BACKGROUND AND PURPOSE
In many health professions, clinical residency training is commonly used to advance education beyond entry level and develop clinical knowledge and skills in a specialized area of practice. Physical therapy (PT) has recently followed this trend. Postprofessional residency education in PT gained recognition through the accreditation process established by the American Physical Therapy Association (APTA) in 1997 and is overseen by the American Board of Physical Therapy Residency and Fellowship Education (ABPTRFE).1 The availability of residency programs has grown quickly, with a 138% increase from 2010 to 2015.2 By 2018, there was a total of 258 accredited programs in 11 specialty areas (Table 1).3 Residency education in PT is intended to promote excellence in patient/client management, translate research evidence into clinical practice, and advance professional development in specialty practice.
The ABPTRFE develops quality standards and curricular guidelines in a defined area of advanced practice for residency education, as described by the Description of Residency Practice.4,5 Other accrediting bodies, such as the American Society of Hospital Pharmacists and the National Commission in Orthotics and Prosthetics Education, use a variety of methods to validate residency curricula. For example, certification in the fields of orthotics and prosthetics requires residency training (although licensure and certification requirements differ by state). The curriculum is based on the results of a practice analysis of certified practitioners conducted every 8–9 years.6 A practice analysis is a systematic study of the professional skills, knowledge, and abilities that comprise practice for a specific subspecialty. Data, often collected via a survey, describe what practitioners know and perform that distinguishes their area of practice.7 Residency training in many other fields (exclusive to medicine) is voluntary, with the purpose of advancing an individual's professional practice skills in a specialty area, as well as advancing the profession in general. Pharmacy's 2-year specialty residencies, as well as the speech language pathology specialty area of practice for fluency and fluency disorders, also utilize a practice analysis to define specialty knowledge, skills, and abilities.8,9 Residencies in some other health professions appear to utilize expert consensus to define curricular standards. For example, the Commission on Collegiate Nursing Education validates curricular standards by notification and broad-based surveys of constituents to provide input, and by periodic review of the standards.10 Similarly, in clinical psychology, the American Psychological Association Committee on Accreditation implements the following criteria: “appropriate public notice, public hearings, and approval.”11 The American Occupational Therapy Association develops curricular standards for fellowship postprofessional training programs through an expert consensus and review process, as well as integrating the Standards for Continuing Competence established by the Commission on Continuing Competence and Professional Development.12,13
The development of residency curricula in PT has been heavily influenced by processes used to validate specialty practice certification. Such certification predated the emergence of residencies as a way to recognize expertise gained through clinical experience and self-directed professional development. The primary purpose of specialist certification is to recognize PT expertise in prescribed, advanced-level clinical competencies.14 Since 1985, the American Board of Physical Therapy Specialties (ABPTS) has certified more than 20,000 physical therapists in 9 specialty areas—Cardiovascular and Pulmonary, Clinical Electrophysiology, Geriatrics, Neurology, Oncology, Orthopedics, Pediatrics, Sports, and Women's Health Physical Therapy.15 For each specialty, a detailed list of competencies is defined by The Description of Specialty Practice (DSP).16 According to the ABPTS, the purposes of the DSP are to (1) describe the current best practice of physical therapists that possess advanced clinical skills in a specialty area of practice; (2) identify the expected knowledge, skills, and abilities (KSAs) possessed by clinical specialists in an area of practice; (3) document the methods and results of studies undertaken to develop the advanced competencies in an area of practice; and (4) describe the changing nature of advanced practice in an area of specialty practice.17 The DSP is based on a formal, comprehensive practice analysis and, as such, represents a validated content outline for board examination in a specialty area.17-19
Since PT specialist certification and postprofessional residency education both represent advanced education and specialized training, the competencies described within the DSPs were naturally extended to form the infrastructure of residency curricula learning outcomes. In fact, residency accreditation by ABPTRFE requires evidence that these DSP competencies are being met.20 The DSP is used to identify the required curricular competencies in the Description of Residency Practice for a defined specialty area. The competencies in the DSP form the gate through which a candidate must pass to attain either specialist certification (through an examination) or residency completion (via a formalized curriculum). Obtaining specialist certification by sitting for and passing the board examination is a common goal of many residency programs. Consequently, the DSP is a critical foundational document for the development of residency curricula. The dynamic nature of clinical practice suggests that the advanced clinical competencies for each specialty in this complex health care environment continue to evolve. It is ABPTS' policy that DSP content must be revalidated every 10 years to ensure the KSAs reflect current advanced practice. This revalidation is completed through a practice analysis conducted by each Specialty Council of the ABPTS.17,21,22 When a new or updated DSP is published, ABPTRFE accredited residency programs must show evidence of updating their curriculum to meet the new KSA competencies.20,23 The Description of Residency Practice outlined by ABPTRFE directly incorporates the updated DSP and is a quality indicator for consistent curriculum expectations across residency programs within a specialty area.
