INTRODUCTION AND PURPOSE
The APTA requires that physical therapist (PT) students graduate with the appropriate entry-level knowledge and skills in pediatrics.1 , 2 The Commission on Accreditation in Physical Therapy Education (CAPTE) requires that, upon graduation, PTs must be competent to treat patients of all ages and across a multitude of clinical settings, including specialty clinical areas that are often difficult for PT students to gain clinical experience (eg, pediatrics).3
While PT pediatric content is required by the CAPTE in all doctoral physical therapy (DPT) programs, there are no established standards for hours, content, or clinical learning experiences to maximize student clinical competencies in pediatrics. Consequently, there is variation in pediatric content hours and clinical learning experiences, thereby making it difficult for many PT students to demonstrate entry-level competency in pediatrics upon graduation.4
Variation in Learning Opportunities in Pediatrics
The lack of consensus on the appropriate amount of pediatric educational learning opportunities has resulted in differences in the number of pediatric lecture hours, laboratory hours, and direct contact hours among DPT programs in the United States. Schreiber et al4 reported that the total number of dedicated pediatric hours in DPT programs reviewed (n = 151) ranged from 0 to 170 didactic hours, 0 to 126 laboratory hours, and 0 to 70 direct contact hours.
More recently, Kenyon et al5 found 2.5% of DPT programs (n = 158 DPT programs sampled) require a pediatric clinical experience. The variation in direct pediatric contact hours and pediatric clinical experiences may result in new PT graduates with an inadequate entry-level clinical competency in pediatrics and raises the issue of what is considered required clinical practice in pediatric education to attain entry-level competency.
To address the variations in pediatric education across DPT programs in the United States, the Academy of Pediatric Physical Therapy (APPT) established 5 essential core competencies: human development, age-appropriate patient/client management, family-centered care for all patient/client and family interactions, health promotion and safety, and legislation, policy, and systems. These competencies should be attained by all PTs upon graduation.6 These established essential core competencies provide DPT programs with clarity about the scope and detail of the pediatric content necessary to meet the needs of graduating PT students and the CAPTE requirements.
To achieve entry-level competency in pediatric clinical practice, learning strategies should provide all students with evidence-based clinical education experiences. Experiential learning is one evidence-based strategy that could be used in PT education to help PT students reach entry-level competency in pediatrics upon graduation.
Schreiber et al7 characterizes experiential learning “... 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”. Gendron et al8 reported that incorporating appropriate experiential learning into the health care education curriculum increases students' ability to apply didactic coursework to real-life situations, while simultaneously improving their confidence in their clinical capabilities. In PT, experiential learning has been shown to improve PT students' clinical reasoning, critical thinking, problem-solving, and personal and professional attributes and skills.9–13 Evidence suggests the use of appropriate experiential learning in PT education to improve PT students' learning and performance, especially in pediatric clinical settings.7–13
Practicing in pediatric clinical settings can present a challenging environment for PT students due to the variety, complexity, and developmental stages of the children receiving therapy services. To meet this challenge, PT students need knowledge, confidence, and clinical skills to succeed in pediatric clinical practice. Schreiber et al7 present a compelling case for increased experiential learning opportunities to allow PT students the opportunity to practice and attain the necessary clinical skills. They report that “physical therapy with children often requires implementation of unique strategies to effectively communicate with, engage, and motivate children” to improve the health outcomes for the child and their family.7 Increasing the number of direct contact hours using experiential learning with the pediatric population presents the opportunity for PT students to increase their self-efficacy, specifically in patient handling and in their communication with the patient, both of which are necessary for reaching entry-level competency.14
“Perceived self-efficacy is concerned with people's beliefs in their capabilities to produce given attainments.”15 Increasing PT students' self-efficacy has the potential to positively enhance their learning and performance.16 The interaction of self-efficacy beliefs with other thought processes and actions should be an important consideration in education and learning outcomes in all DPT curriculum courses.
In PT education, the level of self-efficacy plays an important role in the translation of learned classroom competencies to clinical practice.17 As such, structured and focused experiential learning should be considered an integral approach to increase PT students' learning of pediatric communication and patient handling skills.
