Expectations regarding entry-level competence in physical therapist practice have grown rapidly over recent decades.1,2 As physical therapist education programs in the United States strive to prepare students for the level of practice outlined in Vision 20203 from the American Physical Therapy Association (APTA), the curricular content of these programs must provide graduates with the knowledge and skills necessary for general physical therapist practice with patients of various ages from birth to late adulthood.4–9
Multiple documents guide entry-level curricular content in physical therapist education programs.4–9 A Normative Model of Physical Therapist Professional Education: Version 2004 4 provides a list of the profession's expectations for patient management across the lifespan with explicit educational outcomes related to pediatrics. The APTA has established minimum required skills for entry-level practice, which include foundational abilities specific to pediatric patient care.5 The Commission on Accreditation in Physical Therapy Education (CAPTE) also mandates the inclusion of pediatric curricular content in entry-level physical therapist education programs.6 The APTA's Section on Pediatrics (SoP) publishes a resource that serves to direct the inclusion of pediatric curricular content in entry-level physical therapist education.10
In 2009, the SoP surveyed entry-level physical therapist education programs in the United States to examine and describe the status of pediatric entry-level education.11 Responses were obtained from 151 programs for a 75% response rate. Survey responses indicated the variability of pediatric content in entry-level programs. Whereas 45.8% of the responding programs reported including 3 to 4 credits related to pediatrics, 3.4% reported including 9 or more such credits and 2.0% reportedly did not include any credits related to pediatrics. The greatest variability was seen in the number of contact hours dedicated to pediatric content (not including clinical education experiences) with respondents reporting a range of 0 to 170 lecture hours, 0 to 126 lab hours, and 0 to 70 hours of direct contact with children. In addition, only 7% of respondents reported including a mandatory pediatric clinical education experience.
Previous research related to pediatric curricular content in entry-level physical therapist education programs has been limited to the perspectives of academic faculty. Donahoe-Filmore12 surveyed pediatric instructors at CAPTE-accredited postbaccalaureate entry-level physical therapist education programs in the United States. Respondents were asked to rate the coverage of pediatric content areas on a 3-point ordinal scale (optimal, adequate, or inadequate) and the importance of covering these content areas on a separate 3-point ordinal scale (very important, minimally important, not important). The majority of responses indicated optimal or adequate coverage of content areas deemed important for inclusion in the entry-level physical therapist curriculum.
The purpose of this study was to explore clinical instructors' (CI's) perspectives regarding the specific aspects of pediatric content that should be included in the didactic curricula of entry-level physical therapist education programs within the United States.
This mixed methods sequential explanatory study was conducted using 2 groups of participants. The survey-only group consisted of participants who anonymously completed a Web-based survey. The mixed-data group consisted of purposively selected participants who completed the Web-based survey and then took part in a one-on-one qualitative interview that further explored their responses to the survey. Data gathering for the mixed-data group occurred before opening the Web-based survey for the participants in the survey-only group. Inclusion criteria for both groups included licensure and practice as a physical therapist in the United States, a patient caseload at the time of the study consisting of 75% or more children from birth to 18 years of age, and having served as a CI for at least 1 physical therapist student within the past 3 years. To avoid having respondents complete the survey more than once, exclusion criteria included previous completion of the survey. The study was approved by the institutional review boards at Nova Southeastern and Arkansas State Universities.
