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1. Introduction
Universities have an important role in educating specialist therapists, who are responsible to provide healthcare services for the community [1]. Clinical education is an integral part of educational programs, which combines both theoretical and practical education and plays an important role in developing and enhancing students’ skills [2]. Bachelor’s students of Physio Therapy (PT) have the opportunity to participate in various clinical fields and rehabilitate patients with the various conditions of orthopedics, neurology, cardiology, rheumatism, and so on. For being successful and effective, it is essential to monitor the current situation and recognize the strengths and modify weaknesses [3-5]. Therefore, it is essential for universities to provide continuous monitoring and evaluate clinical education to improve education quality.
Previous studies on the quality of clinical education in different courses, explored some problems such as clinical incompetency, inadequate clinical skills, and failure to observe professional ethics for clinical supervisors. Indeed, irresponsibility, inadequate participation, the lack of learning motivation and self-esteem in some students and inappropriate planning and the implementation of clinical education of PT department and inappropriate interpersonal communication and facilities in clinical settings are main problems in this regard [4-9]. 
Due to cultural and political changes over time, it is necessary to periodically assess the status of clinical education. Furthermore, the students are the main education recipients. Thus, it is necessary to use their experiences to identify the deficiencies and barriers. Therefore, the present study aimed to identify the barriers of clinical education in PT because of its importance and limited studies on this subject. 
2. Methods
In this qualitative study, content analysis method (contractual type) was used. All clinical practice courses were presented during the last two years of undergraduate program; it was decided to conduct interviews with students in their last year of studies. Therefore, 13 undergraduate PT students who were in their last year of studies participated in the study. They were studying at the Rehabilitation Schools of Iran University of Medical Sciences, University of Tehran, Shahid Beheshti University, and University of Social Welfare and Rehabilitation Sciences. Students were enrolled into the study if they had passed at least 6 units out of the total 24 clinical units, during their studies. 
They were selected for the interviews by purposeful sampling method, with a maximum variation in terms of the location of university, gender, semester, and residential place (far from family or with family). The interview process initiated after making the necessary arrangements. An appropriate place for conducting the interviews was arranged (a quiet place with good lighting), and consent forms were obtained from the study participants. Initially, two interviews were conducted as a trial run, to complete the questionnaire. Then, the interview initiated with a couple of open questions.
During the interview, the study participants’ body language, facial expressions, non-verbal reactions, pauses, and statements that were emphasized by them, and voices were recorded. In the interviews, questions leading to “yes” and “no” answers were not used. In case of ambiguity, the researcher asked the interviewees to provide further explanations. Semi-structured interviews were used for data collection; thus, the entire conversation was recorded and transcribed. Afterwards, using data analysis, the important states were extracted and encrypted. 
Conducting interviews and collecting data continued until a new code was added to the previous codes. Finally, data consisted of a sample of 13 PT students. To prevent interference with interviewee perspectives and paradigms, in addition to bracketing, peer checking and member checking were performed. Therefore, two co-authors and participants confirmed the validity of findings. To validate the data, the triangulation method was used in which one faculty member and one graduate student with 2 years of work experience, were both interviewed. The data analysis of these two interviews confirmed the codes received from previous interviews. Each interview lasted 25-53 minutes. 
3. Results
We extracted 182 original codes from interviews analysis. By eliminating and matching the data, we finally developed 4 categories (Table 1). 

Personal and professional characteristics of clinical educators
Table 2 presents the study participants' characteristics. This part includes three sub-categories, as follows: clinical incompetency, inadequate clinical skills, the lack of observing professional ethics. For example, one of the participants described the lack of responsibility in clinical supervisors: “Sometimes during working with the patient, we face a question, but there is no one to ask and we can’t solve our problem without guidance” (A.A). 

Another participant stated about the low level of supervisor’s clinical skills: “Some clinical educators respond to student’s questions or practice clinical skills based on their old knowledge. They don’t update their information” (N.S). Observance of professional ethics is an important task for a clinical supervisor. One of the students discussed the lack of ethical considerations: “Sometimes, during working with a patient, the instructor enters the room and asks questions or shares comments in the presents of patient and humiliates us by this behavior” (F.K).
Personal characteristics of students
This part includes three sub-categories, as follows: student’s irresponsibility, inadequate student participation in education, and the lack of self-esteem. One of the participants described the lack of student’s responsibility: “Some students fail to follow the rules of clinical education, they have irregular entrance and exit time, and due to the lack of motivation or interest, they try not to involve in this process. They usually scape from work” (H.M). 
The students also are not attentive. Their participation in the practice is inadequate. One of the participants stated: “Some students are not interested. This lack of motivation and interest negatively affects the time and quality of clinical education process” (S.F). To illustrate the lack of self-esteem, a participant explained: “Some students, despite adequate theoretical knowledge, have poor clinical performance, because they are not self-confident and they are afraid of making mistakes” (N.M).
Inadequate education system
Educational system problems include the following sub-categories: inappropriate planning and the poor management of clinical education programs. One of the participants described inappropriate planning: “Most of us must repetitively practice in various clinical centers that are not specialized” (A.M). To explain the poor management, another participant explained: “The education group of PT department disregards a proper assessment of the clinical education and supervisor’s performance. In fact, clinical education in each center varies, depending on the interests of the supervisors and their own viewpoints” (M.M).

