BACKGROUND AND PURPOSE
Physical therapists, like many health care professionals, are expected to perform specific clinical skills as part of their everyday interactions with patients and clients. These are foundational skills required for competent clinical practice and range from simple, such as palpation of anatomical landmarks, to complex, such as performing a grade 5 spinal manipulation, assisted breathing techniques, or gait facilitation. Often in a physical therapy curriculum, clinical skills are taught in silos without contextual factors that require the student to demonstrate clinical reasoning including appropriate application, interpretation, and modification of these skills. Clinical content is traditionally taught in a laboratory setting and then practiced in the context of clinical educational experiences that occur in authentic settings.
There is little research describing best practices for teaching clinical and psychomotor skills in physical therapy education to enhance skill transfer to the clinical environment.1 Medical education literature suggests that there are many ways to teach clinical skills and these variations are influenced by curriculum, availability of resources, and faculty involvement.1 When teaching clinical skills, the objective is for students to demonstrate the ability to perform the skill accurately, efficiently, and consistently over time.2 This objective of clinical skill teaching and learning is achieved through guided practice, repetition, and reinforcement. Educators are also compelled to ensure that students achieve a true change in behavior related to clinical skill learning and retention, and avoidance of temporary and simple skill recall and performance,3 not only in the laboratory setting but also within the context of patient care. Additionally, there is a need to facilitate the clinical reasoning associated with the performance of these skills.4,5 Inherent to teaching clinical skills is a concern not only for the learner to perform the skill but also interpret the resulting outcome and discern implications for patient care with consideration for the whole person and creation of a patient-centered plan of care.6 When teaching clinical skills, faculty must seek to maximize all these considerations.
Physical therapists readily apply motor learning principles when teaching psychomotor skills to patients and the same motor learning principles should be used when teaching clinical skills to physical therapy students, but the evidence is lacking.7 Like patients, students must progress through the phases of motor learning: cognitive, associative, and autonomous,6 and practice schedules can facilitate this progression.8 Distributed practice is favored over massed practice for skill retention and transferability to real-life scenarios.7,9,10 Evidence also supports that skill retention decreases after periods of nonuse.11 The rate and intensity of skill decay is influenced by the amount of practice in early stages of learning, the amount of time between initial learning and recall, and the nature of the task.11 Other principles of motor learning (observational practice combined with physical practice, external focus of attention, positive feedback, and self-controlled practice) have been applied to teaching clinical skills with positive influences on learning outcomes.12 For these reasons, repetition and recall of skills over the course of a curriculum are helpful in retention of these skills.13
In clinical practice, physical therapists select interventions to match the context of a patient's needs. Similarly, in teaching clinical skills, learning experiences should match the context of the learner's needs.7 Practice in the laboratory must translate to clinical practice and the need to address context of learning has given rise to many forms of experiential learning.14 Experiential learning includes simulations, role playing, and community engagement that help to stimulate “higher student motivation, more learning at higher cognitive levels, greater appreciation of the subject matter and its utility, and longer retention of material” when compared with traditional lecture learning.15 Evidence in the nursing literature suggests a “theory-practice-gap” where there is an incongruence of skills learned in the academic setting compared with clinical practice and difficulty applying knowledge and procedures learned in one context to another.14,16 Laboratory settings are meant to bridge the gap between theory and practice, but their inauthenticity may limit the transferability of skills.16 Learning in the context of a patient case or encounter provides the foundation needed for mastering clinical skills early in the curriculum.10 Progressive, guided practice with multiple opportunities to apply skills to patients is needed to increase the authenticity and real-world applicability of clinical skills.10
Traditional skills laboratories teach clinical skills as individual tasks, but this does not reflect true clinical practice where the findings of one measure may influence which other tests and measures are chosen to appropriately assess a patient's physical therapy needs. Skills taught as individual tasks without considering context or outcome do not promote translation of theory to clinical practice.10 Incorporating the rationale behind why a skill is chosen and the implications of the result of that skill on patient care becomes integral to the skill itself,17 and thus, the learning environment should provide the clinical application and clinical reasoning necessary to translate to patient-centered practice.18 This learning in context could “enhance the understanding and application of course material, improve personal and professional attributes and skills needed to be an effective clinician and improve clinical reasoning skills.”18 Still, literature is lacking with regards to effective teaching strategies to facilitate this type of clinical skill attainment.7,14
The purpose of this article was to describe a successful model for teaching clinical skills across content areas in a physical therapy curriculum with consideration for motor learning principles, experiential learning, and clinical reasoning.
