Graduate reflections on Community Service, a view of roles in practice

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The transition is complicated by the shortage of rehabilitation personnel, especially in rural and peri-urban areas. While higher education curricula should prepare students for the workplace, the roles and expectations of new therapists remain unclear. Assessing how well current curricula, incorporating the CanMEDS framework, equip students with the knowledge, skills, and attitudes for entry-level CS practice will help to improve physiotherapy training practices. This study investigated the experiences of CS physiotherapists to inform curriculum design and graduate outcomes. Methods A descriptive qualitative study was conducted. Graduates were recruited during their CS year via a class group contact, with a snowballing approach to diversify the sample. Semi structured interviews were conducted over MS Teams, recorded, and transcribed. Reflexive deductive coding was used to interpret the data, which was analysed according to the CanMEDS roles and graduate outcomes, as well as barriers and facilitators during their transition to the workplace. Results Ten CS physiotherapists placed in five of the nine provinces participated. Most identified strongly with their core role as clinicians and felt well prepared for clinical service. However, aspects of roles linked to advocacy, leadership, and professionalism were more complex to navigate. The contexts of placements and the nuances of how the healthcare system operated in each province also impacted their experience. Conclusion Discussions revealed that the physiotherapy curriculum effectively prepared graduates in roles drawing on skills, theoretical principles, clinical reasoning, and lifelong learning. However, exposure to outcomes in roles as leaders, collaborators, and advocates were somewhat limited. These aspects were often not explicitly taught and impacted their transition. These roles, however, became areas of significant personal and professional growth during CS. The learning context is crucial, and embedding placements in more diverse settings could improve graduates' readiness. Where diverse placements are not feasible, curriculum design should ensure graduates can apply their skills in various settings. The variable professional support during CS suggests a need for an audit or policy review by professional and accreditation bodies. Community Service Physiotherapist Entry level practice Graduate Roles Graduate outcomes Curriculum BACKGROUND The purpose of professional academic curricula within the higher education sector is to prepare graduates to succeed within their chosen profession while meeting the demands of the workplace [ 1 , 2 ]. In the field of Physiotherapy, the World Physiotherapy (WPT) education framework [ 3 ] provides guidelines on the curriculum structure of entry-level programmes. These guidelines allow institutions the flexibility to develop programmes around their unique contexts. However, it mandates that graduates provide evidence of and have achieved “specific knowledge, skills, and attitudes according to the entry to practice threshold competence” at the end of their education [ 4 ] (pg. 24). To meet these requirements, a 4-year entry programme must encompass exposure and learning experiences in “the basic, social and clinical sciences, evidence-based practice, skills and training for physiotherapy competence and practice exposure” [ 3 ] (pg. 29). Health professions educators need to ensure their curricula meet both global professional guidelines and are also responsive to the needs of their context. In its simplest form, a professional curriculum can be seen as “a statement about what is worth knowing and how to go about learning” [ 2 ] (pg. 445). However, curricula need to be responsive to real-life demands and instil in graduates not just knowledge but ways of being and understanding the profession. Educators on professional programmes are increasingly being tasked with the responsibility to consider how to enhance both generic graduate abilities and disciplinary expertise, and to produce graduates who possess the correct knowledge, skills, and values to contribute to local and global communities [ 5 ]. There is a need to align graduate (attributes) outcomes to the realities of practice context, to make them relevant and meaningful, mindful of the complexities of practice and to allow them to speak to both policy and pedagogy [ 6 ]. This alignment should help graduates better transition into practice. While Physiotherapy as an autonomous profession has been developed with strong similarities to the development and practice of medicine [ 7 , 8 ], physiotherapists (PT) increasingly have to assert themselves and clarify their role within workplace settings. Challenges arise from the increasingly aging patient demographic and the escalating burden of chronic illnesses. Physiotherapists need to take on multiple roles, engaging with more than just knowledge and skills, to improve healthcare outcomes. This expands their role beyond just curative impairment-focused approaches to incorporating aspects of prevention and health promotion considering broader patient participation. Workplace success is determined by the ability to adapt to the clinical and health system complexity and take on multiple ways of being. While it is expected that undergraduate (UG) training should expose students to both the explicit and implicit practice of the profession, it does not always do this. Since the early 2000s, education and training in the discipline of medicine has strongly shifted in focus to include more competency-based curricula such as the CanMEDS framework [ 9 ]. While this framework was designed to guide the roles and competencies expected of expert physicians, it has since been adopted and adapted for training of other health professions. In 2014, the Health Professions Council of South Africa (HPCSA) in collaboration with stakeholders, including Higher education training institutions, published an amended version of the CanMEDS framework emphasising the expected competencies for UG Health Science students in clinical associations, dentistry, and medical training programmes in South Africa (SA), commonly referred to as the AfriMEDS [ 10 ]. This curriculum regulatory framework is often referred to in relation to training of the Health and Rehabilitation disciplines, yet the potential lack of information on the true scope or expectations around practice for these disciplines within the South African context questions the relevance of the expectations of the AfriMEDS. Considering both the HPCSA document as well as the original CanMEDS, the Physiotherapy division at the University of Cape Town (UCT) adopted an approach to curriculum design that sought to align its graduate outcomes to those within the CanMeds framework. The process entailed the mapping of core competencies for students to attain within the existing curriculum structure. The process resulted in a graduate outcomes document for Physiotherapy training at the institution, aligned to the roles and competencies within the CanMEDS framework. While some outcomes for knowledge, skills, and professional behaviours of the PT as a clinician, communicator, and even researcher are easily monitored and evaluated within the classroom and clinical settings, it is noted that other roles such that of a collaborator, advocate, or manager are more difficult to achieve or monitor within the UG training settings. The difficulty to evaluate the different roles in an equitable manner adds to the complexity of assessing the overall readiness of graduates to practice in the complex SA healthcare settings, where these skills are to be applied. Context Within SA, all graduating Health Science students are expected to complete a mandatory renumerated year of community service (CS) before being registered for independent practice by the HPCSA. Using the CS placement, the SA Department of Health (DoH) plans to expand health care delivery and rehabilitation services by placing therapists in rural and district settings within SA. Currently, approximately 80% of the SA population is serviced in public (government-owned) healthcare facilities [ 11 ], yet these state facilities are often under-resourced. Reports have indicated that up to 70% of all registered doctors are employed by private facilities within SA [ 11 ]. This situation is exacerbated within rural areas, where the ability to retain medical personnel remains problematic. Current records suggest that there are approximately 8000 registered PTs in SA. However, it is estimated that only 1500 are employed in public state-funded facilities. The patient:physiotherapist ratio falls well below the global norm and affects the ability to deliver critical rehabilitation and advocate for the prevention of long-term disability within community settings [ 12 ]. The healthcare needs of South African communities are complex. Faced with a quadruple burden of disease and a growing, yet ageing, population requires multiple approaches from a variety of healthcare workers across all levels of the healthcare system. The need to train health professionals who are competent to manage non-communicable lifestyle conditions in increasingly complex and multicultural settings are therefore important. In a review, Dean [ 13 ] emphasised the potential role of PTs in community settings because they are both “uniquely qualified and positioned to promote healthy communities through the health of its practising individuals” (pg. 345). This way of practicing as a PT illustrates an approach beyond the current narrow curative focus towards empowering people to heal through the delivery of appropriate, cost-effective care. Achieving this goal will require graduates to demonstrate expertise beyond knowledge and skills as normally acquired in traditional clinic or hospital settings. They will need exposure to community settings including schools and facilities where their clients will include multiple and diverse stakeholders. This approach will help them to structure patient education and achieve cultural competence as core attributes as required for contemporary practice [ 13 ]. Universities are expected to equip graduates with the necessary skills and attributes to cope and work independently as generalists in all levels of the healthcare service. Graduates should therefore be able to transition, adapt, and practice effectively in any CS setting. Entry-level PTs are, however, expected to transition into a healthcare system that is fraught with challenges and complexities. Although exposed to aspects of this dysfunction as UGs, they are somewhat buffered in this role by their mentors, educators, and clinicians who assist with navigating this complexity and who typically protect UG students from full accountability and complex decision-making. Internationally, CS or internships are not universally required for graduating physiotherapists; however, research highlights the challenges faced by new graduates transitioning into entry-level practice. A study from the United Kingdom reported that while graduates possessed the necessary knowledge and skills, they identified gaps in cultural awareness, diversity, and the application of knowledge to practice. [ 14 ] Similarly, an Australian study revealed that new graduates in public healthcare settings struggled with workload demands and navigating complex cases they had not encountered during their student training. [ 15 ] Notably, authentic clinical exposure during UG education significantly impacts overall student competency and the ability to transition into the workplace. Similar evidence exists within