Self-directed learning and practice of Italian osteopathic students during summer break: a cross-sectional survey

Connecting adult learning theory with practice is a challenging task for educators in health profession education [1]. There is the need to reframe the adult education considering the learners as active leaders of their own education [2]. In order to learn adults should understand the process of learning and their role in it, should be actively involved in their own education and must take significant responsibility for their learning [3].

Several strategies have been proposed to achieve these goals, including student-centred approaches [4, 5]. Self-directed learning (SDL) is a student-centered [6] approach based on the students’ evaluation about their own learning needs and the means to satisfy them [7]. SDL is a strategy that potentially develops the skills required to effectively address clinical problems [8] facilitating the acquisition and consolidation of new knowledge and providing attractive social effects for the learners (e.g., cooperation and team building) [6, 9]. SDL in clinical skills can provide an opportunity to build confidence and to improve techniques [10]. Self-directed practice (SDP) is a component of the SDL which focus on achieving manual and technical skills [11]. However, students, might be conditioned by the previous teacher-directed learning experiences and might not be prepared for SDL, leading to difficulty in adapting to SDL [12].

Osteopathy is a primary contact healthcare profession [13], characterized by manipulative techniques, coupling medical and scientific knowledge [14], used to promote patients’ health [15‐20]. Osteopaths must be able to perform an accurate and appropriate examination, including relevant clinical testing, observation and palpation to elicit all relevant signs [15]. Osteopathic manipulative treatment (OMT), which follows the osteopathic assessment, currently encompasses a wide range of manual techniques (e.g., balanced ligamentous tension, articulatory, counterstrain, facilitated positional release, high velocity low amplitude and muscle energy) [16, 21].

Given the abundance of manual techniques in the osteopathic curriculum, SDP might be a useful methodology to address the students’ needs regarding the development of technical skills. Furthermore, SDP grants the possibility to accumulate experience. Although the factors that cause large individual differences in professional achievement are only partially understood [22] accumulating experience during the curriculum is important considering that it has been proposed that 10,000 h of deliberate practice might be needed to become an expert in a given field [23]. Indeed, great importance is attributed to offering opportunities for students to practice the physical examination skills extensively [24‐27]. Simulation training among medical students is most effective with repetitive practice and self-reflection on performance [28, 29]. Hence autonomous practice when students are not busy following lectures and have more spare time to spend practicing (e.g, during school break) could contribute to gain palpatory and clinical experiences. In turn, this might contribute to raise the perceived preparedness and competence of students which play a role in a potential stressful transition from school to professional practice [30, 31].

Investigation on the autonomous practice of students during the school break with particular regard to US osteopathic curriculum has been made [32]. However osteopathic curricula, may differ depending on countries’ national laws. Indeed differently from the study of Pierce-Talsma et al. [32], the present study has been designed taking into account the Italian curriculum setting which follows the European Committee for Standardization norm (CEN) EN16686 [33]. CEN norm kept the curriculum organization proposed in the “Benchmarks for Training in Osteopathy” [34] recognizing two types of educational curriculum: type I (T1), where students may enter a programme without a healthcare background; and type II (T2) for students who have prior training as healthcare professionals. Prior to the CEN norm [33], T2 curriculum was both for students who have a previous healthcare degree, and who have a previous sport science degree.

Recently, with the law 3/2018 osteopathy became an health profession in Italy [35], whereby osteopathic education may move from the private college system, as it is now, to the higher education sector. With this perspective, it could be useful to collect data about the learning strategies of Italian osteopathic students. To the best of our knowledge there are no studies taking into account the perspective on SDP during summer break of Italian osteopathic students. The aim of the present study is to investigate the features and perceived usefulness of SDP during the summer break of Italian osteopathic students highlighting the possible differences between T1 and T2 curricula.

This study investigated the features and perceived usefulness of SDP during the summer break of Italian osteopathic students highlighting the possible differences between T1 and T2 curricula. A better understanding of the features and perceived usefulness of SDP of osteopathy students is critical to identify the needs of students to lead possible improvements in the academic curriculum [32].

Demographic data showed a trend of T1 students being younger than T2. The reason could be the beginning of osteopathic education soon after the end of the high school for T1 students. By contrast, T2 students enter the osteopathic school after the completion of an additional healthcare degree. Interestingly, T1 and T2 have an opposite distribution in gender ratio: T1 has more female students. The study of Bleakley highlights a “feminising trend” in medicine. Indeed, women are the majority in terms of entry to medical schools worldwide [38]. This trend is confirmed in the present study only considering T1 students.

Results of the present study showed that T1 students performed less SDP than T2 during the summer break. This significant result could be related to the fact that T1 might not engage in SDP over summer as they have likely not been required to before entering their osteopathy course. Previous exposure to study at an adult education level may help develop SDL behaviours. Furthermore, T2 students are usually already working professionals so they might have a students are usually already working professionals so they might have a perspective oriented to life-long learning [39]. That hypothesis is supported by the significant difference between the reasons for which T1 and T2 students performed SDP. In particular, T2 students reported to perform SDP to be prepared for the future clinical practice. T1 students seem to engage SDP both to develop technical and manual skills and to the be prepared for the future clinical practice. According to one assumption in pedagogy “assessment drives learning” [40], T2 students reported to have practiced SDP in view of future exams. The findings of the present study are consistent with the study of McGrath et al. [8] which demonstrated that imminent clinical skills examinations appear to incentivise engagement with SDP. One of the possible explanation of the observed difference between T1 and T2 could be, as shown by Deng et al. [41] that students engage extensively in SDP and that it is associated with superior performance on a medical licensing examination.

