INTRODUCTION
Data from the Physical Therapy Centralized Application Service and Commission on Accreditation in Physical Therapy Education (CAPTE) suggests that entry-level Doctor of Physical Therapy (DPT) programs struggle to attract, matriculate, and graduate demographically diverse applicants.1 Data trends of practicing physical therapists (PTs) published by the American Physical Therapy Association (APTA) denote limited demographic diversification over the past 22 years.2,3 In the United States, expected population growth through 2060 will result in a diverse population of citizens identifying with different cultures, races, or ethnicities.4 With changing demography, health care professionals must be aware of patient's unique needs, preferences, and goals to achieve successful outcomes.5 Patient outcomes may be negatively affected through cultural misunderstandings and communication barriers between patient and clinician.5-8 Recent discussions have focused on improving culturally competent behaviors and attitudes of health care providers.9-11
In health care, cultural competence is an ongoing process where practitioners strive to bridge the gap with patients from various cultures or belief systems by working within the cultural context of the patient, patient's family, or community to achieve positive outcomes.12 The Core Values for the Physical Therapist and Physical Therapist Assistant13 outline behaviors and attitudes contributing to culturally competent patient care. Although there are models for incorporating cultural competence education into entry-level DPT curriculum,14 there are no clearly defined accreditation requirements for cultural competence.15
Development of culturally competent behaviors and awareness in PT students has been previously studied.16-18 However, a novice PT may not understand what it means to provide culturally competent care until they practice without guidance from professors or clinical instructors (CIs).19 Through autonomous practice, PTs may reflect on their education and provide insight into the strengths or weaknesses of their cultural competence education.
Qualitative phenomenological interviews draw out perceptions based on deeper investigation into personal feelings or experiences that contribute to changes in behaviors, attitudes, or skills.20 The purpose of this study was to examine perceptions of novice/advanced beginner (N/AB) and experienced clinicians (ECs) regarding how well their DPT curriculum prepared them to act as culturally competent providers. Findings can inform whether changes to cultural competence curriculum in PT education may be needed. The investigator sought to answer the questions.
- How do N/AB and experienced PTs perceive their preparedness to engage in culturally competent practice upon graduation based on recollection of the curriculum and training received in their PT education program?
- What influence does clinical practice and method of education or training have on PTs' perceived preparedness to engage in culturally competent patient care upon graduation?
REVIEW OF LITERATURE
Educational Methods for Cultural Competence Development
A barrier to successful delivery of culturally competent rehabilitation services is lack of sufficient training and lack of resources.21 The APTA provides links to published literature, pedagogy suggestions, and assessment tools for incorporating cultural competence into curriculum.14,22 However, absence of CAPTE accreditation standards specific to cultural competence15 can lead to inconsistencies in how PT students receive cultural competence education.
Differences in cultural competence curriculum may result in different perceptions of preparedness and variability in how cultural competence is incorporated into patient care.19,21-25 During clinical rotations, PT students have demonstrated difficulty adapting to patient's cultural differences.26,27 Students reverted to Westernized biomedical models of patient care–focusing on identifying disease and relying on ethnocentric intervention ideologies–and lacked self-awareness related to culturally competent behaviors.26,27 These behaviors limit adaptation of health care strategies for differing cultural, ethnic, or spiritual perspectives patients might hold toward their health.27
Although there may not be significant differences in learning outcomes between students who receive different cultural competence curriculum, student-held perceptions of curriculum effectiveness can vary, along with perceptions of preparedness to practice culturally competent patient care.24,28,29 Students may feel more confident applying certain aspects of cultural competence education into practice than others.28,30 Exposure to different patients during their education can change students' perceptions of their abilities over time.26,29 No studies were found that examined influences of curricular methods on PT perceptions of preparedness to provide culturally competent patient care, or whether perceptions changed over time.
Influence of Clinical Practice on Perceptions of Preparedness
Physicians and occupational therapists reported relying on time in clinical practice to improve their cultural competence rather than their training.23,31 Differences exist between novice and experienced health care providers; ECs demonstrate elevated confidence and skills related to treatment and interactions, along with different perceptions of preparedness compared to novice colleagues.19,32-34
In studies comparing cohorts of PT students, the frequency of interactions with patients from various cultures influenced changes in perception of culturally competent behaviors.16-18 Self-motivation and clinical environment, including mentorship or clinic culture, influenced clinician development and perceptions of clinical practice.19,34 No studies were found comparing perspectives of novice clinicians and ECs on how well they believed their DPT program prepared them to practice as culturally competent providers.
