Standards for accreditation of physical therapist education programs include the requirement for a comprehensive curricular plan. Standard 6 states “The comprehensive curriculum plan is based on: (1) information about the contemporary practice of physical therapy (PT); (2) standards of practice; and (3) current literature, documents, publications, and other resources related to the profession, to the delivery of health care services, to physical therapy education, and to educational theory.”1,p.19 The expectations laid out in this standard necessitate ongoing review and revision of curricular content and educational approaches as new evidence is gathered regarding patient management, the evolution of health care policy, and—as importantly—best practices in teaching and learning. This ongoing process of review and revision may include minor changes in the content or learning experiences or in more drastic changes, restructuring of courses and course sequencing, adding or deleting courses, or changing the teaching model across a curriculum. Regardless of the extent of the changes, such changes require faculty to develop a coherent plan not only to meet the criteria for the Commission on Accreditation in Physical Therapy Education (CAPTE) criteria but also program goals, student expectations, the needs of the profession, and the evolving demands of society and our external environments. The more extensive the changes across a program, the more likely it is that the multiple faculty will be involved, will need to support the changes, and will be affected by those changes.
Experiences with curricular changes in physical therapist education curricula have been described in the literature, including changes in clinical education2 or other experiential learning programs,3-6 reorganization of content within a curriculum,7-11 and the addition of new topical units.12-20 Such changes often parallel those going on in other areas of higher education where the focus is increasingly on courses or programs using problem-based learning, experiential learning, cooperative learning, and inquiry-based learning.21 These pedagogies shift the balance toward how students learn, not just what they learn, giving graduates the tools essential to function in multidisciplinary and interprofessional teams.22,23 For that reason, physical therapy educational program are turning toward newer teaching-learning strategies. Three previously published articles described comprehensive curricular changes in existing physical therapist educational programs, each from more traditional curricula to implementation of a team-based learning (TBL) curriculum24 and change to an integrated, learner-centered curriculum with a focus on active learning.24,25 All 3 articles examined students' experiences in the curriculum implementation process, among other elements. Boucher et al25 also examined perceptions of faculty about the curricular model but did not explore faculty experiences with planning and implementation.
Relatively little attention has been given in physical therapist education literature to the shared experiences of the faculty making large and comprehensive curricular revisions that inevitably will also involve cultural or organizational changes.21,26 The experiences with culture shifts and organizational change may be different than those described in the corporate world. There is evidence that universities encounter more resistance to change among their members than public or private organizations, possibly because of a greater variety of different viewpoints and stronger ideals of consensus-based decision-making associated with the academy.21 Furthermore, the culture and faculty responses to organizational change in physical therapy educational programs may present quite differently than those for faculty in arts and sciences, in business programs, or even in medical education. Yet, there is nothing in the literature on faculty perceptions of comprehensive curricular changes within physical therapist educational programs. Such large-scale curricular changes can be expected to escalate across physical therapy education in the near future. In her address to the American Physical Therapy Association's (APTA's) 2019 House of Delegates,27 APTA President Sharon Dunn spoke to the “genuine threat to the sustainability of our profession” created by student debt and advocated for change that would rethink education in our profession. Since the call to action by President Dunn, institutional responses to COVID-19 further escalated challenges to the delivery of physical therapy education and demands (if not requirements) for changes in delivery. Curricular changes most likely will be extensive and will involve not only increased reliance on online delivery but, as importantly, active learning and more integrated curricula. Such changes will strongly affect the faculty culture and informal organization, among other elements. The purpose of this study, therefore, was to describe the collective experiences of faculty participating in organizational change created by development and implementation of an entirely new curriculum structure that changed both content organization and the prevailing pedagogy. Sharing our experiences and putting them in the context of the organizational change literature may inform and prepare programs embarking on similar organizational changes demanded by today's internal and external environments.
We used qualitative thematic analysis, as generally described by Braun and Clarke,28 to identify, summarize, and interpret the faculty perceptions regarding the experience of planning and implementing a new Doctor of Physical Therapy (DPT) curriculum and pedagogy.
The study was completed in the DPT program at the MGH Institute of Health Professions, a private, not for profit institution classified as Special Focus 4-year: Other Health Professions by the Carnegie classification system.29 Until 2016, the curriculum was traditional, comprising 41 academic courses, 3 full-time clinical education courses, and a terminal clinical internship, for a total of 100 credits. The courses were between 1 and 6 credits and either 3, 8, or 14 weeks in length depending on the timing of the course in the curriculum. Students were taking up to 20 credits and 8 courses in a 14-week semester. Each course was focused on a narrow content area such as pharmacology, prosthetics, anatomy, or management of musculoskeletal disorders.
