Objectives to Assess Student Readiness for First, Full-Time Clinical Education Experiences in Physical Therapist Education

Abstract

Introduction. 

To date, there is a lack of standardization across physical therapist education programs (PTEPs) in the United States as to what qualifies students to be ready for first, full-time clinical education experiences (CEEs). This study aimed to develop readiness objectives for first, full-time CEEs that will be applicable to all clinical settings, based on input from regional clinical faculty.

Methods. 

Clinical faculty (n = 50) accepted an email invitation from the New England Consortium of Clinical Educators to participate in the study. Academic faculty (n = 20) served as facilitators and scribes during the in-person data collection and also completed the survey. Data saturation and consensus building were used in a 2-round modified-Delphi process. Readiness objectives were developed in-person, during the initial round, using the categories of the American Physical Therapy Association's Clinical Performance Instrument (CPI) and Bloom's Taxonomy to inform the process. The second round of data collection asked participants to rate the previously developed readiness objectives for degree of importance and appropriateness of performance level for first, full-time CEEs. This phase was completed via electronic survey.

Results. 

Participants agreed that 22 readiness objectives were “very important.” Eleven of these readiness objectives were within the affective domain, specifically in the CPI categories of Accountability, Professional Behaviors, Communication, and Cultural Competence. Of the remaining readiness objectives, 5 were directly related to patient safety.

Discussion and Conclusion. 

The results of this study are consistent with other health care professional literatures that indicate clinical faculty prioritize students' behaviors in the affective domain and their ability to maintain patient safety. It is incumbent on the PTEPs to provide students opportunities for development and practice in these areas and assess performance related to these readiness objectives before the first, full-time CEEs. Utilization of these 22 readiness objectives is one method by which PTEPs may meet this expectation.

INTRODUCTION

Students in physical therapy education programs (PTEPs) in the United States are mandated by the Commission on American Physical Therapist Education (CAPTE) to participate in a minimum of 30 weeks of full-time clinical education experiences (CEEs), with the expectation that students achieve a level of performance that is consistent with entry-level performance at the completion of their terminal CEE.¹ Until recently,² there were no recommended standardized, minimum criteria indicating that a physical therapist student in the United States is prepared to participate in a first, full-time CEE. This lack of standardization between PTEPs as to the content or amount of didactic preparation that is required of students before the first, full-time CEEs has been discussed at a national level. At the conclusion of the 2014 American Council of Academic Physical Therapy (ACAPT) Education Summit, the final report³ had a list of harmonization and innovation recommendations. One of the recommendations was to develop standards for first, full-time CEEs. These recommendations were reflected in the Best Practice for Physical Therapist Clinical Education annual report to the House of Delegates in 2017,⁴ which stated that “there is an unwarranted variation in student qualifications, readiness, and performance across the professional educational continuum that impacts academic and clinical faculty's ability to plan and implement a quality educational experience that will optimize patient outcomes.”^(p.45) The CAPTE¹ recognizes the importance of clinical readiness and indicates that the PTEPs must have criteria that indicate if a student is prepared to engage in clinical education. This core understanding of student readiness is not isolated to the physical therapy profession and is reflected in the accreditation mandates for medicine,⁵ nursing,⁶ and pharmacy,⁷ making it the responsibility of academic programs to ensure that students are prepared to perform in the clinical environment.

While there is a move to better prepare students for the clinic, there has been little published on what baseline performances are expected of students before CEEs. Medicine established Core Entrustable Professional Activities (EPAs) requiring students to be proficient in 13 of 13 EPAs on day 1 of the residency, regardless of the specialty. The document describes each EPA with associated critical functions that residents are able to perform at the outset of their residency.⁸ These core competencies have progressive milestones that define the trajectory of a resident from beginning to final stages of residency or fellowship. The outcome of developing these milestones is a common understanding among all stakeholders of the minimum expected performance levels of residents and fellows. In 2015, ACAPT appointed Strategic Initiative Panels, one of which was to determine students' readiness for the first, full-time CEEs. This readiness panel was made up of physical therapy academic faculty, Directors of Clinical Education (DCEs), clinical instructors (CIs), and recent graduates. This panel implemented a Delphi Study methodology,² which identified 95 elements that represent 14 themes describing students' knowledge, skills, attitudes (KSAs), and professional behaviors that should be considered when determining students' readiness to begin their first, full-time CEE.

