Magazine international assignment THIM 2021-2022

THIM

2021-2022

Physiotherapy students’ thoughts and opinions

A cooperation between THIM University of Applied Sciences in Physiotherapy in the Netherlands and Switzerland.

Lifelong learning

Innovation

Internationalisation

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Introduction

In order to be able to provide tailor-made health care to people from all over the world, professionals should be able to identify with people from different ethnic, national, cultural, social and/ or religious backgrounds in a foreign language.

Awareness of their own cultural values and behaviour is part of this as well. In this light, and to emphasize the international component of THIM University for physiotherapy, additional study assignments with an international focus have been added to the study program.

This magazine is an elaboration of the international assignment in the first academic year of THIM University. Within this task, first year physiotherapy students were teamed up with an international peer student to explore each other’s thoughts and opinions towards a hot topic in physiotherapy. Each student engaged through Zoom in a meeting with his/her (matched) international peer in which the interviews took place. There were three groups of students that attended: •Fulltime students of THIM in Switzerland (THIM-CH) •Dutch fulltime Students of THIM in the Netherlands (THIM-NL) •International students of THIM in the Netherlands (THIM-NL) THIM lecturers and approximately 90 students have worked on this assignment in an active, committed and cooperative way. After a successful first edition of the international assignment and resulting magazine (2020-2021), the current magazine represents the results of the second edition of the international assignment (2021-2022). A great cooperation between Thim van der Laan BV in the Netherlands and Thim van der Laan AG in Switzerland which has resulted again in a beautiful product that is both professionally and socially an achievement.

We would like to thank all the students and teachers for their contribution and proudly present the international magazine 2021-2022.

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18.

THIM University (NL)

The unmotivated patient

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20.

THIM University (CH)

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Telerehabilitation in physiotherapy

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The physiotherapist as innovator

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E-Health = Health

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First year full-time students of THIM-CH

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Lifelong learning

Table of contents

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First year fulltime Dutch students of THIM-NL

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First year international students of THIM-NL

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The ethical borders of merchandising

24.

Internationalisation

26.

Cultural background

28.

THIM exchange projects

15.

29.

Research and innovation at THIM

Survey internationalisation

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31.

Shared decision making

Contributors

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THIM University (NL)

Location Newtonbaan

Location Archimedesbaan

An open mind To have an international outlook enhances your quality as a professional. It helps to open up your mind to other perspectives and new insights are necessary to keep learning and improve yourself as a professional.

Unfortunately, these are times in which national interests seem to be dominant over international cooperation. Borders and noncooperation have never added anything to prosperity and progress. Trade and exchange of knowledge bring us much more.

Jeroen van der Laan Director Thim van der Laan (the Netherlands)

Students cross borders all the time and that is for the better. Therefore, I welcome this project as a means to have a professional and international exchange of information. Even similar countries like Switzerland and the Netherlands differ in approach, outlook and content. It is a good thing to compare and learn from each other.

However, the last two years crossing borders was harder as a result of the Corona crisis. Let’s hope that this crisis will now be over and we can continue on this path of cooperation by meeting each other not only digitally but also physically.

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THIM University (CH)

Founded in Holland in 1974, THIM has also been active in Landquart, Switzerland for more than 30 years. I am pleased to have been able to lead THIM in Landquart for over ten years now. Looking back at THIM CH's history, our education had exactly 140 students as of 1 January 2011. A decade later, also thanks to the implementation of our “mode B” (a bachelor programme for experienced professionals), we currently count approximately 260 students.

Thim van der Laan Jr. Director Thim van der Laan (Switzerland)

Personally, I strongly believe in the profession of physiotherapy in a modern setting with future-oriented ways of thinking. Accordingly, at THIM CH we try to incorporate the (physiotherapy) trends of the future, such as technology and internationalisation, into the bachelor education. However, the most important component at THIM CH will always be the familiar atmosphere between our students and the THIM staff.

When I'm not fully dedicated to educating the future physiotherapists, one can surely find me on the football pitch of the rather alpine FC Davos of which I am currently the president. Even better however, is hitting the ski slopes in my home town of Davos. For a nice sunny day on the slopes followed by aprèsski, you can always contact me :-).

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Telerehabilitation in physiotherapy Physiotherapy is mostly regarded as a “hands-on” profession. However, over a decade ago, in order to meet with consumers’ demands for faster and more convenient care, physiotherapists began incorporating innovative technology next to traditional inperson care delivery. One of these innovative technologies is telerehabilitation.

Telerehabilitation refers to the use of information and communication technologies (ICT) to provide rehabilitation services to people remotely in their home or other environments. Such services include remote therapeutic interventions (such as training), remote diagnostic procedures, remote monitoring of progress, remote education and consultation and means of networking for people with disabilities. The purpose of telerehabilitation is to increase accessibility and improve continuity of care in vulnerable, geographically remote populations with disabilities with the potential for saving time, costs and resources in health care.

Prior to the recent outbreak of COVID-19 telerehabilitation was acknowledged as an effective adjunct to traditional in-clinic methods. During the COVID-19 pandemic however telerehabilitation was used as a replacement of face-to-face physiotherapy, to allow patients to continue with a current therapy treatment plan, while adhering to social distancing orders. Will this also be a big element in the future of physiotherapy? Is it possible to replace a significant part of the physiotherapy meetings by telerehabilitation or by remote physiotherapy? Six future physiotherapists of THIM studying in the Netherlands and three in Switzerland were interviewed by peers about their thoughts and opinions on the role of telerehabilitation in the future of physiotherapy.

Do you like the idea of remote physiotherapy and do you think that this will be our future?

Most students agree that remote physiotherapy is likely to remain as a small element in the physiotherapist’s future. However, they don’t see a big role for remote physiotherapy in treatment and assessment of patients’ problems. As a Dutch student states: ‘the biggest part of physiotherapy is to make a connection with the patient’. Students think that this might be difficult virtually: ‘As a physiotherapist you need to do a screening face to face because you need to see the emotion or his mental founding’. A Swiss student adds: ‘because physiotherapy is for the main part a contact job with massages and fixing joint problems, I don’t think remote physiotherapy will ever replace face to face physiotherapy’.

Thereby remote contact won’t be tolerated well by all patients: ‘there are many old people who don’t know how to use their phone or search things on the internet. So, I don’t think this will be our future’.

Although most students are not very keen on remote physiotherapy, they do predict a mix of face to face physiotherapy and online physiotherapy. For example giving information, instructions and advice are often named by students as something that could be done online: ‘I like, for example online workout plans or meal plans’.

Students also see advantages in instructing exercises with a combination of a video conference platforms, videos and apps.

Although students state that exercise instructions can be given online, by combining an online meeting with apps and videos, most students state that the treatment can’t be done online: ‘the physiotherapist needs his/her hands for that and it’s impossible to do it online’.

Students see advantages of remote physiotherapy in COVID-19 pandemic like situations or for patients who live in remote areas: ‘I think it’s great, because some people have to travel a lot. For instance in Canada some people have to travel over 2 or 3 hours to go to their nearest town. And I think it can be an improvement for the younger generations because a lot of them are really busy and see the physio as a burden so when you take their travel time away, it could help them really much’.

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What could be a harm when considering telerehabilitation?

One student is very clear in his/her opinion: ‘There are almost no advantages so practically everything would be a disadvantage’. Most other students however are less outspoken negative towards remote physiotherapy.

