Handbook of Teaching for Physical Therapists

Handbook of Teaching for Physical Therapists

Handbook of Teaching for Physical Therapists Edited by

Katherine F. Shepard, Ph.D., P.T., F.A.P.T.A. Professor and Director of Advanced Graduate Studies, Department of Physical Therapy, College of Allied Health Professions, Temple University, Philadelphia

Gail M. Jensen, Ph.D., P. T. Associate Professor, Departments of Physical and Occupational Therapy, School of Pharmacy and Allied Health, Creighton University, Omaha, Nebraska with 11 Contributors

Forewords by

Elizabeth Domholdt, P.T., Ed.D.

Associate Professor and Dean, Krannert School of Physica Therapy, University of Indianapolis, Indianapolis, Indian

Joseph P.H. Black, Ph.D.

Senior Vice President for Education, American Physical Ther Association, Alexandria, Virginia

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Handbook of teaching for physical therapists J [edited by] Katherine F. Shepard, Gail M. Jensen. p. cm. Includes bibliographical references and index. ISBN 0-7506-9596-X 1. Physical Therapy--Study and teaching. 2. Patient education. I. Shepard, Katherine. ll. Jensen, Gail M. [DNLM: 1. PhYSical Therapy--education. 2. Teaching--methods. WB 18 H236 19971 RM706.H36 1997 615.8'2'071--dc21 DNLMjDLC for Library of Congress 96-50472 CIP British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library.

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Contents Contributing Authors Foreword I

vii

xi

Elizabeth Domholdt

Foreword II

xiii

Joseph PH. Black

Preface

xvii

Introduction

xxi

Katherine F Shepard and Gail M. Jensen

1

Curriculum Design for Physical Therapy Educational Programs Katherine F. Shepard and Gail M. Jensen

2

Preparation for Teaching in Academic Settings 37 Katherine F. Shepard and Gail M. Jensen

3

Techniques for Teaching in Academic Settings 73 Gail M. Jensen and Katherine F. Shepard

4

Preparation for Teaching in Clinical Settings 119 Jody Gandy

5

Techniques for Teaching in Clinical Settings . 169 Karen A. Paschal

1

Contents

vi

6

Postprofessional Clinical Residency Education 199 Carol To Tichenor and Teanne M. Davidson

7

Perceptions of Physical Therapists Towa Patient Education 225 Lisa Chase, TulieAnn Elkins, Tanet L. Readinger, and Katherine F. Shepard

8

Understanding Patient Receptivity to Ch Teaching for Treatment Adherence

Gail M. Tensen, Christopher Lorish, and Katherin

9

Teaching Psychomotor Skills

271

Diane E. Nicholson

10

Designing Educational Interventions for Patients and Families 303 Maureen T Nernshick

11

Community Health Education: Planning for Change 345 Christopher Lorish

12

Physical Therapy for the Future: One More Word 373 Geneva Richard Tohnson

ApPENDIX A

Cooperative Group Training Exercise: Broken Circles 387

APPENDIX

B

Cooperative Group Training Exercise: Esptein's Four-Stage Rocket 390

ApPENDIX

C

Theories of Motor Learning Index

397

393

I )

Contributing Author

Katherine F. Shepard, Ph.D., P. T., F.A.P. T.A., is Professor and Dir Advanced Graduate Studies, Department of Physical Therapy, Co Allied Health Professions, Temple University, Philadelph received a bachelor of arts degree in psychology from Hood Co bachelor of science degree in physical therapy from Ithaca Colle master's degrees in physical therapy and sociology and a Docto losophy degree in sociology of education from Stanford Univers is a member-consultant of the Coalitions for Consensus and a s leader for the Commission on Accreditation in Physical Therapy tion (CAPTE). She is the recipient of the American Physical Association (APTA) Baethke-Carlin Award for Teaching Excelle APTA Golden Pen Award for outstanding contributions to physi apy, and the APTA Lucy Blair Service Award. She is a Catheri thingham Fellow of the APTA. She has written and lectured ext on academic and clinical education, the behavioral sciences, an tative research design.

Gail M. Jensen, Ph.D., P. T., is Associate Professor, Departments of Therapy and Occupational Therapy, School of Pharmacy and Health, Creighton University, Omaha, NE. She has a bachelor of degree in education from the University of Minnesota, and a degree in physical therapy and a Doctor of Philosophy degree in tional evaluation from Stanford University. She has been on the boards of Physical Therapy and Work: A Journal of Prevention an bilitation and is currently on the editorial board of the Journal o cal Therapy Education. She also serves as a reader-consultant and evaluator for the Commission on Accreditation in Physical Thera cation (CAPTE), is a teaching fellow for the Society of Orthoped cine, and is on the academic faculty of the Kaiser-Hayward

viii

Contributing Authors

Therapy Residency Program in Advanced Orthopedic Man She has many publications and professional presentations i al education, qualitative research, and orthopedics.

Lisa Chase, M.P.T., is a physical therapist at State University o Stony Brook Hospital and Medical Center. She received he arts degree in psychology in 1987 from the University of D her Master of Physical Therapy degree in 1992 from Temple

Jeanne M. Davidson, B.S., is the senior physical therapist at York York, ME. She received her bachelor of science degree in phy in 1979 from Russell Sage College in Troy, NY, and complete Permanente Physical Therapy Residency Program in Advanc dic Manual Therapy in 1985. For more than 8 years, she was a cialist at St. Mary's Spine Center in San Francisco. She was o at the Kaiser Physical Therapy Residency Program from 1991 continues to be an active faculty alumna. She has taught con cation courses in orthopedics and manual therapy for the pa

JulieAnn Elkins, M.P.T., is a home care physical therapist p Philadelphia. She received her bachelor of science degree exercise science in 1988 from Pennsylvania State Univer Master of Physical Therapy degree in 1992 from Temple Un

Jody Gandy, Ph.D., P.T., is the Director of Clinical Education, Education, American Physical Therapy Association in Ale She received her bachelor of science degree in physical the from Ithaca College, a master's degree in counseling and per ies in 1983 from Glassboro State University, and a Doctor o degree in psychoeducation processes in 1993 from Temple She has presented numerous workshops for physical therapi health professionals on topics related to clinical education current position, she was actively involved in clinical edu assistant professor and academic coordinator of clinical e Temple University and director and center coordinator of cation at Children's Seashore House in Philadelphia. She w ient of the 1995 Excellence in Clinical Teaching Award fro York State Physical Therapy Clinical Education Consortium

Geneva Richard Johnson, Ph.D., P. T., F.A.P. T.A., is dean of t School of Physical Therapy at the University of Mobile in A career has included clinical practice, academic and clinical tion, teaching, research and consultation in education, and

(APTA), she has served in appointed and elected offices at the distric chapter, and national levels. She has been honored by the APTA with t Lucy Blair Service Award and the Mary McMillan Lecture Award. S was one of the first two physical therapists named a Catherine S. Wo thingham Fellow after the initiation of that category of membership. S has published extensively; presented papers, workshops, and semina worldwide; and consulted with numerous developing and establish educational programs in physical therapy.

Christopher Lorish, Ph.D., is an assistant professor in the Department Physical Therapy, Occupational Therapy, and Biocommunications the University of Alabama School of Health Related Professions Birmingham. He received his Doctor of Philosophy in education 1980 from Ohio State University. His research interests inclu patient and community education, treatment adherence, and ps chosocial issues in chronic disease. A focus of his research and pub cations is applying concepts from behavior theory to behavior chan issues faced by allied health professionals.

Maureen T. Nemshick, M.S., P. T., is a clinical assistant professor of physic therapy and academic coordinator of clinical education at Widener Un versity Institute for Physical Therapy Education in Chester, PA. S received her bachelor of science degree in physical therapy in 1985 fro the University of Scranton and her master's degree in physical thera in 1992 from Temple University. Her areas of clinical interest inclu geriatrics, neurologic and general rehabilitation, and clinical educatio Her research interests include patient education in physical therapy a collaborative learning in clinical education.

Diane E. Nicholson, Ph.D., P.T., N.C.S., is assistant professor of physic therapy at the University of Utah in Salt Lake City. She received h bachelor of science degree in physical therapy in 1979 from the Unive sity of Delaware, her master's degree in physical therapy in 1984 fro the University of North Carolina at Chapel Hill, and her Doctor of Ph losophy degree in kinesiology in 1992 from the University of Californ Los Angeles. She is a board-certified neurologic clinical specialist. H principal areas of teaching and research focus on education as a trea ment technique to optimize physical function in persons with neur logic disorders.

x

Contributing Authors

Karen A. Paschal, M.S., P. T., is an assistant professor and directo education in the Department of Physical Therapy at Creigh sity, Omaha, NE. She received her bachelor of arts degree i 1972 from the University of South Dakota and master's deg ical therapy in 1974 from Duke University. She is a doctora development psychology at the University of Pittsburgh. She background in clinical education with a focus on student le

Tanet L. Readinger, M.P.T., is a senior physical therapist and the dinator of clinical education at Moss Rehabilitation Philadelphia. She received her bachelor of arts degree ill bio from LaSalle University and her Master of Physical Therap 1992 from Temple University.

Carol To Tichenor, M.A, P. T., is the director of the Kaiser Permane Therapy Residency Program in Advanced Orthopedic Man in Hayward, CA. Kaiser Permanente provides a year-long sional residency program that combines intensive clinica and course work in advanced orthopedic manual physical received her bachelor of arts degree in psychology in 19 master's in physical therapy in 1973 from Stanford Univers fessional focus is on the design, development, and evaluat professional physical therapy residency education.

Foreword I

Shepard and Jensen's Handbook of Teaching for Physical apists appears at a time when clinicians and academicians alike are challenged to become more effective and more efficient teachers. Pro changes in the way physical therapists (PTs) and physical therapist assi (PTAs) practice, accompanied by changes in the way they are prepa practice, make this book an exceptionally timely addition to our p sionalliterature. The explosive growth of health care and rehabilitation in the U States during the 1980s was mirrored by an explosion in the numbe size of PT and PTA preparation programs. More faculty member more novice faculty members-than ever are now teaching PT and PTA dents in the classroom and clinic. The students they teach are increas diverse with respect to age and previous education and life experiences faculty are teaching more students at one time-in the classroom an clinic. In addition, academic and practice environments are dema higher levels of productivity from their faculty members and clini Teachers who thrive in the midst of these new realities must be adap and innovativej they must reflect on how they teach in addition to m ing what they teach. The first half of this handbook provides a frame for thinking about teaching as well as a set of tools for use in classroo clinical settings. The health care system changes that fueled the explosion in aca physical therapy also fueled reactive growth in cost-containment e within the health care industry during the 1990s. These efforts have formed physical therapy practice as PTs and PTAs see patients for fewe its, prepare them to cope with functional impairments at home when are discharged "sicker and quicker," and persuade them and their famil take an active, engaged role in follow-up care. Clinicians who thrive in

xii

Foreword I

new realities are able to teach complex skills to and facilitate health be ior changes in patients and their families. Anyone who has tried to m even a trivial and temporary health behavior change, such as taking 10 of antibiotics without missing a dose, understands that knowledge is a essary but not sufficient condition for promoting changes in behavior. second half of this handbook is designed to provide clinicians with a s tools they can use to shape their presence as clinician-teachers. PTs and PTAs teach students, patients, families, colleagues, and the lic. We teach movement, values, and facts. We teach in classrooms, i clinic, at the bedside, and in the home. With this handbook, Shepard Jensen provide an important resource for PTs and PTAs who wish to be more effective teachers in any of these many roles.

Elizabeth Domholdt, P.T., E

Foreword II

The physical therapy profession, no less than others, seems always t be in transition. From dependence on the judgment and decisions of othe health care professionals to full partnership in to day's health care deliver system, the profession has proved its ability to meet the challenges posed b changing expectations and a volatile health care environment. Throughou its remarkable history, the profession has always pinned its hopes an aspirations on the kind of educational experiences that would lead to th preparation of the most knowledgeable, competent, and caring profession als-practitioners whose self-confidence, clinical skills, adaptability, an service orientation would serve the interests of the patient. It is readil apparent that the requisite transitions have been well managed becaus physical therapists (PTsJ, in partnership with physical therapist assistan (PTAs), have moved into positions of greater responsibility requiring mor complex decision-making and reasoning skills. Today, as the focus of health care broadens from a matter of the patient disease or physical impairment to wider considerations of prevention wellness, and the patient's "quality of life," including differences of rac culture, outlook, and learning, PTs will likely discover that yesterday achievements will no longer suffice as a guarantor of a successful tran ition. For 2000 and beyond, most transitions will likely involve bot promise and periL For example, even now there is a call for a shift fro practitioner independence, including full professional autonomy, to inte dependence and collaboration based on a certain, but thoroughly flexibl professional identity. Achieving success during these transitions will depen on the profession's willingness to welcome new teaching and learning pa adigms. Proven and innovative teaching theories combined with fres approaches to the practical application of those theories can serve as an inten tional and forward-looking curricular framework for the preparation o

xi

xiv

Foreword II

practitioners who can deliver physical therapy services based on hist precedent, sound research, proven treatment outcomes, and a mast communication and relational skills. One indicator of readiness for such a transition will be an unco mising commitment to shift attention away from narrow regional or tutional interests to those larger interests represented by 11) the r changing expectations of patients and their families for high-quality effective health carej (2) the professional and postprofessional edu needs of all students, PTs, and PTAs j and (3) the global needs of th fession, including the expansion and refinement of the clinical sc known as physical therapy. The larger the view, the greater the poss for constructive change, adaptation, and innovation-and the less risk that the profession will be characterized by confusion, uncertain unresponsiveness. Cultivating that larger view will require continuous improvement quality and efficacy of teaching and learning. For that reason alone, th lication of the Handbook of Teaching for Physical Therapists cou come at a more opportune time. The demand for high-quality car reasonable price, the cost of professional preparation, increased compe among health providers, the inevitable "boundary disputes," and the ex ing role of patients in achieving and maintaining optimum healththese factors place enormous burdens on the processes of teaching and ing. This handbook offers a wealth of resources, not only for those who entry-level students but also for every PT and PTA who, in the course o viding physical therapy services, is charged with teaching a patient or ing from a colleague or mentor. The authors' approach is unique and delightfully utilitarian. Fro specific learning objectives and profoundly relevant "life incidents" beginning of each chapter to the substantive theoretical concept practical applications, this handbook offers an understandable and resource for "transforming" the reader into a more mature, confiden effective teacher/learner. This handbook is for the PT and PTA educat practitioner who recognizes that the preparation of active, interdepe and self-directed practitioners requires teachers with a command of tinuously expanding realm of academic and clinical theory and th too-rare proclivity for admitting to a certain amount of ignorance prerequisite for learning. Every physical therapy educator and practitioner holds the key successful management of the profession's developmental transitions handbook will provide the eager and expectant reader with new and pro tive insights into how teaching and learning can radically transform

based resource for managing the promise and peril of the risky, but inev transition to interdependence.

Joseph P.H. Black

Preface

Every day physical therapists (PTs) and physical thera assistants (PTAs) are engaged in teaching. They identify strategies to fac tate change in patients' health behaviors, demonstrate lifting technique family members, guide students through clinical internships, present service programs to their health care colleagues, deliver professional pres tations at local and national meetings, serve on curricular committees, p health promotion programs for the community, and consult with teacher the local school system. Perhaps no process other than teaching so per ates the professional contributions made by members of the physical th py profession. Teaching is a skill that PTs often take for granted. We have all exp enced many years of being taught. During these years we have observed i fective teaching that leaves teachers and students frustrated and aliena from learning more about teaching-or learning more altogether. Few and even fewer PTAs have been exposed to the substantial body of kno edge and theory that exists in education. From observing expert teacher work we know that skill in teaching requires much more than knowing material or learning how to write an objective or use audiovisual aids. Ef tive learning experiences are crafted by expert teachers, suffused with p tical and theoretical knowledge, and compellingly delivered with accu insight into the needs of the learner. This handbook has emerged from an ongoing dialogue of our own ex riences as PTs, educators, and researchers. Our interest and background educational theory is tied to a specific belief and value about the cen importance of teaching and learning to those practicing physical thera Our philosophy of education provides the philosophical foundation for handbook. Essentially, we embrace William Butler Yeats' observation t II education is not the filling of a pail, but the lighting of a fire. II Students w

x

xviii

Preface

have teachers who understand and engage in this pedagogic process ing fires become clinicians and educators who are delighted by the ment of new skills, are sensitive to the world around them, all creative energies to surface, and embrace the challenge and excit constant growth. Consistent with life-long learning, we ourselves are committe viding the reader with a text that is driven by inquiry and reflec believe that one is always teacher and student in physical therapy These roles are constantly interchanging. The PT and PTA must and engage in both roles to do either well. We also believe that within the clinic or classroom is always more chaotic and complica what theory may account for, and constant inquiry and adapta essential skills. Theory does provide a framework for understandi tice, and practice yields ever more useful theory. Thus, a dedicated inquiry or reflection-that is, becoming a reflective practitioner-i to teach and learn in chaotic settings and maintain the dialogue theory and practice. In an effort to link theory and practice in this text, we have expert contributors known for their practical experience in "the rea as well as their theoretical understanding and expertise. Finally, as qualitative researchers we are committed to under teaching from the inside-that is, from the individual and collectiv ences of learners and teachers. You will read stories from the "tren practice in each chapter. We hope these examples of your colleagues as teachers will facilitate your intuitive understanding of some of the conceptual issues proposed. Teaching and learning are perhaps the most important skills a PTA can acquire. Development of sound, practically relevant, theo based educational strategies could result in significant reform in perceive and deliver education to students, patients, colleagues, public. We have many people to thank for this book. First, thanks to o tors at Stanford University in the Department of Physical Ther School of Education. Our experiences at Stanford are embodied in ford motto "Die Luft der Freiheit Weht" ("the winds of freedom blo were urged to question, grapple with neW ideas, and be intrigued w ures. These experiences set our course as teachers and scholars. thanks to our friends (human and animal) and family members wh ditionally accept us and our life journeys. You each know who Thanks to Barbara Murphy at Butterworth-Heinemann who, from beginning, shared in our excitement about this handbook. Thanks

dents who have taught us so profoundly for so many years.

K.F

C.M

Introduction Katherine F. Shepard and Gail M. Jensen

Good teaching comes in many flavors and colors. It occur when a teacher leads you to a vista that changes forever t way you see. It happens when someone introduces you to delicious idea that you can chew on for the rest of your lif It occurs when somebody helps you discover possibilities yourself you didn't know were there. Good teaching is ma things. It has no essential quality. It takes place through books, it occurs in classrooms, {in health care clinics], it emerges in conversations and in the presence of those who give us a vision of how life in its large and small moment might be lived. -Eliot Eisner, Professor of Education and A Stanford University (Stanford Educa Spring 1995

Purpose of the Handbook

For many students who learn in physical therapy academic tings, the experience is one of struggling to understand and remember endless array of ill-connected knowledge bits. Many of these knowledge have a half-life of 3-5 years, and others already are outdated for phys therapy practice in today's health care system. Certainly the strain of tea ing and learning in academic settings is due in part to the knowledge ex sion in the sciences as well as in the guiding principles and technique physical therapy practice, especially in clinical specialty areas.

xxii

Introduction

For many patients who learn in clinical settings, the expe of attempting to focus attention and grasp information under th cult of circumstances-that is, while ill or in pain or experienc ing loss. Typically, patients are exposed to rapidly delivered so important, perhaps even life-saving, information delivered by a fleeting health care professionals who are strangers (and who m understand or speak the patient's native language). Certainly strain of teaching and learning in health care settings is due to of health care delivery systems in which patients and providers under time restrictions that limit access to clinicians and sho with patients and families. The fragmented learning and embarrassingly limited outcom occur with such experiences in academic and clinical settings a and sad. However, crises also present us with opportunities to nuity and strengths as health care providers and teachers. When selves competing with time and costs to deliver the most eff care possible, do we find ourselves teaching more? Are we i patient as well as family and caretakers much earlier in learnin health care tasks? Are we thinking about what we as physic (PTs) and physical therapist assistants (PTAs) can do to facil practices in the community? And have we figured out what is novice practitioners to know and how we can prepare them to a ledge throughout their professional lives? The primary purpose of this book is to stimulate the growt er in teaching and learning by presenting theoretical concepts practical applications that will improve skills in the education used in academic and clinical settings.

What is Teaching? What is Learning?

From the perspective of many experienced educat teaching involves the following: (1) deeply comprehending the to be taught; (2) being able to transform and present that info way that students "get it"; (3) engaging the student in active c learning experiences; and (4) teaching the student how to learn inquiry and reflection, which leads the student to acquire he new knowledge and comprehensions. (This teaching process more thoroughly in Chapter 3.) Similarly, for students to learn comprehend and transform ideas, information, and beliefs thro and reflection during learning experiences in which they, the active participants and collaborators. Such learning results in

as lithe learner is an artificial distinction much like saying kinesthetic perceptions and functional movement should be considered as two separate and distinct entities. For either process to work well, both processes must work in concert. At any given moment, anyone can be the learner or the teacherpatients and families, students participating in formal academic programs, health care colleagues, community neighbors, and one's self. II

Characteristics of Good Teachers/Learners

As Eliot Eisner stated, good teaching is many things and comes in many colors and flavors. We think, however, that there are three major ingredients that must be present for good teaching and learning to occur:

1. Teachers must know keenly the topics they are teaching and ceaselessly engage in learning about them. To be continually learning requires curiosity and intellectual excitement about uncovering more and more about a specific topic or field. Learning means seeking out and engaging in experiences that foster learning: reading, clinical practice, conferences, research, talking with colleagues over coffee and, of course, being stimulated by one's students. Reflecting on these experiences results in transformation of the knowledge so that it becomes an integral part of what and how one teaches. Where there is no passion for the topic or for teaching, there is no thinking about what and how one is doing and how it might be done better; there is only the repetitive transmission of dusty, uninspired information. 2. Teachers must know about the students they are teaching. This awareness and knowledge comes from listening to students speak-learning what they understand as well as how they think and reason, through watching students' faces, postures, and gestures; observing students perform manual skills; reading student papers; and noting how students interact with people around them. The ability to effectively transform and transmit knowledge rests on understanding students. This understanding undergirds the teacher's ability to figure out ways to capture the students' curiosity and interest, to create experiences that challenge students to think and to risk, and to persistently support students for the discipline, patience, and sometimes tedium it takes for learning to occur.

xxiv

Introduction

The effective teacher remembers well what it is like to be a From this memory comes empathy for students in academic sett must sit through hours of writing down new and often perplexing tion, sitting in uncomfortable chairs, not allowed to move or to sp out permission. From this memory also comes sensitivity to a anxiety about undersupervision and frustration with oversupervisi clinical instructor. Similarly, practitioners in clinical settings w encountered physical disabilities of their own have a greater tac standing of how to teach patients to achieve maximum recovery. Knowing the student is not only easier but a highly pleasurabl if the student is the only individual being taught, is verbal about educational needs, is motivated by the need to know, and is g responsive to the PT/teacher's interest and assistance. However, t tion is rare. The task of knowing a student is clearly daunting w with a classroom of 50 or more students or a minimally verbal pa has no family advocate and is scheduled for discharge tomorrow. daunting, without knowing something about one's students and think, what their values and goals are, and what anxieties or conc have about the information or skill to be learned, one cannot te Simply put, if the information being delivered is inflexible to the pr of the learner, little or no learning occurs. 3. Teachers must be acquainted with a number of different techniques that can facilitate learning. The more one knows ab techniques, the more innovative and flexible one can be in provid ing experiences that match the student's quest. The "military m teaching often prevails in academic and clinical settings. The milit involves the rigid, repetitive sequence of demonstrating a task to b plished; breaking the task into component parts; teaching the co parts; having the student master the component parts; and then p components together. This method is certainly effective in teachi known task for which a right and wrong way is clearly demar example, learning how to assemble and disassemble a rifle. How highly questionable whether this method is responsive to most i learning in academic or clinical settings, which inherently involv tions, attitudes, beliefs, prior learned behaviors, and "building-blo mation that the learner mayor may not hold. There are many intriguing methods that one can use to tea evaluate teaching-problem-solving cases, media, journals, peer portfolios, interactive laboratories with experts, stories, commun ties, and so forth. Many of these techniques are presented in this

Overview of the Handbook

This handbook is divided into two main sections. In the section of the book (Chapters 1-6), the focus is on teaching PTs and PTA academic settings, clinical settings, and in advanced clinical residency grams. In the second section (Chapters 7-11), the focus is on teac patients, families, and colleagues in clinical and community settings. A chapter includes a look at the future of PT and PTA education. While each chapter is designed to be read independent of all other c ters, in some cases understanding will be greatly enhanced if several c ters are read together. For example, the reader would benefit from rea the chapter on preparation for teaching in the academic setting (Chapt before reading about techniques for teaching in academic settings (Ch 3). Likewise, preparation for teaching in clinical settings (Chapter 4) greatly add to one's understanding of teaching techniques used in the c cal setting (Chapter 5). In the second section, an understanding of ho assess the patient's receptivity for learning (Chapter 8) and knowledge o basic tenets of teaching motor skills (Chapter 9) will assist the student designing educational interventions for patients (Chapter 10). It is our hope that readers will enjoy and muse over the ideas prese in this handbook and become stimulated to enthusiastically embrace ongoing development of their own successful educational interventions can teach better!

Curriculum Design for Physical Therapy Educational Programs Katherine F. Shepard and Gail M. Jensen

The physical therapy program at Stanford University had be in existence since 1940. As a young faculty member in t early 1970s I assumed we belonged at Stanford just as much any other department in the university. I never realized ho changing the philosophy, mission, and expectations in oth parts of the university could affect the very existence of o program. In 1982 the School of Medicine changed its missi from developing physicians to developing physicia researchers (MD-PhDs) and covertly designated the land which the physical therapy building was located as the n center of Molecular Genetic Engineering. Subsequently, an a physician review committee informed us that we didn't belo in the School of Medicine because we didn't have a phD p gram and weren't producing "scholars." While meeting w the university president on an early spring evening to plead o case, he informed us that if we were to be considered schol we should be publishing in the Tournal of Physiology (his fi was physiology) and not PhYSical Therapy (a technical journ by his standards). It was devastating to belatedly realize ho the pieces were being put in place to discontinue our progra Our own mission statement, philosophy, and program go were essentially ignored as they were now incongruent w

2

CURRICULUM DESIGN FOR PHYSICAL THERAPY EDUCATIONAL P

the new university sanctioned "direction" of t school. The Stanford University Board of Truste close the program with the graduating class of 198

The moral of this story is that the philosophy and goals of any p apist or physical therapist assistant program must be in concert w losophy and goals of the program's institution or the program will n

Chapter Objectives

After completing this chapter the reader will be ab

1. State the four questions posed by Ralph Tyler' to guide design and describe the three-phase process of how facu in curriculum development as suggested by Decker Wal 2. Defend the need for a clearly stated program philosophy to guide curriculum planning. Demonstrate how program phy and goals can be articulated with university philoso etal needs, and professional functions. 3. Define implicit, explicit, and null curricula and identify nents of each type. 4. Discuss five areas of perennial conflict between the curri of health care professional programs and the academic tr that undergird liberal arts education. 5. State the purpose of professional accreditation and outlin process of accreditation used by the American Physical T Association (APTA).

Curriculum Design

Everything depends upon the quality of the experi is had. The quality of any experience has two asp is an immediate aspect of agreeableness or disagr and there is its influence upon later experiences. obvious and easy to judge. The effect of an exper borne on its face. It sets a problem to the educat business to arrange for the kind of experiences w they do not repel the student, but rather engage h are, nevertheless, more than immediately enjo they promote having desirable future experienc the central problem of an education based upon e

vidual student, as well as relevant to the desired performance of th program graduate, an all-embracing framework for educational exper ences-a curriculum design-must be in place. Curriculum design refe to the content and organization of the curricular elements of philosoph goals, coursework, clinical experiences, and evaluation processes. The is an assumption in curriculum design that what drives the education the physical therapist and the physical therapist assistant is preparatio for practice in the health care arena, which involves the development the knowledge, skills, and attitudes that undergird competent physic therapy practice. A curriculum design reflects input, directly or indirectly, from lite ally thousands of people. People with health care needs, regulatory bodi such as regional and professional accreditation groups and state boa licensing agencies, members of the APTA who establish and act on pr fessional standards, physical therapy clinicians, faculty and administr tors in the college or university in which the program is located, and eac generation of students have an impact on curriculum design. A curric lum design must be steadfastly relevant to the current tasks and standar of physical therapy practice, and dynamically responsive to rapidly chan ing practice environments and human health care needs.

Developing a Curriculum

Eliot Eisner noted that the word curriculum originally cam from the Latin word cUrrere, which means "the course to be run." H states, "This notion implies a track, a set of obstacles or tasks that an ind vidual is to overcome, something that has a beginning and an end, som thing that one aims at completing." 2

Tyler's Four Fundamental Questions

The four fundamental questions identified by Ralph Tyler 1949 are useful in deciding how to develop a "racecourse." 3 These fo questions are rediscovered by each generation of faculty seeking to develo a physical therapy curriculum. 1. What educational purposes or goals should the school seek to

attain?

4

CURRICULUM DESIGN FOR PHYSICAL THERAPY EDUCATIONAL

2. What educational experiences can be provided that are l attain these purposes? 3. How can these educational experiences be effectively or 4. How can it be determined whether these purposes or go attained?

These questions and the answers to these questions should b ed, with each question and answer building on the preceding qu answer(s). However, the easiest and often first place for a group o ulty to begin is with the second and third questions. Faculty ca produce and organize educational experiences based on their o experiences in physical therapy education and practice. Howeve la are designed in such a way that the answers to questions 2 a directly related to question 1, it is like setting sail without plott That is, despite knowing everything about sailing a ship, with n the results can be disastrous. The result of an analogous educati is haphazard curricular growth, which, at the least, is perplexin students, and clinical educators and, at most, can produce gradu ill-focused and perplexed about their roles in the health care sys In designing a curriculum, the elements must be logically o logic can be obtained by thinking about how each level is direct to the levels above and below. As illustrated in the curricular de in Figure 1-1, the content of a physical therapy educational p coursework, learning experiences, and evaluation processes) meeting program objectives designed to fulfill the program's goa 1-1). The program goals reflect the philosophy of the program a tution. Evaluation of the program graduate therefore demonstr cess or lack of success of the program's ability to build a cur meets its stated goals.

Tyler's Question 1: Program Philosophy and Goal Macro Environment

Figure 1-2 demonstrates how the philosophy and physical therapy curriculum are imbedded in a global (macro) that includes society, the health care environment, the higher e tem, and the knowledge related to physical therapy.4 It should be evident to the reader that when any compo macro environment changes, it is necessary to consider chang ical therapy curriculum. For example, the aging of the post-W "baby boomers," the concern with fitness in society at large, a

EXPERIENCES

Coursework CONTENT

'}

t

Program GOALS

t

Program and Institutional PHILOSOPHY

organized?"

"What educational

I

Design Decisions

experi~

enees can be provided that are likely to attain these purposes?"

Program OBJECTIVES

t

"How can these educational experiences be effectively

Deliberation

}

"What educational purposes

should the school seek

to

attain?"

Platform of Beliefs and Vision

Curricular Design

Tyler's Fundamental Questions

Walker's Naturalistic Model

Figure 1·1 Relationship between curriculum design, Tyler's fundamental qu

tions, and Walker's naturalistic model.

procedures for neonatal infants have spawned curricular changes in en level and advanced coursework for physical therapists and physical the pist assistants. s David Rogers proposed a set of goals for medical educators and stude broad enough to be responsive to this global environment (Table 1-1).6 N that what the student is to know (i.e., the language of the discipline and ways of science) is only part of what people who engage in curriculum des must be concerned with. Students must also be prepared to reason, become sensitive and responsive to cultural diversity and society's needs undergird decisions and actions with empathy, and to begin a quest knowledge that will last throughout their professional lives. Authors such as Donald Schon 7 and Ilene Harris 8 write convincin that health professionals must better organize professional education aro what actually happens in clinical practice. Thus, students must be tau thinking skills, such as reflection-in-action and reflection-on-action, prepare them for the complex, unique, and uncertain situations they w face. Clearly the knowledge, thinking, and humanistic skills advocated

6

CURRICULUM DESIGN FOR PHYSICAL THERAPY EDUCATIONAL P

Societal Environment

Physical Therapist Professional Education

THE GLOBAL ENVIRONMENT

Figure 1-2 The global environment within which physical therapy e exists. (Reprinted with permission from American Physical Therapy tion Education Division. A Normative Model of Physical Therapist al Education [4th rev]. Alexandria, VA: American Physical Therapy Association, 1996;13.)