the SA context regarding the experiences of Physiotherapy graduates at the CS level, leading to questions around the effectiveness of local physiotherapy curricula to prepare graduates for practice, often in unfamiliar community settings. Nadasan and Chetty [ 16 ] explored the barriers and facilitators to successful entry into practice for CS therapists, and the influence of the UG curriculum on their perceptions of preparedness. Their study identified the critical role of the clinical education framework and clinical supervision in preparing students for practice. Where the clinical supervision structure and organisational barriers affected the placement quality, this was seen to inhibit progress and readiness to practice. They also reported that while CS practitioners initially lacked confidence, managerial skills, and flexibility to work in teams that impacted their integration to practice, this improved throughout the CS year. Similar findings were reported in a study by Mostert-Wentzel et al. [ 17 ] on community-based PT’s. These findings therefore raise questions about the preparedness of Physiotherapy graduates to navigate the social and health system complexities they encounter as entry-level CS practitioners. Therefore, there remains a need to assess how well current curricula, incorporating the CanMEDS framework with its defined roles, competencies, and graduate outcomes, supports the attainment of knowledge, skills, and attitudes to allow the successful transition of graduates into an entry-level CS work environment. This information will help to evaluate the current training practices for physiotherapy. Aim This study explored the experiences of CS PTs to understand and describe their readiness for entry-level CS practice. There was a particular interest to focus on the roles and expectations of the CS practitioners and their perceptions of how their UG training at the institution of interest may have prepared them for these roles. The study was undertaken as part of a curriculum review process in the discipline of Physiotherapy. METHODS Research design This descriptive qualitative study used semi-structured interviews to collect data from a population of PTs who had graduated from the institution in December 2021 (n = 41). They were purposively selected as all were participating in CS in 2022. Recruitment and sampling Initial contact was made with a former student in regular communication with the researcher. The student was requested to place an initial information message regarding the study on the WhatsApp group used by the CS practitioners for ongoing contact amongst individuals who had graduated from the institution. Those interested in participating were asked to contact the researcher directly for additional information. On contact, additional study details and informed consent information was provided. Sample Twelve individuals indicated their willingness to participate in the study. Ten interviews were conducted over a 6-week period while two interviews were omitted because of scheduling issues. However, it was also considered that a level of saturation had been reached and that the additional two interviews wouldn’t have necessarily added to either diversity of the sample or provided any additional information. Data collection Interviews were conducted via Zoom or Microsoft Teams at a time convenient for each participant. The interviews were structured into two parts. In the initial discussion, participants were asked to describe their roles and responsibilities as CS practitioners. These roles were framed against the UCT graduate outcomes linked to CanMEDS. Following this, specific questions explored how their training had prepared them for CS, as well as gaps, barriers, and facilitators that had helped them to transition into their new role. All participants were known to the researcher in her role as an educator during their UG training. This relationship may have influenced the initial willingness to participate. However, the researcher’s knowledge of the curriculum and training was important to interpret aspects of the feedback from participants. Data was transcribed directly from the recordings and checked by the researcher. The transcription was shared with the participants for clarification and confirmation to ensure trustworthiness. Notes and a summary of each interview were kept by the researcher. The transcribed data was anonymised and any specific reference to individuals or settings was removed before analysis. Data analysis Data was transcribed, stored, and cleaned. Initial analysis was performed through a reflexive deductive process post-interview, using the initial review of transcripts, recordings, and interview notes [ 18 ]. This allowed the researcher to consider the core messages that emerged from the conversation. This interpretation was broadly guided by the graduate outcome framework, the reflection on curriculum content, and the CS structure as described by the participants. A subsequent more detailed analysis allowed specific sub-themes to be identified and explored. These were checked and discussed by the study team. Ethical considerations The study received ethics approval from the UCT Faculty of Health Sciences Human Research Ethics Committee (527/2022). Informed consent was obtained from all participants before the interview and confirmed verbally at the start of the interview process. Anonymity was ensured by the removal of identifiers from the interviews and no specific details of placements, which may have linked participants to sites, was shared in the analysis. All participants could withdraw before the start of the interview process. RESULTS Participants Ten physiotherapy graduates participated in the interviews, 8 females and 2 males. They were all completing their CS year in five of the nine SA provinces, across all levels of healthcare, and in both rural, peri-urban, and urban settings (see Table 1 ). Table 1 Participant Demographics. Participants (n = 10) Gender Male Female 2 8 Province Gauteng (GTG) Western Cape (WC) Mpumalanga (MP) Eastern Cape (EC) KwaZulu Natal (KZN) 2 1 1 2 4 Type of Placement Specialised / Tertiary Hospital District or Provincial Hospital Community Health Care/ Primary Health Care Clinic 2 7 1 Setting Urban Peri- urban Rural 6 3 1 Three themes aligned to the study aims were explored and are discussed below. These included: roles during community service; curriculum barriers or facilitators to transitioning to practice; and personal growth and professional development Roles during community service The participants could all engage easily in their role as clinicians and how they contributed to patient care. They considered themselves sufficiently knowledgeable and skilled to navigate both the in- and outpatient clinical practice areas, which spanned multiple fields. Where gaps were identified – often based on a different burden of disease in specific regions or more specialised exposure - they indicated an ability to apply principles from their UG training or to look for evidence to equip them to manage these specific scenarios ( Table 2 , Quote 1). The participants all also identified with the manager (administrator) role, although the scope of duties and their experiences varied depending on the placement and staffing at each site. While at a basic level, they were often expected to manage booking systems in addition to being responsible for patient notes, statistics, aspects relating to requisitioning equipment, and coordinating transport for outreach ( Table 2 , Quote 2) . Some were more able to step into a leadership role and used opportunities to improve or streamline the range of physiotherapy services at the site. Others took the lead in starting treatment initiatives and developed outreach services. This was often done with little support from senior staff who viewed this as part of the CS practitioners’ job ( Table 2 , Quote 3) . Some participants commented on how their confidence had increased as they noticed the benefits of their improvements. They reportedly struggled more with the logistical understanding of how to launch these projects and they were hampered by a lack of knowledge of hospital or district operational systems and community liaisons on which they could draw. They were aware of the need to use and strengthen opportunities for multidisciplinary service and to develop strong collaborations through their projects. More successful initiatives were reported where the CS PTs collaborated with other CS colleagues, particularly with Occupational Therapists, to coordinate patient care ( Table 2 , Quote 4) . They highlighted the collaborations as hugely valuable in enhancing patient outcomes ( Table 2 , Quote 5 and 6) . In some settings, they noted resistance from senior local staff to multidisciplinary teamwork. These were particular to very high-turnover districts, where workload was seen to present challenges in bringing people together for sessions or consultations. In areas with no other rehabilitation staff, graduates found it more difficult to engage with medical personnel to discuss and plan. This brought awareness to the need to advocate both for their professional role as well as for better health outcomes their patients ( Table 2 , Quote 7 and 8) . All participants were challenged in their roles as professionals and in navigating the work ethics and norms at their placements. They reported being confronted with behaviours and attitudes not aligned with their own or what they had encountered as UG students, which was an ongoing concern ( Table 2 , Quote 9) . The role of the researcher was neither explored nor mentioned in the conversations as it fell outside the scope of expectations of CS practitioners. However, a recognition of the need for lifelong learning and needing to expand knowledge in certain areas did emerge. Table 2 Roles in Community Service. The Clinician 1. "I didn't necessarily have to develop new skills as such as more being fine-tuning of my skills that I got during the studies" (Male, Rural, Provincial, EC). The Manger and Leader 2. “I’ve joined the continuous Professional Development Committee, which is in charge of carrying out the CPD. Also, Resource and quality control. So, where I'm in charge of like stock taking and inventory taking and looking at the finances of things” (Female, Urban, Tertiary, GTG). 3. “Ok, so we, the com serves, we run a Paediatrics clinic. You know and then so that that really like we actually had to pull up our socks and be like leaders and organise that ourselves” (Female, Urban, District, GTG). The Collaborator and Communicator 4. “I'm currently working with the OT, on forming a program for the psychiatric ward where they're going to carry over the activities and run on a program that I'm running with them this year. (But without me), because there was no program prior to me being here ” (Male, Urban Provincial, KZN). 5. “The main one definitely has been with the CBR (community-based rehabilitation) worker as well as CCG (community caregivers). So, it was something I've never really considered. When I was an undergrad. that now life is so important, especially in rural communities where it is difficult for patients to come to clinics or to CHC or to hospital. You know, just having that link between someone that's like in the community knows the people that can tell you this is the situation and then you as a rehab team going out to provide a service” (Female, Rural, Clinic, KZN). 