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Innovation in Pediatric Clinical Education: Application of the Essential Competencies

Kenyon, Lisa K. PT, DPT, PhD, PCS; Birkmeier, Marisa PT, DPT, PCS; Anderson, Deborah K. PT, MS, PCS; Martin, Kathy PT, DHS

doi: 10.1097/PEP.0000000000000144
Special Communication

Background: At the Section on Pediatrics Education Summit in July 2012, consensus was achieved on 5 essential core competencies (ECCs) that represent a knowledge base essential to all graduates of professional physical therapist education programs.

Key Points: This article offers suggestions for how clinical instructors (CIs) might use the ECCs to identify student needs and guide student learning during a pediatric clinical education experience. Pediatric CIs potentially might choose to use the ECCs as a reference tool in clinical education to help (1) organize and develop general, clinic-specific clinical education objectives, (2) develop and plan individualized student learning experiences, (3) identify student needs, and (4) show progression of student learning from beginner to intermediate to entry level.

Conclusions: The ECCs may offer CIs insights into the role of pediatric clinical education in professional physical therapist education.

Suggestions for use of the Education Summit's 5 core competencies are offered for clinical instructors.

Department of Physical Therapy (Dr Kenyon), Grand Valley State University, Grand Rapids, Michigan; The George Washington University (Dr Birkmeier), Washington, DC; Midwestern University (Ms Anderson), Downers Grove, Illinois; Krannert School of Physical Therapy (Dr Martin), University of Indianapolis, Indianapolis, Indiana.

Correspondence: Lisa K. Kenyon, PT, DPT, PhD, PCS, Associate Professor, Physical Therapy Program, Grand Valley State University, 301 Michigan Street NE Suite 200, Grand Rapids, MI 49503 (kenyonli@gvsu.edu).

The authors declare no conflicts of interest.

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INTRODUCTION

In 2009, the Section on Pediatrics conducted a survey of professional physical therapist education programs to gather information regarding the delivery of pediatric curricular content in physical therapist (PT) education. The results of this survey were published by Schreiber and colleagues1 and highlighted the reported challenges and inconsistencies across programs in the delivery of pediatric content within PT education. In addition to the identified variability in the delivery of pediatric curricular content, this survey found that the pediatric academic faculty often considered the Section on Pediatrics document Pediatric Curriculum Content in Professional Physical Therapist Education2 to be a useful, but somewhat overwhelming, list of curricular content areas. Survey respondents further suggested that additional guidelines and direction for providing pediatric PT education would better help the faculty meet the objective of preparing students for entry-level competence in pediatric PT practice.1 In 2012, the Section on Pediatrics held its first Education Summit with the overall goal of addressing these and other issues. A detailed description of the objectives, process, and participants in the Education Summit was published in 2014.3

One of the main themes at the Education Summit was the Commission on the Accreditation for Physical Therapy Education (CAPTE) Accreditation Criteria4 that require all professional physical therapy programs to prepare graduates to be generalist PTs capable of providing care to patients of all ages, including children. In an effort to develop a more effective resource for pediatric academic faculty to meet this requirement, participants in the Education Summit chose to focus on the knowledge, skills, and abilities that are unique to pediatric PT practice. As a result, the participants in the Education Summit came to consensus on 5 essential core competencies (ECCs).3 In addition to describing the new ECCs, the Summit publication offered potential teaching strategies, learning activities, assessment strategies, and 2 examples of how to incorporate the ECCs into different curricular structures (stand-alone course vs integrated throughout multiple courses).3 An abbreviated list of the ECCs is provided in Table 1. Beyond this initial publication of the 5 ECCs, the Education Summit group has continued to work on additional aspects of the education challenges identified by Schreiber and colleagues.1 For example, to assist with academic faculty development, a new faculty toolkit and mentoring network has been developed, an academic track of continuing education offerings was added to the Section on Pediatrics Annual Conference, and the Academic and Clinical Educators Special Interest Group was formed within the Section (J. Furze, written communication, June 10, 2014).