Among the DPT faculty, discussion regarding curricular revision began in 2010, with planning taking place over 5 years (Table 1) that included a self-study for CAPTE reaccreditation of the existing curriculum. The new curriculum was initiated in Fall 2016 with matriculation of the Class of 2019. The new curriculum is outlined in the Appendix (Supplemental Digital Content 1, http://links.lww.com/JOPTE/A84). Course content, sequencing and timing, and pedagogical approach to teaching were evaluated and completely restructured. The new curriculum reduced the number of courses to 23 while increasing the total credits to 102. Contents such as anatomy, pathology, pharmacology, and patient/client management were integrated within and across courses (often referred to as vertical integration30). Curricular threads such as evidence-based practice, movement science, and professionalism were also vertically integrated throughout the courses and semesters. Courses typically emphasized one body system but included consideration of multiple systems through realistic patient narratives as a focus of learning (often referred to as horizontal integration30). Most academic courses were packaged into sequential rather than overlapping 4-week blocks of 6 credits each. Students completed both written and practical examinations at the end of each course. At the end of each semester, the students were assessed with written and practical examinations that addressed the content from all courses offered during the term (eg, 3 courses in a 14-week term). Because the pedagogical approach emphasized team teaching and active learning and because lecture time was minimized, most class sessions were completely redesigned. Faculty developed lesson plans for each of their course sessions and session organizers to guide students' preparation. Faculty developed case narratives used across the course or within sessions to promote patient/client-centered learning and to contextualize students' physical therapy management skills development and clinical decision-making. New strategies and tactics had to be developed to facilitate and stimulate active student engagement in the content of each class session, often through small group discussions. Through the planning phase, faculty were offered development opportunities through the institutional office of instructional design, including one-on-one help, workshops, or lunchtime seminars.
Table 1. -
Curriculum Planning and Implementation Timeline
||Faculty retreat to discuss curriculum revisions and assumptions regarding best practices in teaching and learning
|January 2011 to December 2011
||Curriculum Steering Committee meetings and faculty discussions regarding assumptions and desired outcomes of curricular revision
||Curricular Steering Committee began drafting new curriculum model with targeted implementation June 2013
|January 2012 to December 2012
||Curriculum Steering Committee meetings and faculty discussions leading to revisions to proposed model
||Unanimous faculty vote to accept proposal in principle
|January 2013 to April 2015
||Curriculum Steering Committee and faculty workgroups work on course content, sequencing and scheduling. Faculty workgroups develop syllabi and course content
||Revised timeline to June 2015 implementation
||Revised timeline to June 2016 implementation
||New course proposals reviewed by institutional curriculum review committee for inclusion in 2016 catalog
|April 2015 to May 2018
||Faculty workgroups developed course materials
|June 2016 to August 2018
||Implementation of all new courses
||Graduation of charter class
Partners Healthcare Institutional Review Board gave the study exempt status. Faculty participants in round 1 of interviews were all of those involved in the planning and initial implementation of year 1 of the new curriculum. Round 2 included faculty who taught year 1 courses for the second time and faculty who taught year 2 courses for the first time. Some faculty taught in both year 1 and year 2 so experienced repeating a course and delivering a new course during year 2. Participant demographics are described in Table 2.
Table 2. -
||Years as Faculty Member
We used semistructured interviews to collect data in round 1 and round 2. The first round was conducted at the end of the first year of the new curriculum (April–May 2017). The second round was conducted after the second year of classes (July–August 2018). This period included the full cycle of academic classes in the new curriculum and 2 full-time clinical experiences. The final clinical experience (September–December 2018) did not take place until after the completion of the interviews. One of the 5 study authors interviewed each faculty member individually. All participants were read an explanation of the study and gave verbal consent before each interview. Interviews explored faculty's perceptions by asking the main questions defined by our interview guide (Table 3) and then probing new ideas and exploring responses in greater detail as needed.31 The interviews were audio recorded and transcribed. Interviews lasted approximately 30–60 minutes.
Table 3. -
Interview Questions for Faculty
|Round 1—July–August, 2017 (N = 14)
| What are your perceptions or reactions to planning and implementing the integrated/new curriculum?
| What are your reactions or perceptions to working with your colleagues?
| What is your perception of students' level/depth of learning and performance?
| What are your perceptions regarding the students' preparation for class?
| How do you feel about your teaching or role as a teacher in the new curriculum?
|Round 2—April–August, 2018 (N = 17)
| What do you see as the benefits and challenges of the new curriculum for you? For faculty overall? For students?
| How is your experience as a faculty member different with this curriculum compared to your previous experiences?
| What are the lessons learned from the experience of implementing the new curriculum?
| Was the new curriculum worth it?
Analysis and Methodologic Rigor
We used an inductive, semantic approach with a goal of revealing themes in the data without a preconceived framework.28 In the first phase of analysis, 3 authors independently read all deidentified transcripts from round 1 and labeled features of the participants' responses that seemed important and meaningful using our own words. We then met several times to discuss our initial codes and perceptions of common and contrasting elements among the interviews. These iterative discussions resulted in combining and sorting codes into potential themes that we defined and refined through consensus. We then selected quotes from transcripts that exemplified the themes. The 2 authors not involved in the original theme generation independently reviewed round 1 transcripts for themes, largely validating the themes that had emerged thus far while stimulating further refinement. Round 2 transcripts were subsequently treated in a similar manner. We developed thematic maps to look at relationships among themes and to determine if the themes were inclusive and mutually exclusive.28 Deidentified transcripts and themes from both rounds were sent to an external reviewer. Based on reviewer feedback, we elaborated on 2 of the themes and developed a visual framework that showed the relationships among the themes. No other modifications and no new themes were recommended by the external reviewer.
Ten themes emerged from the analysis of the interviews. Seven of those themes emerged from round 1 interviews, and 3 additional themes emerged from the round 2 interviews. The themes and their subthemes are shown in Table 4. The following pages describe and define the themes and provide supportive data in the form of quotes from the participants.