6. “When I was doing neuro, we would have MDT meetings, we would do ward rounds together, myself, the medical Doctor Then there be an OT, a dietitian and a psychologist. And then with all discuss. And then also on Thursdays with meet in a boardroom with the sister to discuss each patient. Like whether we feel like they fit for discharge from our side. And then we decide management going together” (Female, Urban, Tertiary, GTG). The Advocate 7. “I’ve had to advocate for my position as a physiotherapist a lot" (Female, Urban, Tertiary, WC). 8. “Because the CEO also doesn't quite know what a physio does and what my roles and responsibilities are, then it's like, you know what, there is the old -age home. I can go to them, I can service them. So, kind of spearheading that sort of outreach and leading that and, you know just educating the people and the staff in the area as to what kind of a physio does” (Male, Peri-urban, District, EC). The Professional 9. “But this whole thing I feel like work life has been hard to navigate. Like if the work environment is toxic, you know you don't actually really know to navigate that ” (Female, Urban, District, GTG). Barriers and facilitators to practice Participants highlighted that their theoretical training had provided a sufficient knowledge base to support their roles as clinicians ( Table 3 , Quote 1 and 2). This was supported by knowing how to access resources and new knowledge, as well as applying clinical reasoning strategies ( Table 3 , Quote 3 ). They also spoke to the fact that the clinical placement structure of their UG programme had scaffolded their development and generally provided exposure to support their CS role. There is still a cushioning that exists in clinical training as students are buffered by the presence of clinicians and Clinical Educators in managing challenges during placements. This leaves them variably prepared for acting independently ( Table 3 , Quote 4). The contextual differences between their current placements in different provinces (away from their training institution) and more rural settings challenged their integration into their new work environments. This related to multiple aspects including resource allocation, how hospital systems operated, and general support ( Table 3 , Quote 5). A lack of clear mentorship and support in some areas compounded these challenges with line managers and senior staff not always being available for consultation or advice. This was particularly frustrating for graduates who were placed alone at sites with no other rehabilitation staff ( Table 3 , Quote 6). They also noted difficulty to re-initiate services and set up systems in cases where they were alone and where services had been disrupted due to the COVID-19 pandemic. Table 3 Barriers and Facilitators to Transitioning to Practice. Undergraduate Clinical Practice 1. “(Some blocks ) like gave us quite a nice like load like they made us work at a fast pace and everything and really like have to think on your feet and have a plan when you go into work ” (Female, Urban, District, GTG). 2. “I think a lot was to do with the blocks. We didn't really have many blocks in COVID, but just having really, really good supervisors that can help you with that .” (Female, Rural, District, KZN). 3. “The clinical reasoning and like the holistic thinking around any problem that you're faced with, I would say that I was well prepared in that situation. When you when you are faced with something a lot of time there's no one there to diagnose. So, you have to figure it out” (Female, Peri-urban, Provincial, EC). 4. “The other clinicians were there to kind of help you with that type of liaising, whereas now it's kind of you need to ask and you're not entirely often I've found not been entirely sure if it, like, feel like I'm asking a stupid question to a doctor ” (Female, Peri-urban, District, MP). Context of Learning 5. “I t was more literally like how do I work around this, this health, this public health system on this level and what do I do in a situation in this in, in a rural setting like this where there's a lack of a serious lack of resources and a very like, how can I say very stark social economic issues to deal with because it's very difficult you can plan your patients Rehab program, but they might only be able to come to see you once every three weeks, which is ideal for, say, a fracture, and you can make it work. But then I'm not sure like what they actually doing at home to, you know, to actually follow through on the program. Also, there’s a lot of like social economic issues that you have to work around and it's all about context” (Female, Peri-urban, Provincial, EC). 6. “I don't understand that, the organisation, that's the one thing which I had a problem” (Male, Urban, Provincial, KZN). Support and Mentorship 7. “No sort of guidance at all, which has been a little bit of a frustration for me ” (Male, Peri-urban, District, EC). 8. “I didn't find it a very supportive environment, especially in the beginning of the year” (Female, Urban, District, KZN). Personal growth and development Despite being faced with complex and challenging situations, all participants reflected on how the experience had created opportunity for personal ( Table 4 , Quote 4, ,5 and 6) and professional growth ( Table 4 , Quote 1 and 2) . They arrived as new graduates, but the changes and development of confidence were significant. In addition, the exposure to rural settings created a deeper sense of empathy and understanding regarding the impact of poverty on health, which is important for their positioning as healthcare practitioners within the SA context ( Table 4 , Quote 3) . Table 4 Personal Growth and Development. 1. “You kind of arrive at com serve with almost a bit of a like impostor syndrome kind of feeling just because it's the first time you really on your own and like you, the consultants are asking something about physio and like you're the one who has to answer, which is overwhelming” (Female, Urban, District, KZN). 2. “It felt kind of scary just having that responsibility of. OK, so I'm the person that's going to make a decision like for a patient” (Female, Urban, District, GTG). 3. “So, I think you know, living in this Cape Town, city centre, you don't really get exposed to the hardships that rural living can provide or can give. And I think it's helped me just kind of appreciate more the there's a lot more people in the country than you realize and how they're struggling and the things that, the challenges that they face” ( Female, Rural, CHC, KZN). 4. “Like you come away with life skills and, I don't know, grow into yourself like as a person and as a physio in terms of teamwork. And as I said, dealing with difficult situations” (Female, Urban, District, KZN). 5. “On a personal level, I think I've learned to deal with people a lot better than I ever would have been able to and just kind of learning that, you know what? Not everyone's going to be the same as you. But at the end of the day, it doesn't matter what everyone else is doing. You still must hold yourself to a higher standard. So, I think that's been, I think it's taught me quite a lot about who I want to be and who I don't want to be.” (Female, Urban, District, KZN). 6. “Probably learnt a lot more about just living with myself and how to do that and how to keep myself busy” (Female, Peri-urban, Provincial, MP). DISCUSSION Entering the workplace after graduating from higher education institutions can be daunting for many graduates. In Physiotherapy, the work-based curriculum is designed to facilitate graduate entry into practice by aligning to the anticipated demands that may be placed on graduates during CS. Community Service PTs are expected to have met graduate outcomes and should be able to adopt the multiple roles expected from them in practice settings. Our results show that UG training does not prepare them well for all the required roles. Participants could easily identify with the expectation of the role of clinician, and they embraced some of the other roles over time, while there were also roles for which they felt poorly prepared. While the global context of practice may be variable, others have noted similar challenges for graduates entering the profession [ 14 , 15 ]. This study reaffirmed the findings of a study by Nadasan and Chetty [ 16 ] on the design of clinical practice at UG level. That study found that placement structure and the skill of clinical educators’ impact on the graduate’s readiness to practice and their ability to transition successfully into their CS roles. However, its noted that the shielding of UG students from all responsibility or accountability in patient care by supervisors may leave them less confident in decision making and their advocacy roles in multidisciplinary contexts. This finding also resonates with that of Stoikov et al. [ 15 ] who highlighted how UG placements often protect students from complex decision-making and limits their exposure to the full scope of clinician roles, including prioritising patient lists, screening activities, and family meetings around complex cases. In addition, UG students are seldom expected to navigate personality and multiple workplace issues. This lack of experience and skills were challenging to the CS participants in the current study. Ongoing broader clinical exposure to rural and district care settings was highlighted as a factor affecting transition. Whilst most participants had some exposure to peri-urban settings at UG level – they still experienced rural healthcare as being very different to their university’s placement experiences. While this finding suggests that there has been some improvement within curricula design and placement since early studies on the first CS cohort [ 19 ], there are still contextual gaps. It is relevant to note that this cohort had their third clinical year adjusted due to the impact of the COVID-19 pandemic – which impacted their access to the clinical platform at times and to an expanded range of clinical experiences. In addition, as institutional initiatives to place students in rural and peri-urban areas require both financial and logistical arrangements to travel and live away from the metro and the university, we still lack the capacity to expose all students to a broader scope of community practice settings. Graduates in CS placements are supposed to be placed in locations where they can be supported and supervised. Of concern was the fact that the role modelling and professional support that would buffer their integration was either found lacking or absent in some settings. This gap has previously been highlighted in studies on CS and entry practice within the SA context [ 16 , 17 ]. Some senior staff at placement sites were experienced as being disinterested in supporting the new graduate, as well as in patient care. While this may reflect a level of staff burnout in a system under pressure, it does leave new graduates floundering. Practitioners placed alone also lacked input from district staff and, unless they reached out specifically, had to navigate situations on their own. Limitations of the study This study represents the experiences of a single cohort who graduated from the university in the immediate post-Covid period, and the results may not reflect the readiness of graduates from other institutions. While attempts were made to make the sample representative, potential gaps do exist especially related to practice in some of the other provinces. CONCLUSIONS Discussions with graduates revealed important nuances regarding the extent to which the Physiotherapy curriculum had prepared them to transition to the CS practice setting. Graduates were very aware of the level of skills, theoretical principles, clinical reasoning, and lifelong learning they needed to assume some of the roles of practice; yet competencies aligned to their roles as leaders, collaborators, and advocates were experienced less in their UG