Cultural Competence and Self-perception
Multiple models contributed to the theoretical framework of cultural competence in health care.35-38 The Process of Cultural Competence in the Delivery of Health care Services (PCCDHS) established 5 constructs of cultural competence: cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desires.35 Each construct addresses barriers that hinder culturally competent practice and affect patient outcomes: ethnocentric behaviors, lack of sensitivity to or knowledge of other cultures, difficulty collecting and interpreting appropriate information from patients, and lack of self-awareness or desire to become more competent.21,35
In the self-perception theory, individuals understand their attitudes by reflecting on their behaviors; interpretations of behaviors are influenced by the environment in which they take place.39,40 Development of cultural competence can be influenced by self-reflection on behaviors and development of psychomotor and cognitive skills over time.19,40 The interaction of the PCCDHS theoretical framework and self-perception theory39,40 (Figure 1, Supplemental Digital Content 1, https://links.lww.com/JOPTE/A216) established a foundation to investigate relationships between how curriculum or clinical practice might influence perceptions of preparedness of PTs to engage in culturally competent behaviors.
Most available literature examined PT students, highlighting a need to compare opinions and reflections of practicing clinicians to examine how cultural competence curriculum influenced perceptions of preparedness to practice culturally competent patient care.
SUBJECTS
Sample
The sample consisted of licensed PTs. Physical therapists who did not graduate from an entry-level DPT program, had never participated in patient care, or who received their education outside of the United States were excluded from the study.
Recruitment occurred from May 2021 to July 2021 and included nonprobability purposive sampling of convenience and snowball sampling. Participants were recruited via brochures on social media and through email to all therapists employed at a privately owned company with clinics in Arizona and Oklahoma. Participants were grouped based on years of clinical experience: N/AB therapists with 3 or fewer years of experience and ECs with greater than 3 years of clinical practice. The 3-year cutoff for the N/AB group was based on literature describing characteristics of “novice” and “advanced beginner” clinicians related to years in practice, exposure to novel patient presentations, and development of critical thinking and reflection behaviors.19,41,42
METHODS
Research Design
This study was a phenomenological qualitative study. It was approved by the institutional review board.
Instrumentation
Data collection occurred through semi-structured interviews. Interview questions (Appendix 1, https://links.lww.com/JOPTE/A217) were reviewed by a research advisor and a cohort of 10 health care educators who provided feedback regarding question integrity and structure. Some questions were modified to eliminate redundancy or add depth of detail across interviews based on common response patterns from early participants. Probing questions helped achieve thick description of a participant's unique perceptions.
Researcher positionality was identified in the interview introduction and established the purpose of the investigation. The investigator introduced herself based on her professional title and experience. She described goals of the study from her perspective as a clinician, educator, and student. Concerns that prompted the investigation regarding cultural competence and lack of diversity within the physical therapy profession were shared with participants.
Member checks were conducted for data credibility and validity. Participants were asked to review their transcript and a synthesis of findings from the group data. Two participants provided feedback during the member check process related to clarification in the results synthesis. No participant disagreed with accuracy of their transcripts.
Audit trail maintenance and reflexive journaling contributed to data reliability and was performed before, during, and/or after interviews via pen and paper and through memo attachments to coded material along with codebook maintenance within the qualitative software program MAXQDA.43 These measures contributed to theory development and explanation of biases or investigator positions regarding the study.
Data Collection
Participants completed an informed consent and demographic sheet, which were password-protected on the investigator's computer to maintain confidentiality. Participants entered encrypted Zoom interviews with a password. Interviews were transcribed, participant codes were assigned to audio or video files and transcripts, and all files were securely stored under password protection. Information linking participants to their participant code was kept in a separate locked file.
Data Analysis
Confidential transcribed data were uploaded to MAXQDA. A research assistant external to the investigation compared de-identified interview audio and transcripts for accuracy. Open coding in MAXQDA began after each transcript was edited. Axial codes and subcodes contributed to emergent categories. Constant comparative and inductive analysis of codes contributed to emergent themes, determined whether discrepant cases were present, and when data saturation was achieved. Data cleaning included codebook organization, condensing categories, and clarifying emerging themes. Audit trail and reflexive journals were maintained and reviewed throughout to limit investigator bias.