Across health professions, variation exists in methods used to establish residency curricula. The purpose of this paper was to describe the practice analysis process used to determine advanced practice specialty competencies in PT, and the implications for the results of that process on the development of PT residency curricula. We present the neurologic specialty practice and its recently updated DSP11 as an example, although all PT residency curricula are based on the same practice analysis process.
METHOD/MODEL DESCRIPTION AND EVALUATION
A practice analysis survey is a well-accepted method in medicine and health-related professions to capture data related to the development of a DSP for certification examinations and residency programs.18,24,25 In order to write the survey, the Subject Matter Expert (SME) panel (refer to Table 2 for SME demographic information) began by reviewing documents that inform entry-level and expert practice, evidence for best neurologic practice, contemporary practice frameworks, professional roles, responsibilities and values, and the specialty revalidation process. These documents included: Guide to Physical Therapist Practice 3.0,26 International Classification of Functioning, Disability and Health model (ICF),27 the 2003 Neurologic Physical Therapy Description of Specialty Practice,28,29 curricula for neurologic residency programs30 and entry level neurologic content in doctor of physical therapy (DPT) programs,31 recent research on novice-expert PT practice,32Professionalism in Physical Therapy: Core Values,33 and revalidation policy and procedures from the ABPTS and current DSPs from other peer specialty areas (Pediatrics, Sports, and Geriatrics).34-37 A consensus process was used to write task statements for the knowledge and skill competency areas that represent contemporary neurologic specialty practice and would ultimately comprise items on the practice analysis survey.
The survey was organized into 7 sections. These included: (1) the patient/client management model; (2) professional roles, responsibilities, and values; (3) tests/measures and interventions; (4) knowledge areas of specialty practice; (5) recommendations for board examination content; (6) percentile rankings of neurologic conditions treated; and (7) demographic information. For each competency task statement in sections 1–4, respondents were asked to rate the statement along 3 dimensions: frequency of the knowledge and skill used for specialty practice, the importance of the knowledge and skill to specialty practice, and the level of judgment related to the task for specialty practice (Table 3). Section 5 requested weighted estimates (100% total) for major topics (knowledge areas, professional roles/responsibilities, patient/client examination, intervention, and outcomes) on the certification examination. In sections 6 and 7, respondents estimated the percentage distribution (total = 100%) of specific diagnostic groups in their own caseloads and provided demographic information.
The survey was reviewed and approved by the ABPTS and then administered as a pilot to 25 board certified specialists. In addition to completing the full survey, these individuals were asked to comment on clarity of the task statements and specialty practice knowledge areas and identify any new competencies omitted from the survey. The feedback from this group identified no new areas of competency and made minor suggestions for clarity.
The final survey was divided into 3 portions for final administration, as recommended by ABPTS procedures for practice analysis. All respondents were asked to complete 1 of 2 content sections (section 1 and 2, or section 3 and 4) and sections 5–7 of the survey. Respondents also had the option of completing the full survey. To optimize survey response rates, an email announcement was sent to the sample 2 weeks prior to the survey release and then followed by reminder emails at 2, 4, and 6 weeks after the initial request.