Recognizing that professional physical therapy education consists of 2 curricular components, a didactic component and a clinical education component,4 another objective of the Education Summit was to prepare, develop, and support clinical instructors (CIs) and to summarize models of delivery for optimal pediatric clinical education experiences.3 The Education Summit organizers realized, however, that not all of the original objectives of the summit could be realistically addressed at a single meeting and that the clinical education issues should be further explored while the 5 ECCs were being fully developed and disseminated. Although the competencies were originally developed to describe the optimal didactic preparation of Doctor of Physical Therapy (DPT) students, examples of how the competencies might be used by CIs were presented at the Dianne Cherry Forum at the 2014 Combined Sections Meeting.5

The question of competency and whether it is the same as performance in the clinical setting is a current topic in the health care education literature related to “entrustable professional activities” (EPAs).6 As outlined in the publication from the Education Summit,3 each of the competencies includes specific key outcomes. These outcomes, referred to as EPAs, are the critical professional activities that define a profession.6 In this manner, EPAs can be used to measure and assess outcomes related to achieving competency.6 In the clinical environment, presenting the 5 ECCs within the real-world context of EPAs ensures that the competencies are clinically relevant and meaningful to future practice.6 Miller's7 pyramid for clinical assessment offers additional insights into this concept and provides a hierarchical model for assessing clinical competence. At the base of Miller's7 pyramid, assessment begins with what the student “knows” and moves through stages of “knows how” and “shows how.” The pyramid culminates in what the student “does.” Assessment of an EPA aligns with what the student “does” in Miller's pyramid.7 According to ten Cate,6 once a student is able to adequately perform professional activities (“does”), competence is inferred. Miller7 and ten Cate6 further assert that the student's clinical supervisor (the CI) is the best person to make the assessment of competence. Medical education literature further notes that core competencies are made more meaningful when placed in a familiar context such as patient care,8 and that both supervisors and trainees place considerable significance on the student's self-assessment of readiness.9 Physical therapy clinical education experiences clearly offer this kind of opportunity.

Acknowledging that the ECCs were never meant to be prescriptive in either academic or clinical education, CIs may find the core competencies to be a useful tool to help structure pediatric clinical education experiences for students. Clinical instructors should not feel obligated, however, to use the ECCs or to incorporate all 5 of the competencies into any single clinical education experience. Rather, we hope that CIs will view the ECCs as a document that may help to structure and plan pediatric clinical education experiences that provide students with a broad view of the unique knowledge, skills, and abilities within pediatric PT practice. Therefore, the purpose of this article is to offer suggestions for how the 5 ECCs might be used to identify student needs and guide student learning during a pediatric clinical education experience.

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APPLYING THE CORE COMPETENCIES IN CLINICAL EDUCATION EXPERIENCES

The pediatric CI could potentially use the ECCs as a reference tool in clinical education to help (1) organize and develop general, clinic-specific clinical education objectives, (2) develop and plan individualized student learning experiences, (3) identify student needs, and (4) show progression of student learning from beginner to intermediate to professional entry level. Although CAPTE Accreditation Criteria4 stipulate that the clinical education component of the professional physical therapy education curriculum must include a minimum of 30 weeks of full-time clinical education experiences, the structure and timing of clinical education experiences varies in each physical therapy program. Consequently, students may complete pediatric clinical education experiences at different points in their professional coursework. Some students may participate in a pediatric integrated clinical experience that occurs during an academic term and that is coordinated with concurrent didactic coursework.10 Other students may undertake a full-time pediatric clinical experience in which the student is in the pediatric clinical setting for a minimum of 32 hours per week but will return to the academic setting for additional didactic coursework after the completion of the full-time clinical experience.10 Students may also come to a pediatric setting for a final clinical internship during which the student typically spends an extended amount of time in full-time clinical education after the completion of all didactic coursework required for a degree.10 Given these different types of clinical education experiences and the inherent variability of the didactic curricular sequences within each professional physical therapy education program, students in a full-time pediatric clinical experience may or may not have completed all of their required pediatric coursework. Depending on where a student is within the professional physical therapy education program (first year, second year, or third year), expectations for student outcomes at the completion of a pediatric clinical education experience will also vary. Therefore, not all students will be expected to achieve an entry-level capability by the end of a pediatric clinical education experience.

One potential strategy for applying the ECCs in clinical education is depicted in Figure 1. Because students may enter pediatric clinical education experiences at such disparate points within their academic preparation, 1 way that the core competencies may assist CIs is to help identify a student's level of pediatric-specific knowledge, skills, and abilities within a continuum from beginner to intermediate to an entry level of performance. Identifying a student's performance level in the various core competency areas may help the CI to develop and plan student activities and experiences on a learning continuum from exposure to synthesis. Because student learning within clinical education occurs in all 3 domains of learning, clinical application of the core competencies within the affective, cognitive, and psychomotor domains of learning should also be considered.

