BACKGROUND AND PURPOSE
The profile of American health and the health care system that imparts or supports health will continue to evolve as population demographics shift and scientific discoveries emerge. Evolution of health care delivery assumes a parallel evolution in the education that prepares practitioners to advance and improve health as they deliver that care. For this to happen, a reciprocal relationship must exist between what is needed in practice and what is provided through education, a relationship that must be continually nurtured for quality to ensue. Accountability to accreditation standards is one source of motivation to pursue quality in professional education. In physical therapy, the core values supporting professionalism also compel us to pursue excellence in any professional endeavor.3 Thus, we are intrinsically obliged to continually advance our practice, education, research, and service activities. We believe that the processes and standards of accreditation should reinforce that intrinsic drive for excellence.
As the only agency recognized in the United States to accredit physical therapy education programs, the Commission on Accreditation in Physical Therapy Education (CAPTE) has grown in stature and independence over the past 40 years and has been influential in helping our profession achieve the autonomy and respect it enjoys today.4 Periodic review and revision of CAPTE's accreditation standards are required by the agencies that recognize the CAPTE as a specialized accreditor. These agencies include the United States Department of Education (USDE) and the Council on Higher Education Accreditation (CHEA). As part of its required review process, the CAPTE solicits feedback and insight from stakeholders during its regular call for comment to ensure that its standards are contemporary and fair. Response to this call, however, is not always widespread, leaving the CAPTE little input upon which to refine its standards. In addition, both clinical practice and educational issues can change dramatically during the time that elapses between CAPTE's scheduled reviews that have occurred only twice in the past 3 decades. As stakeholders in the accreditation process, physical therapy educators are obligated to provide the CAPTE with ongoing feedback to ensure that we are meeting the rapidly changing needs and expectations of both the clinical and academic environments.
The impetus for this article is our concern that three elements within CAPTE's 2016 standards5 may constrain the autonomy of academic institutions that have different missions, goals, and resources for their physical therapist education programs. We believe that the modifications we propose to standard 4A (individual faculty qualifications), standard 4G (program director qualifications), and standard 4K (collective faculty blend) uphold the expectations of excellence in the academic environment and support the core mission of accreditation. We also believe that our proposed modifications are well aligned with best practices set forth by the Association of Specialized and Professional Accreditors (ASPA), as well as the expectations of USDE and CHEA. Finally, we believe that this article manifests the spirit of advocacy for excellence in physical therapy education that all educators must embrace. The accreditation process is designed to facilitate quality improvement, not just enforce minimum standards for physical therapist education. All stakeholders must continually explore and advocate for change to make the accreditation process better.
POSITION AND RATIONALE
The three elements of standard 4 discussed below all address the qualifications of academic personnel. These individuals are responsible for leading the program, teaching with rigor, producing scholarly work, and contributing to the institution's service missions. The profession's expectation is that these responsibilities will be carried out with quality, integrity, and commitment to continued improvement. Upon this background, the CAPTE has established expectations for individual faculty members, for the program director, and for the collective faculty. These expectations—and our proposals for change—are addressed individually in the following paragraphs.
