Exploring Approaches to Defining and Assessing Performance Standards for Physical Therapists Entering Clinical Practice
Purpose: The purpose of this session is to describe a continued discussion that centered around exploring competency-based educational models that may allow clinicians, academicians and students to have a shared language regarding the expected performance standards for new graduates entering practice, may assist in focusing instruction and learning to foster the development of students, and may provide a workplace method of assessment that has increased ability to identify differences in performance based on the learner. This discussion is part of the Education Leadership Partnership's (ELP) long-term strategic planning process that specifically focuses on the opportunity to apply a competency-based education to physical therapy if stakeholders believe this approach would be a good fit for the profession.
Methods and/or Description of Project:
Background: The Education Leadership Partnership (ELP) initial scope of work included recommendations from the Excellence in Physical Therapy Education Task Force (EETF) report of 2015. Of those 7 recommendations, most were tied to improving and measuring outcomes. One of those recommendations suggested, "that a concise set of outcome competencies for physical therapist graduates be identified and adopted." In April 2018, 4 additional recommendations from the Best Practices for Physical Therapist Clinical Education Task Force (BPCETF) report were added into its scope of work. Subsequently, a paper published by the ACAPT Education Research Task Force suggested the need for the profession to, "Develop a robust, longitudinal set of professional competencies." An additional request from the Board was that the ELP facilitate the development of, "a long-term strategic plan for physical therapist professional and post-professional education, including staging of activities, be developed to create a work force prepared to meet the evolving needs of society. Engagement with relevant stakeholders will be critical to this effort."
The ELP accepted the Board’s request to facilitate the development of a long-term strategic plan, and chose to combine elements of the recommendations adopted from the EETF and BPCETF reports in its approach. These combined elements resulted in the development of 4 thematic areas: (1) Education Research; (2) Outcomes, (3) Essential Resources, and (4) Academic-Clinical Partnerships. The ELP also agreed that a fifth component, clinical education, should be infused throughout the strategic planning process, rather than being compartmentalized, and that any strategic plan for the future of physical therapy education should consider the entire learner continuum (eg, professional education, post professional education, board certification, practice). The ELP choose a phased approach to developing a long-term strategic plan. Strategy meetings were held for the education research component in January 2017, and clinical education in October 2018. This presentation will describe the outcomes strategy meeting held in April 2019. The strategy meetings for Essential Resources and Academic-Clinical Partnerships are scheduled for September 2019 and April 2020. Following the completion of the 5 strategy meetings, the ELP will have a culminating strategic planning meeting where the findings from the strategy meetings, and any new work completed since, will be considered in the development of a long-term strategic plan for physical therapy education.
Many competency-based education frameworks have been adopted by health professions education groups around the world. While it became clear that physical therapy should not adopt a framework or frameworks just because another group had done so, a question that developed was, “If the physical therapy profession were to move toward a model of competency-based education, what developmental framework(s) would be most appropriate for the physical therapy profession to utilize?” Building on an established framework, “What are the performance expectations of a physical therapist at various points along the continuum of learning?” Establishing specific points in time along the continuum, in particular entrance into clinical practice, would allow the profession to work from that reference in different directions of learner development. Development of a research agenda for education researchers is a critical element in this transformative work that will explore critical questions about learners, the learning process, curricula, faculty development, outcomes assessment, program evaluation, and institutional and organizational structures. The opportunity to develop both a theoretical and practical body of knowledge that is related to the profession’s work in competency-based education is timely and essential.
The purpose of this Outcomes Strategy Meeting was to discuss the benefits and challenges of developmental frameworks and utilizing this information: (1) Identify a possible competency framework(s) to meet the needs of the profession, and (2) define outcomes of learners entering into practice that are essential to develop PTs who will meet societal needs. While the scope of this meeting may appear narrow in the context of all potential applications along the physical therapy learner continuum, the intent was to focus efforts on some very important foundation components of a potential transition to a competency-based education approach.
Method: Twenty-three physical therapists representing academic institutions and clinical sites across the nation were invited to attend the 2-day meeting. Participants were intentionally selected to ensure broad stakeholder representation, including those of deans, program directors, directors of clinical education, academic faculty, clinical faculty, site coordinators of clinical education, PTA education, and employers. Twenty-six percent of the group were Board Certified Clinical Specialists. Participants were asked to read a series of related articles and reports to prepare them for the meeting. Dr. Carrie Chen, Associate Dean of Assessment and Educational Scholarship and Professor of Pediatrics at Georgetown University School of Medicine facilitated the meeting.