Although they are not very keen on the thought of remote physiotherapy, they also see some positive sides.

However, most students mention that examination, diagnosis and treatment will be tough when conducted remotely, although conveying treatment options like exercises form the exception. Hands on therapy however would be impossible remote. ‘You can't examine the patient properly, treatments can't be done and a lot of patients are not that motivated to do exercises at home’. As Swiss physiotherapists seem to make more use of hands-on treatment opportunities than Dutch physiotherapists, it would be interesting whether there was a difference in opinion here between the Dutch and Swiss students.

However, no clear difference was seen in the answers.

Several students state they would miss body language: ‘when I am online like now for example, I only see your face and the part of your shoulders but that’s it’. According to one students it might prevent patients from telling private things, because ‘it’s a strange feeling to say that to a computer’.

Two students think that the elderly would have the greatest disadvantage as they, on average, have less knowledge of, and experience with apps. Thereby, according to one of these students, ‘elderly look forward to the social aspect of the physiotherapy’.

Another disadvantage that was named is that some people can’t afford instruments for digital physiotherapy.

What do you think are the advantages for the patient and physiotherapist?

Eliminating travel time to the praxis is named as a big advantage for the patients. For example ‘when the patient has small kids’ or ‘when they live far away from the praxis’ it might be an advantage.

Most students agree that it could also save time for physiotherapists. To quote one student: ‘it would be easier for the physiotherapist because you don't have to clean up or prepare stuff for a session’. Some students also state that it could enable the physiotherapist to treat more patients simultaneously, ‘for example when you have patients with the same or similar problems and you want to show them an exercise or give them group information on their illness through chat’.

Several students add that in COVID periods it might be safer for the patient and physiotherapist.: ‘in times of a COVID pandemic and total lockdown, physiotherapist can stay at work and help people’.

Furthermore, as named by two students, the physiotherapist could treat patients from around the world and create a bigger market.

Do you think that as a physiotherapist you will no longer be needed, or hardly needed, due to digitalization?

All students agree that the physiotherapist will be needed. ‘A doctor knows a lot, but not everything and especially not that much about the physical therapy, muscles etc’.

Some students expect that there only will be more and more need for physiotherapy, due to the fact that life is more online now and people move less. As a result ‘there will be more people with health issues and if there are more health issues there will be a greater demand for physiotherapist’.

Additionally, the overall aging population will lead to a greater demand on the health system resulting in a bigger need for physical sessions with physiotherapists. One student adds: ‘In the hospital it's even more important to have a trained therapist around to help the patient get out of bed or do their first step together’. So most students believe that the physiotherapist will not be ‘deleted out of the system’.

One student gives a clear summary: ‘I think the physiotherapist will always be needed, because physiotherapists that use their hands dominate the field of physiotherapy and without hands on physiotherapy loses a great deal of effective treatments. But we can’t do physiotherapy without digitalization because we live with it now and use many websites or apps to help us’.

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The physiotherapist as innovator In the recent adjustment of the KNGF professional profile, a more important role was set aside for the physical therapist as an innovator than in the former professional profile. The following part (in italics) was taken from the KNGF professional profile: As an innovative professional, the physical therapist contributes to innovation in care in general and in the professional field of the physical therapist in particular. The physical therapist identifies, analyses and interprets organisational, professional and scientific developments in care in general and in physical therapy in particular and shares these with colleagues. The physical therapist participates in initiatives for the renewal and/or improvement of (physiotherapeutic) care. It is the physical therapist's responsibility to apply and implement relevant innovations in his action. The physical therapist uses care technology, such as blended care and other e-health applications when this fits in with the patient's request for help and the patient’s environment. This can happen in addition to treatment, but also as a (partial) substitution of physiotherapeutic treatment with the aim of making the care better and/or more effective. The physical therapist therefore should have an open and critical attitude towards innovations.

THIM University is curious about its students perceptions on whether this role is equally important as the others and how they would apply this role of innovator within their future praxis. To answer these questions, six future physiotherapists of THIM studying in the Netherlands and three in Switzerland were interviewed on this topic.

How do you think the role of the physiotherapist will change in the future (next ten years)?

Students agree on the thought that physiotherapy will change in the future. As a result of technological innovations and digitalization the usage of distance physiotherapy (tele-rehabilitation) will increase. This is not only due to technological innovations, but according to the students, also due to a shift to more hands off therapy: ‘the idea of massage once a week solves the problems is very outdated’. Another student adds:’This form of active therapy is easier to give online at distance than hands on therapy’. For example, students think that apps to stimulate home exercises will become more popular in physiotherapy.

An important feature for the physiotherapist is that ‘he/she stays creative and open minded, but critical’. According to the students scientific competences will become more and more valuable for the physiotherapist to estimate how reliable new information is. An important reason to innovate is of course to give patients the best possible treatment. However, according to the students, also the workload for the physiotherapist could be reduced by innovating: ‘I`m one-hundred percent sure new technology can make your profession easier and decreases your time spent on a patient.

Because with new technologies you can see more patients and the documentation will get easier’.

What is required to remain a good innovator over your career?

Elements that students deem important are lifelong learning: ’you must keep learning all over the years’. This can be in the form of master studies, courses or as simple as keeping abreast of scientific evidence in physiotherapy. One student summarizes: ‘always staying interested and hungry for knowledge. You don't say, I have to learn this and that and then I'm a finished physiotherapist. It's all a process, you collect different expertises and also compare them. You should not only trust theories, but also make experiences and learn. You should take something from all sides and not rely too heavily on your own experiences’.

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Another student highlights the importance of good bachelor education here to stimulate an open minded, innovative but critical attitude. However, ‘You cannot stop learning after you graduate from university. You have to learn new information and treatments over the time. Otherwise, you will become the old fashioned in your field of expertise’.

So students agree it is important to keep yourself informed with relevant information and research and be open minded but critical on what you read. Then, ‘experimenting different methods is important to identify what methods are the most effective and work the best.

As an important aspect of innovation is keeping yourself abreast to developments in physiotherapy and thereby continuous learning, one student adds that: ‘you really need to have a passion for what you are doing to stay motivated to keep going’.

Innovation is often associated with digitalization which can often be a problem for older people. How can you incorporate innovative ideas with older patients?

How does new technology impact your methods and how would you adapt to that?

Students agree that, when digitalization and distance physiotherapy will become more adherent, there should be a balance between face to face physiotherapy and distance physiotherapy: ‘technological innovations should complement the physiotherapist, not replace him/her’. For example: ‘you can check progress through an app, but more personal details about emotions etc. should be asked in a live face to face session’.

Although students see some disadvantages, according to most students it is important to embrace technology and innovations in physiotherapy: ‘science and technology help create innovation in, not only physiotherapy, but all health sciences. Having an open mind to new research and technological developments is very important. We should always try and see how technology can be used to our advantage to help patients achieve their goals as well as help us, as physiotherapist, help our patients achieve their goals by using the best methods and techniques’. One student adds: ‘If there is an app that would clearly show your exercises in a short video on how to do them and the schedule on how often to do them, than that would have a huge added value. I see great potential there’.