Table 4. -
Summary of Themes
|1. Convoluted planning process
|2. Insufficient resources
|3. Challenging management processes and structures
|4. Crucial teamwork and communication
|5. Overwhelming workload
||Planning required a huge time commitment
|Balancing work responsibilities was challenging for faculty
|Concentrated amount of time faculty spent in 4-wk was arduous
|6. New pedagogy
|7. Integrated curricular structure
|8. Evolving attitudes and approaches
|9. Personal and professional growth
|10. Cautious optimism
Theme 1: Convoluted Planning Process
The planning process for the new curriculum took place over a 5-year period and used an iterative process of decision-making, requiring numerous levels of communication and cooperation among team members and leadership, as well as with various stakeholders.
The process that we went through as a faculty to get to consensus on whether or not we needed to change and arrive at consensus [around] a sort of conceptual idea about the curriculum, I think that was a good collaborative process. (Round [R]1, Faculty [F]14)
At times, the development steps seemed unclear because there were many starts and stops in the process. Team members working on various planning parts changed over time as course content was developed, faculty responsibilities shifted, or faculty were hired or resigned. In addition, a self-study and accreditation visit occurred during the planning period, slowing the process. Because the process took so long, it was sometimes hard for faculty to stay engaged and some steps had to be redone because people could not remember what had already been decided. The faculty were not always sure what was happening at various points in time. The faculty had many planning meetings at which decisions were made that sometimes were not well communicated or well understood as the planning went forward and the personnel changed.
Everything kept shifting; that was part of the difficulty with it. People's roles and responsibilities kept shifting…. It was like a moving target. (R1, F10)
In the course planning process, the teams did not always seem to include the right people. Sometimes faculty planning courses were not those who were going to teach them or were not considered the right people because they did not know a specific content area. The changes in teams over time led to inefficiencies.
I think we would've been in a different place starting the curriculum had we grouped up or been organized into groups that were more closely aligned with what we were going to be teaching. (R1, F13)
Once the teaching teams were established and the actual course planning started, the path was clearer and the planning progressed more smoothly.
Once we got into our definitive groups and we really started on developing the specific objectives and linking the objectives to the sessions and stuff like that, that was manageable, although it was a lot of time. (R1, F11)
Communication within the course team and with other course teams was essential to assure appropriate course content, smooth flow from course to course, and correct leveling of course content.
The planning was challenging because obviously, with all things challenging, the devil is always in the detail. You need to have the big picture as well as the small picture. There are so many details that go into something like this…. (R1, F2)
For some course teams, the planning largely happened ahead of a course start date, whereas other teams were planning sessions week to week during the course.
I think part of my frustrations, part of my dilemma with not really enjoying the implementation process—was that I was still planning. I didn't get [the course] all planned before I started it. And everyone that had gone before me said, “Don't do that.” (R1, F5)
In round 2 of interviews, the planning theme was not as evident. Faculty commented more that planning was still time consuming the second time around but easier because they had been through the process previously. In the second round, faculty were largely responsible for editing and planning their courses, rather than planning courses and the entire curriculum simultaneously.
It felt different [the second year] on me as a teacher. Some of the lesson plans were done and just needed to be tweaked. I didn't have to write objectives. On my workload, it felt a little bit better…. (R2, F7)
Theme 2: Insufficient Resources
Resources in this context included assistance for faculty to manage their workload (eg, release time, financial support, and administrative personnel support) and faculty development opportunities because changing a curriculum and pedagogy may require any of these. Faculty perceptions of the resources available to them differed, and they used faculty development resources to varying degrees.
I can't think of any really formal training we had as faculty. There were some faculty, [including] myself and the co-instructors that I worked with, [who] asked for help from instructional designers and some other resources. I'm not sure everyone did that. (R1, F11)
Many faculty noted a lack of institutional support in providing expected release time for them to create and implement the new curriculum.
I was under the impression that all of us would be freed up, somehow have some support … to lessen our workload so then we would have time to spend doing this curriculum, and that never really happened…. (R1, F11)
Faculty felt that the monetary support to implement the new curriculum was sufficient.
For financial resources, I think that there was a pretty open reception to paying, for example, the LIs [lab instructors] and people and standardized patients; that seems pretty generous to me. (R1, F3)
In round 2 interviews, faculty made similar comments as in round 1 but were reflecting back on the lessons learned from their experience rather than noting resources were a continued issue.
I think the first lesson is make sure the supports are in place before you try to do it. (R2, F19)
Theme 3: Challenging Management Processes and Structures
In both planning and implementation, there were many complicated elements to manage and monitor. Management and implementation of those organizational elements did not happen seamlessly or consistently.
There was a lot of collective decision-making that was made at meetings, but I don't think there was the oversight or the communication, or whatever it took, to make sure that that got implemented. (R2, F4)
I think the challenge that I saw, and it really was a challenge, is we had these great ideas but the feasibility kept getting ignored. (R2, F7)
Furthermore, faculty noted that the management challenges would necessitate ongoing coordination over time.
… but there is always going to be, I think, an underlying administrative need to make this curriculum run smoothly (R1, F11)
The challenge for the chair, a curriculum coordinator or faculty, is going to be this on-going integrative process of review (R1, F6)
Faculty were tasked with developing and maintaining structures that were intended to facilitate content monitoring and communication among faculty so that faculty would know and could reinforce what had been done with students in previous courses.
How do we organize all the masses of information so that it's accessible to [faculty] and [faculty] can find it? (R1, F6)
There was a common template designed for faculty to maintain lesson plans and session planners for students on the electronic learning platform and in the faculty-shared document drive. However, some faculty were more organized or attentive than others to their management tasks, leading to concern about course continuity.