RESULTS
Eighteen PTs responded to recruitment efforts. One therapist had a master's degree in PT and was excluded. Another therapist could not participate in a Zoom interview, and 4 therapists did not respond to scheduling requests. Thirteen PTs were interviewed: 9 had more than 3 years of practice (EC) and 4 had 3 or fewer years of practice (N/AB).
Demographic information of participants is identified in Table 1. Most participants identified as female (61.5%), practiced in an outpatient orthopedic setting (85%), and had more than 3 years of experience (69%). Most participants identified as White/Caucasian (84.6%), followed by Hispanic (7.7%) and Asian (7.7%) (Table 1).
Table 1. -
Summary of Participant Demographics
| Participant Number (N = 13) |
Years of Practicea
|
Geographic Region of PT Educationb
|
Geographic Region of Current Practice |
Nationality |
Ethnicity |
Gender |
| 18 |
≤3 |
Northeast |
Southwest |
American |
White/Caucasian |
Female |
| 17 |
≤3 |
Southwest |
Southwest |
American |
Chinese/Asian |
Female |
| 16 |
≤3 |
Central |
Central |
American |
White/Caucasian |
Male |
| 14 |
>3 |
Southwest |
Southwest |
American |
White/Caucasian |
Male |
| 13 |
>3 |
East |
Southwest |
American |
White/Caucasian |
Male |
| 12 |
≤3 |
Southwest |
Southwest |
American |
White/Caucasian |
Female |
| 11 |
>3 |
Central |
Southeast |
American |
White/Caucasian |
Female |
| 10 |
>3 |
Southwest |
Southwest |
American |
White/Caucasian |
Male |
| 08 |
>3 |
Southwest |
Southwest |
American |
White/Caucasian |
Female |
| 04 |
>3 |
Southwest |
Southwest |
American |
White/Caucasian |
Female |
| 03 |
>3 |
Southwest |
Southeast |
American |
Hispanic |
Female |
| 02 |
>3 |
Southwest |
Southwest |
NR |
White/Caucasian |
NR |
| 01 |
>3 |
South |
Southwest |
American |
White/Caucasian |
Female |
Abbreviations: NR = information not reported or identified by participant; PT = physical therapist.
a≤3 years: in practice less than or equal to 3 years (n = 4). >3 years: in practice more than 3 years (n = 9).
bGeographic label of Southwest relates to Arizona, but encompasses 3 different programs within the state.
The geographical region of practice for participants was Arizona, Oklahoma, and Florida. From the 13 participants, 8 graduated from 3 different programs in Arizona. The remaining 5 participants graduated from programs in the following states: Maryland, Kentucky, Missouri, New York, and Texas.
Three themes emerged: 1) clinical practice and life experiences had greater influence on perceptions of preparedness, 2) suggestions to improve cultural competence curriculum, and 3) experiential learning was valued and contributed to culturally competent practice.
Theme: Clinical Practice and Life Experiences Had Greater Influence on Perceptions of Preparedness
Participant responses ranged between feeling fully prepared to unprepared by their program's curriculum to practice culturally competent care. Years in clinical practice shaped PTs' perceptions of overall preparedness to engage in culturally competent patient care. No NA/B PTs reported feeling unprepared by their program to practice as culturally competent providers. Conversely, 4 experienced PTs reported feeling prepared by their programs, 3 felt unprepared, and 2 felt “moderately” prepared.
Some participants felt prepared by their program to manage certain aspects of cultural competence, such as addressing cultural gender roles, yet felt unprepared to work with patients in the Lesbian, Gay, Bisexual, Transgender, Queer or Questioning, Intersex, Asexual, and more (LGBTQIA+) community or know how to overcome barriers related to disability, socioeconomic status, or language differences. Participant 17 (N/AB) felt comfortable working with patients from various socioeconomic or ethnic backgrounds but struggled finding appropriate resources for patients with disabilities:
“I had the most difficulty [treating patients in different] disability demographics and realizing that the families live very differently…the way they see the world is a lot different, and I didn't realize that before. We never talked about accessibility like that.”
