COMPETENCY-BASED frameworks are prevalent in graduate education and postgraduate training of health care professionals (Carraccio & Englander, 2013 ; Iobst et al., 2010). Health care professionals are expected to pursue ongoing professional development activities to improve the care delivered to patients. Health professions and state regulatory bodies promote continuing competence for health care professionals to ensure delivery of safe and contemporary practice. Physical therapy (PT) state licensing boards establish continuing education requirements for PT licensure, and some states have additional credentialing, certification, or training requirements to provide PT services under the state early intervention program.
State early intervention programs are governed by Part C of the Individuals with Disabilities Education Act (Federal Register, 2011). This federal grant program was created in 1986 for states to develop a comprehensive system of services for infants and toddlers birth to 36 months of age who have or are at risk for developmental delays and disabilities and their families. Early in the implementation of the law, discipline-specific competencies were developed to establish professional identities and inform personnel preparation (Synder, Hemmeter, & McLaughlin, 2011). In 1991, the American Physical Therapy Association (APTA) supported the legislation and adopted competencies specific to PT practice in early intervention (Effgen, Bjornson, Chiarello, Sinzer, & Phillips, 1991). In 2006, these early intervention competencies were updated to serve as a guide for entry-level PT education programs and the professional development of physical therapists delivering services in early intervention (Chiarello & Effgen, 2006). In 2011, extensive variability among pediatric curricula in entry-level PT education programs was reported, followed by the publication of the Five Essential Core Competencies created to inform education programs on the knowledge, skills, and abilities essential for all entry-level PT graduates (Rapport et al., 2014 ; Schreiber et al., 2011). The impact of the Five Essential Core Competencies on preparation of all PT graduates for pediatric practice is under study.
Physical therapists who practice in early intervention must continually pursue professional development activities to progress along a continuum from novice to expert provider (Catalino, Chiarello, Long, & Weaver, 2015). The early intervention competencies were developed to guide education programs and professional development; however, it is unclear whether these competencies continue to be important to the clinical practice of physical therapists in early intervention. Input from physical therapists was included in the revision process of the competencies prior to 2006; yet, there has been no further investigation into their clinical importance and ability to continue to serve as a guide for professional development. The purpose of this study was to examine the perspectives of physical therapists on the level of importance of the early intervention competencies to PT practice in early intervention and differences in perspectives based on demographic factors.
A web-based survey was designed to capture the responses of physical therapists who practice in early intervention or with children from birth to 3 years of age. The survey was framed by the early intervention competencies and divided into the original nine content areas: context of therapy; wellness and prevention; coordinated care; evaluation and assessment; planning; intervention; documentation; administration; and research (Chiarello & Effgen, 2006). Across the nine content areas, there are 35 competencies, each further defined by one to 10 subcompetencies. The survey listed each competency and subcompetencies in random order by content area. Participants rated the importance of each competency and subcompetency according to their own personal experiences working in early intervention using the 5-point scale of “extremely important,” “very important,” “slightly important,” “of minor importance,” and “not at all important.” Demographic information was obtained by closed-ended questions.
A pilot study and a four-member expert panel were incorporated into the development of the survey. A convenience sample of 14 pediatric physical therapists completed the survey and filled out an online evaluation regarding clarity, difficulty level, length of time to complete, and recommendations for improvement. The average completion time for the survey was 22 min. Of these therapists, 10 completed the survey a second time, establishing test–retest reliability (r = .946). Each member of the expert panel reviewed the survey and provided written and verbal feedback on the survey instrument. Each of the experts had more than 15 years of experience practicing in early intervention. Two of the experts held a primary position within an academic institution and two within early intervention. The survey and the study protocol were updated prior to full launch of the study.
The survey was disseminated by nonprobability sampling techniques of convenience and snowball sampling to reach the desired population of physical therapists. An e-mail with a link to the survey was sent to the APTA Academy of Pediatric Physical Therapy (APPT) state representatives requesting dissemination to state members and to physical therapists listed on state early intervention program websites, with direct requests to physical therapists to forward the survey to early intervention physical therapists. Approval was granted by an institutional review board.