Participants in the mixed-data group were purposively selected on the basis of their pediatric practice setting (acute care pediatrics, outpatient pediatrics, private practice pediatrics, pediatric rehabilitation, school systems, and early intervention programs) and geographic proximity to the principal researcher (within a 5-hour drive from the researcher's home). Directors of clinical education (DCEs)/academic coordinators of clinical education (ACCEs) of CAPTE-accredited entry-level physical therapist programs within the researcher's geographical region were contacted to assist in identifying potential participants for this group. Participants in this group were recruited and interviewed until theoretical data saturation was reached and new themes were no longer emerging in the data.13
For the survey-only group, CIs practicing in the area of pediatrics were invited to anonymously participate in the survey portion of the study through several recruitment methods. First, DCEs/ACCEs from CAPTE-accredited entry-level physical therapist programs across the country were contacted and asked to forward an e-mail invitation to CIs practicing in pediatrics. The e-mail invitation introduced the study and included a link to the Web-based survey. Second, the same e-mail invitation was forwarded to the SoP and a link to the survey was included in the SoP's electronic newsletter. Finally, professional contacts established throughout the principal researcher's career were asked to forward the e-mail invitation to potential participants. To maximize the generalizability of the results, every attempt was made to invite as many participants as possible to complete the survey. Data collection for the survey-only group occurred between December 2, 2009, and April 15, 2010.
Data Collection Techniques
The Web-based survey was developed using guiding questions that reflected the patient/client management model.8 Content validity of the survey was established using the methods outlined by McKenzie et al14 and a pilot study was conducted to ensure feasibility.15 The final version of the survey included both open and closed items. Responses for closed items were based on a 5-point Likert scale related to the respondent's perspective as to the importance of including the specific pediatric topic area in the entry-level physical therapist curriculum. Open items on the survey allowed respondents to list alternative responses related to pediatric diagnoses/conditions or pediatric standardized tests that were not encompassed by the closed items. An additional open item asked respondents to provide their opinion about how entry-level programs could improve the preparation of students entering pediatric clinical education experiences.
One-on-one qualitative interviews were conducted face-to-face by the principal researcher with participants in the mixed-data group. The principal researcher had not met any of the participants prior to their individual interview. During the interview, each participant was asked to elaborate on his or her survey responses. Interviews were audio-recorded in an MP3 format. After each interview was transcribed verbatim, additional follow-up questions were posed as necessary via e-mail or over the telephone to clarify responses.13 Data from these interviews were analyzed using the constant comparative method.16 The patient/client management model8 provided the initial framework for analyzing the interview data. Units of information were categorized into themes and a codebook was created in which each theme was described in detail.13,17 NVivo 8 qualitative data management software was used in the data analysis process to help organize, store, and visualize data.
Trustworthiness was assured through the use of member checking procedures, an inquiry audit, and peer debriefing. Member checks involved presenting participants in the mixed-data group with the findings and interpretations of the integrated data and asking these participants to determine whether these interpretations accurately represented their opinions and beliefs. The inquiry audit involved presenting the data analysis and the interpretations of the data to an experienced qualitative researcher for the purpose of establishing the truthfulness of the researcher's findings.16 A reflexive journal was maintained as part of the this audit trail.16 A pediatric physical therapist with experience as a qualitative researcher acted as the expert reviewer for this study. Peer debriefing included exposing data findings to the scrutiny of a peer to explore potential bias and ensure that the analysis was meaningful to those not directly involved in the study.16,18 A pediatric nurse practitioner with experience as a qualitative researcher acted as the peer reviewer for this study.
Demographic information was gathered via both open and closed survey items. The mixed-data group consisted of 9 purposively selected participants. The survey-only group consisted of 278 respondents who met the inclusion/exclusion criteria for participation in the Web-based survey. Not all participants responded to the demographic items on the survey. Demographic information for both groups is provided in Table 1.
Overview of the Quantitative Findings From Both Groups
Quantitative data were collected from participants in both groups and consisted of responses to the closed items on the survey. These closed items were analyzed using the percentages of responses for each category on the Likert-scale. Detailed response percentages for each closed item on the survey that pertain to curricular content are provided in the Appendix (available online as Supplemental Digital Content 1, http://links.lww.com/PPT/A30). Respondents indicated that certain pediatric content areas were Critically Important to include in the entry-level curriculum. In the content area of typical development, 263 of 277 (94.9%) respondents reported that the development of gross motor skills was Critically Important to include in the entry-level curriculum. Cerebral palsy, developmental delay, and complications of prematurity emerged as the 3 medical diagnoses most frequently indicated as Critically Important to include in the curriculum. In the area of pediatric examination, the following areas for tests and measures were most frequently reported to be Critically Important: history gathering and review; gait, locomotion, and balance; neuromotor development; and muscle tone. Of 267 respondents, 123 (46.1%) indicated that the inclusion of developmental test batteries and standardized motor tests was Critically Important with nearly half of the respondents selecting the Peabody Developmental Motor Scales, Second Edition, and the Gross Motor Function Measure as specific standardized tests that were Critically Important to include in the curriculum.
