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METHOD/MODEL PRESENTATION

A Theoretical Framework and Process for Implementing a Spiral Integrated Curriculum in a Physical Therapist Education Program

Jette, Diane U. PT, DPT, DSc, FAPTA; Macauley, Kelly PT, DPT, EdD; Levangie, Pamela K. PT, DPT, DSc, FAPTA

Author Information
Journal of Physical Therapy Education: September 2020 - Volume 34 - Issue 3 - p 206-214
doi: 10.1097/JTE.0000000000000136
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Abstract

BACKGROUND AND PURPOSE

In 2012, the Doctoral of Physical Therapy (DPT) program faculty at the MGH Institute decided to develop a new curriculum in the spirit of continuous quality improvement. Graduate outcomes were excellent, and the program was both respected and highly rated. However, the faculty saw an opportunity not only for improvement but also for innovation in curricular design and delivery. The existing curriculum was traditional in nature with content-specific courses such as anatomy, orthotics, neuroscience, and pharmacology. In most semesters, students took 8 separate courses, many bearing only 1 or 2 credits. The rationale for change included what we considered shortcomings of the existing model: course content was siloed, students were spending far too much time in class to the detriment of self-directed learning, and there was unwarranted repetition of content. General concerns about the traditional curricular model also included students' emphasis on superficial learning in an effort to pass numerous examinations across multiple courses and learning factual knowledge in isolation.1,2 This type of approach limits learning in that new knowledge is not contextualized and is easily forgotten.3 Also, when topics are taught in isolation, students may have difficulty in seeing the relevance of information they are asked to learn and experience problems using it in clinical decision making.2 Faculty agreed that they wanted to bring more current learning theory with active learning strategies to their classes and that such changes would be facilitated by an overall change in the curriculum. The primary basis for the curricular change, therefore, was that the learning structure and environment created by the traditional curriculum was suboptimal and could be improved by implementing a new model. The purpose of this article is to describe a new curricular model framed within theoretical perspectives on learning, including cognitive load theory and constructivism. We also describe how we structured decisions about curriculum at the program, course, session, and assessment levels.

Learning Theories

Cognitive Load Theory

Cognitive load theory was developed in the 1980s by John Sweller.4 Cognitive load theory states that learners have limits on the amount of information that they can process at one time.5 Stimuli (visual, auditory, tactile, etc.) are received into sensory memory from the surrounding environment.6 If the stimulus is attended to, then it is processed in working memory. If the stimulus is ignored, it is lost within seconds. The information must be encoded in working memory, and then it transfers to long-term memory. In order to ensure retention, the information needs to be retrieved from long-term memory and used in working memory periodically.7 Although most researchers agree that the capacity of a learner's sensory memory and long-term memory is limitless,6,8-10 the amount of information held and processed in a learner's working memory at one time is restricted.10-12 The limits are not particularly relevant when attempting to learn straightforward tasks but rather when attempting to integrate complex information.8,9,13 In physical therapist education, students are required to integrate information across different subjects throughout much of the curriculum, making cognitive load an important concept to consider in curricular design. Our traditional curriculum required students to attempt to learn content in 6–8 courses at a time, each with multiple discrete pieces of information of varying complexity. Additionally, each course gave inconsistent amounts of in-class time to practice or retrieve information, and the students were in class for at least 8 hours a day on most days, limiting learning opportunities outside of class.

There was a large volume of information in our traditional curriculum, which consisted of both “need to know” and “nice to know” pieces of information across multiple subjects simultaneously. This volume of information further increased cognitive load due to parallel, largely unintegrated streams of information from the various courses. The expertise of the learner was not considered consistently when presenting information, in that information was not consistently scaffolded for novices to facilitate learning. Additionally, information was presented with limited modalities. For example, most preparatory material was chapter reading and class time consisted of lecture based on PowerPoint slides, straining working memory.13 All of these aspects of the curriculum taxed the learners' cognitive load, thereby making it difficult for students to learn.