programmes and sometimes undervalued. These aspects are often not explicitly taught in daily clinical practice and impacts on their successful transition. They were surprised at how much these roles contributed to their overall success and efficacy in CS practice, and these roles also become the areas of biggest personal and professional growth. The context in which learning happens is important. Embedding placements in more diverse settings both geographically and in terms of human and physical resources would potentially change graduates’ perception of their readiness for practice. Where this is not feasible for logistical or financial reasons, curriculum design needs to consider the impact of the curriculum framework on the ability of graduates to think, reason, and apply their skills and abilities into differently resourced practice settings. The professional support experienced by graduates during CS was variable and may need an audit or policy review by the professional and accreditation bodies. Abbreviations CS Community Service DoH Department of Health EC Eastern Cape Province GTG Gauteng Province HPCSA Health Professions Council of South Africa KZN KwaZulu Natal Province MP Mpumalanga Province PT Physiotherapist SA South Africa SASP South African Society for Physiotherapy UCT University of Cape Town UG Undergraduate WC Western Cape Province WPT World Physiotherapy Declarations Ethics approval and consent to participate Ethical approval was granted by the University of Cape Town, Faculty of Health Sciences Human Research Ethics committee (HREC) (527/2022) Consent for publication Not applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding Teaching buyout to facilitate completion of this project was supported by funds from the Faculty of Health Sciences at UCT through the authors participation in the ELF (Educational Leadership Fellowship) Programme. Authors contributions HT developed the project in conjunction with JvW. Results were reviewed and checked with JvW. The data analysis and write up was completed by HT with input on design, interpretation, flow, and discussion from JvW. Authors information HT notes her position as programme convenor and lecturer within the UCT Division of Physiotherapy and her prior involvement with the research participants. References Sole G, Claydon L, Hendrick P, Hagberg J, Jonsson J, Harland T. Employers’ perspectives of competencies and attributes of physiotherapy graduates: an exploratory qualitative study. New Z J Physiotherapy. 2012;40(3):123–7. Barradell S. Moving forth: Imagining physiotherapy education differently. Physiother Theory Pract. 2017;33(6):439–47. World Physiotherapy. Physiotherapist Education Framework. London, UK; 2021. World Physiotherapy. Guidance for Developing a Curriculum for Physiotherapist Entry Level Education Programme. London, UK; 2022. Hill J, Walkington H, France D. Graduate attributes: Implications for higher education practice and policy: Introduction. J Geogr High Educ. 2016;40(2):155–63. Jones E, Killick D. Graduate attributes and the internationalized curriculum: Embedding a global outlook in disciplinary learning outcomes. J Stud Int Educ. 2013;17(2):165–82. Nicholls D, Larmer P. Possible futures for physiotherapy: an exploration of the New Zealand context. New Z J Physiotherapy. 2005;33(2):55. Gibson BE, Nixon SA, Nicholls DA. Critical reflections on the physiotherapy profession in Canada. University of Toronto Press Incorporated; 2010. pp. 98–100. Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010;376(9756):1923–58. Mnguni L. The Curriculum Ideologies Underlying the AfriMEDS Curriculum Framework for Undergraduate Medical and Dental Education in South Africa. Int Med Educ. 2024;3(1):44–61. Ngobeni V, Breitenbach MC, Aye GC. Technical efficiency of provincial public healthcare in South Africa. Cost Eff Resource Allocation. 2020;18:1–19. Tiwari R, Ned L, Chikte U. HRH planning for rehabilitation services: A focus to reduce inter-provincial inequities. South Afr Health Rev. 2020;2020(1):53–63. Dean E. Physical therapy in the 21st century (Part I): toward practice informed by epidemiology and the crisis of lifestyle conditions. Physiother Theory Pract. 2009;25(5–6):330–53. Chesterton P, Chesterton J, Alexanders J. New graduate physiotherapists’ perceived preparedness for clinical practice. A cross-sectional survey. Eur J Physiotherapy. 2023;25(1):33–42. Stoikov S, Maxwell L, Butler J, Shardlow K, Gooding M, Kuys S. The transition from physiotherapy student to new graduate: are they prepared? Physiother Theory Pract. 2022;38(1):101–11. Nadasan T, Chetty V. Preparedness for practice: Physiotherapists view on an undergraduate programme in KwaZulu-Natal, South Africa. Global J Health Sci. 2019;12(1):88. Mostert-Wentzel K, Frantz J, Van Rooijen AJ. A model for community physiotherapy from the perspective of newly graduated physiotherapists as a guide to curriculum revision. Afr J Health Professions Educ. 2013;5(1):19–25. Pope C, Mays N. Qualitative Research in Health Care. 4th ed. Wiley; 2020. Ramklass SS. Physiotherapists in under-resourced South African communities reflect on practice. Health Soc Care Community. 2009;17(5):522–9. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 07 Nov, 2024 Read the published version in BMC Medical Education → Version 1 posted Editorial decision: Revision requested 19 Jun, 2024 Editor assigned by journal 19 Jun, 2024 Submission checks completed at journal 18 Jun, 2024 First submitted to journal 12 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4568716","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":316401112,"identity":"4203ab74-a0fb-4445-a68e-689619d95eb9","order_by":0,"name":"Heather Talberg","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFklEQVRIiWNgGAWjYBACAyBmhjCZ20CkHDFaGJtBDB4GRrAWY7gRRGtJbCCkxZy9+fnjgop7DPbsB9sefNxTm77h+PkDDD9qGOz5G7Brsew5Ztg840wxAw9PYrvhjGfHczecSWZg7DnGwCxxAIfDbiQYNvO2JQAdltgmzXPgWO6GG0CH8TYwsDHg0nL/+cdm3n9ALfwP26T/HDiWbgDUwvi3gYFHHqctPEBbGoBaJIC2MByoSQBpYQbaImGAS8uZnMLZPMcSeHhuPGw37DlwwHDmmWSDwzLHJAwMcWk5fnzDZ56aBDn2/uRjD34cqJPnO37w4cM3NTb2cji0wAAPlD4MJoGKJfCrRwJ1RKscBaNgFIyCkQMAi0db3o7a7NoAAAAASUVORK5CYII=","orcid":"","institution":"University of Cape Town","correspondingAuthor":true,"prefix":"","firstName":"Heather","middleName":"","lastName":"Talberg","suffix":""},{"id":316401113,"identity":"86edbf89-6227-493e-9fa0-4a4a95c418d1","order_by":1,"name":"Jacky van Wyk","email":"","orcid":"","institution":"University of Cape Town","correspondingAuthor":false,"prefix":"","firstName":"Jacky","middleName":"van","lastName":"Wyk","suffix":""}],"badges":[],"createdAt":"2024-06-12 08:37:01","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4568716/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4568716/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12909-024-06265-6","type":"published","date":"2024-11-07T15:57:15+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":68749863,"identity":"9e980600-8907-4107-8662-3725fb17fd1d","added_by":"auto","created_at":"2024-11-11 16:06:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":955605,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4568716/v1/d5f065de-0727-40f9-912f-0c79443b1afb.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Graduate reflections on Community Service, a view of roles in practice","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eThe purpose of professional academic curricula within the higher education sector is to prepare graduates to succeed within their chosen profession while meeting the demands of the workplace [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In the field of Physiotherapy, the World Physiotherapy (WPT) education framework [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] provides guidelines on the curriculum structure of entry-level programmes. These guidelines allow institutions the flexibility to develop programmes around their unique contexts. However, it mandates that graduates provide evidence of and have achieved \u0026ldquo;specific knowledge, skills, and attitudes according to the entry to practice threshold competence\u0026rdquo; at the end of their education [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] (pg. 24). To meet these requirements, a 4-year entry programme must encompass exposure and learning experiences in \u0026ldquo;the basic, social and clinical sciences, evidence-based practice, skills and training for physiotherapy competence and practice exposure\u0026rdquo; [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] (pg. 29).\u003c/p\u003e \u003cp\u003e Health professions educators need to ensure their curricula meet both global professional guidelines and are also responsive to the needs of their context. In its simplest form, a professional curriculum can be seen as \u0026ldquo;a statement about what is worth knowing and how to go about learning\u0026rdquo; [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] (pg. 445). However, curricula need to be responsive to real-life demands and instil in graduates not just knowledge but ways of being and understanding the profession. Educators on professional programmes are increasingly being tasked with the responsibility to consider how to enhance both generic graduate abilities and disciplinary expertise, and to produce graduates who possess the correct knowledge, skills, and values to contribute to local and global communities [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. There is a need to align graduate (attributes) outcomes to the realities of practice context, to make them relevant and meaningful, mindful of the complexities of practice and to allow them to speak to both policy and pedagogy [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This alignment should help graduates better transition into practice.\u003c/p\u003e \u003cp\u003eWhile Physiotherapy as an autonomous profession has been developed with strong similarities to the development and practice of medicine [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], physiotherapists (PT) increasingly have to assert themselves and clarify their role within workplace settings.\u003c/p\u003e \u003cp\u003eChallenges arise from the increasingly aging patient demographic and the escalating burden of chronic illnesses. Physiotherapists need to take on multiple roles, engaging with more than just knowledge and skills, to improve healthcare outcomes. This expands their role beyond just curative impairment-focused approaches to incorporating aspects of prevention and health promotion considering broader patient participation. Workplace success is determined by the ability to adapt to the clinical and health system complexity and take on multiple ways of being. While it is expected that undergraduate (UG) training should expose students to both the explicit and implicit practice of the profession, it does not always do this.\u003c/p\u003e \u003cp\u003eSince the early 2000s, education and training in the discipline of medicine has strongly shifted in focus to include more competency-based curricula such as the CanMEDS framework [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. While this framework was designed to guide the roles and competencies expected of expert physicians, it has since been adopted and adapted for training of other health professions.\u003c/p\u003e \u003cp\u003eIn 2014, the Health Professions Council of South Africa (HPCSA) in collaboration with stakeholders, including Higher education training institutions, published an amended version of the CanMEDS framework emphasising the expected competencies for UG Health Science students in clinical associations, dentistry, and medical training programmes in South Africa (SA), commonly referred to as the AfriMEDS [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This curriculum regulatory framework is often referred to in relation to training of the Health and Rehabilitation disciplines, yet the potential lack of information on the true scope or expectations around practice for these disciplines within the South African context questions the relevance of the expectations of the AfriMEDS.