531009

research-article2014
POI0010.1177/0309364614531009Prosthetics and Orthotics International X(X)Aminian et al.

INTERNATIONAL
SOCIETY FOR PROSTHETICS
AND ORTHOTICS

Original Research Report

Prosthetics and Orthotics International

Undergraduate prosthetics and orthotics 2015, Vol. 39(4) 278­–285

© The International Society for
Prosthetics and Orthotics 2014
teaching methods: A baseline for Reprints and permissions:
sagepub.co.uk/journalsPermissions.nav
international comparison DOI: 10.1177/0309364614531009
poi.sagepub.com

Gholamreza Aminian1, John M O’Toole2

and Afsoon Hassani Mehraban3

Abstract
Background: Education of Prosthetics and Orthotics is a relatively recent professional program. While there has been
some work on various teaching methods and strategies in international medical education, limited publication exists
within prosthetics and orthotics.
Objectives: To identify the teaching and learning methods that are used in Bachelor-level prosthetics and orthotics
programs that are given highest priority by expert prosthetics and orthotics instructors from regions enjoying a range
of economic development.
Study design: Mixed method.
Methods: The study partly documented by this article utilized a mixed method approach (qualitative and quantitative
methods) within which each phase provided data for other phases. It began with analysis of prosthetics and orthotics
curricula documents, which was followed by a broad survey of instructors in this field and then a modified Delphi process.
Results: The expert instructors who participated in this study gave high priority to student-centered, small group methods
that encourage critical thinking and may lead to lifelong learning. Instructors from more developed nations placed higher
priority on student’s independent acquisition of prosthetics and orthotics knowledge, particularly in clinical training.
Conclusions: Application of student-centered approaches to prosthetics and orthotics programs may be preferred by
many experts, but there appeared to be regional differences in the priority given to different teaching methods.

Clinical relevance
The results of this study identify the methods of teaching that are preferred by expert prosthetics and orthotics
instructors from a variety of regions. This treatment of current instructional techniques may inform instructor choice of
teaching methods that impact the quality of education and improve the professional skills of students.

Keywords
Undergraduate, prosthetics and orthotics, teaching methods, student-centered, international comparison
Date received: 27 November 2012; accepted: 3 March 2014

Background
1Department of Orthotics and Prosthetics, University of Social Welfare
Previous results1 indicated regional differences in and Rehabilitation Sciences, Tehran, Islamic Republic of Iran
Bachelor’s level professional preparation within a com- 2School of Education, Faculty of Education and Arts, The University of

mon commitment to objectives-based programming. There Newcastle, Australia, Newcastle, NSW, Australia
was variation in both theoretical and practical teaching 3Department of Occupational Therapy, Rehabilitation Research Centre,

