Physical therapy (PT) professional education must include content and learning activities that prepare students to work with individuals across the lifespan, including pediatric patients/clients.1 However, often substantial challenges to including this content and the necessary related learning activities to ensure an adequate level of competence in pediatric practice are encountered. At various times over the past several decades, and again in recent years, the Section on Pediatrics (SoP) of the American Physical Therapy Association has developed specific resources to address these challenges and to support improved consistency in pediatric content in professional education programs.2–6 One recent resource is a set of core competencies to guide and inform the content of professional physical therapy education.6
The essential core competencies for pediatric PT education are centered on the attainment of “entrustable professional activities,”7 which are defined as the critical activities, or units of work, that can be used to operationally define a profession and describe the activities that acknowledge professional responsibility. In reaching agreement on just 5 essential core competencies, the participants in the SoP 2012 Education Summit anticipated that all professional PT education programs would incorporate these into their curricula as expectations for all graduates. The 5 essential core competencies reflect content in (1) human development, (2) age-appropriate patient/client management, (3) family-centered care, (4) health promotion and safety, and (5) legislation, policy, and systems. These competencies intentionally address patients and populations across the lifespan, but incorporate specific knowledge and skills that are essential for providing PT for children.6 As noted in the initial publication of these competencies by Rapport et al,6 the core competencies are not meant to be prescriptive, but instead afford individual faculty and PT programs some level of independence and creativity within the unique supports and barriers of each program.
Although PT educators in professional programs are likely to use a variety of strategies to address the core competencies, we argue that the inclusion of experiential learning (EL) with children is necessary to optimize the likelihood that professional students will achieve these competencies. Experiential learning is characterized as a form of practice-based education that provides exposures and opportunities for students to explore the work, roles, and identities they will encounter as future professionals. It is learning by doing, and occurs within a relevant setting.8–11 The purpose of this perspective article is to advocate for the inclusion of EL activities with children, including children with participation restrictions, as a component of professional education for all physical therapist students. For this article, EL with children is operationally defined as activities in which students design and implement an experience that engages a child in meaningful activities, including examination, evaluation, intervention, and/or client/caregiver interaction and instruction. Children with participation restrictions include all children ages birth to 21 years who are unable to participate optimally in age-appropriate activities and experiences during typical daily routines. In an effort to support this recommendation, information about the use of EL activities in a sample of professional programs is shared along with suggestions to optimize the effectiveness of these activities in and out of the classroom setting. Recommendations for research to further investigate the effectiveness of various EL activities are also provided.
EVIDENCE FOR EXPERIENTIAL LEARNING IN HEALTH CARE PROFESSIONS
A review of the literature revealed an absence of evidence that definitively supports the effectiveness of EL opportunities with children for professional physical therapist students. In an effort to increase the scope of our review of the literature, we expanded our search to look more broadly at evidence supporting the use of EL strategies for students in a variety of health care professions, including medicine, nursing, respiratory therapy, occupational therapy, and PT. This evidence is summarized as follows.
Medicine, Nursing, and Respiratory Therapy
- Simulators were a beneficial tool in reaching competency and advancing skill performance.12–19
- Inclusion of learning experiences that combined a didactic component with an opportunity for skill practice led to improved self-reported knowledge and skills for pediatric nursing students.20
- Inclusion of a pediatric simulator during education before entering a pediatric or neonatal intensive care unit was beneficial and reduced the length of the orientation period by 50% for student respiratory therapists.21
- An observational child care experience within a pediatric nursing course led to self-reported improvements in knowledge about developmental skills and behavioral management.22
- Experiential learning led to opportunities to learn from real-life situations and increased confidence and an ability to codify academic learning into more pragmatic experiences.23
- Embedding EL into a didactic course encouraged an explicit connection between curriculum and clinical practice, supported the development of skills, facilitated clinical reasoning processes, and developed self-confidence.24
- Students experienced significant improvement in clinical reasoning and critical thinking scores after participation in an EL program, as measured by the Self-Assessment of Clinical Reflection and Reasoning and the California Critical Thinking Skills Test.25
- An EL activity provided an opportunity for students to examine their emotions and changing emotions over time, and led to increased clarity and understanding about disability.26
- Students reported a significant improvement in ability to perform a multitude of occupational therapy-related skills; EL was an effective method to enhance the understanding and application of course content, improve personal and professional attributes and skills, and improve clinical reasoning.27
- Guided practice, repetition, and feedback were necessary for students to improve clinical practice skills related to manual therapy.28
- Service learning opportunities in community agencies were effective at addressing competencies not readily addressed in didactic or clinical education; students who participated in these experiences were likely to develop an enhanced understanding of the patient's environment, leading to improved problem-solving and clinical skills.29,30
- Integrated clinical experiences within the didactic curriculum provided early exposure to advocacy for patients in a planned experience and allowed for early practice, development, and assessment of affective, psychomotor, and cognitive skills.31
- The best predictor of competent performance with psychomotor skills was repetitive, deliberate practice that was supervised by faculty who provided corrective feedback.28
The body of evidence supporting EL is quite variable and includes a combination of review articles, reports of small randomized controlled trials, lower-quality experimental designs studies, and qualitative and mixed methods research. Methods for EL included low-fidelity simulation (with manikins) and high-fidelity simulation (human patient simulators), supervised practice and interaction with adults and children, and service learning experiences. Outcome measures included learner self-report of satisfaction and preference for the activity, short- and long-term changes in knowledge and skills, scores on clinical reasoning and critical thinking measures, and acquisition of curriculum-based competencies. The overall quality of evidence for EL is weak because of the preponderance of less rigorous experimental research designs and a lack of consistent, valid, and reliable outcome measures. In addition, variability in methodology limits the ability to draw broad or overarching conclusions. Nevertheless, the evidence to date does suggest that students in the health professions do value and benefit from EL. Although evidence supporting the use of EL in pediatric PT professional education does not yet exist, this growing body of literature across the health care professions, including PT, supports its potential value and can therefore provide some guidance in the use of EL for physical therapist students.
