Chiropractic lecturer qualities: The student perspective

Chiropractic education continues to evolve to meet the challenges of health care provision. On graduation, students must meet the changing roles of a chiropractor and manage patient expectations.¹  The councils of chiropractic education worldwide, including the General Chiropractic Council (GCC; the regulator in the United Kingdom) have each developed a list of minimum expectations and competencies expected of graduates.²  This list of competencies and standards provide clarity to the necessary knowledge, understanding, skills, attitudes, and behaviors graduates must achieve prior to qualification.³  These expectations have laid the framework for chiropractic education, with the curriculum designed to enable students to become lifelong learners and advocates for the profession.⁴  To facilitate this philosophy, a move toward a problem-solving and clinical-reasoning curriculum has been acknowledged as important in the education of emerging chiropractors.

Lecturers are at the heart of the educational experience, tasked with supporting the development of students into clinically competent and confident graduates. Teaching is a skill-based profession, and a qualification in a professional area does not necessarily provide the qualities or capabilities required to be an effective lecturer.^5,6  An effective lecturer has been conceptualized as one who produces desired outcomes through a high-quality student-centered approach to learning.^5,7  Lecturers' subject knowledge and their willingness to support the student body and deliver inspirational teaching methods are all components of teaching excellence.⁸  Teaching excellence is built upon a vision of imagination, risk-taking, intention, and invention.⁹  However, academic roles extend beyond immediate teaching responsibilities, directly impacting the student experience in a variety of ways. Harden and Crosby¹⁰  describe 12 roles of teaching, identifying the importance of lecturers as information providers, role models, facilitators, assessors, planners, and resource creators. For chiropractic lecturers to successfully implement these roles, a balance between clinical and educational expertise is required. In relation to chiropractic education, it is unclear how students value and perceive the importance of each role.

A paradigm shift has redirected health care education focus toward a research-informed curriculum, where lecturers move from an opinion-based to a sustainable evidence-based education. This skill set integrates learning and teaching expertise with the highest quality systematic evidence to provide a rich, blended, and innovative clinical education experience.¹¹  Teaching evidence-based health care in this way—through an applied lens—better prepares chiropractic students to become both competent practitioners and lifelong learners.¹²  Lecturers sit at this interface between theoretical education and the transition to clinical practice and are therefore central to a positive and high-quality learning experience. As educators of a vocational subject, the influence of lecturers to the wider course is evident, with direct responsibility for many facets that contribute to each student's success.¹³ 

Despite the obvious significance of chiropractic lecturers to the learning experience, a lack of research exists to understand the qualities students perceive as important in their educators. Understanding the qualities students value allows lecturers to respond and evolve to meet student's expectations.¹⁴  Student outcomes and satisfaction are associated with the attainment of knowledge principally through classroom delivery.^15,16  Students value high-quality teaching both in terms of classroom delivery and in the feedback received within taught sessions and following assignment submission.¹⁷  The relationship between students and the academic faculty is important to the overall student experience.^16,17  Nursing students have previously identified the ability of lecturers to motivate the student body through innovate teaching methods as an important quality.¹⁸  Practical experience and up-to-date theoretical knowledge as well as fostering good interpersonal relationships have been recognized as desirable characteristics in both medical and nursing lecturers.^18,19  The importance of these skills has not previously been investigated in a chiropractic student population. The exploration of the importance of lecturer's qualities to the educational experience of chiropractic students in the United Kingdom provides the opportunity to engage students as coproducers of course and staff development.⁸  Students as cocreators of education are then empowered in the ongoing evaluation of chiropractic preregistration courses through an active voice.

Therefore, the primary aim of this study was to understand how UK chiropractic students rate the importance of lecturer qualities against the 12 described roles of teaching.¹⁰  The study also aimed to understand the importance of specific teaching qualities and the value of lecturers to the overall preregistration course experience.

The online cross-sectional survey aimed to understand the importance of a range of qualities chiropractic students value in lecturers. The study, conducted between July and September 2020, was approved by the School of Health and Life Sciences ethics committee at Teesside University (No. 250/19) and conformed to the Declaration of Helsinki. The survey was composed of a mixed-method approach to questioning, allowing respondents to share their thoughts while exploring the seminal reasons behind their experiences.²⁰  Quantitative questions were a dichotomous response or Likert scale, of which all scales utilized were unipolar. The use of named categories within the survey (1, Not important; 2, Low importance; 3, Neutral; 4, Important; 5, Very important) are considered user friendly and provide acceptable levels of reliability.²¹  Qualitative questions were adopted to investigate students reflections on key areas of lecturer characteristics and qualities. During pilot testing, 10 chiropractic students reviewed the survey for content and construct validity.²²  Following testing, only minor modifications to the wording of specific questions were required. The pilot group were instructed not to complete the live questionnaire.