methods mentioned in curricula accessible from different
university websites, and later expert consultation revealed
concern as to whether the approaches now being followed
worked against the objectives of the programs. Prosthetics
and orthotics require students to develop both technical
and practical skills to enable them to fabricate various
devices for a variety of clients. Consequently, the mix of
School of Rehabilitation Sciences, Iran University of Medical Sciences,
Tehran, Islamic Republic of Iran
Corresponding author:
Gholamreza Aminian, Department of Orthotics and Prosthetics,
University of Social Welfare and Rehabilitation Sciences,
Koodakyar Alley, Daneshjoo Blvd, Evin, Tehran, 1985713834,
Islamic Republic of Iran.
Email: gholamrezaaminian@yahoo.com
Aminian et al. 279
teaching methods employed within prosthetics and orthot-
ics education may differ from other forms of health and
rehabilitation science education. This article further analy-
ses regional differences in preferred teaching methodology
in prosthetics and orthotics and may prove interesting and
useful for other allied health programs.
Overall, review of the literature indicates the impor-
tance of linking the study of curriculum development to
the educational approaches chosen to deliver that curricu-
lum. Biggs2 considered that effective professional prepara-
tion required that presage (combination of previous student
knowledge and ability), process (active learning of stu-
dents), and product (the outcomes of these required activi-
ties) should be aligned within teaching and assessment.
That is, what students already know should be considered
when teacher expectations are being formulated, learning
experiences should be designed to encourage student
achievement of those expectations, and assessment should
evaluate the extent to which such achievement occurs.
Contrary to some interpretations of it, this notion of align-
ment pays significantly more attention to process than it
does to product3 and this signals the importance of instruc-
tor choice of teaching strategy in effective curriculum
implementation. The priority that other expert instructors
place on particular methods may inform such choice.
Education in prosthetics and orthotics calls for a com-
bination of theoretical and practical teaching from medi-
cine and engineering and application in clinical training.4
However, education in this field is now moving beyond
the undergraduate years and this seems an appropriate
time to investigate current teaching, learning, and assess-
ment methods. Some such work has already occurred
within medicine, nursing, and physiotherapy.5,6 Baozhi
and Yuhong,7 for instance, reported a comparative study
of Chinese and American medical schools under the
supervision of China Medical Board in New York, which
revealed diversity between different categories of courses
and divergent teaching and learning styles and varying
use of small group discussion, Problem-Based Learning
(PBL), and more traditional tutorial teaching. A study8
seeking to provide a framework as a model for European
dental education found similar diversity in courses and
methods for teaching them. Interest in teaching and learn-
ing methods may increase under the impact of internation-
alization and some9 have suggested that combining
evidence-based approaches with effective teaching and
learning would improve student learning and develop
increasing competence.
Many studies have suggested small group learning (and
PBL, in particular) as possibly more effective alternatives
to traditional lecture/tutorial patterns of instruction10 that
may smooth the way to an evidence-based practice (EBP)
approach in clinical education.11 PBL was first applied to
medical education at McMaster University in 1965 and its
group research-based approach to student learning seems a
natural fit with contemporary attempts to decrease the gap
between potentially conservative clinical practice and the
increasingly rapid growth of knowledge through EBP.
However, adoption of such approaches remains problem-
atic.5 Loyens et al.12 explained that the PBL environment
increases student collaboration, self-directed learning, and
problem-solving skills. They added, however, that there is
less evidence to vindicate the impression that PBL
improves the factual knowledge of students. Their study
also showed no significant difference in motivation
between students in PBL and traditional programs.12 Many
authors indicated the success of PBL in clinical settings
but noted that it is more problematic for student learning of
basic science in medical education.13 The experience of
tutors proved crucial to the success of such PBL groups
but, not withstanding such success, there was no signifi-
cant difference in student science knowledge between PBL
and traditional approaches. Such concerns about PBL raise
the question of the priority given to it by expert prosthetics
and orthotics instructors, among the other teaching meth-
ods available to them.
These other teaching methods include more recent
approaches to learning, such as e-learning.14 Institutional
use of new technology often involves providing student
access to Learning Activity Management Systems
(LAMS). LAMS can merely replace distribution of paper
documents and reading lists in support of traditional pat-
terns of lecture, tutorial, and workshop or they can provide
a framework for learner-centered approaches where
teacher, learner, and staff encourage collaboration and
communication by means of the new technology.14
This article is a part of a wider comparative interna-
tional study of prosthetics and orthotics curricula and edu-
cational programs, and reports an investigation of
instructor priority given to current teaching and learning