Students agree that ‘it might be hard to get older people to familiarize with technology and more modern ways of treating patients because they did not grow up with such technology’. Their opinions however differ on what would be a good idea here however no consensus was reached. One student quotes: ’You can take for example older patients to your place and try to explain it to them and tell them the same things like five times in a row, so that they really do understand it and that it is really clear to them’.

One student answers more nuanced and wisely: ‘You can never force innovation on someone who is not ready to accept it! We, as physiotherapist need to ensure our patients feel comfortable and we must adapt out methods to their level of comfortability’.

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After Afterreading reading‘the ‘therole physiotherapist of innovator’asJelle innovator’ Jouwsma, Jelle anJouwsma, expert in e-health an expertand in e-health director and director at HealthTrain, was ask atfor HealthTrain, his vision on was digitalisation. ask for his vision on digitalisation.

During my physiotherapy study I was already aware of the increasing demand for care and the changing role of the physiotherapist. There was no mention of e-health or blended care yet, but I already saw an important role for the application of digital tools. When I started as a physiotherapist after my studies, I also started a company that develops healthcare apps, now known as HealthTrain.

In the beginning I was often looked at strangely and I didn't get many people with me. That is now different.

And I think it's wonderful to see that more and more attention is now being paid to digitalisation in education.

In other sectors, you have seen the movement towards the digitalisation of services or processes for decades. Look at banks, retailers, travel companies, publishers, etc. What do all these branches have in common? That they were initially convinced that automating their services was not possible. In practice it turned out otherwise. It will be the same with healthcare, if the need is great enough. That has proven to be the case with Covid-19. If we want to answer the increasing demand for care and labor shortages, the application of digital tools is inevitable.

You also see that the client is increasingly asking for it.

We regularly conduct surveys among the users of our apps. The results clearly show that clients themselves really see the added value of digital guidance.

For example, to the last question 'How does new technology impact your methods and how would you adapt to that?' I read 'If there is an app that would clearly show your exercises in a short video on how to do them and the schedule on how often to do them, then that would have a huge added value. I see great potential there'. This added value is exactly what we offer clients within MijnZorgApp, our most used app that has already been downloaded by more than 1,000,000 Dutch people. MijnZorgApp has been specially developed for primary care providers. We offer more than 15,000 home exercises on video with matching instructions. In addition, practitioners can also add exercises or other video’s themselves and put together a complete customised exercise and guidance program. Clients receive a reminder on their phone every time it is time to perform an exercise or watch video. This increases treatment adherence.

It is no longer a question of whether digitalisation will become a permanent part of healthcare. e-health is slowly but surely becoming normal healthcare. It is good to see that you are actively involved in this within THIM University. Make sure that you acquire digital skills so that you can apply them in the treatment processes when needed, because e-health = health.

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First year full-time students of THIM CH

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Lifelong Learning In the late 1960s and early 1970s, it became apparent that undergraduate education (nowadays: bachelor’s degree) did not fully prepare an individual for working life or imply lifelong competence. As a result, a half-life concept to estimate the extent of becoming out of date with new technology and knowledge was proposed. A half-life of 5 years was applied to medicine and engineering, whilst 10–12 years was applied to psychologists. Mandatory continuing education was then first introduced in the USA for medical practitioners in 1971. It was another 10 years before it was introduced in physiotherapy in several countries.

Lifelong learning requires individuals to take personal responsibility for identifying their learning needs and evaluating if those needs have been met. This includes an awareness of learning needs and self-directed learning based on experience and perceived responsibility, and has been embraced internationally by numerous physiotherapy professional bodies. There has been much debate about whether lifelong learning in physiotherapy should be mandatory or voluntary.

There are wide variations in lifelong learning across different countries, and most rely on professional self-regulation. It is often linked with statutory registration and therefore becomes an inherent requirement for health professionals to practice. Most lifelong learning systems are modelled on hour-related input systems, where 1 hour equals one credit. Generally, accreditation cycles are of 3–5 years duration with a set number of credits required per year/ cycle (see Table). What do future physiotherapist think of the prospect of lifelong learning after they finish their bachelor’s degree? To answer this question, five future physiotherapists of THIM studying in the Netherlands and five in Switzerland were interviewed by peers about their thoughts on lifelong learning as a physiotherapist.

How important is continuous education within physiotherapy to you?

Students agree that continuous education is relevant for keeping up to date. One student quotes: ‘Just imagine surgeons working like they did many years ago, like I don’t think patients would be happy to have an operation without anaesthesia’. As such the introduction of new techniques and technology will need further continuous education: ‘When we receive our bachelor, we are able to work as a physical therapist. But technology is always growing. We need to update our skills. Without continuing education, our treatment can’t be effective and in the wrong cases false’. One student adds that the development of these new technologies or therapies in physiotherapy make the profession of a physiotherapist more exciting and ‘continuous education is the way to incorporate these in our treatment plan’.

‘Just imagine surgeons working like they did many years ago, like I don’t think patients would be happy to have an operation without anaesthesia’

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Continuous education is also of the utmost One International student of THIM-NL was importance in the case of new pathologies, ‘for surprised that further education is not example Corona. If you don't educate yourself mandatory in Switzerland: ‘I don’t as a physical therapist, you don't know understand why there is no about the consequences of Corona. As a uniform system. We all ‘I sometimes notice when a result, you don't know which eventually have the same physiotherapist is a bit older treatments work best for long- term education with a Bachelor’s and has not learned much effects or which treatments can have degree but after that we might more lately, that he gets stuck a negative effect’. differ in level due to the in the hands-on methods’ absence of mandatory Although you also learn from your continuous education’. colleagues by means of discussions, further education is deemed necessary A reason for continuous education to ‘not just stubbornly stay in your to be mandatory stated by a Dutch comfort zone’. A student adds: ‘I student is because you work with vulnerable sometimes notice when a patients and want to give them the best care: physiotherapist is a bit older and has not learned ‘the patients trust you to do the right thing and much more lately, that he gets stuck in the handstherefore you should always be up to date. It on methods’. gives not only the patient but also the physiotherapists some assurance that you are doing the right therapy’.

Should lifelong learning in One student adds: ‘it takes physiotherapy be mandatory or a lot of self-discipline to voluntary? educate yourself.

Therefore it would be Since there is a difference between easier if it is mandatory The Netherlands and Switzerland in for everyone’. mandatory versus voluntary lifelong Two THIM-NL students learning in physiotherapy, potential add that continuous differences between opinions of education should be Dutch and Swiss physiotherapists are stimulated by an official interesting. Four Swiss students body so that answered this question. They are physiotherapists don’t get well divided: two students think it lazy: ‘If lifelong learning should be voluntary and two students would by voluntary I won’t think it should be mandatory. From get myself to do it, the five THIM-NL students (3 Dutch because sometimes you and 2 international students) that just feel lazy and you don’t answered this question however, four feel like it’. students think it should be mandatory.

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Do you think you have time to keep learning besides your full-time job as a physiotherapist?

Students think it is relevant that the practice in which the physiotherapist is working should make time, money and resources available for the physiotherapist for further education. They don’t think this is solely in the time of the physiotherapist as the practice also profits of better educated physiotherapists: ‘Some businesses tend to push for lifelong learning where they would send their staff to take extra courses outside of the job hours and they would also be paid. I find that a great way to keep learning outside of the fulltime job but also a way of evolving your skills and making your job more enjoyable’.