Constructivism

Constructivism has 2 domains: cognitive or personal/individual constructivism and social constructivism.14 Individual constructivism was first introduced by Piaget and has evolved over time based on several psychologists' contributions.15 Individual constructivism focuses on personal knowledge creation.14 Social constructivism is largely attributed to Vygotsky and emphasizes the importance of the social environment for learning.14 We recognize the value of both individual and social constructivism and infused both schools into our curricular design.

Constructivism centers on teaching for understanding16 and therefore focuses on how students learn, not what they learn.17 Constructivism recognizes that students possess preexisting experiences and knowledge, and the goal of education is to build on that foundation.18 Students manipulate new information and reconstruct it within their own experiences and prior knowledge in order to learn.16 Constructivism requires students to actively reflect and engage in a metacognitive process.16,18 Therefore, an important premise in constructivism is that students must be actively engaged to learn. Learners cannot simply passively receive information and effectively learn. Our traditional curricular structure and primarily lecture-based teaching strategies allowed students to be inactive most of the time, whereas deep learning requires time to manipulate and use information. This was one reason we believed that students were not learning optimally in class and that they needed more time than they realistically had outside of the classroom to manipulate the information.

Constructivism is student centric rather than faculty centric.16,19 Students' input and thoughts are valuable and integral to the learning process, and the traditional focus on content to be covered is reduced.16 Students' comments are explored, and discussion dissuades the notion of there always being right versus wrong answers or approaches to a problem.16,17 Faculty create activities targeting large concepts rather than minute details.17,18 Constructivism recognizes that learning is individual and occurs at a different pace for each learner.17

The instructor plays the role of a facilitator in constructivism.16,20 Students control what they learn, educators “develop classroom practices and negotiate the curriculum to enhance the likelihood of student learning.”17(p.20) A constructivist teacher structures activities to challenge students' preexisting knowledge.17 Students test their understanding of new information through discussion with peers and faculty, who may present alternative or opposing viewpoints.16,19 This allows students the opportunity to construct personal meaning regarding the information, which is how learning occurs.16 In this sense, learning is a social process.19,21 Additionally, this makes learning an iterative process where learners constantly take in increasingly complex information, which they compare with their own knowledge, modifying or refuting preexisting thoughts.18 Participating in the constructivism process is much more difficult in a lecture-based curriculum than in a participatory learning environment.

MODEL/METHOD

Integrated Curriculum Model

To better incorporate learning theories in the classroom and address some of the concerns about the traditional curriculum, a new curricular model was conceptualized based on the key notion of integration, eliminating siloed courses, and organizing course content around unifying concepts.22 Brauer and Ferguson23 described 3 types of integration found in the medical education literature. Horizontal integration refers to combining content from separate courses into one, often the foundational sciences. Vertical integration is accomplished by teaching basic sciences and clinical sciences together over time. Spiral integration includes both vertical and horizontal integration in conjunction with iterative and deepening reconsideration of previously learned information over time.23,24 The conceptual framework for spiral integration evolved from the seminal work of Bruner in constructivism in 1960.25 He postulated that learning was enhanced by organizing content around themes that emphasized the relationships of information and progressed from simple to complex. He also noted the importance of continually revisiting and building upon previous knowledge to enhance learning.

Harden and Stamper24 noted that the term “spiral curriculum” was mentioned in the medical literature as early as 1972; likewise, the number of references in the health and life sciences subject areas using the term “integrated curriculum” has increased substantially since 1995.23 One of the first mentions of a spiral, integrated curriculum in physical therapy education was by May in 1977.26 Citing Bruner's work, she described a curriculum in a baccalaureate program designed around 5 themes, with learning experiences sequenced from simple to complex. In 2009, Weddle and Sellheim27 described an “integrative” physical therapist education curricular model at Saint Catherine University. They noted that in their model, “content is presented in an iterative or spiraling fashion.”27(p 14) Their curriculum included students' taking 1 course at a time, each for 5–6 weeks.27 Their courses are organized around practice setting, whereas curricular content is organized into streams (medical and behavioral science; practice environment; examination, evaluation, diagnosis; and plan of care) that are integrated into all courses.27 As we considered a model for our new curriculum, we had the opportunity to meet and consult with the faculty at Saint Catherine University. We also met with colleagues at Arcadia University who have an integrated curriculum organized into 20, 3-week, patient-based units that incorporate content from biomedical sciences, physical therapy, patient examination and intervention, and integrative care. These curricula provided us with a basis for discussion and a vision of possible outcomes for our new curriculum.