methods in prosthetics and orthotics programs at the
Bachelor’s level. Which strategies do expert prosthetics
and orthotics instructors prefer and how do they manage
clinical, practical, and theoretical classes in this field?
The answers to such questions are a necessary precondi-
tion for the development of suggestions for sustainable
improvements.
Methods
The results reported in this investigation come from a
wider study that utilized mixed methods across a three-
phase design. The study began by collecting international
prosthetics and orthotics curricula, analysis of which
informed development of a widely distributed Web-based
survey in 2007, analysis of which in turn informed a con-
sensus-building Delphi study in 2009.
Phase 1 was a qualitative analysis of curriculum docu-
ments. Invitation and consent forms were sent by elec-
tronic mail to the head of the prosthetics and orthotics
280 Prosthetics and Orthotics International 39(4)
Table 1.  Levels of acceptance and agreement for each item.
Median Level of acceptance
percentage of Max. scale (6)
5.5 & 6 (>90% of scales) High acceptance
5 (80% of scales) Moderate acceptance
4 & 4.5 (70% of scales) Low acceptance
3 & 3.5 (50% of scales) Very low acceptance
departments in the 26 institutions for which a contact per-
son was identifiable. A total of 10 Bachelor-level prosthet-
ics and orthotics programs from various regions returned
their full curriculum documentation or allowed us deeper
access to their curricula on university websites. Institutions
that responded came from Europe, the Middle East, North
America, Oceania, and South Asia. Seven of these respond-
ents offered a 4-year full-time program and the remaining
three programs were completed in 3, 3½, and 4½ years.
An initial questionnaire had been developed on the
basis of review of the literature, similar previous studies,
results of the first curriculum analysis phase, and an exist-
ing instrument.5,11,15 The initial questionnaire was modi-
fied after a pilot study and then distributed to form the
basis of Phase 2 of this investigation. The questionnaire
included both 5-point Likert and free response items.
The questionnaire was sent by electronic mail to the 21
institutions that had not explicitly declined to be involved,
with the request that it be distributed to instructors in pros-
thetics and orthotics. A total of 47 surveys were returned
by 14 institutions in 10 nations from Oceania, South Asia,
the Middle East, Northern Europe, and North America.
The nations within these regions differed in terms of eco-
nomic development. While 14 surveys were returned from
developed countries, 33 were returned from developing
countries.
The frequency of individual responses was calculated
and Chi-square was applied to identify curriculum ele-
ments that were common to various institutions (Chi-
square > 0.05) and those which were distinctive between
them (Chi-square < 0.05). Chi-square was considered to be
an appropriate test of the existence of differences worth
comment because Likert scales resemble the categorical
variables for which the test was designed.16 Differences
between the frequencies which survived this more con-
servative test yielded group means that could be usefully
examined further with parametric measures.
Phase 3 of the study consisted of several Delphi rounds,
based initially on the results of the Phase 1 analysis and
Phase 2 survey. Participants came from universities that
had participated in Phase 2 after being identified in Phase
1 and having their prosthetics and orthotics programs ana-
lyzed. The responses to the Phase 2 survey were analyzed
to yield the statements comprising the initial Phase 3
instrument, which were arranged into a more contentious
Percentage of each pair Level of agreement
scales (5–6, 3–4, 1–2)
>80 High agreement
61–79 Moderate agreement
51–60 Low agreement
<50 Not agreement
set of issues and a further set which appeared to have
already achieved a high degree of consensus. Each item
was made up of a 6-point Likert item (from 1 = reject to 6
= strongly agree) and space for participants to add explan-
atory detail. Following precedents from the literature,17,18
this was sent electronically to a panel of 14 experts from 7
institutions from the same regions as the previous phase of
the investigation. Baker considers knowledge and experi-
ence to constitute expertise,19 and thus expert was defined
as possession of a higher degree or a Bachelor’s qualifica-
tion in prosthetics and orthotics, followed by at least 5 or
10 years’ teaching experience in this field, respectively.
Respondent opinions about the statements making up the
initial instrument were fed back to panel members through
additions made before the final round. Analysis of patterns
of response distinguished between “acceptance,” “agree-
ment,” and “consensus.”
Expert acceptance of any statement on the Delphi
instrument is given by the median score for the 6-point
Likert item. For instance, a median of 2 would indicate
low acceptance, while a median of 6 would represent
high acceptance by this group of expert prosthetics and
orthotics instructors. However, merely considering any
measure of central tendency in isolation could wash out
differences between the opinions of these experts. So,
Likert responses were paired (1–2, 3–4, 5–6) to allow
distinction between “acceptance,” “agreement,” and
“consensus” (Table 1).
Expert agreement with any statement on the Delphi
instrument is given by the percentage of respondents who
selected each pair of points on the 6-point Likert scales.
This indicates the distribution of responses more finely.
For example, an item median of 5 shows high expert
acceptance of a statement but lower agreement would be
indicated when a substantial percentage of respondents
chose one of the lower pairs of Likert points, such as 3–4.
