The vision of the American Physical Therapy Association (APTA) is “transforming society by optimizing movement to improve the human experience,” which pairs with its mission of “building a community that advances the profession of physical therapy to improve the health of society.”1 For this article, the terms “human experience” and “health of society” are prominent. To transform society and improve the human experience, a physical therapist (PT) must use knowledge (knowing), skills (doing), and attitudes (being) learned through academic preparation and clinical practice. Learning has traditionally been organized into 3 domains—cognitive, psychomotor, and affective. These are essential to Bloom's2 framework of learning for optimizing skill mastery. The Model of Excellence and Innovation in Physical Therapy Education, the American Council of Academic Physical Therapy's (ACAPT) Excellence Framework in Academic Physical Therapy, and the Education Leadership Partnership's (ELP) Vision for Excellence in Physical Therapy Education support this trifecta from the academic and clinical practice lenses for PTs.3,4 The habits of head (cognitive), hand (psychomotor), and heart (affective) are essential to comprehensively meet the needs of all stakeholders in a learner-centered (education) and patient-centered (clinical practice) context.5
The work of Shulman6 on signature pedagogies and professional preparation suggests that “if you wish to understand why professions develop as they do, study their nurseries.” Figure 1 demonstrates how academic preparation and professional formation in physical therapy education have mirrored outputs that directly support clinical practice. Physical therapy practice parallels education in the same domains: cognitive (knowing), psychomotor (doing), and affective (being). Despite established educational frameworks and foundational theories of teaching and learning, academic preparation has historically been dominated by the cognitive (knowing) and psychomotor (doing) domains.7-9 Pierre and Oughton9 suggest the affective domain (AD) is the access point to learning, yet the cognitive and psychomotor domains globally take precedence in education. This yields a gap in teaching and learning and presents an opportunity to enhance and improve the professional formation process for PTs who can not only think and do but also be and feel.2,5,8,9
The current health care environment, amid the COVID pandemic, has accentuated the need for PTs to be adaptive to meet the diverse needs of various stakeholders in a transdisciplinary context. Health is not a binary construct (e.g., one is either healthy or not); rather, health includes physical, spiritual, mental, and emotional realms that call upon practitioners to exercise the AD in clinical practice. The purpose of this position paper is to demonstrate the importance of developing the AD in the academic preparation of physical therapy students to function as practitioners within the context of individual practice, the health care system, and society.
The AD of learning—which includes interpersonal skills, resilience, self-reflection and awareness, ethical attunement, and compassion—is essential for cultivating the therapeutic alliance (TA), alleviating practitioner burnout and moral injury, building capacity in working effectively on teams, and recognizing the importance of the societal contract to best serve the dynamic needs of communities. It can be taught, facilitated, and developed in learners.10-16 The authors believe academic and clinical educators must demonstrate a sense of urgency and responsibility to cultivate the AD of learning intentionally and explicitly in parallel with the cognitive and psychomotor domains. Physical therapy education must comprehensively develop the KSAs of learners to serve all stakeholders effectively from patients and families to colleagues and society.
THE AFFECTIVE DOMAIN IN LEARNING
Any behavior with an emotional component lies within the AD.2,17 The AD of learning takes the learner from receiving, responding, valuing, and organization to characterization (Figure 2).2 Characterization, the highest order behavior, is accomplished when the learned value system is internalized. This shift in self elicits behavior or disposition change that is pervasive, consistent, predictable, and characteristic of the learner.5,18 Griffith and Nguyen argue that “learning is essential for students to master skills, but if the affective domain is ignored, the cognitive areas are greatly affected. If one feels threatened, sad, stressed, etc., the learning process can break down.”19 The AD reflects attitudes, values, beliefs, needs, and emotional responses that encompass self-awareness, reflection, and “perspective transformation” in developing professional dispositions, habits, and behaviors.20,21 These constructs bleed into every aspect of learning and clinical practice in recognizing the lived experiences of stakeholders. Therefore, the AD is as essential to learning as it is to clinical practice, strongly informing and shaping the cognitive and psychomotor processes.