EXPERIENTIAL LEARNING ACTIVITIES WITH CHILDREN WITH PARTICIPATION RESTRICTIONS
Despite the limited evidence for EL in pediatric professional education, we advocate for the inclusion of EL activities with children as a component of professional education for all students. Practicing psychomotor skills necessary for pediatric practice solely on peers during laboratory activities is insufficient. Clinical instructors in pediatric settings recommend that physical therapist students should have required learning experiences in the didactic curriculum both with children who are typically developing and children with participation restrictions.32 Other authors have recommended that physical therapist students would benefit from about 10 hours of hands-on interaction with children, including children with participation restrictions.4 Pediatric physical therapists must possess adequate clinical reasoning and psychomotor skills to effectively and efficiently meet the dynamic health needs of children. To attain these skills, students must practice and interact with children during the professional education program. As students learn new skills in other areas of practice, multiple opportunities are available for EL with adults during didactic and clinical education. Because most students will not have pediatric clinical education experiences, we argue that EL opportunities with children, including children with participation restrictions, be included as a component of didactic coursework.4
A number of logistical challenges to creating these EL opportunities must be considered. For example, programs located in more rural areas, and those with larger class sizes, may have difficulty accessing adequate numbers of children with participation restrictions who can come to campus or be seen in schools or community settings during the day. In addition, it may be difficult to provide adequate supervision that includes some opportunities for constructive feedback. Lambton et al,33 in their work in pediatric nursing, identified additional multiple challenges to providing students with hands-on opportunities with children, many of which are also applicable to PT professional education. These authors pointed out the increased acuity and decreased length of stay in the pediatric inpatient setting led to a complex and stressful environment not well suited for novice caregivers. A related challenge is that some parents and caregivers may be reluctant to entrust care of their child to novice student practitioners who they view as early learners.
REPRESENTATIVE CURRICULAR EXEMPLARS
On the basis of the results from a previous survey of professional PT programs, a wide range of time in the curriculum devoted to pediatrics and a wide range of hours for hands-on experiences with children were found.4 The median contact hours with children was 10, and the range was 0 to 70. In addition, about 30% of programs reported that the amount of time in the curriculum devoted to pediatrics was inadequate, and in these programs the amount of laboratory and child contact hours was significantly less than those programs reporting that the number of hours was adequate.4 To support our recommendation for the inclusion of EL activities with children, including those with participation restrictions, we have described 6 program exemplars. These exemplars were selected to capture the range of academic settings and program characteristics of professional physical therapist educational programs in the United States, and therefore intentionally include rural and urban settings, public and private universities; large and small programs, research and liberal arts institutions, and programs with standalone pediatric courses and programs with pediatric content delivered in an integrated curriculum. Table 1 illustrates that this current sample is consistent with the curricular models and characteristics of a larger sample reported by Schreiber et al.4Table 2 summarizes these 6 programs and the strategies used by each to create EL opportunities for students.