Standard 4A: Qualifications of Individual Core Faculty
The standards implemented by the CAPTE in 2016 specified the expectations of each core faculty member in standard 4A as follows: “Each core faculty member, including the program director and clinical education coordinator, has doctoral preparation, contemporary expertise in assigned teaching areas, and demonstrated effectiveness in teaching and student evaluation. In addition, core faculty who are PTs and who are teaching clinical PT content are licensed or regulated in any United States jurisdiction as a PT. For CAPTE accredited programs outside the United States, core faculty who are PTs and who are teaching clinical PT content are licensed or regulated in accordance with their country's regulations. (PROVISO: CAPTE will begin enforcing the requirement for doctoral preparation of all core faculty effective January 1, 2020, except for individuals who are enrolled in an academic doctoral degree program on that date, in which case the effective date will be extended to December 31, 2025.”5, page 10
Standard 4A encompasses four important expectations of each core faculty member: 1) doctoral level credentials, 2) contemporary expertise in the area in which one teaches, 3) effectiveness in teaching and student evaluation, and 4) licensure as a physical therapist (PT) for those who teach clinical content. We agree that 1) each core faculty member must meet these qualifications, 2) the proviso allows reasonable time frames for faculty who need to achieve a doctoral credential, and 3) alone a clinical doctorate (Doctor of Physical Therapy [DPT]) as a faculty credential falls short of the expectation shared by the CAPTE and the academy. However, we are concerned that standard 4A is not congruent with CAPTE's own article (“The Doctor of Physical Therapy (DPT) as a Faculty Credential”) revised in 2015 to state that “individuals with the DPT as a clinical practice credential may be qualified as a member of a physical therapy program faculty when they also demonstrate evidence of additional clinical experience, specialty expertise, or advanced training in the content area(s) for which they have teaching responsibilities.”6
To be compliant with standard 4A, we propose that all core faculty members whose terminal degree is a clinical doctorate also be required to provide evidence of an advanced academic or clinical credential in an area related to their faculty role(s). We encourage the CAPTE to describe more specifically the term “advanced training” by including the following as acceptable options: 1) any advanced degree (ie, specialty certificate, master's degree, PhD, EdD, or other academic doctorate) or 2) recognition of clinical specialization granted through an accredited residency, fellowship program, or other formal credentialing process. Modifying standard 4A in this way clarifies the expectation that each core faculty member must complete formal, advanced education or training beyond their first professional degree.
When the DPT first emerged as the preferred professional degree in physical therapy, a small (but visible) number of programs began to fill faculty positions with DPT graduates who had little or no (academic or clinical) experience. We believe that this practice, whether past or continuing into the present, could undermine the profession's standards for faculty qualifications. However, PTs who hold the terminal clinical degree (DPT), have accrued experience that imparts expertise, and have completed formal advanced training are essential to the educational enterprise. Our proposed revision to standard 4A strengthens the commitment to excellence in professional education by clarifying the expectations for core faculty who will contribute their clinical acumen and professional perspectives to all aspects of the academic program.
Standard 4G: Qualifications of the Program Director
In standard 4G, the CAPTE prescribes several qualifications for the program director of physical therapist education programs. In addition to previous experience in the academic environment and recognition of professional status through licensure in the jurisdiction, these include the requirement that: “The program director has an earned academic doctoral degree.”5, page 12
The role of the program director is varied and demanding and requires a mature and committed leader. The program director is responsible for ensuring that the collective faculty can deliver a curriculum that addresses the breadth and depth of the physical therapy profession. Each program director also must be successful in administrative roles, have an active and productive scholarly agenda, show competence in teaching, skill, and vision in strategic planning, have senior faculty status, and be involved in the institutional culture. We agree that this individual must have a doctoral degree, be a licensed PT, and have experience in the academy sufficient to understand and discharge the obligations of the role. However, we question whether possessing an academic doctoral degree necessarily assures meeting these expectations or showing overall leadership excellence. Instead, we propose that the CAPTE requires a portfolio of compelling evidence that demonstrates success in essential areas encumbered in the position of the program director.
We offer two points in support of our view regarding standard 4G. First, a recent dissertation study by Tamara Gravano (personal written communication, December 4, 2017) found no significant differences in the leadership preparation, styles, or characteristics of 107 program directors in physical therapist education programs who had clinical doctorates compared with those who had academic doctorates. Because these individuals were all leading programs fully accredited by the CAPTE and had thus presumably met the expectations of their positions, it is questionable whether leadership success is dependent on the type of doctoral degree held. Second, in similar doctoring professions, an academic doctorate is not stipulated by accreditation as a requirement to serve in the top administrative position (e.g. dean, program director, chair, executive officer, etc.). A sample of qualification requirements for leadership in seven doctoring professions is shown in Table 1.5,7-12 Although a professional degree is required by many disciplines (and we agree should be required in physical therapy), physical therapy is the only profession that specifically requires an academic doctorate. Clearly, the other disciplines are relying on leadership qualities and expertise more than attainment of a particular type of degree.