The survey was hosted at Online surveys (https://onlinesurveys.ac.uk) and included 14 questions. Because of the limited number, within the United Kingdom, of practical chiropractic (n = 5) courses that lead to registration with the GCC, respondents were not asked about the type of preregistration course or year of study to prevent identification of an institution and protect respondent anonymity. Respondents were asked to rate the importance of chiropractic lecturers, using a Likert scale, against the 12 roles of a teacher.¹⁰  In addition, students ranked the importance of lecturer qualities, and the value of clinically active and research-active academics was explored. Respondents rated the importance of lecturers across a number of course measures including overall enjoyment, facilitating their ability to succeed and achieve, the development and understanding of clinical and nonclinical skills.

The author contacted the trade union body of UK chiropractors (the GCC), which currently has approximately 3500 members. Because of the nature of the data held by the GCC, they were unable to identify the number of students registered across all UK-accredited programs. Therefore, a random sample from an existing framework was not possible.²³  The recruitment strategy was designed to reach and represent the maximum number of student chiropractors within the United Kingdom. The GCC shared the study aims and recruitment invitation across their network of members in the form of an electronic newsletter. Respondents were encouraged to share amongst student colleagues using a snowball method of recruitment.²⁴  Respondents were asked to complete the questionnaire only if they were current students enrolled in an accredited preregistration chiropractor course in the United Kingdom. Participants were informed that by submitting their survey responses, they were consenting to taking part in the study.

Following survey closure, data were extracted from the Online surveys site into Microsoft Excel (Microsoft Corp, Redmond, WA) using the analyze function. As the survey was not designed to test for differences between respondents, no such analysis was performed. Using the Wilson procedure, data from the dichotomous questions were converted into proportions with lower and upper limits of the 95% CI calculated.²⁵  Likert scale questions were treated as continuous variables.²⁶  The mean, mode, median, and percentage were calculated for combined responses across each answer. Themes to qualitative questions were identified using a thematic analysis approach to reveal patterns across the data set.²⁰ 

A total of 196 student chiropractors completed the survey, with one incomplete questionnaire removed from data analysis. Therefore, a total of 195 eligible participants completed the survey: 116 men (59%), 79 women (41%); age (mean ± SD), 26 ± 7 years, range, 18–43 years. Owing to the sampling method, it is not possible to estimate the denominator sample size of student chiropractors who received the invitation to complete the survey.

Respondents were asked to rate the importance of a range of effective chiropractic lecturer qualities. Table 1 displays participant responses, against a Likert scale, with mean, mode, median, and percentage of responses for each score presented.

The survey asked participants to rank the importance of several specific lecturer qualities. Table 2 displays the ranking of each quality (1 = highest, 10 = lowest), with median and interquartile range.

In addition, respondents identified important lecturer qualities not previously captured. From the 63 qualitative responses, the highest representative theme in terms of number related to lecturer passion and enthusiasm for teaching (n = 31). It was felt that these characteristics further developed students interest in the subject. Patience and humor were considered important qualities of effective lecturers to facilitate the creation of a professional relationship and a productive learning environment. Organization and honesty were traits considered crucial in a chiropractic lecturer.

A range of student-rated outcomes were evaluated by respondents for the perceived importance of lecturing staff on each measure. Table 3 presents the mean, mode, median and percentage response for each score.

Students acknowledged it was important that chiropractic lecturers were actively involved in clinical practice in some capacity (n = 164; 84%; 95% CI, 78%–89%). From qualitative comments, key themes emerged of clinical relevance, translation of clinical examples and transforming the learning experience. Current links to clinical practice were deemed important for lecturers involved in clinical-skills teaching. The use of clinical scenarios enabled topics to be “brought to life” and enabled a greater understanding of the current health care climate, including its challenges and opportunities. Comments related to the transformational learning experience suggested that chiropractic lecturers who actively engaged in clinical practice positively developed students critical understanding through an applied lens. This bridged the theoretical gap toward autonomous clinical practice.

Research-active staff were perceived as being able to provide insight and support the translation of research into training and ultimately clinical practice. Only 25% (n = 48, 95% CI, 19%–31%) of respondents felt lecturers should be research active. A continuous theme emerged with students suggesting it was more important that lecturers were clinically active and contemporary.