Consensus is the interaction of acceptance and agree-
ment. For example, an item median of 5 was taken to indi-
cate high acceptance of the proposition; 80% respondent
choice of the 5–6 pair was taken to indicate high agree-
ment and these two values would interact to indicate high
consensus. An item median of 2 with 50% respondent
choice of the 3–4 pair would indicate low acceptance and
low agreement and also low consensus. In the former case,
most of the expert prosthetics and orthotics instructors
Aminian et al. 281
Literature review
Similar studies
Bachelor of P&O
International Curricular Questionnaire
analysis development
Pilot study
Final outcome
Delphi study
Figure 1.  Overall design of study.
P&O: Prostheses and Orthoses.
agreed in accepting the proposition, while in the latter they
were less certain about rejecting it.
This article reports analysis of all three phases of the
wider study. It discusses the teaching methods revealed by
Phase 1, suggested in Phase 2 and preferred by instructors
from participating institutions in Phase 3. The Delphi
phase allowed expert instructors to explain their own pref-
erences. The results allow instructional patterns in differ-
ent regions to be distinguished. This study design has
echoes of triangulation strategies. Figure 1 indicates how
the phases built on each other, the results of each phase
providing the basis for the next.
Results
Phase 1 of this investigation indicated that theoretical,
practical, and clinical teaching contexts are common
across prosthetics and orthotics programs, with some vari-
ation in the teaching methods used in different contexts.
Lectures remain the most popular method for teaching
theoretical material across these programs (6 out of 10,
drawn from the Middle East, South Asia, North Europe,
and Oceania regions). Responses suggested that student
participation in discussion of the subject’s main elements
were being motivated by the lecturer. One program from
Oceania apparently supported lectures with detailed infor-
mation on class websites and multidisciplinary group work
toward presentations in tutorials. Several programs (4 pro-
grams out of the 10, drawn from Northern Europe and
North America) indicated that they considered students to
be responsible for developing their own knowledge in
prosthetics, orthotics, and related sciences. These universi-
ties specified student-centered strategies, such as problem
solving, to motivate critical thinking, in-depth learning
and understanding, and lifelong learning in students. Two
programs from North Europe specified PBL, stating that
they used it in an attempt to encourage the students to inde-
pendently acquire the latest knowledge and express their
own findings and opinions to other peers through presenta-
tion and seminar sessions.
The second, survey phase of the wider study allowed
more specific insight into the teaching methods that were
common across the institutions and others that were more
distinctive. Table 2 shows instructor responses to prompts
regarding the use of specific teaching strategies in teaching
theoretical material. The Chi-squared statistic on Table 2
indicates no significant difference between instructors
from developed regions (Oceania, Northern Europe, and
North America) and those from developing ones (South
Asia and the Middle East). The number of responses in the
“Strongly disagree” was extremely small and those
responses have been consolidated into “Disagree” on the
following tables. The instructor responses in Phase 2
reflect some unease with the results of the documentary
analysis from Phase 1. For example, Phase 1 indicated
considerable use of lectures but Phase 2 suggests that
instructors are ambivalent about this, with almost twice as
many doubting its effectiveness.
The more illuminative results of the Phase 3 Delphi
study indicated more support for large group teaching of
theoretical material (Item b on Table 2). There was only
moderate consensus in viewing it as less effective than
other approaches (Median = 5 and Agreement = 61.5%),
although one expert instructor commented that this method
“is good for giving the basic, small groups for developing
individual skill set.” This position garnered slightly more
agreement (Median = 5 and agreement = 69.2%), but there
was a higher consensus regarding the importance of small
group teaching (Median = 5 and Agreement = 84.6%)
among these Delphi participants.
Phase 1 indicated that prosthetics and orthotics pro-
grams usually apply similar methods for teaching the tech-
nical part of prosthetics and orthotics in practical and
clinical classes. These include observation, workshop
practice, laboratory and online practical education, and
clinical training. The initial curriculum analysis indicated
that most (7 out of the 10) included observation of clinical
and workshop practice and site visits in their programs, but
such observation differed in purpose and form. Three pro-
grams from the Middle East and South Asia placed empha-
sis on student process diaries and another asked that they
record their analysis of the design and fabrication process.
Two programs from North Europe claimed to use work-
shop subjects to motivate students to ask questions about
the profession and society and to develop their profes-
sional curiosity and critical thinking.
Almost all programs involve student workshop manu-
facture of prosthetic and orthotic devices. However, two
programs from North Europe and South Asia require that
students record everything that they do during this period
in their workbooks, and one program from North Europe
emphasizes quality assurance and seeks to develop student
skills through EBP. Table 3 provides more details extracted
282 Prosthetics and Orthotics International 39(4)