We believe that removing the requirement that the program director hold an academic doctorate will not compromise the quality of leadership within physical therapist education programs or the academic status of the profession. It will remain incumbent upon institutions to select individuals with appropriate skills and knowledge to meet the expectations of academic leadership in physical therapy expressed through standard 4G. If the imperative that each program director holds an academic doctorate is omitted as we propose, the CAPTE must then develop and implement guidelines for evaluating the leadership profile of these individuals. Requiring a comprehensive leadership portfolio will provide programs with a mechanism to describe their program director's attributes and leadership achievements, to demonstrate institutional concurrence, and to show the unique ways by which each individual achieves the excellence expected of academic leaders in physical therapist education. The proposed revision to standard 4G encourages the best-qualified PTs to serve in formal academic leadership positions regardless of the nature of their terminal degrees.
Standard 4K: Collective Qualifications of Core Academic Faculty
Standard 4 addresses not only qualifications of each individual faculty member but also the collective faculty participating in the didactic education of PTs. In standard 4K, the following expectation for the collective faculty was implemented in 2016: “The collective core and associated faculty include an effective blend of individuals with doctoral preparation (including at least 50% of core faculty with academic doctoral degrees) and individuals with clinical specialization sufficient to meet program goals and expected program outcomes as related to program mission, institutional expectations and assigned program responsibilities.”5, page 14
The 50% threshold of core faculty with academic doctorates incorporated in standard 4K originated in the PT panel before 2006 as a response to the small number of programs that recruited into faculty positions new DPT graduates who had little or no clinical or academic experience. We presume that these programs—even if small in number—may have recruited new graduates because of the persistent shortage of qualified faculty without fully appreciating that this practice could have been construed as accepting a lesser standard for faculty credentials. From that perspective, CAPTE's response to this situation may have been justified. However, even with the best intentions, a potential consequence of this approach is to create an imbalance of PT and non-PT faculty—an imbalance that may not be favorable to the education of clinical practitioners. Commission on Accreditation in Physical Therapy Education's position remains that the DPT alone is not a satisfactory faculty credential. We further agree that the DPT degree should be paired with additional education, experience, and expertise that merit faculty status. However, given that the primary mission of most entry-level programs is still to prepare clinical practitioners, the composition of the collective faculty should not be guided by an arbitrary threshold based on degree achievement. Rather, the credentials of the collective core faculty should represent the needs of delivering a clinically relevant curriculum.
Over time, the rationale for the required 50% threshold of academic doctorates in the collective faculty seems to have shifted from a concern about inappropriate faculty recruitment to a concern about scholarly productivity—the assumption being that faculty with DPT degrees are not adequately prepared to engage in independent research. We agree that faculty must be qualified for their academic responsibilities and that scholarly productivity is a critical obligation. However, although there may be an assumption to this effect, there is no evidence to confirm that core faculty with DPT degrees are less productive than core faculty with academic doctorates when controlling for the influence of academic rank and years of academic experience.13 Furthermore, in other doctoring professions, core faculty with clinical doctorates often engage in independent and collaborative research and scholarship without the benefit of additional academic training. In none of these doctoring professions do accreditation requirements specify a collective faculty threshold based on the degree type.
We also believe that by requiring 50% of faculty to possess an academic doctorate, the CAPTE may be overreaching its authority by interfering with institutional prerogatives to determine staffing configurations that best enable fulfillment of their missions. Both CHEA, to which the CAPTE is accountable, and ASPA, in which the CAPTE is a long-standing member, support such institutional prerogatives. Being too prescriptive about collective faculty composition may be interpreted as interfering with “institutional independence and freedom in academic decision making,”14 a key value of accreditation. Accreditation standards should not be used to promote professional policies or agendas. Requiring a 50% threshold could be viewed as creating a vehicle to accomplish aims important to the academic community but not directly governed by accreditation. Examples of these aims may include using the standards to 1) curtail development of new programs (which must follow a process to meet those standards), to 2) standardize curricula (when quality, not standardization is the primary target of the CAPTE), or 3) to become more productive and visible in the research community (which is important but also not the goal of accreditation). Although these may be current concerns of the academic community, using accreditation standards to solve professional issues violates the USDE's expectations that the professional association and accrediting body be “separate and independent.”15
As we propose, removing the 50% threshold from standard 4K places a considerable onus on each program to demonstrate how their collective faculty can 1) deliver the breadth and depth of the curriculum in the context of the program's mission and 2) fulfill the obligations set forth by the CAPTE to further the body of knowledge through scholarly endeavors. We believe that the revision we propose to standard 4K acknowledges the concern that prompted establishing the arbitrary threshold—that the blend of individuals comprising the faculty must be sufficient to meet program goals and expected program outcomes, assigned program responsibilities, and institutional expectations. This concern can be addressed by focusing on assurance of an effective blend of degrees, credentials, experience, and expertise across the faculty to meet the obligations of academic physical therapy.