Based on the existing variation and lack of standardized expectations regarding minimum performance criteria for students' first, full-time CEE, it would benefit the profession to identify the basic KSAs and professional behaviors that are required before students begin their first, full-time CEE. This level of standardization would provide academic institutions with benchmarks to determine students' clinical readiness and clinical sites with clear expectations regarding students' performance at the beginning of the first, full-time CEE. When CIs understand students' baseline KSAs, they are better prepared to create an appropriate learning environment in which students can apply didactic information to the clinical setting.

The purpose of this study, therefore, was to identify what CIs believe should be the minimal competencies and behaviors that students must demonstrate before the start of the first, full-time CEEs. This research defined the start of the CEE as the first day of the second week of the CEE, to allow students time to complete orientation and adjust to procedures specific to the setting and rotation.

METHODS

Participants

The participants for this study included CIs, Site Coordinators of Clinical Education (SCCEs), and DCEs from New England. Participants were recruited via an email invitation to attend a 1-day workshop with the intent of formulating readiness objectives that would indicate students' readiness for the first, full-time CEEs. Email addresses were obtained from the New England Consortium of Clinical Educators (NECCE) databases consisting of SCCEs and CIs affiliated with one or more of the 17 schools within the NECCE. Using the technique of snowball sampling,⁹ the email encouraged recipients to invite colleagues to increase attendance. The workshop was free to all participants. This research was approved by the Institutional Review Board at Quinnipiac University, and all participants signed a consent to participate.

Design

This research used a 2-round consensus building design that is a modified-Delphi methodology. A Delphi survey is a qualitative research method of developing consensus around a specific topic.¹⁰ The initial round of a Delphi study uses structured questions to glean information, which is then reviewed by researchers and presented back to participants for further input. There are 2 additional premises of Delphi studies: 1) participants are experts and 2) survey rounds continue until the level of consensus from one round to the next is stable.¹¹ In this study, the researchers considered CIs and SCCEs to be experts because they understand the demands of the clinical setting and have had experience with multiple students from multiple PTEPs. The research design for this study, however, was considered to be a modified-Delphi design because it was predetermined to consist of only 2 rounds of data collection. The modification for data collection was intentional because this study included time for face-to-face discussions, providing multiple opportunities to revisit and refine objectives. These robust discussions led to a refinement of objectives at the conclusion of the initial round requiring only one additional round for consensus.

The initial round of data collection occurred in conjunction with a workshop in 2016 with structured question prompts (Appendix A, Supplemental Digital Content 1, https://links.lww.com/JOPTE/A85), and the second round of data was gathered through an online survey. The goal of the study was for participants to develop readiness objectives that students must achieve before the start of their first, full-time CEE. Participants used Bloom's Taxonomy^12-14 to guide them as they created clinical readiness objectives at the appropriate level of performance for the first, full-time CEE. These readiness objectives were directly related to 14 of the 18 performance criteria found in the Physical Therapist Clinical Performance Instrument (CPI).¹⁵ The CPI is the instrument most academic institutions use¹⁶ to assess students' performance during their CEEs. Four performance criteria measured by the CPI were eliminated because, in the experience of the researchers, CIs often commented that these were skills that are developed in subsequent CEEs. The performance criteria eliminated for this study included professional development, outcome assessment, financial resources, and supervision of personnel.

The initial round of data collection was conducted at a 1-day workshop consisting of 5 working hours, at which time participants viewed a short presentation about Bloom's Taxonomy. Handouts^12-14 were provided, which included a list of suggested verbs to describe the hierarchy of learning for each of the 3 domains of learning, ie, cognitive, affective and psychomotor. Participants were assigned to 10 small groups of 5–9 CIs and SCCEs from various practice settings to discuss and develop readiness objectives. Each group was assigned to discuss 4 performance criteria. During this phase of the study, 2 DCEs were assigned to each group. The DCEs did not contribute to the discussion; their role was to serve as facilitators and scribes during the discussions. The scribe documented, on standardized forms, the group's discussion and rationale regarding the proposed readiness objectives. The facilitator assured that the discussion remained on task and were provided in advance with 2–3 prompting questions for each performance criterion. The prompting questions (Appendix A, Supplemental Digital Content 1, https://links.lww.com/JOPTE/A85) ensured consistency among groups when discussing proposed readiness objectives.

