• Feature

    Planning for the Future of Clinical Education

    APTA, the Academy of Physical Therapy Education, and the American Council of Academic Physical Therapy are collaborating through the Educational Leadership Partnership to reshape physical therapy clinical education.

    Clinical Education

    Three years ago, as a physical therapist assistant (PTA) student at Brigham Young University-Idaho, Brendon Larsen, PTA, like his classmates, was required to complete 2 clinical internships. The rotations, he recalls, were "really varied": One primarily was inpatient, the other mostly outpatient, and they exposed him to everything from home-based wound care and pediatrics to palliative care and sports medicine. "I wouldn't say I loved every aspect of my clinicals. I saw a lot of patients whose conditions were outside the niche I'd envisioned for myself. But their variety taught me a lot about the profession and led me to where I am today," Larsen says.

    He now is working with RehabVisions in the therapy services department of a critical-access hospital in rural Prosser, Washington. He's also a credentialed clinical instructor (CI) through the American Physical Therapy Association's (APTA's) Credentialed Clinical Instructor Program, and he serves as the local RehabVisions site coordinator of clinical education. Finally, Larsen says, he's deeply involved with APTA itself, as treasurer of the Academy of Aquatic Physical Therapy and district co-chair within the Physical Therapy Association of Washington. "I'm often going to meetings and conferences. Between work and travel, I have no trouble keeping busy," he says.

    Because of this experience—and especially because he was a relatively new graduate working as a CI in rural health care—Larsen last fall was invited by the Education Leadership Partnership (ELP) to participate in an action-planning meeting focused on the future of physical therapy clinical education.

    Formed in 2016 through a memorandum of understanding between APTA, the American Council of Academic Physical Therapy (ACAPT), and the Academy of Physical Therapy Education (APTE), the ELP was established "to bring together all relevant stakeholders having an interest in promoting excellence in physical therapist education" and to consider how best to achieve a series of recommendations made by the ELP's subgroups: data management, education research agenda, essential resources, faculty development, outcome competencies, performance-based student outcome assessment, PTA education, and student debt.

    In 2017, the ELP adopted as its purpose "to reduce unwarranted variation in practice by focusing on best practices in education."1 Earlier this year, it redefined its purpose as "partnering to drive excellence in physical therapy education," according to Steven Chesbro, PT, DPT, EdD, APTA's vice president of education and an ELP participant almost from the start.

    It would achieve this goal, the partners determined, by following suggestions of the Best Practices for Physical Therapist Clinical Education Task Force (BPCETF). That entity was convened in response to a charge from APTA's House of Delegates to identify and recommend strategies to the APTA Board of Directors for furthering best practices in all aspects of clinical education. Among the recommendations emerging from the task force that were adopted by the ELP in early 2018 are:

    • The physical therapy profession's "prioritized education research agenda" should "include a line of inquiry specific to clinical education."
    • Clinical education should be added to a previous set of APTA Board recommendations dealing with education data management systems. (Within this recommendation, it is suggested, for example, that a "national clinical education matching program" be used to assign students to clinical education sites, and that "outcomes of care provided by physical therapist students/interns/residents are included in patient/clinical outcome registries.")
    • A "framework for formal partnerships between academic programs and clinical sites" should be developed.
    • A "structured physical therapist clinical education curriculum" should be developed and implemented to standardize the clinical education experience and the measurement of student competencies.
    • A "long-term strategic plan for physical therapy professional and postprofessional education" should be developed "to create a work force prepared to meet the evolving needs of society."

    When the ELP contacted Larsen and asked him to join several dozen other PTs and PTAs for its "Clinical Education Strategy" meeting, he jumped at the chance to get involved, he recalls. "I felt like I had a unique perspective to offer—that as a new professional in a place like Prosser, Washington—which most students planning their clinicals haven't even heard of—I could advocate for ways to get more partnerships with rural sites."

    A recurring frustration voiced by many in physical therapy education, Larsen notes, is that there are too few clinical opportunities for the growing number of students in PT and PTA programs. "And that's true," he says. "We do need more places for students to go. But I also think we're underutilizing many clinics that aren't in the big cities or close to colleges and universities." At the hospital where he works, Larsen says, "they see maybe 5 students per year."

    That number is lower than it could be in part, he concedes, because of its rural location. But it's also due to a lack of clinicians who want to teach. "It's the same here as it is in a lot of places: There's not a great love for the idea of being a clinical instructor. People see having students as extra work, extra stress."

    Larsen says he's been trying to change that perception.

    "When I leave for a conference or can't be here for some reason, therapists who wouldn't agree to take a student for 10 weeks usually are willing to fill in for a day or so," he notes. "That small taste might be enough to pique their interest, but otherwise the clinical instruction is mostly up to me." Fortunately, he says, he loves to teach. "It's one way that I can give back to the profession and introduce students to the benefits of rural physical therapy," he adds.

    A "Phased Approach" to a Long-Term Strategic Plan

    When the ELP partners eventually succeed in their mission, it will be thanks to the support of PTs and PTAs such as Larsen, says Chesbro. The partnership, he says, is probably best viewed as a melding of different "strategy groups"—each focused on a separate area of "work that emerged from BPCETF's recommendations and earlier recommendations from APTA's Excellence in Physical Therapist Education Task Force [EETF]."