Table 2.  Strategies for teaching theoretical classes (based on Phase 2 survey).

Items N Strongly agree Agree Disagree Chi-square P<

(developed &
developing nations)
a. Small group teaching is more effective 47 24 18 4 1.36 0.24
b. Large group teaching is more effective 47 0 17 30 1.87 0.17
c. Tutorials help the students learn more 46 12 24 10 5.65 0.06
d. The teachers must have authority in class 47 14 25 8 1.01 0.60
e. The teaching must be student-centered 44 22 19 3 1.85 0.17
f. T
 he teaching must encourage the students 47 37 10 0 0.00 0.98
to participate in class
g. L earning must be sufficiently concerned 45 29 14 2 0.26 0.60
to develop the competence of students
h. L earning must be sufficiently concerned 47 26 17 1 0.12 0.72
to develop the confidence of students
i. T
 eachers must provide good feedback to 47 36 10 1 0.04 0.83
students

from the survey study and indications of difference
between programs located in developed and developing
nations.
Table 3 indicates that instructor response regarding the
teaching of practical material varied according to the level
of development of the region within which they worked
(see Items b, d, and g). Instructors from developing coun-
tries placed more stress on workshop practice, records of
analysis of the design and fabrication process, and online
practical education than developed nations.
Although the panel of experts in the Delphi study
agreed that clinical training is one of the most important
parts of practical teaching (Acceptance = 6 and Agreement
= 84.6%), “Site observation” could not achieve even mod-
erate consensus (Acceptance = 5 and Agreement = 58.3%).
There was moderate agreement with the importance of
both workshop practice and laboratory practice
(Acceptance = 5 and Agreement = 76.9% for both) and
results from the expert panel reiterated the Phase 2 regional
variation regarding online practical education (Acceptance
= 4 and Agreement = 53.8%).
Clinical training provides students with direct contact
with clients, so it is unsurprising that all documentation
placed stress on independent student positive interaction
with patients during clinical training. Moreover, clinical
training provides an opportunity for students to integrate
scientific subjects and the theory of prosthetics and orthot-
ics with practice as they evaluate their practical experience
in real environments. Clinical placement may be seen as
the most important part of prosthetics and orthotics educa-
tion and it exists in all programs, in various forms, and for
differing lengths of time. The results of Phase 1 of this
study showed that half of 10 programs allocate either their
final year or final half year to clinical placement. Such
placements may divide prosthetics from orthotics or com-
bine both. However, there did not appear to be general
consensus across the 10 programs regarding the appropri-
ate time for beginning clinical training. Table 4 shows the
results of responses to Phase 2 questions regarding this
important issue.
Instructors from developing nations more strongly
favored increased student responsibility for their patients.
This group of instructors also preferred increased educator
responsibility (see Table 4). It seems that instructors from
more developed nations more strongly emphasize student
responsibility for independently acquiring clinical skills.
The results of the Delphi phase showed that most expert
instructors agreed that students are responsible for their
own learning and development of their professional skills,
but this remains problematic as the item could only achieve
moderate acceptance and agreement (Median = 5).
Similarly, instructors from developing countries
(78.8%) favored separation of clinical training in prosthet-
ics from orthotics clinics, but 57.1% of instructors from
developed countries did not agree. There appears to be a
lack of consensus between instructors from institutions in
regions with different degrees of development. These dif-
ferences fall into areas of student responsibility for their
own learning, use of PBL, function of workshop practice,
and clinical placements (the role of online resources,
responsibility for clinical supervision, and separation of
prosthetics from orthotics placements).
Discussion
Each program employed different strategies, approaches,
and methods to teach the essential disciplinary sciences.
Teacher-centered strategies for teaching theoretical mate-
rial emerged more positively from this study than may
have been expected. Lectures may be supported by other
approaches, such as class websites, tutorials, group work,
presentations, and multidisciplinary group working, to
Aminian et al. 283

Table 3.  Strategies for teaching practical classes (based on Phase 2 survey).