Students however think that it might be a challenge besides ‘work, a social life, family and hobbies’ to further educate yourself: ‘It clearly would be very stressful to work 100% at a fulltime job and have to learn hours and hours after that as well. But when the institution were we work in that day would give you some time to continue learning or maybe a day off.

I think that way it will be less stressful to keep learning’. One student adds ‘I expect it to be very busy. Last week I went on an internship and experienced what an average day looks like. You have very little time for administration or schedules, etc. So much less to learn next to your work’.

One student however quotes: ‘I think you need to find time. In the healthcare sector you are concerned with people's lives. So you should actually learn to live with spending time on continuous education a little bit when you start with physiotherapy and keep the experiences you've learned’. Backed by another student: ‘120 hours of study in 5 years is not much, but you will have to plan well in advance when you are going to learn or take courses’.

Do you think working as a physiotherapist is enough learning in practice? That training beyond your job is no longer necessary.

Most students answer that although you can learn a lot from discussions with colleagues, further education is necessary.

They don’t think they learn a lot from their patients: ‘because with your patients you always do the same things, you will not always try new methods’.

One student adds: ‘it may be that you have many shoulder patients and suddenly someone comes with knee problems, then you may have forgotten a lot’.

However, further educating yourself shouldn’t be on a daily basis according to them.

When asked how much time continuous education they see as relevant, answers differ. Two Swiss students mention that there are yearly conferences and to follow these would be enough. Another student mentions ‘courses should be every 1-2 years. If they were every three months, that would

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Research and innovation at THIM Research centre Landquart (CH) THIM-CH has its own research department in Landquart in close cooperation with its partner school SUPSI in Switzerland and several external partners. Here you will find a very wellequipped research laboratory in which scientists with many years of experience in carrying out research projects participate in the further development of applied physiotherapy. These research facilities also enables THIM-CH students to be right on top of the latest scientific evidence.

The research at THIM-CH is mainly focussed on prevention and rehabilitation as well as on innovation and technology. The main focus is on the following topics:

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Neurorehabilitation Biomechanics Pain Thermotherapy Exercise and sports rehabilitation

Examples of research projects were the use of virtual or augmented reality in neurorehabilitation, the effects of wholebody cooling at temperatures down to -195 ° C or the influence of anthropometric factors on physical performance. Multiple publications in scientific magazines are produced yearly.

High tech physiotherapy in Nieuwegein (NL) At one of the two locations of THIM-NL in Nieuwegein (Newtonbaan and Archimedesbaan) there is a high tech innovative treadmill located for the evaluation and training of impaired gait and balance. Using augmented reality, virtual reality, acoustic cues, projections and force plate technology, the C-Mill can simulate a broad variety of realistic situations and help patients train for everyday life’s environments and changing circumstances. The C-Mill includes obstacle avoidance games, dual-tasking applications, realistic virtual reality environments and a variety of balance challenges to a training program to encourages gait adaptability strategies. In addition, it provides objective in-depth assessment of balance and gait with its in-build force plate technology.

The use of projections on the treadmill means that obstacles that should be avoided no longer have to be set up, leaving more time for patient exercise.

Patients take more steps during C-Mill training, compared to conventional therapy using parallel bars.

This increases the intensity, repetition and length of treatment, and is more rewarding and fun for the patient as they recover their stability and gait.

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Shared decision making Today, shared decision-making (SDM) is, largely, espoused as the preferred model for making decisions in everyday health care. It is a process whereby professionals and patients share knowledge, values, and preferences for different options for treating, or not, injuries and diseases. This decisionmaking process is greatly relevant if one is to achieve informed consent and patient centred care. SDM typically involves the provision of evidence-based information about options, outcomes and uncertainties.

However, there remains a considerable gap between aspiration and practical reality regarding SDM. Clinicians are still inclined to be hesitant with regard to their coaching role, and there seems plenty of room for improvement in daily practice. Furthermore, the increasing number of clinical options is broadening the complex task of weighing the risks and the benefits of all these options. Research whose main objective is the exploration of the application of SDM in clinical practice remains scarce. In addition, the research which does exist is mainly focused on secondary care providers or on a specific disease and its treatment options, in particular cancer. However, SDM is applicable to all clinical settings, also for non-treatment-related decisions and for decisions which may be perceived as small and not life threatening. Thereby, there remains a lack of clear guidance about how to accomplish SDM in routine practice.

Some healthcare professionals express doubts, saying that patients don’t want to be involved in decisions, lack the capacity or ability, might make ‘bad’ decisions, or worry that SDM is just not practical, given constraints such as time pressure.

Others claim they are ‘already doing it’, though data from patient experience surveys indicates that this is not generally the case. It is therefore clear that the first step for those advocating the uptake of SDM is to ensure that clinicians and others support the underlying rationale. To answer this question, four future physiotherapists of THIM studying in the Netherlands and seven in Switzerland were interviewed by peers on this topic.

Would treatments become shorter if the clients were more involved in decisionmaking?

Students agree that involving the patient in the decision making process will make the patient more motivated for the treatment program. If the patient is more motivated in doing exercises than the treatment will lead to a better result. ‘They feel involved. I think that’s important because that will help them with actually doing the things we say’. According to one student, ‘not only will it be shorter, but also longer lasting’.

Also, involving the patient in the decision making process will, according to several students, show respect from the physiotherapist towards the patient, which will lead to a better bonding between the therapist and the patient, more trust in the treatment, and a better therapy compliance:’The patients get the feeling that they are an important part of their treatment and that the physiotherapist really listens to what they have to say’.

However, most students think that this wouldn’t work for every patient: ‘Patients often don’t know much about their own body or treatments. A patient only wants the 'A patient only easiest way out and that wants the easiest could be very complicated way out’ (for example a lot of massage)’. Another student adds: ‘It would depend on the type of treatment and the type of person whether I involve the patient more’.

One student states that the input of the patient should count for 50% in the decision making process: ‘The balance is 50%-50% between physiotherapist and patient. The patient should not have too much influence, because you as a physiotherapist should also support the decision, therefore a fair divide of 50%’.

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What is the most important point of the shared decision making process?

Communication is the key according to the students. It is important that the physiotherapist listens carefully to the insecurities and needs of the patient and acts upon that by delivering a good explanation and providing education. The goal of education is to increase a possible lack of knowledge that might be apparent in the patient.

‘The most important thing is that the patient knows his problem and understands it. Then you can propose some treatments and explain to him the content of it. You have to talk in the way the patient understands it. Only when the patient understands it he can make a considered choice’.

One of the students told that she (as a patient) once changed to another physiotherapist because of a lack of participation in the choice of treatment.

She felt like her physiotherapist didn’t listen to her while she didn’t progressed with the exercises he selected for her.

What are the benefits of shared decision making?

Several benefits are named by the students.

According to one student an important element is that ‘the patient feels he is taken seriously’. This is beneficial since: ‘the patients believe more in the process and are more willing to participate in it and do their home exercises’. Most students name therapy compliance as an important element: ‘The patient can for instance choose the exercises he likes the most.

In this way he is more motivated to perform his exercises’.

Another benefit students raised is that it improves that relationship between the physiotherapist and patient. The patient has more trust in the treatment and is therefore more willing to cooperate.

One student sums it up as follows: ‘You have the physical therapist who is an expert in the practice, but then you also have the patient who knows herself or himself the most. Every human is unique, and need different sort of help, and therefore shared decision-making is beneficial’.