The Educational Model
Creighton University's entry-level DPT curriculum uses biopsychosocial sciences19 as the foundation for progression to clinical sciences. Those clinical science courses serve to prepare students for clinical experiences that are both integrated and progressive in the curricular sequence. During a curriculum revision in 2015, a decision was made to move the teaching of clinical skills out of system-specific laboratories and into a series of integrated laboratory courses wherein all clinical skills are taught in the context of a single course. This led to the development of a 6-semester series of integrated laboratory courses. Each integrated laboratory course facilitates the teaching and learning of clinical skills across system domains, addressing multiple components of the movement system, and reinforcing concepts from all clinical science courses in a semester. Content from the clinical science coursework that contributes to each integrated laboratory course is listed in Figure 1.
All 6 integrated laboratory courses use the patient and client management model20 as the framework for skill development and practice. Students are introduced to examination procedures, practice evaluation and interpretation of clinical data to form an appropriate diagnosis and prognosis, then learn and practice relevant interventions.
The program embraces a developmental learning approach across the curriculum in 3 areas: medical complexity of a patient, expected clinical performance and clinical reasoning. In the area of medical complexity, students are initially introduced to medical management of the “well adult,” which then progresses across 6 semesters to include more medically complex scenarios with patients across the lifespan. In expected clinical performance, students are expected to progress from the beginner level of the clinical reasoning grading rubric21 to the competency benchmark by the completion of semester 6. Regarding clinical reasoning, students are expected to use a hypothetico-deductive reasoning model early in the curriculum and progress to more inductive methods of reasoning. This developmental learning approach is depicted in Figure 1.
This model capitalizes on motor learning principles and the use of laboratory time as a means for distributed practice of skills across the curriculum with progressive expectations of complexity and flexibility of skills and required decision making. Skills are reinforced across content areas and start with an emphasis on wellness and progress in medical complexity. Experiential learning is threaded through the model with early use of patient encounters with simulated patients, standardized patients, community volunteers, and authentic patients to facilitate hands-on practice that translates to clinical practice. Clinical skills are practiced within the patient and client management model to create a context for application of skills and authenticity of real-world practice. Inherent in our model is an integration of hands-on skills with clinical reasoning and a focus on critical self-reflection to overcome the theory practice gap.
Each didactic semester students are enrolled in courses in both clinical and biopsychosocial sciences that have a single clinical laboratory course, Integrated Laboratory. This comprehensive laboratory experience encompasses the content of concurrent clinical coursework and promotes the developmental learning continuum described above.
Within each integrated laboratory course, a similar model is used to progress students from early skill acquisition, to skill practice, to skill application and eventual skill assessment. For early skill acquisition, the integrated laboratory functions similarly to system-specific laboratories. Students are provided with reading assignments, prelaboratory assignments, and videos to review before attending laboratory. Once in the laboratory setting, skills are demonstrated by content experts and students are allowed ample time to practice skills on their classmates with feedback from faculty and expert clinicians. Special emphasis is placed on distributed practice of psychomotor skills and consideration of clinical skills in the context of patient management while using motor learning principles.
Once skills are initially learned and practiced, appropriate skill performance is assessed by intermittent skills competency tests (SCTs). Skills competency tests are typically specific to each clinical science course and allow faculty to evaluate whether students have acquired the psychomotor abilities required for clinical practice. Basic skill instruction and performance is introduced early in the curriculum, then advanced to performing skills as they relate to a patient case, to finally in the later semesters performing these skills on an authentic patient. Students are allowed 3 attempts to demonstrate acceptable performance on a SCT. Skills competency tests allow for faculty to provide feedback specific to each individual student related to their psychomotor skill performance, as well as provide a level of assurance that the learner is prepared to progress to the next step of the integrated laboratory model.
After students have successfully completed their SCTs, the integrated laboratory model calls for skill application in the context of authentic experiential learning opportunities, which highlights the integrative nature of the laboratory course sequence. Experiential learning opportunities include patient care simulations, practice with community volunteers within the laboratory context, and service-learning events with various community partners. In earlier semesters, this involves one-time patient encounters and then progresses to regular patient treatment sessions in semesters 4, 5, and 6. These authentic experiential learning opportunities allow students to apply the skills they have learned over the course of the semester in the context of patient cases that are designed to require skill sets from multiple physical therapy domains and scaled to the appropriate level of the learner. The application of skills shortly after initial exposure helps to solidify the content,22 and the use of experiential learning in the didactic curriculum allows for earlier identification of gaps in knowledge and performance.23
After each experiential learning opportunity, students engage in critical self-reflection to enhance and highlight their clinical reasoning skills.24 Depending on the learning opportunity, the reflection may be written or in the context of large or small group debriefing and discussion.