Participants 01 (EC) and 04 (EC) cited the absence of LGBTQIA+ education in their cultural competence curriculum as a reason they felt unprepared to adapt to the needs of some patients:
“I think where I struggle a lot is the gender identity view, the spectrum. I'm not good with the pronouns and addressing them well.” (01)
“We did not get ANY education or guidance on…the transgender community and how to approach that…how to bridge that gap and be more competent with that community.” (04)
Participant 02 (EC) reported limited education on how to address different communication preferences or overcome language barriers, which affected patient outcomes in practice:
“I think [programs] need to work more on the interpreter and translation piece, because that was not addressed at all. I think that is probably the biggest thing I see more so than religion or anything…I feel I can't treat people who speak Spanish or Farsi, because I can't treat them as well as I'd like to because of that [language] barrier.”
Participants in both N/AB and EC groups attributed life experiences such as travel, diverse groups of friends, or belonging to a minority group as having a greater influence on perceptions of preparedness to provide culturally competent care rather than their curriculum. Across groups, participants linked previous life experiences to how cultural competence curriculum was appreciated throughout school and applied in practice (Table 2).
Table 2. -
Influence of External
a Experiences on Perceptions of Cultural Competence Preparedness
| Years of Practice |
| More Than 3 y (EC) |
Less Than or Equal to 3 y (N/AB) |
| We traveled all over the world when I was younger. That included Europe, Asia, Madagascar, a little bit in Central and South America. So… exposure to different languages, different cultures, different groups of people, all of that was kind of a part of my consideration already, because of that background. So, I think that was a big part of my comfort level there, too, because I know some of my classmates were more uncomfortable in those situations…that the program put them into, than I was, [because of] that experience. (14) |
I felt prepared enough to deal with situations, but I feel like more from my own cultural experiences, rather than…rather than school. But school did give some good, general things…maybe if I was from a different culture…or only had a single culture that I was kind of bubbled or enveloped in, then maybe I would have more problems, or would have more problems but wouldn't know, so I would still say…neither prepared nor unprepared [by my program]. (17) |
| I think I felt more ok about that than I did about some of the actual PT skills…I could always find a way to connect with a patient. Even before I worked in patient care, I've felt comfortable. I felt like I was prepared enough but I don't think it came from my curriculum, I think it came from other things…but looking back, had I not had any of [my own experience] to back me up…I don't think there was anything in the program that built that kind of character. (04) |
Basing it just off school-wise from PT school, I felt like I was fairly prepared. But I also had a lot of rotations that offered a lot of diversity, so I don't know…if anybody else in our program who stayed in smaller towns or smaller areas, if they would have the same response or same experience. (18) |
| I had conversations with my roommates and my classmates, learning about their cultures and their religions, and how everything is different from rural Colorado where everything is conservative and Christian. So, I think a lot of my preparation came from my interactions outside of school. (02) |
|
Abbreviations: EC = experienced clinician; N/AB = novice/advanced beginner.
aRefers to experiences or interactions outside of the regularly structured curriculum provided within the physical therapy education program.
For participant 02, time in clinical practice shaped some perceptions of curricular strengths and weaknesses of their program:
“I've gone back and looked at the curriculum [my program has] now…my goodness is it different. I wish we had some of the classes they have…they have a gender-specific class, they have a cultural class…knowing that's what they're getting, I would say that I was definitely not as prepared as [students] graduating now.”
Only participants 02, 04, 08, and 11 explicitly reported participating in cultural competence professional development (PD) training since graduation.
Theme: Suggestions to Improve Cultural Competence Curriculum
Participants discussed the role of DPT programs in cultivating cultural competence in students and how changes in the curriculum could strengthen this role. Areas of improvement included how clinical rotations are selected and monitored or how cultural competence is cultivated within the curriculum.
Ten participants reported at least one negative experience related to a CI's cultural competence behaviors, communication style, or professionalism while on clinical rotations. Participant 10 (EC) reported feeling ill-prepared to provide culturally competent patient care when he graduated and also voiced disappointment at some clinical rotations, suggesting his program should have done a better job at monitoring clinical sites to ensure quality CIs and learning opportunities:
“It's nice that we get these clinical rotations, that's really smart…But you can have crappy [clinical] instructors—who's policing that? Somebody needs to police the rotations and it needs to be more hands-on [learning] in school so there is not as much pressure [on rotations].”
Participant 10 remained geographically local for all clinical rotations and reported a lack of diversity in patient demographics throughout his clinical rotations.