Rogers, Schon, and Harris could be incorporated into the goals o ical therapist or physical therapist assistant program. The Mission and Practice of Physical Therapy statement p Table 1-2, which was developed by APTA in 1995, is a descript physical therapists do. 9 This statement or similar statements d APTA should be carefully reviewed and considered when develop ical therapy or physical therapist assistant program's philosoph For example, how should a program include goals (and subsequ work) that are related to the statement, "Assume leadership role tion and health maintenance programs"?

Micro Environment

Figure 1-3 demonstrates how a particular physi curriculum is imbedded in its micro environment, or immed

2. Introduce students to the ways of science. Teach them to understand and res the nature of scientific evidence.

3. Teach students how to reason and manage ambiguities and gaps in knowledg

4. Teach students how to communicate with people from different cultures, val systems, and backgrounds.

s.

Expand students' capacity for constructive empathy. Teach students to help o ers by using their own compassion.

6. Introduce students to the social concerns that exist beyond the issue of the patients they treat. Foster a feeling of responsibility for those who are poor o isolated.

7. Inculcate a personal love of learning. Help students develop habits required f continual learning.

Source: Adapted from DE Rogers. The Education of Medical Students for Tomorrow. Council on Graduate Medical Education. Reform in Medical Education and Medical E cation in the Ambulatory Setting. Washington, DC: U.S. Department of Health and Human Services. HRSA-P-DM-91-4;5, 1991.

tional institution and clinical practice settings. It is this micro envir ment that presses for uniqueness among the philosophies and goals of physical therapy and physical therapist assistant educational programs. example, Table 1-3 demonstrates how the philosophy of the physical th py curriculum at Creighton University reflects the "inalienable wort each individuaL" It also shows the emphasis on "moral values" in miss statements of the University and the College in which the physical ther program is located. More complete examples of how the philosophies and goals of the m environment influence the program's philosophies and goals are dem strated in Tables 1-4 and 1-5. In Table 1-4, the master's of physical ther program philosophy at Temple University identifies the mission of the versity as well as the program's mission. It also broadly sketches the wa which the program will proceed to meet these missions. In Table 1-5 attributes and skills needed by the graduate to meet the primary prog goal of preparing students "to assume the multifaceted roles of clinical p titioner, teacher, researcher, consultant, administrator, and advocate" listed. In this table, the program has clearly explicated its assumptions ab the knowledge, skills, values, and attitudes of entering students and sta

8

CURRICULUM DESIGN FOR PHYSICAL THERAPY EDUCATIONAL

Table 1-2 Mission and Practice of Physical Therapy

Physical therapy is a dynamic profession with an established theoretic widespread clinical applications, particularly in the preservation, deve restoration of maximum physical functions. Physical therapists seek t injury, impairments, functional limitations, and disability; to maintain fitness, health, and quality of life; and to ensure availability, accessibil lence in the delivery of physical therapy services to the patient. As ess pants in the health care delivery system, physical therapists assume le in prevention and health maintenance programs, in the provision of re services, and in professional and community organizations. They also tant roles in developing health policy and appropriate standards for the ments of physical therapy practice.

Source: American Physical Therapy Association. A Guide to Physical Ther (Vol 1): A Description of Patient Management. Alexandria, VA: American P py Association, 1995;1.

EDUCATIONAL OUTCOME A GRADUATE WHO MEETS PRACTICE EXPECTATIONS

Figure 1-3 The immediate (micro) environment within which phy education exists. (Pre Reqs = prerequisites.) (Reprinted with permi American Physical Therapy Association Education Division. A No Model of Physical Therapist Professional Education [4th rev). Alex American Physical Therapy Association, 1996;14.)

are challenged to reflect on transcendent values including their relationship wit God, in an atmosphere of freedom of inquiry, belief, and religious worship. Service to others, the importance of family life, the inalienable worth of each individual and appreciation of ethnic and cultural diversity are core values of Creighton. From mission statement: School of Pharmacy and Allied Health at Creighton University

The Creighton University School of Pharmacy and Allied Health professions prepares men and women in their professional disciplines with an emphasis on moral values and service in order to develop competent graduates, who demonstrate concern for human health. This mission is fulfilled by providing comprehensive professional instruction, engaging in basic science and clinical research participating in community and professional service, and fostering a learning environment enhanced by faculty who encourage self-determination, self-respec and compassion in students. From program philosophy: Doctor of Physical Therapy Program at Creighton University

The faculty of the Department of Physical Therapy subscribe to the general tenets of Creighton University and the School of Pharmacy and Allied Health with an emphasis on affirming that each individual ultimately should assume responsib ity for maintaining the quality and dignity of his/her own life. Source: Department of Physical Therapy, School of Pharmacy and Allied Health, Creighton University, Omaha, NE.

how it believes the program will influence the students' growth. The assumptions were developed by the faculty and provide the framework f development and direction of individual coursework. Time considering macro-level and micro-level philosophy and goals time well spent. Developing program goals together encourages academ and clinical faculty to reflect on and explicate their own philosophy a goals and come to a common understanding of their profession's and co lege's or university's philosophy and goals. Such an activity unifies academ ic and clinical faculty in a common cause.

Tyler's Question 2: Educational Experiences Once goals and philosophy are understood, the next questi to be answered is what educational experiences are needed to achieve the purposes. Coursework in physical therapy and physical therapist assista programs usually consists of foundation sciences, such as anatomy a

10

CURRICULUM DESIGN FOR PHYSICAL THERAPY EDUCATION

Table 1-4 Program Philosophy (Master of Physical Therapy Program, Temple University)

Physical therapy is a health care profession whose purpose is the pro human health and function by application of theory to identify, as ate, or prevent human movement dysfunction. Physical therapists with the physical well-being of their clients and patients, but also need to understand and respond to the sociocultural beliefs of the family receiving physical therapy services. Physical therapists acc sibility for the patients or clients in their care and for the develop profession.

The Department of Physical Therapy is an integral part of the Colleg Health Professions, which in turn is an integral part of Temple Un ticularly the Health Sciences Center. Temple has had a unique mi creation in 1884, to serve the needs of its working class communi founder, Rev. Russell Conwell, created Temple "to make an educ for all young men and women who have good minds and the will The primary missions of the Department of Physical Therapy are: 1. To provide the opportunity for individuals from diverse cultura to enter the physical therapy profession.

2. To prepare physical therapy practitioners to meet the health care n 3. To discover and convey knowledge related to physical therapy.

4. To provide services to the academic, professional, and public co

The faculty believes that participation in physical therapy education University fosters the initial and continuing commitment of the professional service and lifelong learning. Professional preparatio based upon a liberal education in the sciences and humanities. T cation serves to develop the values necessary to function effectiv and humanely in a complex and dynamic society. The curriculum theoretical and practical knowledge, and develops the critical thi that physical therapists need to respond to trends in practice and ical therapy needs of society. Therefore, there is strong emphasis tion of and continuity with clinical education.

The curriculum is designed to include contemporary issues in physic provoke review of these and other issues through critical inquiry, change agents for the science and practice of physical therapy. Th curriculum prepares students to assume the multifaceted roles of tioner, teacher, researcher, consultant, administrator, and advocat

The faculty recognizes its responsibility to be role models for studen of professional behavior. The faculty is committed to the pursuit excellence through lifelong learning and professional leadership a encourages students toward personal and professional self-actuali

Source: Department of Physical Therapy, College of Allied Health ProfeS University, Philadelphia, PA.

researcher, consultant, administrator, and advocate. To realize this goal, all courses in the curriculum focus on developing the attributes listed below. Thes attributes are described at two points in the educational process. The list on th left includes the assumptions that we make about the attributes of the student entering the physical therapy program. The list on the right includes the assum tions we make about the growth and change which we seek to accomplish through our curriculum.

Entry into curriculum

Exit from curriculum

Explicit curriculum Uncritically accepts information

Critically analyzes information

Receives information (as a learner)

Delivers information (as a teacher)

Has minimal knowledge of normal motion and wellness across the life span

Has advanced knowledge of norma and abnormal motion and illnes across the life span

Has minimal evaluation and treatment skills Quest for superb treatment and eva uation skills Learns information from component coursework

Integrates information from founda tion sciences, trans curricular processes, and clinical sciences

Understands and applies knowledge bits

Understands and applies concepts, principles, and theory

Implicit curriculum Is a passive recipient of information

Is an active, reflective learner

Is unaware of professional ethics

Demonstrates professional ethical behaviors

Learns within the confines of an academic institution

Understands and believes in lifelon learning

Has awareness of accountability for self

Has awareness of accountability fo self and the lives of others in a culturally diverse world

Is unaware of personal responsibility to the profession

Has pride in and commitment to t growth and development of the profession

Has personal communication skills

Has professional oral and written communication skills

Source: Department of Physical Therapy, College of Allied Health Professions, Temple University, Philadelphia, PA.

12

CURRICULUM DESIGN FOR PHYSICAL THERAPY EDUCATION

pathology; clinical sciences, such as therapeutic exercise an of patients with specific clinical problems (e.g., orthopedic monary); trans curricular content, such as ethics, admin research; and clinical education (see Figure 1-3). Of course, the work offered depends on the program's practice expectation and depth of prerequisite coursework. Within each course, written objectives identify spec behaviors, and skills that the instructor expects each stude Included in these objectives are expectations that directly re gram's philosophy and goals. For example, if one of the progr develop critical thinking skills, each instructor should pre and related learning experiences to stimulate development of ities to reflect, critically analyze, and make rational decisio shows a logical connection between an element of a program or mission and how a course in pediatrics presents this elem objectives, required readings, and stimulation of student tho examination. Further information on designing coursework Chapters 2 and 3.

Tyler's Question 3: Organization Tyler suggests three factors to consider in org tional experiences: continuity, sequence, and integration.3 Co to the vertical relationship of curricular elements-for exam basic science course, such as physiology, before a clinical s such as cardiopulmonary rehabilitation. Sequence is the process of having each experience build o ence while moving increasingly broader and deeper into th example, students assume greater and greater responsibility f through each successive clinical internship. It would be c sequencing to have a student spend the same amount of time instructor during the last clinical internship as during the fir Integration refers to the horizontal relationship of learnin For example, a kinesiology and anatomy course might be pla that the same body segments are covered within similar tim knowledge gained in one course could overlap and clarify kno in the other course. Obviously, proper continuity, sequence, and integration ordinarily helpful in assisting the student to master curr However, there are many structural constraints to organiz lum. The primary consideration is the academic calendar o university in which the program is located (i.e., the length

~

and the lives of others in a culturally diverse world."

Course

Neurologic Dysfunction I (Pediatrics)

Course Objective

"Discuss the influence of cultural diversity in families and the impact this may have on working with families and their infants with neuromotor

•

j

h'r

Course ContentlLearning

Course Evaluation

Program Evaluation (Graduates)

impairments. "

E.G., Required Reading: Lynch EW, Hanson MJ. Developing Cross-Cultural Competence. Baltimore: Paul H. Brooks, 1992. E.G., take home exam case of a 10month-old child with developmental delays whose family immigrated to the US 18 months ago from Tai Pei, Taiwan. "Discuss the family culture, the impact of their culture on early intervention with this child, and what you as a physical therapist can do."

Student knowledge, attitudes, and behavior related to cultural diversity evaluated in clinical education, initial employment, and lifelong practice.

Figure 1-4 Example of the logical connection between program philosophy, goals, course objective, course content and learning experience, and course an program evaluation. (From: Course designed by D Scalise-Smith, K Nixon-Cav Department of Physical Therapy, Temple University.)

ter or quarter and how many units of work are normally expected of s dents within that institution within the given time frame)_ Primary co sideration must also be given to availability of clinical sites-it would impossible to expect clinical internships to occur only in the summ when the usual academic year is not in session (and clinics may have t greatest number of staff on vacation)_ In addition, faculty and clini expertise must be juggled across classes in different years of the progra with available laboratory space factored in as a major structural constrai

14

CURRICULUM DESIGN FOR PHYSICAL THERAPY EDUCATION

One can see how easy it would be to organize a curriculum b tural constraints alone! In addition to these resource and structural constraints, t design physical therapy curricula are concerned about what know before their first clinical experience. Faculty often desir know at least a little about nearly everything before enterin internships. This is strongly reinforced by clinical instruct with treating patients within dwindling time periods, wa know at least something about typical clinical problems the ing and common evaluation and treatment strategies that wi to be immediately useful. Certainly, due to the pressures of th ronment, most clinical administrators are understandably mo accommodating students during their last clinical internshi with the students' first internship. This desire to have imm patient-care skills even during an initial clinical assignment, w may result in a curricular organization that is antagonistic to overall philosophy and goals. For example, a common strateg in" is the presentation of foundation courses (i.e., biological an ence courses) and clinical skill courses as early as possible in t Courses deemed less relevant to hands-on patient care (e.g., sciences, clinical management, and research courses) are tau in the curriculum. In sacrificing long-term goals for short-ter ty must realize they are also giving students a strong implicit what they consider most important in physical therapy pract Review once again the examples of general curriculum go Dr. David Rogers in Table 1-1 and examples of more specific c set forth in Table 1-5. Is it possible that a student will attain the biological sciences exclusively predominate the initial thi sequent structure of a physical therapy educational program? was echoed in the document produced by the 1993 IMPACT

The word transcurricular was chosen to place e need to interweave principles and applications f tent areas throughout the entire curriculum ... to p to assume the multiple roles required of them i tice, such as provider of treatment, teacher, and s

Table 1-6 illustrates how one physical therapy program expl of the relatively equal importance of foundation sciences, c and research skills, clinical sciences, behavioral sciences, and riences by presenting all these educational components in

MPT I/Spring

MPT II/Fall

MPT II/Spring

Physiology

3

Neuroanatomy

3

Motor control

Pharmacology and nutrition

3

2

and treatment skills Critical analysis II

Critical 2 analysis III

Research I

2

Clinical kinesiology II Basic evaluation and treatment skills Clinical medicine Basic exercise and rehabilitation

3

Musculoskeletal dysfunction I Cardiopulmonary dysfunction

3

Musculoskeletal dysfunction II Neurologic dysfunction I Neurologic dysfunction II Electrotherapy

3

Clinical educa (4 wks May)

3

4 3

3

3 3 3

2 Behavioral science II Human devel- 2 opment Behavioral science III

2

Clinical educa (8 wks Jan)

Year/Semester MPT III/Fall

MPT III/Spring

Foundation sciences

SH

Research

SH

Research II

2

Research III 2

Clinical sciences

SH

Musculoskeletal dysfunction III Neurologic dysfunction III Orthotics and prosthetics Clinical simulations I

2

Clinical simulations II Gerontology

1

2

Behavioral sciences

Clinical practice

SH

SH

Health care organizations I

2

Clinical education III (8 wks, AugOct)

3

Health care organizations II

2

Clinical education IV (8 wks, March-May)

3

SH = semester hours; MPT = master of physical therapy. Source: Department of Physical Therapy, College of Allied Health Professions, Temple University, Philadelphia, PA.

for the faculty member to concentrate on how each student wi after graduation than to concentrate on how many technical ski dent has before the first clinical internship.

Tyler's Question 4: Evaluation If the objectives, content, and learning experienc course or clinical experience relate to the program's philosophy then student, as well as instructor, evaluation of each course a component will give the faculty a good sense of whether the prog are being attained. Of course, the ultimate measure is how the gra form in clinical practice. Program evaluation should cover all general and specific goals. See Figure 1-4 for a specific example of how program eval vides a feedback loop so faculty can determine how successful dent has been taught to achieve a program goal. Referring onc Tables 1-1 and 1-5, do the graduates, for example, know how to manage ambiguities and gaps in knowledge? Are they able to com with people from different cultures and backgrounds? Do they h sonal love of learning? Can they teach patients, families, colle public? Do they demonstrate professional ethical behaviors? R tematic evaluation of recent graduates by surveys, interviews groups will assist the program faculty in completing the curricu connections and answering the most important curricular que the educational program achieve what it stated it would achieve gram's philosophy and goals? See Table 1-7 for examples of a variety of sources that migh for meaningful evaluative information. The data retrieved can with the philosophy and goals of any particular physical therapy therapist assistant program.

Walker's Curricular Platform

Decker Walker proposed a naturalistic model of h really go about developing a curriculum. lo He suggests that facu sions that culminate in a shared vision for a program form the p which all deliberations and eventual decisions about the progra

18

CURRICULUM DESIGN FOR PHYSICAL THERAPY EDUCATIONA

Table 1-7 Examples of Program Evaluation Data Sources

Examples of types of data

Students

Recruitment activities Admissions (prerequisite coursework required tural diversity profile) Academic performance (timely feedback to st diation activities) Retention (assistance available)

Faculty

Resumes (preparation for teaching; scholarsh tions and grants), service to department, un profession; practice and consultation activi and awards) Faculty development plans

Academic curriculum

Course syllabi (content, types of learning exp of evaluation) Minutes of faculty retreats and planning sess Student evaluations Faculty and peer evaluations

Clinical curriculum

Development of clinical sites Types and length of clinical rotations Student evaluation of clinical instructors and opportunities Clinical instructor evaluation of student clin mance

Environment

Support services (library holdings, computer aid opportunities, health care services prov

Graduates

Alumni surveys (clinical positions held; cont tion courses taken; specialist certifications participation in local, state, and national p activities; participation in research and pub community volunteer activities) Licensure exam scores Employer satisfaction surveys Patient satisfaction surveys

GPAs = grade point averages. Source: Western Association of Schools and Colleges Accrediting Commis Colleges and Universities. Achieving Institutional Effectiveness through A Oakland, CA: Western Association of Schools and Colleges, 1992;31.

In addition, Walker suggests that curriculum development does Iowan orderly progression from goals to objectives to content and evaluation, as was suggested by Tyler, but instead faculty move ba forth between all of these elements in a process of deliberation. Thi eration informs the design decisions. We believe the Tyler and Walk els are useful in helping faculty understand the process of curr development. Tyler delineated the component parts of the proce Walker described how faculty actually discuss, debate, and nego arrive at a curriculum. It is useful for all academic and clinical faculty members to h agreed-on program philosophy and goals (a synthesis of the platfo front of them when preparing their academic or clinical course ob and related learning experiences. During this preparation time, facu use the philosophy and goals as a guide in their planning. For exam the program included macro-level goals articulated by Rogers, the i tor would think about how to set up learning experiences that "tea dents to reason and manage ambiguities and gaps in knowledge" or " students' capacity for constructive empathy" (see Table 1-1). Simi the program goals included a quest for superb treatment and eva skills" and awareness "of accountability for self and the lives of oth culturally diverse world" (see Table 1-5), the instructor would consid course learning experiences and material could facilitate student l in these areas. The program philosophy and goals that provide the platform on the physical therapy program rests should be discussed and revised, essary, every year before curriculum planning for the following yea is, before Tyler's second and third questions are discussed and ans Furthermore, every student in the physical therapy or physical th assistant program could benefit from having a copy of the program's ophy and goals and an opportunity to discuss the philosophy and goa the faculty early on as well as during her or his academic program. S cussion and reflection on the intent of the program can be a powerfu helping students understand the coursework and required education riences, as well as socializing them into the profession. For an ad example, see Table 1-8 in which a physical therapist assistant progr clearly stated what the student will be prepared for consistent with th dards of the profession and the mission of the college. /I

20

CURRICULUM DESIGN FOR PHYSICAL THERAPY EDUCATIONAL

Table 1-8 Physical Therapist Assistant Program Mission: Clarkson

The Physical Therapist Assistant program at Clarkson College is design students a diverse educational experience rich in both basic and appli Students of the program will be prepared to work under the supervisi licensed physical therapist and be expected to demonstrate good ethic and compassion in the treatment of patients. The physical therapist a adhere to all professional and ethical standards set forth by the Amer cal Therapy Association.

The Physical Therapist Assistant Program will provide an optimal enviro help prepare students who can deliver quality health care in a variety o settings. The College will offer a broad educational experience to enab titioner to transfer the theoretical learning into clinical practice. The s be nurtured into becoming an integral member of the health care team strating exemplary professional communication skills when dealing w health care providers. Scholarly preparation of the physical therapist as develop a highly motivated critical thinking individual concerned with improvement of the quality of life as is consistent with the mission of Source: Clarkson College, Omaha, NE.

Implicit, Explicit, and Null Curriculum

Throughout the design and implementation of a ph apy curriculum, the faculty can gain insight about the program b ing the three types of curriculum that Eisner identified as being t educational programs: the implicit, explicit, and null curriculu explicit curriculum is publicly stated and is available to eve implicit curriculum, which is more subtle and potentially more p known especially by students and graduates of the program. Th riculum may be known to only a few or to no one since it inclu ments that are left out of the explicit curriculum, and it is a pot spot in planning.

Explicit Curriculum

The explicit curriculum includes those explicitly publicly shared aspects of the curriculum that are found in univ logues, program brochures, and course syllabi. Explicit curricula include, for example, the prerequisite courses, the program's stat phy and goals, the content of required coursework, the sequence clinical affiliations, and the faculty's credentials. Physical therapy students often choose the program they wa based on this explicit curriculum. Explicit elements, such as th

lar information on student preparedness for their clinical affiliation description of coursework completed by the affiliating students). Wh gram outcomes are assessed, alumni are often asked to state their l satisfaction with specific courses they completed. One easily might c er the explicit curriculum to be the only curriculum. However, stu alumni, clinicians, and new faculty can often distinguish and discu presence and power of a second type of curriculum, the implicit curri

Implicit Curriculum

The implicit curriculum includes the values, belief expectations that are transmitted to students by the knowledge, lan and everyday actions of the academic and clinical faculty. The themselves may be less aware of these values, beliefs, and expectation students and alumni of the program. As we wrote in our 1990 a " ... students regularly receive from faculty members implicit me about the relative importance of certain types of knowledge, what ty patients are most interesting and challenging, and what personal and sional behaviors are acceptable and unacceptable II 12 (Table 1-9). Clinical and academic faculty are often unaware that every tim appear before students they are demonstrating behaviors they co appropriate and professionaL These often unconscious behaviors, for or for worse, are powerful socializing elements that mold the future sional behaviors of students. For example, how faculty members eng their own lifelong learning, discuss patients and families, participate concerns of professional organizations, and demonstrate caring absorbed by students as templates on which to model their own prof al values, attitudes, and behaviors. The implicit curriculum is also the basis for many decisions about the explicit curriculum. For example, as discussed earlie sequence of coursework in a program (e.g., biological sciences fir social sciences last) and the length of time devoted to certain topic prevention and wellness versus acute and chronic pathologic cond can give students a strong implicit message about what information sidered more or most important to the practice of physical thera what is considered less or least important. In fact, every aspect of e coursework contains an implicit message. For example, do the object

22

CURRICULUM DESIGN FOR PHYSICAL THERAPY EDUCATIONAL PR

Table 1-9 Examples of Implicit Curriculum in Physical Therapist and Physical Therapist Assistant Programs Curriculum component

Example

Courses considered most important versus those considered least important

Courses that receive scheduling p for class time, location, and op examination time

Modeling of effective stress management

Faculty members· demonstrate c resiliency in response to sudde in class time, broken audiovisu ment, no-show guest lecturers,

Critical thinking considered inherent in professional behavior

Faculty members critically analyz mation, brainstorm ideas, and d strate tolerance for ambiguity

Modeling of effective, professional behaviors

Faculty members demonstrate an of students courtesy, initiative, for other viewpoints, and willin act as moral agents

Expectations for lifelong learning

Faculty members display a contin for the latest information, are v the library, and attend and mak tations at local, state, national, international professional meet

Respect for and trust in one's colleagues

Faculty members demonstrate en for team teaching and express f tion with alternative viewpoin Faculty members demonstrate res other health care professionals

Openness to innovation

Faculty members encourage stude explore alternative health care phies and models of practice (e puncture, Feldenkrais method, method)

Respect for and sensitivity to patients

Faculty members refer to patients viduals characterized by compl unique physical, social, and beh characteristics rather than by d or body parts

Expectations for lifelong service to the profession

Faculty members participate in co and task forces and on boards a state, and national levels of the

APTA = American Physical Therapy Association. ·The term faculty members implies academic and clinical faculty members. Source: Adapted from KF Shepard, GM Jensen. Physical therapist curricula for educating the reflective practitioner. Phys Ther 1990;70:566.

include clinical problems that challenge the student to think ab individual person who is receiving treatment as well as about the impairment problems they are treating?

Null Curriculum

The null curriculum includes those elements of physic apy practice that are missing from the curriculum. Some elements a ing because there is no voice to champion their inclusion. This be blind spot and is especially true about areas of physical therapy where fewer physical therapists are currently engaged. For examp much information do students receive about the role of physical th in obstetrics-gynecology care, hospice care, pro bono work with th less, or contributions that could be made in hospital emergency roo during times of disaster? The null curriculum has the same impact on the professional attitu behaviors of students as the explicit and implicit curriculum. If, for e students are never exposed to extended-care facilities or well-elderly during their clinical internships, who will elect to seek a position in setting as a first choice after graduation? Some elements are missing because there simply is no time to te more information. Every academic and clinical faculty member with how best to spend the limited time available for teaching. "Mor ter" is not the answer. Cramming more and more material into a pandable time sequence encourages rote memorization and repet tasks, drives out analytical and creative thinking, and, worst of al out a desire to learn by setting unattainable goals that leave the s awash in fatigue and frustration. Faculty must carefully consider and consciously weigh what to and what to exclude from each course. Time for reflective thou integration of concepts and ideas, as well as time for being present new information, must be consciously and deliberately built into ricula structure from the beginning. In the same manner, clinical tors must weigh whether to expose the student to a potpourri of di and potential physical therapy treatment techniques or to teach s in-depth assessment and treatment skills for the most common problems the student will encounter in practice. Trying to do b

24

CURRICULUM DESIGN FOR PHYSICAL THERAPY EDUCATION

depth will only promote anxiety and end in frustration fo instructor and the student. Decisions concerning the null curriculum are not easy guideposts faculty might use in deciding what not to include a skills demanded in clinical practice and what skills students c they are in the field. To use the first guidepost, academic f enormously from visiting students at clinical sites and hav from different settings participate in curriculum planning example, how much time are physical therapists and phys assistants spending on hands-on care in comparison with patient and family to manage their own health care needs? Th riculum issues are how much curricular emphasis is placed on dents to teach patients and families compared with how devoted to presenting students with an ever-increasing arra modalities. What skills are physical therapists and physical t tants currently performing? Are they working as teams? Th riculum questions are: (1) Does the physical therapy curr information on physical therapists' and physical therapist as supervision, and the basic elements of effective teamwork clinical education experiences allow guided experiences in p pist-physical therapist assistant teamwork? The second guidepost, an emphasis on lifelong learning, c time constraint frustrations experienced by academic and c and students. If faculty believe that the degree-granting ed gram is only the start of the student's career and that the pro only the most basic building blocks of that career, then att turned from what to learn to how to learn. Thus, if students a to think, to analyze, to reflect, to incubate ideas, to ident learning needs, and to locate needed resources (and observe clinical faculty doing this), then they will become lifelong le ing as much each year in practice as they did during their ma an academic program. A program cannot teach everything, bu to the needs of the current clinical climate and prepare the st for tomorrow. An effective educational program for physical therapists therapist assistants is one in which the explicit, implicit, and are known to the faculty and are complementary. Faculty can i gies that will allow them to garner periodic input about the well as explicit and null, curricula from students, alumni, clin site accreditation teams. Being able to assess and understa

and Liberal Arts Education

In 1974, Lewis Mayhew and Patrick Ford first describ inevitable conflicts that arise between educational programs for profe als (e.g., medicine, education, engineering, and law) and the trad long-standing liberal arts educational programs (e.g., biology, Englis losophy, and physics).13 Since that time, Patrick Ford has spoken these issues directly to physical therapy educators. 14, 15 The issues a cinating because they are so pervasive. Twenty years after they firs revealed, the issues are still unresolved, which is a testament to the standing conservatism and resistance to change that characterizes A can higher education. The conflicts stem from the different educational outcomes that arts programs and professional programs seek to attain. The goal of tional liberal arts colleges is to create a learned person who has a g many aspects of the world and is prepared to function in multiple se The focus is on discourse, theory, and the need to reason, argue, creat as graduation speakers exhort, "to make a difference in the world." Th of professional programs, in general, and physical therapy programs, ticular, is to graduate students who will be prepared to function as sionals in a specifically defined field of endeavor. The focus is on attai of practical skills, behaviors, and attitudes that reflect the ethos and tions, as bestowed by society, of that profession. From these basic differences, five conflicts arise between liberal ar grams and physical therapy programs located within the same institu

1. The curricular content of most physical therapy education pro is debated by college and university academicians and physical therap titioners. Academic faculty from liberal arts departments who have a voice on college and university curriculum committees often argu physical therapy curricula focus too much on practical application a enough on the theoretical underpinnings of the knowledge. (This i cially true of their perceptions of graduate physical therapy programs. versely, clinicians chide physical therapy faculty for spending too muc on theory and not being responsive to the real world. (An unfortunate often echoed by students returning from clinical internships.)

26

CURRICULUM DESIGN FOR PHYSICAL THERAPY EDUCATION

If the physical therapy faculty member has recently come ical setting, she or he is more likely to teach knowledge that formed by experience. Thus, these educators present studen potpourri of clinically relevant information, only some of found in textbooks. In contrast, the longer faculty members h academic setting, the more socialized they are to the tradition and the more theory and critical analysis will playa promine courses. Of course, both perspectives are important and relev therapy curricula. However, conflict arises because there sim to teach both perspectives in depth. Thus, the collective facu struggle with (and faculty meetings are often permeated w about these somewhat antagonistic perspectives. 2. The university has traditionally been perceived as an a in society. It is a place where new ideas, skills, materials, an created and shared with the world. However, to produce pra must work in today's demanding health care environments first ensure that their graduates are ready to practice. That focus their attention on codifying and transmitting the con that is accepted by the profession and will be tested by nat examinations. Creating new knowledge clearly has a seconda fessional programs. This fact has placed many professional gra therapy programs at odds with graduate curricular committee 3. All physical therapy programs rely on the liberal ar colleges and universities to supply prerequisite coursework ing students. The breadth and level of many of these prerequ the biological, physical, and social sciences are an anathem therapy educators. Professional programs, of course, have li content of these prerequisite courses, and similarly titled c munity colleges, small liberal arts colleges, and large uni strikingly dissimilar educational backgrounds among studen ing physical therapy class. Teaching students who enter wit els of prerequisite coursework is frustrating to faculty (an themselves) who must continually readjust their foundation cal science, and trans curricular content coursework to meet dle level of student knowledge. 4. The clinical education portion of the curriculum that t side the walls of the university is not well understood nor pa supported by most institutions of higher education. While stu fee for clinical education coursework to the college or univ costs (e.g., salary for the academic coordinator of clinical educ site visits, legal fees for preparation of clinical contracts, and

education programs long have fallen on the deaf ears of university ad trators. The result is a smoldering conflict between the clinic and the emy that is fanned by resentment and fueled by little hope of resoluti a result of the current health care economic crisis many different mod clinical education are being discussed that may be more cost effec health care organizations than the current costly system of one stud one instructor. See Chapter 4 for further discussion of this issue. 5. Tenure and stability for any faculty member (and the progr which the faculty member teaches) come as a result of proven perfor in three traditional areas of enterprise: scholarship, teaching, and se Of these three, scholarship, or success in developing a research pr that garners external grants and provides the grist for research paper ation of knowledge) acceptable for publication in peer-reviewed p sional journals, is the area that has traditionally counted most t tenure in universities. Most traditional university arts and sciences ty begin their academic careers with a doctorate degree in hand and own well-defined and productive area of research. For these faculty it ficult, but not impossible, to juggle these three areas of endeavor high level of competence. Historically, it has been a very different person who enters the mic world of a physical therapy program. The overwhelming prep ance of physical therapy educators have come directly from c settings, hold master's degrees, and have no well-developed ar research. While the number of doctoral faculty has clearly risen, in less than half of the faculty in professional physical therapy program doctoral degrees. As Patrick Ford states, "Because physical therapy tors have, by and large, been socialized and mentored into a professi ferent from the profession of college and university teaching, they br the academy an ethos and a set of values and expectations that a quently quite at odds with the prevailing value structure within highe cation." lS That is, physical therapy faculty are generally more than re teach students about clinical practice and to maintain their own c competence. However, many are exceedingly ill prepared to embra traditions of scholarship that are expected and needed for full acce in the academic world. Physical therapy faculty who teach in the clinical sciences mu course, keep their clinical skills and knowledge updated. Many of the

28

CURRICULUM DESIGN FOR PHYSICAL THERAPY EDUCATIO

ulty work at least part-time in clinical settings, thus squeezi of activity into their busy academic schedules. However, this is so important to competent teaching in clinical courses, toward tenure in the traditional university setting. It is diff do three things well (teaching, research, service), but it is ne to do four things well (teaching, research, service, clinical cially if one does not have a PhD and is juggling the daily de ly life. Many excellent clinician-educators have found them the university walls after 6 years because they failed to fulfil sic tenure requirements. Of course, knowing that these inevitable conflicts exist ty is the starting place for resolution. At the heart of this r development of physical therapy educational programs that who fit the traditional liberal arts model of excellence i research as well as experienced clinicians who provide stude lence in teaching and exposure to excellence in clinical pr thinking about ways to keep these clinical educators within has prompted such solutions as the development of faculty-ru tices and consultation and service contracts with nearby he cies. Other creative solutions include the creation of cli faculty tracks not subject to the traditional tenure time-li and scholarly demands, faculty positions shared between the health care settings, and the use of skilled clinicians as lab tors in clinical science courses.