Respondents, in the main, believed that lecturers should provide them with the tools to explore their own methods of learning (n = 131; 67%; 95% CI, 60%–73%). Responses suggested that lecturers should facilitate independent learning rather than pursue a passive teaching approach allowing students to meet the demands of continuous professional development upon graduation. Supporting the transition to an active efficient self-learner was rationalized by the individual nature of the learning process. Facilitating and establishing students' own educational methods was believed to be integral to degree success.

The primary aim of this study was to understand how UK chiropractic students perceive the importance of a range of lecturer qualities. Novel findings, in this specific chiropractic population, suggest that all the 12 roles of teaching¹⁰  were considered at least important. Five key qualities were rated as very important, including the ability to deliver high-quality information in both the classroom and clinical settings, effectively planning purposeful learning and assessment strategies, and undertaking curriculum evaluation.

Preregistration chiropractic education provides the underpinning knowledge and experiences required to prepare students clinically and professionally for practice. The translation of values, beliefs, and knowledge conveyed in the classroom and associated learning environments formulates student identity and their capability to meet the standards for practice, regulated by the GCC.^2,27  To meet such competencies necessitates a student-led learning philosophy bridging the gap between education and professional practice, allowing for the provision of high-quality patient care.^28,29  Lecturers sit at this interface between academia and professional practice, and it is imperative that they infuse the curricula with a focus on providing students with the skills to thrive upon graduation. A mainstay of this vision is the deliverance of high-quality information, which takes center stage at the forefront of teaching. Within the United Kingdom, this survey suggests that students value this skill both within the theoretical classroom (mean = 4.71) and clinical setting (mean = 4.60). Disciplinary knowledge is at the heart of teaching approaches, and the cultural expectation of lecturers to deliver high-quality course material to their students remains.^10,30  The faculty teaching chiropractic students need to be entrenched in a multidisciplinary way of thinking, providing the most skilled and experienced teachers to provide an innovative and stimulating educational experience.³¹ 

Curriculum evaluation and development is a fluid continuous process of review and revision with an emphasis on students becoming engaged with the process.³²  The chiropractic curriculum should position itself within a diverse structure, meeting current education and health care needs. This significance was acutely acknowledged by respondents who rated curriculum evaluation and development as the joint most important quality of chiropractic lecturers. This finding suggests that students wish to become active coauthors of learning through the student voice. This notion of lecturers and students acting as coconstructors of knowledge can become a focus for learning to produce a more relevant and authentic experience.³³  Chiropractic lecturers should consider the students-as-partners approach to curriculum design and evaluation. Healey and colleagues'³⁴  conceptual model focuses on student engagement through partnership. True partnership is where institutions go beyond listening to the student voice and engage students as colearners, coresearchers, coinquirers, codevelopers, and codesigners.³⁴  This may take different forms across institutions, but by involving students within the curriculum design process, their footprint and experiences are left for future cohorts to embrace.

Lecturers have a fundamental impact on students' enjoyment of the course (mean = 4.88) and their ability to succeed (mean = 4.54). Student success is influenced by numerous internal and external academic factors.^35,36  Within the institution, student–faculty relationship, attendance, motivation, and time dedicated to study are significant factors behind successful outcomes.^37,38  External factors, including employment conflicts, family circumstances, and emotional stress, are also related to course outcomes.^39,40  This study suggests that lecturers play an integral role in course enjoyment and that the student–faculty relationship is important to overall outcomes. Academics should acknowledge this importance when supporting students both academically and personally throughout the entirety of their course. Identifying barriers or facilitators to student outcomes is linked to the relationship quality between students and faculty.⁴¹  This is true across allied health disciplines, with nursing students reporting that a supportive culture in the clinical and classroom environment has a positive impact on success, educator morale, and attrition rates.^42–44  Three subthemes—mentorship, accessibility, and approachability of faculty—have emerged from the literature as key to student–faculty relationships.¹³  Of interest, the qualities students rated as the most important in this study were directly linked to their academic careers and current course (course enjoyment, ability to succeed). Qualities including supporting the development of clinical and nonclinical skills, rated as important and neutral, respectively, were rated lower but are intrinsically linked to postqualification requirements. To support the transition to postgraduation practice, nonclinical skills including decision making, initiative, prioritization, and time and stress management have been recommended as important components of initial training.^45,46  These skills are desirable attributes of health care clinicians.^47,48  Potentially, these results indicate respondents are focused on their current academic careers rather than considering the broader importance of these skills that lecturers instill as part of their professional development. Signposting the significance of these skills to clinical practice may develop their perceived importance amongst student cohorts.