My experience teaching a thread through different courses is that some people have stuck to that [original organizational] plan and some people have not…. (R2, F4)
Particular areas of challenge expressed by almost all faculty were the logistics around hiring LIs and communicating effectively with them. Faculty were concerned about how to better prepare guest lecturers and LIs who might not understand the integrative, active learning nature of the curriculum, or were participating without context for what they were doing.
There's a philosophy that goes with a class and teaching and so you have these different people coming and going that never have a chance to develop that. (R1, F3)
In addition, it was challenging to find clinician LIs with relevant expertise to teach specific sessions and to keep them consistent over time. Laboratories were not necessarily held on recurring days and times for a full semester, making scheduling challenging for LIs—many of whom had clinical practice schedules. These constraints resulted in larger numbers of different LIs and put a burden on staff to manage semester contracts.
Coordinating of the lab instructors is a challenge. …it's an immense amount of time for us but even more so, staff. (R1, F11)
There are so many of them [lab instructors]. You, practically speaking, can't set up a meeting with them so that everybody is very well on the same page. (R2, F2)
Planning and organizing a practical and written examination for each course and a comprehensive practical and written examination for each course sequence also taxed faculty time and energy. Of particular concern were the logistical issues around scheduling students, examiners (LIs), and standardized patients for the practical examinations and time-urgent practical retakes when necessary.
It's figuring out the “who” scheduling piece, making sure you have all the rooms…you need the rooms for the practical, but you also need a prep room. Oh, and you need to think about this group with accommodations, do they need to be [tested] somewhere else? Then it's getting the information to lab instructors in a timely manner so they have enough time to ask questions and be prepared. (R1, F12)
Faculty acknowledged that the logistical issues did not necessarily require faculty expertise, but it was also a large workload for administrative staff and they needed faculty guidance. As noted by one faculty member, logistical issues were
All challenging even when staff are helping. (R2, F9)
Theme 4: Crucial Teamwork and Communication
Teamwork and communication were found to be critical and inextricably intertwined in the views of faculty. From planning stages through initial implementation, the biggest challenge to teamwork was communication within and across teams.
I didn't know the interpersonal communication piece was going to be such a big part of this teaching…. It's maybe 50% of the work. (R2, F4)
The collaboration necessary to an integrated curriculum with an agreed on philosophy and set of frameworks gave faculty the advantage of learning from each other but also highlighted differences in teaching/learning philosophies, strengths and weaknesses, and work styles. Some faculty reacted positively to the need to navigate those differences.
Different people do things different ways. Different people pay attention to deadlines in different ways. …some people just take on the work. At the end of the day, really everybody—most people—are doing the best they can. …so we have to respect each other through the process. (R1, F10)
Other faculty had more negative perspectives that seemed to be related to the team membership.
One of my groups was a lot easier to work with than the other one. (R1, F12)
I just think there are some people that are a little bit more difficult to work with, and we certainly had one of those people on our team…it was just frustrating, and kind of an uphill battle. (R1, F13)
Although many faculty identified advantages of collaboration, they found the time and energy needed to navigate the complexities of interpersonal communications and manage the challenges of ongoing collaboration to be far greater than anticipated and potentially burdensome.
The challenges around the team teaching… [are that] you have to negotiate a lot. …the time aspect of that negotiation is challenging. (R2, F14)
It takes a lot of consensus building, and we all know how fun that is among the faculty. A lot, a lot of exhausting conversations…. (R1, F1)
Faculty, however, were also able to recognize the benefits that a team can bring to their efforts.
Just seeing people's different ways of processing information and coming up with ideas and ways to engage the students—I think was really beneficial. (R2, F10)
Theme 5: Overwhelming Workload
The amount of work involved in planning and implementation was intense and led to feelings of being overwhelmed and exhausted. The switch in courses and pedagogy required development of many new course elements, including associated lesson plans, case development, guiding questions, clicker questions, PowerPoint guides, in-class learning activities, and student assessments. Many of these elements were novel experiences for some the faculty. Faculty felt they had to think of and plan for every detail because so many faculty and LIs were involved in a course and these individuals needed to understand the materials at a granular level.
I will admit it was a lot more work than I ever thought it was going to be. … I've worked hard in my career, but I don't think I've ever worked so hard. (R1, F11)
I don't think anybody would argue the amount of work that it was. I think initially my perception was that it was going to be a large undertaking. I think it was a lot more than I originally had even wrapped my head around. (R1, F8)
During the 4 weeks of a course, faculty felt they were always “on” during those weeks not only teaching but also coordinating with their team and spending long hours getting things ready for the next week. There was no time for catching up in a course and little time to adapt in the moment and flex the class schedule and content. If one had not planned everything ahead of the course start date, it was even harder to manage the time. Different analogies were used to describing the intensity.
[It] feels like you're on a treadmill going a mile and a half per hour faster than you're really comfortable going. (R1, F4)
This is like the hundred meters. It's not a sprint, but it's kind of sprints [sic]. You can't go all out, but you kind of have to go all out. (R1, F5)
In teaching courses for the second time, faculty sentiment about the time commitment and amount of work was similar, albeit slightly muted. Faculty recognized that there was less work involved for each course; however, there was still the feeling that the workload was intense.
Instead of working 95 hours a week, it was 90 hours a week. I noticed the difference, but it was still absurdly off the charts. (R2, F2)
My organizational skills and time-management were [still] challenged to the max. (R2, F11)
The planning and implementation activities for the new curriculum conflicted with engaging in scholarship and its dissemination, directing student projects and dissertations, advising students, and performing administrative and or service responsibilities for the institution and profession. These other responsibilities often had to be put on the back burner, but they still had to be done despite the intense amount of time required for planning and teaching the new courses.
