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RESEARCH REPORT: EDUCATION

Educational Research Priorities for Pediatric Physical Therapy

A Consensus Study

Moerchen, Victoria A. PT, PhD; Lundeen, Heather DPT, PCS; Dole, Robin L. PT, DPT, EdD

Author Information
doi: 10.1097/PEP.0000000000000666

INTRODUCTION

History of Educational Research in Pediatric Physical Therapy

Educational research in pediatric physical therapy developed slowly until 2011 when the Academy of Pediatric Physical Therapy's (APPT) strategic planning process identified a need for a targeted focus on the education of future pediatric physical therapists. In response to the historic paucity of pediatric educational research and the variability identified among entry-level programs,1,2 the APPT supported its first Education Summit in 2012. Education Summit I sparked interest in and collective momentum for educational research to inform pediatric physical therapist education. Multiple scholarly products arose from Summit I,3–7 with commitment to develop an intentional, systematic approach to identifying best practices in professional pediatric physical therapy education through research efforts.

Despite this growing commitment to educational research, one historic barrier to establishing valid evidence for best practices in pediatric physical therapy education has been the absence of educational research as a specific research priority in the APPT's research agenda. This omission limited the availability of funding to support and promote educational research. As momentum for educational research within the APPT continued, Education Summit II was supported in 2016. APPT funding for educational research became available for the first time in fall 2017, and the 2018-2020 APPT Research Agenda8 is the first to include broad categories of educational research topics and approaches. However, for educational research to make a strong contribution to outcomes of the APPT research agenda, more detailed and more broadly informed educational research priorities are required.

Advancing Educational Research in the Profession of Physical Therapy

The historic and recent efforts of the APPT to promote educational research have paralleled similar processes and progress within the APTA, as well as within the Academy of Physical Therapy Education (APTE). The APTE defers to the APTA research agenda rather than having its own research agenda, and although the APTA's original “clinical research agenda9 had been very specific to clinical practice, its revision in 2011 intentionally added education/professional development. This addition supported the profession's commitment to better understand clinical education, educational effect on professional behaviors, models of professional education, cultural competency, clinical decision-making, and skills required for optimal and cost-effective patient care and advocacy.10 The APTE's 2013-2018 strategic plan includes an intentional effort to enhance educational research with Major Goal 2 “Promote scholarly activities and access to new knowledge that facilitates evidence-based educational practices.”11

The need to recognize educational research as a priority for the physical therapy (PT) profession reached a tipping point with a Journal of Physical Therapy Education (JOPTE) editorial published in 2015 that issued the following call to action: “We challenge APTA, the Education Section, and ACAPT to make the development of an education research agenda a high priority with rapid determination of the best process to use, and with completion of the process within the next year.”12 This challenge argued that the educational component of the APTA's clinical research agenda was not sufficient, and the editors of the JOPTE advocated for the adoption of a new agenda focused on preparation for competent practice, educational enterprise, and the research endeavor.12

Similarly critical to our profession's momentum for educational research were the findings published in an article by Jensen et al13 “Visions of the Possible” in which “4 major challenges and areas that are critical to making transformative change in education research for physical therapy” were identified: (1) conceptual framing of educational research in PT, (2) community of educational researchers, (3) data analytics and big data, and (4) funding and infrastructure. This article was the result of an American Council of Academic Physical Therapy (ACAPT) task force assigned to discuss strategies to develop an educational research agenda for physical therapy. This group “identified the major challenges,” and suggested work, goals, and actions to accomplish the major areas identified. This process culminated in an intentional collaborative effort to develop short- and long-term educational research action plans that were collectively endorsed in 2017 by the ACAPT, the APTA, the Section on Education, and the Foundation for Physical Therapy.14

Concurrent Advances in Educational Research in Pediatric Physical Therapy

The APPT continued to make steps to elevate the importance of educational research in pediatric physical therapy, including supporting Education Summit II in 2016. This summit responded, in part, to Jensen et al's13 “Vision of the Possible” in its goal of developing a community of educational researchers. To achieve this goal, Summit II brought together a cohort of pediatric physical therapists with a demonstrated record of educational scholarship to receive targeted training in educational research by invited physical therapy educational experts. The outcomes of Summit II included: (1) increased knowledge and skills of attendees in educational research theory and methodology, (2) preliminary research priorities for pediatric physical therapy education to guide APPT educational research, and (3) collaborative postsummit research teams with tangible projects to initiate a response to identified educational research priorities. The study reported here extends the preliminary work of Summit II/Outcome 2 toward establishing educational research priorities for pediatric physical therapy.