Data Analysis: Consensus Process and Decision Rules
The analysis included review of the survey data for completeness, calculation of mean and median values for each task statement, frequencies, and correlation among the survey domains for sections 1–4. Decision rules were agreed upon by SME panel a priori for analysis of survey data. The distribution of survey data for sections 1–4 were negatively skewed, as most responses for the Importance and Level of Judgment categories were rated as a 2 or 3 (moderately important or very important; and application or analysis, respectively) and the median rating was higher than the mean rating for each category. Due to this skewed distribution, the SME panel decided to utilize sample frequency distributions for each item as the basis for applying these decision rules. A number of different rule options were considered until the task force came to a consensus on the optimal set of decision rules prospectively, and these rules were then applied to the full data set. The final decision rules utilized by the SME panel were as follows:
- First Rule: Task statements scored as a 2 or 3 rating for Importance or Judgment by at least 70% of more of the respondents were included in the DSP.
- Second Rule: For those task statements identified for inclusion based on the first rule, a reported Frequency of greater than 0 (never) by at least 70% of the respondents was necessary for inclusion of the item in the DSP.
Applying these decision rules, the SME panel reviewed survey data from sections 1 through 4 to identify task statements that met the criteria for inclusion in the DSP and those requiring further review for exclusion. Task statements that did not meet the inclusion criteria were discussed in depth before exclusion; thus, these exclusions were consensus based. The rationale for excluding a task statement was primarily due to the following: (1) the statement did not meet decision rules, (2) limited use of particular knowledge area or skill in neurologic clinical specialist practice, (3) the knowledge or skill was considered more reflective of current entry-level practice as opposed to specialist practice, or (4) the competency did not discriminate between specialists and nonspecialists.
Final survey results were translated into an organized DSP structure with statements for specialty knowledge areas, professional responsibilities, and practice competencies using The Guide to Physical Therapist Practice 3.026 as the organizational framework. Competency statements were carefully constructed to use key terms and concepts reflecting advanced knowledge, expertise, and clinical decision-making skills of a neurologic specialist. Once the new DSP was finalized, the SME panel determined the examination content blueprint for the ABPTS-Neurologic Clinical Specialist board examination and the percentage weighting for each competency area on the examination using a consensus decision-making process and survey data, as well as references on examination weighting from the previous 2004 neurologic DSP and other currently published DSPs in peer ABPTS specialties.28,34-37
Survey data were collected from 131 respondents (response rate = 13%) who were all neurologic clinical specialists. The response rate for noncertified therapists was extremely low (N = 11, or 1%). Therefore, only survey data from specialists were used in data analysis to determine the KSA of a neurologic clinical specialist. Specialist respondents’ demographic characteristics and professional background data are depicted in Figures 1–4 and are a consistent representation of neurologic clinical specialists. Comprehensive statistics on respondents can be found in the 2016 Neurologic Physical Therapy, Description of Specialty Practice.14
Survey Findings and Analysis
Based on the analysis of survey data using the decision rules set in advance, all items in sections 1 and 2 of the survey met the inclusion criteria. For section 3, items that were excluded in Tests and Measures were related to kinetic and kinematic computerized gait analysis, neuromotor development, and sensory integration. For section 4, Foundational Sciences, anatomy, physiology, and pathology of gastrointestinal, genitourinary, and endocrine systems were excluded, as well as physiologic response to substance abuse, models of behavioral change, basic research methods (qualitative and quantitative methods) and statistical models of data analysis. These knowledge areas are now included in entry-level professional education and are no longer exclusive to the specialist. Based on survey results and analysis, several new knowledge and skill areas were identified. Table 4 summarizes the major additions to the DSP per domain. The reader is referred to the updated DSP-Neurology (2016)14 for complete content outline of KSA of the neurologic clinical specialist.