\u003c/p\u003e \u003cp\u003eConsidering both the HPCSA document as well as the original CanMEDS, the Physiotherapy division at the University of Cape Town (UCT) adopted an approach to curriculum design that sought to align its graduate outcomes to those within the CanMeds framework. The process entailed the mapping of core competencies for students to attain within the existing curriculum structure. The process resulted in a graduate outcomes document for Physiotherapy training at the institution, aligned to the roles and competencies within the CanMEDS framework.\u003c/p\u003e \u003cp\u003eWhile some outcomes for knowledge, skills, and professional behaviours of the PT as a clinician, communicator, and even researcher are easily monitored and evaluated within the classroom and clinical settings, it is noted that other roles such that of a collaborator, advocate, or manager are more difficult to achieve or monitor within the UG training settings. The difficulty to evaluate the different roles in an equitable manner adds to the complexity of assessing the overall readiness of graduates to practice in the complex SA healthcare settings, where these skills are to be applied.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eContext\u003c/h2\u003e \u003cp\u003eWithin SA, all graduating Health Science students are expected to complete a mandatory renumerated year of community service (CS) before being registered for independent practice by the HPCSA. Using the CS placement, the SA Department of Health (DoH) plans to expand health care delivery and rehabilitation services by placing therapists in rural and district settings within SA. Currently, approximately 80% of the SA population is serviced in public (government-owned) healthcare facilities [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], yet these state facilities are often under-resourced. Reports have indicated that up to 70% of all registered doctors are employed by private facilities within SA [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. This situation is exacerbated within rural areas, where the ability to retain medical personnel remains problematic.\u003c/p\u003e \u003cp\u003eCurrent records suggest that there are approximately 8000 registered PTs in SA. However, it is estimated that only 1500 are employed in public state-funded facilities. The patient:physiotherapist ratio falls well below the global norm and affects the ability to deliver critical rehabilitation and advocate for the prevention of long-term disability within community settings [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe healthcare needs of South African communities are complex. Faced with a quadruple burden of disease and a growing, yet ageing, population requires multiple approaches from a variety of healthcare workers across all levels of the healthcare system. The need to train health professionals who are competent to manage non-communicable lifestyle conditions in increasingly complex and multicultural settings are therefore important. In a review, Dean [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] emphasised the potential role of PTs in community settings because they are both \u0026ldquo;uniquely qualified and positioned to promote healthy communities through the health of its practising individuals\u0026rdquo; (pg. 345). This way of practicing as a PT illustrates an approach beyond the current narrow curative focus towards empowering people to heal through the delivery of appropriate, cost-effective care. Achieving this goal will require graduates to demonstrate expertise beyond knowledge and skills as normally acquired in traditional clinic or hospital settings. They will need exposure to community settings including schools and facilities where their clients will include multiple and diverse stakeholders. This approach will help them to structure patient education and achieve cultural competence as core attributes as required for contemporary practice [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUniversities are expected to equip graduates with the necessary skills and attributes to cope and work independently as generalists in all levels of the healthcare service. Graduates should therefore be able to transition, adapt, and practice effectively in any CS setting. Entry-level PTs are, however, expected to transition into a healthcare system that is fraught with challenges and complexities. Although exposed to aspects of this dysfunction as UGs, they are somewhat buffered in this role by their mentors, educators, and clinicians who assist with navigating this complexity and who typically protect UG students from full accountability and complex decision-making.\u003c/p\u003e \u003cp\u003eInternationally, CS or internships are not universally required for graduating physiotherapists; however, research highlights the challenges faced by new graduates transitioning into entry-level practice. A study from the United Kingdom reported that while graduates possessed the necessary knowledge and skills, they identified gaps in cultural awareness, diversity, and the application of knowledge to practice. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] Similarly, an Australian study revealed that new graduates in public healthcare settings struggled with workload demands and navigating complex cases they had not encountered during their student training. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] Notably, authentic clinical exposure during UG education significantly impacts overall student competency and the ability to transition into the workplace.\u003c/p\u003e \u003cp\u003eSimilar evidence exists within the SA context regarding the experiences of Physiotherapy graduates at the CS level, leading to questions around the effectiveness of local physiotherapy curricula to prepare graduates for practice, often in unfamiliar community settings. Nadasan and Chetty [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] explored the barriers and facilitators to successful entry into practice for CS therapists, and the influence of the UG curriculum on their perceptions of preparedness. Their study identified the critical role of the clinical education framework and clinical supervision in preparing students for practice. Where the clinical supervision structure and organisational barriers affected the placement quality, this was seen to inhibit progress and readiness to practice. They also reported that while CS practitioners initially lacked confidence, managerial skills, and flexibility to work in teams that impacted their integration to practice, this improved throughout the CS year. Similar findings were reported in a study by Mostert-Wentzel et al. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] on community-based PT\u0026rsquo;s. These findings therefore raise questions about the preparedness of Physiotherapy graduates to navigate the social and health system complexities they encounter as entry-level CS practitioners.\u003c/p\u003e \u003cp\u003eTherefore, there remains a need to assess how well current curricula, incorporating the CanMEDS framework with its defined roles, competencies, and graduate outcomes, supports the attainment of knowledge, skills, and attitudes to allow the successful transition of graduates into an entry-level CS work environment. This information will help to evaluate the current training practices for physiotherapy.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eAim\u003c/h2\u003e \u003cp\u003eThis study explored the experiences of CS PTs to understand and describe their readiness for entry-level CS practice. There was a particular interest to focus on the roles and expectations of the CS practitioners and their perceptions of how their UG training at the institution of interest may have prepared them for these roles. The study was undertaken as part of a curriculum review process in the discipline of Physiotherapy.\u003c/p\u003e \u003c/div\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eResearch design\u003c/h2\u003e \u003cp\u003eThis descriptive qualitative study used semi-structured interviews to collect data from a population of PTs who had graduated from the institution in December 2021 (n\u0026thinsp;=\u0026thinsp;41). They were purposively selected as all were participating in CS in 2022.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eRecruitment and sampling\u003c/h2\u003e \u003cp\u003eInitial contact was made with a former student in regular communication with the researcher. The student was requested to place an initial information message regarding the study on the WhatsApp group used by the CS practitioners for ongoing contact amongst individuals who had graduated from the institution. Those interested in participating were asked to contact the researcher directly for additional information. On contact, additional study details and informed consent information was provided.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eSample\u003c/h2\u003e \u003cp\u003eTwelve individuals indicated their willingness to participate in the study. Ten interviews were conducted over a 6-week period while two interviews were omitted because of scheduling issues. However, it was also considered that a level of saturation had been reached and that the additional two interviews wouldn\u0026rsquo;t have necessarily added to either diversity of the sample or provided any additional information.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eInterviews were conducted via Zoom or Microsoft Teams at a time convenient for each participant. The interviews were structured into two parts. In the initial discussion, participants were asked to describe their roles and responsibilities as CS practitioners. These roles were framed against the UCT graduate outcomes linked to CanMEDS. Following this, specific questions explored how their training had prepared them for CS, as well as gaps, barriers, and facilitators that had helped them to transition into their new role.\u003c/p\u003e \u003cp\u003eAll participants were known to the researcher in her role as an educator during their UG training. This relationship may have influenced the initial willingness to participate. However, the researcher\u0026rsquo;s knowledge of the curriculum and training was important to interpret aspects of the feedback from participants. Data was transcribed directly from the recordings and checked by the researcher. The transcription was shared with the participants for clarification and confirmation to ensure trustworthiness. Notes and a summary of each interview were kept by the researcher. The transcribed data was anonymised and any specific reference to individuals or settings was removed before analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eData was transcribed, stored, and cleaned. Initial analysis was performed through a reflexive deductive process post-interview, using the initial review of transcripts, recordings, and interview notes [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. This allowed the researcher to consider the core messages that emerged from the conversation. This interpretation was broadly guided by the graduate outcome framework, the reflection on curriculum content, and the CS structure as described by the participants. A subsequent more detailed analysis allowed specific sub-themes to be identified and explored. These were checked and discussed by the study team.