In the areas of pediatric evaluation, diagnosis, and prognosis, 178 of 264 (66.7%) respondents indicated that identifying health conditions requiring a referral to a physician or other professional was Critically Important. Of 265 respondents, 210 (79.2%) reported that establishing a pediatric care plan with appropriate goals was Critically Important to include in the curriculum. In the area of pediatric interventions, functional training activities, handling and facilitation techniques, and the use of motivational and play strategies were most frequently reported as Critically Important to include in the curriculum. Opportunities to observe and interact with children were also reported to be Critically Important with 160 of 264 (60.6%) respondents indicating that such opportunities with children developing typically were Critically Important to include in the curriculum. Of 264 respondents, 174 (65.9%) indicated that opportunities to observe and interact with children who have disabilities were Critically Important to include in the entry-level curriculum.
Data From the Open Items on the Survey
Data from the open-ended item related to specific pediatric diagnoses/conditions that should be included in the entry-level curriculum were grouped by diagnostic category and data from the open-ended item related to specific pediatric standardized tests that should be covered in the entry-level curriculum were grouped by test name. Table 2 provides a list of the most frequent responses for these open-ended items. Data from the open-ended item concerning ways programs could improve student preparation for pediatric clinical education experiences were categorized by theme. Table 3 provides a description of these themes.
Overview of the Interview Data
Analysis revealed the following themes related to pediatric curricula in entry-level programs obtained from the mixed-data group: Opportunities for Interactions With Children, Foundational Skills, Knowledge of Typical Development, Awareness of Differences, Pediatric Diagnoses, Pediatric Examination Skills, Standardized Tests, Pediatric Intervention Techniques, and Clinical Reasoning Skills. Table 4 provides a description of these themes and sample quotes that support each theme.
Integration of the Quantitative and Qualitative Data
In accordance with the research design, integration of the quantitative and qualitative data occurred following the collection and analysis of both data types.18,19 On the basis of the data integration, a diagram was created to depict the participating CIs' perspectives related to structuring pediatric content in the entry-level curricula (Figure). At the center of this diagram is the participants' perspective that the General Foundational Skills necessary for general physical therapist practice in any setting provide a base from which to build skills and knowledge in pediatrics. Surrounding these Foundational Skills is the participants' perspective that Knowledge of Typical Child Development should be included in the entry-level curriculum. This should emphasize the phases and milestones of gross motor development and should also include information about all areas of child development. On the basis of this knowledge of typical child development, the curriculum needs to help students develop an Awareness of the Differences between providing physical therapy services to children and adults. Building on both the knowledge of typical development and an awareness of the differences between working with children and adults, the participants voiced their view that students need to acquire knowledge and skills in 5 pediatric content areas that stem from a solid foundational base in general physical therapy skills: Pediatric Diagnoses, General Pediatric Examination Skills, Standardized Tests, General Pediatric Intervention Skills, and Interactions With Children.
In the content area of Pediatric Diagnoses, participants felt that the entry-level curriculum should cover diagnoses and conditions that are commonly seen in pediatric physical therapist practice. Participants further felt that didactic content related to General Pediatric Examination Skills should result in students being able to perform a basic examination of a noncomplicated pediatric patient/client. The curriculum should also provide students with an awareness of the Standardized Tests commonly used in pediatric physical therapist practice and some hands-on experience administering these various standardized tests. Participants expected, however, that students would achieve competency in administering and interpreting these tests during pediatric clinical education experiences. Didactic content pertaining to General Pediatric Intervention Skills should result in students being able to perform basic pediatric procedural interventions including the ability to use play and motivational strategies to actively engage a child in the intervention process. Participants felt that the curricular sequence should include multiple opportunities for Interactions With Children who are developing typically as well as with children who have developmental delays or medical conditions.
