been a skill that students have struggled greatly with in the past. The role of a physiotherapist in a health care team in Australia can be very different to their role in other countries and the way that physiotherapists communicate with other health professionals is therefore also different. The classes in 2004 focused on identifying ways in which communication differed and how different modes of expression are construed as either polite or impolite, appropriate or inappropriate in different cultural contexts.
The academic language and communication stream contained an increased emphasis on critical review of literature. One of the main concerns voiced by teaching staff involved in this particular Masters Program was that students from the Indian subcontinent had very little understanding of what research is and how to critically evaluate it, which seriously disadvantaged them in written assignments. An extra session on understanding research was introduced, and more practical classes in critical thinking and evaluation of research were introduced. Another change was to emphasise oral paraphrasing of literature. In the past written paraphrasing had been emphasised, but this turned out to be a very difficult skill for students to master. They could take the original text and put it into their own words, but then to put it back into academic English without it sounding too much like the original (as would be required for writing an essay or literature review), was extremely difficult as they did not have that scope of English language available to them. It was decided that if the aim was to assess their understanding of literature rather than their ability to write in polished academic English, it might be fairer to stop at the second step - asking them to tell us what it means in their own words. Finally oral presentation skills training included skills in fielding questions as in previous years it was noted that this art is fraught with cultural traps, perhaps more so than the oral presentation itself.
In order to support the changes made to the content of the course, changes were made to the assessment in all three streams of study. In previous years, academic language and communication was assessed via an assignment testing the ability to recognise plagiarism and reference correctly and a workbook requiring students to complete exercises in paraphrasing and summarising. Whilst the plagiarism assignment remained unchanged (it is a program requirement), the workbook was entirely altered. Instead of written summary and paraphrasing exercises, students, working in groups were involved in an extensive literature search on a topic of their choice, and then prepared an oral presentation that involved critiquing the literature on that topic, allowing oral paraphrasing to demonstrate understanding rather than relying on written paraphrasing and summary skills. This new assessment item combined skills learned in the art of oral presentation and skills in finding and evaluating literature.
The assessment for written professional communication built on the increase in formative assessment provided. The final assessment was to write letters related to a case study in exam-type conditions and submit these along with the previous letters as a portfolio, allowing development in culturally appropriate letter writing to be tracked. In addition, students were asked to write a reflection on their perceived strengths and weaknesses, and it was envisaged that this portfolio would be useful for them on clinic during the following year, to allow clinical tutors to further assist their development in this skill. The portfolio allowed for recognition of the fact that written professional English is as difficult to develop in the space of a semester as written academic English.
In the past, none of the assessment items focused on students' awareness of cultural competence, so a new item was introduced which required students to reflect on three experiences. One was the experience of being a physiotherapy patient themselves, allowing them to reflect on culture differences and 'power dynamics' in the client/therapist relationship. The second was a record of an interview on health beliefs that they conducted with a non-health sciences acquaintance. The third was an experience of their own choosing that demonstrated an understanding of how communication varies between cultures and how miscommunication can be recognised and solved.
Evaluation of the changes made to the curriculum was arranged by two different means. The first was the use of pre- and post- course questionnaires for the students. The second was review of the assessment items by other staff involved in the Post Graduate Program. The process was reviewed and approved by the Human Research Ethics Committee of the University of South Australia. The questionnaires were collaboratively designed by staff teaching on the course and the questions were carefully framed to be open ended, with the intention of encouraging students to share their ideas. Two questions including a visual analogue scale were also used, and the scales were designed without numbers, allowing students to indicate anywhere along the line that they felt would best represent their response. All responses were assessed qualitatively, using description of changes in response to visual analogue scales, and thematic analysis of text responses.
The pre-course questionnaire assessed their base line knowledge on the topics that were given increased emphasis this year - for example there were questions relating to their understanding of culture and of research. There were also questions assessing their level of confidence in communication with patients and with doctors in the Australian health care setting. The post-course questionnaire included these identical questions again to assess for change and also asked them which topics/classes/assessment pieces they found most and least useful.
The assessment review by other post-graduate staff involved at least one staff member external to the course, but involved in teaching later courses in the program, providing comments on the usefulness of the assessment item in assessing the qualities it was designed to assess and also on the level achieved by students compared to what might be expected the following year. To achieve this, the external staff members reviewed a selection of the assessment items, and then were interviewed by the course coordinator regarding each of the above factors. Staff involved in teaching the course also provided feedback to the course coordinator on perceptions of how different classes went and whether students seemed to pick up on various concepts with the amount of tuition given, or whether more or less emphasis might be required the following year. The questions to be answered by the evaluation can be summarised as follows,
Thirteen students completed the course LCP in 2004. Twelve students were from India and one was from Bangladesh. Of these students, 12 returned both the pre-course and post-course questionnaires, giving a 92% response rate.