Professional Accreditation for Phys Therapist and Physical Therapist Assistant Programs

All institutions of higher education receive p from one or more state, regional, or federal agencies. If the in the standards of performance set by these agencies, they accredited. The general purposes of accreditation are listed i Performance standards by which programs are judged in tive criteria and qualitative analysis. Quantitative criteria mi example, state board licensure examination scores of program professional qualifications of the faculty. Qualitative analysi the type of learning experiences students are engaged in and h riences impact the performance of the program graduates. Th judgments can only be made by other people, and thus an onvisit is common practice. In this way, the public is assured t

self-study and planning.

3. To assure other organizations and agencies, the educational community, a general public that an institution or a particular program (a) has clearly defined and appropriate objectives, (b) maintains conditions under which i achievement can reasonably be expected, and (c) accomplishes its goals an continues to do so.

4. To provide counsel and assistance to established and developing programs institutions.

5. To encourage the diversity of American postsecondary education and allow tutions to achieve their particular objectives and goals.

6. To endeavor to protect institutions against encroachments that might jeop their educational effectiveness or academic freedom.

Source: Reprinted with permission from KE Young, CM Chambers, HR Kells, et a Understanding Accreditation. San Francisco: Jossey-Bass, 1983;22.

tion meets or exceeds the general standards set for similar program institutions.

Judging quality is not easy. It cannot be reduced to quant indices or formulas. Such judgments are made by ga appropriate information about an institution or progra by having knowledgeable people appraise it. This essence of accreditation (COPA).16

Physical therapy educational programs can receive accreditation t a process established by the Commission on Accreditation in Physical py Education (CAPTE).16 This 19-member commission is comprised of cal therapy and physical therapist assistant academic and clinical edu administrators from institutions of higher education, basic scientists, cians' and public representatives. Since 1983 this commission has be sole accrediting agency, with authority granted by the U.S. Departm Education and the Council on Postsecondary Accreditation (COPA, no ignated as Commission on Recognition of Postsecondary Accred [CORPAI). As the sole accrediting agency, CAPTE makes autonomou sions regarding the accreditation status of physical therapy and physic apist assistant programs.

30

CURRICULUM DESIGN FOR PHYSICAL THERAPY EDUCATION

While accreditation of physical therapy educational pro sidered a voluntary process because there are no federal la program to be accredited, all viable physical therapy educati in the United States are accredited or in the process of beco ed. The reason, beyond assuring students and the public tha conforms to general standards for the education of compet ers, is that all 50 states, the District of Columbia, and Puert graduation from an accredited program as a prerequisite f practice license. The preaccreditation process for a new program is a involving the APTA Accreditation Department staff and p py educational consultants who work with an institution it first inquires about developing a program. In this pr phase, the program submits substantive documentation 9 enrolling students. This documentation contains a comprehe tus that includes an overview of the entire curriculum plan tion of 'faculty, clinical sites, college or university resource space, and libraries) in place or needed to support the progra for evaluating performance of the graduates. This documen oughly reviewed and commented on by a reader-consult makes a visit to the institution to further review the progra development. The reader-consultant prepares a report tha with the program director, faculty, and college administrat with updated materials, is forwarded to the commission for regarding candidacy status.

Self-Study Report

The accreditation process is somewhat paralle creditation process in that a program prepares and submits study report. The self-study process is a continual cycle f accreditation (Figure 1-5). During a self-study, the program's fac aged to use a system of ongoing review and evaluation for all pr With respect to the previous COPA quotation, in ph accreditation, "gathering appropriate information" would re study report, and the "knowledgeable people" would be the m on-site team as well as members of CAPTE. The program is guided in its ongoing program review an of the self-study report by the Evaluative Criteria for Accred cational Programs for the Physical Therapist or a comparable tive criteria for the physical therapist assistant program. 16 T

CAPTE Accreditation Action

Self-Study

\CMrn Deliberation

On-Site Visit and Preparation of Report (ROSET)

+

Program Response to On-Site Report (ROSET)

Figure 1-5 Ongoing self-study by the educational program is central to th

accreditation process. (CAPTE = Commission on Accreditation in Physica Therapy Education; ROSET = report of the on-site evaluation team.)

criteria are periodically revised by CAPTE with input and feedback many sources to reflect current standards of professional practice. Reviewing these criteria will provide the reader with an exc overview of the standards against which comparable physical therap cational programs are assessed. These criteria can be used on an on basis by faculty for program evaluation. Reading these criteria also giv an appreciation for the amount of extensive documentation regardi phases of the program that is contained in a self-study report and rev and evaluated by the faculty as well as CAPTE. The process of preparing a self-study report allows academic and cal educators to review in-depth all components of the curriculum to mine what is done and done well, what is done to an average or les average degree, what is missing that should be included, and what c omitted to update and strengthen the program. Thus, the process of piling a self-study report is the first and most important aspect of en and enhancing the quality of a physical therapy or physical therapist tant educational program. While the self-study report contains extensive information in four areas (i.e., organization, resources, curriculum, and performance of pr graduates), the most important of these areas is the outcome performa the graduates. All physical therapy and physical therapist assistant pro are urged to collect, compile, and review this outcome data at fre

32

CURRICULUM DESIGN FOR PHYSICAL THERAPY EDUCATION

intervals. These data may include national physical therap therapist assistant licensing examination scores, surveys of gr ing their opinions about the strengths and weaknesses of t program, information that reflects the ongoing professional g uates, input obtained from employers, and patient satisfa Review Table 1-7 for a more complete list of examples of pot evaluation data. The self-study report is reviewed by a three-member onteam for physical therapy programs and a two-member onteam for physical therapist assistant programs. The team con one physical therapy (or physical therapist assistant) educator cal therapist (or physical therapist assistant) clinician. The th ber may be a physician, basic scientist, or higher education The purpose of the on-site team visit is to confirm the inform ed in the self-study report, to decide on the qualitative aspects that cannot be determined by simply reading a paper docume vide summary information and consultation to the programY the on-site evaluation team (ROSET) functions as a powerful the program at the time of the site visit. The program's se along with the ROSET and any updated information the prog present as a result of the report, is reviewed by members of CA this review, the program is granted one of three general types o status: accreditation, probationary accreditation, or nonaccr intensive process is currently scheduled to occur 5 years after tation and then every 8 years, with smaller biennial accreditati taining updated program information due to CAPTE every oth Virginia Nieland, MS, PT, director of the APTA Departm tation for 12 years, states:

The beauty of the accreditation process is that producing but not punitive process. The entire desire to make things better. The individuals faculty and program directors to on-site visitor mission [CAPTEj have a mind set that rests question, "How can this program be enhanced personal communication, 1995.)

Faculty, clinicians, students, graduates, and administrator opportunity to become involved with any aspect of the accred are encouraged to do so with enthusiasm. In doing so, one witn ing process in which a community of professional peers work

This chapter has given the reader an overview of the r yet dynamic process of curricular design and has identified componen have the potential to support or hinder implementation of a coherent, ingful curriculum. Curriculum conflicts that may appear internal or e to the program have been identified. Finally, this chapter presents a sized overview of accreditation, which is an engaging process that pro stimulus and benchmark for quality physical therapy and physical th assistant education. The focus of all these efforts is to ensure excell clinical practice and provide learning experiences that will, as John states, "live fruitfully and creatively in subsequent experiences. II I

References

1. Dewey J. Experience and Education. New York: Collier Books, 1 2. Eisner EW. The Educational Imagination: On the Design and Eva of School Programs (3rd ed). New York: Macmillan, 1994. 3. Tyler RW. Basic Principles of Curriculum and Instruction. Chicag versity of Chicago Press, 1949. 4. American Physical Therapy Association Education Division. A N tive Model of Physical Therapist Professional Education (4t Alexandria, VA: American Physical Therapy Association, 1996. 5. Reynolds JP. Ah-hahs and ambiguities: towards the 21st century i ical therapy education. PT Mag Phys Ther 1993;1:54. 6. Rogers DE. The Education of Medical Students for Tomorrow. In cil on Graduate Medical Education, Reform in Medical Educat Medical Education in the Ambulatory Setting. Washington, D Department of Health and Human Services HRSA-P-DM-91-4;5, 7. Schon DA. Educating the Reflective Practitioner: Toward a New for Teaching and Learning in the Professions. San Francisco: Josse 1987. 8. Harris lB. New Expectations for Professional Competence. In L C Wergin (edsl, Educating Professionals. San Francisco: Josse 1993;17. 9. American Physical Therapy Association. A Guide to Physical T Practice (Vol 1): A Description of Patient Management. Alexandr American Physical Therapy Association, 1995;1.

10. Walker D. The process of curriculum development: a nat for curriculum development. School Review 1971;80:5l. 11. American Physical Therapy Association Education Div lum Content in Physical Therapy Professional Education reate Level. A Resource from the IMPACT Conferences. American Physical Therapy Association, 1993. 12. Shepard KF, Jensen GM. Physical therapist curricula for cating the reflective practitioner. Phys Ther 1990;70:566 13. Mayhew LB, Ford PJ. Reform in Graduate and Professi San Francisco: Jossey-Bass, 1974. 14. Ford PJ. The Nature of Professional Educations. In JS Ba Curricula in Physical Therapy Education. Washington, Education, American Physical Therapy Association, 198 15. Ford PJ. The nature of graduate professional education: tions for raising the entry level. J Phys Ther Educ 1990;4 16. Commission on Accreditation in Physical Therapy Edu tation Handbook. Alexandria, VA: American Physical T tion, 1996. 17. Jensen GM. The work of accreditation on-site evaluators development of a profession. Phys Ther 1988;68:1517.

Annotated Bibliography

American Physical Therapy Association. Professional Educa Therapy: Developing an Academic Program. Alexandria Physical Therapy Association, 1993. Provides an overv study the feasibility of establishing a physical therapy p sents guidelines for planning and developing a profess program. Especially useful for academic administrators ering developing a physical therapy program. American Physical Therapy Association Education Division Model of Physical Therapist Professional Education (4 dria, VA: American Physical Therapy Association, 1996. model was developed as a result of a series of national cu ences sponsored by the APTA Education Division. Using tations for the field of physical therapy, this book conta objectives, suggested content, and sample teaching strate work in physical therapy educational programs. Ongo this model are expected to ensure responsiveness to ch education, and health care environments. Educators c

1996. A "must" book for all physical therapy faculty. Contains the uative criteria for all physical therapy and physical therapist assi programs. Interpretive comments and guidelines provided under th teria are very useful in helping faculty to understand all relevant ponents of a physical therapy educational program and wh important to focus on to meet national standards. Curry L, Wergin J. Educating Professionals: Responding to New Expecta for Competence and Accountability. San Francisco: Jossey-Bass, One of the few books in higher education written especially for teaching in the professional fields. There are many excellent cont tors, most of whom write from the perspective of the field of medi A central theme of the book is that a closer, more relevant, conne between education and practice is needed especially in light of the economic, cultural, and technological changes looming in the tw first century. Tyler R. Basic Principles of Curriculum and Instruction. Chicago: The versity of Chicago Press, 1949. This small (124 pages) classic book gests ways to go about finding answers to the four questions Tyler p as fundamental to curriculum development. The methods propos seek these answers have stood the test of time. An easy to read, en ening, common sense approach to curriculum design. Walker DF, Soltis JF. Curriculum and Aims (2nd ed). New York: Colu University Teachers College Press, 1992. One of the Thinking A Education series of excellent paperback books produced by Tea College Press. Summarizes and critiques major curriculum theo Argues that thinking and theorizing about curriculum help teache make their practice "intelligent, sensitive, responsible, and moraL

Teaching in Academ Settings Katherine F. Shepard and Gail M. Jensen

I went on a treasure hunt yesterday. It began in my found the flour, sugar, and butter but I couldn't find t I looked in every cookbook, on every shelf, in every was no where to be found. As I stood staring at the in my grandmother came to mind. "She would know do," I thought. I imagined adding a little of this and that and finally created a small treasure, a cookie, ju ing my way through the process. I closed my eyes, l gers do the baking ... Voila! Butter cookies galore. As I turned from the kitchen into the living ar apartment, I saw yet another treasure hunt unfold b There were piles of papers and books, empty book long phone cord, and tiny little Post-it notes strun row. This" circle of knowledge" had no beginning an Its main purpose was to design a I-hour lecture for students. Although I knew this purpose, questions o had begun and where I had learned all of this inform at my very soul. How was I to compile all of this in into such a small package? Looking down, I noted I had reread one of my favor Inspiration Sandwich. In this book is my favorite phr ativity is all around you." Surveying the circle of pape

there was no other way to accomplish the task information with a little of this and a little of t subtracted, mixed it all together, and created treasure-my first lecture. I found the experien baking: I identified, closed my eyes, and let m rest. Bon appetit! (Janice Franklin, first-year tea

Getting ready to teach a class or a course for the first always a perplexing situation. Where to start? Educators there are at least three kinds of knowledge essential to teac (1) knowledge of the subject matter, (2) knowledge of th (3) knowledge of the general principles of teaching (i.e., kno gogy).l-4 This chapter presents an overview of the type of physical therapy and physical therapist assistant educators missing-knowledge of pedagogy.

Chapter Objectives

After completing this chapter the reader will b

1. Identify and discuss the characteristics of five different p orientations to curriculum design and give specific exam each applies to physical therapy or physical therapist as 2. Describe three learning theories that are based on th views of how students can learn: (1) behaviorism, (2) lem-solving experience, and (3) Piaget/cognitive stru cific examples of course materials that could best be learning theory. 3. Discriminate among three major learning domains ( affective, and psychomotor) by citing elementary to within each that can be used to guide design of cour dent evaluation of that coursework. 4. Identify the four learning styles described by Kolb 24 ples of student behavior that may be manifested by a interest in each learning style. 5. Discuss construction of and specify the use of three of objectives that can be used to guide student learni ioral, (2) problem solving, and (3) outcome. 6. Demonstrate how student evaluation is linked to ph entations, learning theories, learning domains, stude styles, and course objectives. Describe the pros and c

Preactive and Interactive Teaching

Thirty years ago, a yellow paperback book entit book for Physical Therapy Teachers was printed and distribut American Physical Therapy Association (APTA).s This small developed by a publication committee comprised of Ruth Dic Columbia University, Hyman L. Dervitz at Temple University, Meida at Western Reserve University. This book was the only information regarding physical therapy education at the time an information on how to develop, organize, and teach a physical th riculum. The teaching focus of that pioneering book and this preactive teaching. The terms preactive and interactive teaching were coined by gist Phillip Jackson. s Preactive teaching refers to those elements o ers when preparing to teach a course. Such activities includ background information, preparing course syllabi, developing m even arranging the furniture in the classroom. These activities rational-that is, the teacher reads, weighs evidence, reflects, relates the current class content to past and future classes the st involved in, and creates an optimal environment for learning. Lik year teacher who was grappling with how to organize a I-hour lec of these activities occur when the teacher is alone and in an en that allows for quiet, deliberative thought. Preactive preparation teacher time to think through the breadth and depth of informat to be presented (subject matter knowledge) to a particular group o (knowledge of learners), as well as the most coherent and unde way to present the information (pedagogical knowledge). By contrast, interactive teaching refers to what happens teacher is face to face with students. Interactive teaching activitie or less spontaneous-that is, when working with large groups o the teacher tends to do what he or she feels or knows is right. 6 In of a classroom or laboratory, little time is available to reflect on appropriate and useful strategies. Obviously, experienced teache siderably more skilled in interactive teaching and "reflectionthan novice teachers. This is similar to experienced clinicians wh know the right thing to do with patients with an ease and confi

Teacher Philosophical Orientation

Institution +

Learning Theory

('Yo)

('Yo)

_Cognitive Processing- _Behaviorism Reasoning _GestaltIProblem_Academic Rationalism Solving Experience _Technology _PiagetlCognitive _Social Adaptation Structure _Social Reconstruction _Personal Relevance

Teaching Aids

Domain of Learning +

A. Audiovisual _Computer Generated _Blackboard _Overhead Projector _Slides _Videotape; film B.~

Student Learning Style

DatefTim

+

('Yo)

('Yo)

_Cognitive _Affective _ Psychomotor _ Perceptual _Spiritual

_Concrete Experience _Reflective Observation _AbstractConceptualization _Active Experimentation

Formal of Delivery + Student Evaluation

+

Class Size

Audience

+

+

Teaching Environment +

('Yo)

('Yo)

_Lecture _Laboratory _Seminar-Discussion _Independent Study

_Practical Exam _Room Arrangement _Written Short Answers _Room Environment: _Written Essay temperature, light, _Report or Project acoustics, cleanliness _Teacher Materials: podium. chalk/pens, media setup

_Class Objectives _Small Group Tasks _Assigned Readings _Lecture Outline _Laboratory Exercises

Figure 2-1 The preactive teaching grid.

amazes novice clinicians. However, thoughtful preactive teach tion can allow even the novice teacher the freedom to focus understanding and growth rather than lecture notes. Preactive ments are covered in this chapter. Chapter 3, Techniques for Academic Settings, focuses on interactive teaching elements.

Preactive Teaching Grid

This handbook assumes that the teacher is ex competent regarding the subject matter to be taught (subject m edge) and is a physical therapist or physical therapist assistan good knowledge of the students to be taught and what informati for competent clinical practice. However, to organize and presen a manner that is responsive to the overall curriculum design and dent outcomes (pedagogical knowledge), the teacher is urg through the components identified in the preactive teaching gr 1). This grid is useful whether designing a whole course or a

elements will contribute to the presentation of a particular conten

Philosophical Orientation

Eliot Eisner conceived of five philosophical orientati can be used to guide curriculum design: development of cognitive p academic rationalism, technology, societal interests (social adapta social reconstruction), and personal relevance. 7 These orientations a on what teachers think the aims of a curriculum, course, or clas be-that is, why they are teaching what they are teaching.

Development of Cognitive Processes Development of cognitive processes focuses on teach dents to develop and refine their intellectual processes (e.g., how and sift data, how to pose and solve problems, how to infer, how to esize, and how to locate needed resources). The concern of the educa the how rather than the what. Little emphasis is placed on acquiri as this orientation proposes that by teaching students how to thin use resources, they will always be able to locate the specific info they might need. Problem-based curricula, such as that at MacMaster Univ Canada described by Solomon, are entirely based on this philoso this orientation, faculty identify cognitive processes that are n practice as a physical therapist. These problem-solving cognitive es are then strengthened through a series of problem-based exp that are similar to clinical situations that physical therapists enc In a problem-based curriculum, the entire curriculum is com clinical problems. For example, rather than a class of students sittin ditional physical therapy courses, such as anatomy, pathology, the exercise, and health care policy, students in small groups guided b tor discuss patient problems. With any given patient problem, stude to seek out, analyze, and act on the information they need. That is, gather information from a variety of sources, including anatomy, p therapeutic exercise, and health care economics, as these sources the patient problem under consideration. Of course, in any class or any course in any curriculum one working toward the development of cognitive processes. For exam

might ask students to use their "hunch" regarding the outco care problem. Students could then identify and analyze w hunch was based on and what additional data they would n their hunch. By this process, the student is introduced to processes of inductive and deductive thinking, and how bot used in health care decision making. As another example, st presented with a clinical problem that represents a moral dil ing such a problem involves the cognitive processes of iden dent's own values, comparing and contrasting these va principles contained in a professional code of ethics, and work nal, empathetic decision. As time to evaluate and treat pati be declining in all health care settings, teaching students to ly, humanely, creatively, and quickly is time well spent in e

Academic Rationalism Academic rationalism focuses on traditional that faculty think represent the most intellectually and arti cant ideas of the field. This approach relishes the history inquiry that have led to formulation of universal principle concepts useful in today's world. In this type of orientation spent on theory and less on practical application. The belief i dents learn of the great ideas created by the most visionary field (and related fields), they are able to perform as edu women. As Eisner states, "The central aim is to develop man ities by introducing his rationality to ideas and objects tha son's highest achievement."7 Thus, college classes based o great thinkers, such as Darwin, Emily Dickinson, Einstein, G and Martin Luther King, would have as their focus academic Obviously, no health care education could be based sole rationalism because too many ideas are outdated within a f ever, physical therapy and physical therapist assistant edu with how much academic rationalism to put into curriculum in a recent issue of Neurology Report, educators grappled w students should be taught about the historical perspectiv Rood, Maggie Knott, Berta and Karl Bobath, and Signe Bru compared with the time devoted to the emerging theories o and motor behavior. 9

Technology Technology focuses on practical or technical be student should attain to become proficient in her or his field

students receive immediate corrective feedback. In this approach, can repeat material until a certain proficiency level is attained. In physical therapy and physical therapist assistant program many areas of content and skill knowledge that lend themselves nology approach. For example, in anatomy there are clearly righ answers, and the teacher's task is to determine how much anato level, and what approach can be used that will help students m apply the material accurately. Practical skills knowledge, such mechanics of lifting or the steps involved in a wheelchair transfe itself to this technological approach. Many of the "tools of th taught from this orientation.

Social Adaptation and Social Reconstruction Social adaptation and social reconstruction focus interests. This is a two-pronged orientation with one prong adaptation and the opposite prong being social reconstruction. tation focuses curriculum, student knowledge, and student sk society needs to maintain the status quo. That is, under this physical therapy and physical therapist assistant students woul ed to immediately fill those areas of practice with the greates job vacancies. In contrast, social reconstruction focuses the curriculum fying the ills of society and the skills that will be needed in t solve them. Such skills might include working to change cer of society, such as intolerance, environmental pollution, o ness. For example, in a physical therapy or physical therapi curriculum, students would be engaged in experiences design op their tolerance for working with patients whose lifestyles siderably from their own, become involved in environme groups, or embrace participation in pro bono services for th Thus, while social adaptation and social reconstruction ha aims, they are tied by the common philosophical belief th needs should guide curriculum.

Personal Relevance Personal relevance focuses on what is personally the student. In this orientation, the teacher and the student

educational experiences that are meaningful to the stud states, "The task of the school is to provide a resource-rich e that the child will, without coercion, find what he or she ne groW." l Probably the archetype of this orientation is portraye famous boarding school, Summerhill, founded in Englan designed to "make the school fit the child instead of maki the school." l0 This orientation probably has the least meaning to entry therapy and physical therapist assistant educators who hav time to teach groups of students the basic tenets and tasks sion without responding to the individual personal relevanc of each student. However, the personal relevance orientatio in evidence in post-professional master's and doctoral degree most successful of these programs appear to be those that o a great deal of latitude in what she or he chooses to pursue faculty is dedicated to encouraging and supporting students in

Using the Five Curriculum Orientations to Guide Course Development There are two useful ways to use these five cu tations in developing a course. The first is to decide before course how much of each philosophical orientation will b example, for a course in basic skills the teacher probably wa centage of class time devoted to technology (e.g., 60%). One m to teach students how to think about applying basic skills in of clinical situations, so the teacher may plan to devote 15% stimulating cognitive processes. Finally, the teacher might skills students will need to use immediately in clinical practi ing a blood pressure or performing bed-to-wheelchair trans remaining 15% of the time might be used for laboratory ses around common clinical problems in which students can le that are immediately applicable in their next internship. Go process of thinking about philosophical orientations or the go can guide the teacher in apportioning the classroom and l appropriately. Such a process can also ensure that all class tim ed to a single philosophical orientation. The second way the five philosophical orientations ca review the multiple courses that comprise the curricul what philosophical orientation(s) the curriculum emphas Faculty might realize that they are spending too much tim gy or academic rationalism and not enough time on develo

Behaviorism

Piaget/Cognitive Structure

Figure 2-2 Learning theories.

processes. You might find that the social reconstruction orien nice thread throughout the curriculum or it may be left out This is an enjoyable and often revealing activity for individual well as the collective faculty. It will clarify the teacher's own beliefs about physical therapy or physical therapist assistant e well as how any group of faculty envision the present and futu of physical therapy.

Learning Theories

The next column in the preactive teaching grid con ing theories (see Figure 2-1). Phillips and Soltis, in their book Per Learning, provide an excellent synthesized overview of classical learning theories. II Theories about how people learn have been d least since the time of the Greek philosopher Plato (428-347 Be). lated that knowledge was innate-that is, in place at the time o function of a teacher was to help the learner "recall" what one already experienced and learned. Nearly 2,000 years after Plato, philosopher John Locke (1632-1704) proposed an opposite view of Locke postulated that infants were born with the mind a blank sla rasa. The teacher's role was to provide experiences that would fil slate with knowledge.!1 The current traditional learning theories fall somewhere pyramid model pictured in Figure 2-2. There are essentially thre different theories about how people learn: (1) behaviorism, problem-solving experience, and (3) Piaget/cognitive structure. other learning theories are some combination of these three persp therefore fall somewhere within the learning theory pyramid. Le ories provide the teacher with ideas about how to present differ

knowledge and skill in a way that reinforces the underlying orientations the teacher is focusing on.

Behaviorism The behaviorism theory was developed in the fir twentieth century as a result of numerous experiments, prim mals and birds, by the experimental psychologists E.1. Tho B.F. Skinner. l3 The basic theory of behaviorism rests on their that behaviors that were rewarded (positively reinforced) wo For behaviorists, the process of learning involves rewarding c ior until the behavioral change is consistently demonstrated Physical therapists and physical therapist assistants use principles continually in patient care to teach psychomoto example, patients are reinforced with enthusiastic praise fo and subsequently achieving self-care activities, such as donn ing a prosthesis. In classrooms, acquiring accurate knowledg ing the right answer) is rewarded by receiving high grades an faculty. Lack of responsiveness to acquiring the knowledge quelled by poor grades and perhaps even failure to proceed in Computer-assisted instruction is based almost exclusively o ing theory. Students receive immediate feedback contingent racy of their responses. Clearly, many psychomotor skills facts that need to be memorized are successfully taught usin tic principles.

Gestalt/Problem-Solving Experience In the early to mid-1900s, gestalt psychologists

theory of human learning that was diametrically opposed to t iorists. The word gestalt means organization. Gestalt p believe people experience and organize the world in meanin or contexts. Therefore, information must make sense withi text or the learner will not be able to learn. ll Gestalt p believe that to identify and reinforce isolated behaviors (i.e., is a clear distortion of how humans actually learn. This principle of learning in context clearly operates in tice and academic settings. Physical therapists, who in the p patients for functional activities by working on strength and specific muscle groups, now ascribe to the modern motor lear in which teaching movement within functional patterns acquisition of motor skills (see Chapter 9). In academic s known that students need a framework for information so tha

the function of muscle groups in a kinesiology class and learning assist patients to improve the function of muscle groups in a ther exercise class. In this manner, students learn and understand the and insertion of muscle groups in the context of muscle function the context of the use of this information in patient care. Thus, rization of anatomic structures is easier because it has a useful con therefore "makes sense." John Dewey (1859-1952), who has been called America's great cational philosopher, expanded on the learning theory of gestalt o ing within a context. 14 For Dewey, the issue of activity (i.e., studen actively involved in an experience from which they could learn) important. Phillips and Soltis have clearly captured Dewey's belief how learning occurs, and thus how teachers should teach usi gestalt/problem-solving learning theory:ll

Dewey described the process of human problem solving tive thinking, and learning in many slightly differen because he knew that intelligent thinking and learning just following some standard recipe. He believed that gence is creative and flexible-we learn from engagin selves in a variety of experiences in the world. Howeve of his descriptions, the following elements always appe some form: Thinking always gets started when a perso uinely feels a problem arise. Then the mind actively back and forth-struggling to find a clearer formulation problem, looking for suggestions for possible solution veying elements in the problematic situation that migh evant, drawing on prior knowledge in an attempt to understand the situation. Then the mind begins forming of action, a hypothesis about how best the problem m solved. The hypothesis is then tested; if the problem is then according to Dewey something has been learned. 1

Thus, in the classroom and in the clinic, when teachers present st with clinical problems to solve, they are following the traditions o Dewey. Perhaps even more important, Dewey illuminates for us h

learn from our experience in clinical practice. His postulation occurs from actively solving meaningful problems explains the wisdom of experienced practitioners that is far beyond the kn tained in current textbooks. The concepts of reflection in act tion on action described by Donald Schon and elaborated on i this book are the present-day versions of this gestalt/probleming theory that was first articulated by Dewey.6

Piaget and Cognitive Structure Jean Piaget (1896-1980) was a Swiss developmenta who looked at learning in terms of development of mental or c ties that make learning possible. IS Much of his work is based on vation and description of the cognitive abilities of his three child Wancy to adolescence. From this work, he postulated that think ing were bound to the child's biological development. He sugges of biological development through which all children proceed:

1. Sensorimotor stage (birth-2 years): grasping, objects to 2. Preoperational stage (2-7 years): concrete physical man objects 3. Concrete operations stage (7-11 years): beginning conc (e.g., use of abstract numbers) 4. Formal operations (11-14 years): full conceptualization problems in the abstract

While there has been a good deal of criticism of the spe Piaget's stages, he does present for us the useful concept that th ops through a series of stages that is limited as well as facilita and experience. Certainly, children at 2 years of age are no understand abstract concepts that would help them deal m with many issues with less emotional energy! For students beyond Piaget's stages (the ages of physica physical therapist assistant students), the work of Robert Gag hierarchy of learning that begins with the simple and concrete the complex and abstract. 16 The ideas contained within stages suggest that higher-order cognitive abilities build on lower-o abilities. That is, students must master lower-order abilities b master higher-level ones. For example, Gagne suggests the fol chy: (1) facts, (2) concepts, (3) principles, and (4) problem solv example, students should be able to identify the muscles, ne nective tissues involved in the shoulder rotator cuff (facts) b

student has missed anyone of these steps it would be difficult to proce the next step. For example, if the student did not understand concept how the various tissue structures are related, then it would be very dif to understand the biomechanics of movement. Thus, cognitive stru learning theories that began with Piaget's observations are very usef thinking about organizing and presenting information.

Relationship Between Philosophical Orientations and Learning Theories When the learning theory used is not compatible with underlying philosophical orientation, course materials tend to be jum leaving students and teachers frustrated with the teaching-learning pro For example, suppose a teacher believes strongly in the development o nitive processes (philosophical orientation) and regards that as the a teaching. In fact, the teacher sets up examinations in the format of pa cases about which he or she asks a series of questions. The question designed to require the students to use cognitive reasoning skills. How suppose the material was actually taught using the behaviorism lea theory. Behaviorism is the learning theory that has predominated class life for most students since first grade, and they are well prepared for m orizing and parroting information. Does it seem that these students w be ready and able to take specific facts for which they know correc incorrect responses and apply these facts without having had some lea that involved the patient care context-that is, gestalt/problem-so experiences? This "miss" between how the material has been taugh how the students are asked to apply it on a test is often apparent. The represents a discrepancy between the teacher's philosophical aim o course and the learning theory that guides instruction. Looking at the preactive teaching grid (see Figure one can see if a large percentage of the philosophical orientation to the material is nology (wanting students to learn specific facts and skills), then the lea theories of behaviorism and cognitive structure could logically guide th sentation of the material. Likewise, if a teacher is interested in the s reconstruction philosophical orientation, then the gestalt/problem-so learning theory approach could be a useful way to present course mate Remember that seldom is only one philosophical orientation and lea theory used in a class. However, just thinking through the emphasis

2-n

placed on each orientation and learning theory and their resulta bility will help guide teaching and evaluation efforts in a way th students learn rather than be frustrated.