Approaches by Other Professions to Establish Educational Research Priorities or Agendas

The recent chronology of increased value of and momentum for educational research is not unique to the profession of physical therapy. The development of an educational research agenda was undertaken by other professions to align educational research priorities with their broader research agendas. For example, the American Occupational Therapy Association15 identified 6 major research priorities for occupational therapy education intended to complement their overall research agenda, including theory building, pedagogy, instructional methods, learner characteristics and competencies, socialization to the profession, and faculty development and resources for educational research. The American Association of Nurse Anesthetists and the American Association of Physician Assistants explicitly identified education as a broad research priority in their overall research agendas, and each then identified research subpriorities within education.16,17 These subpriorities included defining quality education, curricular design, and/or best practices; other subpriorities focused on questions nuanced to a profession (eg, examining the value of the Doctor of Nursing Practice16) or inclusive of admissions processes and faculty preparation and support.

The call for educational research agendas within medical education has increased in recent years. One article opened with the following compelling statement: “Given how much is spent annually on medical education, it is quite remarkable how little is invested in research to spur the generation of theories and provide evidence about what works and what does not.”18 The conceptualization of educational research as translational research has also gained momentum in medical education to support research agendas,19–21 and was recently used as a framework for a proposed educational research roadmap for pediatric physical therapy.22 A persuasive argument for an educational research agenda is to ensure that professional education today prepares practitioners for tomorrow.23

Arguably, central questions, such as “how to demonstrate that education produces graduates who deliver high-quality care,” or “what clinical outcomes will measure the performance of education,”23 span medical professions and subspecialties. Some authors suggest using themes in education and practice to drive themes for educational research,18 while others suggest focusing questions on key components of medical education including admissions, faculty, curriculum, and educational outcomes.24 In the studies reviewed, the approaches used to identify, refine, and update these themes and key questions to inform educational research agendas varied, but typically included a group of stakeholders and leaders convening to collectively identify priorities.25

Consensus Development of Educational Research Priorities for Pediatric Physical Therapy

Vetted pediatric educational research priorities for the APPT are needed to (a) support and perhaps drive initiatives to identify and invest in educational research for the APPT, (b) develop and advance the capacity for educational research within the profession and within the APPT, (c) promote excellence in educational research within the profession and within the APPT,26,27 and (d) increase awareness, understanding, and value of educational research to internal and external stakeholders including academic institutions, clinical institutions, and the public.

Preliminary research priorities for the APPT emerged from Education Summit II with input from a limited group of participants. These preliminary priorities, including uptake of essential competencies, clinical reasoning, assessment, preparation for pediatric practice, and learning/instructional methods, were intended to support the development of research teams and projects as outcomes of Summit II. The process of identifying these priorities during the Summit, however, did not include sufficient methodological rigor or breadth of stakeholder groups to guide the Academy's farther-reaching consideration of priorities for inclusion of educational research in its research agenda. The purpose of this study was to address this need by engaging internal and external stakeholders in a consensus exercise toward determining and refining priorities for educational research for pediatric physical therapy.

METHODS

Design

The Delphi method was used to support consensus building across stakeholder groups to achieve convergence of opinions on educational research priorities broadly and specific pediatric physical therapy.28,29 The Delphi method provides methodological rigor through (a) identifying and inviting groups of individuals with expertise related to the topic, (b) developing, distributing, and collecting responses to surveys that iteratively build on the responses of all participants in subsequent rounds, and (c) completing the study when consensus is achieved. Respondents are anonymous to each other throughout the study, and the richness of this methodology is that multiple iterations allow the researchers to ask the experts to respond to their interpretation of the data, thus supporting a group decision-making process.28 This study was approved by the Institutional Review Board of the University of Wisconsin-Milwaukee, with institutional agreements at the University of Mary and at Widener University.