Approach to Curriculum Development

In spite of the substantial literature addressing integrated curricula, Goldman and Schroth28 noted that both a clear understanding of the purpose of curricular integration and a conceptual framework for organizing an integrated curriculum were often lacking. They cited the necessity of a systematic approach and conceptual framework for curriculum development to maximize the potential of integration. They proposed a framework that considers curricular integration initially at the program level, then at the course level, and finally at the session level. Table 1 demonstrates how we used this framework to guide the development of the curriculum that was implemented in 2016.

Table 1. - Organizing Framework for Developing an Integrated Curriculum
Questions Decisions
Program level
 What is the purpose of an integrated curriculum? To graduate physical therapists who could meet the needs of the patients they would care for
Improve students' learning experiences by applying more adult learning theory
Reduce time spent in class
Reduce cognitive load
Facilitate deep and applied learning
Help students to see patients holistically
 What is integrated? Knowledge, skills
 When does integration occur? Within and across courses, over time
 Where does integration occur? Class sessions, integrated clinical education experiences, seminars
 How does integration occur? Body systems and impairments
Course level
 Course objectives? Emphasis on apply, analyze, evaluate, create
 Course sequence? Similar across courses but focused on different body systems and impairments
 Course content? Broad concepts to specific, applied at increasingly complex levels
 How does integration occur? Exemplary cases reflecting holistic view of patient/client
 Who is responsible Faculty teams of 2–3 with different expertise
Session level
 How do students prepare? Assign reading or other media, provide guiding questions
Outline planned learning activities and share with students
Develop session objectives
 How are knowledge and skills linked? Reference learning from previous courses, sessions, or clinical experiences
 How are learners engaged? Use cases and provide the patients' story
Assign small group activities in practice and problem solving
Use low stakes, nongraded quizzes to stimulate discussion and check depth of knowledge
 Who is responsible? Individual faculty, faculty teams, and/or laboratory assistants
Assessment level
 Types? Written objective examinations, practical examinations, knowledge checks for each course
 Content? Authentic, based on cases
 How are assessments integrated? Comprehensive written objective examinations, practical examinations at end of each semester reflecting content from all courses
 How are students graded? Each course grade partly determined by end-of-semester comprehensive written and practical examinations

Program Level

Program-level decisions were related to what our purpose was in developing an integrated curriculum, what elements of the curriculum we wished to integrate, the parameters for integration, the learning environments in which integration would occur, and the principles or themes of integration. Our overall purpose was to graduate physical therapists who could better meet their patients' needs. An advisory group of local physical therapy leaders and employers assisted us in this consideration, creating a model of the ideal novice clinician that was independently confirmed by our faculty in a separate process (Figure 1). The model both guided and supported our emphasis on individual and social constructivism because most attributes were about the “how” rather than the “what” of practice. Other considerations were to improve students' learning experiences by applying contemporary learning theory, reducing time spent in class, reducing cognitive load, and facilitating deep and applied learning using constructivism principles. Another important goal was to help students to see patients holistically by integrating learning about various body systems and psychosocial and behavioral issues using patient narratives throughout the program. It was also important that students be able to transfer information from the classroom to the clinical setting and from one practice area to another. We agreed that we wanted to integrate the foundational, behavioral, and clinical sciences both within and across courses (Table 2). To that end, faculty worked together to develop a plan for course content, sequencing and timing, and strategies for integration of topics across courses.

