Essential Competencies in Entry-Level Pediatric Physical Therapy Education

Abstract

Background: 

The Section on Pediatrics (SoP) convened an Education Summit in July 2012 to examine, discuss, and respond to documented inconsistencies and challenges in teaching pediatric physical therapy (PT) content in entry-level professional education programs. Despite previous attempts by the SoP to provide guidance around teaching pediatric PT, variability continued to be extensive across programs.

Key Points: 

This article presents the core competencies developed out of the Summit to inform pediatric content in the entry-level PT curriculum. In addition, the core competencies were linked to teaching strategies, learning activities, assessment outcomes, and curricular structures.

Statement of Conclusions: 

Consensus was reached on 5 core competencies that represent a knowledge base essential to all graduates of PT programs. In contrast to prior SoP documents, these competencies were specifically designed to focus on knowledge and skills unique to pediatric practice but essential for all graduates of accredited entry-level PT education programs.

For more insights from the authors, see Supplemental Digital Content 1, at https://links.lww.com/PPT/A50.

In Brief

The authors present 5 core competencies that represent a knowledge base essential to all graduates of PT programs.

INTRODUCTION

Historical Background

The Section on Pediatrics (SoP) of the American Physical Therapy Association has a history of addressing the education for entry-level physical therapists associated with knowledge, skills, and abilities related to the care of the pediatric patient/client. This work was documented beginning in 1994,^1,2 and the background and the rationale for content were outlined in April 2001 and revised in November 2008 in Pediatric Curriculum Content in Professional Physical Therapist Education, a document prepared by and made available for purchase through the SoP.³ This curriculum document has provided a thorough and comprehensive list of content areas and topics to be addressed in physical therapist education that would specifically prepare “a well-rounded generalist in physical therapy (PT) to assess and treat any patient/client from birth onward.”^{3(pg. 4)} In 2008, the updated document provided sample behavioral objectives and incorporated language from the International Classification of Functioning, Disability and Health (ICF)⁴ as well as information from the Guide to Physical Therapist Practice⁵ and the Normative Model of Physical Therapist Professional Education.⁶ The Pediatric Curriculum Content in Professional Physical Therapist Education has been useful to many educators across academic programs.⁷ However, collegial discussions, conference presentations, surveys conducted periodically by the SoP, and other informal evidence have demonstrated a large gap between the substantial list of topics and content covered in the latter document and the knowledge, skills, and abilities expected of a new graduate entering clinical practice.

The SoP conducted a survey in 2010 to examine the extent to which physical therapist education programs were teaching pediatric-related content and the types of experiences used to support student learning about the pediatric patient/client. These results were published in 2011 by Schreiber and colleagues,⁷ who reported on the extensive variability in teaching about pediatric PT across educational programs. Schreiber et al⁷ also reported on the interest of SoP members in having additional guidelines, direction, or information to assist in educating students to a common level of competence. In 2011, the SoP leadership in response to the continuing inconsistencies and challenges in teaching pediatric PT content, despite the available materials,³ approved a proposal to hold an Education Summit specifically to address 6 objectives for the education of pediatric physical therapists (see Table 1).

TABLE 1: Objectives for Education Summit 2012

Education Summit

A committee of 5 was appointed to plan and lead the Summit. Four speakers were invited to address specific topics and participate in the conference. Additional participants were selected to represent both experienced and more junior/novice faculty teaching pediatric PT in entry-level education programs, pediatric physical therapists in clinical practice who were also clinical instructors for students, and a new professional (graduate within a period of about 5 years preceding the Summit). Selection criteria also ensured representation across geographic areas of the United States and experience in different pediatric clinical settings. A complete list of Summit attendees and categorical representation is found in Appendix A (available online as Supplemental Digital Content 2, at https://links.lww.com/PPT/A51).

The Education Summit took place in July 2012 in Alexandria, Virginia. Extensive preparatory work was completed by all participants before the Summit including review of pertinent documents, analysis and commentary on related literature, and consideration of each of the objectives within small preassigned task groups. A Wiki website was established to post and share documents, to foster discussion, and to “house” the process of Summit development. The Summit included 2 days of onsite meetings, presentations, and discussions. A process of both large group discussion and smaller working groups was used to facilitate interaction, encourage full participation of all attendees, and broaden the possibility that the group would reach consensus. Ground rules were established early to ensure that the Summit would generate discussion and culminate in a collective decision to guide the future of pediatric PT professional education.