Question 1: 'Has the curriculum improved knowledge and confidence in key skill areas as intended?'
To investigate this, eight questions in the pre- and post-course questionnaires were used. Two of these questions assessed students' confidence in communicating with patients and with doctors in the Australian health care environment, asking students to rate their confidence on a scale from 'not at all confident' to 'very confident'. The other six questions required text responses. Two questions asked them what they expected to be different in communication between physiotherapists and patients and between physiotherapists and doctors in their home country compared with in Australia.
The other four questions assessed their knowledge regarding culture, the significance of cultural competence, requirements for successful interviews with patients and their understanding of the differences between quantitative and qualitative research. These topics were chosen as those which had received the most change in emphasis in the new course structure for 2004.
The two questions relating to confidence in communication in the Australian health care setting demonstrated a considerable shift in confidence from the beginning to end of the course. At the start of the course, when asked how confident they were to communicate with doctors in Australia, 8 out of the 12 students had marked the 'not at all confident' end of the scale, with 3 marking somewhere near the middle and one towards the 'very confident' end. All students finished by indicating a high level of confidence, representing a large change for the 8 students who had been not at all confident at the start. Results for the question asking students how confident they were to communicate with patients in the Australian Health care setting, were also positive, with 9 out of 12 students indicating a large change in confidence, moving from the 'not at all confident' end towards the 'very confident' end. Two students indicated a small change, as they were confident at the start and moved to 'very confident' and one student indicated no change, marking somewhere near the middle both times. These results indicate that in general students finished the course with much more confidence in their ability to communicate both with doctors and with patients in Australia than when they started.
Analysis of the answers to the questions asking students what they expected to be different in communication between physiotherapists and doctors and physiotherapists and patients in Australia revealed some interesting shifts in emphases from before to after the course. Firstly, regarding communication with patients, before the course, the most common response was that they thought Australian patients would have better health literacy and would therefore be easier to treat. They also expected to be able to spend more time with patients because of the lower patient to physiotherapist ratio in Australia. The second most common response was that they thought they might struggle with language differences. After the course, the most common theme identified in their responses was that they needed to adjust to cultural differences, highlighting particularly the difference in the types of questions considered polite or impolite in the two different cultures, and the different, more casual relationship between the therapist and the client in Australia. They also made more specific comments related to differences in health care practice, such as noting the different interview styles, the increased involvement of patients in their own care and the emphasis on evidence based practice. Health literacy of the patient population and expected language problems became lesser themes.
When asked what they expected to be different in communication with doctors, the most common answers at the start of the course were that they expected a different referral system in Australia, and a better understanding of physiotherapy by doctors, resulting in a more equal relationship between the professions. One student wrote, "In our country physiotherapy is a second contact practice and we usually get the referrals from them (doctors) and we are forced to be under their control." Interestingly, students indicated that these were particular reasons why they had come to do a Masters Program in Australia. However, after the course, the most common reply to this question was that they thought the extent of documentation, and the expectation for formal communication, such as letters between health professionals in Australia far exceeded what was expected back at home. They used expressions such as 'more formal' or 'more professional'. This indicates a shift from focusing on what they expected in a more equal professional relationship to a focus on the extent and content of documentation and letter writing required, which they seemed to find surprising. This may in part explain why writing letters to doctors has been a skill that they have found particularly difficult - it is something that is not often required of them in their home environment.
Of the four questions assessing a change in knowledge regarding culture, cultural competence, successful interview skills and research methodologies, the answers to the question on the latter were most revealing, and most concerning. The question asked, 'what are the main differences between quantitative and qualitative research?' Before the course, the most common answer was "I don't know" (50%) and the remaining 50% demonstrated misconceptions, with the most common being that qualitative research was of high quality whereas quantitative research involved large numbers. After the course, only one student answered, "I don't know' and interestingly this was a student who had presented a misconception at the start. It seems that the information on research presented during the course served to reveal the misconception, but then did not help to solve it! Seven students demonstrated various misconceptions with some moving from one misconception to another. Only four students gave answers which indicated a beginning, though incomplete understanding of the two kinds of research. This indicates that staff concerns that students enter the program with very limited knowledge regarding forms of research are well founded and that much more work is required to assist students to develop a sound understanding of the types of research and how to evaluate it.