At the end of the discussion, the CIs and SCCEs changed groups twice during the workshop so they could begin to refine readiness objectives with different participants in the workshop. This was done to maximize participants' input in creating readiness objectives. Using verbs identified in Bloom's Taxonomy,^12-14 participants in each group discussion were asked to write 1–2 readiness objectives related to 4 assigned performance criteria. At the end of the workshop, participants had the opportunity to view and comment on all the readiness objectives created by the groups.

The readiness objectives developed by all groups were reviewed by 1 of the researchers. During this review, the researcher eliminated readiness objectives that were duplicated among groups, and a preliminary list of readiness objectives, associated with the 14 CPI performance criteria, was generated. Then, all researchers reviewed the preliminary list of readiness objectives to determine overlap of content areas. This process culminated in a proposed list of 44 readiness objectives. Once the 44 readiness objectives were developed, it became evident that readiness objectives associated with the performance criteria of “Evaluation” and “Diagnosis and Prognosis” overlapped. Therefore, these 2 performance criteria were collapsed into a single performance criterion. Likewise, the performance criteria of “Procedural Interventions” and “Educational Interventions” were collapsed into a single performance criterion. Table 1 indicates the distribution and reduction of readiness objectives developed throughout this process. Table 2 provides a list of the 44 readiness objectives identified at this step, grouped by performance criteria.

Table 1. - Data Reduction Chart

Performance Criteria	Safety	Prof Beh	Acct	Comm	Cult	Clin Reas	Screen	Exam	Eval	Diag/Prog	PoC	Proc Inter	Educ Inter	Doc	Total
All participants (round 1)	9	8	8	12	6	7	9	11	6	4	10	9	5	4	108
One researcher	4	4	4	6	2	3	4	3	4	2	1	3	3	4	47
All researchers	5	4	4	5	3	3	3	4	4		3	3		3	44
All participants (round 2)	5	4	4	2	1	1	0	1	1		1	2		0	22

Abbreviations: Acct = accountability; Clin Reas = clinical reasoning; Comm = communication; Cult = cultural competence; Diag/Prog = diagnosis/prognosis; Doc = documentation; Educ Inter = educational intervention; Eval = evaluation; Exam = examination; PoC = plan of care; Prof Beh = professional behavior; Proc Inter = procedural intervention; Screen = screening.

Table 2. - Readiness Objectives Organized by Performance Criteria (44)

Safety (5)

Summarize pertinent information from the medical record and physical therapy examination that could potentially impact patient safety.

Explain safety concerns, including red flags, status changes, and precautions, and their potential impact on treatment plan.

Demonstrate safe techniques for guarding and transferring noncomplex patients (or simulated patients) using proper body mechanics.

Demonstrate accurate monitoring of vital signs for noncomplex patients (or simulated patients).

Respond to any red flags, status changes, and/or unexpected reactions to treatment intervention by seeking immediate guidance from CI (or Faculty).

Professional behaviors (4)

Display professional appearance consistent with expectations of various cultures/environments (classroom, lab, clinic, etc.)

Adhere to policies regarding use of electronic and social media such that the privacy and dignity of individuals is maintained.

Engage in meaningful self-reflection as a means to enhance performance.

Respond to feedback from others without defensiveness.

Accountability (4)

Manage personal schedule to be prompt and prepared for all learning experiences.

Respect that patients' needs supersede student's needs/goals.

Acknowledge when s/he does not feel competent or confident with content and seek appropriate assistance.

Accept responsibility for actions and errors, including remediation or reconciliation.

Communication (5)

Listen to all patients, peers, faculty/instructors, and other health care providers with positive regard.

Provide a cogent description of the role of the PT in patient care to patient, family, and other health care providers using appropriate language.