Participants

Stakeholder Group Identification

The goal was to recruit 50 “expert” participants, equally dispersed among 5 distinct stakeholder groups, who would possess an area of expertise that would assist in developing pediatric physical therapy educational priorities and represent diverse viewpoints on the subject matter. Five stakeholder groups were identified to achieve comprehensive and diverse viewpoints: APPT leaders, APPT Education Summit I or II participants, APPT members invested in educational research, physical therapists outside of the APPT invested in educational research, and pediatric physical therapy clinical and residency educators. When a participant could fit into more than one stakeholder group, a decision for group assignment was made to keep groups as equal as possible.

A purposive sampling technique30,31 was used to select relevant experts and to ensure equal representation among the stakeholder groups. Potential participants were identified through accessing publically available resources including: rosters of key APPT leaders from the past 5 years; lists of editorial teams for Pediatric Physical Therapy and the Journal of Physical Therapy Education for the past 5 years; a directory of pediatric physical therapy residency directors; a list of educator authors who submitted proposals for the 2017-2018 special series on Pediatric Education in the Journal of Physical Therapy Education; lists of participants in the APPT's Education Summits I and II; the directory of physical therapists who are currently board-certified pediatric specialists and certified clinical instructors; and electronic searches of the physical therapy educational research literature. Obtaining an appropriate panel of experts via a Delphi study does not depend on a statistically representative sample; an essential panel of experts for a Delphi study includes individuals who have a deep understanding of the topic and represent important perspectives therein.29

Inclusion Criteria

In total, 101 physical therapists were identified as potential participants representing the 5 stakeholder groups that would potentially meet the inclusion criteria for the study (Table 1). The potential participants were contacted electronically and were informed of the purpose of the study as well as their potential role. If they indicated a willingness to participate they were asked to respond by self-identifying the inclusion criteria that they met. They were also informed that if they were found to meet the inclusion criteria, their response to the initial e-mail invite would indicate consent to participate. To enhance objectivity, the potential participants were not informed of the number of inclusion criteria required for selection. Expertise for the purpose of this study was functionally achieved by requiring that each person selected for participation met 2 of the inclusion criteria. These criteria captured stakeholder groups with relevant expertise in clinical or academic education, educational scholarship, and/or professional contributions to competency documents or strategic initiatives.29 Of the 101 individuals initially identified, 27 did not respond, 13 declined, and 4 did not meet inclusion criteria. Ultimately, 57 pediatric and/or educational physical therapists were invited to participate in this study.

TABLE 1
TABLE 1:
Inclusion Criteria

Participant Demographics

The highest educational degree/status identified by the participants included 69% with a nonclinical doctorate degree (DSc, EdD, PhD) and 18.5% with a clinical doctorate degree (DPT). Seventy percent of the participants had been licensed physical therapists for more than 20 years, 17% for 16 to 20 years, 7% for 11 to 15 years, 6% for 5 to 10 years, and none of the participants had been licensed for fewer than 5 years. The current primary employment of the participants included 75% in academic teaching, 7% in clinical practice, 11% in academic administration, and 7% in clinical administration. The clinical education background of the participants included 20% who were or had been residency or fellowship directors, 20% who were or had been residency mentors, and 60% who were or had been clinical instructors for professional physical therapy education. Finally, 100% of the participants were APTA members, and 80% were members of the APPT.

Delphi Process

The survey process using the Delphi technique is displayed in the Figure. For each round the participants were asked to complete their survey within 4 weeks and additional time was given as needed. Reminders were sent prior to the close of each round based on response rate to increase participation and to ensure equal distribution as possible among groups.

Survey Rounds Invitation

In each of the 4 rounds, all participants, regardless of their participation in past rounds, received an e-mail with information specific to the respective round and a link to a survey questionnaire to be completed.

Survey Round Details

Round 1

The survey for round 1 contained general information about the study, a working definition of pediatric physical therapy education, demographic questions, and 3 open-ended questions intended to initiate development of an educational research agenda for pediatric physical therapy by focusing on unanswered questions, gaps, and special considerations in pediatric physical therapy education (Figure, round 1).