Survey data analysis
Participant responses for each early intervention competency and each subcompetency were analyzed both as nominal categories and as the interval scale. The percentage of responses in the five nominal categories was calculated across all participants for each competency and subcompetency and also as a percentage of total responses for each nominal category. Means were calculated by averaging across competency and subcompetencies for each participant and then averaging the scores across the participants to calculate means and standard deviations for each of the 35 competency statements.
Descriptive statistics on the overall sample and by groups were conducted for each outcome and grouping variable. There were 35 outcome variables of interest, namely, the early intervention competencies. Grouping variables included early intervention experience, practice setting, education, APTA membership, and Pediatric Certified Specialists (PCS) certification. One-way analysis of variance (ANOVA) was used with three or more groups (early intervention experience, practice setting, and education) and independent-samples t tests with two groups (APTA membership and PCS certification). Significance was set at p < .05. Tukey post hoc tests were conducted on significant ANOVA tests for pairwise comparisons. With the sample size in this study, the parametric tests were assumed to be robust to moderate skewness and non-normality (Norman, 2010). Effect size for each significant result was calculated to measure effect magnitude, independent of sample size. Differences were determined to be meaningful for interpretation and practical application when the ANOVA or t test was statistically significant and when effect size was d = 0.5 or more, indicating medium to large effect (Cohen, 1988).
E-mail distribution of the survey link resulted in 373 responses. Eighty-five surveys were eliminated on the basis of exclusion of demographics or missing greater than 25% of responses, resulting in 288 surveys included in the analysis. The 288 participants were widespread across regions of the United States, with nearly all 50 states represented aside from Delaware, Hawaii, and Wyoming. The states with the greatest number of participants were Indiana (14.9%), California (7.3%), Pennsylvania (6.3%), Illinois (5.9%), and New York (4.9%).
The largest number of participants was Caucasian (90.6%) and female (95.1%) working full-time (60.8%). Participants worked within multiple practice settings such as outpatient within a private practice or hospital-based clinic (31.2%), early intervention in the natural environment (29.5%), school system (18.8%), academic institution (12.2%), acute care hospital (5.6%), and other inclusive of subacute rehabilitation hospital, adult home health care, or an extended care facility (1.7%). The majority of therapists (87.1%) were providing direct services in early intervention at the time of survey completion. The highest number of participants had 11–20 years of experience in pediatric PT (32.6%) and early intervention (31.6%). The level of education most commonly represented were a master's degree (31.9%), followed by a Doctor of Physical Therapy (DPT) degree (29.9%) and a bachelor's degree (28.1%). The majority of participants were APTA members (72.6%) and PCS (66.0%). Participant demographics are detailed in Table 1.
Perceived importance of the early intervention competencies
The results from the survey data analysis are displayed in Table 2. The average percentage of total responses within each Likert category was “extremely important” (50.5%), “very important” (29.9%), “slightly important” (10.8%), “of minor importance” (4.4%), and “not at all important” (4.4%), respectively. The overall mean score of 4.18 was between the “extremely important (5.0)” and “very important (4.0)” categories. The 13 competencies that received greater than 60% of the responses within the “extremely important” category with mean values ranging from 4.50 to 4.83 are as follows:
- Demonstrate knowledge of family systems theory, recognize the central importance of the family, and be able to provide family-centered services (67.8%).
- Recognize the impact of a child with special needs on a family unit throughout the family life cycle (69.3%).
- Support the parents' primary roles as mother and father to the child (69.1%).
- Collaborate and encourage family involvement with the early intervention process (65.7%).
- Select, administer, and interpret a variety of screening instruments and standardized measurement tools (66.6%).
- Promote child safety by educating caregivers on child development, environmental and toy hazards and safety measures, accident prevention, and recognition of child neglect and abuse (66.3%).
- Evaluate and assess child abilities and strengths (85.6%).
- Use valid, reliable, and nondiscriminatory examination instruments and procedures for identification and eligibility, diagnostic evaluation, individual program planning, and documentation of child progress, family outcomes, and program impact (65.3%).
- Actively participate in the development of the Individualized Family Service Plan (65.4%).
- Develop and implement appropriate intervention programs and strategies (70.5%).
- Integrate therapy intervention strategies into home and community settings (73.4%).
- Produce useful written documentation (63.9%).
- Evaluate and document the effectiveness of therapy intervention strategies and therapeutic procedures (61.9%).
