IntroductionAccordingto Hubert (2013) international placement provide not just the valuableexperience for practice learning, but ‘students who work abroad are betterprepared than their non-participatory peers to face some of the challenges theywill encounter in the increasingly globalized hospitality industry of tomorrow’.Consequently, having international placement adds a significant value to astudent’s physiotherapy education. My elective placement has been within a rehabilitationdepartment in a hospital in Guangzhou, China, which is a rehabilitationfacility providing treatment for both outpatients and inpatients that havecomplaints and/or diagnosis of musculoskeletal and neurological problems (SeeAppendix A).

Through this critical and reflective evaluation on my placement, Iwill be exploring my learning and personal development in areas like handhygiene compliance. Moreover, I will also be looking at my learning in publichealth initiatives targeting antimicrobial resistance, healthcare needs of thepatient group, and linking theory of cultural competence to my practice whichhave all been a significant value from my placement. Learning Outcome: Critically evaluate their own experience of health care practice in anarea that may not be available as part of the organised placements within theBSc physiotherapy programmeHandHygiene Compliance in ChinaBeing in a hospital environment there was undoubted a largeemphasis on infection control in which is vital in all aspects of health careprovision to improve patient safety. In fact, improving patient safety hasreceived more and more global attention in recent years, and the first campaigninitiated by the World Health Organization (WHO), “the Clean Care is SaferCare” (2005) emphasized the importance of hand hygiene, and WHO (2009) also publisheda guideline for every healthcare worker with a systematic hand-washingpractice.The efficiency of hand hygiene is well-recognized and hasalways been emphasized in my university training and previous placement.

However, what I realised from this placement is that there was recurrentepisode of healthcare professionals not washing their hands after every directcontact of care. Upon this incident happened, I started wonder why there is adifference from the healthcare professionals between UK and China. Although at thebeginning I held some of a negative view with their noncompliance of handwashing practice, but working closer with those healthcare professionals on thedepartment, as well as spending time in the hospital, I came to see how limitedtraining and input has been given for those healthcare professionals in Chinato build up their hand washing habits. The absence of training and input that Ihave noticed is they have never receive any university training with theimportance of hand hygiene, no poster or reminder was held around the handwashing area in the hospital, no hand soap was provided in washing room, andeducator was not demonstrating the hand-washing practice after every directcontact of care.

Upon reflection I realised the importance of universitytraining and external support while in practice settings has provided me abetter environment to support my learning of hand hygiene and infection controlin general. Thus with regards to my learning I found that a well-developeduniversity training and external input in practice area has nourished theunderlying rationale for the infection control work I did. Through conducting arisk assessment prior to the start of the placement (See Appendix B), I wasable to identify and expect a poorer quality of infection control, and as suchfurther directed myself that maintaining infection control could become evenmore important when I am doing the elective placement. According to a number ofstudies including one by Xia Mu et al. (2016), education of hand hygieneinstructions can greatly increase the compliance rate of hand hygiene.Consequently, I did a presentation (See Appendix C) at the end of my placementtrying to share the value of infection control, at the end of presentation Ihave received some positive presentation feedback (See Appendix D) about thegain of understanding on the importance of hand washing, and it is verypleasing to see their gain from my presentation.Underpinning my practice of infection control is the values Ihave gained from my previous work environment, and in this placement there wasa limited focus on infection control practice.

Moreover, I learnt that as aprofessional I was also a resource in that I was able to educate differenthealthcare professionals where necessary. I felt that as the placement progressed,my knowledge in inflection control and awareness of the infection riskincreased, I was able to provide a better service and value to the team.    Learning Outcome: Evaluate UK Government public health initiative relevant to the electiveplacement setting. Antimicrobial ResistanceWidespread antibiotic use is considered to be a majorcontribute to the growing problem of antimicrobial resistance (AMR) in UK,China and many other countries. Unlike many other drugs used in medicine, themore we use antibiotics the less effective they become against their targetorganism, thus threatening our ability to treat infectious disease.