Fig
Fig:
Delphi study.
Round 2

The survey for round 2 consisted of a list of 46 statements organized into 8 categories, which were determined by consolidating all the unique responses from round 1. For this second round, the participants were asked to identify and provide comments with regard to clarity, redundancy, or fit (including any omissions) for each of the categories and statements generated from the analysis of the round 1 data (Figure, round 2).

Round 3

After analysis of the round 2 results, which included feedback about the organization of the data, the researchers revised the statements into those that represented research priorities and those that represented research considerations (defined in results based on outcomes from round 2). The survey for round 3 then contained the revised list of potential pediatric physical therapy educational research priorities and considerations based on round 2 data analysis. For this survey, the participants were asked to indicate their level of agreement using a 5-point Likert scale (strongly agree, agree, neither agree nor disagree, disagree, and strongly disagree) for each priority and consideration that emerged from round 2. They were also asked to indicate whether they felt each priority and consideration was (a) unique, specifically important, or nuanced to pediatric physical therapy education, (b) a concept that could be sufficiently captured in a broad educational research agenda for the profession, or (c) both (Figure, round 3).

Round 4

The survey for round 4 consisted of the priorities and considerations that met the threshold for consensus based on responses to round 3. For this final survey, the participants were asked to rank, in ascending numerical order (1 = highest value), the priorities and the considerations that had met consensus for inclusion in a pediatric physical therapy educational research agenda. The participants were also invited to explain “why” they chose the prioritization they did. Finally, the participants were asked to review the priorities/considerations that did not achieve consensus and to identify or justify any that they felt should be moved forward for future consideration (Figure, round 4).

Data Analyses

Qualitative content analysis was used for consolidation of responses from rounds 1 and 2. In round 1, all unique ideas were captured, coded, and consolidated into themes by 2 of the researchers. The third researcher served as the masked reviewer, examining the coded data and the raw data in parallel to ensure the collapsed categories were representative of the initial data. An example of how researcher consolidated participant responses into statements and categories is shown in Table 2. During consolidation of round 2, each author independently worked with 2/3 of the data to assure overlap of 2 authors' efforts at all times. Group decisions for overall consolidation of round 2 data were conducted in person at 2018 Combined Sections Meeting of APTA. round 3 required examining consensus based on an a priori agreement threshold of 80% among all “expert” participants and/or “expert” participants in at least 3/5 stakeholder groups to advance possible priorities and considerations for final rank ordering. Ranked data from individual responses to round 4 were examined within and across stakeholder groups by calculating an overall score as (the rank value) × (the number of people giving that rank), summed across all stakeholders,32 where higher scores indicated lower rankings and lower scores indicated higher rankings. This provided an average rank score for each statement.

TABLE 2
TABLE 2:
Example of Consolidation Process

RESULTS

Participants and Stakeholder Groups

This study began with 57 identified physical therapists with pediatric and/or educational expertise distributed across 5 stakeholder groups and 10 to 12 invited participants per group. Participation across survey rounds ranged from 94.7% in round 1 to 80.7% in round 4, with each stakeholder group represented 67% to 100% across rounds (Table 3). The summit participants and clinical/residency educators stakeholder groups achieved the highest participation across rounds at 96% and 95%, respectively.

TABLE 3
TABLE 3:
Respondents by Round by Stakeholder Group

Outcomes of Survey Rounds

Round 1

The round 1 survey resulted in multiple stakeholder responses to generate an initial set of categories of research questions, gaps, and special considerations in educational research in pediatric physical therapy. The open-ended nature of the questions allowed for multiple responses per question by each participant, which supported the intended broad reach of initial inputs to shape an educational research agenda.

Through content and thematic analysis, the responses from open-ended questions 1 and 2 (Figure) were consolidated into 4 categories. The first category included 10 items or statements related to curricular content and outcomes in general. The second category included 8 items or statements related to curricular experiences and structure in detail. The third category included 6 items or statements related to pedagogy in teaching and learning and the fourth category included 3 items or statements related to postprofessional levels of education.

The responses from open-ended question 3 (Figure) were consolidated into 4 additional categories to make 8 categories. Category 5 included 4 items or statements related to institutional and personnel resources, category 6 included 5 items or statements related to rigor in pediatric educational research, category 7 included 4 items or statements related to stakeholders in studies and recommendations, and category 8 included 6 items or statements related to diversity of programs and learners.