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APPLYING THE INDIVIDUAL CORE COMPETENCIES IN CLINICAL EDUCATION

The following sections consider each of the ECCs through the lens of clinical education with the goal of suggesting ways that a CI might consider addressing the core competencies within the clinical education setting. Sample student behaviors, select indicators of student performance, and suggested learning activities are provided for each core competency. Given the nature of clinical education and the realities of providing physical therapy services in actual pediatric settings, the core competencies may overlap in the clinic and make it difficult to artificially separate out each individual core competency. The following concepts are therefore not meant to be prescriptive in nature, but may help CIs to organize, facilitate, and evaluate student learning in the pediatric clinical education environment.

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Core Competency 1: Human Development

This competency acknowledges that therapists must have extensive knowledge of typical development across all developmental domains as a foundation for executing the patient/client management model in pediatrics.2,3 In the clinical setting, knowledge of development informs the PT's decision to make recommendations for skilled pediatric physical therapy services and to make referrals to other health care providers. Students must be able to identify when a child's development is delayed and yet acknowledge expected variability within a sequence of typical development.11,12 Student PTs also need to be able to determine a child's abilities in all developmental domains so that the student can engage the child in developmentally appropriate play and use suitable motivational techniques during physical therapy interventions.11,12

Students at a beginning level of performance within this competency area may benefit from an overview of the sequence of developmental milestones across developmental domains. With assistance from the CI, students at an intermediate level of performance should be able to use direct observation and parent/caregiver report to screen a specific child's attainment of developmental milestones. In contrast, students at an entry level of performance within this competency area should be able to integrate developmental information about a particular child from all developmental domains and use this information to communicate, motivate, and select toys, as well as to make and modify appropriate decisions about interventions, all under the oversight of the CI. The degree of guidance provided by the CI and the specific learning activities chosen to facilitate student learning will vary depending on what aspects of human development to which the student has already been exposed within the academic program as well as the student's level of performance. Sample behaviors at various levels of student performance and suggested learning activities related to human development are provided in Table 2.

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Core Competency 2: Age-Appropriate Patient/Client Management

This competency synthesizes learning in the other competency areas and is perhaps the most traditional and familiar of the competencies in the clinical education setting. In the clinical setting, therapists must be able to apply the patient/client management model in a manner that recognizes the effect of a child's chronological and developmental age on the provision of physical therapy services.2,3,11,12 Students must be able to modify their clinical reasoning processes when working with children and learn to consider the potential effect of multiple factors such as the child's age, developmental level, family, and environment to appropriately execute elements of the patient/client management model with pediatric patients.11,12

Students at a beginning level of performance within this competency area may benefit from exposure to the various types of procedural interventions commonly used with pediatric patients. With assistance from the CI, students at an intermediate level of performance should be able to implement specific procedural interventions. In contrast, students at the professional entry level of performance within this competency area should be able to synthesize information about a particular child (eg, age, diagnosis, and goals), select developmentally appropriate procedural interventions, and carry out the interventions all under the oversight of the CI. The degree of guidance provided by the CI and specific learning activities chosen to facilitate student learning will vary depending on the student's level of performance. Sample behaviors at various levels of student performance and suggested learning activities related to age-appropriate patient/client management are provided in Table 3.

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Core Competency 3: Family-Centered Care

This core competency recognizes the need for therapists to consider both the child and the family in the provision of physical therapy services.2,3,11,12 Family-centered care is characterized by sensitivity, positivity, and responsiveness and predicates the belief that the family is the expert on their child.13 A key concept within family-centered care is the need to involve and collaborate with the family to optimize care for the child. In the pediatric clinical education environment, the student PT must be able to develop a relationship with both the child and the child's family, yet the student must learn how to maintain professional relationships and develop boundaries with family members.11,12 The student must also learn how to ascertain a family's priorities and goals in consideration of the family's values and beliefs while simultaneously recognizing the effect of a child's special needs on a family's structure and function.11,12