Where is the difficulty in integrating shared decision making into daily physio routine?

According to most students the difficulty lies in the fact that the patient won’t have the same knowledge and experience as the physiotherapist. ‘It can be hard to tell the patient that they are plain wrong, what they want isn’t possible or their expectations aren’t realistic’. Here communication and education are (again) of the utmost importance: ‘For the physio it can be hard to explain those options in the language the patient understands. Talking clearly and easy is therefore necessary but that’s not always easy’.

Students also see a time problem: ‘as a therapist, you only have 30 minutes per patient. If a client doesn't understand what the goal is or has many questions, in the end you don't have time for the actual treatment’. Another student adds: ‘You can also imagine that some patients (as well as physiotherapists) are just know-it-alls’. That could also lead to time consuming discussions about the treatment.

One student states that cultural differences between the therapist and patient could play a part in difficulties related to shared decision making according to one student: ‘There could be a cultural belief that gets in the way of a client wanting to do a specific treatment that has been proven by science to be the most effective way’.

Is a patient always able to make a decision about their therapy?

Most of the students don’t think a patient is always able to do so. A lack of specialized knowledge, education, and experience are named most often as reasons here for. Also younger patients (kids) or mentally restricted people are named as examples of patients who are not able enough. However, most students admit that in the latter case a caretaker could play a role in the decision making process.

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Unmotivated patients Due to an increased emphasis on healthy living in society, it is the expectation of the KNGF (Dutch Physiotherapy Society) that the contribution of the physiotherapist will increase in the coming decade. They see a ‘double aging’; because not only will there be more elderly but there will also be older elderly. This will lead to more chronic diseases and multimorbidity within the population. As a result, the prevalence of almost all diseases will increase. The importance of physiotherapy will expand although there will be a further shift in the physiotherapists' work that takes them 'from treating patients to moving people.

Physical exercise is an effective treatment strategy for a broad range of health issues.

Physiotherapists are well placed to promote exercise – as part of secondary and tertiary prevention, but also primary prevention.

Accordingly, the World Confederation for Physical Therapy (2017) highlights the role of physiotherapists as exercise experts who ‘promote, guide, prescribe and manage exercise activities and efforts’.

There is evidence that a considerable proportion of physiotherapists feel it is their responsibility to promote exercise and include exercise promotion in their therapy.

Despite these efforts, it is well known that many patients lack motivation for ‘active physiotherapy’ and prefer more passive interventions. Also, patients that underwent active physiotherapy might fail to transfer exercises adopted during the course of physiotherapy into everyday life. As motivation is an important predictor of successful physical therapy, it is important to know how future physiotherapists would deal with unmotivated patients for ‘active physiotherapy’. To answer this question, six future physiotherapists of THIM studying in the Netherlands and three in Switzerland were interviewed by peers about this topic.

‘Physiotherapists used to 'treat' people, now we prescribe exercise’

At which point do you decide you won’t help the patient any further due to their lack of motivation?

Most students agree that, if the patient shows too little progress or stays unmotivated for a longer period, a conversation is necessary to figure out their motives. If there is still no progression in motivation after that conversation, then students would advise the patient to go to another physiotherapist. One student expresses this very nicely: ‘It is the goal of the physiotherapist to avoid getting in the situation that the patient feels unmotivated. Though it can happen that despite seeing the patient for some time there is no evident progress or result. In this case, it is an option to advise the patient to see a different physiotherapist or to search for additional ways to motivate the patient’.

How can a good relationship between the patient and physiotherapist contribute to the success of the treatment?

Students agree that a good relationship between the patient and physiotherapist is one of the top priorities. ‘It is important that the patient trusts his therapist and his methods’. Students agree that when there is a bond of trust, the patient feels he can talk about every topic with the physiotherapist. As sometimes physical complaints are an expression or a reflection of a problem elsewhere (such a problem can be physical or psychological) honest and open communication is quite important. ‘Patients are more likely to be honest to a physiotherapist that they have a connection with and answer honest on questions like how much you drink or how many cigarettes you smoke’.

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Why do you think people won't get active while it forms the solution to become healthier?

Several reasons for inactivity were given by the students. However, most students think the main reason for staying inactive is ‘that people are just lazy’. One student adds: ‘People usually take the easier way out, and obviously doing exercises is harder for them than doing nothing’. This is backed by another student: ’People have become lazier because they sit in the office all day, then in the car, and then at home. This is reflected in physiotherapy’.

Another student adds: ‘Many people pay for a membership at the gym, yet don’t manage to go there.

Sometimes people exercise regularly and quit after some months’.

However, also other reasons are named. For example the environment of the patient: ‘If the family’s economy is not sufficient to pay for certain sports that the patient wants to engage in’. Or: ‘it is also known that a person raised in an active and healthy family will also generate those positive attributes later on in life’. Also busy lifestyles were named as reasons that people don’t do their homework.

One student states that patients may come to the physiotherapist with wrong expectations. ‘They think a physiotherapists ‘massages the pain away’ and are not keen on taking responsibility for their own health by an increase in activity’.

How would you convince a patient that your treatment is necessary and important?

The students agree that educating the patient is of the utmost importance. This can be done for example by physiology or pathology education but also inform them about results of scientific research. ‘To motivate a patient, I would try to present him different facts of former patients with the same or similar problem. Maybe statistics can also be helpful.

But if he or she doesn’t want to believe me, I can do nothing to help him or her’.

Some students also mention a thorough explanation of all the steps in the treatment plan as essential.

Education and explanation can also play an important

‘People have become lazier because they sit in the office all day, then in the car, and then at home’

Several students name psychological problems as a reason not to get active: ‘some people are depressed and find it hard to even get up in the morning’. But also fear that their health could worsen due to activity is named by two students as a potential negative factor for getting active. ‘Then it would be good to have physiotherapists that can inform and educate patients about their complaints and help them get active to change their lifestyle’. Another student adds: ‘There is always some physical activity a person enjoys whether it is hiking or playing volleyball. Maybe many people haven’t found the right activity for them yet. Therefore I believe that stimulating the patient’s self-management is very important’.

'People are just lazy’

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First year, full-time Dutch students of THIM-NL

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First year, international students of THIM-NL

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The ethical borders for merchandising or public advertising Marketing ethics have been a topic of debate in healthcare for years. In its original 1847 Code of Ethics, the American Medical Association (AMA) banned advertising for health care services in the United States. This ban was maintained until 1980 after which advertising for health care services increased steadily. The majority of these advertisements are designed to attract patients and promote specific clinical services, such as therapeutic interventions or diagnostic tests.

However, this is viewed with scepticism by several commentators.

Can healthcare organizations, hospitals, and practices spend large amounts of advertising dollars to attract vulnerable patients? Shouldn’t patients naturally drift towards quality organizations?

Questions like these are still a debate within medical care and thereby within physiotherapy. What do future physiotherapists think about this matter? To answer this question, seven future physiotherapists of THIM studying in the Netherlands and four in Switzerland were interviewed by peers on this topic.

What do you think in general of advertising for healthcare organisations?

Most students think that it can be a good and bad thing, depending on the goal of the advertisement.

For educating people on measures regarding prevention students think this is a good thing: ‘Reaching more people to get their physical health checked is without a doubt a good thing’. Another students adds: ‘advertisements could be very important to raise awareness and take preventative methods as well as treating the patient, once an ailment has befallen them’.