Domains of Learning

The third column in the preactive teaching grid i domains of learning (see Figure 2-1). In considering aspects of b that are subject to growth and development and, thus, have imp teaching and learning, at least five domains of learning can be i • • • •

Cognitive (thinking) Affective (feeling, willing) Psychomotor (purposeful movement, doing) Perceptual (involving all the senses, including vision, olf tory, taste, and kinesthetic) • Spiritual (faith)

The first three domains, the cognitive, affective, and psych well known to physical therapy educators as clinical practic involves knowledge and skill in all three areas. These are the d have been most well defined and developed for educators. In 1956, Benjamin Bloom and associates wrote the first book entitled Taxonomy of Educational Objectives, Handbook I: Th Domain.17 A companion book (Handbook II: Affective Dotiiti duced by Krathwohl, Bloom, and Masia in 1964. 18 In the 19 books appeared on the psychomotor domain, one of the most that by Simpson. 19 The primary reason these books have been teachers is that they clearly define lower-order and higher-ord psychomotor, and affective abilities. Thus, similar to Piaget's contribution to cognitive structure learning theories, the doma ing provide a guide to the order in which students can most ea information, skills, and values.

Cognitive Domain The six levels of this domain are depicted in Figu upward progression of steps illustrates that students must a basic knowledge of the material before they can comprehend must comprehend the material before they can apply it. The levels illustrate that it is easier for students to analyze informa synthesize it, and only after achieving the levels of analysis a

Knowledge cite count

define draw list name

record relate repeat underline

calculate

calculate

compute describe discuss explain

demonstrate

categorize compare contrast

express

illustrate

identify locate report restate

interpret operate

review

tell translate

dramatize employ examine

practice schedule sketch solve use

debate diagram differentiate examine inventory

question test

construct create

design formulate integrate manage organize

plan prescribe propose

Figure 2-3 The cognitive domain. (Reprinted with permission from C

led]. Clinical Education for the Allied Health Professions. St. Louis: M 1978.)

can one evaluate the materiaL The list of verbs under each level the kind of behaviors students might exhibit under that domain. ple, in learning how center of gravity is a key to moving one's bod space, the student might learn logically through the following ste

1. Knowledge: Define the center of gravity. 2. Comprehension: Describe principles of the center of gravit involved in body movement. 3. Application: Demonstrate how center of gravity relates to 4. Analysis: Compare how center of gravity differs in mainta ting, stooped, and standing postures. 5. Synthesis: Design a wheelchair-to-car transfer that employ principles involved in the body's center of gravity. 6. Evaluation: Compare several different wheelchair-to-car tr and determine which is the safest using the principles of th of gravity.

Thus, knowing the various levels of the cognitive domain and at which level(s) the student is ready to learn will help ensure tha have not missed any knowledge component that would lead to un ing. Similarly, the teacher can review examinations to ensure tha are being asked to respond at the same domain levels that have be

Ch Organization Valuing Responding Receiving accept attend develop realize receive

recognize reply

behave complete comply cooperate discuss examine obey observe respond

accept balance believe defend devote influence prefer pursue seek value

codify discriminate display favor judge order organize relate systematize weigh

(form doe

Figure 2·4 The affective domain. (Reprinted with permission from Clinical Education for the Allied Health Professions. St. Louis: Mo

This is similar to the need for teaching-evaluation coherenc the prior section on the relationship between philosophical or learning theories.

Affective Domain The affective domain that deals with student i tudes, appreciation, and values is obviously more difficult evaluate. 18 Basically, behaviors in this domain are taught by approach-avoidance tendencies, meaning positive believed to exist if a student approaches and grapples with a than avoids it. The levels of the affective domain are depicted in Figu domain, the first step is to attend to an issue or "receive" it. A an issue, one responds to that issue and then may demonstrate is valued. The highest levels of organization and characteri deciding the importance of that issue given other competing ing consistently according to the value one places on the issu ing is an example of how the affective domain could be us therapy education regarding the issue of valuing diversity a nondiscrimination.

1. Receiving: Realize that health care professionals may and families differently because of race, gender, or life 2. Responding: Discuss how responding differently to pa of race, gender, or lifestyle might affect treatment outc

5. Characterization: Internalize the belief in individual patient family rights regardless of race, gender, or lifestyle and act co tently with those beliefs.

Krathwohl et al. note that there is a good deal of hesitancy by t to evaluate students in the affective domain. Teachers, as well as st often see it as inappropriate to grade on interest, attitudes, or ch development, all of which are regarded as personal or private matte thermore, education in the affective domain may be seen as indoctri that is, persuading or coercing students to adopt a particular viewpo in a certain manner, or profess to a particular value or way of life. 18 Certainly the issue of professional socialization and ways that care professionals are expected to behave is central to consideratio affective domain. In physical therapy and physical therapist assistan ula, clinical educators are regularly called upon to evaluate students i tive areas, such as enthusiasm, dependability, judgment, and sensit patient-family care. Clinical educators also evaluate how well s adjust to a department, how well they work with colleagues, how re they are to new ideas, and how they react to constructive criticism. it is unlikely that any clinical evaluation form exists that does not these important affective professional attitudes and behaviors. However, it is much less likely that academic educators deli teach and evaluate in the affective domain. Students see such evalu illegitimate. Take the example of the student who is perennially class, or students who leave the lab when their work is done regar whether their colleagues have completed the scheduled group tasks students are reprimanded for these irresponsible professional behavio often claim that they not only have good reasons for their behavior, b they would not exhibit such behaviors in the clinic setting. Is this tr For affective behaviors to be seen as legitimate in the academic teachers must determine before the class begins what clinically behaviors are acceptable and unacceptable and explicitly notify s that such behaviors will or will not be supported and will be evalua Table 2-1 for examples of affective behaviors that can alert the stu expected clinical behaviors and guide the teaching and counseling e educators in the academic setting.

Table 2-1 Examples of Affective Behaviors Pertinent to Academic and Clinical Settings Satisfactory

Needs improvemen

Demonstrates ability to recognize and discuss own beliefs and values as different from others Seeks opportunities to augment learning and improve knowledge in theoretical and practical areas Works cooperatively with persons of varied ethnic, gender, lifestyle, and disability backgrounds

i:

Recognizes and handles personal and work-related frustrations in a nondisruptive and constructive manner Demonstrates ability to recognize, examine, and influence own strengths and limitations in academic and clinical settings Accepts role as a moral agent and moves to thoughtful deliberative action when moral dilemmas arise

Psychomotor Domain The stages of the psychomotor domain are noted The steps of these stages are self-evident, especially to the m therapy educators and students who have participated in sp remembering how skill in a specific sport was acquired may be guide to teaching patients motor skills. (For more on the spe learning motor skills, see Chapter 9.) The following examp applied to most sports as well as to patient tasks, such as gait 1. 2. 3. 4. 5.

Perception: Distinguish among various maneuvers. Set: Position oneself to engage in each maneuver. Guided response: Duplicate the maneuver a skilled perfor Mechanism: Adjust the maneuver to the needed respon Complex overt response: Coordinate various maneuver plish successful play or task.

Perception distinguish hear see smell taste touch

adjust approach locate place position prepare

copy determine discover duplicate imitate inject repeat

adjust build illustrate indicate manipulate mix set up

demonstrate maintain operate

develop supply

Figure 2-5 The psychomotor domain. (Reprinted with permission from CW Fo led]. Clinical Education for the Allied Health Professions. St. Louis: Mosby, 1

6. Adaptation: Adapt maneuvers to obtain the most successful respo 7. Origination: Create new maneuvers.

As with the other domains, thinking through the steps in the chomotor domain before teaching, as well as before an evaluation such practical exam, will help the teacher determine at what levels he or s presenting and requiring students to demonstrate motor skills.

Perceptual and Spiritual Domains Neither the perceptual nor the spiritual domain has yet fully described or classified in a series of learning steps, as has been with the cognitive, affective, and psychomotor domains. However, ne of these domains should be neglected in physical therapy education. C ly, the perceptual domain involving all the senses plays a dominant ro how patients receive and use information regarding their body image what their bodies can and cannot do. Think about how the percep domain can be incorporated into classes, such as motor learning or ca vascular physiology. The spiritual domain appears to be very comfortable or very uncom able for health care professionals in their work with patients and fami The same is true of academic and clinical faculty in their work with dents. The degree of comfort appears to be directly related to one's exploration and understanding of spirituality, as well as how colleagues port or dismiss attention to this domain. Certainly, this domain plays a

nificant role in how patients and ness in their lives. Perhaps, simila physical therapists should be discu in our educational processes. 20, 21

Relationship Betwee Learning Theories, a Think about teachi exercise. It is likely you will use s for example, technology (60%), c rationalism (10%). The predomin ism (75%) and cognitive structur the cognitive domain (100%). Co a class about sexuality of person you might choose to teach pred losophy using the gestalt/problem attending to the affective and psy tive domain. Is it clear how thin edge of pedagogy) can lead to a co different as it is remarkably cohe

Student Learnin

The fourth column 2-1) displays one example of how Identifying your own learning st prefer to learn. It is important for to teach using the learning styl example, if the teacher likes to reading list will probably be in teacher likes to learn by doing, t practical learning experiences for teacher to be aware of her or his p learning styles that she or he fav may be ones that some of the stu learn the most from. Thus, one c ated teacher through devising acti of student learning styles. Presented below is an exam how it can be used in academic learning style inventories, such a

Reflective Observation

Experimentation

Abstract Conceptualization

Figure 2·6 Learning styles.

the Canfield Learning Styles Inventory,23 both of which have been health professionals.) Kolb postulated a model of normal learning processes that was ally developed into the Learning Styles Inventory.24 As seen in Fig learning is depicted as a recurring cycle consisting of four stages, be with a concrete experience. Most concrete learning experiences other people in everyday situations. This type of learning relies on and intuition rather than logic and reasoning. The second stage, re observation, involves learning by observing what happens to oneself as what happens to others during a concrete experience. In this st action is taken but through observation one learns to understand sit from different points of view. The third stage, abstract conceptual involves logic and reasoning. In this stage, theories or explanations ar oped about what has been done and observed. Then actions may b and problems solved based on these theories. In the fourth and fina active experimentation, learning is through testing different app based on the theories generated. In this stage, the practical use of i well as theory, is evident. Physical therapists and physical therapist assistants use thi constantly in clinical practice when treating a patient (concrete ence), observing and reflecting on what happened to the patient as of that treatment (reflective observation), thinking about how a s

ful intervention with one patient ma rizing why (abstract conceptualizatio on other patients (active experimenta icians create the ever-expanding kno use in practice. The Learning Styles Inventory con dent ranks according to his or her lear

"When I learn, _ I like to deal with my feelings _ I like to watch and listen. (Re _ I like to think about ideas. (A _ I like to be doing things." (Ac

Completing this inventory takes the scores and plot them on a grid co normative data using the self-scoring quickly see your most and least prefer In preparing for each class, think presentation of material will most em to observe, theorize, or engage in a Kolb's Learning Styles Inventory or a is to become aware of learning style teaching and student learning. The g ble learning styles so that the teacher each learning opportunity.

Objectives

The last column in the p tives (see Figure 2-1). Objectives ident ly what the student is to learn as a r three types of objectives: (1) behavioral Behavioral Objective

The most popular and m is the behavioral objective. The behav

1. Condition: In what situation is 2. Behavior: In what action is the 3. Criterion: What is considered acc

Thus, the student is asked to engage in a behavior that can be seen and uated, such as describe (cognitive), demonstrate (psychomotor), or d (affective). By identifying specific behaviors rather than expecting stu to "know" or "understand" material, the expected level of performa much clearer to students and the teacher. Even partial behavioral objectives, which identify at least the tent area of knowledge to be acquired and the level of mastery (beh but not the grading criterion, are useful in identifying for the stu what is to be achieved by her or his efforts. At the beginning of chapter in this book, partial behavioral objectives are stated to ide for the reader what is to be gained from reading the chapter. Obvio if the reader is able to perform the stated objectives there is no ne read the chapter! The problem with using only behavioral objectives in teachi that education is and should be more than the sum of a uniform l behavioral objectives. Along with behaviors that can be seen and sured, teachers also hope to stimulate and accentuate in students behaviors as insight, curiosity, creativity, and tolerance. Addition students will encounter an endless number of situations in the ch world of clinical practice for which they would be ill prepared if the riculum focused solely on the competencies stated in behavioral o tives. Teaching students to learn constantly from the clinical pra environment (lifelong learning) requires setting up the type of objec that alert students to the complex skills required of them in cl practice.

Problem-Solving Objective The following clinical case is an example of a problem us fulfill the problem-solving objective.

Mrs. Gonzales is a 76-year-old Hispanic female with a history of hemiplegia of approximately 1 year. She fell 8 weeks ago and sustai Colles' fracture of the right wrist. She was seen late last week by he orthopedist, Dr. Barbara Feigenbaum, who removed the cast and ref Mrs. Gonzales to physical therapy for evaluation and treatment.

Using this brief case, students m evaluative information needed and t information. Students at different l will give different answers based o encounters. In using cases, specific stressed is thinking through the cas information a therapist would nee treatment program for the patient.

Outcome Objective Outcome objectives a that specify practice expectations fo mative Model of Physical Therapist of these practice expectations, whic learning experiences for physical the

1"1'

'I '

1. Demonstrate clinical decisi soning, clinical judgment, a 2. Educate others using a varie mensurate with the needs a

Under each of these outcome obj APTA document), specific behaviora in the APTA document) are used to id the student to achieve the outcome o For any class, course, or curricu and problem-solving objectives coul student learning to prepare students tives). The teacher can use objectives In addition, writing objectives is the behaviors that are congruent with h sophical orientations, learning theo learning styles that will receive focu

Lower Half of the

As can be seen in the lo Figure 2-1) the next steps are to prepar consider the delivery format and type thorough discussion of delivery form presented in Chapter 3, Techniques fo

Educational outcomes

The graduate: Identifies and prioritizes educational needs of audience and self.

Designs, conducts, evaluates, and modifies educational programs based audience needs. Recognizes role as educator, including capabilities and limitations. Engages in self-directed learning activities.

Provides education for a variety of audiences, such as patients, family, caregivers, clinical educators, community, policy makers, payers, an

apractice expectation. bEducational outcomes. Source: Reprinted with permission from APTA. A Normative Model of Physical pist Professional Education (4th rev). Alexandria, VA: American Physical Therap ation, 1996.

Continuing with the preactive teaching grid, the teacher mu thinking about how to evaluate students' knowledge well before the of class. (Course requirements, such as papers, quizzes, practical exa portfolios, are identified for students in the course syllabus.) The fi tion of this chapter includes ideas for written evaluations. Note that the last element in the pre active teaching grid before ly preparing the lecture or laboratory experience is attention give teaching environment. Preactive teaching includes preparation advance as well as arriving at the classroom early to attend to th arrangement and the room environment (including cleanliness and ature) and being sure that all media and materials needed for teach available and working.

Preparing a Course Syllabus

Preparing a course syllabus is an excellent way of deali the often-paralyzing gap between what one would like to teach and ity of the time available for teaching. From the students' perspe

Table 2-3 Contents of a Course Syllabus A. Name of university

Name of department Course title and number Overview description of course Name of instructor Phone number Office location and number Office hours Course requirements (e.g., type of exams on, and the percentage each counts Attendance policy Policy on incompletes and time extensio B. List of course objectives

C. Detailed information regarding required (e.g., content, length, resources need D. Required and recommended reading list E. Course outline and required readings

Date Topic Readings due

"~ il

course syllabus provides a complete ove requirements, and timeline on the first d students to organize their semester in a ing and achievement. Table 2-3 contains ed in a course syllabus.

Student Evaluation

Evaluations of students are see how well they have engaged the teac should be consistently related to the elem and specifically guided by the course obje content and student learning. A basic ped dents perform on tests, the better the tea rials and engaged students in their ow demonstrates the level of success of teac As previously stated, the design and should be thought through well before th

tion, such as short answer tests, essays, and quick checks, as commonly used, but perhaps even more powerful ways of promo learning and growth-the use of journals and portfolios. The use examinations will be covered in Chapter 3. Think broadly abo that can be evaluated that could facilitate professional growth. F you might have the students do a book review that could be se fessional journal or magazine for consideration of publication have students attend a research symposium and write a critique tion styles or attend a chapter business meeting and write a th on one of the topics discussed. Evaluations should be filled wi fun, and professional growth whenever possible!

Examinations on Course Content

One of the best ways to identify questions to be u ten evaluations is to make notes of possible questions in color gins of the lecture and lab materials. When it comes time to p a test, you have already identified many good possible question A word of caution: Be sure that the questions posed in any are culturally sensitive and do not reinforce stereotypes. Fo avoid "cutesy" or derogatory patient names (Mrs. Badhip)' o and gender stereotypes (women are always housewives and men executives), and racial and socioeconomic biases (gunshot inju happen to African-American males). Students read exam que great intensity and are vulnerable to absorbing, somewhat unc these destructive stereotypes.

Short Answer Questions

Short answer questions typically require a student distinguish, state, or name something. Answers can be free form simple questions or a fill-in-the-blank, or fixed format, such a multiple choice, or matching. Students can also be given a prob to read followed by a number of short answer questions.

Free Format Question The following are exa

• Describe bucket handle rib m • Label the parts of the thoraci • The type of justice concerne ate share of the therapist's ti • Diagram the components of

.::! 'I.~

I:

.,,1 ...

-I;'

,~ "

The advantages of free format ing, they give no clues as to corre they are easy to write (alternative choice questions), and they can ac disadvantages are they can be diffic of wording as well as content can be very specific subject matter, such a blank questions are more difficult cient, but not overabundant, amou one- or two-word response.

Fixed Format Questio

True or False Questio The following are exa

·~.i i

• T or F The extensor digitor minimi are the main muscle langeal joints of the fingers. • T or F The legal concept in out the consent of the person

The advantages of true or false can be answered quickly. The disad

• When guessing, a student ha be remedied by asking the st which decreases guessing. • It is difficult to avoid ambig about the key point you wan of key names, actions, or con as whether a fact should be s

c. Forearm crutches d. Axillary crutches • Patients with genu vara tend to develop degenerative changes a a. medial facet of the patellofemoral joint. b. medial aspect of the femorotibial joint. c. lateral aspect of the femorotibial joint. d. lateral facet of the femorotibial joint.

Advantages of multiple-choice questions are that well-constructed tions can measure knowledge and comprehension as well as applicati analysis (i.e., higher levels of the cognitive domain), they are very e grade and can be scored by a computer, and a great deal of material covered quickly and in a single question. The following are disadvantages of multiple-choice questions and ble solutions. 26, 27

• It is difficult to write plausible distractors. Try to think of a

three good distractors that are equal in length and parallel in str to the correct answer. Do not overuse "all of the above" or "n the above" for lack of inspiration in finding good distractors. commonly made by students are a good source of distractors. focus on major points related to your course objectives. Avoid ity and irrelevance. • Refrain from using words such as "always," "never," "all," or " Students know that few facts or concepts are always true. • A certain degree of success can be obtained through guessing o ing out in what order the instructor is likely to put the correct a Teachers are more systematic than they think. Given four cho a multiple-choice question, the correct choice is most often middle (i.e., b or c). Use a table of random numbers to guide the ment of the correct response. • Avoid trick questions, such as those using negatively worded along with negatively worded choices that test semantics an rather than knowledge of the subject matter.

Essay Tests The following are example

• Read the research paper provide strengths and weaknesses of the m • Discuss at least four strategies th public attitudes toward persons w • Compare and contrast the major t vention in episodes of acute rheum • Read the following community ho the recommendations you would m

Advantages of essay questions are th suring the upper three levels of the cog and evaluation); the student is free to de what information to use, what aspects the response; it is the easiest type of q teacher can determine the student's dep the student's critical thinking abilities. The following are disadvantages of e

• Scoring is difficult and time consu ments on each paper regarding t essay are imperative for student u during grading can lead to grading of short essay questions, grade th (without looking at the student's n tion to increase the consistency of • Writing ability influences the grad they read over their answers quiet plete or run-on sentences and Reviewing common errors with t and necessity of good writing skill

Good in-depth information on all typ (1993), Ory and Ryan (1993), and Linn a tated bibliography at the end of this chap

Quick Checks

Quick checks are like pop q anxiety imbedded in the process. Take th

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consider working to change to avoid physical therapist-physic assistant conflict. Think about grading quick checks as "excellent," "good," or If the student receives a try again, he or she can do just that-t in another response within the week. When the second response the student's grade may be moved up to a good or a goodmethod of grading avoids the stress of a one-shot pop quiz and p on students grappling with ideas and transforming knowledge. Q are easy to grade quickly and give the instructor information abo vidual students are absorbing the information presented.

Evaluation Methods that Promote Ref 1-

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One of the central themes of this book is the role in facilitating the development of "reflective practitioners." De reflective thinking as a state of doubt or perplexity in which th nates and a process of inquiry begins that is aimed at finding wa the doubt or problem. 28 Schon, in studying several different prof ognized reflection as an important vehicle for acquiring all typ sional knowledge. 6 More than a decade of research, dialogue, and transpired since Schon's Educating the Reflective Practitione educational community. One recurring element is the use of promote reflection, such as the use of portfolios and journals. 29

Evaluation Methods that Promote Reflection in Students

Student Portfolios Student portfolios can be useful tools as formati mative evaluation measures to assist students to investigate the ing experiences. It is important to provide some structure for the follow. The teacher might want to give students guidelines for nents of their portfolios (e.g., must include papers, reflective jou and a self-assessment); but the rule is variety; neither limit n

what the evidence must be in each of thes ture gives students permission to do creat al reflective strategy to integrate into the levels of reflection. 32 He describes three le

1. Technical: "How to" questions-th

nical skills and knowledge 2. Interpretive: "What does this mean interpretation of words and actions 3. Critical: "What ought to be" ques and nature of social conditions

By encouraging students to question classroom and clinic experiences at the thr is assisting students in linking their kno and moral actions.

Student Journals Writing is an essential tool i writing is a common learning activity use cal education experiences. Again, adding helpful in facilitating reflection. 33 For exa dents deliberately think about key aspects they learn from patients, their views of their clinical instructor teaches. The thr interpretive, and critical) provide another s itate reflective thinking and journal writin

Evaluation Methods th Reflection in Teachers

Peer Review Evaluations As educators who teach stu pists, teachers also need to be involved in cators, this is usually an informal process colleagues about what may have worked a laboratory. Begin to think, however, of te you may be able to raise the level of conve of pedagogy. For example, the American has recently instituted a teaching initiativ One of the motivating factors for this pr

arly work. The following sample questions were given to assist f their reflective process:

1. How does your course begin and why does it begin where i 2. What do you want to persuade your students to believe or q 3. How could a colleague develop a sense of you as a scholar b ining various features of your course? 4. What are some metaphors you use for characterizing your c 5. How does your course fit with the larger conception of cur program, or professional experience?

The project design also included a structure for the peer review Faculty select a partner who will serve as their peer review partner out the academic year. The partners can negotiate the kinds and experiences and feedback they want from one another. In addition are encouraged to form interdisciplinary clusters.35 For exampl School of Pharmacy and Allied Health at Creighton University, w cluster group that includes physical therapy, occupational therapy, macy faculty. The group has monthly meetings to exchange ideas a mation. This peer review activity has been initiated and is supp school administration. If educators are trying to facilitate reflectiv among students, we, too, must engage in our own reflective proces

Faculty Portfolios A core element in facilitating reflection is the role of as demonstrated in the previous faculty example (e.g., assigned task tive questions, and the opportunity for collaboration). One inc more common assessment item seen in higher education is the dev of a professional faculty portfolio. This portfolio may then be used the tenure and promotion process. 36 A professional portfolio is a c of physical evidence that assists in documenting professional acc ments. The advantage of the portfolio is that it develops and chan the educator and his or her accomplishments over time. For this faculty generally draw from the traditional areas of the academy for

of their teaching, scholarly activity be thought of in a broad and cre including traditional documents: goals to drive the development of and systematically, (3) keep up w (4) remember that the process may portfolios may be more important

Summary

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This chapter provides ical therapy or physical therapist and in concert with preparing the mic teaching-learning experience. elements. This chapter, along wit knowledge) to think about organizi courses in a manner that supports

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References

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1. Brophy J. Teachers' Knowledge Practice. Greenwich, CT: JAl P Grossman PL. The Making 2. Teacher Education. New York: 3. Reynolds A. What is competen erature. Rev Educ Res 1992;62 4. Irby D. What clinical teacher 1994;69:333. 5. Dickinson R, Dervitz H, Me Teachers. New York: American 6. Schon D. Educating the Refle Bass, 1987. 7. Eisner EW. The Educational Ima of School Programs. New York: 8. Solomon P. Problem-based learn cation? Physiother Theory Prac 9. Neurology Report. American Ph 10. Neil AS. Summerhill: A Radical Hart, 1960. 11. Phillips DC, Soltis JE Perspect Teachers College Press, 1991.

16. Gagne RM. The Conditions of Learning. New York: Holt, Rineha Winston, 1970. 17. Bloom B (ed). Taxonomy of Educational Objectives, Handbook I: Cognitive Domain. New York: David McKay, 1956. 18. Krathwohl DR, Bloom BS, Masia BB. Taxonomy of Educational Ob tives, Handbook II: Affective Domain. New York: David McKay, 19 19. Simpson EJ. The Classification of Educational Objectives in the chomotor Domain. Washington, DC: Gryphon House, 1972. 20. Carr KK. Integration of spirituality of aging into a nursing curricu Gerontol Geriatr Educ 1993;13:33. 21. McKee DD, Chappel IN. Spirituality and medical practice. J Fam P 1992;35:201. 22. Harasym PH, Leong EJ, Juschka BB, et al. Myers-Briggs psycholog type and achievement in anatomy and physiology. Am J Phy 1995;268:561. 23. Theis SL, Merritt SL. Learning style preferences of elderly coro artery disease patients. Educ GerontoI1992;18:677. 24. Kolb DA. Learning Styles Inventory. Boston: McBer and Co., 1985. 25. American Physical Therapy Association. A Normative Model of Ph cal Therapist Professional Education. Alexandria, VA: American Ph cal Therapy Association, 1996. 26. Davis BG. Tools for Teaching. San Francisco: Jossey-Bass, 1993. 27. Linn RL, Gronlund NE. Measurement and Assessment in Teaching ed). Upper Saddle River, NJ: Prentice-Hall, 1995. 28 . Dewey J. How We Think. Buffalo, NY: Prometheus Books, 199 Reprint, Lexington, MA: D.C. Heath, 1910. 29. Loughran J. Developing Reflective Practice: Learning about Teac and Learning through Modelling. Washington, DC: Falmer, 1996. 30. Russell T, Korthagen F. Teachers Who Teach Teachers. Washington, Falmer, 1995. 31. Jensen G, Saylor C. Portfolios and professional development in health professions. Eval Health Profes 1994;17:344. 32. VanManen M. Linking ways of knowing with ways of being practi Curriculum Inquiry 1977;6:205.

33. Jensen G, Denton B. Teaching physi gestion for clinical education. J Phy 34. Hutchings P. Peer review of teachin Association of Higher Education Bu 35. Shulman L. Teaching as communit 36. Lambert L, Tice S, Featherstone P Graduate Students. Syracuse, NY: S

Annotated Bibliogr

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Davis BJ. Tools for Teaching. San Franc filled with hundreds of good ideas t to teaching and testing. There are e students' written work and testing stimulate your thinking regarding c reinforce learning. Linn RL, Gronlund NE. Measurement a Upper Saddle River, NJ: Prentice-H of instructional objectives and their mation on constructing objective a mation on how to tell if your tests with clear examples. A classic in th Ory JL, Ryan KE. Tips for Improving T CA: Sage Publications, 1993. Easy t struction of test items. Contrasts p well written questions. Useful info Phillips DC, Soltis JF. Perspectives on L ers College Press, 1991. Shortest, available on learning theories.

Teaching in Academic Settings Gail M. Jensen and Katherine F. Shepard

As you walk into the physical therapy classroom-also the laboratory-you are hoping that you will be able to all of your material in the next SO minutes. The studen into the room having just finished a 3-hour anatomy tion laboratory. They disperse themselves all over the room/laboratory and look like they could hardly stay for the next hour. You think to yourself-Thank good don't want too many questions anyway and just need through this material so that we can get on with lab session tomorrow. In this corning hour you are to g overview lecture for the upcoming laboratory session o cal measurement. You are very comfortable teaching th ratory portion of goniometry and manual muscle testing bit nervous about having to cover measurement conc this overview lecture; therefore you have included seve initions of terms in your handout. You begin going thro of your overheads that complement the handout. You d ask a few questions of the class, but they appear to be ly taking notes and not very interested in interacting. think to yourself, well that is all right, I will just get t

the material and then we tomorrow where I am far ical skills.

Chapter Objectives After completing this cha

1. Describe how the four compone ing" apply to experience in teac 2. Discuss the design and implem including purposes, lecture plan 3. Discuss essential elements of la strategies to initiate discussion, questioning techniques. 4. Apply the phases of learning ps cal laboratory skills. 5. Discuss how to enhance demon more complex psychomotor ski 6. Justify the use of conceptual mo tory skills. 7. Outline the process for develop 8. Design a collaborative learning training and implementation. 9. Discuss the use of seminars, tu method, and narrative in teachi 10. Discuss ways students can lear including traditional technolog interactive devices.

If you were in the teaching situation you do? How might you learn from this are your options? Before focusing on spe demic settings, let's think about how t of a larger process of teaching and learn ter revisits the essential elements involv tent and knowledge that a teacher hold transformation (transforming what is taught to others), (3) instruction (teach evaluation (learning from one's teaching ter then discusses basic teaching tools

TRANSFORMATION (preparing, selecting, and adapting teaching materials)

REFLECTIVE EVALU (teacher and student and evaluation)

INSTRUCTIONAL PERFORMANCE (teacher-student interaction)

Figure 3-1 A model for teaching representing each of the key compo 1

the teaching process for teachers and students.

tings, followed by examples of strategies for facilitating collabor ing and strategies for facilitating problem analysis and critical th

A Practical Model for Teaching Knowledge of the Subject Matter

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Good teachers have a thorough knowledge of the s ter that allows them to display more self-confidence and creativi ing. Investigations of teachers also demonstrate that teachers no information in the area but also understand how the key conce are connected, as well as the ways in which new knowledge is validated.! Using the previous sketch, remember that the instruct vous about having to cover measurement concepts and was unabl the students in any interaction during a lecture. The teacher end ering the material on the handout with little student interactio this happen? Perhaps the instructor, although very comfortable ing the clinical skills of measurement (i.e., goniometry and man testing), was much less certain of his or her knowledge of clinic ment concepts; therefore, the instructor covered the content wit

cussion. For example, in discussing the m manual muscle testing, a teacher with t surement would move beyond the defi the use of manual muscle testing for t Use of muscle testing for assessing mu tion. 2 Research on teachers supports th know the subject matter well, they tend teachers who know their subject well tea practical application of key concepts an is known and not known about the subj

Transformation

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The transformation phase "transform" the material so students who are quite expert in certain subjec second component of teaching is the tea teaching." As detailed in Chapter 2, th involved in taking what is known and teaching. First, one must review any what is known about the subject: A changed? Has the thinking changed in t formation is thinking about how to rep Will you use a clinical case, a class acti A final step is deciding how to tailor yo students' understanding. Students are depth of knowledge that the instructo instructor to adapt what he or she kno representations that fit the students' p tent. Again, in the example of teaching discussing range of motion measures as measures and argue to students that th functional limitations the patient may assumes that the students remember been presented and discussed the prev discovers that the students do not und backtrack, using the overhead of the k in a simple and direct way to patient ca dents give examples of what functiona ical impairments, and the instructor sh (Figure 3-2).

ment of a patient case. (ROM = range of movement.) (Reprinted from Physical disablement concepts for physical therapy research and prac Ther 1994 j 74:380, with the permission of the APTA.)