Table 5 provides examples of new task statements resulting from the practice analysis. These statements are consistent with evolving knowledge areas of specialist practice in the clinical sciences, application of the ICF Model to clinical decision making, expanded expectations in patient/client education, knowledge and application of emerging technologies, and increased roles of the specialist in collaborative care management; prevention, wellness and health promotion; and social responsibility and advocacy. Significant modifications were made to some of the task statements from the 2004 Neurologic Practice DSP, with new language reflecting specialist practice and demonstrating the breadth of roles and responsibilities.14,28 Within some domains, which have expanded or developed since the previous DSP, greater detail was provided for examination, evaluation, and intervention knowledge and skill areas. Table 6 provides a few comparisons of these modifications in task statements. Finally, the blueprint for the Neurologic Specialty Examination was determined by the SME panel (Table 7). Compared with the 2004 Neurologic DSP, the number of examination questions allocated to the knowledge (vs practice) area increased, reflective of expanding foundational knowledge that guides specialty practice.
The outcomes of this practice analysis represent the ongoing changes in neurologic specialist practice, evolving knowledge areas, application of emerging technologies, and expanded role expectations of the specialist.14 The analysis results provide direction for curricular revisions in accredited neurologic residency programs and a framework for curricular development for new neurologic residency programs.
Within the PT profession, there are several methods described to identify core competencies.25,35,38,39 Doctor of Physical Therapy professional education curricula are guided by the Commission on Accreditation in Physical Therapy Education (CAPTE) standards and postsecondary institutional requirements. Revision of the CAPTE Standards for Accreditation occurs approximately every 5 years. The Commission seeks comment from stakeholders (e.g., program directors, institutional administrators, APTA leadership, PT practitioners) about the sufficiency of the current standards as an evaluation tool and whether they adequately prepare students for current clinical practice. Comments are reviewed and, if deemed appropriate, result in a draft of revisions. These revisions are assessed and reworked internally. The recommended standards are then distributed to communities of interest, and at least one public hearing is held. Based on the input from these various internal and external constituencies, CAPTE finalizes the revisions and votes on their adoption.38
This paper describes a very different method of guiding curricula and learning outcomes for accredited postprofessional residency curriculum. The process for revalidation of specialty competencies combines the expertise and consensus procedures used by a SME panel with quantitative (survey) data that represent current specialty practice. The Federation of State Boards of Physical Therapy (FSBPT) uses a very similar practice analysis process to determine the blueprint for the National Physical Therapy Board Examination, which arguably influences the DPT curricula development and revisions.25 Additionally, a comparable practice analysis process is used as basis for defining knowledge and skills for residency curricula in PT residencies that do not currently have an established DSP through the ABPTS.39 The framework of these practice analyses is not consistent, and the practice analysis methods vary.25,35-40 Although we are using practice analyses to determine competencies within various stages of PT education (vs expert consensus), there does not appear to be a general consensus of the best methods to conduct a practice analysis or an established framework from which these analyses should be conducted.40
A need to establish competencies across the continuum of PT education from entry-level to residency and fellowship postprofessional education has been proposed.40,41 Jensen et al41 suggested developing a “foundational framework for professional performance standards” through the mutual collaboration of the APTA, ABPTS, ABPTRFE, and the American Council of Academic Physical Therapy. The inclusion of the FSBPT and CAPTE would be beneficial in this collaboration since they identify the current standards for entry-level physical therapists on a regular basis.25,38 Systematic and periodic assessment of such performance standards across the spectrum of PT education will continue to be important to distinguish specialist from entry-level practice.
A conscious effort was made by the SME panel to describe the clinical reasoning and critical inquiry skills that underlie specialist practice. This process highlights the benefit of combining consensus-based decisions with the quantitative practice analysis data. For example, the new DSP describes the clinician who can synthesize and interpret complex examination data, use clinical reasoning skills to fully understand important interrelated elements based on a patient's life context, and prioritize interventions.14 Also important is the specialist's ability to critically analyze and translate evidence into clinical practice, thereby promoting optimal patient outcomes. Finally, the updated neurologic DSP distinguished important expanded professional roles of the specialist in advocacy, leadership, and in prevention, wellness, and health promotion. These changes in neurologic practice highlight the dynamic health care climate and the advancement of skills that define specialty practice. As a result, it is expected that neurologic specialists will continue to advance clinical practice by integrating evidence into practice, engaging in collaborative clinical research, and using knowledge translation strategies to act as change agents. Residency programs should design structured learning experiences and mentoring opportunities to develop and assess these higher level competencies.