It takes a lot of time away from other things that are probably equally as important and are expected of you as well. And it's not like the implementation of this [curriculum] has decreased the expectations of these things. (R1, F2)
In the second year, faculty felt they did a bit better in balancing their work responsibilities; however, particularly during the time faculty were teaching in their 4-week course, challenges remained in meeting obligations for institutional service and, for part-time faculty, clinical practice.
I think the challenges for me are the outside committee work during that time that I'm with the students so much. (R2, F19)
Balancing my clinical position with this—with this new curriculum…was very, very challenging. (R2, F16)
Theme 6: New Pedagogy
The newly adopted pedagogy included a new teaching style for many faculty and a more consistent use of active learning principles in every course. Faculty noted the impact of the change in pedagogy on themselves and students. All faculty remarked that teaching in the new curriculum provided them with a different teaching experience compared with the old curriculum. Many faculty felt that teaching in the new curriculum enhanced their teaching experience.
… so much more stimulating for me as a faculty member. (R2, F116)
I like being in the classroom more than I used to. (R1, F9)
…people [faculty] were saying “wow, that was really kind of cool.” (R1, F6)
The new approach to teaching allowed faculty to develop new ways of thinking about teaching, particularly how to engage and motivate students.
I'm starting to think more about things like student engagement, student feedback…Thinking [about] the whole picture of how do I make this classroom a place that's safe, that people will want to participate? (R2, F17)
At the same time, faculty commented that teaching in a more active learning format was not always comfortable for them.
I've gotten much more comfortable with not having control. (R1, F10)
I found it very challenging to occupy that time productively, in an active way. (R2, F1)
I think it was a little more of a stretch for some people than [for] others. (R2, F3)
Faculty felt the new curriculum facilitated students' learning in a different way than they had observed previously.
I think teaching in that integrated way is definitely better learning-giving [students] the context as to [the] “why” is important. (R1, F9)
A fundamental component of the new curriculum was having the students work in groups, and faculty noted the benefits of this approach for students. The students were more participatory.
The students are much more engaged and I think that the small groups allow people that might be a little bit more hesitant to speak up in a crowd, to be more participatory. (R1, F11)
Faculty noted that students were engaged in deeper levels of discussion and applying information from the first day of each course.
I can say that from the very beginning the conversations students were having and the levels we were bringing them to were way beyond what they had done in the past. (R1, F10)
Furthermore, faculty felt that the pedagogy laid the groundwork for the skills related to lifelong learning.
I think that the benefits are that they're preparing themselves better to be lifelong learners. I think they're preparing themselves better… to take initiative in the clinic. (R2, F13)
Faculty did identify, however, that the short [4-week] timeframe limited student processing time.
Another difficulty … is how compact the courses are. I think processing the material is a real challenge [for students]. (R1, F2)
Last, faculty felt limited in the assessments that they could reasonable incorporate into a 4-week course that would be formative rather than only summative.
It's almost impossible to have a [written assignment] handed in, graded, and handed back in the amount of time it would [take to] actually provide a student with quality feedback. (R1, F8)
Despite the shortcomings, most faculty agreed that teaching in the new curriculum style was beneficial to the students and themselves.
I do still philosophically believe that this is a modern and better and more interesting way to deliver and maybe more pedagogically sound way to deliver adult education. (R1, F4)
Theme 7: Integrated Curricular Structure
Faculty talked a great deal about the concepts of an integrated curriculum in the second round of interviews after they had had a chance to step back and see the forest for the trees. However, it also became clear that “integrated curriculum” seemed to mean different things to different faculty and individuals used the term to refer to both content integration and concept integration. Challenges to integration of content (horizontal integration) included the need for faculty with different areas of expertise to contribute to course and case development, the ability of faculty in the course to apply principles to content outside their own expertise, and the need to maintain a curriculum overview.
We're supposed to be an integrated curriculum. Being responsible for a case that's being discussed that day that integrates cardiovascular or orthopedics and neuro [is] something that maybe the primary instructors don't feel as comfortable with. (R2, F16)
The challenge … is going to be this ongoing integrative process of review, tweak, keeping a comprehensive view not only of what the curriculum as a whole is doing, but what each individual course is contributing. (R1, F6)
Faculty had differing views on the degree to which content integration had been achieved.
I think despite what we intended to do—which was approach it as the whole patient… [and not] put things in silos, I think we went right back into silo-ing things. (R1, F14)
I don't know that we've reached [integration] totally the way we might ultimately want to reach it, but I think we're headed in the right direction. (R2, F17)
Another notion was that courses should be vertically integrated, including the 5 curricular threads (clinical decision-making, professionalism, evidence-based practice, the movement system, and interprofessional collaborative practice), and faculty were unsure that that type of integration was effectively occurring.
…it's still hard to make [threaded content] perfectly seamless. (R2, F2)
In the second round of interviews, faculty noted the value of concept integration with the new curriculum better preparing students to apply the patient management model and use clinical decision-making across curricular content to translate their learning into person-centered care.
It was amazing the level to which we could take the students. Two weeks into the curriculum they were working through the clinical decision-making process and coming up with basically impairments and activity limitations and almost establishing goals without knowing anything. (R2, F10)
Faculty also noted that learning with an integrated approach better reflected clinical practice using a process rather than content focus.