Antimicrobial stewardship programme has been initiated both in UK (Public HealthEngland, 2011; 2015) and China (Xiao etal., 2013) in 2011. Both has showed manysuccesses, not least the reduction in total consumption of antibiotics (Xiao YHand Li LJ, 2015) without significant change in the prevalence of infection (Publichealth England, 2017) and the gain in global awareness and national initiativesin different countries (Research Council UK, n.d.). However, the burden of AMRassociated infections continues to rise, and are in danger of spreading andfurther highlighting the need of additional input (Public Health England, 2017).As a result, AMR policy needs to remain central to the work of Public HealthEngland (PHE) and Ministry of Health (MoH) in China.

A Annual Report of the Chief Medical Officer (2011)highlighted the urgent need of the strategic management of AMR in England,suggesting the scale of threat of antimicrobial resistance been seen from theHealthcare Associated Infection and antimicrobial usage in England PointPrevalence Survey (2014), and the need for action. In response to this,Department of Health set out UK 5 Year AMR Strategy 2013 to 2018 (2013) and PHEtook in charge of the role of providing surveillance data, and has workedclosely with National Health Service on implementation of antimicrobialstewardship programme and facilitation of professional education and publicengagement. The most recent English Surveillance Programme for AntimicrobialUtilisation and Resistance (ESPAUR) (2017) highlighted that the development ofNHS antimicrobial stewardship initiatives, namely Quality Premium (QP) andCommissioning for Quality and Innovation (CQUIN) showed the most significantresults.

The report stated that both has quantified their achievement and madeit clear that action was needed across every Trust. Even similar action hasalso been carried out in China, such as Administrative Regulations for ClinicalUse of Antibiotics (2012) and National guidelines for antimicrobial therapy (2013),but a number of studies including the one by Li W et al. (2016) was highlycritical of the strategic management of AMR in China. Suggesting thatregulation policy and following actions was not solving the most problematicarea which is the rural area. The report criticised the lack of input and theidentified major challenges are the lack of qualified healthcare professionalsand poor access of information.

More broadly, official guideline specificallyfor tackling antimicrobial resistance has only recently been developed in 2016,and thus evidence-based use has not yet been widely investigated, so thebenefits and outcomes of the initiatives are still hard to tell andquestionable.Consumption of Antibiotic without change of infection episodehave declined over this period, but limited research been done, it is hard toshow and conclude its effectiveness in China. But what I realised from chattingwith the staff in elective placement hospital is that UK and China will becollaborated to tackle the antimicrobial resistance problem especially in ruralChina region. What I do know now is that large-scale, interdisciplinary, UK-China collaborative research would be done in humans, animals and the widerenvironment in China (Research Council UK, n.d.). The first confirmedcollaboration would be done in Anhui with University of Bristol, investigatingon localised strategies to optimise AMR regulation (2016). All the project willbe started in early 2019 so it is still impossible to attribute success to anyone collaboration, nor it is possible to tell which components of thecollaboration would benefit the most.

But what I do know is the multimodal,region-adapted research and interventions can show us where the problem is. Ialso know that having the backing of a national guidance and global surveillancegains the attention of government executives, bringing focus and resource toAMR where needed and providing strong reinforcement. But much learning aboutwhat works in China has been limited because so little research and evaluationwas conducted to determine effectiveness or to identify mechanisms of changeand contextual influences. A key thought upon reflection is that future AMRregulations in China or even global context would benefit from a programme ofhigh quality evaluation research running in parallel to help understand whatworks and why.

Most importantly, as a future physiotherapist, ensuring ownresponsibility to infection control to prevent infection from occurring in thefirst place should be one of the best way for me to reduce the need toprescribe antibiotics and prevent antimicrobial resistance. Therefore in thefuture practice, infection prevention and control would become even moreimportant and I should regularly reflect my practice to ensure an optimal contributionin infection control.   Learning Outcome: Evaluate the health care needs of the population served by the electiveplacement and demonstrate cultural competence with adaptation of practiceappropriate to the placement.Althoughpatients were targeted to have their own individual treatment plans tailoredwith their own needs throughout my placement, I noticed that patients tend totake an uninvolved role in clinical decision making process and there weredisproportionate amount of passive treatment implementation comparing to myplacement experience in UK. As the placement progressed I noted that Chinesemanual therapy, acupuncture, electrotherapy and traction therapy formed a largeproportion of the treatments (See Appendix E). A number of studies includingone by Rongchong et al.