But, according to the students ‘there are malicious adverts that can be misleading for a person who isn’t very knowledgeable about the topic and may be misled by what the clinics are saying’. This is backed by a student: ‘health facilities should be truthful in their advertising and put the needs of the patients first, instead of tapping into their vulnerability’.

Another student exposes another problem: ‘what’s problematic is that bigger, more powerful healthcare organisations have way more recourses than the local physiotherapist. While, according to several students, advertising might be more relevant for smaller practices to get enough patients.

Several Swiss students mention that there might be some differences between The Netherlands and Switzerland regarding advertising. They state that in Switzerland physiotherapist don’t advertise because there is indirect access to physiotherapy: ‘a person is referred to the physiotherapist by a doctor, not the patient himself’.

Followed by another student: ‘What I want to say is, that in Switzerland you have to advertise your physical practice to the doctor and in the Netherlands, you have to reach out to the people’.

‘What I want to say is, that in Switzerland you have to advertise your physical practice to the doctor and in the Netherlands, you have to reach out to the people’

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What do you think is the added value of advertising for the physiotherapist?

How will advertising for physiotherapist look like in the future?

Students think that advertising could be of added value. However, the goal of this, according to most students, should be informative and not based on economic arguments: ‘Most people have misbeliefs about their pathological conditions and are unaware that physiotherapists can support and help them to deal with their conditions’. Another student adds: ‘I think educating your patients or almost guiding them onto a path of knowledge and of learning, can be super important because that can also decrease the level of fear they experience’. This is followed by a student: ‘An important goal is reaching a higher number of patients in need of a physiotherapy treatment, meeting their specific needs and helping them as fast and as good as possible’. So students are well aware of their responsibility.

Students disagree with each other on how physiotherapy advertising will change in the future. One student believes advertising will change more and more towards prevention: ‘it should focus a lot more on prevention than recovery. Knowing that it’s there for recovery is great but if you can prevent a problem, why go through the whole thing unnecessarily?’ Some students think that the usage of advertisements within physiotherapy will increase because the physiotherapist will have a greater range due to the digitalization of physiotherapy and the possibilities for a physiotherapist to deliver online help to people from all over the world.

One student explicitly states that younger people should not be targeted through advertisements: ‘15-16 year old teenagers form their opinions on the internet. They are naive and believe what is online, but a lot of information on the internet is fake. They can no longer decide whether it is real or fake’.

Several students state that advertisement can also be used ‘to show them you´re a professional’. This can be done by usage of a website or social media.

However, also company clothes with logo of the praxis can be used as advert to show professionality: ‘It looks better with the same clothes and stuff with logo. It's more professional’.

Most students see an increase in physiotherapy advertising in the future by social media. One student has a more innovative view: ‘I thinks that in the future we will use drones to do the advertisements, or we will use robots to make the advertisements more attractive and special for the people’. How this student pictures this, stays unfortunately unclear.

Several Swiss students however don’t see advertising changing, because they don’t see the indirect access to physiotherapy changing in the near future. ‘Only a website and advertising with logo on the clothes is enough’.

Although most students see an added value, one student sees this differently: ‘If I go to a physiotherapist, I will go to the nearest by, even though it is maybe not the best’.

However, student acknowledge that a lot of advertisement is done through the word of mouth.

‘When you are a professional and a good physiotherapist, people will recommend you to others’. Another student adds that this word of mouth is also spread digitally: ‘on Google, a patient can rate the physical therapy center. If the rating is good, the next person looking for a physical therapy center will be tempted to go there’.

‘If I go to a physiotherapist, I will go to the nearest by, even though it is maybe not the best’

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Internationalisation The recent emphasis on globalisation in healthcare education includes the importance of internationalisation as an approach for providing students with international and intercultural competence. Despite the wellcited benefits and increased internationalisation opportunities within physiotherapy education, it seems that student participation in these experiences remains quite low.

THIM University also strongly believes in the benefits of international experience for students. The aim is to give students opportunities to develop international competences and skills, in order to optimise not only their international career opportunities as a physiotherapist, but also their personal growth.

By offering international/intercultural experiences either abroad or digitally at home, THIM believes to hand students opportunities to gain invaluable knowledge, skills and attitudes that are essential to not only be(come) a more complete professional, but also a more active member of society. In today’s and tomorrow’s pan-European society, looking across borders, and thus learning new viewpoints and different approaches, gaining understanding of different cultures and making new friends and connections, is invaluable for personal and professional growth. Student mobility will enable participants to become aware of their own international and intercultural competencies that are essential in their (future) professional field and will essentially make graduates more social, integrated and employable within Europe.

THIM strives to make internationalisation a fundamental part of the programme for all its students, be it through studying or courses abroad, short term blended mobility or digital exchange from their home country.

Although the vision of THIM University is clearly described, THIM would like to know whether students support this vision on internationalisation. To answer this question, three future physiotherapists of THIM studying in the Netherlands and four in Switzerland were interviewed by peers on this topic.

Do you think, that a longer stay in another country or a cooperation with people from abroad, would be helpful for a better understanding of the patients from a different culture?

All students agree that this would be helpful. One student states: ‘I think the best way to get to know a new culture is by experiencing it yourself and seeing how it works’. This is backed by another student: ‘You can learn a lot and improve your patient care by making patients of every culture feel welcome and respected in your practice’.

Again another student adds: 'For example, Muslim women wear a headscarf. however, this headscarf is in the way during a neck treatment. I would then have to put the headscarf on the side or simply massage/treat over it which limits my treatment options if I don't know how to deal with it’.

According to one student a longer stay in another country could also make planning your agenda as a physiotherapist easier fit to different cultures: ‘For example, an Islamic patient prays five times a day and has specific times he can’t come for an appointment or work out’.

One student specifies that ‘a stay for longer periods of time in varieties of locations around the world to get to experience more societies will complement you as a physiotherapist and helps build up a name for yourself internationally’.

Does international contact with other professionals have a positive effect on your development as physiotherapist?

All students agree unanimously. They think international contact has a big impact on their development as a physiotherapist: ‘All around the world we have different ways things work, like the direct access approach (Switzerland vs.Netherlands for example). Being connected to physical therapists from different places lets you learn about how things work in their country of practice. Especially cool in countries which are far ahead of your own, like Australia for example which works with methods, which come to us later, if at all’.

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One student of the international class of THIM-NL answered: ‘Since I attend the school in the Netherlands, where they are a few steps ahead when it comes to physiotherapy, I’ve learned about new techniques which they haven’t started doing yet in my home country Norway’.

Students are aware that physiotherapists can learn from each other, whether they live in the same country or another country. All the encounters, talks and discussions with other therapists can form you as a physiotherapist.

Having discussions with physiotherapists abroad can be a great asset. Thereby, these could even possibly lead to improvements in the health care system according to one student ‘For example in Switzerland we have to go to the doctor before you can go to a physiotherapist. In other countries you can go by yourself. That difference could be changed by a lot of speaking with professionals’.

How do you think digitalisation influences internationalisation in studying and working as a physiotherapist?