Significant differences between independent variables
There were nine significant findings between grouping variables with at least a medium effect size and 166 nonsignificant findings or a significant finding with less than a medium effect size. There were no significant findings among groups on the rating of “extremely important” for the 13 competencies that received greater than 60% of the responses within the “extremely important” category.
The therapists with less than 11 years of early intervention experience perceived the competency of “Function as a consultant” with less importance than the therapists with more than 20 years of experience. The competencies of “Function as an administrator” and “Demonstrate leadership abilities in promoting effective team processes” were found to have a lower level of importance by therapists with 11–20 years of early intervention experience than therapists with more than 20 years of experience. The therapists with a primary position in early intervention perceived a greater level of importance of the competency “Assist families in accessing services that promote full inclusion of child and family into the community” than therapists primarily working in an outpatient facility. The therapists with a DPT degree perceived the following competencies with higher importance than the therapist group with a bachelor's degree: (1) Evaluate family strengths, resources, concerns, and priorities; (2) Demonstrate knowledge of current research relating to infant development, medical care, and development intervention for infants and toddlers; (3) Apply knowledge of research to the selection of therapy interventions strategies, service delivery systems, and therapeutic procedures in early intervention; and (4) Partake in program evaluation and clinical research activities with the appropriate supervision. The competency of “Evaluate family strengths, resources, concerns, and priorities” also resulted in a greater importance rating by APTA members than by nonmembers. The nine significant findings are displayed in Table 3.
Graduates of entry-level PT education programs are expected to be prepared with a minimum of entry-level competence to manage patient care across the life span. Physical therapists are obligated to participate in ongoing professional development to advance their knowledge, skills, and abilities for excellence in practice (American Physical Therapy Association [APTA], n.d.). The variable exposure to pediatrics during entry-level PT education programs and the unique nature of early intervention make it necessary for physical therapists to pursue ongoing professional development activities (Catalino et al., 2015). The early intervention competencies were developed to provide an overview of the knowledge and skills a physical therapist is recommended to acquire across a continuum to reach an advanced level of practice in early intervention (Chiarello & Effgen, 2006). The findings from this survey reveal that physical therapists who work with infants and toddlers from birth to 3 years of age perceive the early intervention competencies as important to PT practice in early intervention, with few significant differences among therapists based on demographic factors. These results further inform the use of the early intervention competencies as a guide when planning for professional development by the individual therapist or by those who design professional development activities.
From this study, there are 13 early intervention competencies that have been highlighted as extremely important to PT practice in early intervention and may be considered a priority for professional development activities. It should be noted that the early intervention competencies with the lowest means remain on the positive side of the importance scale. All competencies relating to family-centered care were recognized by the survey participants, and in the published literature, as an essential component for high-quality services and positive outcomes (Kuhlthau et al., 2011 ; Tomasello, Manning, & Dulmus, 2010). Another area of extreme importance indicated by the survey participants is wellness and prevention in early intervention settings in regard to screening children using standardized measurement tools and education of caregivers to promote child safety. A physical therapist's knowledge of the movement system (musculoskeletal, neuromuscular, cardiovascular, pulmonary, endocrine, and integumentary systems) enables screening for signs and symptoms that may indicate a referral to another health care professional (Jette, Ardleigh, Chandler, & McShea, 2006). A physical therapist's scope of practice includes prevention and promotion of health, wellness, and fitness (APTA, 2014) that are inclusive of education to families about developmental activities and prevention of childhood injuries. The remaining competencies highlighted as extremely important by the physical therapists reflect primary responsibilities of a physical therapist under the Physical Therapy Patient/Client Management Model as it relates to infant and toddlers and their families (APTA, 2014 ; Rapport et al., 2014).