During the Education Summit, the group came to consensus on 5 core competencies that represent a knowledge base essential for all graduates of PT programs regardless of their interest or intent to provide PT services for children postgraduation, either sporadically or regularly, in any practice setting. In contrast to the prior SoP documents that were broad in scope, the current competencies were specifically designed to focus on knowledge and skills that are unique to pediatric practice and delivery of services to pediatric patients/clients. As such, these competencies were determined to be applicable for all graduates of the Commission on the Accreditation of Physical Therapy Education-accredited entry-level PT education programs.

The competencies were further refined through feedback from several constituent groups in the 6-month period after the Summit. The processes used for feedback included a “call” to all SoP members in the fall of 2012 through the SoP monthly e-mail newsletters. Members were asked to view the competencies and provide any written feedback directly to the authors. In addition, feedback was solicited through a roundtable discussion of the draft competencies at the SoP Annual Conference in the fall of 2012. All feedback received through these solicitations was reviewed, discussed, and integrated where appropriate on the basis of consensus among the initial planning committee.

A Conceptual Framework for Development of Core Competencies

The conceptual framework depicted in Figure 1 illustrates the dimensions and foundation upon which the core competencies were developed. In addition, this figure highlights the interconnected nature of these elements in pediatric PT practice. The foundational concept of Learning for Practice, discussed by Jensen⁸ most recently in her 2011 Mary McMillan Lecture, challenges educators to create meaningful learning experiences—building a community of learners, excelling toward excellence, and embracing creativity—which would lead the learner down the path of clinical expertise. In this framework, Learning for Practice is a dynamic component encompassing the dimensions of expert practice—knowledge, clinical reasoning, movement skills, and virtuous behavior⁹—and is driven by societal need and the vulnerability of children in particular. We believe this concept of Learning for Practice envelops the entire process of addressing the content and approach to educating future professionals in pediatric PT. Learning for Practice was one of the grounding elements of the discussions at the Summit.

The meaning of competence and competency has been discussed in academic medical literature as related to clinical education and the attainment of educational targets.¹⁰ In developing competencies for pediatric physical therapists, there is an inherent expectation that the competencies establish educational expectations with measurable outcomes. The term competency is used here, as defined by ten Cate and Scheele, as “The abilitity do do something successfully.”^10(p543) We hope that professional PT education will both embrace and support the integration of these core competencies into curriculum for the preparation of future pediatric physical therapists.

Fig. 1: Conceptual framework for the development of pediatric essential competencies.

Integrating Earlier Curriculum Guidelines With New Competencies

The competencies are not intended to displace the work by SoP educators and leaders in the 2008 Pediatric Curriculum Content in Professional Physical Therapist Education.³ Rather, these new competencies are intended to provide a specific framework for understanding the most important aspects of knowledge, skills, and abilities unique to working with children. As pediatric physical therapists, we recognize that working with children often means addressing the needs of the child within the family unit and providing education to parents, families, and caregivers. We also recognize that children span many ages and developmental stages; as pediatric physical therapists, we must be able to work with children of any age and throughout their lifespan. The 2008 version was viewed as more prescriptive in terms of the extensive array of content knowledge expected to be covered across the curriculum, whereas this new competency-based approach provides educators and clinicians with a more general framework of overarching competencies and outcomes but leaves the specifics of how to best address them up to individual faculty and educational programs. By narrowing the expected repertoire of content from the longer and more expansive list offered in 2008, the intent is that all physical therapist education programs will adapt these competencies as a guide to ensure that every student is adequately prepared for pediatric patients/clients upon graduation from an entry-level Doctor of Physical Therapy professional education program. These 5 essential competencies include human development; age-appropriate patient/client management; family-centered care; health promotion and safety; legislation, policy, and systems.

Each core competency is outlined later (and in Table 3), and each competency is followed by several Entrustable Professional Activities (EPAs) as identified key outcomes. EPAs are the critical activities, or units of work, that can be used to operationally define a profession and describe the activities that acknowledge professional responsibility. Thus, EPAs are the outcome measures of reaching or achieving compettency.^10,11 Although these outcomes should be used to measure the ability of the graduating student, the identification and assessment of specific requirements to achieve the expected level of competence will be up to each educational program. Each of these new core competencies can also be “tracked” back to the 2008 Pediatric Curriculum Content in Professional Physical Therapist Education³ by following the identified reference to the 2008 document that is listed after each competency. By including these links, we recognize that the 5 competencies do not necessarily represent new and novel concepts, but they offer further refinement of the 2008 document and highlight knowledge, skills, and abilities we believe are essential for pediatric physical therapists.