A practice analysis process has limitations that should be considered as the profession moves forward with this work. This practice analysis of neurologic specialty practice was limited by: (1) a low survey response rate despite dividing it into 3 parts in an effort to reduce the time burden; (2) a low percentage of respondents who work in home health care or skilled nursing facilities; (3) a low response rate of nonspecialists that precluded comparisons between specialist and nonspecialists in survey respondents; and (4) the possibility of inherent bias in the SME group analysis. The 13% response rate from neurologic clinical specialists is similar to other published web-based practice analysis surveys in the health professions, including athletic trainers (18%),42 physician assistants (13.4%),43 registered nurses (27.9%),44 and licensed practical or vocational nurses (10.5%).45 It also reflects a trend of lower response rates for practice analysis surveys among PT specialties, including the most recent orthopedic and sports practice analyses with respective rates of 33% and 23%.34,35,46 The International Association for Medical Education (AMEE) identified challenges related to health care providers’ level of participation in surveys and published a guide in 2016 for improving response rates and evaluating nonresponse bias in surveys.47 The authors suggest that survey response rates may be improved by offering small incentives to all who complete the survey (vs a larger incentive to a few through a lottery drawing, as was done in this practice analysis survey) and making the electronic survey compatible with mobile devices (vs requiring a computer).47 Future practice analysis committees may want to consider incorporating the suggestions recommended by the AMEE to improve overall survey response rates.
The low percentage of survey respondents who work in home health care or skilled nursing facilities was consistent with the 2.4% of board certified NCSs who are working in long-term care and skilled nursing facilities, 1.9% working in home health, and 0% in nursing homes (Derek D. Stepp, Director, Postprofessional Credentialing, APTA; email communication; August 29, 2018). In this survey analysis, we have captured 96.6% of the neurologic practice areas, which suggests that these data are a robust sampling of neurologic specialty practice settings. The low response rate of nonspecialists was also typical and similar to the response rates for nonspecialists in recent ABPTS practice analysis surveys, which ranged from 1% to <2%.14,46 Since the primary aim of the ABPTS practice analysis survey is to identify current specialty practice, not to differentiate specialists from nonspecialists, the data collected from nonspecialists has not been included in the final DSP for specialties with a low nonspecialist response rate and is no longer a requirement of ABPTS revalidation surveys (Derek D. Stepp, Director, Postprofessional Credentialing, APTA; email communication; August 29, 2018).14,46 Finally, the inclusion of quantitative data provided by the practice analysis survey and the application of the a priori decision rules during the data analysis minimizes SME group bias.
Postprofessional education and competencies would benefit from a consistent framework and assessment process. The research on the effectiveness of each is limited. Further standardization and examination of how residency programs integrate DSP KSAs into curricula and outcomes could assist in validation of specialist practice. The identification of shared domains would set the stage for the development of core competencies across residency curricula, in addition to specialty specific KSAs defined by the DSP. Indeed, the need for critical examination and development of established standards and frameworks across all practice analyses within our profession would be instructive. Furthermore, the establishment of core competencies across the educational continuum, from the entry-level practitioner to the postentry level residency and fellowship graduate, would support assessment of the practitioner's readiness to enter a residency program and their advancing level of competence. This recommendation is in alignment with the Core Entrustable Professional Activities for Entering Residency developed in medicine and has been recommended elsewhere in the PT literature.40,41,48,49
The recent practice analysis, combining expert consensus and quantitative methods, provided a systematic approach to update the Neurologic Description of Specialty Practice and residency curricular guidelines. There are variable processes used in the PT profession to determine accreditation standards for entry-level programs and residencies. The profession may benefit from standardization of language, processes, and competencies to assist with delineating the ever-changing continuum of skills of entry-level practitioners to those expected from residents and clinical specialists.
The authors would like to acknowledge Don Straube, PT, PhD as consultant and Kathryn E. Brown, PT, MS and Diane Wrisley, PT, PhD as Subject Matter Expert panel members for their contributions to the practice analysis study and the development of the Description of Specialty Practice-Neurology (2016).
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