There were few significant differences among groups of physical therapists on the perceived importance of the early intervention competencies based on early intervention experience, practice setting, education, and APTA membership. The participants with the most years of early intervention experience (>20 years) rated both administrative competencies and functioning as a consultant as significantly more important to their practice than less experienced physical therapists (<11 years). This suggests that more experienced physical therapists are more involved in administrative and consultative roles than less experienced physical therapists; however, even less experienced therapists still considered these competencies as having some importance to their practice. Similar to Jette et al. (2003), physical therapists with a DPT degree rated all research competencies as significantly more important to their practice than physical therapists with a bachelor's degree; yet, physical therapists with a bachelor's degree on average still considered these competencies important to their practice. This difference may reflect the emphasis on research and evidence-based practice in entry-level PT education programs nowadays. Another significant finding is an increased level of importance for providing services in the natural environment by physical therapists who primarily worked in early intervention compared with physical therapists who worked predominately in an outpatient facility. This finding may relate to the location where each group of therapists primarily practices, with the early intervention group practicing in the natural environment compared with the group of therapists primarily practicing in an outpatient setting. Service delivery in early intervention is recommended in natural and inclusive environments during daily routines to promote participation in learning experiences (Division for Early Childhood, 2014). The significant difference between physical therapists who were APTA members and held a DPT degree and nonmembers who held a bachelor's degree on the competency relating to the evaluation of family strengths, resources, concerns, and priorities is unclear without further investigation.
Expert practice in PT emphasizes the importance of self-monitoring and reflection for continued learning and development from previous experiences (Jensen, Gwyer, Shepard, & Hack, 2000). Experience alone without ongoing reflection is insufficient for the development of clinical reasoning and recognition of knowledge awareness to direct professional growth (Hayward et al., 2013). A professional development plan is one method used by various health professions and in the education field to self-reflect on previous experiences to better understand competence and performance levels and guide professional development activities (Driessen, van Tartwijk, van der Vleuten, & Wass, 2007 ; ten Cate et al., 2015). Creation of a professional development plan can be used to support attainment of competencies on the basis of demonstrated performance to meet desired outcomes of training. The APTA APPT Early Intervention Special Interest Group developed a resource to assist physical therapists in utilizing the early intervention competencies to develop a personal professional development plan to guide continuing competence in early intervention practice (Academy of Pediatric Physical Therapy of the American Physical Therapy Association, 2017). The template for this personal professional development plan is given in Table 4.
A two-dimensional approach involving both competencies and Entrustable Professional Activities (EPAs) is now widely applied in the education of health professionals (ten Cate et al., 2015). Competencies are general attributes or a description of abilities, whereas EPAs are measurable tasks or responsibilities that that can be fully entrusted to a trainee as soon as the trainee has demonstrated the necessary competence to execute this task unsupervised (ten Cate et al., 2015 ; ten Cate & Scheele, 2007). For instance, the Five Essential Core Competencies include EPAs as key outcome measures for achieving competence in knowledge, skills, and abilities relating to entry-level pediatric PT education (Rapport et al., 2014). Further study and discussion on the early intervention competencies and assessing competence in practice in terms of EPAs are warranted. Further study and discussion on the commonalities and differentiation between the Five Essential Core Competencies in entry-level pediatric PT education and the early intervention competencies in PT practice are recommended to more clearly define advancement from novice to expert practice.
Preparation for early intervention should be discipline-specific and interdisciplinary. The early intervention competencies have similarities in the knowledge and skills across disciplines more so than reflecting PT-specific knowledge and skills (Chiarello & Effgen, 2006). Catalino et al. (2015) describe the unique contribution that physical therapists offer to an early intervention team as movement specialists and opportunities for interdisciplinary and discipline-specific professional development. The Early Childhood Personnel Center (ECPC) has collaborated with several organizations representing disciplines providing services in early childhood to identify four common core areas of competence across all disciplines: Collaboration and Coordination, Family Centered Practice, Interventions as Informed by Evidence, and Professionalism and Ethics (ECPC, n.d.). These interdisciplinary competencies will necessitate further discussion and study on dissemination and inclusion in professional development activities.
Limited information is available on physical therapists in early intervention, with no clear method to access this population; thus, it is unclear whether the participant characteristics in this study accurately represent therapists in practice. Many of the participants were APTA members; thus, nonmembers may be underrepresented. Nonprobability sampling techniques and self-selection bias limit generalization of the findings.
Health care professionals are expected to be knowledgeable in their fields and employ that knowledge safely and effectively in practice. Physical therapists who practice in early intervention require unique and shared knowledge, skills, and abilities to effectively serve infants and toddlers and their families. The early intervention competencies were perceived as important to PT practice in early intervention and may assist in guiding the pursuit of professional development of physical therapists. Continuing competence is a journey that begins with self-reflection on clinical practice experiences to guide ongoing learning activities.
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