Surrounding all of these content areas is the participants' perspective that the entry-level curriculum should facilitate students' development of the Clinical Reasoning Skills necessary for safe and effective physical therapist practice. From the viewpoint of the participants, pediatric curricular content should further help students to develop the Clinical Reasoning Skills that reflect the critical thinking and decision-making abilities necessary for effective physical therapist management of pediatric patients/clients.
Results of the Inquiry Audit and Member Check Procedures
Both the expert and peer reviewers were in agreement with the findings from the qualitative data. Seven of the 9 participants in mixed-data group took part in the member check procedures during which participants were presented with the figure created from the integration of the quantitative and qualitative data. The majority of these participants' comments supported the model. Comments from participant 6 did not dispute the model but suggested changing the placement of components within the model such that typical development was a point of the star, that standardized tests were encompassed within examination skills, and that an additional ring be added to represent professionalism. All data were reviewed in light of these suggestions and it was found that the data gathered during the study did not support these changes.
This study explored CIs' perspectives regarding the specific aspects of pediatric content that should be included in the didactic curricula of entry-level physical therapist education programs in the United States. The mixed methods research design resulted in a greater understanding of the topic by integrating both quantitative and qualitative data. Survey methodology allowed anonymous responses to be gathered from a large group of participants whereas the qualitative interviews provided a more detailed description of individual participants' perspectives and added depth to the survey findings.
Responses to the closed items on the Web-based survey were largely clustered on 1 side of the 5-point Likert scale, indicating that a majority of participants felt it was Critically Important or Very Important for the entry-level curriculum to include almost every pediatric content area addressed by the survey. Of the 87 pediatric content areas on the survey, 84 (96.55%) were most frequently cited as Critically Important or Very Important to include in the entry-level curriculum. Only 3 pediatric content areas were most frequently cited as Important to include by a majority of respondents and none were most frequently rated as Somewhat Important or Not Important to include in the curriculum. Such skew is not unusual when examining the perspectives of a group with a vested interest in a topic area.20 The 5-point Likert scale used in the Web-based survey asked respondents to consider the importance of including each pediatric content area in the entry-level curriculum and did not require the participants to rank order the content areas. As pediatric physical therapists, respondents were likely to feel that it was essential to include pediatric content in the entry-level curriculum. This likely led to the polarized distribution of responses and suggests that from the perspective of the participants, pediatric content should be an integral part of the entry-level curricula in physical therapist education programs.
A similar polarization of data can be noted in the survey study by Donahoe-Filmore.12 Although the study by Donahoe-Filmore12 explored the importance of including specific aspects of pediatric curricular content from the viewpoint of pediatric academic faculty members, a majority of the survey respondents in the Donahoe-Filmore12 study also indicated that it was important to include almost every pediatric content area addressed by the survey in the entry-level curriculum. Other similarities in the participants' perspectives can be noted between this study and the study by Donahoe-Filmore.12 Responses to both surveys indicated the importance of including the medical diagnoses of cerebral palsy and complications of prematurity in the entry-level curriculum. In the area of pediatric examination, responses to both surveys indicated the importance of including history gathering and review, gait, and neuromotor development in the entry-level curriculum. Responses from both groups also indicated the importance of including the formulation of a pediatric treatment plan or plan of care and interventions such as functional training activities in the entry-level curriculum.