Figure 1.
Figure 1.:
Ideal Novice Clinician. CDM = clinical decision making
Table 2. - Content Integration
Type of Content Specific Course Content
Foundational sciences Anatomy
Physiology
Exercise physiology
Biomechanics/kinesiology
Neuroscience
Pathology
Pharmacology
Genetics
Histology
Nutrition
Imaging
Clinical sciences Cardiovascular/pulmonary
Lymphatic
Endocrine/metabolic
Immune
Gastrointestinal/hepatic
Genitourinary/reproductive
Hematological
Integumentary
Musculoskeletal
Neuromuscular
Behavioral sciences Communication
Psychosocial factors
Teaching and learning
Health policy and management Leadership
Systems thinking
Advocacy
Laws/regulations/practice
Threads Professionalism
Evidence-based practice
Interprofessional practice
Clinical decision making
Human movement system

Course Level

Course-level integration mirrored program-level integration in that every course integrated foundational, clinical, and behavioral sciences and each of the curricular threads. Furthermore, faculty considered the course objectives, how they might overlap and develop over time across courses, and implications for teaching assignments and class schedules. We determined that even early course objectives would include the higher levels of Bloom's modified taxonomy,29,30 including “apply,” “analyze,” “evaluate,” and “create” in the cognitive domain. Objectives also reflected some of the higher levels of the psychomotor and affective domains. Course-level integration was accomplished by several means. Faculty teams of 2 or 3 representing different areas of expertise worked together to determine the unifying themes of a course and how information would be integrated across the foundational, behavioral, and clinical sciences. The teams determined the specific course content based on the emphasis of the course, objectives, and appropriate sequencing. The teams developed patient narratives that supported spiral integration and course objectives by beginning with a patient's story, including social context and information about the patient's reasons for seeking care rather than a medical profile. Teams from different courses also worked with each other to determine what knowledge and skills students might be able to build upon with each subsequent course. We believed that the various strategies would help to reduce the cognitive load for students.

Session Level

Session-level integration occurred within individual class sessions. Objectives for each session were developed by the course team, taking into consideration such issues as how previously learned information would be stimulated and incorporated, how students would actively engage in achieving objectives, and how social constructivism would come into play. Faculty assigned to teach a session determined what students needed as background information to be prepared for session activities, what options existed for students to obtain that information, and what teaching strategies and learning activities would be employed during the session. Faculty also determined which patient narratives or more traditional patient cases would contextualize students' learning and draw on their previous learning. During a session, students typically worked in small groups, using the narrative as a starting point, analyzing the relevance of given information, and justifying the need for further information. New data might be provided sequentially as the narrative unfolded in that session, as students worked to address increasingly complex and ambiguous concerns. Faculty were asked to develop explicit, written lesson plans for their own use and translated these to session organizers for the students detailing the objectives for the session, the preparatory work required, and the session's learning activities.

Assessment Level

Assessment-level integration was also considered important to meeting our goals, although outside of the framework proposed by Goldman and Schroth.28 Decisions were made by the faculty as a whole as to how students were to be assessed, how course content would be integrated for the assessments, and how the assessments would be reflected in course grades. Faculty worked in teams to develop the assessments.

Curriculum Structure

The curriculum we developed was unique in its structure and its processes. Table 3 illustrates the curricular plan implemented using the principles described in this article. Three early courses in fundamentals of patient/client management engaged students in learning frameworks for clinical decision making and the sciences needed to support basic understanding of the steps in the patient/client management model. These courses serve as examples of the spiral curricular model. The first course included (1) foundational sciences such as principles of biomechanics and theories of motor control; (2) clinical sciences such as task analysis, patient/client management models, and clinical decision-making models; and (3) behavioral sciences such as elements of interprofessional team practice and patient/client communication approaches. The second course similarly incorporated foundational, clinical, and behavioral sciences, such as (1) the inflammatory process and connective tissue behavior; (2) patient handling skills in elementary patient examination strategies; and (3) strategies for evoking an effective patient interview, respectively. Examples for the third patient/client management course include (1) neuroscience of the sensorimotor (foundational science); (2) examination of static and dynamic balance (clinical science); and (3) key psychological and cognitive elements that affect patient/client management.