Integrating New Competencies Into Current Curricula

Each professional education program will need to establish objectives and link the competencies to specific courses on the basis of their program's unique didactic and clinical education curricula to reach intended outcomes and levels of competency. In addition, each education program will be responsible for the use of optimal teaching strategies necessary for the delivery of content to adult learners. Information to assist educators and clinical instructors in connecting these competencies to learning and outcomes for physical therapist students is addressed later.

Thus, the purpose of this article is twofold: first, to describe and discuss the core competencies developed as a result of the Education Summit to inform pediatric content in the entry-level PT curriculum, and second, to assist educators by linking the core competencies to teaching strategies, learning activities, assessment outcomes, and curricular structures through examples.

Five Essential Core Competencies

There are 5 Essential Core Competencies that should be attained by all graduates of an entry-level Doctor of Physical Therapy education program. These 5 Essential Core Competencies reflect the graduate's ability to demonstrate knowledge, skills, and abilities related to the following:

1. Human development—includes all domains of development, but with an additional emphasis on motor development, especially at key transition points throughout the lifespan.³ (Section 1, pp. 5-8, Section 6, B7, p. 15)
• Integrate knowledge of human development across all domains and at lifespan transition points with clinical decision making.
• Analyze the development of movement skills across the lifespan.
• Apply knowledge of psychosocial, cognitive, and communication developmental level to effectively interact with individuals across the lifespan.
2. Age-appropriate patient/client management—effective application of the patient/client management model to children and their families³ (Section VI, B5, p. 15, Section III, pp. 10-12)
• Perform developmental screening for the identification of potential growth and motor delay/impairments.
• Conduct an appropriate interview/history with the child and/or parent (including systems review).
• Gather information on the child's play/recreation/preferred activities, participation, educational setting/level, and family unit.
• Select appropriate tests and measures on the basis of the child's age, interview/history and systems review, and setting.³ (Detailed list in Section III, C, pp. 11-13)
• Conduct appropriate tests and measures and gather data—in most cases, this will minimally include gait/mobility, postural control, motor development, pain, range of motion, muscle performance (strength), sensation, self-care, physical fitness, and activity endurance.³ (Detailed list in Section III, C, pp. 11-13)
• Interpret examination findings to determine impairments in body structure and function, activity limitations, and participation restrictions.³ (Section IV, A-C, pp. 12-13)
• Develop an age-appropriate and developmentally appropriate plan of care to address participation restrictions/activity limitations/impairments of body structure and function.³ (Section V B and V C, p. 13)
• Solicit input on goals and service delivery from parents/primary care providers and from the child when appropriate (on the basis of age, communication, and cognitive ability).
• Select age-appropriate and developmentally appropriate procedural interventions including play/recreational activities, natural environment, toys, and equipment.³ (Section VI, A7, pp. 13-16)
• Implement age-appropriate and developmentally appropriate procedural interventions including play/recreational activities, natural environment, toys, and equipment.³ (Section VI, A3, 5, 12, pp. 13-16)
3. Family-centered care for all patient/client and family interactions—key characteristics: positivity, responsive, collaborative, sensitive³ (Section VII, C5A, p. 17)
• Consistently collaborate with families throughout the patient/client management process in all settings where intervention is provided.
• Address family priorities in the plan of care.
• Identify the role of the family in all aspects of care under the Individuals with Disabilities Education Act (IDEA), Parts B and C.
• Understand the focus on the family's needs in the Individualized Family Service Plan (IFSP) and the focus on the child's needs in the Individualized Educational Program (IEP).
• Describe the influence of a child with special needs on the family system.
• Describe the factors of the family system that influence the development of the child.
4. Health promotion and safety—specific considerations for child vulnerability include environmental factors, age-specific safety, screening of healthy populations, fitness and health promotion, and recreation.³ (Section VI, B5, p. 15; Section I, B3b, p. 7; Section I, D1a, p. 16; Section VI, C7e)
• Determine the need for referral to other health care professionals.
• Develop a plan to address age-appropriate health and wellness for all children, including those who are typically developing and those with special needs.
• Educate caregivers about age-specific and developmentally appropriate environmental safety considerations.³ (Section 1, F2, p. 13; Section IV, D and E, p. 15; Section VI, B1, B4, and B6)
5. Legislation, policy, and systems—related to environmental factors of the ICF, IDEA, state and federal regulations, and mandatory reporting of child abuse and neglect.³ (Section VII, C6, p. 16)
• Understand requirements related to mandatory reporting of suspected child abuse and neglect in one's state.
• Discuss the major tenets of IDEA; know how to access and share information about IDEA, Medicaid, and other public programs related to care for children.
• Identify the required elements of an IFSP and IEP and work with the team to write appropriate family-focused IFSP goals and educationally relevant IEP goals.
• Describe appropriate care settings available to extend pediatric rehabilitation services.