Engage in respectful dialogue with faculty/instructors, peers, and health care providers about professional issues and patient care/management.

Articulate questions to clarify understanding of information, especially in context of patient safety and management.

Express learning goals appropriate to stage of learning and level of skills/knowledge.

Cultural competence (3)

Reflect on own cultural influences and seek to identify one's own biases.

Demonstrate respect and unconditional positive regard for patients/families, faculty/instructors, peers, and health care providers.

Collect information from reliable sources, including patients, to gain greater understanding of patients' cultural preferences and perceptions of health and wellness.

Clinical reasoning (3)

Seek a variety of sources to inform clinical decision making for patient/client management.

Examine the value and limitations of sources of information.

Discuss rationale for clinical decisions regarding examination, evaluation, and plan of care/interventions.

Screening (3)

Summarize findings from chart review, patient interview, and patient observation that are inconsistent with normal presentation and warrant further testing.

Accurately perform basic systems screen for noncomplex patients or simulated patients, using standardized procedures and positions.

Assess results of screening, including whether normal/unimpaired or abnormal/impaired.

Examination (4)

Collect pertinent information from chart review and from patient/family interview for history and current condition.

Select relevant tests and measures for given patient, or simulated patient, presentation and justify rationale for choices.

Accurately perform basic tests and measures (eg, goniometry, MMT, vital signs) for noncomplex patients, or simulated patients, using standardized procedures and positions.

Assess findings from basic tests and measures, including whether normal/unimpaired or abnormal/impaired.

Evaluation, diagnosis and prognosis (4)

Summarize impairments, functional limitations, red flags, and precautions.

Present examination findings in a logical provisional evaluation including a credible provisional diagnosis(es).

Discuss positive and negative factors that may influence patient's, or simulated patient's, prognosis and rehabilitation potential.

Construct provisional physical therapy goals based on patient goals and examination findings.

Plan of care (3)

Outline a provisional plan of care that addresses impairments and functional limitations and includes plans for discharge from physical therapy.

Explain how elements of the plan of care relate to desired goals/outcomes.

Recognize when a treatment plan/intervention needs to be modified (regressed or progressed).

Interventions (3)

Explain desired outcomes/expected responses, indications, and contraindications for common procedural interventions.

Implement common or familiar procedural interventions in a safe manner for noncomplex patients or simulated patients.

Provide effective patient/family education from established plan with noncomplex patients, including verification of patient/family understanding.

Documentation (3)

Describe necessary elements of different forms of documentation (eg, daily encounter, initial evaluation, discharge summary, etc.)

Acknowledge the role of timely documentation as it relates to legal and facility requirements for reimbursement and communication.

Draft selected portions of documentation using professional language.

Abbreviations: CI = clinical instructor; MMT = Manual Muscle Test; PT = physical therapist.

In an effort to maximize feedback from multiple stakeholders, the second round of data collection occurred through an online survey, which was sent to all the participants who attended the workshop, ie, the clinical faculty, who assisted in writing the objectives and the 20 DCEs, who served as scribes and facilitators during the face-to-face discussions. Participants reviewed the proposed 44 readiness objectives, which were listed with the corresponding performance criteria. The survey asked participants to rate each readiness objective for 1) the appropriateness of the expected level of performance for the first, full-time CEEs, and 2) the importance of the students' ability to perform each objective. The rating for expectation was assessed on a 3-point Likert scale asking participants if they felt the readiness objective was written for performance levels that were “too low,” “just right,” or “too high.” The rating regarding the importance of student performance was also assessed on a 3-point Likert scale of “not very important,” “somewhat important,” or “very important.” The survey was open for 3 months with 3 email reminders to complete the survey.