DISCUSSION AND CONCLUSION
Clearly, accreditation standards should reflect each profession's expectations but also embrace the freedom of each institution to create an academic culture that best fits its mission and vision. Attempting to concurrently achieve these aims creates an ongoing dilemma that is not unique to physical therapy. We believe that the institutional prerogative to define appropriate credentials of faculty and administrators and determine an ideal blend of the collective faculty does not have to compromise the rigorous standards of a profession or the aims of accreditation. Individual programs must take responsibility for determining what best meets their communities' needs and mission and what meets the expectations of the profession and its accreditation process. Other disciplines in the doctoring professions achieve this without being prescriptive and so can physical therapy.
We have addressed three elements within the current CAPTE standards that we believe should be modified in the following ways to seek betterment of the accreditation of physical therapist education programs:
- Standard 4A: this element should retain CAPTE's position that the DPT alone is not sufficient as a faculty credential but specify options to demonstrate “advanced training.” We believe that one or more options for advanced training should be required and should specifically include advanced educational degrees (at the certificate, masters, or doctoral level) or clinical specialization through an accredited residency program or other recognized specialty credential as acceptable enhancements of the DPT degree for core faculty. Retaining the proviso remains important to communicate the timeframe for enforcement of obtaining the advanced training or education required to meet this standard.
- Standard 4G: this element should promote the appointment and retention of program directors whose portfolios demonstrate success with academic administration, scholarly endeavors, and mentoring of faculty in teaching, scholarship, and academic service. We believe that the portfolio must include at least evidence of 1) postprofessional degree(s) and/or certificate(s) related to teaching, research, and/or leadership; 2) productivity and visibility in grantsmanship, research, and scholarship; 3) demonstrated leadership in institutional or professional arenas; and 4) success in mentoring junior faculty in teaching, scholarship, and academic service. Meeting these expectations should easily comply with CAPTE's expectations of a well-qualified, doctorally trained, program director in physical therapy education without prescribing the type of terminal degree.
- Standard 4K: this element should omit prescriptive percentage distributions across the collective faculty based on the type of doctoral degree. Rather, the CAPTE should require institutions to determine an optimal blend of faculty credentials and demonstrate how this blend meets professional expectations. Each program must “build a case” for how their faculty's combined credentials best meets this standard and expresses the mission of the individual program.
We applaud the CAPTE for adopting a new mission statement that emphasizes the commitment to “ensure and advance excellence in physical therapy education.”1 We firmly believe that this mission is shared by all programs and embraced by the profession. Only by continuing to get better at what we do can we strive for excellence. We hope that this article can be a vehicle for discourse among academic colleagues, CAPTE commissioners, and CAPTE's myriad stakeholders to ensure that our accreditation standards are well considered, reflect contemporary practice, and support institutional autonomy. Accreditation standards have changed and must continue to change, so the profession evolves. Always at the forefront should be our pursuit of excellence that supports PTs' power to influence the health and functional independence of our patients as our profession evolves. We believe that the perpetual labor of advocating for change in accreditation will yield betterment in education for the practice of physical therapy. This is the pathway to excellence.
The authors acknowledge the academic colleagues who have contributed input to the accreditation processes over the years and, through CAPTE's response, have shown that the Standards and Elements are a “living document” that grows with the profession.