(2015) have found that Chinese patients are more likelyto take an uncomplaining role on clinical decision-making process and morelikely to prefer inactive treatment like manual therapy and acupuncture.Additionally this is not only limited to geographic location, a number ofstudies also found out that multiracial Chinese in other countries are having ahigher tendency of taking uninvolved role among other ethnicity (Leung YM etal., 2014; Kwok C & Koo FK, 2017). At thestart of the placement, having no experience of working with this service usergroup I felt slightly challenging and limited with their passive approach towardstheir healthcare. As a healthcare professional trained with a large emphasis ofholistic patient care and engaging patient to take control of their healthcare,it is difficult and challenging to see patient comment exercise and anyself-management strategies as an invaluable part of the treatment. This was nothelped with advocating the benefits of exercise, because this often led topatient not value your professionalism once you have given and encouraged theseself-management advices. Upon reflection I felt that my difficulties werelargely due to the differences on healthcare beliefs, especially the patients’belief that ill people needed to be looked after, and responsibilities oftaking care of their health should be solely on healthcare professionals.Through working a longer period of time in the unit, I further understood andreflected that these views were not only a result of a lack of patients’awareness about the benefits of engaging in their healthcare journey, but alsoabout the influence of the cultural belief that most of the Chinese had grownup with.

I realised that these views were something that I would need tocontinually be aware of throughout this placement so as to practice inculturally competent manner. According to NHS England (n.d.

), effective practice should be having patients tobe actively involved in their own care; therefore, being aware of patientuninvolved behaviour and being culturally competent to respect patients’cultural differences and adapt my practice accordingly can contributeeffectively to delivery of care. A number of studies including one by (LongtinY et al., 2010) have found a lower satisfaction rate and quality of outcome canbe compounded by different cultural factors such as the passivity – thetendency that Chinese patients are more likely to disagree the value of takingcontrol with their healthcare. Inrespond to this, I performed a cultural competence self-assessmentquestionnaire published by American Speech-Language-Hearing Association (2010) to measure mychange of awareness of how I view patients from different cultural backgroundat the end of my placement (See Appendix F).Messner and Schafer (2012), defined culturalcompetence as “the ability to communicate effectively and appropriately withpeople of other cultures.” Through my time on the department I demonstratecultural competence in a number of ways.

This included ensuring I respected mypatients’ beliefs and decision in traditional and alternative medicines when Iprescribe a treatment regimen. I also ensured I incorporated their views in myassessment process and actively listened with their opinions. Furthermore, becauseof the understanding of the importance of family relationship, I sometime askedif family member could be involved to facilitate the process of gainingpatient’s understanding of exercises and self-management strategies ifnecessary. I also ensured that I gained their consent to include their familyin determining decision-making.

I also ensured to seek assistance frombilingual co-workers and patients’ family members and friends if patient mayhave an insufficient level of proficiency in Mandarin and/or Cantonese.Additionally, I did some specific work assisting in interpreting Cantonese andEnglish, gained feedback from patients that they positively change their view onreceiving exercise treatment, and gained an improvement with the marks from thecultural competence self-assessment questionnaire (See Appendix G) all of whichare very motivating to see.  ConclusionReachingthe end of this placement has allowed me to reflect back on my personal andprofessional progress not only in this placement but also throughout my studiesas a whole. This placement has provided me with the opportunity to evaluate mypractice and knowledge in international context.

I was able to identify theinfection risk and further contribute with educational value to others; I was ableto develop a greater global sense of how public health initiatives influence mypractice; and I was able to refine my skills in demonstrating culturalcompetent practice.Ifelt this placement has offered me greater understanding and knowledge of the healthcarestatus in China and overall I found it will be easier having an internationalplacement to link theory and academic issues and to compare the difference fromdifferent countries to my practice and I felt that this could be beneficialwith my career prospect. Overall I have thoroughly enjoyed this placement and Ihope that I made a positive contribution to the team and also to the patients.

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