Students agree that digitalization increases opportunities for internationalization: ‘digitally exchanging thoughts in this international assignment is a nice example’. They think that this would be an easy way to expand your vision towards a more international view: ‘You can quickly meet with a physiotherapist from Switzerland or another country via Zoom and have a short conversation without having to travel to him’. Another student adds: ‘For countries out of Europe, where they have a bad health care, maybe an online appointment with a welleducated physiotherapist from western countries could help them’. This can also be applied on physiotherapy studies in less well developed countries, when students of those countries come into contact with students of better developed countries.

Let's talk about the ability to work cross-cultural - How can that skill effect our everyday working life in the future as a physio?

Students agree that having knowledge of other cultures and experiencing other cultures will help the physiotherapist interact with these patients: ‘It’s helpful when you’ve learned skills from a very different culture, that you can use in your own country. For example, after an exchange you know better to deal with women with a headscarf than before’.

One student adds: ‘We are getting more and more immigrants, especially in Europe. It has already become unaidable to work with simply one culture now a days. We learn new things which are important for the patient, for example having a female therapist for women coming from the southeast. Learning such information about different cultures, allows me to improve my patient care and make my patient feel understood and respected’. Another student adds: ‘It would be good if we’re going once a working-life abroad and make an exchange’.

Students acknowledge that cross-cultural skills are very useful ‘since you work with all kinds of people.

By sharing information and gaining new knowledge from other professionals with different cultural backgrounds you can discuss the best way of doing’.

Do you think it would be effective if English lessons would be added in to the degree?

Students also unanimously agree on this point. They think that English lessons should be added to the degree. Several reasons are given: -‘Because in our study we read a lot of scientific reports and a lot of them are in English’ -‘It could help with communicating with other physiotherapists that don’t speak the same language and with patients’ -‘As I speak for myself, the English level isn’t really high. So to interact with people it will make it a lot easier’ One student of the international class at THIM-NL (where they do the study in the English language) speaks out of experience: ‘The possibility I have now within my class is something great and an opportunity to exchange easily. Additionally, we also improve our English skills every day since it’s the only way to communicate’.

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Cultural background Working and studying in another country within the European Union (EU) is encouraged which has contributed to an increased migration significantly in recent years. The EU has set up the Erasmus programme to encourage student exchanges with foreign countries. THIM has also recently received accreditation for student exchange with other countries through this Erasmus programme. This means that it is possible for THIM students to study abroad for some time.

Whether through international work or within the multicultural societies where many clinicians live and work, physiotherapists are exposed to cultures that differ from their own. Regardless how universal we like to think our therapeutic concepts are, each culture has a different understanding of the body, health, illness, and healing. Cultural competence, the ability to work in cross-cultural situations, has been acknowledged as a core skill for physiotherapists and other health professionals.

As a culturally competent physiotherapist, you recognize, respect and respond to individual needs, and adapt your practice accordingly.

Understanding and reflecting on your own culture including the underpinning values and beliefs that contribute to it, is the starting point for the process of acquiring cultural competence.

Differences in cultural background can also exist in cultures that are very similar, for example Switzerland and the Netherlands. In general Dutch people may experience Swiss people as very friendly and polite, but more reserved and introverted. The Swiss may experience the Dutch as open and easy-going, but also as very direct and sometimes thoughtless. Also, where the physiotherapist in the Netherlands is seen more as a coach who guides people, in Switzerland he/she is seen more as a practitioner who treats people.

There are differences between the organization of the healthcare system of both these countries too.

For example, in the Netherlands, in contrary to Switzerland, there is direct access to physiotherapy.

In general people are not consciously aware of their own cultural background, but the awareness of one's own cultural values and beliefs according to which we live and perceive the environment is the basis for knowledge and understanding of each other's cultural background. This is referred to as cultural sensitivity.

THIM University is curious about its students cultural sensitivity. Therefore, five future physiotherapists of THIM studying in the Netherlands and six in Switzerland were interviewed by peers on this topic.

Would you like to study abroad to increase your cultural sensitivity? Why? And where would you go?

All students agree on this question that they think this would be a great asset to their development.

One student formulates it nicely: ‘exposing oneself to a different culture is very educational. You are suddenly surrounded by completely new ways of thinking and get insight in different perspectives’.

Another student adds: ‘I think mainly about the differences in how we treat and interact with patients, what methods we use, and how they do those things in different countries. I think international cooperation is exciting and vital and this project we are having right now (international assignment) is an excellent example’.

Some students prefer a short stay in a neighbouring country (‘not too far away from Holland though.

Belgium, Germany, etc. would be a nice challenge for the first time around’), whereas other students would want to go further away with more cultural differences (‘like Africa, where I can experience a culture-shock’).

‘Not too far away from Holland, Belgium, Germany, etc.’

‘Further away like Africa, where I can experience a culture-shock’

Three students that answered this question study in the international class at THIM-NL and are studying abroad now. Two of those students explicitly state that they are very happy about their decision to come to the Netherlands (of the third student, this is unknown). They state: -‘I find it interesting what different ideas Norwegian and Dutch physiotherapists have. I also did an internship in Denmark and they also had other ways of treating a patient than I was used to’.

-‘I have a new challenge every day, which I really like. I always need a challenge in my life and studying abroad is a big challenge’.

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When asked where students would go, most students answered USA, Canada or Australia. Those answers were mostly due to the language. But also as Australia is seen as a country where physiotherapy is ‘ahead’. Another student would want to study in a Scandinavian country or the Netherlands for that same reason. One student states that the interest in USA is because ‘there is a lot of overweight there and I would like to see how the physiotherapist deals with that’. But also African countries are named, ‘because I want to know how they handle it with not much equipment or instruments’.

One student refers to a positive review from a family member: ’yes because it is a new adventure.

My brother went to Gran Canaria and worked at a private organisation where he could speak German.

He said it was cool and that he learned everything about the culture in Spain and how everything works there.

However, learning the language may take a bit more time’.

If you study abroad, what would you like to learn?

Most students would really want to learn more about the culture of that country, and not only focus on different thoughts and visions of that country on physiotherapy. They see it not only as increasing their physiotherapeutic competences but also as a way to ignite personal development. However, they acknowledge that knowing and experiencing other cultures might play a role in their treatment at home.

-‘I would like to learn what people do in their everyday life activities’ -‘what they eat, what hobbies do they have, are they doing sport?’

-‘how do they celebrate Christmas, holidays and constitution day?’

Multiple students also state they would like to get to learn the view of people in that country at healthcare and physiotherapy: ‘for example in the Netherlands the physiotherapist plays a bigger role than they do in my home country Norway’. Or several Swiss students mention that they would like to experience direct access. One student however is not sure whether there would be a great difference between physiotherapists in Europe: ‘I think that there will be more differences between Europe and for example USA’.

How do you think your cultural background influences how you approach problems?

One student formulates it very nicely: ‘culture influences us unconsciously. We have grown up with this culture and therefore we think our culture is normal. But for a physical therapist it is very important to admit that there are other cultures and that we can also orient ourselves to them’.

Another student also shows good cultural sensitivity to her own background: ‘since the Swiss are very strict and disciplined, being Swiss will help me in my career as a physiotherapist, for sure. The Swiss value punctuality and are in general very accepting of others.

This has to do with the multiculturalism in Switzerland, thanks to the influences of France, Italy, Liechtenstein and Austria. This gives Swiss people a great basis and a huge advantage when it comes to acceptance of other cultures’.