Data Analysis

Round 1—Face-to-Face Workshop

The readiness objectives written at the workshop were initially consolidated by the researchers removing redundancy and using thematic content analysis combining similar themes. Thematic content analysis^11,17 is a common qualitative research technique used in Delphi studies. Initially, one researcher read each of the submitted readiness objectives for all performance criteria and summarized language for similarly themed objectives. Similar content for each performance criterion was grouped together and rewritten. For example, readiness objectives that referenced the need for the student to respond to “patient red flags,” “changes in patient presentation,” and “patient cues related to safety” were rewritten to encompass all these changes. Once these similarly themed objectives were consolidated, all researchers reviewed the list of objectives and further refined the language, making sure that verbs from Bloom's Taxonomy^12-14 were used in each objective. An example of thematic data reduction is provided for the Safety criterion in Appendix B (Supplemental Digital Content 2, https://links.lww.com/JOPTE/A86).

Round 2—Online Survey

The data from the online survey, which included the readiness objectives finalized from round 1 of the study, were analyzed using descriptive statistics. Percentages were calculated for participants' rating of each readiness objective on the 3-point Likert scale for both the expected level of performance and the importance. To identify a readiness objective as necessary for a student to achieve before the start of the first, full-time clinical experience, consensus was required. Consensus was defined as readiness objectives that were rated as both “very important” and “just right” by ≥80% of the survey respondents. We determined ≥80%, as a conservative measure of agreement on the readiness objectives. The literature^11,17 references a range 51%–100% as a commonly accepted threshold for Delphi studies.

RESULTS

Seventy participants attended the workshop, 50 (71%) clinical faculty and 20 (29%) academic faculty. The 50 clinical faculty participating in the workshop represented six different practice settings, including acute care, inpatient rehabilitation, long-term care/skilled nursing facility, outpatient, and school-based pediatrics. Sixty-three participants completed the online survey, for a 90% response rate. Table 3 provides the demographic information related to the participants.

Table 3. - Participants

	Initial Workshop (70)		Final Survey (63)
CIs	19	Clinical faculty: 50	21	Clinical faculty: 47
SCCEs	8		11
CIs/SCCEs (dual role)	23		15
Academic faculty (DCEs)	20	Academic: 20	14	Academic: 14
Not reported			2	Not reported: 2

Abbreviations: CI = clinical instructor; DCE = Directors of Clinical Education; SCCE = Site Coordinators of Clinical Education.

Twenty-two of the 44 readiness objectives were ranked as “very important” by ≥80% of the participants. The list of these final readiness objectives, found in Table 4, is paired with their associated performance criterion and domain of learning. The table also provides the percent response for participants who indicated that the level of expectation for the readiness objectives was “just right.” Greater than 80% of the participants indicated that all 22 readiness objectives indicated a level of expectation that was “just right,” except the objective that stated, “Recognize when a treatment plan/intervention needs to be modified (regressed or progressed).” Five participants rated the objective as written “too low” and nine indicated that the objective was “too high.”