Items N Strongly Agree Disagree Chi-sq (developed & P<

agree developing nations)
a. Site observation 47 30 14 3 1.87 0.17
b. Workshop practice 47 28 15 4 12.04 0.001
c. Laboratory practice 47 22 21 4 2.99 0.08
d. Online education 47 0 28 19 4.71 0.03
e. Clinical Training 47 37 8 2 0.00 0.98
f. Keep processing diaries 47 12 27 8 1.88 0.38
g. Records of analysis of the 47 23 21 3 6.03 0.01
design & fabrication process
h. Professional curiosity 47 23 21 3 0.53 0.46

Table 4.  Strategies for teaching clinical training (based on Phase 2 survey).

Items N Strongly agree Agree Disagree Country level

  Chi-square P<
a. S elf-directed learning skills are very important in clinical 47 15 25 7 2.73 0.25
education
b. S tudents should have direct responsibility for their 47 22 17 8 9.09 0.01*
patients in clinical training
c. Clinical educators should not have responsibility for all 46 2 19 25 5.38 0.02*
P&O skills
d. C  linical training in Orthoses should be separate from 47 15 17 15 5.84 0.02*
clinical training for Prostheses
e. Clinical training must begin early in program 47 9 22 16 1.41 0.23
f. Each clinical educator should have a maximum 3 students 46 14 22 10 6.34 0.02*
in clinical training
g. Clinical training must be done in the final year 47 8 12 27 0.38 0.53
h. The teacher must pay attention to student 47 36 11 0 0.43 0.83
communication skills

P&O: Prostheses and Orthoses.

*The p-value<0.05 is significant.