We hypothesized that a structured and focused pediatric experiential learning opportunity would increase PT students' perceived self-efficacy in communication and patient handling skills. The purpose of our study was to investigate changes in PT students' perceived self-efficacy in communication and patient handling following a structured and focused 8-week experiential learning opportunity with a pediatric population.
Institutional Review Board approval for the study was obtained from the University of Jamestown.
A psychometric instrument, Pediatric Communication and Handling Self-Efficacy Scale (PCHSES), consists of 18 communication items and 8 patient handling items and was specifically developed by the authors to identify changes within the constructs of communication and patient handling in a pediatric setting (Supplemental Digital Content 1, available at: http://links.lww.com/PPT/A229).
To develop the PCHSES, a literature review was conducted that included search terms relevant to self-efficacy within health care, physical therapy, education, pediatrics, and pediatric physical therapy. Following a review of the literature, items were developed pertaining to the constructs of self-efficacy beliefs in communication and patient handling. In development of the PCHSES, 6 steps were implemented to increase the reliability and validity: (1) peer review, (2) content expert review, (3) respondents “think-aloud,” (4) piloting of the instrument, (5) review of the pilot data, and (6) final content expert review.
PT students, older than 18 years and in their second year of the DPT curriculum at the University of Jamestown, Physical Therapy Program, were invited via e-mail to take the PCHSES using SurveyMonkey (n = 37). Of those invited, 25 were females (average age = 25.7 years; standard deviation = 1.7) and 12 males (average age = 25.5 years; standard deviation = 1.0). Two PT students reported having children of their own prior to the pediatric experiential learning opportunity. PT students' decision to participate in the PCHSES was voluntary.
Experiential Learning Opportunity
The PT students participate in a total of 16 hours (8 hours in semester 5 of 8 and 8 hours in semester 7 of 8) of structured and focused experiential learning with the pediatric population in our community (Table 1). In addition, PT students engage in 5 hours of experiential learning with the pediatric population through didactic and laboratory classroom activities (semester 7 of 8; Table 1).
Each second-year PT student was required to participate in the pediatric experiential learning opportunity that included adapted fitness classes held at TNT Kids Fitness and Gymnastics 1 hour per week for 8 weeks throughout the semester. TNT Kids Fitness and Gymnastics is a nonprofit organization in the community that provides competitive gymnastics, recreational fitness and gymnastics, and adapted fitness programming for children and adults with special needs. TNT Kids Fitness and Gymnastics has preexisting partnerships with regional school districts to provide adapted fitness and gymnastics classes for the children who have an individualized education program.
Children with an individualized education program are transported to TNT Kids Fitness and Gymnastics during school hours for 1-hour classes with the staff. Our partnership with TNT Kids Fitness and Gymnastics allows our PT students “one-on-one” time with a child with special needs in an active environment to observe the child's gross motor skills, balance, coordination, endurance, and social abilities during the 8-week experience. PT students assist the child throughout the adapted fitness class activities by providing physical assistance, handling, verbal interactions, emotional support, and encouragement.
The children participating in the experiential learning opportunity were in elementary school (n = 23; K-5th grades) and middle school (n = 7; 6th-8th grades). The adapted fitness and gymnastics classes varied in the number of boys and girls and diagnoses of the children. Common diagnoses included cerebral palsy, Down syndrome, autism spectrum disorder, emotional and behavioral disorder, attention-deficit hyperactivity disorder, and cognitive impairment. The pairing of our PT student with a child was a random assignment made at the first experiential learning session.
Participating PT students were asked to complete the PCHSES before and after their completion of an 8-week pediatric experiential learning opportunity at TNT Kids Fitness and Gymnastics as part of the approved DPT curriculum. Up to 2 reminder e-mails were sent to each PT student. Each second-year PT student who voluntarily agreed to participate was assigned a unique 6-digit code-identifier to ensure anonymity. The unique 6-digit code identifier was used to identify changes in individual PT students' pretest and posttest results.