Once students have acquired skills, demonstrated competence, and applied their newly learned skills, summative assessment of skills in the context of patient care can be completed. In this curriculum, each integrated laboratory course concludes with a Clinical Competence Performance Examination (CCPE). This is a case-based examination that is completed one-on-one with a core faculty member, an associate faculty member, or a physical therapy resident and serves as the final examination for the integrated laboratory course. During this examination, students are provided with a patient case that requires them to integrate skills from all clinical science courses that have been covered in the curriculum. Examples of integrated cases used in these examinations may include a patient who has experienced a cerebrovascular accident and is reporting shoulder pain, a patient with Parkinson disease who is experiencing low back pain or a postop orthopedic patient with cardiopulmonary complications. They are expected to treat the examination as a patient care scenario and progress through all stages of the patient client management model. Students are assessed using the Clinical Reasoning Grading Rubric developed by Furze et al21 in 3 domains: content knowledge, psychomotor skill, and conceptual knowledge/reasoning. Expectations for performance on the Clinical Reasoning Grading Rubric are outlined in Table 1.
Table 1. -
Benchmarks for Student Outcomes on the Clinical Reasoning
Grading Rubric and CPI
|Patient Management I
|Patient Management II
|Cardiovascular and Pulmonary I
|First integrated clinical experience with CPI expectation at Advanced Beginner
|Second integrated clinical experience with CPI expectation at Intermediate
|Integrated Patient Care
|Cardiovascular and Pulmonary II
|First terminal clinical experience with CPI expectation at entry level
|Second terminal clinical experience with CPI expectation at entry level
Abbreviations: CCPE = Clinical Competence Performance Examination; CPI = Clinical Performance Instrument.
Successful completion of the CCPE serves as a means of summative assessment to determine readiness for clinical experiences. Expectations for performance on the Clinical Reasoning Grading Rubric are progressively increased in all 3 domains over the course of the didactic curriculum to respect introduction of new content as well as advancement of student skill and knowledge toward that of an entry-level clinician.
The curriculum also uses both integrated and terminal clinical experiences as a means to apply didactic information in the context of patient care. The Clinical Performance Instrument (CPI) is used to assess student performance on all clinical experiences, again using the same progressive improvement expectation. Benchmarks related to CPI outcomes are also described in Table 1.
Figure 2 demonstrates implementation of this model using the second semester of the curriculum as an example. In this semester, Patient Management II, Cardiovascular and Pulmonary Physical Therapy I, and Movement Science contribute content to Integrated Laboratory II. Specific psychomotor skills learned in this laboratory include transfers, gait with assistive devices, cardiovascular and pulmonary assessment, and manual muscle testing and goniometry.
Motor learning principles are implemented through distributed practice of these skills, including recall and progression of skills learned in the first semester (vital sign assessment) as well as practice of skills in multiple laboratory sessions. Students first observe a demonstration of the skill before completing physical practice and also have access to videos of all skills for review at a later date. Positive and constructive feedback is used by faculty during practice times to further use motor learning principles. Two to 3 weeks after initial learning, SCTs are used to assess learning of specific psychomotor skills, allowing for self-controlled practice, opportunities to seek clarification and enough time to challenge recall of skill performance.
Once skill competency is established, authentic experiential learning is used to apply the learned skills in the context of a patient case. For this example, students complete a simulated acute care experience with standardized patients as well as community-based cardiovascular and pulmonary screens with volunteers. Both experiences require students to implement multiple skills from the semester (transfers, gait, cardiopulmonary status, strength, and range of motion) to assess patient function.
After each of these experiential learning opportunities, clinical reasoning is promoted through large group discussion and debriefing and the use of guided critical self-reflection in written assignments. Finally, formative assessment of skills learned is completed with the CCPE in the context of a patient case. Cases used for this examination necessitated the demonstration of skills from all content areas (Patient Management II, Cardiovascular and Pulmonary Physical Therapy I, and Movement Science) to be successful.
This study used retrospective outcome data collected throughout the 6 semesters of integrated laboratories for the first cohort of students taught using this model. These data included SCTs in each semester, the 6 CCPEs, CPI outcomes for 2 integrated clinical education experiences and 2 terminal clinical education experiences, clinical education summaries, and National Physical Therapy Examination (NPTE) results. Narrative responses from the CPI were compiled by clinical education faculty into clinical education summaries, which were reviewed by the authors. Figure 3 represents the data points that were collected in review of this model. This study received approval from the Creighton University Institutional Review Board.
Evaluation of success of the integrated laboratory model utilized assessment methods used within the 6 integrated laboratory courses, clinical education benchmarks, and NPTE results.