Almost the totality of the students who practiced the SDP during summer break consider it useful, but more than half of them reported that the amount of SDP was not sufficient since they would have like to perform it more. The reasons why students did not perform or did not perform sufficiently SDP should be considered to find appropriate solutions. The main difficulties varies from personal and general reasons: lack of time, lack of an appropriate place, lack of time and practice buddies. These factors could be potentially challenged through an active strategies that involves both students and schools. One of the reasons which prevented the students to practice SDP during the summer break was the lack of a dedicated didactic/clinical environment. This can be a useful data for the schools to plan to maintain an open tutored didactic environment during the summer break as an extracurricular activity. It may be interesting to evaluate the attitudes of students towards the SDP during the extracurricular activities and to assess if it produces as a complementary effect an increase of students’ entrepreneurial behaviour towards their future profession. Furthermore it is possible for the osteopathic institutions to suggest students to organise some autonomous meetings during the summer break to overcome the reported lack of practice buddies. Pierce-Talsma et al. [32] suggested the possibility to enhance in the curriculum those techniques that do not require a table and that require less time to challenge the lack, respectively, of appropriate place and time. Furthermore, the institutions might potentially make space available to students, allowing them the physical space to practice and practice with peers. To evaluate if SDP is aligned to the future clinical scenario it is possible to compare the clinical conditions encountered at least once by students (Fig. 2) and those encountered by professional osteopaths [42]. There is a quite overlapping between them. Indeed low back pain, neck pain, headache, sciatica are the most common clinical conditions faced both from students and from professionals. It is possible to consider that self-directed practice starts to show clinical reality. The students, in this way, could begin to interact with common elements of those so frequent conditions to be met in the future. The lumbar and cervical spine, skull and pelvis were the most common anatomical areas on which students practiced (Fig. 3). This trend is similar to the one found by van Dun et al. [20]. It may be interesting in future studies to qualitatively evaluate the reasons of this prevalence. A possible explanation is that techniques on these areas are perceived by students as more difficult and therefore they need more practice to be mastered. Another possible explanation is related to the idea that students may have of the professional identity. It is possible that they look at the osteopathic professional as the healthcare professional that mostly work on these zones. Since part of the professional identity is learned by students through hidden curriculum [43] understanding the reasons underlying the prevalence of SDP per area could allow the institutions to start a curricular improvement process and faculty development activities [44, 45]. In the present study ‘articular mobility test’, orthopedic test’ and ‘positional evaluation test’ were the most practiced tests (Fig. 4). This finding is only partially comparable to the one reported by Van Dun et al. [20]. Indeed, in their study the most used tests were ‘inspection’, ‘positional evaluation test’ and ‘articular mobility test’. The biggest discrepancy with the Van Dun et al. study regards the most used techniques. Students from the present study reported a frequent use of the following techniques (Fig. 5): ‘muscular energy techniques’, ‘high velocity low amplitude techniques’ and ‘fascial techniques’, while professionals from Van Dun et al. study declared to use more frequently: ‘visceral manipulation’, ‘cranial techniques’ and ‘general osteopathic mobilization’ [20]. This discrepancy might depend on the fact that respondents of Van Dun et al. study were professional osteopaths while in the present study respondents were osteopathy students.

A major students’ concern emerged from the survey was related to the interpretation of the osteopathic manual tests (94.25%; n = 164). The heterogeneity of the interpretation of a palpatory osteopathic test is a central topic in osteopathic literature as highlighted by Basile et al. [46]. The literature shows that students’ monitorization of their own learning is important in self-directed learning [47]. Indeed, it is critical for learners to monitor their learning in line with their own needs and goals, to identify wrong or deficient learning and to adopt new strategies accordingly [48]. It is possible that students might not be able to develop their own learning goals as they do not always know the most appropriate level at which to pitch the goal. Furthermore, a possible way to manage these deficiencies might be for the institutions to focus on a consensus training methodology during the in-class training. It has been demonstrated that a specific consensus training could positively affect the inter-rater reliability of an osteopathic test [49].

One of the strengths of the present study is the heterogeneity of sample coming from different Italian osteopathic schools. Secondly, the prompt administration of survey soon after the end of summer break potentially reduces the recall bias of student in remembering the features of their SDP.

This study has several limitations. First, the item creation process might have intrinsic bias due to the low number of researchers involved. Despite one of the researchers has a qualification in osteopathic education, it cannot be excluded that researchers own beliefs regarding SDP might have influenced the items creation. Secondly, the low response rate (10.51%). Indeed a similar study conduct in USA achieved a way higher response rate (81.6%) [32]. Thirdly, considering the algorithm of survey administration it is possible that there have been some issues with [1] e-mail sending/receiving process, [2] solicitation to the students, [3] survey return to the database. The low response rate implies another limitation: a low sample size that impedes to do different sub analyses and this could potentially prevent statistical significance in some results. Furthermore it is possible that the sample may not be representative of the actual population of osteopathic students in Italy. This aspect should be control in the future studies.

This study is a cross sectional survey aimed to investigate the features and perceived usefulness of SDP during the summer break of Italian osteopathic students. Despite some different findings between T1 and T2 students like inclination to SDP and reasons why they perform it, the entire sample shown an homogeneous trend regarding the majority of the aspects of SDP. Findings of this study are consistent with the available medical education literature. The results of this study might be useful to reveal some aspects of students’ academic education and future clinical practice. Despite the number of respondents is currently too low to draw any specific conclusions considering the higher education of Osteopathy in Italy, the present findings might be useful information to tailor implementation of SDL to the students’ needs. Therefore, to develop strategies to overcome the reported problems students have towards SDP this survey-based study is potentially replicable in the years to have a perspective view on the evolution of summer break SDP on a larger sample.