Instruction

Instruction is what is known as teaching, yet ins only the "performance" of teaching. It includes everything from the material, to classroom management, to asking and respondin tions. Many of the specific teaching tools discussed in this chap of the instructional process. Active learning is frequently discuss component of the instructional process. S- 7 Some general charac and strategies for active learning have been suggested by Bonwell They are:

1. Students do more than listen. 2. Less emphasis should be placed on transmitting informati more emphasis should be placed on developing students' s 3. Students are involved in higher order thinking skills of th tive domain (e.g., analysis, synthesis, and evaluation). 4. Students are engaged in learning activities, such as writin or discussing. 5. Emphasis should be placed on students' exploration of the attitudes and values.

Bonwell and Eison define active learning as learning that "in dents in doing things and thinking about the things they are doin

Reflective Evaluation and New Compreh

The last two components of the model include pr ongoing assessment and learning. This last component of the

model for teaching is the ongoing process process of reviewing, reconstructing, and c formance and the class's performance is l central to teaching. For example, in the sk ter, the teacher found that after presenting the patient clinical measurement data the respond to questions. What could be done class and admit that there appears to be so then begin to go through the model again b understanding of the concepts and the could clarify each concept while going th This is an example of reflection. In the re with some uncertainty, so one engages i about what is going on and alternative s involves seeing the problem. In this cas because he or she recognizes that studen reviews the disablement model to gain understanding, which can then lead to a re the instructor's guidance. The reflective p lead to new understandings or comprehens Figure 3-1). The last two sections of this niques used to facilitate collaboration and

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Teaching Tools for La

When thinking of a large cla nificant amount of material, the teaching ture and discussion. If there is a lot of mat discussion and a lot of lecture. This sectio al lecture for large groups, including purp delivery, and advantages and disadvantage tion is followed by active learning strategi cussion and questioning.

Lectures

A professor's response to wh part of my training, and seems like what I guilty when I am not lecturing."8 The lecture method of teaching was nating information before the invention of

Lectures are often used to transmit a lot of informatio ciently to large groups of students. McKeachie summarizes the skill good lecturer, saying lI[e]ffective lecturers combine the talents of sc writer, producer, comedian, showman, and teacher in ways that cont to student learning./llD Research comparing the lecture to other for teaching demonstrates that the lecture is as effective as other metho teaching knowledge. In addition to the cognitive component, lecture also motivate. A skilled lecturer can stimulate interest, challenge stu to seek more information, and communicate passion and enthusiasm f subject matter. Lectures can also be used as an efficient method to co date and integrate information from a number of different printed so Lecture material can be specifically adapted or tailored to the class, an ficult concepts can be clarified in lecture. Lectures can set the stage fo cussion or other learning activities. 9, lD Perhaps the most important use of lecture is that it is a powerful to building the bridge between student knowledge and the structures subject matter. For example, imagine that a teacher is lecturing about siology of the shoulder complex. The students have a strong anato understanding of the subject matter and some understanding of the biomechanical principles. It is important in this case for the teacher the lecture as an opportunity to facilitate mutual levels of applicatio understanding when presenting how concepts from anatomy and kine gy apply to a clinical problem. The lecture also can be used to explor analyze specific concepts or ideas, and the teacher can demonstrate her problem-solving process. As most teachers find out, lecture prepa involves seeking broad ranges of information and is a process of ana synthesis, and integration of subject matter from various sources. What Makes an Effective Lecture?

Planning Good overall questions to start with when planning a le in contrast to II covering the subject matter,/I are: (1) What do you really students to remember from this lecture over time? (2) How should stu process the information? (3) Are you trying to be a conclusion-oriente

80

TECHNIQUES FOR TEACHI

turer or is your aim to assist students activity? One of the major concerns study reports that students recall 70% minutes of class and only 20% of ma How does the instructor capture strategy is to announce that the infor ers might also plan the lecture as they about the overall organization, the in

Introduction An effective introducti the specific topics that will be cove will be discussed. The introduction the students' existing cognitive know questions. Pre-questions can be used the lecture. For example, imagine th role of culture in professional-patien ture by standing in the back of the ro The teacher may ask the class to sh role of the teacher and then proce meanings of classroom behavior. Ano a story or a case that highlights the ture subject matter. lO

Body The body of the lecture process information. Perhaps the mo to put too much information into the overestimates the students' ability relationship between concepts and strated that increasing the density of tion of basic information. Often, tryi the result of inadequate preparation been identified. The lecture should not be writte very effective in guiding the body of sentations, computer flow charts, or m resentation of the structure of the m also place cues in the lecture outline strategies to be used along the way board, or brief dyad discussions amon

facilitating student comprehension:lO

1. Use visual representations. 2. Develop the idea or concept, then give examples. Reiterate your initial point. 3. Pauses give students time to think-give periodic summaries in your lecture. You do not have to cover everything. 4. Check for understanding.

Conclusion

The conclusion is a time to summarize the importan points of the lecture by going back over the outline or key graphics. The teacher may also use this as an opportunity to have students summarize the material orally or in writing. Other strategies include having the students do a 3-minute writing exercise summarizing the major points of the lecture or looking at student lecture notes to see what they are writing to determine if they grasped key concepts. These methods provide additional information about the students' understandings of the lecture.9, 10, 12

Delivery Earlier in this chapter, we stated that instruction can be thought of as performance, and lecture delivery provides one of the mos obvious chances to perform. Passion and enthusiasm for the subject matte are key aspects of any lecture. The teacher is a powerful role model in fron of the class and represents a thoughtful scholar to the students. The following are five tips for improving lecture presentation: 9

1. Create movement. Change your position in the room. Do no remain anchored at the podium. 2. Use visuals. Use various visual teaching tools (e.g., overheads, the blackboard, charts, graphs). These visuals are particularly good for high lighting key points. Videotapes can be powerful tools for illustrating exam ples from the real world in the clinic or community.

82

TECHNIQUES FOR TEACH

3. Pay attention to the effect o of volume, rate, and tone. If your vo hear, a microphone may be necessary ery. Voice is one of the key ingredi the students. The use of audiotape mechanism. 4. Pay attention to body langu also communicate with students th nervous habits, such as playing wi other persistent movement of the han points of emphasis and enthusiasm. 5. Pace the delivery and clarify excellent lectures are a simple plan w examples. 1O The structure of the lec the delivery of the material. Observe up with note taking, are confused, or consideration is how to go about cla gies can be helpful. The previous se teachers are responsible for transfor Ideas can be represented through an forming a grade-l mobilization mov do deep knee bends" to over-illustrate can be useful for having students thi ple, which metaphor best describes th therapist assistant: teacher, gardener,

Perhaps the greatest advantage particularly when the teacher has strongest disadvantages are the pass student engagement in higher order uation). Many campuses have cent additional resources and ideas for excellent resource, by Westberg and ence list at the end of this chapter.

The Interactive Lectur and Questioning in La

Initiating the Discussi Questioning and discu interactive lecture within a large gro

begin by having students brainstorm what they know about the the teacher can use these ideas to build a framework consistent w dents' understandings and discuss with the group any misconcep Another well-known technique is the use of Socratic dialogu sion. This approach has been used extensively in the education In this method, teachers focus on teaching from a known case principles, thus teaching students to think like a lawyer. The ge tioning strategy is to use a known case to formulate general prin then these principles are applied to new cases. lO For example, begin by discussing the following with students:

Imagine that your patient asks you to not docum medical record that he has been playing softball, e he is still unable to return to work with his low bac students to identify all the factors that might lead ask a therapist to do that. Then you might ask stu they would do if they were the therapist and why the students to talk about the importance of th record and the professional's responsibility to be you discuss this case, you begin to introduce the g cal principle of beneficence. Then you can mov about deception, and how the principle of benefice apply or not apply in this case. Then you propose a s wherein the therapist does not exactly record the the medical record. Now the therapist is involved in because he or she wants to make sure the patient ge tional rehabilitation that is necessary to get the pati work. These two cases can be discussed, looking fo ences and then applying the ethical principle of ben

Common Discussion Problems The two most common discussion problems are stu talk too much or too little. What can be done about students who

during discussion? A supportive classro involves more than encouraging studen ive classroom environment, the teacher lectual climate supportive of risk takin facilitating a supportive classroom envi

1. Learn the students' names. 2. Demonstrate a strong interest sensitive to subtle messages th presentation. 3. Respond to student feelings abou to listen. 4. Encourage and invite student qu their personal viewpoints. Consi their questions first then ask the 5. Demonstrate interest in the imp the material. 6. Encourage students to be creativ the material. Begin by asking stu ideas about general questions th answer.

What about the student who talks to tion? McKeachie lO suggests the followin

1. Ask the class if they would like distributed. 2. Audiotape a discussion and play improve the discussion. 3. Assign class observers who obse class. 4. Speak directly with the student

Finally, what kinds of actions hav Frequently, a teacher can slow a discuss actual discussion with students. Eaton e behaviors as inhibitory in student discu

Questioning Questioning is an importa tate the process of active learning. In qu

Judgmental responses Interrupting student responses Hiding behind the role of the teacher

Source: Adapted from SEaton, GL Davis, P Benner. Discussion stoppers in t Nurs Outlook 1977;25:578.

concepts, evaluate ideas, or apply knowledge. Skilled teachers us to guide the student's thought process. To be able to ask effectiv one needs to understand more about levels or types of question to apply them. One simple model classifies questions under three types: ( (2) abstract, and (3) creative. 9 Concrete questions generally focu of facts, literal meaning, and simple ideas. These are the " where, and when" questions. Abstract questions have students classify, or reason to a conclusion about the facts presented. Th "how" and "why" questions. Creative questions ask students to concepts into a new pattern that may require abstract and con ing. The teacher may ask, "What would happen if ... ?" or "How you go about...?" A more frequently used classification system is based on th domain of Bloom's taxonomy as discussed in Chapter 2. This been used to classify educational objectives. Table 3-2 provides each level of the cognitive domain along with key concepts a words for initiating questions.

Questioning Technique In addition to being aware of the type of question b a teacher should attend to technique or performance in the clas following are recommendations for effective questioning techni

86

TECHNIQUES FOR TEAC

Table 3-2 Examples of Classification Category (cognitive domain) Knowledge

Cognitive requirement Recall information

Comprehension Understanding (quest can be answered by restating material i a literal manner) Application

Solving (questions involve problem solv in new situations)

Analysis

Exploration of reason (questions require student to break th idea into its compo parts)

Synthesis

Creating (questions re students to combin ideas into a statem

Evaluation

Judging (questions m judgment about so thing by making th judgment principle

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Source: Reprinted with permission from nursing instructors. J Nurs Educ 1981;2

1. Use open-ended, not closed answered with "yes" or flno 2. Plan ahead to have key que 3. Avoid combining too many ambiguous question. 4. Ask your questions logicall 5. Use different levels of quest plex, or higher order, questi

dent participation. For example, after a response, ask for to the response.

Tips for Grading in Classroom Teachin Testing

For many teachers, making up tests, evaluatin and assigning grades are difficult and, at times, unpleasant re of being a teacher. Physical therapy teachers want students vated to study and learn not because of grades, but in pur knowledge and skills that will make them physical therapis cal therapist assistants. Teachers want students to be lifelo who are motivated by their own thirst for knowledge and evaluate their own learning. lO See Chapter 2 for various traditional and innovative ways student learning using a written format. Later in this chap ment of clinical skills using practical examination is discusse

Grading

What do students, teachers, and employers grades? Students usually want to know how well they are d they are succeeding in their pursuit of becoming a physical t physical therapist assistant. For teachers, grades provide info how well the students are learning the material, are part of th role in an academic institution, and provide a measure for ass minimal level of competence for preparing professionals. Emp use grades as one factor in hiring decisions. How one feels a and grading is likely to depend on values and educational Regardless of whether grades are seen as a motivator or a nec the following general guidelines should be considered!2:

1. Avoid grading systems that mates by limiting the numb on the curve or the norm-re 2. Keep students apprised of th 3. Emphasize learning, not gra 4. Consider allowing students ments for their grade (e.g., w tional module). 5. Deal directly with students to their complaints, think a change a grade because of a 6. Keep accurate records of gra and assignments rather than

Grading Systems

Criterion-Referenced Criterion-referenced g student's level of achievement com the instructor. So if all students ob nation, they would all receive As o scales that schools and departments ical grading system. 12 t ,: ;:~:"

Norm-Referenced Gra In norm-referenced g percentages of the class so that the more Bs, quite a few Cs, and some system has received a fair amount cationally dysfunctional. lO

Competency-Based G Competency-based gr sions in which educational program for safe practice of a profession. St demonstrate competency in perfor according to specified objectives. St tives continue to be assessed until an 80% cutoff is established as a de

Self-Grading and Peer-Grading Providing students the opportunities to engage in self- an peer-assessment should be aspects of every professional educational pro gram. Self- and peer-assessment activities will certainly be part of the stu dent's future as an employed therapist. Self-assessment can be included as component of a course grade for any kind of course. Portfolio developmen discussed in Chapter 2, is a method for facilitating self-assessment through out the educational program. Peer-assessment is frequently used for grou projects and presentations. Students will provide better assessments if give explicit criteria for evaluation and if each student evaluates each of th group members.12

Tools for Laboratory Teaching: Development and Assessment of Clinical Practice Skills

You remember well entering your first laboratory class sessio with 30 eager students just dying to learn the "real thing" from a real clinician. Of course, just a few months ago you receive a call from the director of the physical therapy program at you local university, and you were thrilled to be asked to coordina this musculoskeletal assessment laboratory. After all, you hav 15 years of clinical experience, have clinical specialty certifica tion through the American Physical Therapy Association, an have served as a clinical instructor for several physical therap students in the past. Now as you enter the laboratory for you first session, you realize this part-time teaching task may tak much more of your time and energy than you imagined. Yo eagerly dive into the task, structuring your laboratory muc like your own past experiences of learning clinical skills. Yo have picked up a few neat ideas along the way from your exten sive continuing education background and wealth of clinic

experience. Basically, y class, have them perfo the lab along with yo pairs of students with you go around the lab, diversity of effort amo task-oriented, practici others do the activity tion. You also find stu to perform this or tha to yourself. What can tory so that I am not o clinical skills but shar with students as we go

This sketch describes the ultim who teach in the clinical sciences. cation environment help students d that is responsive to practice need problem solving, application of clin ical skills? Physical therapy is not al of professional competence, includ sonal attributes, problem-solving s skills/practice skills, is an ongoing c of professional education.3 It is cer portion of the programs is essential sional competence; however, teache oping all aspects of competence i focuses on three critical concepts in clinical practice skills, (2) developm and (3) assessment strategies.

Clinical Laborato Psychomotor Skil

One of the major task students new psychomotor skills, fr the handling of patients, to the sen in soft tissue structures, to the abi cating support and care. This task is professional competence. There is

two phases. The first phase is understanding the idea of the movem which includes learning the skill that is specifically linked to the goal. A the skill is successfully performed, the learner can move to the second ph of refining the skill and committing the skill to memory. This phase is ca the stage of fixation and diversification. In the learning process, the lear is exposed to many stimuli and needs to devote selective attention to regulatory stimuli (i.e., those stimuli that affect accomplishment of goal). These stimuli could be visual, verbal, written, equipment, noise, so on. Skills can also be categorized as closed or open. In a closed skill, e ronmental conditions and relevant stimuli remain stable throughout performance. An open skill takes place in a changing environment and regulatory stimuli vary. Open skills are obviously more difficult for learner because of the changing situation. After the learner can recogn and attend to the relevant stimuli, a plan for movement, or motor plan, t meets environmental demands can be formulated. When the skill or sub of skills is performed, the learner receives feedback on the skill execut This feedback may be intrinsic (from the learner) or extrinsic (from the o side; a person or the environment). The second stage of skill learning comes after the performance is s cessful. In this stage, the learner refines his or her performance through p tice. Consider the following example: You are teaching a lab in clin measurement that starts with basic range-of-motion measurement wit goniometer. You would probably classify this skill as closed because environment is the laboratory and the skill or measurement activity is be applied to a person with no limitation of movement. Teaching the Skill The following are suggestions for skill teaching:

1. Establish a problem that leads to a goal and ensures adequ learner motivation. Students will know that they (most likely) do not kn how to go about measuring the range of motion. In this way, the prob (i.e., they don't know) and the goal (i.e., they need to know) are presente

2. Attend to regulatory sti skill. In doing this, the teacher nize the stimuli. This could be d

• Demonstrate the skill a involved in performing th of time.) • Use a visual, taped demon • Use the guided-discovery a manual and discover, thro

3. Control the learning en realistic the laboratory should be skills, when teaching open skills ble. Teachers may provide stude depending on a specific patient structured to provide different s role play). 4. Provide feedback. Each back. Intrinsic feedback should b or internal, feedback allows the l own feedback to self. Extrinsic, teacher. This feedback is most e ty between the skill performanc er can be given about an error, t large lab groups, the instructor moments when common mistak mistake to the entire group. 5. Have the students prac move students to the fixation a motor pattern is practiced and re students may move quickly to practice. To improve skills, con back. Repetition without feedb Feedback could come in ways ot could provide ongoing feedback tapes of themselves or use other 6. Design effective timing effective if it is massed practic (planned rest periods)? For moto practice is best. The rest period not a problem, and reinforcemen

1. Plan and prepare ahead of time. Have the necessary equipment a practice the skill ahead of time. Determine how it will appear fr the student's vantage point. 2. Perform the procedure step-by-step and explain as you go along. The entire skill will be demonstrated more than once. If the ski complex, you may wish to demonstrate the entire skill first and then break it down into the step-by-step procedures. 3. It is best not to have students take notes so that they can conce trate on the demonstration. Have explanatory information in th text or a laboratory manual. 4. You may wish to videotape your demonstration or have someon take slides of key teaching points. 5. Ensure that the demonstration always adheres to fundamental p ciples of professional practice, such as proper body mechanics, patient positioning, and proper draping. 6. Demonstrate the skill more than once. Perform from different angles or sides so that students can see different approaches.

Suggestions for Teaching Open or More Complex Psychomotor Skills

Graduated Practice Psychomotor skills that are difficult may need to be bro into subcomponents; this process is known as graduated practice. This g the student the opportunity to concentrate on the component steps. example, in teaching students how to perform proprioceptive neuromu lar facilitation patterns, one might begin by having the students learn movements on themselves. The students can then proceed to doing sim straight-arm patterns on a fellow classmate. Finally, the students shoul ready to apply a pattern to a specific patient condition. Each of these tasks takes students through guided practice-that is, practice with eac the components. I ?

Mental Practice Mental practice, used by many athletes to he For some clinical skills, stud of steps involved in the maste mental rehearsal of a procedu a chair). With mental imagery for their practical examinatio ing the steps and imagine the each stepY

Clinical Labo How to Take

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When teaching only interested in facilitating skills but also in developing t problem solving, evaluating, performing the deliberative processes are often referred to soning, and decision-making "wise actions" that come from ing, or reflection on practice. "knowing how"-that is, kno second category of profession knowing about things. In prof increasing amounts of this ki facts), ranging from understan els, to understanding system f more likely to focus on "know nitive abilities, than on "know rationale for their practical sk In the clinical laboratory, the performance of skills. H inquiry processes that allow s ence. Physical therapists are no able to respond to the complex ical practice. Schon 16 argues t inquire about situations that a should design laboratory expe

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WORKING HYPOTHESIS (Diagnosis) Assessment

Figure 3-3 An example of how components of a musculoskeletal evaluation can be used to facilitate students' clinical thinking and reasoning processes. IAdapted from CJ Tichenor, J Davidson, G Jensen. Cases as shared inquiry: model for clinical reasoning. J Phys Ther Educ 1995;9:57.1

life, clinical settings. He draws the analogy that educators should move from the more traditional "follow me" laboratory, in which technical skills ar emphasized, to the "hall of mirrors" laboratory, where students are cha lenged to not only perform the skill but also discuss and critique the perfo mance among peers. Providing structure or a conceptual framework for analysis can be on way of facilitating a student's thinking or reasoning process in a "hall of mir rors" laboratory. For example, in the area of musculoskeletal dysfunction application of concepts from a clinical reasoning model can be used to assi students to think about integrating evaluative skills with their interpretive ongoing thoughts about the data (Figure 3-3).1 8 A second example is the use of a conceptual model, like the disabilit model, that can assist students in seeing the larger issues involved in man aging a patient (see Figure 3-2).4 Even though much of laboratory teachin may be focused on skills development, these skills have to be understood a tools for gathering data, facilitating movement, and teaching patients an caregivers to ultimately have an effect on the patient's functional limita tions and quality of life.

Clinical Laborat of Clinical Skills

It is your first experi

tions. You remember now you see the strug number of hours that ation. How do you ac remember again from evaluation sessions c self-confidence. How vides the opportunity evidence of a studen done in less than 100

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Practical Examin and Implementat

The basic ingredients cal examinations include rationale ation tools (including evaluators), a

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l. Rationale. What is the ove just checking competence of select students think on their feet, their d size information? Are you using th mation across courses? Should th self-assessment or only evaluator a 2. Format. The format of the the overall purpose of the examina tive assessment strategy to check you may want to use a simple che should identify a list of psychomo the skills involved. Students perfor checklist. On the other hand, if the of certain skills and the student's o choose to have the student create audiotape, transcription, case desc interview process, you may want another individual. They can do

about student performance. To assist with the evaluation pro need to create an evaluation form that identifies the behavio psychomotor, and affective) that you wish to assess. This also first step in demonstrating consistency across evaluators. A the beginning teacher would be the lack of a data bank regarding "student performance." Even though your evaluatio most likely criterion referenced on paper (i.e., identify the expected behaviors of students in order to pass), there is likely ment of norm-referenced evaluation (i.e., student performan with other students who are taking the exam). When perform examinations, it is usually not the case that you will judge ence of a behavior but the quality of the behavior as well. I tions, it is important to have a more experienced teacher a consult to learn about what is average or excellent student You may find that a videotape analysis of your own evalu mance can be helpful. Because the evaluation of clinical skill jective than evaluating cognitive performance, one should clear about specific expectations in the course syllabus. 4. Implementation. You may have wonderful ideas for y examinations, but are they realistic to implement? Time a are perhaps the two biggest resources. Creative thought ca Perhaps there are clinical faculty who might love the i involved in an assessment day or clinic. You may be able t unteers for patient role models (e.g., elders in the commun from another year in the program, or students from other p there are severe time constraints, you may want to provide s the patient cases for the examination ahead of time. The then prepare and practice for all of the cases, even though t do selected elements in their examination time. However, students have prepared for all of the cases, your objective is a Also, think about ways to include peer-assessment and self-a part of the process.

Performance-Based A of Standardized Pati

Although performance-bas health professions for many years, there use of standardized patients. 19 Standard patients in a standard and consistent m tests called objective structured clinica by having students or examinees rotate they perform a variety of clinical tasks, cal examination. Standardized patients rating forms regarding the students' inte these kinds of examinations are more r tice, they entail a great amount of tim implementation. In summary, it is recognized that identify skills that cannot be measured tions. It is also recognized that scores on not generalize well across situations ( case does not necessarily predict perfo experts in the health professions argu assessment methods. 19

Strategies for Facili Collaborative Learn

The best answer to the qu method of teaching? 11 is t dent, the content, and the "Students teaching other

This section covers several teachin ties for collaborative learning. These co group work for learning tasks, discussi ing, and other strategies.

Small Groups Proces

Groupwork is an effectiv achieving intellectual goals (e.g., con solving) and social goals (e.g., oral com

has an element of "social construction" (i.e., knowledge includes shared understandings within the group or discipline). Bruffee 21 argues in higher education, teachers should work toward cultivating stu, intellectual interdependence through collaborative learning. Students need to experience that knowledge is not transferred from one 's head to another, but that knowledge is a consensus among members of a community of knowledgeable peers; it is dynamic understand; ings among people. The role of the lecture and discussions in large class settings was discussed earlier. Small groupwork is another teaching strategy to engage students in large classes in active learning. In any small-group process, there will always be issues of leadership, individual performance, and communication. Therefore, the use of small groups requires the same careful preparation and planning as a good lecture.

Preparation Students need to be prepared for successful groupwork. The following are two key concepts central to good small groupwork2o:

1. Learning to be responsive to the needs of the group. Responsiveness to the needs of the group is a skill required for any cooperative task. Awareness of this skill can be facilitated through small group game activities, such as "broken circles," in which the group must cooperate to solve the group problem 23 (see Appendix A). 2. Developing a norm of cooperation and working toward equal participation. Having students learn about working toward equal participation is another important norm for small groups, whether the group's task is discussion, decision making, or creative problem solving. Only when students believe that everyone in the group should have a say can any future problems of dominance be handled. Students need to appreciate that group leadership is a function shared between group members.20,21 A small-group exercise called Epstein's four-stage rocket 24 is a good prepara-

tory exercise for facilitating Appendix B).

After students have gone th work can be used as a teaching str for using small groups20-22:

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1. A group size of five to sev when the task is so large t 2. Groups should be diverse and any other status chara interaction. Allowing stud work with their friends is 3. The teacher must delegate direct supervisor who defi might go about accomplis charge . 4. If the overall goal is conce should require conceptual nique or information recal 5. The group must have the or assignments.

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Group Expert Techn The group expert t that builds confid,ence and coll cover several example cases. Th class into small groups (Figure 3 is given a different task (e.g., di time, the teacher circulates aro on the right track. Each indivi solving the case, because the c sentatives from each of the pati each group member is an expert the second group division is to d resident expert available to fac strategy provides the class with in a short amount of time and g expert for one case.25

analyzed case correctly.

I Step 4: Second Division of Groups I Class now divides a second time according to the letter assigned. This means each of the groups will have representation from each of the patient problems.

I Step 5: Group Expert Discussion I All groups discuss each of the patient problems. Every group will have a resident expert (a member from the original group) who can facilitate the discussion.

Figure 3-4 The steps involved in implementing the small-group expert tech nique. (Adapted from E Cohen. Designing Groupwork. New York: Teachers College Press, 1986.)

Seminars The seminar is another small-group teaching method usu associated with graduate study. The seminar can be used in undergrad and professional education after students master some content. The pur of a seminar goes beyond discussion of an important topic and incl analysis, critique, and application of a topic. A seminar is not a class small enrollment nor is it an undirected or unfocused discussion of a t A seminar is a guided discussion in which students take the intellectua tiative. 26 Using seminars as a teaching method requires prior plann explicit guidelines linked to objectives, and a clear structure for the stud (see Table 3-2). The following are ideas for structuring a seminar: 1. Progress from teacher-led to student-led seminars.

2. Assign topics or allow students to select from a list of suggested topics. 3. Give responsibility for resources to students (e.g., a bibliography and readings).

4. Use guidelines for pres responsibility for facili 5. Use peer evaluation.

Tutorials A small-group work. In recent years, severa cating the central importanc group tutorial as the teachin faculty tutor assists students centered learning.27 Essential than a discussion group. Gro and one facilitator. The tuto learning at the metacognitiv thinking about their think process. 27,28 Learning groups practice skills they will need and supervision, as students u Using learning groups may strategies as well as curriculu

Peer Teachin

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Peer teaching is learning experiences already be classified into five areas: ( tutors who work one-on-one in advising peers, (4) peer pa the roles of student and teac larly useful peer strategy is t students alternate the role o questions. Use of learning c and independent study is a m class size, level, or the natur Why does peer teaching an als read journals and attend co their fields, yet most of the in difficult case or problem, how experts for advice, or research gain is invariably far better ret

Other Useful Collaborative Strategies

Brainstorming Brainstorming is a useful initial classroom strategy for thinking and group participation. The following is an example of g for a brainstorming process applied to a physical therapist assistan tory session on teaching gait training activities to patients whose guage is not English6, 10:

1. All ideas are fair game and should be recorded even if they off the mark. The class generates a list of ideas, such as dem strate the task, draw pictures, get a translator, just take the through the motions (don't talk), and demonstrate the task another person first. 2. There is no judgment rendered of the initial list of ideas un the ideas have been generated. That is, no one in the class allowed to judge any of the ideas until the class cannot com with any more suggestions. 3. The initial focus is on the quantity of ideas not the quality ideas. Again, keep the class focused on the number of ideas 4. After the list is generated, combinations and transformatio ideas are encouraged. After the list is complete, the class sh discuss which of the ideas or combinations of ideas are the practical and useful for the case.

Debate Debate is a form of discussion that allows one to see and cons of an issue. The following is an example of an issue and for applying a framework that facilitates debate. 29 The issue is physical therapists or physical therapist assistants should suppo training" of health care workers-that is, individuals trained to skills for more than one diScipline. The following are suggested debate this subject:

Step 1. Divide the class into training, another group t third group that serves as Step 2. The two debate grou of their position. Likewis formulate the criteria the ria may include strength tions, flaws in the argum Step 3. The initial affirmati time limits. Step 4. Debate teams meet second round of the deba Step 5. Teams present time Step 6. Panel deliberates an Step 7. Entire class discusse

One criticism of debate is t Teachers may want students to ted to when making the initial versial issues work best for the

Role Play, Simulat Role playing is a f taneously act out roles withou used in a variety of settings an interaction. For example, the activity to have students apply assumes the role of therapist, a "unmotivated, difficult patient. ing purposes lO :

1. Illustrate principles from tice in the skills they hav pist and difficult patient, applied and both student skills in their interaction 2. Develop insight into hum between students and ca dents perform a brief role record their observations can be used for further a

Role-playing activities can be done with the entire class or w students as an example for the class. An essential aspect of role analysis and discussion in a small or large group setting. Games and simulations are advantageous in that students participants rather than passive observers. They are usually stimulating learning activities. Educational games usually inv dents in some form of competition in relationship to a goal. T games can be a refreshing change to traditional learning exper long as the competition element does not facilitate negative among students. Whereas role playing involves a form of drama the learners act out roles, simulation exercises involve a contro sentation of a part of a real situation. The learner can then m key elements to better understand the real situation. 9 Simulatio fun and interesting and usually require students to use creative gent thinking. lO Perhaps the most frequently used simulation i therapy is a disability field exercise, in which students assume having a physical disability in the community. Another well-kn ulation is the aging game,30 in which students experience the ch occur with aging. Expert panels are another teaching strategy in which studen to hear first-hand from experts about their experiences. These exp can be used to represent a broad array of expertise (e.g., physical and physical therapist assistants talking about working par patients living with physical challenges, or parents coping with a special needs).

Strategies for Facilitating Reflection and Problem Analysis

None of us can ever teach students to think. We ca er, create experiences for students that will caus think and develop ideas. None of us can set think "terminal objective." Our obligation to the profess

our students is to help t minds with increasing po they grow and learn. 28

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The greatest American philosophe many contributions to education. Perha butions was his writing about thinkingDewey was a combination of mental rea thered Dewey's theory in his writing on viously, reflection is the element that t the process of thinking and inquiring them. Physical therapy and physical th with the challenge of many ill-structur application of knowledge cannot produc vide students with opportunities to "tur Recall that in Bloom's taxonomy, kn beginning levels of cognitive ability, an upper levels. 32 Language can be one way students' thinking and discussion. F "explain," "hypothesize," "compare and provide students with a more engaged about their thinking. 33 A key term used is metacognition. Cognition is the c metacognition is the awareness and mo learning process. The teacher's role is to through the instructional process. This facilitating this process-the use of case

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Case Methods

Educators have long been nated by the twin demon method designed to predig and principles through exp of students.34

Case methods are widely used in b method of teaching should be differen description of an intervention with a pa person accounts of detailed descriptions ple to things). Cases are used to stimu

tification, problem solving, and analysis. The facilitator does not lead t group but questions and probes for student reasoning and analysis. Case fo mats can vary from a written paper case, to a videotape case, to a simulat or real patient. 27, 28 A critical dimension of case method is the formulation of the case as relates to the broader issues of general principles and concepts. The ca writer should ask, "What is this a case oH" Business education has perha the most detailed approach for assisting case writers. For the health profe sions, cases may go beyond the notion of the patient or client and inclu any number of real-world practice problems (e.g., management issues, sta problems, ethical dilemmas, reimbursement issues). Writing cases that are grounded in real-life experience gives students a faculty the opportunity to address complexity of practice. Cases that a developed from practice or are adapted from situations in practice challen faculty and students to move from a course orientation to integration a application of many courses. Table 3-3 presents a patient case developed that students would synthesize information learned in biological, physica clinical, and behavioral science courses during the semester and integrate with prior knowledge. Student groups were given specific questions for ea area (Le., clinical medicine, physical therapy procedures, and psychosoc and cultural factors) to guide their case analysis (Table 3-4). In designing a challenging case, one may want to gather data beyond t usual patient cases. This might include information gathered from inte viewing, documents, or the media or artifacts provided as part of the ca (e.g., documentation and videotape). A critical element in the formulation the case is consideration of the case dimensions (e.g., knowledge, analytica and conceptual).34 A physical therapy community management case is us as an example in Table 3-3. As stated earlier in the section on tutorials, cases engage the way in whi practitioners think and continue to learn. As an instructional strategy, cas allow students to be actively involved in the information gathering, proble solving, and decision making that are applied to real practice problems.