Despite different academic settings, resources, and curricular designs, much is similar across these programs. Most notably, observations of typical development are most often guided by standardized measures (eg, Alberta Infant Motor Scales, Peabody Developmental Motor Scales, or the Bruininks-Oseretsky Test of Motor Proficiency 2). In addition, content on typical development frequently precedes the primary pediatrics course and is often embedded in another course within both traditional and integrated curricula. In programs with traditional curricular designs, the primary pediatrics course is taught near the end of the didactic phase. In addition, natural environments and family-centered care were evident across all programs reviewed. Experiential learning activities with children who are typically developing occurred in all programs, often combining both laboratory-based experiences and experiences in natural environments. Each of the programs also integrates EL activities related to pediatric examination. Five of the 6 programs include EL activities with children with participation restrictions, and this exposure is largely community-based. Similarly, 5 of the 6 programs also include EL focused on intervention activities with children. All programs provide students with opportunities to interact with families. In addition, all programs provide experience with documentation, and in several programs this documentation is also shared with families.
A common approach to delivery of pediatric education in each of the programs reviewed involved integration with the community, and interaction with community clinical pediatric physical therapists often anchored EL experiences for students. Three of the 6 programs have students observing children with area clinicians, and 4 of the 6 programs use these community collaborations to give students community-based EL experiences with children. Service learning that occurs within or adjacent to the primary pediatrics course(s) also provides a mechanism for exposure to children and youth with participation restrictions. Developmental screenings at community preschools are included in several programs. Across all programs, student exposure to family-centered care is embedded in community experiences.
Each of the 6 programs also identified challenges to the use of EL, along with potential solutions to each barrier. These challenges to EL included the number of students in the professional program, the population size and geography of the adjacent community, the number of other professional programs in the same geographical region, and the productivity requirements of community clinical partners. Some solutions to these challenges included the faculty member's ongoing participation in clinical practice, incorporation of community PTs into course(s), inclusion of a pediatric advisory board for the professional program, collaboration with local pediatric special interest groups, pro bono clinic models that include children and youth, and a campus-based practicum within a pediatrics course.
Our recommendation for use of EL activities with children in professional education is based on a combination of expert opinion and research from other related fields, as there is no specific evidence to date to fully support these recommendations. Additional support comes from our collective clinical and academic experience and our passion for excellence in pediatric PT education. The author group includes representatives from each of the exemplar programs. The author group represents a combined 95+ years of experience in providing academic pediatric PT education (mean, 13.5 years; range, 3.5-20 years). As noted and illustrated in Table 1, which describes means and ranges of pediatric didactic and child contact hours for the exemplar programs, these programs are similar to other programs in the United States.4
Experiential learning that occurs within an immediate and relevant setting can be an effective tool for successful student learning. Through interaction with patients, and with skilled mentoring, students attain heightened professional identity, confidence, and motivation to learn. Student learners are also better able to link theory with practice and to demonstrate increased understanding and satisfaction with didactic studies as a result of EL.8–11 These EL activities are more likely to foster learning by providing opportunities for students to adapt to the unique constraints and opportunities inherent in interacting with children at different stages of growth and early development. Ideally this will support attainment of knowledge and skills related to the 5 core competencies in pediatric professional education.
During professional education, physical therapist students have multiple opportunities for EL activities with adults. All students participate in clinical education experiences with adults who have a wide variety of diagnoses and clinical presentations. In addition, on-campus laboratory sessions provide an array of EL episodes that integrate practice with adult peers with close supervision, guidance, and feedback from skilled instructors. In contrast, only 7% of programs require that students participate in a pediatric clinical education experience.4 Also, it is our assertion that limiting practice of clinical skills necessary for pediatrics to traditional on-campus laboratory sessions where students practice solely with their adult peers is inadequate. Smaller body sizes require modulation of force and adaptation of testing procedures. Physical therapy with children often requires implementation of unique strategies to effectively communicate with, engage, and motivate children. Experiential learning affords students the opportunity to practice psychomotor skills related to appropriate testing procedures. Students will also have opportunities to develop and practice strategies to engage and motivate children as a component of EL. As noted in Table 2, each of the exemplar programs uses a variety of approaches for creating EL activities with children who are typically developing.
We also argue that all professional physical therapist students should have opportunities for EL activities with children with participation restrictions. Interaction with these children will require students to modulate testing procedures and handling skills to elicit and support optimal movement patterns with children who often present with impairments and activity limitations. Motivating and engaging children with participation restrictions can be even more difficult as the effort necessary for testing and intervention activities is often substantial for these children. Potential barriers to these EL activities are more extensive and include limited time and space available in the clinical facilities and limited time with community pediatric physical therapists. The logistics of placing moderate to large class sizes in clinical settings where children with participation restrictions are available is often extremely daunting. Also caregivers, and in some cases the children themselves, may be reluctant to use limited therapy time for students to practice and learn. Suggestions provided in Table 2 to address these barriers include the importance of ongoing faculty member clinical practice, and concomitant close integration of clinical faculty into the professional program. Clinical faculty can serve as laboratory assistants, guest lecturers and problem-based learning group facilitators, site coordinators and instructors for the EL activities, and participants in program advisory boards. Academic faculty should also support the integration of local clinicians and clinic sites into the professional program through a variety of strategies including access to university libraries and facilities and enhanced opportunities for continuing education.