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eEthical considerations\u003c/h2\u003e \u003cp\u003e The study received ethics approval from the UCT Faculty of Health Sciences Human Research Ethics Committee (527/2022). Informed consent was obtained from all participants before the interview and confirmed verbally at the start of the interview process. Anonymity was ensured by the removal of identifiers from the interviews and no specific details of placements, which may have linked participants to sites, was shared in the analysis. All participants could withdraw before the start of the interview process.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eTen physiotherapy graduates participated in the interviews, 8 females and 2 males. They were all completing their CS year in five of the nine SA provinces, across all levels of healthcare, and in both rural, peri-urban, and urban settings (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant Demographics.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParticipants (n\u0026thinsp;=\u0026thinsp;10)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProvince\u003c/p\u003e \u003cp\u003e\u003cem\u003eGauteng (GTG)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eWestern Cape (WC)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eMpumalanga (MP)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eEastern Cape (EC)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eKwaZulu Natal (KZN)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of Placement\u003c/p\u003e \u003cp\u003e\u003cem\u003eSpecialised / Tertiary Hospital\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eDistrict or Provincial Hospital\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eCommunity Health Care/ Primary Health Care Clinic\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e7\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSetting\u003c/p\u003e \u003cp\u003e\u003cem\u003eUrban\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003ePeri- urban\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eRural\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThree themes aligned to the study aims were explored and are discussed below. These included:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eroles during community service;\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ecurriculum barriers or facilitators to transitioning to practice; and\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003epersonal growth and professional development\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eRoles during community service\u003c/h2\u003e \u003cp\u003eThe participants could all engage easily in their role as clinicians and how they contributed to patient care. They considered themselves sufficiently knowledgeable and skilled to navigate both the in- and outpatient clinical practice areas, which spanned multiple fields. Where gaps were identified \u0026ndash; often based on a different burden of disease in specific regions or more specialised exposure - they indicated an ability to apply principles from their UG training or to look for evidence to equip them to manage these specific scenarios \u003cem\u003e(\u003c/em\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, \u003cem\u003eQuote 1).\u003c/em\u003e\u003c/p\u003e \u003cp\u003eThe participants all also identified with the manager (administrator) role, although the scope of duties and their experiences varied depending on the placement and staffing at each site. While at a basic level, they were often expected to manage booking systems in addition to being responsible for patient notes, statistics, aspects relating to requisitioning equipment, and coordinating transport for outreach \u003cem\u003e(\u003c/em\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, \u003cem\u003eQuote 2)\u003c/em\u003e. Some were more able to step into a leadership role and used opportunities to improve or streamline the range of physiotherapy services at the site. Others took the lead in starting treatment initiatives and developed outreach services. This was often done with little support from senior staff who viewed this as part of the CS practitioners\u0026rsquo; job \u003cem\u003e(\u003c/em\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, \u003cem\u003eQuote 3)\u003c/em\u003e.\u003c/p\u003e \u003cp\u003eSome participants commented on how their confidence had increased as they noticed the benefits of their improvements. They reportedly struggled more with the logistical understanding of how to launch these projects and they were hampered by a lack of knowledge of hospital or district operational systems and community liaisons on which they could draw.\u003c/p\u003e \u003cp\u003eThey were aware of the need to use and strengthen opportunities for multidisciplinary service and to develop strong collaborations through their projects. More successful initiatives were reported where the CS PTs collaborated with other CS colleagues, particularly with Occupational Therapists, to coordinate patient care \u003cem\u003e(\u003c/em\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, \u003cem\u003eQuote 4)\u003c/em\u003e. They highlighted the collaborations as hugely valuable in enhancing patient outcomes \u003cem\u003e(\u003c/em\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, \u003cem\u003eQuote 5 and 6)\u003c/em\u003e. In some settings, they noted resistance from senior local staff to multidisciplinary teamwork. These were particular to very high-turnover districts, where workload was seen to present challenges in bringing people together for sessions or consultations. In areas with no other rehabilitation staff, graduates found it more difficult to engage with medical personnel to discuss and plan. This brought awareness to the need to advocate both for their professional role as well as for better health outcomes their patients \u003cem\u003e(\u003c/em\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, \u003cem\u003eQuote 7 and 8)\u003c/em\u003e.\u003c/p\u003e \u003cp\u003eAll participants were challenged in their roles as professionals and in navigating the work ethics and norms at their placements. They reported being confronted with behaviours and attitudes not aligned with their own or what they had encountered as UG students, which was an ongoing concern \u003cem\u003e(\u003c/em\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, \u003cem\u003eQuote 9)\u003c/em\u003e.\u003c/p\u003e \u003cp\u003eThe role of the researcher was neither explored nor mentioned in the conversations as it fell outside the scope of expectations of CS practitioners. However, a recognition of the need for lifelong learning and needing to expand knowledge in certain areas did emerge.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRoles in Community Service.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe Clinician\u003c/p\u003e \u003cp\u003e1. \u003cem\u003e\"I didn't necessarily have to develop new skills as such as more being fine-tuning of my skills that I got during the studies\"\u003c/em\u003e (Male, Rural, Provincial, EC).\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eThe Manger and Leader\u003c/b\u003e\u003c/p\u003e \u003cp\u003e2. \u003cem\u003e\u0026ldquo;I\u0026rsquo;ve joined the continuous Professional Development Committee, which is in charge of carrying out the CPD. Also, Resource and quality control. So, where I'm in charge of like stock taking and inventory taking and looking at the finances of things\u0026rdquo;\u003c/em\u003e (Female, Urban, Tertiary, GTG).\u003c/p\u003e \u003cp\u003e3. \u003cem\u003e\u0026ldquo;Ok, so we, the com serves, we run a Paediatrics clinic. You know and then so that that really like we actually had to pull up our socks and be like leaders and organise that ourselves\u0026rdquo;\u003c/em\u003e (Female, Urban, District, GTG).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eThe Collaborator and Communicator\u003c/b\u003e\u003c/p\u003e \u003cp\u003e4. \u003cem\u003e\u0026ldquo;I'm currently working with the OT, on forming a program for the psychiatric ward where they're going to carry over the activities and run on a program that I'm running with them this year. (But without me), because there was no program prior to me being here\u003c/em\u003e\u0026rdquo; (Male, Urban Provincial, KZN).\u003c/p\u003e \u003cp\u003e5. \u003cem\u003e\u0026ldquo;The main one definitely has been with the CBR (community-based rehabilitation) worker as well as CCG (community caregivers). So, it was something I've never really considered. When I was an undergrad. that now life is so important, especially in rural communities where it is difficult for patients to come to clinics or to CHC or to hospital. You know, just having that link between someone that's like in the community knows the people that can tell you this is the situation and then you as a rehab team going out to provide a service\u0026rdquo;\u003c/em\u003e (Female, Rural, Clinic, KZN).\u003c/p\u003e \u003cp\u003e6. \u003cem\u003e\u0026ldquo;When I was doing neuro, we would have MDT meetings, we would do ward rounds together, myself, the medical Doctor Then there be an OT, a dietitian and a psychologist. And then with all discuss. And then also on Thursdays with meet in a boardroom with the sister to discuss each patient. Like whether we feel like they fit for discharge from our side. And then we decide management going together\u0026rdquo;\u003c/em\u003e (Female, Urban, Tertiary, GTG).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe Advocate\u003c/p\u003e \u003cp\u003e7. \u003cem\u003e\u0026ldquo;I\u0026rsquo;ve had to advocate for my position as a physiotherapist a lot\"\u003c/em\u003e (Female, Urban, Tertiary, WC).\u003c/p\u003e \u003cp\u003e8. \u003cem\u003e\u0026ldquo;Because the CEO also doesn't quite know what a physio does and what my roles and responsibilities are, then it's like, you know what, there is the old -age home. I can go to them, I can service them. So, kind of spearheading that sort of outreach and leading that and, you know just educating the people and the staff in the area as to what kind of a physio does\u0026rdquo;\u003c/em\u003e (Male, Peri-urban, District, EC).\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eThe Professional\u003c/b\u003e\u003c/p\u003e \u003cp\u003e9. \u003cem\u003e\u0026ldquo;But this whole thing I feel like work life has been hard to navigate. Like if the work environment is toxic, you know you don't actually really know to navigate that\u003c/em\u003e\u0026rdquo; (Female, Urban, District, GTG).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eBarriers and facilitators to practice\u003c/h2\u003e \u003cp\u003eParticipants highlighted that their theoretical training had provided a sufficient knowledge base to support their roles as clinicians \u003cem\u003e(\u003c/em\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, \u003cem\u003eQuote 1 and 2).\u003c/em\u003e This was supported by knowing how to access resources and new knowledge, as well as applying clinical reasoning strategies \u003cem\u003e(\u003c/em\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, \u003cem\u003eQuote 3\u003c/em\u003e). They also spoke to the fact that the clinical placement structure of their UG programme had scaffolded their development and generally provided exposure to support their CS role. There is still a cushioning that exists in clinical training as students are buffered by the presence of clinicians and Clinical Educators in managing challenges during placements. This leaves them variably prepared for acting independently \u003cem\u003e(\u003c/em\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, \u003cem\u003eQuote 4).