Round 2

The results of the round 2 survey refined and clarified the data collected in round 1, and achieved a stakeholder-vetted list of what was most important to include in an educational research agenda. Stakeholder responses specific to fit, clarity, and redundancy of the round 1 statements were collapsed, combined, reordered, and recategorized. Two distinct components of a potential research agenda emerged: priorities defined as statements about the most important areas of educational research for pediatric physical therapy; and considerations defined as statements about what should be given attention when conducting educational research for pediatric physical therapy education. The resultant 3 priority categories included curricular content and outcomes in general, methods and practice of teaching and student learning outcomes, and postprofessional levels of education. The 4 consideration categories included institutional and personnel resources, rigor in pediatric educational research, including stakeholders in studies and recommendations, and variety of programs and learners. The 3 categories of priorities then retained 20 subsequent statements and the 4 categories of considerations retained 13 subsequent statements.

Round 3

Researchers analyzed agreement among stakeholders (individually and per stakeholder group) for each priority and consideration based on strongly agree/agree responses. Consensus was set at 80% or more among all participants or 80% or more among 3 or more stakeholder groups. A total of 21 statements representing priorities were rated for consensus and 12 achieved the threshold for consensus. A total of 13 statements representing considerations were rated and 13 achieved the consensus threshold (Table 4; see Supplemental Digital Content 1, available at: http://links.lww.com/PPT/A279).

TABLE 4
TABLE 4:
Ranking of Priorities and Considerations for Educational Research in Pediatric Physical Therapy

Round 4

In this final step, participants provided rank ordering of the priorities and considerations that had achieved the level of consensus during round 3 (Table 4). The ranking in this final phase was to delineate which statements the participants thought were most important or should be studied first. In the researchers' analyses of the average rank scores, there was clear and consistent ranking of the top 4 statements across all stakeholders for each priority and consideration statement.

DISCUSSION

To continue the momentum within the APPT for educational research, and to support the alignment of future collaborative educational research and funding to achieve an evidence base for pediatric physical therapy education, this study used the Delphi methodology to engage physical therapist stakeholders, internal and external to pediatric physical therapy education, in identifying and ranking pediatric physical therapy educational research priorities. Participation of stakeholders in the 4 rounds remained above 80%. In rounds 1 and 2 of the study, participants were asked to identify gaps, questions, and any special considerations in educational research in pediatric physical therapy. As the responses were consolidated, 2 organizing categories for responses emerged: priorities operationally defined as statements about the most important areas of educational research for pediatric physical therapy, and considerations operationally defined as statements about what should be given attention when conducting educational research for pediatric physical therapy education. An agreement threshold of 80% among all “expert” participants and/or “expert” participants in at least 3/5 stakeholder groups (round 3) was used to advance possible priorities and considerations for final rank ordering (round 4).

Educational Continuum

As the responses to rounds 1 and 2 were consolidated and the researchers reviewed comments related to clarity and redundancy from participants, it became necessary to define the scope of the educational continuum within pediatric physical therapy research. Participants were instructed to consider the full educational continuum as spanning professional, residency, fellowship, and specialization in all ways in which they may occur. These educational programs were used conceptually and not prescriptively in this study to allow initial research priorities and considerations to be viewed as broadly as possible.

Educational Research Priorities in Pediatric Physical Therapy

The top 4 research priorities identified focus on determining relevant content for pediatric physical therapy education, effectively measuring outcomes of educational experiences, identifying effective teaching, and identifying indicators of readiness for clinical practice. These themes are consistent with the research priority area of preparation for competent practice argued by Gwyer and Hack12 and add specificity to the 2018-2021 APPT strategic plan goal 1(c) of improving the quality and consistency of pediatric physical therapist education.33 Further, prioritizing research to identify effective outcome measures of educational experiences is consistent with the sentiment in the medical literature that quality preparation of students should be measurable in outcomes of practice,19,20 and achieving this would address the deficiency noted by Rapport and Furze in their editorial for the Pediatric Special Series in the JOPTE5 that educational research in pediatric physical therapy needs to move beyond description. The priorities that reached consensus in this study span from general educational theory, pedagogy, and measurement to more nuanced considerations of essential competencies for pediatrics, preparation across the educational continuum, and even preparation of educators.