They're presented with these complex patients and these narratives, but they were able to use these decision-making frameworks…. we saw this carry through in a very challenging kind of rigorous academic medical center. (R2, F15)
Theme 8: Evolving Attitudes and Approaches
As reflected in round 2 of interviews with faculty, the curriculum transformation is a process of evolution—a work in progress. As evolution implies, the faculty noted that their ideas about curriculum structure, processes, and pedagogy were continually reconsidered, retested, and altered both as they were implemented and after implementation.
Any time you change [a] curriculum it's going to take 3 years. We aren’t there yet. (R2, F5)
The new curriculum is still changing and evolving on a week to week, month to month basis. (R2, F4)
Attitudes were modified by increased comfort levels.
I feel more positive about the [curriculum] than I did, but I think that's just because I feel like I'm getting better at it. (R2, F2)
Attitudes shifted from aspiring to perfection in the first iteration to realizing that perfection was not realistic.
I was worried about stuff less [the second time] and I let things be less perfect than they were—than I tried to make them year 1. (R2, F5)
There was a common sentiment that there was still need for change for faculty to achieve better work-life balance.
I think, absolutely, there's a lot that has to be worked out in terms of our health and wellness, and balance. (R2, F16)
Theme 9: Personal and Professional Growth
Through the process of planning and implementing the new curriculum, faculty noted experiencing personal and professional growth, including improved awareness of their own strengths and weaknesses and areas that needed further development in teaching, in teamwork and collaboration, and in self-reflection.
I think I personally grew a ton in my classroom teaching. (R2, F8)
My collaboration skills, my communication skill with my fellow faculty are growing enormously. (R2, F5)
…despite the fact that we tend to like to have control over our own stuff, when you open up, you gain more…. [like an understanding of] the importance of not holding so hard to your own viewpoints. (R2, F10)
Theme 10: Cautious Optimism
When asked if the curricular change was worth it, the overall tenor of the faculty was one of cautious optimism. Many faculty reflected on the benefits of the new curriculum, particularly the shift in pedagogy while leveling criticism at some aspects such as the amount of work involved for faculty.
Every system presents some rewards and some challenges…overall, it's been a very good thing for the students, but I think it's hard to ignore the toll it's taken on faculty. (R2, F1)
Some disagreed that the change was worth the cost and effort.
This has been an inordinate amount of work, and I'm not sure what the benefit is. (R2, F2)
There would have been a fair middle ground that would have met the objectives without so many of the negatives. (R2, F3)
Jury is still out. If you asked me today “would you do this again,” my answer would be absolutely not. (R2, F4)
Others endorsed the change.
I think that I love the new curriculum. (R2, F11)
I'm not digging my heels in and saying there's not things that could be done and changed, but it was absolutely worth it. (R2, F17)
I would not go back. The thought of going back to the traditional model makes me shudder. (R2, F19)
In the second year, most of the faculty continued to support the change but felt that further changes were necessary to fully achieve the vision of the new curriculum.
I think it's worth it. I think it could still be better. (R2, F9)
I think it has a long way to go. (R2, F10)
I think we should have a retreat or something, as a faculty, and really analyze what's happened and what's currently happening and what we're committed to. (R2, F14)
Our findings reflect the perceptions of members of only one program during extensive curricular change. Although these findings may not extrapolate to all programs, our experiences are consistent with the organizational change literature. Our study may allow leaders and faculty in other PT education programs to better anticipate the types and breadth of faculty responses likely to be encountered during extensive curricular change.
Ten themes evolved from the qualitative assessment of this faculty's experience with a comprehensive curricular change over the first 2 years of implementation. When first looking at the themes that emerged, we considered that 7 of the themes reflected elements of the change process, whereas 3 reflected outcomes of the change process (Figure 1). The 7 change process themes were consistent with the accepted premise that shifting to a new curriculum is always difficult and stressful.32 When a curricular change includes both horizontal and vertical integration as well as changes in pedagogy (as was true in our program), navigating change of that magnitude is likely to be particularly trying. Among our faculty responses, we saw differences within themes in perceptions, expectations, and experiences. These differences may be explained, in part, by how individuals experience the informal organization or culture of the faculty, with those differences—in turn—influencing how faculty respond to changes.33 Elements of informal organization include personal views of the organization, interpersonal relationships, social norms, trust, risk-taking, values, emotions, and needs.33 The informal organization is disrupted by curricular change; this disruption is likely to trigger fear of the unknown, disruption of routine, destabilization of the status quo, feelings of loss of control, and perceived threats to power and self-interest.33,34 In the context of these common consequences to curricular change (or to organizational change in general), the criticisms and concerns voiced by our faculty are typical of those experiencing large changes both inside and outside education.
Armenakis and Bedeian35 reviewed organizational change literature during the 1990s and concluded that all change processes shared 4 common issues: content issues, contextual issues, process issues, and criterion issues. Using this framework to recategorize our 10 themes, 2 of the initial elements of change were recategorized as process issues and 5 of the initial elements of change were recategorized as contextual issues, and the 3 initial outcome elements were recategorized as content issues35 (Figure 1) Armenakis and Bedeian's criterion issues (“outcomes commonly assessed in organizational change efforts”) did not emerge sufficiently from our findings to constitute an element, most likely because these were not the focus of the interview questions. We can further examine our 10 themes using this framework.