The integrated laboratory model was implemented with an initial cohort of 62 students. Fifty-nine students successfully completed the didactic and clinical education curriculum and passed the NPTE. Two students were unsuccessful in non–laboratory-based coursework and rejoined the program with the following cohort; one student was unsuccessful in the laboratory-based course in semester 6 and also rejoined the program with the following cohort.
The 59 students who graduated met programmatic benchmarks throughout the integrated laboratory course sequence. Each student passed the SCTs administered during semesters 1–6, given a maximum of 3 trials. Except for the one student in semester 6, each student passed the CCPE administered at the end of each semester in one of 3 trials (Table 2).
Table 2. -
Comprehensive Clinical Performance Examination Outcomes
||First-Time Pass, No. (%)
||Total Pass After First Attempt, No. (%)
||Total Pass After Third Attempt, No. (%)
||Exemplary Performance, No. (%)
||Overall Pass, No. (%)
Having been deemed safe and competent to progress into clinical education experiences, each student met expectations for performance as measured on the CPI, including entry-level performance after each of the 2 terminal experiences. Eight CPI elements that most closely reflected the objectives of integrated laboratory were chosen for assessment of this model. These elements were most closely aligned with the outcome objectives for the integrated laboratory courses and focused on clinical skills and clinical reasoning. They included clinical reasoning, screening, examination, evaluation, diagnosis and prognosis, plan of care, procedural interventions, and educational interventions. Students were expected to meet Advanced Beginner at the end of their first integrated clinical experience, Intermediate at the end of their second integrated clinical experience, and Entry Level at the end of their last 2 terminal clinical experiences. Subjective comments from clinical instructors were required to support and confirm CPI markings. All students met these expectations for each of their clinical experiences and many students exceeded these expectations. Figure 4 displays the percentage of students who exceeded performance expectations for each clinical education experience.
Narrative responses from students and clinical instructors on the CPI suggest that the integrated laboratory model for teaching clinical skills and clinical decision making leads to successful preparation for clinical education and practice. Furthermore, students cited the integrated laboratory experience as a curricular strength after each clinical experience on the Student Assessment of Clinical Experience form, noting that early and frequent interaction with patients was valuable to their professional development.
Students identified the integrated laboratories as strong preparation for clinical experiences:
I believe that the added integrated labs to the curriculum was the most beneficial in preparing me for this clinical experience…The skills that were developed from the combined courses brought into integrated laboratory and documentation and patient management skills were strengths that were apparent in my third clinical experience.
The blending of the different classes was also very helpful. It allowed me to make almost a seamless transition between cardiopulm interventions, to orthopedic intervention to neuro interventions.
Strengths of curricular preparation include: case examples of common outpatient physical therapy diagnoses and practicing examination and evaluation skills on mock and real patients.
The CCPE greatly prepared me for this clinical having previous experience of practicing in the acute care setting with a professor before participating in this clinical experience. It was also beneficial having observation experiences in the acute care setting throughout our curriculum.
I also think doing the CCPE's was helpful to realize we are treating the whole person and to put everything together. I feel like going into this clinical I was extremely well prepared. I really appreciate going over standardized tests and knowing the different ones for balance and gait etc. I felt comfortable with evaluations and examinations. I think the curriculum really prepared me well for this setting.
I believe the pediatric related coursework was very sufficient in preparing me for this clinical experience. I felt like I had the foundational information for various diagnoses and had the resources to look information up when I had questions. I also feel like I had basic manual and handling skills when working with infants. I especially enjoyed the pediatric patients that came into laboratory because that was a real-life situation/scenario.
All 59 students passed the NPTE after graduation; 98.3% passed on the first attempt.
DISCUSSION AND CONCLUSION
This model was designed and implemented to reinforce motor learning strategies in clinical skill development, increase experiential learning opportunities, and promote clinical reasoning across the curriculum. Outcomes demonstrate that this model of teaching clinical skills and clinical reasoning across content areas in the context of the patient and client management model was successful in meeting expected student outcomes. Because the integrated laboratory model was implemented in the context of a larger curriculum revision, there were associated confounding variables that limit opportunities to isolate the impact of the model on student outcomes. Although comparison between models is beyond the scope of this article, variance of student learning outcomes between the nonintegrated and integrated models is inadequate for statistical analysis, with both models resulting in similar student outcomes related to success on clinical experiences, postgraduation employment, and NPTE pass rates. In the absence of significant differences in student outcomes between models, future studies could examine outcome differences related to faculty workloads and engagement of the clinical community in the academic program partnerships.