Students at a beginning level of performance within this competency area may benefit from casual interactions with clients and their families to build rapport, which is essential for relationship building. For example, a beginning student may be put in charge of greeting clients and/or their parents, transitioning them to the therapy room, and getting them prepared for therapy (eg, take off shoes and orthotics). With assistance from the CI, students at an intermediate level of performance should be able to engage family members and caregivers in discussions related to the family's concerns, needs, and desired outcomes. In contrast, students at a professional entry level of performance within this competency area should be able to synthesize information about a particular child, explain a child's strengths and needs, develop appropriate goals, and report findings and recommendations to family members all with oversight from the CI. The degree of guidance provided by the CI as well as the specific learning activities will vary depending on a student's prior exposure to children and clinical education experiences. Sample behaviors at various levels of student performance and suggested learning activities related to family-centered care are provided in Table 4.

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Core Competency 4: Health Promotion and Safety

This competency recognizes the special considerations that must be taken to protect the general welfare, safety, and health of children.2,3 In the clinical setting, therapists must consider health promotion and safety in regard to age-specific safety needs, environmental factors, screening in healthy populations, wellness and fitness, recreation, and prevention.3 Students must be able to integrate concepts related to wellness and prevention specific to the pediatric population.3 These concepts are reflected in routine patient care activities such as monitoring the fit and function of a child's adaptive equipment, creating a skin check regimen for a child with sensation deficits, or referring a child with a particular developmental condition such as Down syndrome or cerebral palsy to appropriate recreational activities within the community.3

Students at a beginning level of performance within this competency may gain knowledge and skills within this competency area by looking up age-appropriate fitness guidelines for children who are typically developing. With assistance from the CI, students at an intermediate level of performance should be able to determine differences between fitness guidelines for children and fitness guidelines for adults. In contrast, students at an entry level of performance within this competency area should be able to develop parent-friendly handouts related to physical fitness guidelines that incorporate age-appropriate suggested activities to complement the guidelines. The degree of guidance provided by the CI and the specific learning activities chosen to facilitate student learning will vary depending on what aspects of health promotion and safety to which the students have already been exposed within their academic program as well as the students' level of performance. Sample behaviors at various levels of student performance and suggested learning activities related to this competency are provided in Table 5.

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Core Competency 5: Legislation, Policy, and Systems

The final competency considers the effect of legislation, policy, and systems on pediatric PT practice.3 Pediatric practice is carried out under unique local, state, and federal laws, policies, and within systems that must be understood and acknowledged when providing services to children.2,3,12 For example, the Individuals With Disabilities Education Act (IDEA) Parts B and C as well as Medicaid have a significant effect on how children receive physical therapy services in any setting.14,15 Even though the IDEA pertains to school-based services, therapists in a pediatric acute care hospital must have an understanding of the IDEA to refer a child for appropriate community-based services and to provide realistic recommendations for a child being discharged.3 Students must be able to find, identify, interpret, and follow the laws, policies, and system procedures that dictate the delivery of physical therapy services as well as professional responsibilities related to the pediatric patient.3

Students at a beginning level of performance within this competency area may benefit from increasing their knowledge concerning the continuum of care with pediatric physical therapy and the importance of professional collaboration between PTs serving a child in different settings (eg, at school and in an outpatient practice). With assistance from the CI, students at an intermediate level of performance should be able to explain the differences between providing services under the IDEA versus providing services in an outpatient or private practice setting. In contrast, students at a professional entry level of performance within this competency area should be able to determine frequency and duration of physical therapy in relation to a child's needs and the setting in which the physical therapy is delivered with oversight of the CI. The degree of guidance provided by the CI as well as the specific learning activities will vary depending on the students' prior exposure to governing laws and regulations pertaining to pediatric physical therapy within their academic program as well as the students' level of performance. Sample behaviors at various levels of student performance and suggested learning activities related to this competency are provided in Table 6.

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DISCUSSION

Developed to address specific issues identified in the 2009 survey by Schreiber and colleagues,1 the 5 ECCs have the potential to improve professional pediatric PT education.3 Accreditation criteria put forth by CAPTE require all PT students to have exposure to pediatric patients, even if this does not take the form of a full-time clinical experience or internship.4 Although the ECCs were explicitly developed for the didactic aspect of the professional curriculum,3 CIs may find that the core competencies are also a useful tool for designing and structuring clinical education experiences. We reiterate that the ECCs were not meant to be prescriptive and that a single clinical education experience is unlikely to encompass all of the core competencies.