The 2 themes of Convoluted Planning Process and Challenging Management Processes and Structures reflect process issues—that is, “actions undertaken during the enactment of an intended change.”35,p2
The nonlinearity and inconsistent velocity of the planning process, as well as the team-switching, seemed to disrupt the process and the equanimity of the faculty as reflected by their comments in the Convoluted Planning Process theme. Fullan36 identified change as both complex and messy but argued that disruption of the status quo is necessary to the generation of creative ideas and novel solutions. Our curricular change did have the initial advantage of full faculty support to embark on the initiative, with the shared sense of purpose being a critical element of implementing change or sustaining change.37,38 As teams stabilized during the initial planning process, there was less agitation among faculty as new strategies and solutions to curricular work, teamwork, and communications emerged. As faculty moved into the second year of teaching in the new curriculum, they could build on those new strategies and on now existing foundations.
The Challenging Management Processes and Structures theme shared the same need for new solutions to emerge from messiness as for the Convoluted Planning Process theme. Faculty were concerned about oversight of and accountability for implementing elements that were part of shared decision-making. They also worried about strategies that had been agreed on but seemed to need more management (leadership or coordination) than was consistently evident because some faculty persisted in past practices. Shankar32 noted that the limitations of an integrated curriculum can be uncomfortable for faculty who are used to complete control over the manner and sequence of teaching content within their courses. Development of written policies that support student engagement and appointment of individuals who provide detailed course oversight to assure consistency have been recommended by others.39,40 Elmore,41 however, argued that peer interactions rather than other forms of reward or accountability would be more likely to yield faculty alignment. These organizing components were not sufficiently present for our faculty to feel that organizational strategies we had agreed on were being supported or to hold accountable those that inadvertently or by choice went their own way.
Contextual issues are defined as “forces or conditions existing in an organization's external and internal environments” that influence perceptions of change.35,p.2 The 5 themes that seemed to address contextual issues were Inadequate Resources, Crucial Teamwork and Communication, Overwhelming Workload, New Pedagogy, and Integrated Curricular Structure.
The Overwhelming Workload theme was pervasive throughout most round 1 and round 2 interviews. Our interpretation, as shown in Figure 1, is that the 6 other process issues themes fed the perceptions of overload. The challenge to past behaviors and beliefs created by curriculum change and the competition of course or curricular change with faculty's other institutional commitments often led to feelings of confusion and being overwhelmed.21,36,42 There may have been a social-psychological fear of change that contributed to being overwhelmed and, for many of our faculty, a lack of pedagogical know-how to make the change work.36
Our faculty recognized they were embarking on an arduous journey. The difficulty of the journey was further exacerbated for many faculty who were teaching out the old curriculum at the same time they were embarking on the new curriculum. For everyone, planning and implementing so many new and different elements in new teams seemed to have an unexpected psychosocial impact. Faculty expected that the excessive work of teaching a course the first time would make teaching the course a second time much easier; this easing of the burden did not occur to the degree expected. Faculty recognized, as have others elsewhere, that the processes of shifting beliefs, necessary development of curricular materials, and gaining expertise in new pedagogical approaches takes considerable time and energy.39
The themes of Insufficient Resources, Crucial Teamwork and Communication, and Integrated Curricular Structure echoed the feelings of medical school faculty 1 year after shifting to a problem-based learning pedagogy.43 When asked what they liked least about their new curriculum, the most common faculty responses included demands on faculty time, lack of support, resource problems, faculty conflicts, and integration issues—particularly competition between program parts.
Mirabella and Balkun44 offered advice on resource support after implementing a new 4-year undergraduate core curriculum. They suggested that course reductions, stipends, and faculty development programs can be used to incentivize faculty to participate. Although stipends were allocated to many if not all of our faculty, these might have been insufficient. Faculty development programs (including access to instructional designers) were available but unevenly used. Interestingly, Fullan36 suggested that professional development opportunities alone are not sufficient and that ultimately, one must learn “in context”—learning in context being a premise of the active, case-based strategy we adopted that Fullan applied to faculty teaching.
The Critical Teamwork and Communication theme demonstrated a paramount concern among faculty. The often-expressed sentiment was that navigating teamwork and communication was a substantial portion of their work, requiring much more negotiation and consensus-building than anticipated. Shneider45,p.1, referencing Duke University's undergraduate overhaul of their general education requirements, wrote frankly that “Curriculum reform often sparks more back-biting than back-patting. Coalitions form. Tuff [sic] wars erupt. Lofty debate degenerates into low-stakes bickering.” Others argue that differences of opinion, expressed doubt, and even resistance to the changes can be formative, assuring that elements are not being missed and the “group think” is minimized.36,46 Although our faculty found conversations with each other to be “exhausting,” some also recognized the benefits of team deliberations in what Schein46 referred to as semantic redefinition (recognizing that words can mean different things to different people), cognitive broadening (expanding one's views or interpretations on a concept or issue), and generating new standards of judgment (judgments that change when the anchors for judgments shift with discussion).