Participant 18 (N/AB) did not feel supported by her CI to address the unique needs of a diverse patient population and independently incorporated self-reflection and self-awareness to adapt to her patients:
“It was a very diverse clinic setting and you could tell like he didn't handle certain things as well as some of the other employees…I keep that in the back of my head and try not to be like that, because I was put off by it…that's something I would not want to experience [as a patient].”
Despite these challenges, participant 18 felt prepared by her education to provide culturally competent patient care, which she attributed to her choice to participate in clinical rotations that were geographically and demographically diverse. Selecting clinical rotations with geographic variety was not required by her program, and she noted many of her classmates opted to stay close to the rural area surrounding campus.
Participant 11 (EC) reported exceptional clinical experiences and was encouraged by her program to seek out opportunities across the country, resulting in a sense of preparedness:
“I had the basics of what I needed to know to be [culturally] competent. And I had the skills to know that I was going to have to reflect and learn more. So, I think that mindset was really instilled in us, and that was helpful.”
Participant 01 (EC) was required to have clinical rotations locally as well as out of state. She recalled seeing less cultural adaptability from CIs who were local to her university; they represented the cultural norms of the program and the primarily White upper-middle class community surrounding campus:
“I know schools need CIs, and it's easier to reach out to an alumni base…but then those CIs are promoting the same biases that are taught in the program…everything you learned they learned.”
Participant 03 (EC) only felt “25% prepared” to act as a culturally competent provider, attributing any preparedness she had to clinical rotations in Puerto Rico, Miami, and through the Indian Health Service program. Although many of her clinical opportunities were provided by supportive CIs, she felt discouraged by a CI who did not adapt treatments based on comorbidities or health disparities seen more frequently in certain cultural groups:
“He was very jaded…every single patient got [the same] exercises. He wasn't willing to veer from that, even when I brought in research articles, he was not willing or open to anything…I thought I'm not going to learn anything from this guy.”
Overall, participants within the EC group experienced more challenges associated with problematic behaviors from CIs as it related to cultural competence.
Participants described their curriculum and compared it with their experiences in current practice. Twelve of 13 participants wanted more experiential or hands-on learning opportunities during their education, such as community outreach, interacting with patients from diverse socioeconomic or cultural backgrounds, and mock interactive scenarios to improve cultural competence. All N/AB participants suggested DPT programs to provide more opportunities for development of interpersonal skills such as empathy and altruism within the curriculum. Additionally, participants suggested integrating cultural competence curriculum across courses by providing “nonideal” mock patient scenarios or learning how to engage in “tough” conversations with patients where language barriers were present. Participants also suggested that DPT programs increase the diversity of the student body. Comparisons of suggestions are provided in Table 3.
Table 3. -
Suggested Areas of Improvement for Cultural Competence Education
| Areas of Improvement |
Groups |
| Experienced (>3 y in Practice) |
Novice/Advanced Beginner (≤3 y in Practice) |
| Provide more experiential and diverse learning opportunities |
I think if they would have allowed us to do some sort of community outreach, where it was part of our program, where we had to be in front of patients from various socioeconomic classes, from different ethnicities and races, I think that would have helped me. (03) |
Maybe opening up [patient experiences in labs] to a more diverse group of people would be helpful…expanding it to where we go to a different [town] to just kind of feel it out, versus the small town feel where everybody already knows everybody. (18) |
| Increase diversity in cohorts |
I know there were, like, [almost] 1000 applicants to my program, and [they] only pick 50. I find it hard to believe that out of that…you couldn't put together a diverse group of 50 from 900. (13) |
When you look at the population of [my] class, [my] class was White for the most part, and you definitely don't see a lot of varied culture within. I applied to PT schools that were more culturally based and their biggest thing was “how do you stick out, how are you different from everyone else?” In [my] program, you didn't see a lot of cultural variation. (12) |
| Interpersonal skill development (leadership, empathy, etc.) |
I don't think there was anything in the program that built that kind of character. The way classes were put together, it was not something where you had to be incredibly present…so you could blow it off and not get anything out of it. Like my ethics class…you could be in the back of the class on Facebook all day and not get anything out of it. (04) |
I think assessing yourself sometimes is important, so allowing students to go through [self-assessments] before they even graduate, I think, would be good…it allows you to really kind of assess what your strengths are, where your weaknesses are, who you gel with, who you mesh with…that way, you know how to handle these situations. (16) |
| Include cultural competence curriculum throughout all courses |
I think cultural competence should be instilled throughout the curriculum; that will have students practicing not just once but throughout their time, and [have them] thinking about: how can you best incorporate that person's values and culture into their goal setting, your plan of care? (11)
You're so used to using your words and gestures based on what they mean in English, but they don't mean anything in a different language, or it means something derogatory…I think [being put in non-ideal situations in class] would have been really good. (04) |