Table 3. - Curriculum Plan
Credits
Year 1—Summer semestera
 4 weeks Fundamentals of patient/client management 1 6
 4 weeks Fundamentals of patient/client management 2 6
Year 1—Fall semestera,b
 4 weeks Fundamentals of patient/client management 3 6
 4 weeks Patient/client management: cardiovascular and pulmonary 1 6
 4 weeks Patient/client management: cardiovascular and pulmonary 2 6
Interprofessional practice 1
Year 1—Spring semestera,b
 4 weeks Patient/client management: hip/lumbopelvic region 6
 4 weeks Patient/client management: lower extremity/gait 6
 4 weeks Patient/client management: head/neck 6
Interprofessional project 1
Year 2—Summer semestera
 4 weeks Patient/client management: upper extremity 6
 10 weeks Clinical experience I 3
Year 2—Fall semestera,b
 4 weeks Patient/client management: balance 6
 4 weeks Patient/client management: acquired brain dysfunction 6
 4 weeks Patient/client management: degenerative disease/lifespan 6
Capstone initiation 0
Year 2—Spring semestera
 4 weeks Patient/client management: spinal cord injury/amputation 6
Capstone continuation 0
 10 weeks Clinical experience 2 3
Year 3—Summer semestera
 4 weeks Patient/client management: contextual factors 3
 4 weeks Health policy, practice, leadership 3
Capstone completion 2
Electives(s) 2
Interprofessional ethics 1
Year 3—Fall semester
 14 weeks Clinical internship 5
Post-graduation
 8 months Clinical internship (continued) Not applicable
aIncluding 2 hours per week of integrative seminar across the semester.
bIncluding half day per week integrated clinical education experience (ICE) across the semester.

In subsequent courses during the first and second years, students gained deeper understanding of systems-related issues while continuing to build and reinforce knowledge of foundational, clinical, and behavioral sciences that support evidence-based, person-centered care. In the final summer of the curriculum, students learned how to manage complex patient problems while gaining greater depth of knowledge of the micro- and macrosystems within which health services are delivered. Students were also engaged in a multisemester, team-based capstone project that resulted in a written paper and professional presentation. Options for capstone projects included conducting a systematic review, working with a faculty member on their research, conducting a community-based health promotion activity, consulting with a clinical partner to address a practice-based concern, or participating in an international service learning project. In the final semester, students had the opportunity to take 1 or 2 elective courses such as vestibular rehabilitation, women's health, or adaptive sports. In addition to taking physical therapy courses, students interacted with those in other programs at the institution in required interprofessional classes, practice experiences, and projects spread across the curriculum.

Because we had to fit the curriculum within a typical semester time frame, students took 3 courses in a typical fall or spring semester, and 2 courses in a summer semester, one at a time. Foundational, behavioral, and clinical sciences were included in all but 1 course at the end of the curriculum that focused on health policy and practice management issues. Part-time integrated clinical education experiences (ICE) at local clinical sites were integrated into courses across most semesters as half day, 4-hour experiences that typically included cognitive, affective, and psychomotor skills building. All courses also included an additional 2-hour weekly on-campus seminar designed to integrate students' most recent learning. The seminars were typically facilitated by clinical faculty who were also the ICE clinical instructors. Consistent with constructivism, the seminars facilitated connections between classroom learning and ICE experiences. Similar to the original curriculum, 3 full-time clinical education courses were embedded into the curriculum, the last one progressing into a postgraduation, year-long, paid internship for most students. This internship model has been previously described.31

Assessment comprised 3 “knowledge checks,” 1 written examination, and 1 practical examination during each 4-week course. The knowledge checks could take on different forms (eg, quizzes, documentation assignments, skills checks) based on the instructors' course design; the knowledge checks always accounted for a total of 30% of the grade in each course. A written and a practical examination each comprised 20% (for a total of 40%) of the course grade and were completed at the end of each 4-week course. Consequently, at the end of each course in a semester, students had accumulated only 70% of their grade for that course. At the end of each semester, students were given a comprehensive written and comprehensive practical examination that assessed learning across all the courses in the semester. Grades for these examinations comprised 15% of students' grades for each of the semester's courses. Therefore, students did not receive final grades for any of the courses within a semester until the comprehensive examinations were completed, contributing the final 30% of each course grade. Finally, after all academic coursework was concluded in Summer of Year 3, students undertook a summative, case-based written and practical examination that assessed learning across all courses in the curriculum. These 2 comprehensive examinations and the capstone project were each graded as pass or fail, and students had to pass all 3 to continue into the final clinical education experience (Table 4).