Common Health Conditions/Diagnoses

As in most PT practice areas, it is not possible to list all conditions that physical therapists may encounter when providing care for children and their families. The 2008 revision to the Pediatric Curriculum Content in Professional Physical Therapist Education: A Cross-Reference for Content, Behavioral Objectives, and Professional Sources (Section II, pp. 8-10)³ provides a relatively comprehensive list of conditions within specific categories. We have chosen not to present that list again here and suggest looking at pediatric PT textbooks and other resources (Appendix B, available online as Supplemental Digital Content 3, at https://links.lww.com/PPT/A52) commonly used in entry-level curricula or to the Pediatric Description of Specialized Practice¹² to view more complete listings of conditions that would be encountered by a pediatric physical therapist. This shorter list includes only more commonly encountered pediatric conditions that have PT interventions supported by some evidence in the current literature:

• Autism spectrum disorder
• Brachial plexus injury
• Cerebral palsy
• Congenital limb deficiencies
• Cystic fibrosis
• Developmental coordination disorder
• Developmental delay (includes infants “at-risk” for delay)
• Down syndrome
• Muscular dystrophy
• Myelomeningocele (with or without hydrocephalus)
• Torticollis (with or without plagiocephaly)

Teaching Strategies, Learning Experiences, and Assessment of Student Learning

Throughout the Education Summit, and in the months following, there was discussion around the number of hours devoted to teaching pediatric PT-related content in the entry-level curriculum. Without definitive evidence to support the need for a designated amount of time or approach to guide us, the group determined that each educational program should continue to make these decisions in relation to its own curriculum. Thus, this document does not provide specific recommendations for the total number of hours, child contact hours in classroom or laboratory settings, or overall lecture or laboratory hours devoted to pediatric content within an entry-level professional PT curriculum. However, a variety of active learning strategies that include some hands-on, face-to-face experience with children, including children with disabilities, and their families will optimally support student learning in pediatrics. It is also important to note that face-to-face exposure of students to individuals of all ages is an accreditation (Commission on the Accreditation of Physical Therapy Education) requirement.

Table 2 provides a side-by-side comparison of 2 approaches commonly used by entry-level PT education programs to address pediatric competencies within their curriculum. As examples, these 2 approaches—1 addressing pediatric content integrated across the curriculum and the other designating a specific course for pediatric content—have been applied specifically to the second competency: age-appropriate patient/client management-effective application of the patient/client management model to children and their families.

TABLE 2: Example of 2 Curricular Approaches to Competency 2 (Age-Appropriate Patient/Client Management)

An integrated approach to delivering pediatric content across the curriculum throughout many courses without a separate pediatric course is 1 approach. In this example, the pediatric content in the first year of the curriculum focuses on observation skills, identifying typical versus atypical development, introduction to specific conditions/diagnoses, and learning how to engage a child in developmentally appropriate therapeutic activities. The second and third years of the curriculum feature courses that are divided into tracks (ie, neuromuscular, musculoskeletal, medical conditions) and focus on both examination and intervention. Basic skills learned in the first year are refined and adapted to patients with a specific condition or diagnosis. The bulk of the pediatric content is in the neuromuscular track, but pediatric content is also integrated into the other 2 tracks as appropriate. Each course has an assignment that addresses pediatric content, and several examples of these are included in the table.

A few unique challenges were encountered when developing an integrated curriculum. The first was deciding what those “basic” skills were that could be included in first-year courses. Previously, only typical development had been presented in the first year. The second challenge was to find a way to “pull the pediatric concepts all together” given that the pediatric content was spread across many courses. Cooperation from all faculty members was essential to designate time in each course for pediatric content.