    "We have 4 work categories in all," he explains: educational research, outcomes, essential resources, and academic-clinical partnerships. Each category overlaps with the others, he says, so, as each group develops a plan to achieve its work goals, "the groups also are coming together to develop a strategy for the entire partnership."

    That long-term strategic plan, Chesbro explains, will recognize that clinical education is at the heart of professional training and will unfold over the course of decades, not years. "Many see physical therapy education as having 2 parts—the didactic and the clinical. What we're saying now is that this is the wrong approach: Your education should be a seamless experience, not something where your clinicals are an educational add-on or afterthought."

    The clinical education strategy meeting that Larsen attended last October was intended to serve as an initial brainstorming session, with all of the ELP strategy groups at the same table. "They sat down and developed a priority list of things the ELP needs to do," Chesbro says. "Now, over the course of the coming year, they'll each meet individually again to develop strategies related to their specific work." The last of those 4 meetings—for the academic-clinical partnerships strategic group—is scheduled for April 2020, he says.

    Later, in fall 2020, the 4 groups will get together once again. "Our goal will be to create the strategic plan that the APTA Board of Directors asked the ELP to facilitate. It's a phased approach, an intentional process, and in the end it's going take us 2 or 3 years, considering broad stakeholder feedback, just to develop the framework for change. But by the time that meeting happens, our hope is that we'll have everything in place to be able to do it right."

    ELP Evolution

    While it helps to understand where the ELP is headed, to really get a sense of its reason for being one has to look back to when the partnership was founded. Three years ago, leaders from ACAPT, APTE (then the APTA Education Section), and APTA recognized that they were pursuing many of the same educational goals.

    The 3 groups already had coordinated in 2014 at the Clinical Education Summit in Kansas City, and they'd developed some ideas around what needed to change in clinical education to better prepare students to become PTs and PTAs." "That was a great meeting," recalls ACAPT president Barbara Sanders, PT, PhD, FAPTA, "and a lot of things came out of it. But we weren't organized enough to figure out how we would follow up in any substantial way."

    The 3 groups dove into separate education-related initiatives following the summit, she says. (APTA's Clinical Education Task Force was one of them.) But it wasn't until 2016 that they formally joined forces through the ELP. "We'd started having these discussions about what we could do differently, and how we might get these groups with their 3 different perspectives to collaborate and communicate so we're not tripping over each other's feet. The ELP came out those talks," Sanders said.

    APTA President Sharon Dunn, PT, PhD, and Gina Musolino, PT, DPT, EdD, MSEd, who at the time was president of APTE (her term ended in 2018), were the other key leaders at the ELP's start. The 3 are recognized as the partnership's founders.

    "At first," Dunn recalls, "it was, ‘Whose work is this? Who owns what?' But now with the ELP we all own the work. We're just trying to figure out how best to accomplish it." On the docket, Dunn explains, are the 4 work categories and the many complicated challenges involved with each: "There is work to be done in standardization and the structure of educational models from entry-level to clinical practice. There is the need for data management and data analytics. There's the very important area of educational research, and making sure that, as we make these decisions about the direction to take in the future, they're based on evidence. The biggest challenge is the academic and clinical partnership. We need to ensure that when our PT and PTA graduates hit that clinical mark, they have the skills and abilities to bring to our communities."

    Like Dunn and Sanders, Musolino says the ELP came into being gradually, as the founding members saw they could make better progress as a team. "It initiated more as a group to just communicate what was going on within each entity. And then we evolved in our discussions and realized we probably needed to be something greater." The ELP today, Musolino says, is "driving the agenda toward excellence in physical therapy education—be it clinical education, academic education, instructional strategies, or, most important right now, in my opinion, scholarly research in education."

    Just as practicing clinicians must be efficient and effective when they provide patient care, "we want to be efficient and effective in the way we educate," she says. "So, what are the best practices for how to educate future physical therapists and PTAs? That's where we need to focus our research."

    For example, Musolino explains, the profession needs to determine how much time students should spend on clinical rotations. It also would benefit from research that looks at institutional and regional differences in how clinicals are structured, to arrive at "an ideal approach" for all programs to adopt.

    "This kind of work, which we need in order to advance the profession, requires too many resources for any of the partners on their own," she says. "With the ELP, we can pool our resources and collaborate, so we're no longer just spinning our wheels."

    Addressing Challenges From the Front Lines

    If Dunn, Sanders, and Musolino together represent the ELP's origins and the 3 organizations upon which it's built, Christopher Meachem, PT, DPT, and Amy Smith, PTA, can offer insight into its potential for the future.

    Meachem, an acute care therapist and physical therapy director of training and clinical education at Jesse Brown VA Medical Center in Chicago, and Smith, regional director of operations with Restore Therapy Services in Alabama, both took part in the ELP's clinical education strategy meeting and came away optimistic that positive change is in the works. "Having been part of the conversation for a little over a year now, I'm confident that we're headed in the right direction," Meachem says.