\u003c/em\u003e\u003c/p\u003e \u003cp\u003eThe contextual differences between their current placements in different provinces (away from their training institution) and more rural settings challenged their integration into their new work environments. This related to multiple aspects including resource allocation, how hospital systems operated, and general support \u003cem\u003e(\u003c/em\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, \u003cem\u003eQuote 5).\u003c/em\u003e A lack of clear mentorship and support in some areas compounded these challenges with line managers and senior staff not always being available for consultation or advice. This was particularly frustrating for graduates who were placed alone at sites with no other rehabilitation staff \u003cem\u003e(\u003c/em\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, \u003cem\u003eQuote 6).\u003c/em\u003e They also noted difficulty to re-initiate services and set up systems in cases where they were alone and where services had been disrupted due to the COVID-19 pandemic.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBarriers and Facilitators to Transitioning to Practice.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUndergraduate Clinical Practice\u003c/p\u003e \u003cp\u003e1. \u003cem\u003e\u0026ldquo;(Some blocks\u003c/em\u003e) \u003cem\u003elike gave us quite a nice like load like they made us work at a fast pace and everything and really like have to think on your feet and have a plan when you go into work\u003c/em\u003e\u0026rdquo; (Female, Urban, District, GTG).\u003c/p\u003e \u003cp\u003e2. \u003cem\u003e\u0026ldquo;I think a lot was to do with the blocks. We didn't really have many blocks in COVID, but just having really, really good supervisors that can help you with that\u003c/em\u003e.\u0026rdquo; (Female, Rural, District, KZN).\u003c/p\u003e \u003cp\u003e3. \u003cem\u003e\u0026ldquo;The clinical reasoning and like the holistic thinking around any problem that you're faced with, I would say that I was well prepared in that situation. When you when you are faced with something a lot of time there's no one there to diagnose. So, you have to figure it out\u0026rdquo;\u003c/em\u003e (Female, Peri-urban, Provincial, EC).\u003c/p\u003e \u003cp\u003e4. \u003cem\u003e\u0026ldquo;The other clinicians were there to kind of help you with that type of liaising, whereas now it's kind of you need to ask and you're not entirely often I've found not been entirely sure if it, like, feel like I'm asking a stupid question to a doctor\u003c/em\u003e\u0026rdquo; (Female, Peri-urban, District, MP).\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eContext of Learning\u003c/b\u003e\u003c/p\u003e \u003cp\u003e5. \u0026ldquo;I\u003cem\u003et was more literally like how do I work around this, this health, this public health system on this level and what do I do in a situation in this in, in a rural setting like this where there's a lack of a serious lack of resources and a very like, how can I say very stark social economic issues to deal with because it's very difficult you can plan your patients Rehab program, but they might only be able to come to see you once every three weeks, which is ideal for, say, a fracture, and you can make it work. But then I'm not sure like what they actually doing at home to, you know, to actually follow through on the program. Also, there\u0026rsquo;s a lot of like social economic issues that you have to work around and it's all about context\u0026rdquo;\u003c/em\u003e (Female, Peri-urban, Provincial, EC).\u003c/p\u003e \u003cp\u003e6. \u003cem\u003e\u0026ldquo;I don't understand that, the organisation, that's the one thing which I had a problem\u0026rdquo;\u003c/em\u003e (Male, Urban, Provincial, KZN).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSupport and Mentorship\u003c/b\u003e\u003c/p\u003e \u003cp\u003e7. \u003cem\u003e\u0026ldquo;No sort of guidance at all, which has been a little bit of a frustration for me\u003c/em\u003e\u0026rdquo; (Male, Peri-urban, District, EC).\u003c/p\u003e \u003cp\u003e8. \u003cem\u003e\u0026ldquo;I didn't find it a very supportive environment, especially in the beginning of the year\u0026rdquo;\u003c/em\u003e (Female, Urban, District, KZN).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003ePersonal growth and development\u003c/h2\u003e \u003cp\u003eDespite being faced with complex and challenging situations, all participants reflected on how the experience had created opportunity for personal \u003cem\u003e(\u003c/em\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, \u003cem\u003eQuote 4, ,5 and 6)\u003c/em\u003e and professional growth \u003cem\u003e(\u003c/em\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, \u003cem\u003eQuote 1 and 2)\u003c/em\u003e. They arrived as new graduates, but the changes and development of confidence were significant. In addition, the exposure to rural settings created a deeper sense of empathy and understanding regarding the impact of poverty on health, which is important for their positioning as healthcare practitioners within the SA context \u003cem\u003e(\u003c/em\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, \u003cem\u003eQuote 3)\u003c/em\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePersonal Growth and Development.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. \u003cem\u003e\u0026ldquo;You kind of arrive at com serve with almost a bit of a like impostor syndrome kind of feeling just because it's the first time you really on your own and like you, the consultants are asking something about physio and like you're the one who has to answer, which is overwhelming\u0026rdquo;\u003c/em\u003e (Female, Urban, District, KZN).\u003c/p\u003e \u003cp\u003e2. \u003cem\u003e\u0026ldquo;It felt kind of scary just having that responsibility of. OK, so I'm the person that's going to make a decision like for a patient\u0026rdquo; (Female, Urban, District, GTG).\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. \u003cem\u003e\u0026ldquo;So, I think you know, living in this Cape Town, city centre, you don't really get exposed to the hardships that rural living can provide or can give. And I think it's helped me just kind of appreciate more the there's a lot more people in the country than you realize and how they're struggling and the things that, the challenges that they face\u0026rdquo; (\u003c/em\u003eFemale, Rural, CHC, KZN).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. \u003cem\u003e\u0026ldquo;Like you come away with life skills and, I don't know, grow into yourself like as a person and as a physio in terms of teamwork. And as I said, dealing with difficult situations\u0026rdquo;\u003c/em\u003e (Female, Urban, District, KZN).\u003c/p\u003e \u003cp\u003e5. \u003cem\u003e\u0026ldquo;On a personal level, I think I've learned to deal with people a lot better than I ever would have been able to and just kind of learning that, you know what? Not everyone's going to be the same as you. But at the end of the day, it doesn't matter what everyone else is doing. You still must hold yourself to a higher standard. So, I think that's been, I think it's taught me quite a lot about who I want to be and who I don't want to be.\u0026rdquo;\u003c/em\u003e (Female, Urban, District, KZN).\u003c/p\u003e \u003cp\u003e6. \u003cem\u003e\u0026ldquo;Probably learnt a lot more about just living with myself and how to do that and how to keep myself busy\u0026rdquo; (Female, Peri-urban, Provincial, MP).\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eEntering the workplace after graduating from higher education institutions can be daunting for many graduates. In Physiotherapy, the work-based curriculum is designed to facilitate graduate entry into practice by aligning to the anticipated demands that may be placed on graduates during CS. Community Service PTs are expected to have met graduate outcomes and should be able to adopt the multiple roles expected from them in practice settings. Our results show that UG training does not prepare them well for all the required roles.\u003c/p\u003e \u003cp\u003e Participants could easily identify with the expectation of the role of clinician, and they embraced some of the other roles over time, while there were also roles for which they felt poorly prepared. While the global context of practice may be variable, others have noted similar challenges for graduates entering the profession [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study reaffirmed the findings of a study by Nadasan and Chetty [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] on the design of clinical practice at UG level. That study found that placement structure and the skill of clinical educators\u0026rsquo; impact on the graduate\u0026rsquo;s readiness to practice and their ability to transition successfully into their CS roles. However, its noted that the shielding of UG students from all responsibility or accountability in patient care by supervisors may leave them less confident in decision making and their advocacy roles in multidisciplinary contexts. This finding also resonates with that of Stoikov et al. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] who highlighted how UG placements often protect students from complex decision-making and limits their exposure to the full scope of clinician roles, including prioritising patient lists, screening activities, and family meetings around complex cases. In addition, UG students are seldom expected to navigate personality and multiple workplace issues. This lack of experience and skills were challenging to the CS participants in the current study.\u003c/p\u003e \u003cp\u003eOngoing broader clinical exposure to rural and district care settings was highlighted as a factor affecting transition. Whilst most participants had some exposure to peri-urban settings at UG level \u0026ndash; they still experienced rural healthcare as being very different to their university\u0026rsquo;s placement experiences. While this finding suggests that there has been some improvement within curricula design and placement since early studies on the first CS cohort [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], there are still contextual gaps. It is relevant to note that this cohort had their third clinical year adjusted due to the impact of the COVID-19 pandemic \u0026ndash; which impacted their access to the clinical platform at times and to an expanded range of clinical experiences. In addition, as institutional initiatives to place students in rural and peri-urban areas require both financial and logistical arrangements to travel and live away from the metro and the university, we still lack the capacity to expose all students to a broader scope of community practice settings.\u003c/p\u003e \u003cp\u003eGraduates in CS placements are supposed to be placed in locations where they can be supported and supervised. Of concern was the fact that the role modelling and professional support that would buffer their integration was either found lacking or absent in some settings. This gap has previously been highlighted in studies on CS and entry practice within the SA context [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Some senior staff at placement sites were experienced as being disinterested in supporting the new graduate, as well as in patient care. While this may reflect a level of staff burnout in a system under pressure, it does leave new graduates floundering. Practitioners placed alone also lacked input from district staff and, unless they reached out specifically, had to navigate situations on their own.