Table 4. - Assessment Components
Contribution to Each Course Grade
Each 4-week course
 3 knowledge checks assessing course-specific knowledge/skills 30%
 1 course written examination assessing all course-specific knowledge 20%
 1 course practical examination assessing all course-specific behaviors and skills 20%
  Subtotal for each course 70%
End of each semester
 1 comprehensive written examination assessing knowledge across all semester courses 15%
 1 comprehensive practical examination assessing behaviors and skills across all semester courses 15%
  TOTAL for each course in the semester 100%
End of didactic curriculum
 1 comprehensive case-based written examination assessing knowledge across all courses in curriculum Pass/fail
 1 comprehensive case-based practical examination assessing behaviors and skills across all courses in curriculum Pass/fail
 Capstone project completion Pass/fail

DISCUSSION

Learning Theory and the Spiral Curriculum

As noted by Goldman and Schroth,28 an integrated curriculum is not a goal in itself, it is a strategy to improve students' learning and achieve program goals. To meet our goals at each level of curriculum development, we incorporated the following precepts of a spiral curriculum and learning theory. The model is illustrated in Figure 2.

Figure 2.
Figure 2.:
Curriculum model (Adapted from Harden and Stamper)24

Integration of Content

As noted by Kulasegaram et al,32 integration is more than the structure of the curriculum but reflects the process of learning as students develop understanding of how concepts fit together.2,23,24,27,28,32-34 We intentionally started this process at the beginning of the curriculum, as training broad concepts leads to improved retention and transfer of information.13,16-18 As infusing context and accounting for the environment are important components of constructivism,16,35 foundational, behavioral, and clinical sciences and our curricular threads were integrated and contextualized through the use of patient narratives and traditional cases. The integration process can be exemplified by sample elements from one of the first courses in the curriculum in which the patient narrative was about an individual with a primary injury to the knee. Students learned knee anatomy, physiology of the inflammatory process, and the response of tissues to applied stresses (foundational science). They applied their understanding of the patient/client management model to determine what they wanted to gain from the patient interview, how the patient's societal role might impact their plan, what they wanted to observe as the patient moved given the injury, and what their next steps might be for clinical management (clinical science and behavioral science). Students planned and conducted an examination of knee range of motion using reliable methods, effective communication, and safety principles (clinical science and behavioral science). Our 5 curricular threads were contextualized through the case and learning activities. Students learned how knee pain and limitations to range of motion affect the patient's role and what impaired motion looks like (the human movement system). They learned how what one knows about the patient and patient's injury affect examination, evaluation, and prognosis (clinical decision-making). Students were required to seek and find literature about the effectiveness of conservative treatment of an anterior cruciate ligament tear (evidence-based practice). They applied interpersonal communication skills to gain the patient's trust and assessed their own performance based on professional behavior expectations (professionalism). Finally, they interacted with other members of the patient's team based on an understanding of their role in meeting the patient's goals (interprofessional collaborative practice).

Patient narratives allowed students to learn how these sciences underpinned clinical decisions. Scaffolding and examples were employed to promote long-term learning by reducing cognitive load.9,10 Faculty worked in teams within courses to take advantage of their various areas of expertise and increase multidimensional approaches to patients. Explicit content linkages were made between courses and across sessions within courses. Learning activities required students to engage in the effort of making inferences, to generalize information to new situations, to identify commonalities across problems, and to draw conclusions applicable across disciplines considering the context of a problem. This deliberate practice was used to help students build schema and solidify concepts into long-term memory.36

Explicit Iterative Learning

Building on previous knowledge, topics and themes were deliberately revisited over time, with deepening levels of understanding and synthesis required by students with each encounter.2,23,24,37 Consistent with constructivist theory, new learning was explicitly related to previous learning, including life experiences, clinical encounters, and classroom activities. Students' knowledge, skills, and behaviors were reinforced or adapted with continuing exposure and feedback, moving from simple to complex scenarios. This process required students to consistently retrieve information from long-term memory and relate it to new content, facilitating learning and transfer of knowledge to different conditions.7

Emphasis on Depth of Content and Learning Versus Breadth

The curriculum emphasized what a new clinician really needed to know and eliminated nice-to-know and unnecessarily redundant content, thereby minimizing cognitive load.2,37 Cognitive load was further reduced by presenting concepts with an increasing level of difficulty in a controlled manner that was manageable for students. Faculty strategically gave students opportunities to deal with complex problems individually and in small groups, which enhanced flexible and higher-order problem solving, and clinical reasoning. This approach was based on the evidence that this type of iterative learning would allow students to more readily transfer knowledge, skills, and behaviors to new situations and to adapt to complex and ambiguous situations.19 Therefore, we hypothesized that it was unnecessary for students to practice all concepts in all practice settings or with all body systems to ensure learning.