    Throughout the country, the US Office of Veterans Affairs hosts 120,000 health care-provider trainees per year, including many who are launching careers as PTs and PTAs, Meachem notes. "It's part of our statutory mission and a huge part of what we do. It's mainly about meeting the health care needs of veterans and society, but it's also for succession planning and maintaining our recruitment pipeline."

    At the ELP meeting, Meachem says, he contributed as a co-coordinator in the academic-clinical partnerships strategic group, bringing with him not only his experience at Jesse Brown, but also his perspective as chair of the Veterans Health Administration's National Physical Therapy Clinical Education Committee. Like Brendon Larsen at RehabVisions, he's concerned about the competition among academic physical therapy programs fighting to place students in appropriate clinical experiences.

    "CAPTE [the Commission on Accreditation in Physical Therapy Education] requires academic programs to provide a minimum of 30 weeks of training, yet regionally there are only so many clinical slots to go around," Meachem points out. Many organizations and private practices that might otherwise be willing to provide clinical training, he notes, hesitate to do so because of the financial pressures they face, including restrictions around reimbursement. (PT students, for example, are not paid for treating Medicare B patients.) "Our profession has made a conscious decision to focus on excellence in physical therapy education. So, how do we maintain that focus within the current environment while meeting the needs of our colleagues and future clinicians?"

    It's clear, Meachem says, that the ELP eventually will find the answer to this and other difficult questions—whether it's how to track outcomes in training to ensure that new clinicians can provide high-quality care or how to design the optimal clinical experience. "One of the goals of the academic-clinical partnerships group is to look at what's out there in our profession, as well as within other health care professions, and to open ourselves up to what is working. That requires a national discussion with all the key stakeholders—which is where the ELP comes into play."

    Smith, who manages 12 skilled nursing facilities and 3 outpatient clinics in central and northern Alabama, says she has participated in a PTA subgroup within the ELP and also attended the academic-clinical partnerships session. Restore Therapy almost always has at least a few students at its various sites, and most come from local institutions such as the University of Alabama at Birmingham, Wallace State Community College, and Samford University.

    Coming changes to the payment model for skilled nursing facilities implemented by the Centers for Medicare and Medicaid Services is one of her primary clinical/education- related concerns from the "employer's perspective," Smith says. "Within our company, we've been looking at the investment and time that we spend on student clinical rotations, and on providing sites to these physical therapy programs. How do we continue to be effective and efficient with our resources at a time when reimbursement is changing?"

    At the strategy meeting, Smith recalls, she was encouraged by the "grassroots involvement" the ELP had harnessed, and was left with the impression that the partnership is open to anyone in the field who is willing to provide input. "All ideas were welcome for discussion. It was an opportunity for educators, for employers, and for PTs and PTAs to sit down and talk about what works, what doesn't work, and how to improve things in the future."

    A Long Path Ahead

    Indeed, as the ELP continues to gather steam in preparation for putting a strategic plan into motion, many with active roles in the partnership say they want to see more clinicians like Smith get involved. "It's important to participate," says Sanders, "because the future of the profession is in the hands of every PT and PTA."

    Carol Beckel, PT, PhD, assistant professor of physical therapy and athletic training at Saint Louis University and chair of the Clinical Education Special Interest Group within APTE, agrees. "This is not just an academic issue," says Beckel, a member of the partnership's essential resources group. "For the ELP to accomplish its mission, it needs people who are living physical therapy practice—that firsthand account of what's going on in the clinical world."

    At the strategy meeting last October, as Beckel and her colleagues ran through the challenges facing clinical education, she found herself on the edge of her seat, wishing she could do something right then and there. "It's always hard when you're in the planning stages—in which the intent is not to fix it, but to identify [the issues]. I kept thinking, if we just did ‘X,' that's all we needed. But that's not allowing for the process. It's important to allow all the participants to comment and put forward all of the information we have available."

    Looking ahead, Beckel says, she's confident that the ELP eventually will find solutions to the profession's clinical education hurdles. Centralization of clinical placement, for example, might lead to less competition between physical therapy programs while reducing the paperwork required from CIs. The student assessment process, meanwhile, might be improved through an update or overhaul of the APTA Physical Therapist Clinical Performance Instrument.

    "There are things that may be low-hanging fruit, and then there are challenges that will take longer to resolve," Beckel says. All told, there are now more than 600 accredited PT and PTA programs, with a total of nearly 45,000 enrolled students. "No matter what happens," he says, "when you're this big, change isn't going to happen overnight. But we can get started. We can put something on paper. The ELP is the path we need to take to get there."

    Chris Hayhurst is a freelance writer.

    References

    1. 2017 Annual Report. Educational Leadership Partnership. https://www.apta.org/uploadedFiles/APTAorg/Educators/ELP/ELPAnnualReport.pdf. Accessed March 19, 2019.
    2. 2018 Annual Report. Educational Leadership Partnership. http://www.apta.org/uploadedFiles/APTAorg/Educators/ELP/ELP2018AnnualReport.pdf. Accessed March 19, 2019.
    3. Commission on Accreditation in Physical Therapy Education (CAPTE). http://www.capteonline.org/home.aspx. Accessed March 19, 2019.

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