Table 4. - Final 22 Readiness Objectives Ranked by Percent Consensus

CPI Criteria	Bloom's Taxonomy Domain	Objective	Percent Ranking Importance as “Very Important”	Percent Ranking Expectation as “Just Right”
Accountability	Affective	Acknowledge when s/he does not feel competent or confident with content and seek appropriate assistance.	96.8	95.2
Safety	Cognitive	Respond to any red flags, status changes, and/or unexpected reactions to treatment intervention by seeking immediate guidance from CI (or faculty).	96.8	87.3
Safety	Psychomotor	Demonstrate safe techniques for guarding and transferring noncomplex patients (or simulated patients) using proper body mechanics.	95.2	87.1
Safety	Cognitive	Explain safety concerns, including red flags, status changes, and precautions, and their potential impact on treatment plan.	93.5	85.7
Safety	Cognitive	Summarize pertinent information from the medical record and physical therapy examination that could potentially impact patient safety	91.9	84.1
Professional behaviors	Affective	Display professional appearance consistent with expectations of various cultures/environments (classroom, laboratory, clinic, etc.)	91.8	98.4
Communication	Affective	Listen to all patients, peers, faculty/instructors, and other health care providers with positive regard.	90.3	95.2
Cultural competence	Affective	Demonstrate respect and unconditional positive regard for patients/families, faculty/instructors, peers, and health care providers.	90.3	93.7
Accountability	Affective	Accept responsibility for actions and errors, including remediation or reconciliation.	90.3	88.9
Communication	Affective	Articulate questions to clarify understanding of information, especially in context of patient safety and management.	90.3	88.9
Professional behaviors	Affective	Adhere to policies regarding use of electronic and social media such that the privacy and dignity of individuals is maintained.	90.3	85.7
Evaluation, diagnosis/prognosis	Cognitive	Summarize impairments, functional limitations, red flags, and precautions.	90.2	87.1
Professional behaviors	Affective	Respond to feedback from others without defensiveness.	88.7	92.1
Clinical reasoning	Cognitive	Discuss rationale for clinical decisions regarding examination, evaluation, and plan of care/interventions.	88.5	80.6
Safety	Psychomotor	Demonstrate accurate monitoring of vital signs for noncomplex patients (or simulated patients).	87.1	90.5
Plan of care	Cognitive	Recognize when a treatment plan/intervention needs to be modified (regressed or progressed).	86.9	77.0a
Accountability	Affective	Respect that patients' needs supersede student needs and goals.	85.5	90.5
Professional behaviors	Affective	Engage in meaningful self-reflection as a means to enhance performance.	85.5	87.3
Interventions	Psychomotor	Implement common or familiar procedural interventions in a safe manner for noncomplex patients or simulated patients.	83.6	93.5
Accountability	Affective	Manage personal schedule to be prompt and prepared for all learning experiences.	82.3	96.8
Examination	Psychomotor	Accurately perform basic tests and measures (eg, goniometry, MMT, vital signs) for noncomplex patients, or simulated patients, using standardized procedures and positions.	82.0	93.5
Interventions	Cognitive	Explain desired outcomes/expected responses, indications, and contraindications for common procedural interventions.	82.0	91.9

Abbreviations: CI = clinical instructor; CPI = Clinical Performance Instrument; MMT = Manual Muscle Test.

^aThe plan of care objective is the only one that achieve ≥80% consensus in “just right” ranking, but not in “very important.”

None of the 44 original readiness objectives associated with the “Documentation” and “Screening” performance criteria met the consensus value of ≥80%, for “very important” or for the level of expectation of “just right.” The originally proposed readiness objectives for “Accountability,” “Safety,” and “Professional Behaviors” all met the consensus value of ≥80%, for “very important” and “just right.” Readiness objectives associated with the collapsed criteria for “Procedural/Educational Intervention” performance criterion retained two of the original three readiness objectives and “Communication” retained two of the original five readiness objectives. Readiness objectives associated with the performance criteria: “Cultural Competence,” “Examination,” “Clinical Reasoning,” “Plan of Care,” and the collapsed criteria for “Evaluation/Diagnosis/Prognosis,” all retained one of the original readiness objectives.

Figures 1–3 represent the distribution of the 22 readiness objectives, arranged according to the hierarchy of learning within Bloom's Taxonomy^12-14 and domain of learning. Figure 1 indicates that 11 of the 22 readiness objectives are reflective of behaviors in the affective domain, with at least 1 readiness objective representing the five levels of the learning hierarchy from the lowest level of “receiving” to the highest level of “internalizing.”¹³ In Figure 2, seven readiness objectives were reflective of skills in the cognitive domain,¹² with three of those readiness objectives associated with the “Safety” performance criterion. Finally, in Figure 3, there were four readiness objectives reflective of skills in the psychomotor domain,¹⁴ with two of those readiness objectives associated with the “Safety” performance criterion.

Figure 1.: Objectives in Affective Domain¹³

Figure 2.: Objectives in cognitive domain¹²

Figure 3.: Objectives in psychomotor domain.¹⁴MMT = Manual Muscle Test

DISCUSSION

Current literature describing physical therapy competencies is associated with entry-level practice. The APTA developed the Minimal Required Skills¹⁸ and many of the academies and sections within the APTA have developed core competencies for their respective content areas such as pediatrics,¹⁹ neurology,²⁰ geriatrics,²¹ acute care,²² and women's health.²³ Most of these documents focus on behaviors and skills required for students to achieve entry level. This study explored students' readiness for the first, full-time CEEs and supports a recent study that described readiness skills and behaviors for the first, full-time experiences.²