THE AFFECTIVE DOMAIN IN PHYSICAL THERAPY EDUCATION
The academic preparation of PTs aims to prepare the future of the profession for entry-level clinical practice and beyond. Davis20 suggested three goals of affective education in professional formation: (1) effective interpersonal communication and relationships, (2) excellence in education and practice with high expectations, and (3) confidence to leverage knowledge and skills as rooted in attitudes, values, beliefs, and behaviors. Education must be comprehensive and holistic, taking the learner beyond graduation, passing the National Physical Therapy Exam (NPTE), and earning a license to practice. Despite these measures satisfying the Commission of Accreditation in Physical Therapy Education (CAPTE) minimum standards for program success, this simply affords the student the privilege to practice and is entrenched in the cognitive taxonomy.22 The cognitive, psychomotor, and AD should be achieved in unison to strengthen the mastery of KSAs.2 Evidence recognizes and supports the importance of the AD of learning and clinical practice, yet it remains elusive in adult learning and has not been intentionally, consistently, or fully integrated into most physical therapy curricula.
Many academics would argue the AD is embedded in physical therapy education in satisfying the CAPTE 7D1-15 required elements.22 Program narratives often broadly meet these abstract 7D expectations with evidence of dedicated professionalism or ethics courses or other standalone modules within curriculum—an approach that fails to integrate CAPTE elements intentionally, longitudinally, or meaningfully within the curriculum. A deeper concern is minimal understanding among programs of the outcomes and evidence used to evaluate true competence of the learner and how, or if, the AD is being facilitated, threaded, measured, and learned throughout the curriculum. Indeed, little research has been published on formative and summative outcomes that ensure learners or graduates have the capacity to fully address complex needs and demands of stakeholders and industry versus simply satisfying course or program assessment checkboxes.23-25 This paucity of evidence suggests a general low prioritization of the AD in physical therapy education. The AD is conceptual, complicated, unpredictable, difficult to quantify, and at times uncomfortable to engage for both learner and teacher.20 Teaching methods and assessment related to the AD could be improved, and curricular content emphasis should also be strongly reconsidered.26-28
The demands of patient care, clinical practice, and the expectations and needs of society require educators to facilitate learning in all domains to strengthen students’ bandwidth to function effectively and efficiently.2,6,19 If the AD is silenced in teaching and learning, the capacity for developing the cognitive and psychomotor aspects is blunted, as is the capacity of being a PT.19 To understand humans holistically, cognition and affect must be integrated and not independent of each other, refuting a dichotomized approach to education and clinical practice. Figure 1 illustrates the bidirectionality between physical therapy education and practice with the overarching influence of organizational culture and structure. Physical therapy education mirrors and informs clinical practice, whereas clinical practice mirrors and informs physical therapy education. The inputs to learner-centered education are steered by the ELP, ACAPT, and the Model of Excellence and Innovation in Physical Therapy Education. These models strongly attest to the importance of shared beliefs and values, collaboration and inclusive cultures, leadership and innovation, and the drive for excellence with high expectations for the profession.4,5,22 They build capacity for and underpin the inputs to clinicians providing patient-centered practice. Physical therapy practice inputs recognize the demands, expectations, and dynamic needs of patients, industry, and society—all essential stakeholders. The funneled outputs of physical therapy student and physical therapy practitioner are mirrored products and aggregates of cognitive, psychomotor, and AD for both learning and clinical practice.