One student shows less cultural sensitivity: ‘I don’t think there are huge differences between most backgrounds. I think everyone looks for themself how they approach problems and how they solve them’.

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What attitudes and skills should a therapist have to treat patients with different cultural backgrounds?

Most students agree that communication is vital if one deals with patients (with different cultural backgrounds): ‘the therapist should explain the way she works so there are no misunderstandings’. This could also give the patient the possibility to react if it doesn’t match his/her cultural or religious background. Another student adds: ‘I was raised to talk with each other. So I would also choose to talk with the patient, to try to clear up cultural differences.

I think 80% can be solved by talking’.

Also having an open and empathic attitude towards patients/people: ‘being able to put yourself in your patient’s shoes and understand the situation is part of being a physiotherapist. There is no room for prejudices, because it is natural that not everybody has the same opinion, beliefs and religion as you’.

This creates a comfortable and safe environment for the patient and ‘increases a bond of trust’.

If you have experienced different cultures, for example by (physiotherapeutic) adventures abroad, this could lead to more understanding and openness to that culture: ‘the patient maybe thinks differently of the world and healthcare. If you understands his view of life, you can better imagine how you can help him’.

If you do not have experience with the cultural background of a certain patient, one student states: ‘I would have a discussion with my patients about their culture to know more about them. I would try to make a good relationship and ask open questions about their country and culture. Like that, I can learn what opinions they have and how I can work with them’. The interviewer agreed and said: ‘I really like the idea! I'm going to keep that in mind’ However, according to another student, ‘physiotherapists must not forget in which country they live and that the foreign population also need to adapt to the country’.

THIM Exchange projects Last year, major steps were taken towards a closer connection with THIM in Nieuwegein (Netherlands).

Several exchange projects were set up with the aim of intensifying the connection between the schools, teaching students intercultural skills and encouraging them to communicate with international colleagues in English.

The various projects offer a great opportunity to exchange experiences across national borders and increase the international THIM feeling.

A good example of an exchange project took place in October 2021 third year students were offered the opportunity to exchange schools for a week. 15 Swiss students visited the Netherlands to study for a week in Nieuwegein and 9 Dutch students studied in Landquart for a week. Besides the foreign lessons, the Swiss students had time to enjoy Dutch culinary specialities, such as bitterballen, stroopwafels or pepernoten biscuits and sightsee Utrecht and the Netherlands, whereas the Dutch students enjoyed raclette, cheese fondue and speeding down the mountains in Sankt Antoniën with a ‘trottinet’.

Besides the above physical exchange of students, there was also a physical exchange of Dutch students who did measurements for their bachelor thesis in Landquart, of Swiss and Dutch students going on internship and of Swiss teachers that teached in Nieuwegein for a week and digital exchange(s), for example as done in the international assignment.

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SURVEY INTERNATIONALISATION Survey amount students about their thoughts on internationalisation during their study

Answers As the answers in the interviews about internationalisation were interesting for THIM, we decided to do a survey among all the first year students that cooperated in the international assignment. In total 77 students filled in the survey. The survey consisted of four closed questions and one open question. The results of the respondents can be found here.

Noteworthy: In total 66.5% of the students would be interested to study abroad for a while from whom more than 50% of the students would be strongly interested.

Most students (63.7%) agree that assignments where THIM-NL and THIM-CH students cooperate would stimulate their international skills, from whom 23.4% strongly agree.

63.7% of the students agree that contact with foreign students will make them a better physiotherapist, from whom 27.3% strongly agree.

36.9% of the students are willing to get in digital contact more often with foreign students to exchange views on physiotherapy.

39.8% of the students are neutral and 26.3% of the students are negative towards such a digital exchange.

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As can be seen in the figure below, there were some differences between the answers of the Swiss, Dutch and international students. Although the international students, by studying in the Netherlands As can be seen the figure below,they thereare were answers of the Swiss, already study in ainforeign country, stillsome mostdifferences willingly between to studythe abroad if possible.

However, Dutch and international students.

Although the international students, by studying in the Netherlands there were no significant differences here between the students. already study in a foreign country, they are still most willingly to study abroad if possible. However, were no significant Thethere international students differences agree mosthere thatbetween contact the withstudents. foreign students makes them a better

physiotherapist by broadening their view physiotherapy, the makes Swiss them students agree least. This The international students agree most thaton contact with foreignwhile students a better difference is significant (p=0.026).

There were no other significant differences here. physiotherapist by broadening their view on physiotherapy, while the Swiss students agree least. This difference is significant (p=0.026). There were no other significant differences here.

The international students are significantly more willing to get in digital contact with foreign students to exchange views on students physiotherapy than Swiss students and Dutch (p=0.049).

The international are significantly more willing(p=0.038) to get in digital contactstudents with foreign studentsThere to were no significant between the Dutch and(p=0.038) Swiss students. exchange views ondifferences physiotherapy than Swiss students and Dutch students (p=0.049). There were no significant differences between the Dutch and Swiss students.

The Dutch students agree most that assignments where THIM-NL and THIM-CH cooperate would The Dutch agree most thatwhile assignments where THIM-NL THIM-CH cooperate would stimulate theirstudents international skills, the Swiss students agreeand least.

There were no significant stimulate their international skills, while the Swiss students agree least.

There were no significant differences here between the students. differences here between the students.

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1

Contributors

Swiss students (THIM-CH)

Lisa Da Silva Fabian Durrer Dominika Grembowicz Nuria Guerra Martina Hofer Colin Hoffmann Soraya Howlader Josefine Kaisig Tanja Lieberherr Sarah Montavon Alina Risi Björn Scheidegger Yves Schönenberger Thomas Schwerzmann Dominik Stocker Gavin Thomi Fabienne Tiefenauer Mario Wiesendanger Ron Baumgartner Sirine Ben Khalifa Lukas Brida Celina Brumann Sina Büchel Ramona Caluori Mauro Capaul Gianna Carpanetti Andrea Conrad Jana Fischer Lars Grob Lucie Koci Maximilian Lingg Yara Lutz Anna-Lena Marent Anna-Lena Messner Livia Moos Meret Rhonheimer Shona Thompson David Widmer Nathalie Winet Jenny Arnold Renée Aschwanden Michelle Bärlocher

Dutch Students (THIM-NL)

Chiara Wolkorte Hannah van Caldenborgh Isabelle van Duren Jord Spoorendonk Jur Goedegebuure Lola Schipper Martijn Kornet Michel Heus Fleur Muilwijk Ronis van Everdingen Victor Aung Caroline Dijkstra Daan Schipperheijn Fleur Blank Naomi Allen Jamie Snellenburg Jordy Kleuver Anique Tavenier Joris Felius Layra Top Marielle Laureijsseen Maurits van den Berg Mik Buitenhuis Noortje van Scherpenzeel Djille Wesselius Ceciel Rippen Bart Bruijne Julian Kuit Jean Breno Jansen Friso Engel Sophie van de Velde

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Int. students (THIM-NL)

Ali Hashemian Anastasia Hadjidemetriou Denzel Ignacio Eisele Basil Emile Jacolino Enya Reklev Erlend Hårstad Jack Pringle Joshua Steyn Julie Torsvik Lorenzo Lissandro Marlene Danielsen Mehrnaz Gholamizadeh Micaela McGrady Ronald Rocco Prisca Obi Paul Seyr Shalini Bish Mehran Mehri Evander Blijden

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