Chiropractic students, in this study, ranked communication as the most important lecturer quality. Command of the subject and the ability to motivate and inspire the student body were all ranked highly. These personal qualities are intrinsically linked to the student–faculty relationship. Lecturer passion and enthusiasm for teaching was clearly identified by respondents as important. A combination of the lecturer's subject knowledge, willingness to help, and inspirational teaching methods generates a good university lecturer,⁸  and this survey suggests that these qualities support chiropractic education. Qualities ranked as the least important included teacher image and closeness to students.

Eighty-four percent of all respondents felt that it was important that chiropractic educators were still actively involved in clinical practice in some capacity. Developing a philosophy of experiential learning through educator clinical experience links together theory, practical experience, and professional development.⁴⁹  The promotion of active-learning strategies through clinical application may be the best method to develop critical-thinking and clinical-reasoning skills in health care students,⁵⁰  and this importance was recognized within this survey. This experiential learning, an important component of health care courses, includes knowledge translation during practical and laboratory classes, where students discover and synthesize clinical skills through simulated and actual patient interaction.⁵¹  Critical patient-facing skills are developed when students can focus on complex issues, dissect them, examine interlinked relationships, and process them in a way that is transferrable to clinical practice.⁵²  The emphasis should focus on learner self-direction and reflection.⁵³  Bringing the curricula to life through educator experiences was valued by respondents with students relating clinical experiences as an important factor in concept understanding. It was deemed less important for lecturers to be research active (25%), but qualitative analysis suggested that a research-informed curriculum improved teaching and student outcomes. Research-informed teaching is a fundamental aspect of health care education delivery and should become part of pedagogic practice considered through the lens of how to transfer knowledge most effectively. Teaching chiropractic students through an applied evidence-based health care strategy may better prepare them for the challenges of clinical practice and lifelong learning. Fostering evidence-based practice assists with lifelong learning and the promotion of best practice.³¹  Though an integrated approach to learning utilizing best available evidence is desirable, the respondents in this survey clearly valued the attributes of clinically active lecturers.

Respondents identified the need for lecturers to support them in finding their own methods of learning (67%) to promote the skills for continuous professional development required of the modern-day chiropractor. To enable this development, lecturer guidance should be structured initially and become more fluid as students' skills progress.⁵⁴  Active-learning strategies often include experiential learning, peer tutoring, laboratory work, role-playing and case study adoption.⁵⁵  Such strategies present opportunities for students to actively challenge and critique taught concepts, through their own experience or the experiences of others, under the guidance of lecturers encouraging necessary cognitive conflict.⁵⁶  Methods to engage and motivate the student body are fundamental in the progression of identifying one's own learning. This professional continuous development requirement of ongoing enhancement of knowledge, skills competence, and performance to improve patient outcomes through independent lifelong development was recognized by respondents.⁵⁷ 

The sample of respondents within this study may not be entirely representative of the target population.⁵⁸  It was not possible to obtain the current number of active students at each institution owing to data-protection restrictions. The overall proportion of student responses cannot be calculated, and it is therefore important to acknowledge that the results of this survey do not present the views of all UK chiropractic students. Additionally, the results cannot be generalized across global chiropractic students; however, the results do offer insight into the desirable qualities of chiropractic lecturers. Future research may wish to investigate how global chiropractic students perceive the importance of lecturer qualities enabling local lecturers and institutions to reflect upon this aspect of the student voice. It is possible that nonresponder bias may exist within the study sample.⁵⁹  Students rating of effective lecturing is only one method of evaluation.¹  Future research may wish to broaden the scope of this study to explore how lecturers can further facilitate high-quality chiropractic education and reduce the gap between education and clinical practice. This would include understanding the reasons and motivations behind why students valued some lecturer qualities over others. Further understanding of the qualities students perceive as important throughout their academic studies would be of value. As students transition through preregistration education, critical-thinking skills, knowledge understanding, expectations, and perceptions may change, and this should be explored further. Having lecturers themselves reflecting on their own experiences as teachers and learners, through the student lens, provides a framework for educational development.⁶⁰  Using the available learning and teaching literature to inform an evidence-based approach to education delivery will continue to improve standards of health care education across the sector.

Chiropractic students in the United Kingdom value the role of lecturers who contribute to both their ability to succeed and overall course enjoyment. Student–faculty relationships are important to student outcomes. A range of lecturer roles were valued and regarded at least as important. The ability to deliver high-quality information and to evaluate the curriculum were the highest ranked qualities. Communication and command of the subject were personal qualities students valued in their lecturers. The current students surveyed felt that it was important for lecturers to be clinically active in some capacity to provide the best possible learning environment, thereby ensuring that they are confident and competent upon graduation.