The New Pedagogy theme emerged as some faculty struggled with active, small group learning and case-based teaching. This may have contributed to faculty stress and perceptions of overwork, especially for faculty who were not comfortable with how to best use classroom time or relinquishing some of the control they had as the “sage on the stage.” There were also concerns expressed about how quickly a 4-week course went by, perhaps providing students with insufficient processing time and eliminating some formative assessment options that could not feasibly be turned around by faculty in that timeframe. However, there clearly were upsides that may have offset the energy drain somewhat. Many faculty found their time in the classroom “stimulating” and surprisingly enjoyable, with more student engagement and participation—especially at the small group level. Mirroring faculty from other curricula making the shift from “what to learn” to “how to learn,” our faculty remarked that students' discussions were more integrative and the level of clinical reasoning higher; there was a sense that this would lead to graduates being better lifelong learners.22,23,25
As was true for issues with the new pedagogy, faculty addressed the downsides to the integrative nature of the curriculum in the Integrated Curriculum Structure theme but also recognized counterbalancing upsides. There was a fairly consistent sense that content and concept integration had not been fully realized in the first 2 years, although “headed in the right direction.” This might have been both because of the difficulty of the task of integrating cross-curricular threads in particular but also because of the need for faculty to think beyond their usual areas of expertise as patient narratives addressed multiple systems and the many elements of a person-centered clinical decision-making process. The challenges of implementing an integrated curriculum have been reported in similar efforts in medical education. Integration of social and behavioral sciences (analogous to our cross-curricular threads) were thought to be the least well-integrated, with collaborations across disciplines (content areas in our curriculum) hampered by different assumptions and teaching practices as well as by inadequate communication.32,40 On the positive side, faculty were amazed to see students working through the clinical decision-making process including goal setting for their patient only 2 weeks into the curriculum. Students' ability to later apply their processes to complex patients in inpatient settings reflected the “benefits of an integrated curriculum for learning and retention, emphasising [sic] that learning is enhanced when it is meaningful, relevant and learned in the context in which it will be later recalled.”40,p.779
The final 3 themes (Evolving Attitudes and Approaches, Personal and Professional Growth, and Cautious Optimism) reflect what Armenakis and Bedeian35,p.3 referred to as the content issues common to change, that is, the transformational and transactional dynamics inherent in change efforts. In the Evolving Attitudes and Approaches theme, faculty verbalized their recognition that it takes multiple years to fully realize the change and that the elements of change were evolving continually. They also recognized that there was an increased comfort both as they got better at the different teaching style and when they let go of trying to get it exactly right. In a multiyear view of a redesign to a general psychology course, Hudson et al42 observed that it took time to refine both the approach and the pedagogy as well as time for the change in the informal organization, recommending that faculty adopt the mindset of a marathoner rather than a sprinter. The reduction in discomfort may also indicate that faculty are benefitting from the semantic redefinition by Schein46, cognitive broadening, and are developing new standards of judgment.
The theme of Personal and Professional Growth provided evidence, as noted by Fullan36 and by Schein,46 that the reorganization created by disruption, although uncomfortable, can change faculty behaviors and beliefs. Faculty reflected on their growth as teachers, on their improved collaboration and communication skills, and on the value of opening up to the opinions of others. The theme of Cautious Optimism also addressed the cost-benefit ratio of innovative change. Most faculty recognized the benefits to themselves and, more importantly, to the students. Others were not sure at the 2-year mark that it was worth the toll on faculty. There was a distinct recognition that both the process elements and the culture elements were still works in progress. Faculty were looking forward to assessing student outcomes for the first few cohorts and looking for opportunities to reflect as a full faculty on what was working as envisioned and where and how they could do better.
This is the first study, to our knowledge, that describes the perceptions of a physical therapy faculty planning and implementing an entirely new integrated, active learning DPT curriculum. For the most part, their observations, insights, and concerns paralleled those of other nonphysical therapy faculty going through similar changes to innovative curricula—although angst may have been greater than is evident in other studies. Medical faculty undergoing comparable curricular change identified some of the same challenges expressed by our faculty, including “achieving truly interdisciplinary lectures, overcoming the reluctance of faculty to shift to a new curriculum model; getting faculty to communicate with one another, and establishing oversight and continuity of themes across courses.”40,p.783 Despite their concerns, most faculty remained hopeful that continued curricular development and faculty growth would move them increasingly toward the original goal of a patient-centered integrated curriculum that better prepares graduates to function in a dynamic health care environment where best practices continually shift with emerging biopsychosocial research and the demands or requirements of our external environments.
In sharing our experiences in the context of curriculum and course change literature, it would be exciting if the outcome was a how-to manual on how faculty can smoothly navigate through extensive curricular change. However, the literature is consistent in pointing out that faculty experience perceived disruption in highly individualized ways,33,34 and that those experiences are affected by the unique philosophy, culture, and standards of an organization.47 These factors argue against a one-size-fits-all approach. We can, however, reiterate some elements from our experiences and from the change literature that warrant particular attention.
- Stress may be unavoidable, but fostering a shared sense of purpose may mitigate anxiety and facilitate more effective change.37,38
- When a curriculum is entirely rebuilt, making it work smoothly requires a commitment of time and effort to building new relationships and teams among faculty.
- A large range of supports for faculty are needed for smooth implementation, including administrative oversight, financial, workload adjustment, and faculty development resources.39,40
- Faculty discomfort with planning and implementing contemporary pedagogies may be reduced with implementation of communities of practice for faculty development. As proposed by de Carvalho-Filho et al,48 a successful community of practice offers an effective and sustainable mechanism for shared best practices and co-created practical solutions.
- The disruption of a major curricular change creates challenges for faculty and administrators who should recognize the change processes tend to be slow and iterative39
- Improvements in curricular outcomes require time because faculty refine approaches, develop expertise, and shift personal values and beliefs.36,39,42
The call to rethink physical therapy education to reduce graduate indebtedness27 and address current and future public health crises will demand that many programs undergo extensive curricular change. It must be recognized that such changes to the status quo have repercussions not only on the program but also on its faculty. “Change is a leader's friend but it has a split personality: its nonlinear messiness gets us into trouble. But the experience of this messiness is necessary in order to discover the hidden benefits—creative ideas and novel solutions are often generated when the status quo is disrupted.”36,p.107