Participants in this study identified 22 readiness objectives, within 10 CPI¹⁵ performance criteria. Sixteen of the 22 readiness objectives reaching a consensus of ≥80% were within 5 of the 5 red-flagged items on the CPI,¹⁵ ie, “Safety,” “Professional Behaviors,” “Communication,” “Accountability,” and “Clinical Reasoning.” Participants in this study also identified the greatest number of readiness objectives, at the higher levels of performance, within the affective domain.¹³ The 11 objectives within the affective domain¹³ reflected abilities at multiple levels within Bloom's Taxonomy, with 5 objectives above a level 3. One of these objectives was for students to “Accept responsibility for actions and errors, including remediation,” which is reflective of the highest domain of learning, ie, “internalizing.”¹³ The emphasis that students demonstrate high levels of performance in professional and affective behaviors is reflected in other studies within the physical therapy literature.^2,24,25 The ACAPT Task Force on Student Readiness by Timmerberg et al² identified 95 elements that required students to perform at one of three defined levels of competency of, “at least familiar,” “emerging,” and “proficient,” before the start of their first, full-time CEE. Only 9 of the 95 elements required students to be “proficient” before the start of their first, full-time CEE, with 6 of these 9 elements describing behaviors in the affective domain. Likewise, Cross and Hicks²⁴ identified 8 constructs that clinical educators found to be important for students to demonstrate during CEEs, 3 of which include elements in professionalism and affective domain characteristics including “general disposition” and “approach to learning and commitment.” The emphasis on students' ability to demonstrate appropriate professional and affective behaviors in the clinical setting is not unique to the physical therapy profession. A study by Chipchase et al,²⁵ including professionals in physiotherapy, occupational therapy, and speech pathology, identified key characteristics that clinical educators expected students to demonstrate. Clinicians rated, “willingness,” “professionalism,” and “personal attributes” higher than students' content-based knowledge and skills.

The 5 readiness objectives within the safety criterion in the current study, consistent with the 8 elements in safety theme by Timmerberg et al,² indicate that students are expected to perform safe patient care before their initial CEE. Three of the 5 safety objectives in this study were related to the cognitive domain¹² of learning and 2 to the psychomotor domain.¹⁴ Within the cognitive domain,¹² one objective was identified as being a higher level than the others. This objective specified that students, “Summarize pertinent information from the medical record and physical therapy examination that could potentially impact patient safety.” It should be noted that the verb, “summarize” is usually associated with the lower level of “understanding” in Bloom's Taxonomy.¹² However, as the researchers considered the context of summarizing “pertinent information” impacting “patient safety,” it was felt that this readiness objective reflected the higher level of “analyzing” within Bloom's Taxonomy¹² because analysis is required to determine whether information is pertinent related to patient safety. The 2 safety objectives in the psychomotor domain were both at the level of “precision,”¹⁴ with participants expecting students to accurately perform basic skills for noncomplex patients. The current results are consistent with the ACAPT report on student readiness, which identified the need for students to have remediation and reassessment for safety concerns before the first, full-time CEE.²

Although “Clinical Reasoning” is a performance criterion linked as a “red flag” item on the CPI,¹⁵ our participants identified only 1 readiness objective within “Clinical Reasoning” that met the criteria as “very important” and “just right.” The final readiness objective that was retained was linked to a higher level of performance, according to Bloom's Taxonomy.¹² It specified that students, “Discuss the rationale for clinical decisions regarding examination, evaluation, and plan of care/interventions.” The 2 “Clinical Reasoning” readiness objectives that were not retained after analysis were “Seek a variety of sources to inform clinical decision making for patient/client management” and “Examine the value and limitations of sources of information.”

Interestingly, despite the emphasis on diversity and respect for cultural differences in health care, clinicians rated only 1 of the 3 original readiness objectives as “very important” and “just right.” This objective was for students to, “Demonstrate respect and unconditional positive regard for patients/families, faculty/instructors, peers and health care providers.” The 2 readiness objectives related to the “Cultural Competence” performance criteria that ranked as “very important” by fewer than 50% of respondents were, “Reflecting on one's own cultural influences and biases,” and “Gathering information on a patient's cultural preferences as they relate to health and wellness.”