The question asking students 'what do you think culture is' was generally thoughtfully answered at the beginning of the course, but was very briefly answered at the end of the course, with generally fewer ideas presented, which is perhaps a result of the timing of the questionnaire. At the start of the course it was the first thing they did, and all students appeared to put a lot of thought into what they were writing. At the end of the course, it was given out at the end of their last class, and students filled it out as quickly as possible, giving less thought to their answers. It is therefore not as useful a tool in detecting whether students' ideas on certain concepts had changed as had been anticipated. With the question on research, even the brief answers given revealed misconceptions, whereas with the remaining questions on culture, cultural competence and effective interview skills, it is difficult to know whether the responses reflect their understanding in its entirety or merely the first few things that came to mind.
Responses to the question 'how is an understanding of culture relevant to the practice of physiotherapy' were slightly more revealing. Three main ideas emerged in both questionnaires - understanding is relevant because it helps to better understand the patient's beliefs and attitudes, because it helps to foster more successful interactions with the patient (better able to relate to them and to formulate effective management plans) and because it might help in understanding different causes or contributing factors to diseases and disabilities. The second two ideas were fairly equally represented both pre-course and post-course, but more students focused on the idea that it helps to better understand patients in the post course questionnaire, particularly focusing on different explanatory models regarding health care, which was one of the themes introduced in the 'culture and communication' section of the course. The question asking students what they thought contributed to a successful patient interview also revealed that students had picked up some new ideas about skills or attributes that were useful. Prior to the course they came up with a wealth of ideas, the most common being that the types of questions asked, a conducive environment, good interpersonal skills and developing a good rapport with patients all contribute to a successful interview. Other ideas such as giving adequate explanations about process to the patient, managing the interview and using appropriate language were also mentioned. These same ideas were popular answers in the post- course questionnaire, but two new ideas were that skill in clinical reasoning and understanding and respect for cultural values and beliefs and different explanatory models also contributed to successful interviews. Whilst it is difficult to judge how much students' understanding of culture or the process of cultural competence changed form the responses to these questions, it is evident that they did at least gain some appreciation of the role that cultural competence plays in physiotherapy practice.
A summary answer to the question, 'has the curriculum improved knowledge and confidence in key skill areas as intended?' is that it appeared to be very successful in increasing student's awareness regarding differences in communication and their confidence in communicating with patients and doctors in the Australian health care setting. It improved their appreciation of the importance of cultural competence in clinical practice, though it is difficult to ascertain the depth of their understanding as the questions were fairly hastily answered in the post-course questionnaire. It was not successful in improving their understanding of research, this area requiring more thought and development in the future.
Questions 2 and 3: 'Which aspects of the curriculum were perceived as most useful by students?'
and "which aspects of the curriculum were perceived as least useful by students?'
To answer these questions, students were asked which topics were most or least useful and which assessment tasks were most or least useful. The majority of students listed more than one item for each question. Regarding topics, 10 of the 12 students (83%) listed classes on culture and communication as amongst their favourites, with the activities of attending a clinic as a patient themselves, and interviewing a friend regarding health beliefs being specifically identified by 3 students. This indicates that students at least recognised and appreciated the overarching theme of the development of cultural competence in the course. The second most favoured topic was letter writing (58%), followed closely by classes spent on preparing for the oral presentation (42%). Three other topics were listed as favourites by each of two students; research methods, plagiarism and critique of literature. Very few students listed least favourite topics. For the three who did, it was either the classes in the library or classes on skills such as paraphrasing and summarising literature that were listed as the least favourite. Regarding assessment items, their responses were reasonably even. Six students favoured the oral presentation, five the plagiarism assignment, four the reflective journal and three the letter writing portfolio. The only suggested changes to assessment were to allow extra time for oral presentations and to have individual rather than group presentations. There is no apparent link between the favoured topics and the favoured assessment items, suggesting that factors other than interest may play a part in the choice of favourite assessment items.
Question 4: 'Which activities/classes were perceived by students as most useful for their learning?'
Most students did not distinguish between this question and the questions asking about their favourite topics and assessment items, indicating that the questions may need revision. Of the three students who did appear to understand the question, it is interesting that their opinions are unanimous - the most helpful class activities were group discussions. These discussions were held for many of the topics covered in the course, particularly those on culture and communication, and were well received at the time.
Question 5, 'How do staff involved in the teaching of the subsequent courses view the new assessment items
in terms of preparing students for clinical courses in the following year?