form a blended teacher-centered approach.8 There has,
nonetheless, been some apparent movement from tradi-
tional lecture-based, teacher-centered practices to more
interactive student-centered approaches within prosthetics
and orthotics programs, although only moderate consensus
was achieved in the Delphi study concerning teacher-
centered approaches as being less effective. Such student-
centered approaches appear to be widely advocated within
allied health education, as some authors indicate that stu-
dents in a PBL program read more text books and more
library resources and texts are needed than for traditional
programs.12,20 This approach might be an appropriate
response to rapid technological and healthcare changes
and increase the competency of students in the domains of
critical thinking, technical, and communication skills.21
However, the number of prosthetics and orthotics pro-
grams which employ student-centered approaches appears
small. Greater consensus emerged during the Delphi study,
but this may be a response to reports of its effectiveness.22
These expert instructors do not appear to be confident
about the impact of PBL on learning outcomes and this
echoes ambivalence within the literature.12,15,20,23 It may be
that the expertise of these instructors did not extend to
experience with PBL. This limitation of the study could be
overcome by deliberate recruitment of expert instructors
with experience of the approach, although the reticence of
this group may reflect a wider attitude. However, that
would be a useful topic for a later study.
This panel of expert instructors agreed that client con-
tact at the beginning of study may motivate the students to
better understand theoretical subjects, as Manogue et al.8
earlier recommended for dental students.
Instructors from developing countries paid greater atten-
tion to workshop practice and online practical education
than instructors from developed nations. They were also
much more positive about the possibilities of online
284 Prosthetics and Orthotics International 39(4)
practical education for practical teaching in their nations, in
line with some other authors who believe that online educa-
tion is useful for students. Somewhat surprisingly, instruc-
tors from developed countries were less enthusiastic.24–26
Consensus was not achieved about the use of online practi-
cal education for better understanding of practical courses
during the Delphi phase, which revealed a similar range of
views concerning the use of computer software. Although it
seems to be a feature of many programs, the majority of
instructors accepted this method only for instruction in
practical skills previous to real practice, stating that clinical
activity and client contact have more impact than the vir-
tual environment. However, instructors from developing
countries relied more on student-produced records than did
those from developed nations, which may be related to low
numbers of patients for practical training and the conse-
quent need for students to write and review reports of their
own practical activities.
Professional curiosity forms a foundation for self-
directed learning, which is necessary for clinical training
and student problem solving during patient management.
Clinical training was considered very important as a prac-
tical teaching method and observation from sites followed
it in terms of instructor priority. The students have direct
contact with clients and responsibility to manage the
patients during clinical training, and clinical educators
may employ various learning strategies, such as solving
problems and encouraging lifelong learning. Problem
solving may lead to EBP, which is seen by some as one of
the most important issues to emerge in rehabilitation.27
Other prosthetics and orthotics authors have suggested that
curricula and assessment methods should be modified to
train the students for critical thinking, which will be useful
either in making appropriate decisions in clinical practice
or in responding to rapid changes in information.28,29
The results show that instructors from more developed
nations more strongly emphasize student responsibility for
independently acquiring clinical skills than those from
developing nations. The results of the Delphi phase also
showed that most experts agreed that students are indepen-
dently responsible for their own learning and development
of professional skills. Instructors from developing nations
may prefer to educate their students in their university,
under the closer supervision such a location allows, instead
of during clinical training which happens off campus and
with associated problems of quality control.
There were some limitations to this study, such as insti-
tutional policies that prohibited access to their curricula or
review of some curricula that would have otherwise been
available and language of communication, all of which
contributed to some restriction on the number of programs
whose instructors could participate in the study. The pos-
sibility of expert bias raised by this restriction has already
been mentioned. However, the main aim of teaching and
educating in any discipline and institution is to increase
the professional competence and confidence of its gradu-
ates, and the teaching and learning approaches presented
above could well form components of EBP in allied health
professions.30
Conclusion
A number of themes emerge from the results of this inves-
tigation of the priorities that expert prosthetic and orthotic
instructors place on different teaching methods. Perhaps,
most fundamental is the extent to which students are
responsible for their own learning. Instructors working in
developed nations saw students as bearing much responsi-
bility for their own learning, even in clinical contexts,
while those from developing nations placed greater respon-
sibility on them for the quality of the devices that they fab-
ricated for patients and the general quality of care that they
offered.
This difference expressed itself in the priority given to
different methods. Traditional patterns of lecture, tutorial,
and workshop were present in all regions, although these
expert instructors seemed quite aware of their shortcom-
ings and of the impact that institutional facilities have
upon instructor choice of teaching methods. Student-
centered approaches were broadly supported, although
PBL was less common than might have been expected
from the general health sciences literature.
Regional differences in locus of responsibility also sur-
faced with respect to clinical teaching, with instructors
from developing nations being more likely to see its func-
tion as revolving around skill development, while those
from developed nations looked for emerging student criti-
cal thinking as a result of work in prosthetic and orthotics
clinics.
This difference in the locus of responsibility for learn-
ing seems to underlie many of the priorities expressed by
these expert instructors. Where the student is seen as more
responsible, methods are chosen over which the instructor
has less control. Where the instructor is seen as more
responsible, methods which allow that responsibility to be
more effectively managed seem more important.
Contemporary discussions can sometimes obscure the
actual state of instructional practice. The research reported
in this article provides data for one area of health science
education. This data may be useful as a baseline from
which important and fruitful changes can be encouraged.
The next step would be to involve student priorities and
outcomes in the exploration of current teaching practices
in orthotics and prosthetic education. Hunt et al.6 urged
that the curriculum designer consider the relation between
the teaching and learning processes, recognizing that,
while educators attempt to teach scientific materials and
professional skills, the amount of learning is determined
by students. This seems true, wherever the instructor or
institution places the locus of responsibility.
Aminian et al. 285
Acknowledgements
This article emerged from the first author’s doctoral study, which
was carried out under ethical approval from the University of
Newcastle, Australia (Approval Number H-350-1206). We
would like to thank the institutions and expert prosthetics and
orthotics instructors whose participation made this study
possible.
Author contribution
All authors contributed equally in the preparation of this article.
Conflict of interest
The authors report no conflict of interest and they are responsible
for the content and writing of this article.
Funding
This research received no specific grant from any funding agency
in the public, commercial, or not-for-profit sectors.
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