…Be more open to talking about anything, cultural or diversity wise; people kind of try to tiptoe around a little bit because some aspects can be a slightly controversial, depending on the topic or whatever…making it a little more inclusive, where we're kind of touching base on everything. (18) |
Theme: Experiential Learning is Valued and Contributes to Culturally Competent Practice
Experiential opportunities embedded in the curriculum and outside of class–such as service-learning, community outreach, or participation in pro bono clinics–were a highly valued method of cultural competence education. Four participants reported having one lecture-only course, whereas 7 participants noted they had lectures related to cultural competence interwoven through different courses. Eight of these 11 participants reported their didactic cultural competence curriculum was not comprehensive enough. Four of 13 participants perceived lecture-based formats of cultural competence training to be ineffective at instilling cultural competence, as indicated by participant 03:
“What's sad is I probably don't remember it because I was so concentrated on the other core courses, right? Like neuro rehab, musculoskeletal [courses]?…And I'm sorry, I don't think you can teach cultural competence by having someone read a book.”
PTs in the EC group noted their curriculum included either a formal lecture or a lecture with some experiential learning, but these were insufficient to teach cultural competence concepts based on what they have learned in clinical practice. Most N/AB PTs had difficulty recalling specific details of cultural competence coursework (Table 4).
Table 4. -
Novice/Advanced Beginner Therapists' Reflections on Depth of Cultural Competence Curriculum
| Participant |
Reflection on Lectures or Coursework |
| 12 |
I feel like it kind of got maybe sprinkled into some of our like lectures, dependent upon what unit we were having. I honestly don't recall a specific class or like anything in school. |
| 17 |
I do not really remember any type of cultural competence training, especially in terms of different ethnicities or cultures. I mean being Asian American, I would be like, “Oh, you know that's kind of cool.” I don't really recall anything…I don't recall an absence of it, like we needed this, and it was lacking, or [thinking] when they did [teach] it they didn't do it very well. I just don't really remember; it wasn't really a thing…If we did, the concentration was a little bit more on like you know, “Don't be that person.” |
| 18 |
We were educated on, you know, there's different races, different religions. Those are all things we need to take into consideration. But…I can't think of anything that was like a specific, learning moment, or class, or section, or anything that we spent a lot of time on. |
| 16 |
We actually had a semester-long course about all this stuff, and we would have scenarios where she would put you in, you know, kind of awkward situations, sometimes, and you had to really think about it, because it really tests like your mind and thinking “Okay, what's the right answer here? What's the right thing to do?” |
Six EC PTs and 2 N/AB PTs reported having some experiential component of their education they felt contributed to their cultural competence development. All participants acknowledged the value of experiential learning, role-play, or cultural immersion opportunities as either the primary contributor to developing culturally competent practice or as a component that would have been helpful to have as a part of their cultural competence curriculum (Table 5).
Table 5. -
Perceived Value of Experiential or Immersive Learning
| Subject Number (Years of Experiencea) |
Opinion on Experiential or Immersive Learning |
| 13 (>3 y) |
What my school did well is our clinical experiences or…when we went out into the community, the community service, the outreach stuff. You know, we went into the community on several occasions for that type of thing. We would go to different hospitals in the area…we would you know see burn victims, we would see pediatrics, a lot of cardiac. So, I think the way that they did it was more real-world experience as opposed to just an educational class, and I feel like that was probably a bit more beneficial for me. |
| 03 (>3 y) |
One thing that I think [my program] did not do a good job with [was] put us in a situation where we had to go out into the community. Because cultural competence cannot be taught in a classroom. That's my belief…I think making it mandatory in a program so that students have to go out and be a part of a pro bono clinic, they have to do community outreach, go out into community areas and volunteer, I think that would be a better use of the university's time than having it be taught in a class. |
| 14 (>3 y) |
So…that opened my eyes to some things that are, not necessarily in my world, they're not necessarily in my culture, but to somebody else it's just their life, it's just exactly how they function, right?…It touched on how to find somebody's motivations and…really give yourself a view of what their life includes. |
| 16 (≤3 y) |
It was kind of cool to have that—I shouldn't say training—but you know just kind of exposure to an awkward situation of “How do I handle this” or “How do I respond to this?” |
| 18 (≤3 y) |
Right across the street from our school was…a hospital and an inpatient clinic…so they let us…for a semester, to go there once a week, or once every couple of weeks, to get us exposed to more patients. Our program also [has a] class, where one day a week for an hour, we would do programs with community-dwelling seniors. So, your first year, you would be the mentee, and then second year you're the mentor and then you each get…your team gets one community-dwelling senior that you work with for the semester. And then my second year…our school put together a pro bono clinic that's pretty much student-run…So that's another cool thing we got to do. |
a≤3 years: in practice less than or equal to 3 years. >3 years: in practice more than 3 years.