The inappropriate clinical education environment
This category includes two subsets; inappropriate interpersonal communication, and the lack of facilities in clinical settings. Lack of facilities and therapeutic equipment can affect the quality of clinical education. For example, a participant stated: “Some centers lack complete therapeutic equipment; e.g. there are not enough cabins in some centers, so the patients and students have to wait for a while” (A.A).
Most of the student’s clinical experiences are environment-related. Inappropriate interactions of the center staff with students can turn clinical education into an unattractive environment. Another contributor talked about inappropriate interactions: “Sometimes during the work a nurse comes to our room, shows an aggressive behavior and forces students to stop their clinical work, to record a clinical report” (N.M).
4. Discussion
By categorizing, eliminating and matching the data, we finally developed 4 categories, as follows: 1. Personal and professional characteristics of clinical educators; 2. Personal characteristics of students; 3. Inadequate education system; and 4. The inappropriate clinical education environment. In the learning-education process, the students and educators are in close contact. Undoubtedly, their inadequate interaction negatively impact students’ performance [10-12]. Studies have revealed that accompanying students with clinical supervisors has the greatest impact on the quality of clinical education [13-15]. 
The present study suggested that the characteristics of clinical supervisor such as irresponsibility, insufficient clinical skills and the lack of paying attention to professional ethics, are barriers to the effectiveness of clinical education. Chiang and Sloan in similar studies have argued that clinical proficiency, the ability to transfer skills to students, responsibility, effective communication with students, and adherence to the clinical ethics, are facilitators of clinical education [10, 16]. To make the clinical education more effective, students also need to have features like willingness to learn, responsibility, high self-confidence, a sense of compassion and sympathy, sufficient information and a spirit of partnership with the supervisor [1, 4, 5, 11]. 
In this study, the participants’ experiences suggested that laziness, the lack of motivation and self-esteem in students prevent the achievement of educational goals. Lack of interest in the field of study, considering the clinical education as an unimportant period, as well as the inappropriate training environment with respect to student’s expectations are the main reasons for this issue. Other studies also reported that lack of self-confidence leads to depression and anxiety among students and affects their clinical performance [17, 18]. 
Taheri et al. in a descriptive study, argued that the individual characteristics of clinical supervisor and students, had the most significant effects on the clinical education of rehabilitation students [19]. From the perspective of contributors, the inappropriate planning and implementation of clinical education system programs are another hindrance to the process of clinical training. Abdi et al. also reported that the condition of clinical settings and undergraduate PT curriculum are undesirable [3, 4].  In this study, the students acknowledged that despite the wide range of PT skills, they lacked a specific program for managing various cases in different clinical settings, such as orthopedics, neurology, and so on. According to them, clinical practice courses are tedious and repetitious. 
It could be explained by the limited number of hospitals affiliated to the university, as well as the lack of specialized centers of clinical education. Moreover, the study participants complained about the lack of adequate opportunities to learn important clinical skills such as the interpretation of radiological images, manual techniques, dry needles, kinesiology tape, and so on. Kamali et al. also documented that undergraduate PT curriculum does not provide enough opportunities to learn clinical skills [5]. 
Perhaps the conversion of a bachelor’s degree in PT to a professional doctorate can greatly compensate for the lack of required clinical skills. Another barrier to the efficiency of clinical education was the lack of adequate supervision over the performance of clinical educators and the implementation of training programs in clinical settings. Other studies have also reported that monitoring and evaluation is an important indicator in the measurement of achievement to educational goals, because it determines the strengths and weaknesses of training program [1, 3, 5, 20, 21].
The most significant part of student’s clinical experiences is formed in the context of the environment. Papathanasiou stated that the characteristics of learning environment are among the important and influential factors in clinical education [22]. The study participants acknowledged the lack of facilities and inappropriate interpersonal communication, as the most important environmental barriers. It seems that the unfair distribution of training spaces due to organizational policies and the lack of funds allocated for equipping the PT settings are among reasons for students’ dissatisfaction with the training environment. Consistently, Dastgheibi, Kamali, Gard and Dunn, highlighted the role of environmental factors such as the availability of suitable space, appropriate facilities and equipment [4, 5, 23, 24].
It is suggested that the quality of clinical education be assessed through periodic evaluations, to improve the quality of clinical education by empowering the strengths and defeating barriers. 
5. Conclusion
Clinical incompetency, inadequate clinical skills, and failure to observe professional ethics are the most frequent problems among clinical supervisors. Furthermore, student’s irresponsibility, inadequate participation, the lack of self-esteem in some students, inappropriate planning, the implementation of clinical education of PT department, and inappropriate interpersonal communication and facilities in clinical settings, can be considered as barriers for clinical education. Considering the obstacles and attempts to resolve them, reviewing the clinical education process can improve the quality of clinical education. It seems to improve the quality of clinical education.
Participants of this research were selected from Medical Sciences universities in Tehran. Therefore, the results cannot be generalized to other rehabilitation schools in other cities. 
Ethical Considerations
Compliance with ethical guidelines
The ethics code was received (IR.IUMS.REC 1395.9311340008).
Funding
This paper was extracted from the MSc. thesis of Fatemeh Menatnia in Department of Physiotherapy, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran.
Authors contributions
All authors contributed in preparing this article.
Conflict of interest
The authors declare no conflict of interest.
Acknowledgements
We appreciate all the faculty members and supervisors of clinical education, physiotherapy students and hospital staff.


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