Our study included 47 clinicians in contrast to 24 in the study by Timmerberg et al.² Additionally, during the initial round of this study, participants had the opportunity to discuss their thoughts about objectives during the time they were assigned to a table and collectively during a debriefing session at the conclusion of the workshop. This allowed participants to hear the ideas related to the creation of these objectives from multiple perspectives and develop a minimum level of consensus about the objectives in an informed manner. This is in contrast to the study by Timmerberg et al,² which engaged participants via survey and not discussion.

The Certified Clinical Instructor Program²⁶ encourages CIs to reference Bloom's Taxonomy^12-14 when they create objectives for students during CEEs. Therefore, the concepts related to Bloom's Taxonomy^12-14 should be familiar to a growing number of CIs. In summary, the strength of this study was the expectation that participants create readiness objectives using Bloom's hierarchy and descriptive verbs as a guide. The use of Bloom's Taxonomy was critical to the goal of creating objective criteria, which could be easily understood by students, academic and clinical faculty, to define standardized expectations for students to achieve before their initial, full-time CEE, across PTEPs. The current study identified 22 readiness objectives, using verbs from Bloom's Taxonomy^12-14 to identify the level of performance required of the student. Twenty-two of the objectives in the current study align with 11 of the 14 performance themes identified by Timmerberg et al.² The manageable number of identified readiness objectives and use of verbs associated with Bloom's Taxonomy in this study lend themselves to be used as a screening tool for PTEPs to use before students' initial CEE. Furthermore, having been developed with input from SCCEs and CIs, the objectives could also serve as meaningful reference that CIs could use within the first 2 weeks to determine if students were prepared for the initial CEE.

There are limitations to our study. Participants in this study represented a small sample size from one region in the United States, with 47 SCCEs and CIs who participated from multiple settings. Although there was effort to ensure that SCCEs and CIs from a variety of settings worked together during the in-person round, data on personal and professional demographics beyond role of DCE, SCCE, or CI were not collected for the online data collection. Participants' feedback about the readiness objectives on the survey for importance and level of performance may have varied, depending on the participants' clinical setting. Finally, participants may have been influenced by their knowledge of the CPI¹⁵ as they created readiness objectives. This may have been particularly influential when they considered the creation of readiness objectives within “red flagged” performance criteria.

This study provides academic institutions and clinical sites with the potential to standardize guidelines about behaviors and skills that students should demonstrate before the first, full-time CEEs. Participants in this study indicated a strong interest in skills and behaviors in the affective domain, as evidenced by the fact that 10 of 22 (45%) readiness objectives were within the performance criteria “Professional Behaviors,” “Communication,” and “Accountability.” Additionally, these readiness objectives spanned multiple levels of the hierarchy described in Bloom's Taxonomy, with 1 of the readiness objectives at the highest level of learning (ie, Affective Domain Bloom's “internalizing”¹³) compared with readiness objectives from the cognitive¹² and psychomotor domains.¹⁴ Participants also indicated that students must demonstrate basic levels of safety in the cognitive¹² and psychomotor domains¹⁴ of learning.

Further research is required in the application of these readiness objectives. Comparison can be made between student's achievement of readiness objectives with their success in meeting benchmarks on the CPI¹⁵ during the first, full-time CEEs. This comparison would indicate whether the readiness objectives have predictive validity. The results of these comparisons should inform the implementation of these readiness objectives across PTEPs.

CONCLUSION

Physical therapy education programs are responsible for preparing students for the first, full-time CEEs. Therefore, it is necessary for academic and clinical faculty to have mutual agreement about the behavioral and clinical skills objectives that students must demonstrate before they are allowed to participate in CEEs. The participants in this study prioritized students' behaviors in the affective domain and their ability to maintain safety as part of their readiness for the first, full-time CEEs. The 22 readiness objectives identified in this study need to be validated in further study. If validated, these readiness objectives could be used as standardized, baseline expectations to define student performance before the first, full-time CEEs. A mutual understanding of these expectations between academic and clinical faculty will bring greater cohesion between these aspects of physical therapy education for the enhancement of student clinical experiences.