Data analysis was performed using Stata 15.0 for Windows.18 Descriptive statistics was performed for PT student demographics. The Cronbach α was used to assess the internal consistency of the PCHSES constructs of communication and patient handling with an acceptable reliability coefficient of 0.7 or higher.19 , 20 The mean and standard deviation for the constructs of communication and patient handling were calculated. A paired-samples, 2-tailed t-test was performed for each construct (communication and patient handling) to determine the mean difference between paired observations. The α level was 0.05 or less. The effect size (Cohen's d) was calculated to determine the magnitude of the effect that the pediatric experiential learning opportunity had on PT students' self-efficacy beliefs for their communication and patient handling skills. An effect size of 0.80 or above is considered a large effect, 0.50 to 0.79 a moderate effect, and 0.20 to 0.49 a small effect.21
Thirty-two of 37 PT students completed the PCHSES before and after a structured 8-week pediatric experiential learning opportunity. The Cronbach α for internal consistency was high for the communication construct (pretest = 0.98, posttest = 0.96) and for the patient handling construct (pretest = 0.97, posttest = 0.89). The results for the communication construct for each item are shown in Table 2. The average pre- (6.1 ± 1.7) and posttest (7.4 ± 1.1) changes in PT students' perceived self-efficacy for communication with the pediatric population are shown in the Figure. The results for the patient handling construct for each item are presented in Table 3. The average pretest (5.7 ± 1.9) and posttest (6.9 ± 1.4) changes in PT students' perceived self-efficacy for patient handling with the pediatric population are illustrated in the Figure. There was a significant increase in PT students' perceived levels of self-efficacy for both the communication construct (P = .000; Table 2) and the patient handling construct (P = .001; Table 3). Cohen's d was large (1.03) for the communication construct and moderate (0.73) for the patient handling construct.
Our principal finding was that, following a structured pediatric experiential learning opportunity in a clinical setting, there was a significant increase in second-year PT students' self-efficacy beliefs in their communication and patient handling skills. Our results are consistent with Schreiber et al,7 Benson et al,9 and Plant et al,17 who identified experiential leaning opportunities as a strategy to positively enhance self-efficacy beliefs in PT students. Our pediatric experiential learning opportunity was the PT students first structured and focused contact with children in the PT curriculum. Each item's postscore was greater than the prescore, indicating that PT students' confidence in their communication and patient handling with the pediatric population increased.
The significant increase in our PT students' self-efficacy beliefs in communication is consistent with the results of Silberman et al,14 who found that increased confidence in communication for health professional students leads to improved health outcomes for patients. In the construct of communication, PT students' perceived self-efficacy had the greatest increases in their ability to effectively communicate with nonverbal children (communication 1), effectively communicate with a child's family (communication 5), and keep a child engaged throughout an activity (communication 10).
During the pediatric experiential learning opportunity, all of the PT students had an opportunity to interact and facilitate purposeful activities with children who had varying levels of communication abilities. Given the structured one-on-one interactions with children both nonverbal and verbal, we expected to see our PT students' perceived self-efficacy in their ability to communicate with a nonverbal child (communication 1) and ability to keep a child engaged through an activity (communication 10) increase significantly. However, it was surprising to see a significant increase in our PT students' perceived self-efficacy to effectively communicate with a child's family (communication 5), as there were limited opportunities to directly interact with family members. Our PT students did have opportunities to communicate directly with the children's paraprofessionals, which may have contributed to the significant increase in PT students' self-efficacy to communicate effectively with a child's family.
Effective patient handling skills are also essential for all entry-level PT graduates,3 especially when working with children.22 Stevenson et al22 found that “... the type of patient handling their curriculum covered and the students' perception ...” influenced PT students' ability to correctly and effectively perform patient handling techniques.
In the construct of patient handling, PT students' perceived self-efficacy had the greatest increases in the use of “hands-on” techniques to effectively calm a child (patient handling 8), safely perform a sit-to-stand transfer with a child (patient handling 7), and safely guard a child during a therapeutic activity to prevent an injury (patient handling 4). Each of these items was expected to significantly increase. During the pediatric experiential learning opportunity, many of the children had difficulty with self-regulation, required physical assistance with transfers, and needed guarding for safety during physical activities. Given the needs of the children, our PT students regularly practiced patient handling techniques to help calm a child, assist with transfers, and guard a child during physical activities.