Inclusion of pediatric content area in the entry-level curriculum is endorsed by the SoP in such documents as the Pediatric Curriculum Content in Professional Physical Therapist Education.10 Given that not all entry-level programs require pediatric clinical education experiences, it can be inferred that the pediatric content in the didactic curriculum alone should prepare graduates to execute pediatric patient management tasks. Yet, many of the CIs participating in the one-on-one interviews or responding to the open items on the survey appeared to express concerns that the pediatric content included in the didactic curriculum of many entry-level programs may not sufficiently prepare students for physical therapist practice in pediatrics. These concerns appear to be an ongoing issue, based on statements by Spake21 that suggest pediatric CIs had similar concerns in the early 1990s.
The overriding concept that emerged from both the quantitative and qualitative data was the participants' perspective that the entry-level curriculum should include opportunities for students to interact with children. An overwhelming 80.68% indicated that such opportunities to interact with children developing typically were Critically Important or Very Important to include in the entry-level curriculum. Similarly, 92.42% of respondents indicated that it was Critically Important or Very Important to include opportunities to observe and interact with children who have disabilities. Qualitative findings from both the interviews and the open items on the survey also point to the participants' belief that opportunities to interact with children is essential to include in the entry-level curriculum.
There are multiple limitations related to this study. The exact number of CIs practicing in the area of pediatrics within the United States is unknown and statistics related to APTA members do not provide information related to pediatric certified specialist status, years of practice as a pediatric physical therapist, and so forth. It was thus difficult to develop an adequate sampling frame from which to recruit participants and determine whether the participants in the study were truly representative of the target population.22 Not all physical therapists are members of the APTA, not all pediatric physical therapists belong to the SoP, and a central database of physical therapist CIs does not exist in the United States. Participant demographics for both groups were thus provided to allow the reader to decide whether he or she shares the experiences and background of the participants.18,23
Because potential respondents are more likely to open an e-mail from an individual that they know and respect,24,25 relying on individuals outside of the study such as ACCEs/DCEs and professional contacts to forward the e-mail invitation to potential participants in the survey-only group likely maximized the number of survey respondents. However, the e-mail invitation may not have been forwarded to all potential respondents but may have been selectively forwarded or not forwarded at all, based on the personal perspectives of those asked to forward the invitation.24,25 Not only does this make it difficult to know the exact number of e-mail invitations that were forwarded to potential participants, such methods may have introduced bias into the sampling methods and must be acknowledged as a limitation in the study.24,25
Other limitations include the use of open-ended survey items to collect demographic data such as the number of years practicing as a pediatric physical therapist and the number of students supervised in pediatric clinical education experiences as this made it difficult to report mean response values. Participants may have also answered questions on the survey or during the interview in ways that they felt would please the researcher or in a manner that they believe is expected by professional colleagues.18,22,26 Survey and interview responses may have been influenced by recent events in the respondents' lives creating a halo effect that could over- or underrepresent the importance of various concepts within the data.22 Memory recall factors, participants' interpretation of the questions in the survey, and truth-in-responses are other factors that may have potentially affected response on the survey portion of the study.18 Data collected during the qualitative interviews may have been limited by the skill of the interviewer and by the perceptions of the participant.16,18 The exclusion criteria did not include part-time teaching in entry-level programs. Such participants may have a different view than those who do not do such teaching. Researcher bias was also a potential limitation of the study as personal experiences and attitudes may have affected qualitative data collection, analysis, and interpretation.16,27 Although every attempt was made to limit researcher bias, the potential for bias must be recognized as a limitation in this study.
As competency expectations continue to build toward the level of practice depicted in Vision 2020,3 entry-level physical therapist education programs must prepare graduates to provide care for patients of various ages from birth to late adulthood. Clinical instructors' perspectives offer valuable insights that can be used to guide and direct entry-level curricular content in pediatrics. Of particular interest was the finding that the entry-level curriculum should include opportunities for students to interact with children: both children developing typically and children with special needs. The results of this study may assist physical therapist faculty in preparing students for entry-level practice in pediatrics.
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child; curriculum; educational status; humans; pediatrics/education; physical therapy modalities; physical therapy specialty/education; physical therapy specialty/methods; professional competence; professional education; program evaluation; qualitative research; survey research; United States
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