As a profession aiming to “optimize the human experience,” we must realize affective skills (being) afford us the opportunity to engage and use our ability to know (cognitive) and do (psychomotor) in learning and clinical practice.1,22,29 Educators who infuse the AD into teaching and learning are student-centric and pair the inner (subjective) with the observable (objective) aspects of behavior while promoting deeper thinking and reasoning through self-reflection and awareness.20 Academic and clinical educators must model behaviors that influence attitudes and beliefs, guiding characterization of students in “being” a PT.2,7,9,19,20 A strengthened AD improves empathy, positive emotions, work engagement, and social cognition while building learners' resilience, communication skills, and ability to challenge practice.30-33 The AD of learning and clinical practice strongly inform cognitive and psychomotor aspects in serving stakeholders through clinical reasoning, clinical decision making, collaboration, and fulfilling society's moral contract. Despite evidence supporting the AD for education and clinical practice, the cognitive taxonomy continues to be the major driver for curriculum design, student evaluation, and accreditation standards in physical therapy education.2,22 The academic preparation for the future of the profession must intentionally develop the AD congruently with the cognitive and psychomotor domains, or the future of the profession may be ill-equipped to serve, function, or sustain in years to come.
THE AFFECTIVE DOMAIN AND CLINICAL PRACTICE
Patients seek physical therapy because of limitations in physical function that disrupt their roles, identities, and taken-for-granted ways of being in the world. Physical therapy leverages the biopsychosocial model and the International Classification of Functioning, Disability, and Health (ICF) framework to acknowledge the influence of personal and environmental factors on health and well-being.34 PTs have a professional responsibility to craft unique patient-centered interventions where individuals are “known as persons in the context of their own social worlds, listened to, informed, respected and involved in their care.”35 We must exercise strong technical skills while creating value and purpose for patients by building a therapeutic alliance (TA). The TA is the relationship between the patient, who seeks change, and the clinician, the “change agent.”36 A strong TA affords practitioners the opportunity to better understand the complexities of the lived human experience to support clinical reasoning and critical thinking, which the AD strongly informs.
A practitioner's ability to engage and develop the TA is essential to clinical practice for those served and the practitioner. The TA and a patient's perceived sense of empathy and genuineness has a moderate influence on patient outcomes through mutual trust, empathy, and collaboration.37-41 Ignoring the impact of the TA and patient-centered care can yield reduced practitioner satisfaction, loss of meaningfulness of care, and increased risk of burnout associated with negative attitudes and behaviors toward patients.42 Many practitioners experience “emotional and physical exhaustion coupled with a sense of frustration and failure” in an environment of “unrealistic goals and work overload.”43,44 Moral injury has occurred due to unattainable productivity demands and unethical clinical practices thrust upon clinical staff, despite the Quadruple Aim of industry (Figure 3).45 These “factory-like encounters,” as Piemonte described, transform patient care into “treatment of the head and the hands with no room for treatment of the heart.”46 Burnout and moral injury create barriers to developing the TA that clinicians must navigate to avoid a compromise of ethos in clinical practice. It is imperative that physical therapy education address the AD of learning by building foundational awareness of the “moral dimensions of patient-centered care.”35 Doing so builds sustainability as it “inoculates against practitioner burnout and moral injury.”47 Physical therapy educators must equip future professionals with KSAs to competently navigate the challenges of the health care industry and provide quality patient-centered care while preserving their professional and personal integrity within the context of organizational culture and structure.
PTs need to function in transdisciplinary networks through relational coordination to support all constructs of the Quadruple Aim for positive patient outcomes within their organizations.48-51 Physical therapy education should aim to develop learner self-awareness and the ability to actively listen and influentially respond with knowledge, compassion, and a sense of advocacy for patients and the profession.20 Educators must develop and enhance students' competence in professional values and ethics, interprofessional communication, teamwork and collaboration, and awareness of their roles and responsibilities in parallel with other practitioners.52 This will optimize the socialization of the profession and the transdisciplinary team's capacity to meet the Quadruple Aim and provide quality, comprehensive, and unsiloed patient care.