Focus on Motivating Learning

The faculty sought to stimulate students' engagement, curiosity, and level of inquiry by making the context for all information explicit rather than requiring simple memorization of factual knowledge.37 Learning activities focused on deep learning as compared with surface learning and on applying information in order to motivate learning, improve comprehension, and enhance retention over time. Many classroom learning activities were designed to be accomplished in small groups where discussion among classmates could allow students to explore their ideas with their colleagues and test their knowledge, motivate them to delve deeper into solving problems, and solidify the learning process.21

Outcomes Driven

The expected outcomes for our graduates drove the course objectives and session learning experiences, focusing on self-directed learning and higher levels of learning, including applying, analyzing, evaluating, and creating knowledge, rather than on knowledge recall.37 In order to meet our program goals, the new curricular model was accompanied by agreed-upon changes in our approaches to teaching, based on constructivism and cognitive load theory. Faculty reduced time spent on knowledge transfer (ie, lecture) during class sessions and placed more responsibility on students to prepare for class using a variety of resources, including readings or other media and materials prepared by the faculty. Faculty also provided students with a set of guiding questions to help them navigate the depth and breadth of their preparation for each session. Faculty agreed that their role in class sessions would be to assist students to explicitly connect and relate information from various sources and to stimulate thinking by questioning and probing. To accomplish this, faculty developed classroom activities that engaged students in constructing their own knowledge and discovering meaning in their learning. Group activities were used extensively for case-related discussions or elaboration of information, and practical, hands-on learning was interspersed with discussion during many sessions.

Ongoing Curricular Review

The type of curriculum we developed requires in-depth and continuous communication and collaboration among faculty, within courses, across courses within semesters, and across semesters. Course faculty met weekly to discuss progress and implement adjustments as need. Semester faculty groups met at the end of each semester to discuss the structure, process, and outcomes of the courses. Structure questions were related to issues such as whether there was enough time spent on a particular activity, whether the right faculty were in each session, or whether the content was appropriately placed. Process issues included how well students engaged in or understood certain learning activities or how well student small groups worked. Outcomes were discussed in terms of how well students were able to meet the objectives and how well prepared they were for each subsequent course. Both strengths and limitations were discussed and changes planned for the following year. Faculty from one semester then met with the faculty planning the next semester to confirm students' progress and perceived learning needs going forward. These types of discussions are essential in an integrated curriculum to optimize student learning.

CONCLUSION

For those considering an integrated curriculum, we recommend a process that includes reviewing literature on curriculum structure and learning theory, engaging an advisory panel of practicing clinicians and employers to determine their perception of an ideal graduate, determining the institutional resources available to assist faculty in development, verifying institutional structural or procedural requirements that might influence implementation, and using a structured process of decision making to determine levels of integration at the program, course, and session level. In order to break down siloed content and attain desired integration, we recommend faculty work together in teams, across areas of expertise, to develop the curriculum as whole and specific courses and sessions. It is also important for the faculty to derive consensus around a theory-based approach to teaching and to link that theory to curriculum development, classroom environment, and student assessment. We recommend ample faculty development opportunities to support implementing the changes. An ongoing process of communication, collaboration, critical study, and review and revision of the curriculum by the faculty is also imperative to assure excellent student learning experiences, learning environment, and outcomes.

ACKNOWLEDGMENTS

The authors wish to acknowledge the contributions of Janet Callahan, PT, DPT, MS, and Tracy Brudvig, PT, DPT, PhD, who are members of our research team.

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Keywords:

Spiral integrated curriculum, Constructivist learning theory, Cognitive load theory

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