DISCUSSION AND CONCLUSION
The purpose of this qualitative investigation was to understand PTs' perceptions of preparedness to engage in culturally competent patient care and how their education may have influenced this preparedness. Three themes emerged from the data.
Theme: Clinical Practice and Life Experiences Had Greater Influence on Perceptions of Preparedness
Years in clinical practice shaped PTs' perceptions of overall preparedness to engage in culturally competent patient care after reflecting on their curriculum. All N/AB PTs felt prepared by their program to provide culturally competent care. Most experienced therapists described how life experiences, such as culturally diverse interactions through travel or work, discussions with classmates, or growing up in culturally diverse areas contributed more to their cultural competence development. Four experienced therapists shared that they had cultural competence PD since graduation.
PD guidelines from the Federation of State Boards of Physical Therapy encourage personal and professional growth for PTs and encourage clinics to provide environments of mentorship, inclusivity, and collaboration.44 However, there is little accountability for PTs to advance their cultural competence.45 Only 4 states require PTs to show proof of implicit bias training for licensure and renewal.46 Differences in perceptions of preparedness between N/AB and EC therapists in this study may be related to differences in cultural competence PD opportunities and the amount of time in practice spent integrating culturally competent behaviors learned after graduation.
Health care providers develop clinical reasoning, attitudes, and behaviors throughout their education and as they transition from novice clinicians into ECs.19,26,32-34,45,47 N/AB practitioners rely heavily on their practice environment to guide their behaviors, learning, and treatment methods.19,45,47,48 Early years of practice and development of self as a PT are also influenced by encounters with colleagues and patients; mentorship and a structured learning environment encourages N/AB clinicians to seek out additional PD and learn to advocate for themselves and their patients.19,45
It is possible that N/AB clinicians interviewed in this study were practicing in clinical environments where EC provided guidance and demonstrated characteristics necessary for novice PTs to become autonomous and culturally competent providers. An easy transition from student to clinician may promote positive thinking and reflection on how well a program prepared novice PTs for practice. Clinicians from the EC group may have had more opportunities to reflect on their own development as a clinician, changing their opinions about the efficacy of their education.
Theme: Suggestions to Improve Cultural Competence Curriculum
Clinical Education
Participant perceptions suggested that DPT programs should accept a larger role in developing student's cultural competence instead of relying on students to develop these skills during clinical rotations. There are risks to relying on clinical rotations to instill culturally competent behaviors or attitudes in students. Clinic culture shapes student and novice clinician's perspectives and attitudes toward patient care,16,19,27 and a clinical site may not support development of culturally competent behaviors. Clinicians must engage with individuals from different backgrounds and cultures to better understand and modify their beliefs toward those individuals.12,35 A CI may be unwilling or unable to reinforce culturally competent strategies, and students may not know to seek out additional learning opportunities.27 One must recognize or be made aware of their own limitations and biases to change them.12,35 Students may perceive themselves as culturally competent and feel adequately prepared to practice culturally competent care because they have never been told otherwise.
The PT Clinical Performance Instrument (CPI) requires students to demonstrate “entry-level” professional behaviors (ethical and moral reasoning), communication skills, and cultural competence during their final clinical rotations.49 CPI ratings are subject to the preferences and biases of the CI and whether opportunities arise for a student to demonstrate these skills.50 Risks associated with biased or inaccurate CPI measures can be mitigated if development of interpersonal skills (communication, body language, active listening, situational adaptability, etc.)51 and culturally competent behaviors are embedded, measured, and reinforced throughout the curriculum. Participants suggested students work through “non-ideal” or challenging mock patient scenarios throughout their curriculum to build culturally competent behaviors and interpersonal skills.