Our pediatric experiential learning opportunity improved PT students' confidence in their ability to communicate and perform handling techniques with children. Refined communication and patient handling skills are essential to meeting the APPT's core competencies.6 Without experiential learning opportunities embedded within a DPT curriculum, most PT graduates may not have an opportunity to work directly with a pediatric patient nor achieve entry-level competency in pediatrics as defined by the CAPTE.
These structured interactions allowed the PT students time to adjust their communication style to their specific child, which resulted in better rapport, trust, and engagement during the sessions. Many of our PT students reported an improved level of confidence when communicating with children, and specifically with children who are nonverbal or limited verbally.
Our PT students had the opportunity to practice their handling techniques on children with diverse neuromuscular clinical presentations in the presence of a licensed PT, who guided their learning and ensured the safety of the child. The structured and supervised practice improved the PT students' perceived self-efficacy with their handling techniques and decreased their fear and hesitation associated when handling complex pediatric patients. Following the pediatric experiential learning opportunity, PT students commented that they were no longer “afraid” to have a pediatric patient in the clinic setting. Furthermore, the interactions facilitated the development of a relationship between the PT students and the children.
Our DPT program has prioritized pediatric education with an emphasis on experiential learning opportunities through the engagement of community groups and establishment of functional community partnerships. The structured hours of experiential learning also provided the faculty and DPT program with the opportunity to evaluate our PT students' clinical competency level with the pediatric population prior to graduation.
Our findings provide further evidence of the benefits of incorporating structured and focused pediatric experiential learning into a DPT curriculum. Our approach for pediatric experiential learning provides evidence that only a small number of focused experiential learning hours (8 hours) are needed to have a significant effect on PT students' self-efficacy beliefs in pediatrics. Given the difficulty in attaining direct contact hours and clinical experiences in pediatrics, developing community partnerships may be an effective strategy for DPT programs to provide additional learning opportunities to increase PT students' self-efficacy with the pediatric population. Furthermore, our approach offers a strategy that enhances PT students' learning and positions our PT students to reach the essential competencies of an entry-level pediatric PT.6
There are limitations to the study. First, only 32 out of 37 PT students completed the PCHSES both before and after their experiential learning opportunity. Due to the small sample size from 1 DPT program, our results should be interpreted with caution and optimism. The pediatric experiential learning opportunity was unique for every PT student. While all PT students were required to participate in and complete the 8-hour experiential learning opportunity, each PT student worked with a different child. Depending upon the needs of the child, some PT students may have had more opportunities to practice their communication or patient handling strategies than others. The amount of practice each PT student had using various communication or patient handling strategies may have influenced the degree that PT students' self-efficacy levels changed. As it was not possible for all of our PT students to have a child with the same diagnosis and severity of that diagnosis, our significant findings with children with different diagnoses are a strength of the PCHSES.
Prior to the experiential learning opportunity, each PT student likely had varying types of experience with children prior to the structured pediatric experiential learning opportunity, which was not accounted for in the data analysis. The PCHSES was developed using a documented and scientific approach and is in the early stages of instrument development. Factor analysis and test-retest reliability have not yet been performed.
Our study found that a structured and focused 8-week (1-hour per week) experiential learning opportunity with the pediatric population significantly increased PT students' self-efficacy beliefs in their communication and patient handling skills. Our findings, together with the results of others, reinforce experiential learning in PT pediatric education as an effective way to provide PT students the opportunity to reach the APPT's essential core competencies upon graduation and, importantly, be an effective clinician.
Thank you to all for their contributions—Gregory Gass, PhD; Jackie Madsen, PT, DPT; Tara Haj, PT, DPT; Janelle Askvig, PT, DPT; Marilyn Hedberg; Wendy Breitbach; and TNT Kids Fitness.
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