Essential to this model is the consistency of a single instructor of record over consecutive integrated laboratory courses (one laboratory director for semesters 1–3 and a second laboratory director for semesters 4–6). Because these faculty members are involved in multiple clinical science content areas and are familiar with the content taught, the laboratory directors become experts on the curriculum and have firsthand knowledge of students' previous clinical skill development. This unique knowledge and perspective facilitate the creation of experiences that allow for distributed practice of previously learned skills and well as progression of performance expectations related to those skills. The laboratory director has specific knowledge of how each skill was taught and can reinforce important concepts with confidence. Additionally, the laboratory director becomes the point of contact for students and other faculty members for all things related to laboratory learning because of their in-depth knowledge of content across the curriculum.
For example, students learn how to assess vital signs in the first semester. The laboratory director knows the specific expectations of how these skills should be performed, is familiar with how students were exposed to the skills, can reinforce practice in subsequent classes with the same expectations and can progress expectations with regards to accuracy and efficiency of skill performance. The laboratory director can thread this skill through assessment of the well adult, individuals with pathology, across the lifespan and in unique situations. This allows for application of motor learning principles through distributed practice of clinical skills7,9,10 with progressive expectations related to complexity, efficiency, and flexibility, and requires the learner to consider the skill within the context of the situation, thus further challenging clinical reasoning abilities.10
In addition to student outcomes, there are several curricular outcomes that have been enhanced with implementation of the integrated laboratory model. This model allows for improved integration of clinical sciences and a laboratory environment that more closely reflects clinical practice. Because patients seeking physical therapy treatment frequently have impairments in multiple domains,25-28 and multiple domains contribute to the movement system,29 teaching and practicing skills across domains promotes physical therapy management of the patient as a whole. This model allows for consistent exposure to a comprehensive and holistic approach to patient care. The integrated laboratory model has also contributed to increased faculty communication and collaboration in development of experiential learning opportunities that cross content areas. Although increased collaboration among faculty is required, individual faculty are asked to forgo some of the dedicated, content-specific laboratory time to promote integrated experiences.
The use of experiential learning in development of clinical skills and clinical reasoning is supported by the literature.18,30 This model allows for early and frequent exposure to real clinical situations and the use of reflection after these experiences helps students to integrate the impact of simulations and patient encounters on their future practice and to gain confidence in providing quality care.24,31-33 The pairing of experiential learning and reflection is intentional to promote the development of clinical reasoning skills. These authentic experiences with patients, distributed across the curriculum, encourage the translation of skills from the laboratory setting to clinical practice.
Student feedback about the integrated laboratory learning model has been positive. They feel confident in their abilities to integrate the various clinical sciences together to treat the whole person. There are benefits for the faculty, as well. This type of laboratory course design promotes faculty engagement and interaction. No longer are faculty teaching their individual courses in isolation but rather faculty are coming together to plan laboratories that support multiple clinical science courses. For example, in semester 5, the neuromuscular and musculoskeletal courses faculty coordinate an entire lecture and laboratory experience around concussion management and how one would preferably manage a patient with a concussion, highlighting content from the musculoskeletal and neuromuscular physical therapy courses.
Implementation of this model has shown several benefits, but there have been several challenges. With more faculty involved in the laboratory to maintain content expertise as well as appropriate faculty to student ratios, more consideration has been paid to scheduling, coordinating, and preparing for laboratory sessions. Although time intensive initially, this has become less burdensome in subsequent years based on experience. Additional challenges are posed when clinical skills do not integrate seamlessly across the clinical science course content being taught.
The challenge in the role of laboratory director is the need to have knowledge and skill across content areas and strong organizational skills to ensure that all laboratory objectives from multiple domains are addressed. In recognition of the fact that the laboratory director does not possess expertise in all fields of physical therapy, this model requires that several content experts be present in each laboratory class to ensure contemporary expertise. Associated faculty from the community that have content expertise are frequently used as laboratory assistants to ensure that students are getting contemporary expertise. Although this poses challenges in recruitment and scheduling, there is immeasurable benefit in the collaboration and involvement of community clinicians within the department.
Assessment of the model is ongoing. Areas of interest moving forward will be assessment of skill development and retention, assessment of individual laboratory activities in meeting learning outcomes, expansion of experiential learning opportunities, and assessment of clinical reasoning skills resulting from model implementation.
A model for teaching clinical skills across content areas was implemented in an entry-level DPT program and was successful in meeting expected student and program outcomes. Initial assessment of the model is positive related to both didactic and clinical outcomes. The integrated laboratory framework can be used by programs using different curriculum models by adjusting the content to correlate with concurrent classroom learning. Assessment of the model and related outcomes is ongoing, and refinement of the model will continue through evaluation of assessment data.
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