Educational Research Considerations in Pediatric Physical Therapy

The top 4 research considerations include growing a community of educational researchers, identifying resources to sustain high-quality educational research, striving to achieve high-quality designs and methods in educational research, and building on what is known in other relevant fields. These top-ranked considerations align with the recommendations that came from the Educational Leadership Partnership14 for a focus on communities of educational researchers and on funding and infrastructure. They also match and extend the contribution of Education Summit II toward growing a community of educational researchers within the Academy. Faculty development and institutional value of and resources for educational research are barriers identified across medical professions.34,35 The conceptualization of educational research as translational research22–24 is arguably critical to moving educational research in pediatric physical therapy beyond proof of concept studies to comparative effectiveness and educational outcome studies.

Nuances in Education for Pediatrics

The richness of the Delphi approach in achieving a breadth of stakeholder inputs was evident in responses to rounds 1 and 2, where expert participants provided comments and questions about topics being relevant beyond just pediatrics. For round 3, this overlap of themes was probed in asking respondents to indicate whether they felt each priority and consideration was (a) unique, specifically important, or nuanced to pediatric physical therapy education, (b) a concept that could be sufficiently captured in a broad educational research agenda for the profession, or (c) both. Respondents conveyed that physical therapy knowledge of best practice pedagogy and outcomes is sufficiently lacking across physical therapist education in general, such that knowledge gained in any area would inform the profession and specialist areas, concurrently. Special considerations such as including children and families in informing research and in evaluating educational outcomes, which may be nuanced to pediatric physical therapy, were not in the top 50% of the ranked items, albeit that they did reach overall consensus. It is likely, therefore, that the efforts of educational research in the APPT will inform and be informed by educational research in the profession. The fourth-ranked research consideration suggests building on what is known in other fields. Thus, the nuances of specialty practice such as pediatrics can benefit from and perhaps inform physical therapist education, broadly.

Limitations

While additional stakeholder groups were considered, including consumers or educational experts from outside of physical therapy, it was determined that the 5 stakeholder groups sufficiently captured the breadth of perspectives for this initial consensus identification of educational research priorities. Consumers including children, families, or employers of pediatric physical therapists were discussed as having insights to practice, but perhaps not to the nuances of education. Based on this distinction, these groups were not included at this stage of informing educational research. While the roles of these same groups were identified as important to educational research by the stakeholder participants, as evidenced in the list of considerations that reached consensus in round 3, they did not appear in the top-ranked considerations at the end of round 4, supporting the decision on stakeholder group selection in the design of this initial study to identify educational research priorities. Stakeholder participation across rounds is imperative to the Delphi design. This study was successful at maintaining 80% participation across 4 rounds of surveys with relatively stable and equal participation within and across groups. While there was attrition throughout the 4 rounds, the consistency of participant involvement within and across stakeholder groups provides strength to the consensus that was developed and confirms the level of commitment and interest of this expert panel.

RECOMMENDATIONS AND CONCLUSIONS

We believe that pediatric educational research priorities and considerations that were identified through this consensus study will support the Academy in its ongoing and expanding efforts to develop and advance the capacity for educational research, to promote excellence in educational research, to invest in educational research, and to increase awareness, understanding, and value of educational research among internal and external stakeholders including academic institutions, clinical institutions, and the public. The outcomes of this study support educational research as a more central component of a research agenda for the physical therapy profession and add detail to the present inclusion of educational research in the 2018-2021 APPT Research Agenda.

ACKNOWLEDGMENTS

The authors would like to thank the stakeholder participants who made this study possible by sharing their insights, concerns, and dreams for educational research across 4 iterations of surveys. Additionally, we would like to thank Julie Dwyer, DPT, for her management of survey distribution and raw data. We would also like to thank the Academy of Pediatric Physical Therapy for its support of Education Summit II that led to discussion and initial steps toward this study.

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Keywords:

Delphi study; educational research; pediatric physical therapy; research agenda

Supplemental Digital Content

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