Table 3-3 Example of a Patient Ca Across Courses in the Curriculum

Betsy is a 27-year-old former fifth gra uation and treatment of bilateral ropathy secondary to acquired im

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Social and medical history No one is aware of her diagnosis exce ment and immediate family memb ciency virus (HIV) positive, and hi or the husband's diagnoses. The co ative. They live in a one-story hom She has around-the-clock care and Her husband and caregivers expres lack of knowledge of how to best h before the diagnosis of HIV in 199 monia (PCP) twice, mycobacterium ly hospitalized for a deep vein thro

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Current medical status The patient is in the advanced stage requires assistance to transfer and with a walker and frequent verbal She has periods of lethargy and co

Medications The patient takes Bactrim (antibiotic ciprofloxacin hydrochloride (Cipro coagulant), ethambutol hydrochlo conazole (antifungal agent), trazod (Marinol; appetite stimulant), mo dine (AZT)/ddi (antiviral).

Physical therapy examination finding Arrived in clinic in wheelchair assist Chief complaint: pain and weakness Range of motion: grossly within func Strength: Shoulder elevation 4/5 Triceps 4/5 Biceps 4/5 Hands 5/5 Ankle planter flexors 2/5

Hip f Hip e Knee Ankl

Transfers: supine to sit with maximu assistance of 1. Ambulates 15 feet with wheeled wal needed to maintain knee and hip

Source: K Paschal, J Gale. Patient Case Physical Therapy, Omaha, NE, 1995.

Could preventive measures, early intervention, or environmental adaptations minimize functional limitations?

Generate a problem list.

How would you go a establishing a ther peutic relationshi with this patient?

What other health care professionals might this patient benefit from working with?

What is the working hypothesis(ses)?

Identify any cultural variations that ma have an effect on interaction with t patient and caregi

List your short- and longterm functional goals.

What specific verbal nonverbal strategi would be most eff tive with this case

Source: K Paschal, J Gale. Patient Case Materials. Creighton University Depart of Physical Therapy, Omaha, NE, 1995.

Concept Mapping

Concept mapping is a multipurpose, fun graphic techn that can be used to see how students "build what they know" (i.e., how structure their prior knowledge). A concept map is an illustration of tionships between concepts and facts developed by moving from a ge idea to specific instances. The technique can be used by teachers and dents to identify the structure of prior knowledge, to organize or present information, or to assess progress and change. 35, 36 Figure 3-5 compares a dent's concept map of evaluation to a clinical instructor's concept map

Educational Technology

Computer Technology There is no question that computer-based technologies rapidly transforming education. They allow students and teacher

Patient seen in physical therapy following a total knee replacement

PT EVALUATION

PT EVALUATION

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Joint swelling Circumference measure

NMT Work environment

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patient with a total knee replacement. (ROM tension.)

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Learning Through Computers Learning through computers, with computer-assisted instru tion, has been the emphasis in education. Hundreds of programs (e.g., o line tutorials, simulations, and interactive learning programs) have be produced in medicine. There are a growing number of computer-bas learning resources on the market (e.g., CD-ROM, multimedia databas videodisc, and networked resources). Computer-based knowledge resourc continue to expand. 33, 37

Learning with Computers The most powerful approach to learning with computers is require students to use computers on a day-to-day basis to support th classroom activities. The following are suggestions for beginning to in grate computer-based technology into instructional activities37 :

1. Require electronic data bases in bibliographic searches. 2. Encourage the use of electronic mail for questions and assignment 3. Use a computer-based learning tool, such as CD-ROM, as one source of information. 4. Survey students at the beginning of class to determine computer l eracy and have them share their knowledge with each other. 5. Use a word processor to prepare handouts and overheads. 6. Encourage or require students to use visual elements in their presentations.

Halpern's book, Changing College Classrooms,33 has several excelle chapters that specifically address teaching with new technologies.

Traditional Instructional Technology What about the use of more traditional instructional techno ogy? The most commonly used instructional media include handou chalkboards, overhead transparencies, slides, and videotapes.

Chalkboards Chalkboards (a been in the front of classroom allows spontaneity of visual Some tips for the use of ch enough for the class to see, (2 the most visible parts of the b ing down only key principles numbers or sections.12

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Overhead Trans Overhead transp taneously writing down ideas parencies is that the visual is alongside providing comment slides and the teacher can hi while he or she is talking. Tra copies of diagrams or drawing ples for writing on a chalkbo for using overhead transparen the order in which they will one item at a time; (3) after di ing; (4) make sure the transp legible; and (5) do not look at

Slides In teaching som dents understand the necessar and easy to store, and the teac The biggest disadvantage of makes class interaction diffic little chance to interact with puter technology to generate

Videotapes and Videotapes and f the classroom. Again, as with are passive viewers of the med viewers. This means that stu for viewing the video or film. for follow-up activities and di

their senses of the meaning of the human experience, to g them the tensile strength to be healers and physicians rath than simply biomedical consultants.38

One of the assumptions of this book is that clinical practice in physi therapy demands striving for expertise in all domains of learning: cogniti affective, psychomotor, perceptual, and spiritual. A student's identity as a ph ical therapist or physical therapist assistant depends not only on integrating t knowledge and skills of the discipline but also on developing self-knowled through self-reflection. A very powerful teaching tool for facilitating t process of self-knowledge is the use of narrative, through one's own writing the stories of others. 39 Experiences of therapists and patients provide additio al insight in understanding the meaning of experiences, decisions, or even For example, a student may be asked to write an account of a time in the cl ic when he or she was confused. In this account, students address questio such as: "What really happened here?" "Why did you do what you did "Would you do anything differently?" "What have you learned?" "You m have a patient with a terminal illness, how can you respond empathetically the face of suffering and death?" "What inner resources can we develop to he us deal with our own limitations?" The student may also want to listen ca fully to the patient's story and write a similar account. Stories are useful not only as a vehicle for expressing one's though but they can also be read aloud in class. The reading aloud of narrati (stories or poems) brings yet another opportunity for students to hear a think about the meanings embedded in the narrative. A recent spec issue of Academic Medicine focused on the role of the humanities medical education. A theme throughout the issue was the central role using cases, examples, stories, and vignettes of real situations described rich particularities. There are many learning exercises teachers can use to facilitate the ro of narrative, such as journal writing, short free-writing or 5-minute writi

exercises, reflection or reaction paper poetry. All of these tools provide stud in the experiences of themselves and

Summary

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There are many educat have not changed much in the last 10 the teacher stands in front and uses a information with students. Most fac teaching more comfortable because t that is the way that the teachers them that inhibit change in the classroom (2) the teacher's definition of self res stable, (4) innovative ideas cause fee (5) faculty like to think aloud and le all is risk. 6 Active learning for studen skills and taking risks. In closing, diagnostic judgment an be essential capacities for students. processes used by physical therapy knowledge, advocates that methods, s ing, may enhance conceptual learning educators quite well, saying,

In any college or univer pendence-that is, socia maturity-may be the m be asked to learn. Stude and university teachers them teach today. Colle way they do because th tain kind of thing. Chan depends on changing tea edge is. Most of us ... a understanding of knowl instead that knowledge a community of knowle construct by talking tog

4. Jette A. Physical disablement concepts for physical therapy research a practice. Phys Ther 1994;74:380. 5. Dewey J. How We Think. Buffalo, NY: Prometheus Books, 1991;1. 6. Bonwell C, Eison J. Active Learning: Creating Excitement in the Clas room. Washington, DC: ASHE-ERIC Higher Education Report, Geor Washington University, 1991. 7. Harmin M. Inspiring Active Learning. Alexandria, VA: Association f Supervision and Curriculum Development, 1994. 8. Creed T. Why we lecture. Symposium. St. John's Faculty Journ 1986;5:17. 9. DeYoung S. Teaching Nursing. Menlo Park, CA: Addison-Wesle 1990;73. 10. McKeachie W. Teaching Tips (9th ed). Lexington, MA: DC Heath, 1994;3 11. Russell I, Hendrieson W, Herbert R. Effects of information density medical school achievement. J Med Educ 1984;59:881. 12. Davis BJ. Tools for Teaching. San Francisco: Jossey-Bass, 1993;63. 13. Eaton S, Davis GL, Benner P. Discussion stoppers in teaching. Nurs Ou look 1977;25:578. 14. Winstein C, Knecht HG. Movement science and its relevance to phy cal therapy. Phys Ther 1990;70:759. 15. Gentile A. A working model for skill acquisition with application teaching. Quest 1972;17:3. 16. Schon D. Educating the Reflective Practitioner. San Francisco: Josse Bass, 1987;3. 17. Watts N. Handbook of Clinical Teaching. New York: Churchill Livin stone, 1990;139. 18. Tichenor q, Davidson 1, Jensen G. Cases as shared inquiry: model f clinical reasoning. J Phys Ther Educ 1995;9:57. 19. Swanson D, Norman GR, Linn R. Performance-based assessmen lessons from the health professions. Educational Researcher 1995;24:5

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20. Cohen E. Designing Groupwo 21. Bruffee K. Collaborative Lear Press, 1993;1. 22. Bouton C, Garth R (eds). Lear 1983. 23. Bavelas A. The five squares p eration. Studies in Personnel 24. Epstein C. Affective Subjects Drugs. Scranton, PA: Intext E 25. Gandy 1, Jensen G. Group w therapy education: models fo Ther Educ 1992;6:6. 26. Tornyay R, Thompson M. Str York: Wiley, 1982; Ill. 27. Barrows H, Pickell G. Develo York: Norton Medical Books 28. Bridges E, Hallinger P. Imple OR: Educational Resources I 1995;3. 29. Fields E. Use of debate form critical thinking. J Phys Ther 30. Dempsey-Lyle S, Hoffman T. the Later Stage of Life (simu ing, 1990. 31. Schon D. The theory of inqu lum Inquiry 1992;22:119. 32. Bloom B. Taxonomy of Edu Educational Goals. New York 33. Halpern D. Changing Colleg 1994;13. 34. Shulman J. Case Methods in College Press, 1992;1. 35. Beissner K. Use of concept m Ther Educ 1992;6:22. 36. Clarke J. Patterns of Thinkin Teaching. Needham Heights, 37. Koschman T. Medical educa through and with computers 38. Caelleigh AS, Dittrich LR. P tion. Acad Med 1995;70:758.

ington University, 1991. A short book on practical teaching strategies for facilitating active learning in higher education classrooms. The authors argue that active learning is central to engaging students in higher order thinking tasks. The book provides several ideas for lectures, discussions, and creative learning strategies. An excellent resource for a quick introduction and idea source for changing your classroom. Cohen E. Designing Groupwork. New York: Teachers College Press, 1986. A very practical book for facilitating the small group process in the classroom. Cohen covers all aspects of group work, including research findings, goals, common problems, preparatory strategies, and planning groupwork tasks. Although much of the research on groupwork has been done in secondary education, the author does an excellent job of integrating the core theoretical concepts that apply to all levels of education. Davis BJ. Tools for Teaching. San Francisco: Jossey-Bass, 1993;63. This book is a wonderful resource for quick reference on specific teaching tools. The book covers everything from traditional teaching tools to educational technology. There is an excellent chapter on the use of instructional media. Halpern D. Changing College Classrooms. San Francisco: Jossey-Bass, 1994;13. Halpern's book covers a wide range of contemporary topics, including major sections devoted to the rationale for promoting active learning in the classroom, promoting multicultural understanding, and use of computer technology. The book also contains an excellent chapter on the use of portfolios for student assessment. McKeachie W. Teaching Tips (9th ed). Lexington, MA: DC Heath, 1994;31. McKeachie's text is a classic, now out in a ninth edition. The text is a must for every teacher in higher education. The book provides quick answers and reference to any question you may have on course development and management. McKeachie does an excellent job of integrating the most recent research on teaching methods and

evaluation. What the boo for with annotated refere on the specific topic. Westberg J, Jason H. Making E tional Support (CIS); Guid der, co: Johnson Printing teacher's guide that can b several vignettes of com accompanying questions fo from the Center for Instruc with Patients, Clinical T Using Video in Teaching. V PO Box 1437, Boulder, CO ........ '"

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Undertaking New Challenges: Preparation for Teaching in Clinical Settings (Calvin and Hobbes © 1995 Watterson. Distributed by Universal Press Syndicate. Reprinted with permission. All rights reserved.)

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After 1 year of clinical p ready to serve as a clinic ly comfortable with flex and all related activities, summaries, interim and ferences, utilization rev and attainment of the expected time duration, tionships with other p club and weekly in-serv attending monthly profe than a simple proclamat for her first clinical edu baccalaureate physical when I was feeling like I a competent practitione tions, one more responsi The center coordinato copy of the academic pr tives, dates of the clinic coordinator of clinical ed used to assess the stude experience. In addition, was written in the stu illegibly, that indicated and housing and parkin would be arriving at our need an orientation, "go her skills, and a schedul I had any questions. Afte Not only did I not know tion, but I was absolute responsibility. I assume student after 1 year of serve as a clinical instruc differently than my peer Afterwards, I realized for this student's clinic clue as to how to structu evaluation, especially si ment to be used, and a

my four clinical experiences by posing questions such did they provide an orientation to the facility and the health care environment? What issues were discusse the first few days of the experience? What were their tions for my performance? Did I get a schedule on the and what was included on that schedule? What did th make me feel comfortable or uncomfortable? Wh remember most about my clinical educators that was or negative? Based on my limited discussions wit sional peers and my personal reflections, I developed albeit limited, understanding of my perceived r responsibilities. All too soon, it was time for me to t first student.

This sketch is all too common in contemporary clinical educa it illustrates a situation that can be prevented or eliminated given training and resources. This chapter provides the clinical educa information and resources about the clinical education milieu; the responsibilities of faculty, clinicians, and students involved in clin cation; how to prepare to be a successful clinical instructor; and al models for delivery of clinical education.

Chapter Objectives After reading this chapter the reader will be able to:

1. Understand the complexities of and the relationships betwe

different contextual frameworks in which the students' aca and clinical learning occur. 2. Recognize the dynamic organizational structure of clinical tion and the roles and responsibilities of persons functionin this structure. 3. Define the preferred attributes of clinical educators that co to enhanced student learning.

4. Identify qualities of effect grams that enhance clinic 5. Determine how to collabo expectations and objective ensure attainment of clini 6. Explore the concept of alt approaches to student sup strengths, limitations, and

Physical Thera

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Imagine education pist assistants occurring solely i clinical practice as an integral pa fession's conception, clinical pra been and continues to be of para dents' educational experiences. O students' progression through th does this by bridging the worlds world" laboratory lessons that ca ducing students to the peculiarit fession, and refining basic knowl patients with progressively more ical therapy professional curricul one hand, clinical education is no tice setting or its geographical lo serving as clinical educators, or t tors serve. 2, 3 On the other hand, for students during their professi ence where, how, and with whom and whether they choose to beco outcome of physical therapy educ of clinical educators who help pre effective services to meet the nee ic health care environment.

Comparison of Health Care En

Many parallels and temporary higher education and

of public accountability, credibility, cost containment, outcome me ments, service orientation, and cultural diversity.8-10 Each of these has altered the systems in ways that most would have thought unimagi 10 years ago. No longer is health care or higher education funded mere the basis of historical precedent, longeVity, or reputation, but rather fu also depends on consistently attaining explicitly defined outcomes. systems must provide, for patients and students, services that are ren in a timely and cost-effective manner. Each system is held to a cons standard of performance that is based on predetermined or institutio defined norms that cannot be easily compromised, no matter how justi the reasons, without consequences. Possible repercussions include l funding or reimbursement and organizational restructuring, whic result in a workforce reduction or reconstitution. ll Outcomes assessment research, a relatively new term to conte rary society, began 15 years ago but has now become the predom health care buzzword of the 1990s. Health care facilities are expec describe and attain explicit and defined measurable outcomes for the ity, patients, and patients' families. Likewise, institutions of higher e tion are required to account for and be able to define measurable outc for students in each of the programs offered that relate to the func needs of society at large and the demands of students and their paren future employment. Not surprisingly, the outcomes assessment movement was ini during the sweeping business reform of the 1980s, when terms such as quality management and continuous quality improvement were c which have now permeated higher education and health care. 12 The q movement in business streamlined the organization of middle manage reduced unnecessary costs, improved customer services through techn and increased employees' vested interest in an organization by helping take pride in delivering better customer services. 13- 1S The fact that h care and higher education are perceived as big business enterprises sho longer be surprising given the influence of business on both of these sys The idea of "customer service" has profoundly influenced healt and higher education. Customer service no longer applies exclusiv traditional business services but also to all human services provid

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persons of all cultures. Certai student and his or her family) more probing and sophisticated ty of service, value for his or he cism or distrust of the system. C dollar for services rendered by t research professor or medical st ist physicians. Like it or not, s more efficient and cost-effecti comes to the recipient. 16- 18 Society has also become far tural diversity. Higher education affordability and accessibility. S provide access to all but do not als. Students and patients are as represent the cultural needs of so students and teachers and patie services to persons of all custom ers and practitioners in physical incumbent on the profession to can prepare future generations to and demands of a multicultural Many similarities between described. Closer examination o academic and clinical educatio between the two environments.

Differences B and Clinical E

The greatest fund cation and clinical education l therapy academic education, si the primary purpose of educatin and behaviors. In contrast, clini environment, exists first and for and education for patients, clie demic faculty are remunerated f nity and professional services. C services as practitioners by rend most cases, unless as a function

Other differences between physical therapy clinical education and a demic education relate to the design of the learning experience. Educat students in higher education most often occurs in a predictable classro environment that is characterized by a beginning and end of the learning s sion and a method (written, oral, practical) of assessing the student's rea ness for clinical practice. Student instruction can be provided in numero formats with varying degrees of structure, including lecture augmented the use of audiovisuals, laboratory practice, discussion seminars, collabo tive and cooperative peer activities, tutorials, problem-based case disc sions, computer-based instruction, and independent or group wo practicums. With the emergence of technology, such as distance learnin hypermedia, and virtual reality, the traditional archetype is being challeng by some educators and may eventually lead to an alternative paradigm classroom learning. 22, 23 Higher education has evolved in its design to provide more active ad learning that stresses the learner, not the teacher. Fundamental conce and theories and their application to physical therapy practice must be fu developed in the academic program to ensure that students are capable progressing through each phase of the curriculum into the real world practice. 24, 25 Students, however, have found it difficult to divest the selves of the conventional role of the professor as the expert or "sage on t stage"26 who transmits all the knowledge needed to move successfu through the curriculum and accept responsibility and accountability their own learning. In contrast, the clinical classroom by its very nature is dynamic a flexible. It is a more unpredictable learning laboratory that is constrain by time only as it relates to the length of the patient's visit or the wo day schedule. Sometimes to an observer, delivery of patient care and ed cating students in the practice environment may seem analogous in th they appear unstructured and at times even chaotic. Remarkably, stude learning in the clinical setting occurs with or without patients and is n constrained by walls or by location (e.g., community-based services, wa ing or driving to patients). Student learning is not measured by writt examination, but rather is assessed based on the quality, efficiency, a

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outcomes of a student's care whe performance. 27 Resources availa many of those used by academic visuals, practice on a fellow stu and discussion of a journal articl to the educator in practice inclu learning among and between dis in-service education, grand roun and screenings (e.g., seating clini education to prevent common tions, on-site continuing educa interactions with other health pr research. Rich learning opportun plement and clarify much of wh mic education. 28 Because learning occurs withi the clinical teacher is characteriz an expert. The clinical teacher te handling of patients and assum coach, supervisor, role model, a educator provides opportunities She or he also asks probing quest by posing questions to herself or curiosity by fostering scholarly and, by example, teaches students ing functional and psychosocial n of the health care system).29-31 In summary, higher educatio of the same challenges, althoug lenges may differ given their or accountability measures. Not su relation to student learning bec roles and responsibilities that ar learning occurs and the primary ferences, the two systems must basis to fulfill curricular outcome concerted effort must be made by ners, to consciously bridge their that these forces, if left to run the ly drive education and practice f systems currently interact to en

to be efficient. It is also designed to provide a way for academic facult inform clinical faculty of their respective curricula and of student expe tions. In return, clinical faculty inform academic faculty of the relevanc academic curriculum to entry-level practice and the ability of student translate knowledge and theory into practice as evidenced by their clin performance. 33 Excluding students, the organizational system is form designed with three essential positions within clinical education. Per assuming these roles must continually interact to ensure the provisio quality physical therapy education for students. These three roles are m commonly titled the academic coordinator of clinical education (ACCE), center coordinator of clinical education (CCCE), and the clinical instru (CI). The ACCE is situated in the academy, while the CCCE and CI are b in clinical practice. Although the roles are clearly defined as integral to the clinical lear experience, clinical education is not the sole domain or responsibilit these three individuals. Clinical education represents approxima 28-30% of the total curriculum and is characterized as that part of the cational experience that allows students to apply theory and didactic kno edge to the real world of clinical practice. 34 As such, all academic fac contribute to the effectiveness of the clinical learning experience, becau student's performance in the clinic is a direct reflection of the educa received during the didactic portion of the curriculum. Faculty must see better understand how their classroom experiences relate to student per mance in the clinic, and clinicians should comprehend how and what in mation presented in the classroom relates to the clinical education pro and entry-level performance expectations. This is accomplished when fa ty become involved in clinical site visits using established guidelines3 when they facilitate continuing education and clinical research in coll ration with dinicians. 36 Decisions about student clinical competence should not rest so with the ACCE but should reflect the collective wisdom of academic clinical faculty assessments, student self-assessments, and the patie assessment of the student's performanceF Furthermore, expectations student performance during progressive clinical experiences should c

sider faculty's perspectives, b stepping stones that will enabl While physical therapy cl three primary players and the it is every physical therapy a responsibility to be vested in effort between academic and ment of programmatic outcom mic program has a responsibil to clinical educators by activ relevant aspects of curriculum responsibilities of individuals are defined below. '¥- : ~ ""

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Students, and th clinical learning experiences, p zational structure. The true m Students provide feedback to system. Given the configurat heavy burden, because learning tion received from academic p rate in relation to perceived l their needs to the CIon a dai bility for their learning if they dents ultimately will be held actively participate in the dec tion38 and be willing to assume learning experiences that perm riculum. This means that ong which recognizes the student's ciencies, and inconsistencies, students must feel comfortable ic and clinical faculty. This ensure that succeeding classes Self-accountability for beh students as part of their learn and model appropriate profes areas in which the students' p ered inappropriate or problema

Since 1982, the roles, responsibilities, and career issue ACCE in physical therapy education have been investigated and di by several authors. 41 -44 Even though issues associated with the ACC been investigated, the role remains rather unique to higher educatio comparable positions found primarily in professionally based academ grams (e.g., occupational therapy, speech therapy). Although these span more than a decade, the responsibilities assumed by the ACC essentially remained consistent, except for those areas in which tech and collaborative initiatives have enhanced administrative efficien effectiveness and those times when the ACCE is on a tenure rathe clinical track. The ACCE is a pivotal faculty role in physical therapy educati or he serves as the liaison between the didactic and clinical comp of the program. In some programs, due to the number of students resultant number of clinical education sites required, more than o son has assumed ACCE responsibilities (as co-ACCEs or as AC assistant ACCE). In some cases, the ACCE may also be called th tor of clinical education. This occurs when the responsibilities a sidered to be commensurate with managing and directing a p (including its budget). The ACCE's responsibilities are multidimensional and permea room and clinical settings. She or he is challenged by a demanding r expects the same performance (if tenured or on a tenure track) as ot ulty members. This means the ACCE must teach students, engage i arship, and provide community and professional service while balan many other unique responsibilities associated with the position. 45 clinical track, the ACCE is expected to teach on a limited basis and form only those responsibilities associated with being ACCE.46 The responsibilities of an ACCE generally include:

1. Managing the clinical education program. 2. Coordinating and facilitating clinical education within the a demic program. 3. Developing and maintaining quality clinical education sites mitted to providing student clinical learning experiences.

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4. Educating and empoweri fulfill their roles as clinic 5. Fostering and encouragin cation between academic written and computer co 6. Developing policy and pr 7. Maintaining the academi associated with all aspec 8. Coordinating student cli 9. Educating and advising s their responsibility to ac clinical learning experien 10. Counseling students abo strengths and limitations 11. Determining whether stu learning objectives for th continued progression th 12. Obtaining feedback abou curriculum to assist in o sions.43, 44, 46

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Additional activities that the ticipation in consortia activities ( clinical educators that sponsor related activities, (3) curriculum research, (5) management of budg and (6) coordination of clinical cases, ACCEs assume a "broker" cal educators to facilitate clini alternative student clinical expe ships for solo or rural practices) tionships with other academic in by developing alternative superv numbers of students. 43 Deusinger and Rose challeng ical therapy education at their fir dinosaur, the position of the AC therapy education. The viability the present preoccupation with seling, a preoccupation that pr physical therapist." They go on t

edge called clinical education. This can be achieved by critically e ing research on clinical teaching, educating others about the cl science of clinical education, actively seeking equal status wit recognition of other faculty members by embracing the demands o demia rather than functioning as administrators, and by serving th fession's needs by constantly challenging clinical educators to max student learning experiences based on strong theoretical construc experiential learning. 43 Confronting these challenges may allow A to be thought of as valued, recognized, and integral members of the ical therapy faculty.

Roles and Responsibilities of the Center Coordinator of Clinical Education

The CCCE's primary role is to serve as a liaison betwe clinical site and the academic institutions. From the student's pe tive, the CCCE functions in a unique but critical capacity. The CC viewed as the neutral party at the clinical site who functions in th of active listener, problem solver, conflict manager, and negotiator differences occur between a student's perception of his or her perform and the CI's perception of the performance. In some situations, C also function as mentors for individuals serving as or potentially int ed in becoming Cls.2 Because of the current pressure in health care to maximize h resources, it is as likely that the CCCE is a physical therapist or ph therapist assistant as it is that the individual is a non-physical therap fessional (e.g., an occupational therapist or speech therapist). Wheth CCCE is a physical therapist or another health care professional, c qualities are considered universal to the role. This individual should tively demonstrate the following attributes: 1. 2. 3. 4.

Experience as a practitioner. Ethical professional behaviors. Experience in providing clinical education to professional stud Interest in providing quality learning experiences.

5. 6. 7. 8. 9.

Good interpersonal and commun Knowledge of the clinical facilit Capability to consult in the eva Administrative, organizational, Knowledge of contemporary issu management, clinical education

If the CCCE is a physical therapy p she will have attributes commensurat below). CCCEs should assess their capa ing the American Physical Therapy Ass the CCCE.2 Responsibilities that are considered ed with clinical site development inclu

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1. Obtaining administrative suppo program by providing clinical si nale and evidence for developme 2. Determining clinical site readin 3. Contacting academic programs t clinical education philosophy an academic program's. 4. Completing the necessary docum ical education program (e.g., legal responsibilities of the clinical site clinical center information forms mation about the clinical facility, learning experiences). The CCCE tion is completed accurately and warranted by changes in personn

Activities of the CCCE that are as viding on-site student learning experien

1. Coordinating the assignments a the clinical site. 2. Scheduling the number of stude modated by the clinical site on 3. Developing guidelines to deter physical therapist assistants ar students.

Although this position is considered essential to the physical clinical education, a word of caution must be provided given the c which contemporary physical therapy clinical education occurs. A care reform contim.les, especially in hospital-based practices, the CC is on senior staff and carries a partial to full caseload may be the firs his or her position eliminated. It is also important to note that th sion is finding itself in precarious situations in which no CCCE is de or the individuals who serve as CCCEs lack the appropriate quali and clinical teaching experience to serve in this capacity. Of eve concern is the possible loss of qualified mentors in clinical practic cate the next generation of clinical teachers who are ultimately res for ensuring the future quality and effectiveness of physical the vices.ll The profession must be sensitive to this situation rather th mizing or denying its existence. Therefore, it must be open to e alternative and collaborative strategies that are mutually beneficial ensure the continuation of this role and its essential functions by p support to the physical therapy department or by advocating and ne a position with the clinical facility'S administ~tion.

Roles and Responsibilities of the Clinical Instructor

When asked if they can recall any of their CIs, most he professionals will invariably answer lIyes./I Many say they remem only the CIs who were exemplary but also those who were percei poor role models. Likewise, they will remember why a particula remarkable or why they were disappointed in a CI's clinical teachin mance. Impressions left by clinical educators are lifelong; a laudabl and commentary on the role that the CI plays in the life of every he fession student. The CI is integral to clinical education and is involved w responsibility and overall direct provision of quality student clinic ing experiences. In the organizational structure, the CI works at th of the clinical education process. Students often believe that the s

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failure of their clinical learning experi vidual. The CI has also been called a cli ical preceptor, clinical teacher, and cli can be identified with one or more role forms. Much has been written in the lit role and responsibilities and the attribu learning. 27, 52-57 CIs significantly contr and competence in physical therapy c role models that guide students' visions in the future. The CI should remembe education is to provide an environmen ism and encourages the development of a reflective and competent practitioner. for new graduates are fully described in Therapist Professional Education, which of what the physical therapy professio level practice expectations, content, an physical therapist professional educatio

Skills and Qualifications o In general, CIs' roles are m behaviors, such as facilitating, supervis teaching, evaluating, counseling, advisi and socializing. Before serving as a C competence should be demonstrated dimensions:

1. Professional skills, including eth 2. Clinical competence demonstrat solving skills, and reflective prac 3. Communication skills, including th 4. Proficient interpersonal skills in clients, students, colleagues, and 5. Instructional skills, including or ing, and evaluating planned learn facility resources. 6. Supervisory and observation sk mance expectations, timely fee structured learning experiences tive practice skills. 29 7. Performance evaluation skills to

mum of 1 year of clinical experience (or less in special programs o of expertise in which less experience has proved satisfactory); (2) ingness to work with students by pursuing learning experiences i cal teaching; (3) a current state license, registration, or both (as re by specific state practice acts) or graduation from an accredited p therapist assistant program; (4) positive representation of the pro by assuming responsibility for professional self-development and d strating this responsibility to students; and (5) willingness to act a fessional role model and the ability to recognize the impact of th on students. 6o Developing skills as a CI begins with an awareness of the parall exist between the roles of practitioner and CI. By recognizing these pa one can better understand how to transfer knowledge, skill, and be used in delivering patient care to the task of designing a clinical learning experience. Understanding the relationship between the rol practitioner and the CI role allows the instructor to analyze the CI att that can be used to augment the teaching experience. Table 4-1 illu parallel relationships between practitioners and their management o cal therapy service delivery and CIs and their coordination and imple tion of student learning experiences. Furthermore, exploration practitioner-patient relationship can serve as a useful tool in explor CI-student relationship and the learning process. 61

Qualities of a Successful Clinical Instructor A successful CI develops a framework for the teaching ing model by determining characteristics of the teacher, student, and and the dynamics between them to facilitate teaching and learning maintaining patient satisfaction with clinical services. Moore and found that the following factors were essential to enable all students a successful clinical education experience: (1) an atmosphere that is tive to students, (2) staff who are interested in teaching students, opportunity for students to practice patient care, (4) students who ha cific goals, (5) feedback on performance provided, (6) clinical assig that are long enough to accomplish objectives, and (7) students who a prepared. Additional essential factors for advanced students are patie

Table 4-1 Roles of the Practitioner and C Roles of the practitioner

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Patient referral and taking a patient history

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Determining long-term goals mutually with the patient

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Performing patient re-evaluations and assessing the level of progression

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Performing patient outcomes assessment and discharging patients from physical therapy

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Clinical Instructor: Comm

Sheets and Schwenk focu the triangular relationship between the or more of the relationships within th studies have focused on factors related to effective learning experiences. 52, 56, 6 ical therapists found to contribute posi tive clinical teaching include a positi

in the clinical learning process. Communication and interpersonal rel include intrapersonal, small group, conflict, organizational, and profes types of communication. 66 The smallest statistical differences between "best" and "worst" clinical teachers were demonstrated in p sional skills and knowledge. 52, 67, 68 As a component of a comprehensive study of clinical education in ical therapy in the early 1970s, Moore and Perry62 surveyed clinician ranked selected behaviors of communication and interpersonal relati the most essential traits of an effective CI. However, in actuality, CIs shown to demonstrate these behaviors less frequently. They offere explanation for the discrepancy seen between those traits ranked as i tant and the actual behaviors demonstrated by the CI. They postulate this divergence resulted from a lack of adequate preparation on the p the CI rather than from a lack of appreciation for the importance of behaviors. This was supported by the fact that at that time only 25 % surveyed had attended any type of teacher training. In a study by Emery, students ranked many of the behaviors iden to be necessary for effective clinical teaching as weak in their CIs. S2 more CIs are attending clinical education training courses,21 it mig assumed that these deficiencies would be reported less frequently. One probe further to determine if there are other explanations for inconsist between affective behaviors desired in a CI and affected behaviors ac demonstrated by CIs. The area of student performance most frequently cited by CIs as ing is also in the affective domain, specifically interpersonal relation communication. 69 , 70 However, ACCEs have reported that they are un to fail students for solely affective problems unless they occur in co tion with psychomotor or cognitive deficiencies or both. 71 Perhaps exists in physical therapy education, which does not adequately defin cific behavioral expectations for students and then assesses those p sional, affective behaviors throughout the curricular process in clas and clinic settings. If students are provided with clear behavioral p mance expectations and held accountable for their behaviors, perhap will demonstrate better interpersonal relations and communication as practitioners.