The meeting included foundational presentations on: the impetus for change in other health professions, competency-based education, key terminology, and various developmental frameworks that have been used by health professions around the world to define outcomes of learners. Participants worked in both small and large groups to explore 6 models and discussed the benefits and challenges that each model might bring if the physical therapy profession chose to move in that direction. The group used a similar process to begin thinking about what competencies physical therapists entering clinical practice should be able to do. Finally, participants engaged in a facilitated discussion about research questions that might need to be considered and pursued as the profession considered its opportunity to purse a competency-based education approach.
Results/Outcomes: After many rounds of discussion, the participants came to consensus that identifying standards of performance for physical therapists at various points along the continuum of learning would be helpful for all stakeholders. The standards of performance may: • Assist students in understanding what is expected of them and if they didn’t meet the standards there could be focused instruction and learning to foster their development
• Assist academicians in designing curriculum to allow students to achieve the standards as well as design remediation for those who need additional support to reach that point.
• Allow clinicians to feel comfortable that all students, regardless of what program they come from, will have demonstrated competence in the identified standards of performance. This will allow clinicians to design appropriate workplace learning activities and feel comfortable that students will be safe working with patients on particular activities.
Participants felt that a combined framework of Entrustable Professional Activities (EPAs) and Domains of Competence (DOC) would be most beneficial for the physical therapy profession. EPAs are observable and measurable concrete clinical activities that represent the day to day work of a professional that require proficiency in multiple competencies. They should be executable within a given time frame and completion of the activity leads to a recognized outcome. These professional practice activities can be “entrusted to a sufficiently competent learner or professional.” DOCs offer a more analytical approach to assessment that would be helpful when attempting to delineate where a student may be actually having a challenge and require some remediation. After examining different domains of competence utilized in numerous health professions, participants indicated that the domains utilized by Canadian physiotherapists aligned best with the physical therapy profession. The group felt that slight modifications to the Canadian PT DOC would be needed.
Participants began to develop a list of the EPAs they felt represented what physical therapists entering practice should be able to do. Thirty-six items were generated from all of the small groups and the facilitator placed those identified in one of three categories: patient evaluation and management, additional direct patient care activities, and other related patient care activities. In small groups, participants selected a suggested EPA and used the Equal rubric (Taylor D, 2017) to evaluate the draft for quality and structure.
Conclusions/Relevance to the conference theme:
Competency-based education frameworks have been adopted by health professions education groups around the world and serve as an educational philosophy and approach to educational design. Movement by the PT profession toward a CBE framework would constitute a paradigm shift from the current educational model utilized in the physical therapist education so the potential for such a shift is not taken lightly. Utilization of such a model to define and assess standards of performance for physical therapists may provide benefit to students, academicians, clinicians and inevitably our patients. This exploration of outcomes through a competency-based education approach is part of ELPs long-term strategic planning process.
Across the globe, some health professions are utilizing an EPA framework, some a DOC framework, and others a combination of frameworks. The participants in this meeting felt a combined model of EPAs and DOC would best align with the physical therapy profession. This combined framework may allow for a holistic view of a learner while also allowing an analytical approach to assist in remediation. Thirty-six EPAs were drafted that fell under three categories: patient evaluation and management, additional direct patient care activities, and other related patient care activities. An EPA drafting panel will continue to work on this list to elaborate on the language and in time go through a validation process with extensive feedback from all stakeholders. Once formed the draft set of Core EPAs for clinicians entering practice would be piloted by programs who volunteer to take part.
Participants attending this meeting unanimously agreed that the opportunity to pursue a competency-based education approach should be considered by the profession, and recognized that if the profession chose to move that direction that the journey would be long and should be grounded in theory and research. Educational research is needed to answer various questions that will assist our profession in making an evidence based informed decision as to whether this is the right path to best meet our profession as well as societal needs. All also agreed that each step along this journey will require effective, transparent, and collaborative communication as well as feedback from all stakeholders.