THE AFFECTIVE DOMAIN AND SOCIETY
The APTA's vision of “transforming society” and mission “to improve the health of society” segues the profession to be advocates for disease prevention and health promotion within primary prevention while informing and strengthening secondary and tertiary prevention.1,52 We are obligated to recognize societal inequities and “the influence of the social determinants of health on the consumer.”53 Magnusson et al. endorses a framework for population health in physical therapy education, practice, and research that details actionable and effective opportunities for integration.54 This expands the profession's reach beyond individual patients making a powerful impact on health disparities that exist in society through innovation, access, equity, and advocacy.55
Future PTs must learn to recognize the “complex interrelations between individuals' health condition and their social and physical environment over time.”54 Recognition of pertinent contextual factors is enhanced through an understanding of social determinants of health across socioecological levels from individuals and organizations to communities and society.54 The APTA Core Values and Code of Ethics clearly state our responsibility to serve society, promote justice, and improve the health of populations in communities.56,57 Physical therapy educators are obligated to engage the next generation of PTs through cultivation of the AD to adopt and fulfill the profession's fiduciary responsibility to improve the movement health of society.
The need to enhance health outcomes by improving population health and patient experiences, supporting the work–life balance of health care workers, and reducing health care costs are encompassed in the Quadruple Aim (Figure 3).48-51,58 For the Quadruple Aim to be achieved, the AD must be exercised by health care professionals to realize, navigate, and support the complexities and lived experiences of all stakeholders in the system.59 The capacity for the future of the profession to engage in population health initiatives and respond with fundamental interventions while realizing the intent and value behind them will be reduced without addressing the AD of learning in physical therapy education.54,55
The physical therapy profession espouses “the science of healing and the art of caring,” but the art of caring is often overlooked in education.60 In contrast, Laura Lee Swisher suggests physical therapy is the “science of caring and the art of healing” and “there is a science AND an art to both healing and caring.”61 The cognitive and psychomotor domains and the AD cannot be compartmentalized within physical therapy curriculum—something that can easily occur in academic programs with an independent curricular thread for professionalism, leadership, etc. The AD of learning should be intentionally threaded throughout all curricular coursework and endorsed among academic and clinical faculty in all content areas.
Current physical therapy curricula can support the cultivation of the AD without monumental curricular changes. Numerous theory-based teaching strategies can be used to activate the AD of learning in parallel with the cognitive and psychomotor domains in the classroom and clinic. Strategies include experiential learning opportunities with interpersonal encounters, self-reflection exercises, personal narratives, and other activities that pair emotion and feelings with content material.62,63 Nonetheless, there must be a shift in culture and values of the academic program, clinical partners, faculty, and students that positively endorses the idea that the AD in learning and clinical practice is as essential as the cognitive and psychomotor curriculum.
Physical therapy education must endow new graduates with the KSAs to navigate and thrive amidst the many demands of practice from patient care, transdisciplinary collaborations, and organizational expectations to serve society and communities at large. We must model, evaluate, lead, and facilitate learning within practice in ways that align with the profession's mission, vision, and core values. If our pedagogical framework does not integrate the AD—including resilience, grit, self-awareness, self-reflection, ethical practice, empathy, and humanism—one can expect fatigue, professional dissonance, and failure. Although for some programs the AD may be implicitly taught or communicated, the strained environment of physical therapy practice suggests that these concepts must be more explicit and pervasive. To sustain the profession and be at the metaphorical table in health care, educators must better integrate the AD of learning into physical therapy education.
The time is now to attend to and intentionally engage the AD of learning in physical therapy education. As academic and clinical educators, we must lean into the discomfort and forge forward in comprehensively facilitating the learning process for the future of the profession to think (cognitive), do (psychomotor), and be (affective) by guiding the development of habits of head, hand, and heart for future PTs. Everyone can imagine. Imagine different. Imagine better. Imagine and act on making the AD a pervasive component of physical therapy education in solidarity for our learners, ourselves, and the future of our profession.
The authors thank Dr. Gail M. Jensen, Dr. Lisa Black, Dr. Kenneth Learman, and Graphic Design Team at Youngstown State University's Office of Marketing and Communications.
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