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Successful Clinical Instr Other factors that contri ing and supervision are (1) the provisio gies that encourage activities such increased student autonomy; (3) appli ries applied in clinical learning that h sibly in their learning experiences 72, clinical practices in physical therapy; problem solving and decision making, making better management decisions cially under ambiguous situations. 74 shown to be more effective when sys preparation, briefing, planning, practi opportunities are available to student ment of student learning occurs when is defined, expectations for student a level of commitment is determined fo experience, and the timing, structure, and summative evaluations are provid for the CI is to find a balance in the rel turance and separateness: This is no with patients when providing physic niques for teaching in clinical settings In a qualitative case study examin ing experience, Harris and Naylor83 s enthusiasm were enhanced when the education and feedback rather than so physical therapy student with "good c focused rather than technique-focused. sition that students must make to bec

Preparation for Clinical I To develop the requisi needed to effectively perform their res must have adequate formal preparation interpersonal relations, communicatio and competence. Montgomery84 believ training, many CIs also lack the "ex serve as mentors to physical therapy st be an abundance of trained and expe ever-increasing numbers of physical th

training objectives. Nevertheless, the development of formal training pr grams for CIs does not adequately address issues of quality in clinic instruction. In addition to academic programs and consortia that provide fo mal training programs for CIs, students can also be better prepared by ac demic programs and clinical educators for their eventual role as CIs b teaching them about learning and evaluation processes. Many CIs believe that they are inadequately prepared for teaching. 27, Preparation for clinical teaching requires experiences that relate to teachi issues. This includes (1) application of questioning and problem-solvi techniques; (2) application of levels of questioning in the domains of lear ing (see Chapter 2); (3) application of behavioral questioning to address affe tive issues and ways of improving the quality of questions; (4) application learning theory, including domains of learning and their hierarchies and understanding of the elements of and methods used to assess learni styles 85 ; (5) application of educational methodology, including adult learni and teaching theories and principles 86; and (6) understanding of the conte in which learning occurS. 84 Clinical teaching provides opportunities f obtaining knowledge and developing skills in articulating and writing me surable cognitive, psychomotor, perceptual, and affective performance obje tives; revising performance objectives 64; and clarifying academic, studen and CI performance expectations. Aspects related to performance expect tions and objectives are discussed in the section entitled "Student Obje tives and Expectations of Clinical Learning Experiences./I

Training Programs for Clinical Instructors Training programs for CIs should provide specific informati about selecting appropriate, creative, and effective teaching methods th actively involve learners in self-directed and guided experiences. 30, 86, These approaches should guide students to use available resources to acce information, maximize learning opportunities, assume responsibility f self-directed and lifelong learning, apply critical thinking skills to sol problems,88 apply skills learned to new situations, communicate learni needs effectively, enhance observation skills, and develop as professiona Clinical teaching methods can include demonstration-performance, teach

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exposition, seminars, case analyses, ca nals, conferences, brainstorming sessi ed activities, and so on. 89- 91 Clinical training programs shoul evaluation. Basic concepts of clinical mative, and formative evaluations; competency-based evaluations and (3) methods and techniques of evalua uations, outcomes performance asse student self-assessment; (4) problems uation 50; and (5) a basic understandin including how to critique their relati to determine the most appropriate ev clinical setting. 89, 92-95 Development of effective comm skills should also be included as part content to be addressed includes comp tion; ways of improving interpersonal, munication; sources of conflict in th identifying, managing, and resolving c Fundamental components of clini standing of the roles, characteristics, organizational structure of clinical ed and management of the clinical env within that environment. 96, 97 Manage

1. Assessment of available learn 2. Establishment of guidelines fo students. 3. Understanding federal regulat Disabilities Act. 4. Creation of a filing system for forms. 5. Development of a schedule fo 6. Motivating students to perfor 7. Development of a policy and p 8. Selection of a student orienta comprehensive. 9. Understanding the managemen 10. Promotion of positive learning tracts or other approaches. 89

education training programs for their clinical faculty at little to cost. 21 , 98, 99 In addition, continuing education training programs are erally offered as basic or advanced courses in clinical education. Trai issues addressed in this chapter, in general, reflect content found in b CI training courses. Some training programs offer state or regional certification or reco tion, continuing education units, or recognition by APTA as a course d ered by an approved provider. However, many continuing education training programs do not have a mechanism for assessing the ability of program to instill knowledge, skills, and competence. 100, 101 To address concern, a 1994-1995 pilot study, which was funded by APTA and di ed by principal investigator Michael Emery in collaboration with Na Peatman and Lynn Foord, was assigned to develop a valid and reli training and assessment system for credentialing clinical educators. 102

outcome of this study has yet to be determined, but it may have far-re ing implications in providing quality training programs for physical the clinical educators. In addition to continuing education programs in clinical educa formal postprofessional graduate programs specializing in education training for academic and clinical faculty exist in physical therapy. L wise, self-instructional programs available in clinical education in o health professions (e.g., occupational therapy's Self-Paced Instruction Clinical Education Series [SPICESp03 or Health Occupations Clin Teacher Education Series for Secondary and Post-Secondary Teache could also provide an alternative mechanism for clinical educators in p ical therapy to further their continuing education. Another method enhancing clinical teaching skills is through formalized mentor or pre tor programs, which are similar to teacher education programs. In programs, the clinical teacher and mentor jointly identify specific g and expectations for learning and performance. Once engaged in the c cal teaching process, the mentor provides ongoing feedback and evalua of the teacher's performance used in conjunction with teacher appraisals. 104, 105 However, a significant limitation to this approach is an experienced clinical educator must be available and willing to give and energy to the mentoring relationship.

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Realistically, developing expertise and experience with positive and probl Not unlike the learning experiences opportunities to practice and reinforc clinical training programs and to apply uations, preferably with the guidance Thus, the process of learning to becom unlike that of learning to become an subject matter related to providing e standing the context in which clinica confidence in one's ability as a practi educational theory into the practice of tion through reflective practices all con master clinical teacher. 108- 110

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Designing a clinical educa structural framework, or road map, for experience meets the expected perform demic program must determine, in the experiences will, in conjunction with t the curricular performance outcomes practice. Although at times the. road ma clinicians, and academic faculty can c learning and performance outcomes, th out the clinical experience according to Determining student performance requires coordinated effort from studen practice. Each party must be actively in tives and setting performance expectati vided within the curriculum. Academic students must achieve and those that through the curriculum. In certain circ faculty may have curricular gaps and nee clinical site. The clinical site must determine wh tives for those experiences that can be ac ical setting and available time frame. T how the academic program's objectives

with organizational structure provided for learning, and personal knowl of the facility and its reputation. Students must actively seek learning riences in areas in which their knowledge is deficient or with which have no prior exposure. The literature is consistent in considering the determination of o tives in clinical education as fundamental to planning learning experie Although several methods can be used to provide objectives, many au prefer the use of objectives expressed in behavioral terms. 64 In this for the objectives describe the learner's behavior at the completion of the l ing experience, the conditions under which the learner must function the evaluation method(s) that will be used to assess the learning. Thus CI is explicitly aware of the planning and evaluative components requir determine student competence, and the students understand precisely is expected of them during the experience. 58 Objectives for clinical education serve four purposes: (1) design development of the clinical education program, (2) help in determinin teaching methods to be used, (3) a method for assessing the learning ex ence and students' achievement of the objectives, and (4) augmentati the abilities of persons involved in developing the objectives. 64 Objectiv a learning experience may be culled from multiple sources, all of w result from some type of evaluative process involving questions about is needed, what is available, and where gaps in knowledge exist. 37, 92 The four major factors that determine the objectives in health pr sional programs are (1) the health needs and demands of society, (2 nature of the subject matter, (3) characteristics of the learners, and (4) fessional standards. 64 Obviously, with the rapidly changing and expan need for physical therapy services, dramatic shifts in technology, and tuations in health care, it is critical that academic programs contin reassess performance outcomes, reflected by curricular objectives, to en their relevancy. Curriculum content must be adjusted accordingly to e graduates with the tools necessary to cope with contemporary and fu health care. Evidence shows that in the past 5 years, characteristi learners within physical therapy programs have remained essent unchanged. III However, faculty report anecdotally that learners have cha

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their values and attitudes about thei influenced curricular design, imp comes. 16 Lastly, as part of a professio basis, determine those behaviors th graduates when entering practice. 58 Behavioral objectives in clinical e learning at multiple hierarchical lev are incremental and comprehensive through successive clinical experien defining behavioral objectives that within each domain. For example, behavioral objectives in the cognitiv comprehension, and basic application that expect students to perform in analysis, synthesis, and evaluation. T degree to which students are able to s formance for entry into practice . Effective clinical educators use g objectives describe the broader, more dent performance, while behavioral o further define each incremental learn objective in the psychomotor doma able to evaluate a patient." A speci this global objective might state, 1/ •• patient with complex shoulder patho approach substantiated by the literat ioral objectives should lead to achiev tial components of a written behavio criterion, and the audience or learne clarified in Table 4-2 with examples Well-written objectives should b centered, be outcome-oriented rather ented rather than a statement of description of only one outcome, b observable and measurable. Table 4-3 and contrasts correct and incorrect m Global objectives should provide for determining behavioral objectives subsequent clinical experiences, som in nature, while others may be dist global objectives in clinical education

Condition

Describes the circumstances under which the objective will be achieved and the methods used

Following a patient demo stration ... Given a skeleton ...

Criterion

Describes the level of acceptable performance

Student completes an ev tion of the shoulder w 10 minutes. Student completes an ev tion thoroughly.

Learner or audience

Focuses on the learner or audience rather than the instructor

The student will ... The learner will...

Source: Adapted from The New England Academic Coordinators of Clinical Education The Role of the Clinician as Clinical Educator. Boston: The New England Consortiu Academic Coordinators of Clinical Education, 1994;14.

riculum, should adequately address those performance aspects that required of students to satisfactorily progress through the curriculum an prepared for initial clinical practice. In summary, it is critical that behavioral objectives in clinical educa are sequenced in light of didactic components that have been comple achievable within the specific clinical setting; comprehensive, in that address all domains of learning and progress students through each of respective hierarchies; and congruent with the philosophy, goals, miss and outcomes of the academic program.

Alternative Supervisory Patterns in Clinical Education

To do justice to alternative supervisory patterns in clin education would require space beyond that which can be allocated in chapter. Therefore, only salient points will be highlighted. An attempt been made, however, to provide the reader with a table that consolid

Table 4-3 Appropriate and Inappropriate Writing Behavioral Objectives Requirement

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Describes only one outcome vs describing multiple outcomes

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information into a quick and function theless, the reader is encouraged to fu section. Propelled by changes within he become one of the most exciting and research within health professions disc Frequently, physical therapy clinic native student supervisory patterns w 1960s and 1970s and that this issue is that time, little or no empirical eviden supervisory patterns, their benefits or

more collaborative and interdependent methods for providing high-q student learning experiences in varied practice settings. The fundam basis for these changes lies in the need to 1/ adjust our focus-even re the lens-and explore alternatives that more efficiently use available ed practice and education resources and provide an environment for lea that more closely approximates current and future practice." 113 In th decade, pervasive changes have occurred in the configuration of practic the delivery of physical therapy services, the design of physical therap ricula to accommodate increased numbers of students, and the level of rience of persons providing on-site student clinical supervision. Collect these changes have forced the profession to rethink the one CI to on dent supervisory model and to consider and evaluate the use of other s visory designs. Like the variance within physical therapy curricular configuration health care delivery systems, there are equally as many innovative an laborative approaches to the supervision of students in the clinic. Ma these designs offer distinguishing features reflecting philosophical ben professed outcomes (e.g., active learning, collaborative peer teaching, erative teaching, mentoring, clinical decision making and problem so and reflective practice). Some of these designs have been implemented ly by happenstance or due to creative problem solving.1 14, 11S Others been intentional decisions to engage in an empirical and critical in process to systematically develop, implement, or evaluate specific su sory approaches with an explicit outcome of expanding our knowled supervisory patterns in clinical education. 11 6-121, 126 Although this list no means fully inclusive, some of the supervisory designs used in cl education include:

• One CI to one student (traditional design) • One CI to two or more students (collaborative-peer design)116-126, • A physical therapist and physical therapist assistant team to one ical therapist and physical therapist assistant student team (su sor-delegator design)114 • One CI to two or more students paired from the same academi gram where a student with more clinical experience superv

Table 4·4 Strengths, Considerations, an

Supervisory Designs in Clinical Educat

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Strengths

One CI to one Allows the CI to main student (tragreater control of th ditional design) learning experience Can easily monitor st performance Familiar student learn design

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One CI to two Fosters collaborative learning through pe or more students (collaborinteractions ative-peer deEnhances clinical com sign)1l6-125,142,143 tence related to clin judgment Develops greater selfreliance, independen and interdependenc Teaches students to u and maximize limit resources Allows the CI to facil and guide the learni experience Fosters student proble solving and criticalthinking skills Makes orientation les costly and time con suming Teaches students grou presentation skills b providing collabora projects or in-servic Enhances service prod vity in some setting le.g., acute care)121 Is useful for structure time group learning periences l43 One PT and Enhances understandi PTA/CI team and skills associate to one PT and with supervision an PTA student delegation team (superEnhances understandi visor-delegator the roles and respon design) II 4 bilities of the PTA

tion between PT and PTA students Maximizes clinical site resources and minimizes competition for limited numbers of clinical sites when PT/PTA programs provide the student clinical education concurrently

strengths, and limitations so that they can learn from each other

Same as one CI to two or more students design Allows the experienced student to develop supervisory skills Allows students to use each other as a resource and accept feedback more easily Allows the experienced student to orient the inexperienced student when beginning times are staggered Allows the experienced student to serve as the lead in situations in which the inexperienced student has not completed the didactic content Is useful in situations in which the inexperienced student has a shorter clinical experience

Same as one CI to two or more students design Can be problematic if students are not compatible in their learning styles or interperson al interactions Requires alternative leadership design situations in which on student is the leader and the other the aide, and vice versa

Two part-time CIs Maximizes opportunities for part-time personnel to be inor two CIs on difvolved as CIs (often experiferent rotations enced clinicians) to one or more students 13O,144 Increases opportunities for clinical sites with part-time clinicians to participate in

Requires excellent communication between CIs Can confuse students if expecta tions of the CIs differ Requires additional planning an organization Requires greater coordination

One CI to two students paired from the same program at different clinical levels (student-peer mentor designJl27-129

Table 4-4 (continued) Design

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clinical education Exposes students to mu approaches to care del Allows part-time and ful CIs to show compara abilities in providing ing experiences l44 Permits students in the setting to be exposed ferent learning experi with different CIs Allows a clinical site to commodate more stu by using multiple rota within the same setti Allows for greater varia in length of the clinic perience Increases CI productivit comparison with clin that are not involved Reduces supervisors' dir tient-related responsib Decreases the number of ficial questions posed students

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Two CIs (one highly experienced and one less experienced) to two or more students (teacher-mentor designj123, 131, 132

Provides a mechanism to tor and develop an ine ienced CI through rol modeling and teachin Allows students to learn parallel processes as i perienced CIs Ensures that the experi CI's knowledge is pass to others Allows students to be p a positive learning CI that can be emulated

Multiple rural or single practices offering collaborative clinical learning experiences (coopera-

Permits solo practice se to network with othe to provide student cli experiences Provides a support syste clinical teachers in ru

rural and solo practices Augments student learning experiences through interactions with multiple clinicians who provide care in different clinical settings One or more CIs Provides a learning model that to one or more teaches collaborative team learning among different students from disciplines different disciplines (interdis- Gives students a better understanding of the roles and reciplinary/cooperative delationships between different sign)133, 136, 137 disciplines in real practice Teaches students team leadership and follower skills Models a more ideal learning environment to learn how to work more effectively in an interdisciplinary setting Assists in minimizing "turf battles" that affect quality learning

Applies only if different plines exist at the clin Requires excellent comm tion between and amo different disciplines Requires exceptional pla and organizational ski Requires that CIs trust, and value each other's tise and contributions learning process May cause problematic " battles" if interdiscipl cooperation does not e where "turf battles" a exist

CI = clinical instructor; PT = physical therapist; PTA = physical therapist as

• • • •

student from the same program with less clinical experience (s peer mentor designJl27-129 Two part-time CIs (or on different rotations) to one or m dents130, 144 Two CIs (one highly experienced and one inexperienced) to more students (teacher-mentor design)123, 131, 132 Multiple distinct rural or single practices collaborating to o dent clinical experiences (cooperative-network designJl33-136 One or more CIs to one or more students from different prof disciplines to provide an interdisciplinary clinical learning exp (interdisciplinary-cooperative designJl33, 136, 137

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For each of the designs listed i tions, and limitations have been s determining if an approach is rele Table 4-4 is useful in beginning th alternative supervisory designs mi The majority of these designs are students design, which stresses ac ing and collaborative and cooperat Collaborative and cooperative educating people of different ages, dependence. Cooperative learning school education to assist children in learning to work together succe dents accountable for learning col one another, and to provide social sity. Collaborative learning is simi is to help persons work together o tive learning was developed prima education more efficient and effec content driven, to shift the locus o student groups, and to facilitate str of higher education. 138 Although perceived by some to minology, collaborative and cooper group learning are markedly dissim and cooperative learning are genera ity of knowledge. The major disad in attaining self-directed and peer ity.138 Whereas, cooperative learn accountability it risks replicating tional model of teacher autonomy terms of style, function, and teach dents need to be trained to work to as mastery of facts, development edge; the importance of different growth among students; and imp tion, task construction, and gradin However, collaborative and co damental assumption that knowle tasks that facilitate collaboration classroom environment. 138 The tw

ideas in a small group setting enhances students' abilities to critic reflect on their own thought processes and assumptions; belonging small group and supportive community increases student success retention; and appreciating diversity is essential for survival in a mult tural society. 139 Although there are distinctions between these two typ learning, for the purposes of exploring and implementing alterna designs in physical therapy clinical education, it is preferable to unite learning approaches by drawing on each of their strengths to enhance achievement of desired outcomes. It is important to note that merely placing two or more students tog er during a clinical experience does not connote cooperative or collabor learning. Specific components must be present for small group learning truly cooperative and collaborative. As Johnson et al. stated, "[a] group m have clear positive interdependence and members must promote each ot learning and success face to face, hold each other individually accountab do his or her fair share of the work, appropriately use interpersonal and s group skills needed for cooperative efforts to be successful, and process group how effectively members are working together." 141 Finally, assessment of any approach should be considered in lig (1) the context in which learning must occur; (2) the academic program pectations; (3) the available resources; (4) the availability of patients; (5 support of administration for clinical education specifically addressing ductivity and cost-effectiveness of care delivery; (6) the expertise, experie and attributes of individuals serving as clinical educators; (7) the relation between all individuals involved in the teaching-learning process; (8) characteristics of students; (91 strengths, limitations, and considerations particular supervisory design; (10) the time available for planning and e ating the alternative design; (ll) the desired outcomes of the learning ex ence; and (121 the strategies for ensuring successful implementation.

Summary

This chapter discusses topics perceived to be most critic understanding how to adequately prepare effective physical therapy teac in clinical settings. It is understandable how situations like the one pre

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ed at the beginning of this chapter m preferred approach for preparing fut clinical teaching have been shown to conceptual models and investigative essential for quality education and t The reader is encouraged to exp ed bibliography at the end of this instruction. As more clinical educ alternative supervisory models, the edge and understanding about the ev designs and their resultant outcome cussions espousing the benefits of o based on empirical evidence rather t personal anecdotes. Before becomin self-assessment, professional develo ship should be made available to sp clinical educators. It is my belief that advocating ment programs is not sufficient. To p the physical therapy profession, the when educating students during th should be oriented as part of their a to understand the roles and respon Students should also learn how to learning experiences, and routinely their growth and development throu They should also begin to develop an analogous processes used in providin services. In this way, students will delivery, which is the primary focu practice, to teaching students in cli roles they will assume as practitione Clinical educators must be hel behaviors that they would like fut demonstrating good clinical teachin the things that the profession belie Understanding the principles of pe teach in the clinical setting in the CIs must critically examine their approach is the legacy they wish to learning, applies to physical therapy

patients in an uncertain health care environment.

References

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82. Plaut SM. Boundary issues in tea ital Ther 1993;19:210. 83. Harris D, Naylor S. Case study: of clinical education. Educ Train 84. Montgomery T. Clinical Faculty for Education and Department o Education Present Status/Futur Physical Therapy Association, 1 85. Claxton CS, Murrell PH. Learni Educational Practices. ASHE-ER Washington, DC: Association fo 86. Merriam SB. An Update on Ad for Adult and Continuing Educ Bass, 1993;15. 87. Bonwell CC, Eison TA. Active L Classroom. ASHE-ERIC Higher DC: The George Washington U Human Development, 1991. 88. Kurfiss TG. Critical Thinking: Th ities. ASHE-ERIC Higher Educa Association for the Study of Hig 89. Shea ML, Boyum PG, Spanke Teacher Education Series for Sec Urbana, IL: Illinois University D cal Education, 1985. 90. Hayes E. Effective Teaching St Education (No. 43). San Francisc 91. Watts N. Handbook of Clinical ingstone, 1990;37. 92. Deusinger SS. Evaluating the eff Ther Educ 1990;4:66. 93. Henry TN. Using feedback and e visiop: model for interaction ch 1985 ;65 :354. 94. May WW, Morgan B1, Lemke TC ment in physical therapy educat 95. Barr TS, Gwyer 1, Talmor A. Eva therapy. Phys Ther 1982;62:850. 96. Greenberg NS, FeHer I. A structu clinical and didactic componen Health 1980;9:59.

99. Perry JF. Who is Responsible for Preparing Clinical Educators? In tion for Education and Department of Education, Pivotal Issu Clinical Education Present Status/Future Needs. Washington, American Physical Therapy Association, 1988;22. 100. Norcross JC, Stevenson JF. Evaluating Clinical Training: Measure and Utilization Implications from Three National Studies [abs Presented at the Annual Meeting of the Evaluation and Research ety. Toronto: October, 1985. 101. Skeff KM, Stratos GA. Issues in the Improvement of Clinical Ins tion. Presented at the Annual Meeting of the American Educ Research Association [abstract]. Chicago: April 1985. 102. Deusinger S, Cornbleet SL, Stith JS. Using assessment cente promote clinical faculty development. J Phys Ther Educ 1991 103. Crepeau EB, Lagarde T. Self-Paced Instruction for Clinical Educ (SPICES). Bethesda, MD: American Occupational Therapy As tion, 1990. 104. Kirsling RA, Kochner MS. Mentors in graduate medical educati the Medical College of Wisconsin. Acad Med 1990;65:272. 105. Shahmoon R. The Supervisory Relationship: Integrator, Resourc Guide. In E Fenichel (ed), Learning Through Supervision and Me ship: A Source Book. Arlington, VA: Zero to Three/National Cent Clinical Infant Programs, 1992;37. 106. Edwards JC, Brannan JR, Plavche WC, Marier RL. Teaching Resi to Teach Medical Students: An Experimental Study [abstract] sented at the Annual Meeting of the American Education Res Association. Washington, DC: April 1987;137. 107. Jensen GM, Shepard KF, Hack LM. The novice versus the experi clinician: insights into the work of the physical therapist. Phys 1990;70:314. 108. Grossman PL. The Making of a Teacher: Teacher Knowledge Teacher Education. New York: Columbia University, 1990. 109. Meyer S. Cultivating reflection-in-action in trainer develop Adult Learn 1992;3:16. 110. Barr RB, Tagg J. From teaching to learning-a new paradigm for u graduate education. Change 1995;27:13.

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111. Division of Research, Analysis Report. Alexandria, VA: American 112. Sussman B. Effects of Staff Short in the Future. In American Ph Issues in Clinical Education Pres VA: American Physical Therapy A 113. Gandy JS. Clinical education thr interdependence. PT Mag 1995;3: 114. Foord L, Kaufman R. Strategies fo ical therapist assistant clinica 1994;74. 115. Emery MJ, Nalette E. Student sta tion during times of constraint. C 116. DeClute J, Ladyshewsky R. Enha laborative clinical education mod 117. Nemshick MT, Shepard KF. Phy 2:1 student-instructor education 118. DeDea L. The Process, Design, an Collaborative Approach to Clinic Supervisory Model. Presented at World Confederation for Physic 1995. 119. Koga KR. Use of the two student model in a rehabilitation setting 120. Haffner Zavadak K, Konecky Dol cation series: 2:1 collaborative m 121. Ladyshewsky RK. Enhancing ser tient settings using a collaborat Ther 1995; 75:503. 122. Ladyshewsky R, Healey E. The 2: tion. A Manual for Clinical Instru bilitation Medicine, Division o Toronto, 1990. 123. Dupont L. Group Supervision of sented at the Joint American Phy Physiotherapy Association Cong Education within Higher Educati els and Measurements of Student 124. Ladyshewsky R. Clinical teachi instructor ratio. J Phys Ther Educ

ical teaching model. J Nurs Educ 1984;23:206. 128. Slavin RE. Cooperative learning: can students help student Instructor 1987;96:74. 129. Escovitz ES. Using senior students as clinical skills teachin tants. Acad Med 1990;65:733. 130. Solomon P, Sanford J. Innovative models of student supervis home care setting: a pilot project. J Phys Ther Educ 1993;7:49. 131. Pruett KD. A Clinical Approach to the Training of Superviso Model of Cosupervision. In E Fenichel (ed), Learning Through vision and Mentorship: A Source Book. Arlington, VA: Three/National Center for Clinical Infant Programs, 1992;61. 132. Kirkpatrick H, Byrne C, Martin ML, et al. A collaborative m the clinical education of baccalaureate nursing students. J A 1991;16:101. 133. Delehanty MJ. Recruitment and retention of physical thera rural areas: an interdisciplinary approach [abstract]. Phy 1993; 73:70. 134. Clark SL, Schlachter S. Development of clinical education sit area health education system. Phys Ther 1981;61:904. 135. Scherer S. What do I do now? Clin Manage Phys Ther 1992;12 136. Blakely RL, Jackson-Brownlow V. Interdisciplinary rural healt tion and training (IRHET) [abstract]. Phys Ther 1993; 73:66. 137. Perkins J, Tryssenaar J. Making interdisciplinary education e for rehabilitation students. J Allied Health 1994;23:133. 138. Brufee KA. Sharing our toys-cooperative learning versus co tive learning. Change 1995;27:12. 139. Matthews RS, Cooper JL, Davidson N, et al. Building bridges b cooperative and collaborative learning. Change 1995;27:35. 140. Gamson ZE Collaborative learning comes of age. Change 199 141. Johnson DW, Johnson RT, Smith KA. Cooperative Learning: ing College Faculty and Instructional Productivity. ASHE-ERI er Education Report No.4, Washington, DC: The George Was University, School of Education and Human Development, 1

142. Whitman NA. Peer Teaching: To Higher Education Report No.4. Study of Higher Education, 1988 143. Grisetti GC. Planned small-gr clinical education. J Phys Ther E 144. Williams PL. A comparison bet time clinical tutors: is there 1994;14:427. 145. Halcarz PA, Marzouk DK, Avila dents for a future roles as cli 1991;5:78.

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American Physical Therapy Associati (Vol I). Alexandria, VA: American This resource is a collection of 79 physical therapy literature that dimensions in clinical education. ulty (ACCEs, CCCEs, and CIs), design of clinical education, ev resources. This is an excellent ref education because relevant litera tion. Volume II of this publicat updates the physical therapy liter and includes articles from other d American Physical Therapy Associati Self-Assessments. Alexandria, VA tion, 1993. This reference lists g CCCEs, and CIs that were endors 1993. These voluntary guidelines mental and essential performanc tion and development of clinica clinical educators. These guidel assessment documents that allow to evaluate their areas of strength gleaned from the self-assessment for clinical site and faculty develo Fife J. ASHE-ERIC Higher Educat George Washington University, Development. These annual ser

the publication.

• Claxton CS, Murrell PH. Learning Styles: Implications for Imp Educational Practices. ASHE-ERIC Higher Education Report Washington, DC: Association for the Study of Higher Education, • Kurfiss GJ. Critical Thinking: Theory, Research, Practice, and bilities. ASHE-ERIC Higher Education Report No.2. Washington Association for the Study of Higher Education, 1988. • Whitman N. Peer Teaching: To Teach is to Learn Twice. ASHE Higher Education Report No.4. Washington, DC: Association f Study of Higher Education, 1988. • Johnson 0, Johnson R, Smith K. Cooperative Learning: Increasin lege Faculty Instructional Productivity. ASHE-ERIC Higher Edu Report No.4. Washington DC: The George Washington Univ School of Education and Human Development, 1991. • Bonwell C, Eison J. Active Learning: Creating Excitement Classroom. ASHE-ERIC Higher Education Report No.1. Washi DC: The George Washington University, School of Educatio Human Development, 1991.

Grossman P. The Making of a Teacher: Teacher Knowledge and T Education. New York: Teachers College Press, 1990. This text pr an insightful and deeper understanding of educational practic how to improve it through a sound conceptual framework and t of case sketches. Her cutting-edge research provides an understa of the differences in what teachers believe and value, how those are actually enacted in the classroom, and how beliefs and affect content that teachers teach. At first glance, clinical edu may perceive that an examination of six English teachers, as th jects of this text, have little to no relationship to their roles in c practice. However, of great significance is the realization that t education programs that provide a coherent vision for teachin learning do influence the quality of teaching in any setting. In tion, these teacher education programs ultimately affect how stu construct their emerging and evolving knowledge and understa

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of content, which subsequently knowledge into practice. Ladyshewsky R, Healy E. The 2:1 Teach Manual for Clinical Instructors. Tor Medicine, Division of Physical The This manual describes the two-stud orative clinical teaching design an implement this supervisory approac friendly, easy to understand, and pr understanding some of the issues de al assists the CI in organizing, plan the collaborative learning design. Th the University of Toronto, Depar Division of Physical Therapy, 256 Canada M5T lW5. New Directions for Continuing Educat volumes in this series of quarterly of diverse topics of interest to instr with adult and continuing educatio focused on such issues as ways o process and selecting and developin many of these volumes are relev enhancement of adult learning, the recommended. The titles are self-e vided in the publication.

• Brookfield S. Self-Directed Learn Directions for Continuing Educa Bass, 1985. • Hayes E. Effective Teaching Style tion (No. 43). San Francisco: Josse • Merriam S. An Update on Adult L Adult and Continuing Education 1993.