Programs may consider examining the direct and indirect influence their CIs have on developing PT students' cultural competence during clinical experiences. Directors of clinical education (DCEs) previously reported that face-to-face interactions are most effective at evaluating student and CI performance.52 Data triangulation from student discussion posts, CI and student clinical site assessments,53 and focus groups between DCEs, CIs, and site coordinators may help DCEs ascertain strengths and weaknesses of a clinical site or CI based on multiple factors, including cultural competence.
Program-Specific Curriculum
Participants suggested increasing opportunities for interpersonal growth and socialization throughout the curriculum. Physical therapists must show attitudinal and behavioral flexibility to listen and learn from patients, practice introspection and compassion in patient care, and communicate effectively.35,38,54 Interpersonal skills can be improved with self-reflection and socialization, whereby an individual recognizes their limitations, searches out, and participates in interactions with others that push them out of their comfort zone to understand different perspectives and beliefs.51
Participants suggested that programs incorporate service-learning, community outreach, or pro bono patient services into the curriculum for cultural competence education. Students who participate in international service-learning adapt to patient needs based on cultural beliefs, reduce communication barriers by learning conversational and medical terminology in the local language, and can positively affect community perceptions of disability and health care intervention.55,56 Local or international service-learning opportunities require students to interact with patients who may present with complex or unfamiliar biopsychosocial histories.55,57,58 Unfamiliarity can stimulate creative thinking and execution of clinical care and produce self-reflection of personal perceptions, behaviors, and attitudes.55,57,58 Designing and implementing community-based health and education initiatives build and enhance professional behaviors in PT students to include core values that are the foundation of culturally competent practice.59
Theme: Experiential Learning is Valued and Contributes to Culturally Competent Practice
Experiential learning opportunities such as community outreach, service-learning, or pro bono opportunities within the curriculum were highly valued as a method for cultural competence education compared with lecture-only formats. Only a fraction of participants reported an experiential component of their cultural competence education. All participants cited experiential learning, role-play, or immersion in culturally diverse situations as either the primary contributor to their cultural competence education or as a component that would have been valuable to have in their curriculum. Some participants reported feeling less prepared to adjust to the needs of patients from the LGBTQIA+ community—along with difficulty addressing socioeconomic or language barriers—compared with addressing the cultural differences of patients from different races or ethnicities. Focused experiential learning has been effective in improving confidence and preparedness to work with different social groups or cultures.60-62 Adding interactions or experiences with patients from multiple communities or backgrounds may produce a more culturally competent PT and contribute to equitable health care standards for an increasingly diverse patient population and improve patient outcomes.62,63
Limitations
Recruitment efforts were limited to email distribution to all PTs within one company consisting of 14 clinics in the greater Phoenix, Arizona area and 5 clinics in the greater Oklahoma City, Oklahoma area, and via social media. Recruiting more N/AB providers may have been more representative of perceptions regarding current cultural competence curriculum. Despite limitations, there was geographical variety in where participants attended school. Furthermore, most participants in this study identified as White/Caucasian, which may have influenced participant perspectives and limited the depth of results. Although participant demography was consistent with demographics of the profession, it may have been beneficial to have more participants from historically marginalized communities for a wider range of perspectives.
Some participants were, or were recruited by, colleagues or former classmates of the investigator via snowball sampling, which could have promoted some biases from both the investigator and the participant during interviews. Researcher positionality, reflexive journaling, audit trail, and member checks were completed to control for bias.
Conclusions
Findings of this qualitative study suggest that DPT programs need a broader approach to cultural competence curriculum. Curricula should address cultural influences related to patient's socioeconomic status, access to health care, gender preferences or identities, communication preferences, and social identity through a variety of learning methods.
Future research should focus on whether PTs view themselves as culturally competent providers, whether self-assessment is accurately reflected in professional behaviors and attitudes, and whether methods of cultural competence curriculum, time in clinical practice, or participation in cultural competence PD influences self-assessed or objective measures of cultural competence. This study focused on the perceptions of PTs who have been in practice between 1 and 10 years. Investigation into current DPT program curriculum across the United States would provide insight into how PTs are trained to provide culturally competent care and explore whether experiential learning or topics indicated as deficient by participants in this study are being included in the curriculum.
FUNDING
Nil.
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