Given the importance of EL, and the challenges and limited opportunities for EL with children, each of these activities must be structured so that the benefits for the student are optimized. Clear communication between the academic faculty member, the student, and the clinician(s) responsible for mentoring and supervising the students is critical to reinforce learning objectives and expectations for the EL activity. Students should receive supervision and mentoring as essential components of these activities. An additional suggestion to further enhance the learning process is to require written documentation from the students for each EL activity. See Table 2 for some specific examples. Requiring documentation affords an additional opportunity for feedback from the academic faculty member and can also be used to encourage student reflection.
The lack of evidence for the beneficial effect of EL in professional education suggests that pediatric PT educators and researchers, along with the SoP, have a responsibility to collaboratively build evidence that can be used to guide decisions about the optimal structure and sequencing of the EL episodes in the educational process. Investigation of pedagogical approaches that support the attainment of the core competencies during professional education should further serve to guide and inform academic faculty. Some specific questions to guide future investigations in teaching and learning are listed below, and build upon those offered by Spake in 2014.5
- How much EL is needed to adequately prepare a professional physical therapist student? Is there a threshold at which performance peaks?
- What is an optimal structure for EL learning activities, including mentoring, feedback, and student reflection and documentation?
- To what extent do pedagogical techniques and instructional technology influence the effective delivery of EL content?
- What factors contribute to the success/failure of nontraditional teaching methods in pediatric PT?
- How do instructors establish the content validity of examinations or other instruments used to measure student performance in pediatric PT, including student performance during EL activities?
- How well do student performance evaluations given during didactic curriculum correlate with performance on pediatric clinical experiences? Do some measures have better predictive validity than others?
- At what point postgraduation do new pediatric physical therapists perceive themselves to be autonomous practitioners? Is this related in any way to the type of curricular structure in the professional education program, including use of EL activities?
Table 2 highlights 6 exemplars and provides information on common content, similar approaches, and creative solutions to barriers that draw on the resources of the program, campus, and faculty. This information should be of benefit to individuals from similar programs who plan to create and/or improve EL activities with children. The expanded descriptions of the activities and approaches used within each of the 6 programs provide specific details that might be helpful to faculty members who are advocating for adequate resources to effectively include EL activities. Contact information for representatives from each program is provided in the appendix as an additional resource for individuals interested in gathering more information about a specific program. We recognize that the content in Table 2 is not exhaustive and is not meant to be prescriptive. Instead, the information should afford individual faculty and professional programs some level of independence and creativity in integrating opportunities for meaningful EL activities with children within the unique circumstances and needs of each program. Key recommendations include the following:
- Students in professional PT education programs should have opportunities for EL activities with children, including children who have participation restrictions.
- Resources are available (see Table 2 and Appendix 1) to aid educators in creating or revising EL activities with children within the unique individual needs of each professional program.
- Additional work needs to be done to better understand the effect of EL on the development of future pediatric physical therapists.
- The SoP should support research initiatives aimed at further exploration of EL with children as a standard educational strategy in professional education.
The authors wish to acknowledge Lisa Dannemiller, PT, DSc, PCS, Assistant Professor, University of Colorado, for her contributions to this work.
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Author Contact Information
- Joseph Schreiber, PT, PhD
- Physical Therapy Program
- Chatham University Pittsburgh, PA 15232
- Victoria A. Moerchen, PT, PhD
- Associate Professor
- Physical Therapy Program
- University of Wisconsin-Milwaukee
- Milwaukee, WI 53211
- Mary Jane Rapport, PT, DPT, PhD, FAPTA,
- Professor, Physical Therapy Program
- University of Colorado
- Anschutz Medical Campus
- Aurora, CO 80045
- Kathy Martin, PT, DHS
- Professor and DPT Program Director
- Krannert School of Physical Therapy
- University of Indianapolis
- Indianapolis, IN 46227
- Jennifer Furze, PT, DPT, PCS
- Associate Professor
- Department of Physical Therapy
- Creighton University
- Omaha, NE 68178
- Heather Lundeen, PT, DPT, PCS
- Physical Therapist
- Sanford Children's Hospital
- Bismarck, ND 58501
- Adjunct Faculty
- Physical Therapy Program
- University of Mary
- Bismarck, ND 58504
- Eric Pelletier, PT, DPT, PCS
- Assistant Professor, Department of Physical Therapy
- University of the Sciences
- Philadelphia, PA 19104