Other PT education programs have chosen to use a standalone required course to deliver the pediatric content in the curriculum. In the example here, the pediatric content is delivered primarily during 1 course in the 6th semester of the program using 7 different problem-based learning (PBL) cases under a modified PBL format for teaching clinical arts and sciences course work. The carefully crafted cases are the “anchors” around which other content is taught. These cases provide an opportunity for the students to carry out self-directed learning about conditions most frequently encountered in pediatric PT. The conditions addressed during PBL sessions include bronchopulmonary dysplasia with infant delay, cerebral palsy, Down syndrome, myelodysplasia, muscular dystrophy, autism spectrum disorders, and developmental coordination disorder. The cases are created to ensure that students address learning objectives related to each core competency. The curriculum also includes extensive laboratory experiences as well as special topic seminars, which complement and reinforce content learned in PBL sessions. Programs offering a more traditional curricular model should expect to use a variety of lectures, seminars, and laboratory activities to aid students in achieving the outcomes for each core competency.

Regardless of the curricular model or approach, a process of assessment to ensure learner acquisition of new knowledge and skills generally follows teaching of that knowledge and skills. Examples of assessments are provided in Table 3 and Appendix C (available online as Supplemental Digital Content 4, at https://links.lww.com/PPT/A53). The intentional linear nature of explicitly linking the behavioral objectives with potential learning activities and assessment strategies may assist novice educators in understanding how to create learning activities and assessments that specifically tie to one or more objectives, whereas the developmental and progressive flow shows how activities can build on one another and/or be used independently.

TABLE 3-a: Learning Activities and Assessment Strategies^a

TABLE 3-b: Learning Activities and Assessment Strategies^a

TABLE 3-c: Learning Activities and Assessment Strategies^a

TABLE 3-d: Learning Activities and Assessment Strategies^a

Learning activities and assessment strategies can be mixed and matched with different core competencies depending on the learning institution, instructor, and student variables. Bloom's taxonomy¹³ of the cognitive domain of learning was applied to the assessment strategies in Table 3 in a developmental fashion that began with the learner understanding information at the remembering and understanding level and then advancing through applying, analyzing, evaluating, and creating levels as evidence of higher order understanding and reasoning over time. Appendix C offers examples of grading rubrics that have been used to assess student learning around specific assignments or learning activities included in the table.

Instructors also have opportunities to use different types of technology and social media to develop learning activities and promote active learning with their students. These tools can be incorporated into many of the learning experiences and assessment strategies listed in Table 3 as options to more “traditional” activities. For example, audience response systems can be used as both a learning experience for students and a method to assess understanding for instructors. Use of other types of technology, such as “chats,” discussion boards, Wikipages or Wikispaces, YouTube video sharing, online modules, blogs, or social networks (eg, Facebook or Twitter), may be used as methods for increasing the level of student engagement. Many colleges or universities have rules and policies for the use of newer technology and communication options. Several articles are listed in Appendix B (available online as Supplemental Digital Content 3, at https://links.lww.com/PPT/A52) for further reading on technology-related topics.^14–16

DISCUSSION AND APPLICATION

The concepts introduced and included in earlier SoP education documents continue to be both relevant and integral to pediatric PT and to the educational preparation of all physical therapists. However, over time, physical therapist educators have come to use the content as a checklist, of sorts. This approach to addressing pediatric content seems to have flourished despite the statement: “The intent is that this document be used as a resource based on accepted models of contemporary practice rather than as a set of prescriptive guidelines.”^{3(pg. 2)} In essence, physical therapist educators most responsible for teaching pediatric PT content sought to accomplish each and every item on the list, regardless of the amount of time available in courses or placement of content within the entry-level PT curriculum.

Thus, the new list of Essential Core Competencies is the culmination of work by the SoP aimed at providing the PT profession, and particularly physical therapist educators and clinical instructors, with a useful tool to promote learning and develop essential competency in entry-level physical therapists around concepts most relevant to pediatric patients and settings. This shorter and more condensed set of competencies should be used by all entry-level physical therapist professional education programs and by clinical instructors as we foster the preparation and practice of the next generation of physical therapists.

ACKNOWLEDGMENTS

The authors thank the SoP of the American Physical Therapy Association for their support of the Education Summit in July 2012 and recognize the following individuals for their contributions in developing the competencies during the Summit: Suzann Campbell, Donna Cech, Paul deRegt, Gail Jensen, Lisa Kenyon, Heather Lundeen, Kelli Parks, Eric Pelletier, and Ellen Spake. The authors also acknowledge the SoP members who demonstrated their interest in the Education Summit, and those who provided feedback on earlier drafts of the competencies.