\u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eLimitations of the study\u003c/h2\u003e \u003cp\u003eThis study represents the experiences of a single cohort who graduated from the university in the immediate post-Covid period, and the results may not reflect the readiness of graduates from other institutions. While attempts were made to make the sample representative, potential gaps do exist especially related to practice in some of the other provinces.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eDiscussions with graduates revealed important nuances regarding the extent to which the Physiotherapy curriculum had prepared them to transition to the CS practice setting. Graduates were very aware of the level of skills, theoretical principles, clinical reasoning, and lifelong learning they needed to assume some of the roles of practice; yet competencies aligned to their roles as leaders, collaborators, and advocates were experienced less in their UG programmes and sometimes undervalued. These aspects are often not explicitly taught in daily clinical practice and impacts on their successful transition. They were surprised at how much these roles contributed to their overall success and efficacy in CS practice, and these roles also become the areas of biggest personal and professional growth.\u003c/p\u003e \u003cp\u003eThe context in which learning happens is important. Embedding placements in more diverse settings both geographically and in terms of human and physical resources would potentially change graduates\u0026rsquo; perception of their readiness for practice. Where this is not feasible for logistical or financial reasons, curriculum design needs to consider the impact of the curriculum framework on the ability of graduates to think, reason, and apply their skills and abilities into differently resourced practice settings. The professional support experienced by graduates during CS was variable and may need an audit or policy review by the professional and accreditation bodies.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCS Community Service\u003c/p\u003e\n\u003cp\u003eDoH Department of Health\u003c/p\u003e\n\u003cp\u003eEC Eastern Cape Province\u003c/p\u003e\n\u003cp\u003eGTG Gauteng Province\u003c/p\u003e\n\u003cp\u003eHPCSA Health Professions Council of South Africa\u003c/p\u003e\n\u003cp\u003eKZN KwaZulu Natal Province\u003c/p\u003e\n\u003cp\u003eMP Mpumalanga Province\u003c/p\u003e\n\u003cp\u003ePT Physiotherapist\u003c/p\u003e\n\u003cp\u003eSA South Africa\u003c/p\u003e\n\u003cp\u003eSASP South African Society for Physiotherapy\u003c/p\u003e\n\u003cp\u003eUCT University of Cape Town\u003c/p\u003e\n\u003cp\u003eUG Undergraduate\u003c/p\u003e\n\u003cp\u003eWC Western Cape Province\u003c/p\u003e\n\u003cp\u003eWPT World Physiotherapy\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was granted by the University of Cape Town, Faculty of Health Sciences Human Research Ethics committee (HREC) (527/2022)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTeaching buyout to facilitate completion of this project was supported by funds from the Faculty of Health Sciences at UCT through the authors participation in the ELF (Educational Leadership Fellowship) Programme.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHT developed the project in conjunction with JvW. Results were reviewed and checked with JvW. The data analysis and write up was completed by HT with input on design, interpretation, flow, and discussion from JvW.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHT notes her position as programme convenor and lecturer within the UCT Division of Physiotherapy and her prior involvement with the research participants. \u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSole G, Claydon L, Hendrick P, Hagberg J, Jonsson J, Harland T. Employers\u0026rsquo; perspectives of competencies and attributes of physiotherapy graduates: an exploratory qualitative study. New Z J Physiotherapy. 2012;40(3):123\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarradell S. Moving forth: Imagining physiotherapy education differently. Physiother Theory Pract. 2017;33(6):439\u0026ndash;47.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Physiotherapy. Physiotherapist Education Framework. London, UK; 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Physiotherapy. Guidance for Developing a Curriculum for Physiotherapist Entry Level Education Programme. London, UK; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHill J, Walkington H, France D. Graduate attributes: Implications for higher education practice and policy: Introduction. J Geogr High Educ. 2016;40(2):155\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJones E, Killick D. Graduate attributes and the internationalized curriculum: Embedding a global outlook in disciplinary learning outcomes. J Stud Int Educ. 2013;17(2):165\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNicholls D, Larmer P. Possible futures for physiotherapy: an exploration of the New Zealand context. New Z J Physiotherapy. 2005;33(2):55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGibson BE, Nixon SA, Nicholls DA. Critical reflections on the physiotherapy profession in Canada. University of Toronto Press Incorporated; 2010. pp. 98\u0026ndash;100.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFrenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010;376(9756):1923\u0026ndash;58.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMnguni L. The Curriculum Ideologies Underlying the AfriMEDS Curriculum Framework for Undergraduate Medical and Dental Education in South Africa. Int Med Educ. 2024;3(1):44\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNgobeni V, Breitenbach MC, Aye GC. Technical efficiency of provincial public healthcare in South Africa. Cost Eff Resource Allocation. 2020;18:1\u0026ndash;19.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTiwari R, Ned L, Chikte U. HRH planning for rehabilitation services: A focus to reduce inter-provincial inequities. South Afr Health Rev. 2020;2020(1):53\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDean E. Physical therapy in the 21st century (Part I): toward practice informed by epidemiology and the crisis of lifestyle conditions. Physiother Theory Pract. 2009;25(5\u0026ndash;6):330\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChesterton P, Chesterton J, Alexanders J. New graduate physiotherapists\u0026rsquo; perceived preparedness for clinical practice. A cross-sectional survey. Eur J Physiotherapy. 2023;25(1):33\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStoikov S, Maxwell L, Butler J, Shardlow K, Gooding M, Kuys S. The transition from physiotherapy student to new graduate: are they prepared? Physiother Theory Pract. 2022;38(1):101\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNadasan T, Chetty V. Preparedness for practice: Physiotherapists view on an undergraduate programme in KwaZulu-Natal, South Africa. Global J Health Sci. 2019;12(1):88.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMostert-Wentzel K, Frantz J, Van Rooijen AJ. A model for community physiotherapy from the perspective of newly graduated physiotherapists as a guide to curriculum revision. Afr J Health Professions Educ. 2013;5(1):19\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePope C, Mays N. Qualitative Research in Health Care. 4th ed. Wiley; 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRamklass SS. Physiotherapists in under-resourced South African communities reflect on practice. Health Soc Care Community. 2009;17(5):522\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Community Service, Physiotherapist, Entry level practice, Graduate Roles, Graduate outcomes, Curriculum","lastPublishedDoi":"10.21203/rs.3.rs-4568716/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4568716/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eIn South Africa, newly qualified Physiotherapists transition to workplace during Community Service (CS), often in diverse healthcare settings and complex patients. The transition is complicated by the shortage of rehabilitation personnel, especially in rural and peri-urban areas. While higher education curricula should prepare students for the workplace, the roles and expectations of new therapists remain unclear. Assessing how well current curricula, incorporating the CanMEDS framework, equip students with the knowledge, skills, and attitudes for entry-level CS practice will help to improve physiotherapy training practices. This study investigated the experiences of CS physiotherapists to inform curriculum design and graduate outcomes.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA descriptive qualitative study was conducted. Graduates were recruited during their CS year via a class group contact, with a snowballing approach to diversify the sample. Semi structured interviews were conducted over MS Teams, recorded, and transcribed. Reflexive deductive coding was used to interpret the data, which was analysed according to the CanMEDS roles and graduate outcomes, as well as barriers and facilitators during their transition to the workplace.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eTen CS physiotherapists placed in five of the nine provinces participated. Most identified strongly with their core role as clinicians and felt well prepared for clinical service. However, aspects of roles linked to advocacy, leadership, and professionalism were more complex to navigate. The contexts of placements and the nuances of how the healthcare system operated in each province also impacted their experience.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eDiscussions revealed that the physiotherapy curriculum effectively prepared graduates in roles drawing on skills, theoretical principles, clinical reasoning, and lifelong learning. However, exposure to outcomes in roles as leaders, collaborators, and advocates were somewhat limited. These aspects were often not explicitly taught and impacted their transition. These roles, however, became areas of significant personal and professional growth during CS. The learning context is crucial, and embedding placements in more diverse settings could improve graduates' readiness. Where diverse placements are not feasible, curriculum design should ensure graduates can apply their skills in various settings. The variable professional support during CS suggests a need for an audit or policy review by professional and accreditation bodies.\u003c/p\u003e","manuscriptTitle":"Graduate reflections on Community Service, a view of roles in practice","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-04 11:29:56","doi":"10.21203/rs.3.rs-4568716/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-06-19T12:27:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-19T06:03:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-18T14:03:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2024-06-12T08:35:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c090378a-b6af-4628-aa1c-a77620ea393f","owner":[],"postedDate":"July 4th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-11-11T15:59:57+00:00","versionOfRecord":{"articleIdentity":"rs-4568716","link":"https://doi.org/10.1186/s12909-024-06265-6","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2024-11-07 15:57:15","publishedOnDateReadable":"November 7th, 2024"},"versionCreatedAt":"2024-07-04 11:29:56","video":"","vorDoi":"10.1186/s12909-024-06265-6","vorDoiUrl":"https://doi.org/10.1186/s12909-024-06265-6","workflowStages":[]},"version":"v1","identity":"rs-4568716","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4568716","identity":"rs-4568716","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}