Three staff members volunteered to cross-mark a selection of assignments and to comment on the effectiveness of the assignment in preparing students for the following year. One staff member attended the oral presentations, one read a selection of the letter writing portfolios and one read a selection of the reflective journals, each providing feedback. The plagiarism assignment was not included in the review as it has not changed from previous years.
The least successfully completed assignment was the oral presentation. This reflects the significant difficulty students had in understanding and therefore being able to critically review literature on the topic of their choice. This assignment also brought in other skills which had been developed over the course, including skills in referencing and oral presentation skills in themselves. The latter was perhaps the area where most improvement was demonstrated, with referencing style being disappointingly careless in many cases. Considering that by the time students gave their oral presentation, all had passed the plagiarism assignment, some doubts have been raised as to its effectiveness in teaching students how to reference correctly.
The staff members who marked the letters and the reflective journals both indicated that the assessment items were generally well done by students and that as assessment tasks they were appropriate in preparing students for further study in the program. Particularly in letter writing skills there appeared to be significant improvement compared with skills demonstrated by students in previous years, reflecting the usefulness of increased practice and feedback provided throughout the course.
The aim of the curriculum review presented in this paper was to redevelop a course to better align with principles of 'internationalisation of the curriculum', seeking to avoid a deficit model of meeting international students' needs. International students come to learn physiotherapy skills, but in order to do so successfully they need to manage culturally different education and health care systems. Deciding how to assist them with this without devaluing their own cultural ways of learning or practicing and unnecessarily imposing Australian or western norms was a key question that guided decisions made in the review. The changes made were based on a review of literature on teaching international students and individual and collaborative reflection on practice amongst staff teaching in the Physiotherapy Masters Program.
Evaluation of the changes reveals that the intentions of increasing students' confidence in communication with patients and doctors in the Australian health care environment and increasing their understanding of the role of cultural competence in physiotherapy practice were at least in part achieved. Staff who co-assessed the written professional communication and culture and communication reflective journal assignments were positive about the skills demonstrated by students in these tasks and the value of the assignments in promoting the learning required. However, the aim of increasing students' understanding of research was not achieved, and this was reflected in the poor performance in the oral presentation. Significantly, this review has highlighted the problem that international students from the subcontinent face in understanding research and the disadvantage that this causes them in assignments requiring a critical analysis of literature. As a result, a wider program review has been prompted in order to ensure that students' learning needs in this area are better met. Timing of courses within the program and timing of assessment items within courses, are being discussed as part of this review, to ensure that this skill is taught and assessed effectively and in such a way that disadvantage to international students is minimised. In LCP specifically, classes addressing the understanding and critique of literature are being augmented in 2005, as this is the first course in which students encounter the need to be able to critically review literature.
Ultimately the most useful feedback as to whether students seem better prepared for the rest of the program, particularly the clinical components, will come from both students and clinical supervisors when the students attend placements in health care settings. Interviews with both students and staff regarding students' confidence and competence in the clinical arena are planned, and this feedback will be incorporated into further planning for changes to LCP. Particular feedback will be sought on the activities and knowledge gained during LCP which students have found most useful in preparing them for clinic. Equally, ideas on any activities considered not useful, or new activities that students would suggest for inclusion will be sought.
Reflective practise on the part of the course coordinator and other staff involved in teaching LCP was a key process involved in the course review and evaluation. In attempting to design learning activities to support the aim of developing students' cultural competence, deep reflection on teachers' own values, expectations and attitudes towards students was required. This kind of reflective practice does not only provide outcomes for students. It also furthers teachers' own journeys into the challenging and ever evolving experience of cultural competence. Internationalisation of the curriculum is certainly not as simple as increasing the intake of international students. In order to promote the development of culturally aware and responsive students, University staff need to be prepared to walk that road themselves.
The experience of undertaking a review involving collaborative reflection on teaching has been of great use in increasing the understanding of students' needs, and in gaining insights into the very practical level of curriculum design to achieve required learning outcomes. Immersing this in an overarching goal of more sensitively and fairly providing education to international students has been personally challenging.
To embrace principles of 'internationalisation of the curriculum' and avoid a course that follows a deficit model of "patching up" students to fit Australian norms, it was decided to focus on the development of cultural competence in students, so that they could reflect on their own practice and on practice as they learn it here, recognise differences and adjust. Evaluation of changes made to LCP has revealed that some measures introduced were helpful in achieving this aim whilst others need significant revision. This course review has prompted further course-specific modifications for this year as well as wider review of the structure of the entire program.
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