This article has offered suggestions and strategies to use the ECCs for the entire continuum of clinical education, from exposure with integrated clinical experiences to synthesis on a final clinical internship. An example of this continuum for competency 2 (age-appropriate patient/client management) may be that students might observe the CI administering a standardized development assessment tool with a child with special needs in an integrated clinical experience, assist the CI with administering and scoring a developmental assessment tool during a full-time intermediate clinical experience, and independently administer and score that assessment with oversight from the CI during a final clinical internship. The beginning, or exposure, learning activities may occur before the student has completed the didactic content related to pediatrics, whereas intermediate learning activities may be better placed after at least a portion of the didactic content has been presented. Even if specific concepts have been presented in the didactic portion of the curriculum, the clinical environment offers a richer, context-filled environment to reinforce these concepts.

Clinical instructors may also find the 5 ECCs helpful in developing clinical education objectives for their particular pediatric setting. Using competency 1 (human development) to illustrate this concept, CIs at a specific clinic might determine that the ability to recognize age-related changes in the development of a mature gait pattern is an important skill for a student to develop during a clinical education experience in that clinic. The CIs could then establish a continuum of performance from beginner to intermediate to entry level within this skill area. For example, perhaps the CIs determine that students at a beginning level of performance in this area should be able to list the characteristics of gait in children of various ages that are typically developing. Students at an intermediate level of performance might then be expected to recognize select components of an immature gait pattern during observation of a specific child's gait. Students at an entry level of performance in this area might then be expected to compare and contrast the gait patterns of children of various ages, recognize when a child's gait pattern is not age appropriate, and apply concepts related to the development of a mature gait pattern to patient/client management. A CI in this clinic could then use this continuum to help identify a student's level of performance in this skill area and then develop and plan appropriate student learning activities and experiences. Throughout the learning activities, the CI and the student could also use the continuum to monitor the student's learning and progress within the skill area.

Clinical instructors could additionally use the ECCs to identify learning activities that are already available at the specific clinical site and then develop learning objectives on the basis of those opportunities. The CI may find the suggested examples of student performance within each competency helpful to guide the development of behavioral objectives and learning opportunities. The PT student could also use the core competencies as part of a self-assessment and then share this with a CI as a way to highlight potential areas of focus for the clinical education experience. Student self-assessment with the core competencies may be especially helpful to those students who do not fully realize that the scope of pediatric PT practice involves much more than patient/client management.

A frequently identified barrier to beginning and intermediate pediatric clinical education experiences has been lack of CI knowledge about what a student has been taught thus far, and what the academic faculty's expectations are for the PT student during a clinical education experience (Lisa K. Kenyon, unpublished data, 2013). This barrier can only be addressed with open and direct communication between the academic faculty, the PT student, and the CI. Expectations about what is needed should be addressed before the start of the clinical education experience. This conversation should include relevant physical therapy knowledge and skills, as well as student learning style, communication style, and professional goals.

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CONCLUSIONS

Because every PT student, every child that we treat, and every clinical setting is unique, a single tool or document will not be completely appropriate for all situations. The ECCs should not supersede the Clinical Performance Instrument or the Physical Therapist Manual for the Assessment of Clinical Skills, and they are not a mandate for CIs to create learning experiences that do not already exist in their clinical practice. However, the ECCs may offer a new and unique insight into how pediatric clinical education relates to the overall picture of professional pediatric PT education.

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ACKNOWLEDGMENTS

The authors thank the Section on Pediatrics of the American Physical Therapy Association for their support of the Education Summit in July 2012 and recognize the following individuals for their contributions in developing the competencies during the Summit: Suzann Campbell, Donna Cech, Lisa Dannemiller, Paul deRegt, Paula A. DiBiasio, Jennifer Furze, Gail Jensen, Lisa Kenyon, Heather Lundeen, Kathy Martin, Victoria A. Moerchen, Kelli Parks, Eric Pelletier, Mary Jane Rapport, Joe Schreiber, Ellen Spake, and Sheree York.

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REFERENCES

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curriculum; educational measurement/methods; humans; internship; pediatrics/education; physical therapy specialty/education; professional competence; teaching/methods

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