Watts N. Handbook of Clinical Teaching 1990. This book provides a pract health professionals to augment the clinical education for students. For Watts uses a multidisciplinary a teaching and encourages the comp nerships or collaborative interdisci

Teaching in Clinical Settings Karen A. Paschal

When you are a Bear of Very Little Brain and you th things, you find sometimes that a thing which seeme thingish inside you is quite different when it gets out i open and has other people looking at it. - Winnie-the-Pooh in AA Milne's The House at Pooh

Clinical education has long been recognized as a nec part of physical therapy education. In 1968, Callahan et al. stated t purpose of clinical education was "to assist the student to correla ical practices with basic sciences; to acquire new knowledge, at and skill to develop ability to observe, to evaluate, to develop re goals and plan effective treatment programs; to accept profe responsibility; to maintain a spirit of inquiry and to develop a patt continuing education." I Despite major changes in health care deliv physical therapy, this purpose reflects the goal of physical therapy cal education. The importance of clinical education is expressed by students wh remind instructors that "real learning" in physical therapy occurs clinic. In fact, long after physical therapists forget what was taught in course during academic preparation, they remember their clinical ed experiences. Physical therapists remember not only specific expe with patients but most also remember their clinical teachers. It

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unusual to hear a clinical teacher say my clinical instructor. ... " Whether the clinical teacher has a profound e they want to teach the next generat instructors (CIs) know, do, and valu they were students. However, as stro very "thingish" ideas CIs have abo quite differently when enacted. Consider these accounts of a cli quite differently by a young CI and a

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CLINICAL INSTRUCTOR: Jeff is a eager to learn. I know this is o he hasn't had all of his classroom I've really tried to spend time te a student. My CI just let me go but I would have liked to have h and teaching me more advanc helped Jeff. JEFF: This is different from my fir my CI most of the time. Like w ing. I started the history, but sh the questions. Then, I started something quite right, so she st me all the time. I know I can't d to try. I could think of most of t all I got to do was watch her. T ultrasound.

This CI's intentions are good bu into practice. In trying to improve focuses on herself as the teacher ra restructure her teaching to better fa and at the same time allow Jeff to l pragmatic teaching techniques for us ly specified, technical explanations o uses an approach that recognizes the of fundamental, practical, and real unique and often ambiguous conditio therapy practice.

Figure 5-1 Fundamental elements of clinical education.

Chapter Objectives After completing this chapter the reader will be able to: 1. Describe the dynamic environment in which clinical education

occurs. 2. Describe the clinical learning process and identify expected outcom 3. Discuss and give examples of the four roles of a clinical teacher. 4. Identify practical strategies for enhancing clinical teaching metho

Context of Clinical Education

Clinical learning is situated in the context of physical ther practice: It occurs in real practice settings, with real patients, and with physical therapists as clinical teachers. Figure 5-1 diagrams the essential ments in clinical education that provide context for the experience. Historically, clinical education has occurred in settings in wh administrators, directors, and, most importantly, physical therapy clin teachers have been willing to provide it. As the treatment of patients w impairments and functional limitations related to human movement movement dysfunction has moved from inpatient to outpatient settin physical therapy clinical education has moved from hospitals to a var of community-based centers, including outpatient health care facilit schools, retirement centers, health promotion and wellness centers, preschools. Changes in how and where health care is delivered h affected, for the most part positively, the traditional inpatient basis students' clinical education. The modern teaching hospital has becom

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large intensive care unit where access to critically ill patients w tion of the total spectrum of fuller view of the quality of lif only during acute illness requi clinics where patients are tre impact everyday activities. Th student can have is tremendou Explicitly defining the desir dictate the appropriate timing in ence, the type of setting, and th dents' early experiences may b occur after the completion of th erally short and the impact of th student to develop patterns of l off observation for students are o a busy clinical practice where p little time for teaching and prac enter the clinic setting and inte to start. They must come with t ing and doing with a patient. What does a student need t rience? What is best taught in th learned during a clinical educat are prerequisites to clinical lea 5-1. Muscle performance exam therapists. Knowledge of these e performing them is acquired in setting, the student learns to u sion making and patient manag

Academic and 'IWo Different

The primary diffe ing is that control of academic te control of clinical teaching lies the patient. This fundamental d a clinical education program, an in clinical education programs. the efficiency and convenience

Selection of specific tests and measures Expected examination outcomes Laboratory

Acquisition of skill Tests and measures for conducting a muscle perfo mance examination, including generation of dat

Clinic

Use of knowledge and skill for clinical decision mak and patient management in: Evaluation Diagnosis Prognosis Determination of appropriate intervention

Source: Adapted from American Physical Therapy Association. Guide to Physical Th pist Practice. Phys Ther 1995;75:709.

ty, and technologies, while the clinical system is generally organized fo convenience of delivering health care to the patient. Most educational is flow from this basic difference, including those of appropriate and attain educational objectives, effective instruction and evaluation methods, e of clinical education on the patient and patient care, and costs of teachi

Prevailing Conditions in the Clinical Environm

The clinical setting is a unique and complex learning envi ment. Student performance is based on knowing and doing in a real situa with a real patient or client. The learning situation within the clin framed by several factors or ground rules. Scully2 suggests that there are three generic sources for the ground r that frame the clinical learning environment: (1) those originating exte to the clinical education facility, (2) those originating internal to the clin education facility, and (3) those originating from within the clinical teac Table 5-2 gives examples of each. Although these delineations are helpf understanding the origin of factors influencing the context of the clin experience, examples may not fit exclusively in one category.

Table 5-2 Ground Rules Framing th Education Experience Sources

External

Internal

Clinical teacher

University Assignmen Time and l Departmen Assignmen Health req Preparation Value judg

Source: Adapted from RM Scully. Clinic Clinical Education. Ph.D. diss., Columbi

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Consider the examples of Nat students assigned to a pediatric cli programs. Student assignment or p the method used varies from pro tions of the placement procedures example of external factors that im

NATASHA: A pediatrics rotation experience with children. But, for kids with AIDS (acquired the pediatric elective. It was to to do all we talked about. The was a great place! ANNE: I'm not planning to get a got sent here-I was at the en rounded and everything, but I to get the basics. You know, so what to do with them.

Upon closer examination, how placement procedures, may not be physical therapists who could be a

CLINICAL INSTRUCTOR A: It's want to be here. You can't jus physical therapist. Where do I

Anne's clinical education experience. Think of other external and inte constraints imposed upon the clinical education process. In almost e case, the CI's knowledge, skill, values, and attitudes could reframe the le ing context in a way that would dramatically change the outcome of clinical experience. Consider the demands imposed by the changing health care delivery tem. Although addressed by academic programs in the curriculum, the ity is often expressed by students as follows:

ROBERTO: This isn't a very good place right now. There's a lot of ch going on. The patients don't come to the physical therapy departm anymore. We see them in their rooms or in little satellite departm on the floors. I can hardly get the evaluation done before the patie discharged. The biggest job the therapists have is deciding where to the patients when they're discharged from the hospital. I want to do physical therapy.

The CI, Mariah, has the ability to reframe this response and chall Roberto to make the most of his learning experience by expressing so thing like the following:

MARIAH: You're absolutely right. I think we sometimes get the notion physical therapy means using our hands all the time. Someti though, the emphasis is on using our heads to think and plan. We learn about the patient's functional status before admission, we k what's happened here, and then it's our job to make the best pos guess about the future and make recommendations based on that. W a challenge! Discharge planning is a focus from the beginning and our treatments need to take that into consideration. What do you t about Mr. Baird whom we saw this morning?

After the context of the clinical education experience is underst physical therapists can develop ways to mold it like Clinical Instruct and Mariah did. CIs can often reframe the circumstances if they view

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ground rules as defining opportunitie better enable student clinical learning Given these prevailing conditions dents learn in the clinic? What is help understand about the clinical learning

Clinical Learning

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The purpose of this sec learning theorists 3- 8 nor to examine t cal therapists' learning. 9, 10 Rather, th of clinical learning to use in the upc Teacher: Diagnosing Readiness, Pla Dewey provided key descriptors of th stated, "education is not an affair of 'te constructive process."ll Successful cli make meaning of knowledge in a clini ing when providing physical therapy s

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Student Ownership

The clinical education despite the fact that it will occur in t for whom the CI has legal and ethica Cl's time, energy, and creativity. It is i accept ownership and responsibility f is an opportunity for a student to lear ues, and attitudes of the profession, b lifelong pattern of learning and contin pist. Table 5-3 summarizes principles age self-determination in actions. It is responsibility for learning what they learning it.

Process of Clinical L

Clinical learning is a pro the student and CI during the provisio is a situated learning experience in around the patient in a series of compl may think, it doesn't just happen. Con

Prescriptive, mandatory experiences

with recommendations to meet student needs

Instructional strategies

Routine Extrinsic rewards and incentives

Challenging Encouraging deep and ric mental processing

Feedback and evaluation

Available but infrequent Clinical instructor dominates and controls from external sources, e. student behavior the clinical instructor

Institutional and personal premiums

Emphasize conformity

Emphasize creativity, inn vation, and alternative perspectives

Source: Adapted from R Lewthwaite, JM Burnfield, L Tompson, et al. Education and Development Principles. Presented at Seventh National Physical Therapy Clinical Educ tion Conference. Buffalo, NY: April 1995.

CI described it to the Academic Coordinator of Clinical Education (ACC during his on-site visit:

CLINICAL INSTRUCTOR: She's doing fine. I don't have any complain You know, she's right where she should be. I don't mean that she's pe fect, but time and more experience will help. She just has the usual st dent problems. She asks questions. She fits in here and she'll be a go physical therapist someday. KATIE: I don't know. It's not bad, but I'm not sure that I'm learning. I mean know I'm learning, but I think I could be doing more. I sort of feel like junior therapist. I come in, treat my patients with some help, and go hom

Katie is participating in the third of four clinical education experience She performs adequately but seems stuck. She thinks that she isn't learni as much as she is capable of, but she does not seem to know where to from here. Consider steps the ACCE might take, the CI's responsibilitie and what Katie needs to do to continue the learning process.

Bridging Theory with A primary goal of cli build bridges between theory and p damental skills taught in the physic be couched in a patient problem learn in the clinical context until The need for bridging theory and p statement by Becky, a student in h

BECKY: I was doing OK until the wrong answer to my question. her shoulder all night long unl that. I was pretty sure she had

Clinical practice is all about p book diagnoses. There are no mul around the best answer will restore be reformatted in the contextual b based on far more than knowing a lowing example:

STUDENT: My CI is so smart. Ho a patient tried to refuse treatm answer. The patient ended up d than I had ever seen him do. T wasn't up to physical therapy later." An hour later they calle thing. There was nothing to pr

Physical therapists practice wi and rarely described in the literatu veyed to students.

Ability to Perform Ef Knowing is not eno knowledge to work and, in doing so to enhance movement. Physical th and treat. They palpate, stabilize, teach, motivate, simplify, and mod comes only with practice, develop year student, describes her struggle

tive actions.

Acculturation Acculturation is the process by which a student is social into the profession of physical therapy. The socialization process is account of how a new person is added to the group and becomes a mem capable of meeting the traditional expectations of the profession. Phys therapy is a service-oriented profession. Clinical education occurs in setti where patients come to receive care. Patients are not exhibits who give t and money to come to a clinic to provide an example of a diagnosis for a dent. They are real people with movement dysfunctions that limit their a ity to live their lives the way they would choose. Students must learn w it means to provide service. The majority of students use their own lives as the primary example the way others live and may assume that their own beliefs, values, and soc conomic status are those of the people whom they will serve. Cons Cindy's comment. She is a 21-year-old student from a Midwestern farm community. She has been assigned to the liver transplant service of a me politan teaching hospital on the East Coast.

CINDY: We are waiting to discharge this woman until her maid flie from the Middle East. Her husband is too lazy to help her at the Fam House. I can't believe it. She doesn't even need that much help anym

Cindy's narrow norms of culture indicate a need for learning. Con er any suggestions you could give her CI that would help Cindy enla her view. Although most students have experienced physical therapy as a pat or have a friend or relative that has, they often fail to realize the broad sc of physical therapy practice even after classwork. Difficulties in learn within this very broad context of practice may not be evident until the c ical education experience. For example, consider the challenge Joe face you read about his experience, beginning with a phone call from his CI to ACCE in the third week of an 8-week affiliation on a trauma unit:

CLINICAL INSTRUCTOR: I'm s lunch. I probably should have just kept getting worse slowly to begin. He's late all the tim engage him. It's almost as enough and has good ideas ab do anything. Sometimes up o hiding from me.

Joe's behavior is atypical in r ical education experiences. Duri the next morning, when Joe wa ing, he focused exclusively on Je brain injury at rancho level I w accident when he was thrown fr siblings, and girlfriend were de never going to be the same." As commented that Joe's CI had e avoiding her. "What are you hidi estlyanswered, "Life." Experienced physical therapi complexities of specialized pra skilled nursing facility, preschoo disabilities, athletic training roo pice. Consider techniques a CI ca tions to difficult issues within possible to validate a student's fe ity to practice professionally i whelming context of practice.

Critical Analysis of Accurate self-asses practice. Students acquire expecta sources. Successful experiences are observing role models or receivi teacher or a patient. 12 Consider ho accurately self-assess performanc actions, and how a student learns with entry-level competence or th

Other-Assisted to Self-Assisted Learning When students begin the clinical education process, thei learning is directed by the academic faculty, CIs, and physical therapist rol models. As they progress through their clinical learning experiences, how ever, each student assumes more responsibility for his or her learning. Thi progress is demonstrated by selected statements from students at variou stages in an academic program:

CLAUDIA: I wanted to show you this schedule that I received from m clinical site. Each of the 4 weeks has particular things I'm going to focu on. The first week I get an in-service on "Overview of Patient Evalua tion" and by the end, I'll do all the peripheral joints.

Compare the assistance from others Claudia accepts with the initiativ in self-assisted learning that Brad demonstrates:

BRAD: I kept thinking about this patient and his problem. I just had t devise a way to gain more mobility. I came up with a mobilization w hadn't learned in class and one that probably wouldn't even be possibl on a normal elbow. I had the patient sit on a stool next to the treatmen table and place his forearm on the table. I stood next to him and palpa ed for the displaced radial head. Then, I would place my thumbs on th head and direct a force caudally. At the beginning of treatment, only min imal displacement was possible. By the end, I believe 4 or 5 millimeter might have been possible. It was very interesting to think about thi problem and quite satisfying to come up with a unique solution. I fe very good about being successful with it.

Consider how a CI interacts with each of these students to enable them to progress in self-assisted learning, and how the teacher knows when th students are ready to assume more responsibility for their learning.

Lifelong, Reflective Pr Lifelong, reflective p behavior. With so much to learn in how does a student begin this endeav a journal or may be asked to prese tional program during their clinical versations with their CIs, these activ and question their actions. But thes clinical experience. Consider wha process will become lifelong, and w assumes for this during the clinical

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Roles of the Clin Readiness, Plann Evaluating

Good clinical teachers inviting students to participate in th tice, then they plan, model, coach, q and evaluate to optimize the learnin specific enabling acts used by good throughout this discussion. Scully describes the role of the c professional competency," which inv clinical problems, supervision, and not exhaustive or exclusive, provide functions of the clinical teacher.

Diagnosis of Stud

Traditionally, the clin specific student's background befor upon the academic institution to tional program and the didactic curr needs to gain an understanding of objectives of the academic program which the curriculum is presented. descriptions provide the content to suggest curricular themes around w to instruct. Recalling previous clin from a particular program at your c

of excellence. 7. Sit on the same physical level as your students when conversing with and speak in simple, clear language. Expect that they will do the same. S. Avoid didactic monologues. Don't expect a given answer in discussions 9. Encourage dialogue between the experiences and ideas of students and experiences and ideas of experts. 10. Work from experience into theory and vice versa. 11. Move students from success to success, yet prepare them to accept occ failure. 12. Help students view mistakes as opportunities. 13. Exercise imagination. 14. Capitalize on storytelling. 15. Provide opportunities for responsible decision making. 16. Enable students to think about learning as "finding" in addition to "rec 17. Enable understanding of the whole instead of bits and pieces. IS. Become vulnerable to students by sharing feelings with them about the work you are doing with and alongside them. 19. Arrange that students see, do, and remember in the context of practice 20. Encourage humor and spontaneity. 21. Plan so that no learning experience is useless. 22. Enable students to own the knowledge, skills, and values of professional 23. Cultivate rigor and joy in practice. 24. Help students refine their uses of emotion. 25. Always make practice an act with meaning. 26. Avoid badgering and cruelty. 27. Avoid excessive praise of students' works. 2S. Test student work against work in the world outside. 29. Find ways of making public good works of the students. 30. Show students that work habits taken on in the clinic will prove valua 31. Provide evaluations of students' work when the evaluation least interf with learning. 32. Give students ample time to complete their work. 33. Help students polish and refine work as they complete it. 34. Sense the moments for letting go of students. 35. Never deny students their lives.

Source: Adapted from K Macrorie. 20 Teachers. New York: Oxford University Pr 1984.

Knowing the student's academic little information about the implic which knowledge, skills, and values ical competency the student will be of Natalie and Beth, classmates wh first clinical learning experience:

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NATALIE'S CLINICAL INSTRUC more quickly than most studen of work as a physical therapist a with patients and other member fundamental handling skills. Sh we began co evaluating and cotr er, but she has assumed more a She is working hard to take ou clinical judgments, and then w goals and think of creative wa competent in so many of the "pi er level objectives. BETH'S CLINICAL INSTRUCTOR: I felt I needed to push her to ge She did say that this was rea patients. They're never quite li though. After several days of obs together. She's participating in as morning, for example, she reeva man we're seeing following mul accident. She had planned a rout to change positions and practiced going to be responsible for the su ing in for the first time following

Life experiences, particularly tho starting point in the clinic. Other, l mental skills in communication, ma ponents of professional practice. In essential to accurately diagnose read

Pre-Experience Plannin Preparation for the clin ponent that begins after a student is

range of neuromusculoskeletal problems and management related to outpatient rehab services at all of our sites. I also see patients in Osteoporosis Clinic at the Center one afternoon per week. My working hours are 7:00 AM-3:30 PM. I do work one weekend at the Center every 6-8 weeks, and that's an opportunity you may want to consider. This is an exciting time at the Medical Center. We recently consolidated with several other health care facilities and are in the process of restructuring the management of physical therapy services at all the sites. Although change can be a bit disconcerting at times, I think this will be a wonderful opportunity to experience first-hand what changes in health care delivery really mean! In addition, we'll work as a team with a physical therapist assistant, Ken, and another student who will be joining us for the last 6 weeks of your affiliation. I enjoyed working with a student from your University 2 years ago and I'm anxious to learn about any changes that have taken place since then. From looking at your curriculum, I know that you've had three short-term affiliations during your academic preparation and this is your first of three 12-week affiliations before graduation. I'm enclosing a copy of our updated Clinical Center Information Form, a copy of brochures about the Medical Center and the city, and a list of additional clinical learning opportunities for students at our facility. I hope these will begin to answer some of the questions you may have and help you prepare for this affiliation. I want to involve you in planning this experience so we can work together to meet your needs as well as the goals and objectives of your academic program. After you've had an opportunity to review the enclosed materials, please write down your goals and objectives for this experience. Please send them to me at least 2 weeks before you arrive. We'll devote 2 hours your first morning to orientation, discussion, planning for the 12 weeks, and getting you off to a good start. In the meantime, if you have questions or need additional information, please let me know. I can be reached at 123-456-7890. If I'm not available, please leave a message on my voicemail and a telephone number where I can reach you. If it's better to call you at home during the evening, just let me know. I look forward to meeting you in person! Sincerely, Susannah Perez, M.P.T, O.C.S.

Figure 5-2 Sample letter of welcome.

duce himself or herself and begin to exchange information as soon as po ble. The time and energy spent in this process allows the clinical teacher the student to reap rich rewards during the experience. The instru should communicate directly with the student. This can be done in per by telephone, or by mail. See Figure 5-2 for a sample letter welcoming a dent. This letter contains key elements important to any of the types of tial contact. It does the following: • Welcomes • Introduces the clinical teacher and facility

• Demonstrates truth telling, or te honest, frank, and open manner • Conveys expectations • Encourages student's active par

The combination of information p dent and clinical teacher to begin thin

Student Orientation to t and the Clinical Educati The first day of any new well-planned orientation session can duce the student to key members o provide pragmatic information the st ple, the hand-held dynamometers in the left of the hydrocollator packs be probably not essential. These three What does the student need to know text of patient care? What can wait u the way? Orientation is the time for the CI bal exchange. What can the student t age the students to talk about physica therapy means to them. Share experi and standards. If you are able to shar what you learned from them, you can risks, make mistakes, and learn from objectives. They may not be realistic variety of reasons. Help students deter experience. Determine if students' rev sured with the evaluation instrumen Review clinical education materials demic program and determine if ther student to complete. Orientation is also the time to planning expectations for yourself an and planning that occurs during orien and learning activities that will cont ence. It is essential for the instructo truth telling and create an environme

that has been shared congruent with what I'm seeing?" Performance testing is an ongoing piece of clinical teaching that mu done in a manner that allows the student to focus on learning and dev ment rather than the adequacy of performance. Thad's CI did it in the lowing way:

THAD: At first, we talked about the patient before he came. If the pa had a preliminary diagnosis, I told Cassie, my CI, what I knew, an figured out what I didn't know. Sometimes Cassie didn't know ei and then we looked it up. And then we planned where I'd start. I tho you started with the history, but you really start by watching the pa walk back from the waiting room. She helped me plan the history b on what we knew from the referral. I'd go in to the exam room wit patient and take the history. Cassie would knock and come in later I'd tell her what I knew, and we'd get the patient to chime in. S times, Cassie asked questions if she didn't understand. That he remind me of important things I might have forgotten to ask. Th was up to me to tell the patient what I was going to do in the exam do it. Cassie might say something like "You might want to check _ to see if _ _," which would clue me in. Then I'd do it, and C would help if I got stuck or seemed to be headed in the wrong way hard to explain, but it's like the three of us are all working togeth figure out the best way for the patient to get better. Now I do mo my own. I know Cassie will never let me really m ess up, but I also k that I'm the one in charge, and she's not going to let me off the hook starting to feel like a real physical therapist!

Cassie is able to determine Thad's performance capabilities by wor and conversing with him over the patient right in the context of prac She uses questioning to assist in assessing the congruency between assessment and demonstrated abilities. Abrams 13 describes four typ questions: (11 knowledge questions, (21 translation questions, (31 excogit questions, and (41 evaluation questions. Each can be an effective tool to

I

Table 5-5 Questions to Enhance Clinic Types of questions

Knowledge Translation Excogitative Evaluation

Recall of facts

or

p

Demonstrate unde Challenge the stud making skills Require the stude ideas, solutions,

Source: Adapted from RG Abrams. Ques tion. JDent Educ 1983;47:599.

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understanding of the student's abiliti See Table 5-5 for a brief description o

1. Knowledge questions are dire

or principles. This information may ture, a text, or a previous clinical edu a student has the prerequisite kno patient with a particular disease, imp ing early clinical education experien clinical teacher with an understand edge of the student, confusions the ideas that are fuzzy or not clearly d perceptions. These questions should tion but as a tool to aid in diagnosin learning experience. Knowledge ques encourages verbal exchange and prov support and reinforce basic informat lowing are examples of knowledge q

• Why does maintaining a moist (This question may lead to a application, and the choice of mend for the patient being tre • What motions are contraindica ing a total hip replacement? (T dent as he or she proceeds to t and begins to transfer the patie

patient, a peer, the el, or another health care practitioner. Translation tions enable the student to use knowledge. The following are examp translation questions:

• How would you explain ultrasound to a 72-year-old patient? question provides an opportunity for the student to practice tra ing his or her classroom and laboratory knowledge into clear, co and understandable terms for a patient.) • After observing the total knee arthroplasty in the operating room terday, what functional limitations might you expect this patie have? (This question directs the student to consider the physical apy meaning of a supplemental learning experience. The passive rience of observing a surgical procedure becomes active as the st is required to make meaning of it.)

3. Excogitative questions challenge the student's problem-solvin clinical decision-making abilities. They require a student to reorg knowledge, apply principles, and predict outcomes. These questions m especially appropriate after a student has taken the patient's histor performed the objective examination. They may guide the developm goals as well as the treatment plan. The following are examples of ex tative questions:

• What is the patient's functional limitation? Based upon your find what can you recommend to this patient? (These questions re that the student think about function related to the impairm found on examination. The student must then decide what c done to improve function.)

4. Evaluation questions "use all of the previous thought proces judge the value of ideas, solutions, methods, or materials."13 The pr of self-assessment is a critical component of the lifelong lea process. Phrased properly, evaluation questions reinforce self-as learning and encourage critical analysis. The following are examp evaluative questions:

• What criteria do you use to de transfers? • How do you determine if the • After working with this pati think the rehabilitation progr in the context of patient eval cal teacher to gain a better u what the student is doing, and

Ongoing Reevaluation Thad's depiction of hi above describes the opportunity his mance on an ongoing basis. The co environment in which the CI can e monitor and reinforce, and questio Ongoing reevaluation is critical to e experiences matches the student's re A note of caution: Accurate dia endeavor. Just as in physical thera always lead to an accurate diagnosis in her first clinical experience, as sh was referred for evaluation and trea

DANEEN: Jose, I'm going to do yo out any problems with your cer we can concentrate on your sho That means bringing it out lik innervated by the axillary nerve Good. Now I want you to ....

Daneen's CI is concerned about at an appropriate level for her patien providing patient education at all. performing evaluation techniques th to talk herself through the procedure and why. She has not yet reached demonstrate proficiency in the ski appropriate patient-oriented langua would lead the CI, in this case, to a until it was automatic, then she w

based on the potential they provide for useful learning. The CI ma to choose between patients, but this may not be possible in the real practice. More than likely, the CI will need to identify learning op ties within the context of practice that day or even at that moment General guidelines for the selection of clinical learning exp must acknowledge that students need to learn routines and standar they develop creative alternatives. Students are searching for a righ think and perform and their tolerance for ambiguity} unexpected e variation is relatively low. Once confidence develops, students can when routine evaluation and treatment approaches fit and when the Routines are rare when comparing patients, but there may be many ities when considering "pieces" of physical therapy intervention. F ple, have the student work with patients with similar diagnoses to confidence in procedural reasoning and technical skills. Repeated over time will enable students to look for patterns, develop hypothe learn to respond to the unexpected. Once the pattern of learning lished, challenge the known and dare the student to stretch beyon her comfort zone. Consider the following example: Mary has worked with Joe for 2 days of his first full-time experience following completion of the curriculum in his educational program. So far he has been obser seems comfortable conversing with patients, asks appropriate questi demonstrates adequate fundamental handling skills when he partic cotreating. Mary suggests the following:

MARY: Joe, you observed me evaluate Sam Jones, Dr. Stevenson's who was I-day postop (postoperative) ACL (anterior cruciate l reconstruction. It looks like Diane Reeves, a new patient com 1:00 PM this afternoon, may have a similar diagnosis. I'd like y her. I'll be there if you have questions or need assistance} but I'd to take the lead. Why don't you take the next 20 minutes and how you would proceed? We can discuss your plans at 12:30 you'll be ready to go.

Mary selected this learning opp the previous day when he had observ ilar diagnosis. This time, however, M the evaluation and his skill in perfor ticipating in a supporting role durin actions, protect the patient (if ne process as needed. A student with more advanced focus on a different learning experie lowing example:

CLINICAL INSTRUCTOR: I know al patients who have had ACL r about treating them at the sam The staff has discussed this off setting up patients' treatment p scheduled at the same time? A group? What effect would this developing a proposal for the this with factors such as time, tor, has gathered the data we gested meeting with you tom discussing this project with yo ing with patients with this diag I think you're ready to view the a broader scope.

The selection of clinical proble throughout the clinical experienc readiness, types of patients, numb responsibility. Choose clinical prob It is not so much a choice of patien dent do with them in the contex should progress from self-centered tion for real-world practice. Specifi dependent but should build on pas intended to be a sampler in which technique is tried. There is no evid tioner. If a student can problem-so diagnosis and learn to improve the p

CI, works alongside Thad and observes his performance on an ongoing bas However, at a more advanced level, ongoing, direct observation may be l frequent with information derived from written documentation or ev patient outcomes. Most important, Cassie conveys to Thad her strong bel in his present and future clinical capabilities. While providing supportive guidance to students, a clinical teacher m also provide targeted instruction. In the first section of this chapter, Jeff's describes the instruction she provides to him. Her teaching is not focus and is perceived as a didactic monologue that got in the way of Jeff's lea ing. It is important to move beyond the book knowledge and laborato skills a student brings to the clinic, but it is essential to listen to the stud and teach in response to the student's questions-when asked or when y think the student should be asking. It is important to teach over the pati and enable the student to build the bridge between theory and practi Make your reasoning process explicit while providing a safe environment the student to develop an understanding of her or his own reasoning proc while working with you. Students should be encouraged to question th own practice, and they should be given permission to question the instr tor's. The instructor should teach students to take effective actions. Good clinical teachers do not have to know everything. Hopefully, student will generate questions that the instructor can't answer. A vi component of clinical education is learning where to find those answe The instructor should model and teach the student to use the resour available by looking it up in a reference, asking another therapist, asking patient, or asking other health care practitioners. Experienced clinical teachers admit that the most difficult part working with students is giving up their own patients. Physical therapi value the relationship they develop with their patients and take pride their ability to help them. Giving up ownership of that responsibility is easy for the therapist. Likewise, it is difficult to give up control of the s dent as the student moves from other-assisted to self-assisted learni Supervision should focus on encouraging independence and professio

initiative in the broadest sense of p patient and student.

Evaluation of Stud

The purpose of evaluat attainment of goals, and minimize ri pre-experience planning phase and c ing experience, concluding with a s experience. This summative evalua information to make the decision ab by assessing the students' cognitive, The evaluation is used by the academ or failure of the student's clinical training regarding the use of the eva academic program is provided by th necessary to minimize risk to the co petence. For the student, they repres ties at a given moment and provide to give input regarding the next phas tant, they should encompass an elem pists occupy the role of clinical te period of time. It is imperative tha assess his or her capabilities and are Formative evaluations need to oc as a continuous part of clinical teachi he or she is and where he or she is g clinical education is a learning experi form. But based on this performance, opportunities for teaching and learni competent professional practice. Th evaluation that occurs as a part of dia Students often need assistance mance and their feelings about that dence may feel uncertain and judge h those observed by the clinical teac with a patient's progress, may fail to tion where improvement is needed. their own performance out loud. T limitations in knowledge and skill a abilities to rethink and plan for im

it should be addressed immediately with the student. If the instru unable to resolve the problem, he or she should seek advice from the coordinator of clinical education or the student's ACCE. These are ap ate people from whom to seek information. Questions or concerns a addressed before they become problems. Clinical educators at all le involved in the process of learning to provide better clinical educatio Often, a student is progressing satisfactorily and then learning p or stalls. In such a case, the instructor must give the student a "jump If the student has been able to accomplish the program's goals and ob and his or her personal goals, or is progressing toward that end, can th be extended or new goals set that move beyond entry-level compet mastery? It is important for students to learn that professional devel includes ongoing self-assessment and reevaluation followed by defini goals targeted at enhancing knowledge and skills. Learning is a process that continues throughout clinical practice.

Conclusion

This chapter attempts to deal simply with a complex The answers to questions about clinical teaching are dependent on t text in which they are asked. Teaching techniques used by one CI m molded and modified before they can be applied in another situatio topic addressed suggests many more questions. It is my hope that as tinue to plan, develop, and deliver clinical learning experiences, the of physical therapists to continue learning will be reflected in selfefforts to know, understand, and become more able and skilled in th cal education process.

References

1. Callahan M, Decker R, Hirt S, Tappan F. Physical Therapy Ed Theory and Practice. New York: Council of Physical Therapy Directors, 1968;35.

, . "

2. Scully RM. Clinical Teaching of P Education. Ph.D. diss., Columbia 3. Skinner BF. About Behaviorism. N 4. Bruner JS. Beyond the Informatio Knowing. New York: Norton, 197 5. Guba EG, Lincoln YS. Fourth-Ge CA: Sage, 1989. 6. Poplin MS. Holistic/constructivi process: implications for the field 1988;21 :93. 7. Vygotsky LS. Mind in Society. Press, 1978. 8. Lave 1, Wenger E. Situated Learnin New York: Cambridge University 9. Van Langenberghe HVK. Evaluatio in a problem-based physical therap 10. Graham CL. Conceptual learnin dents. Phys Ther 1996; 76:856. 11. Dewey J. Democracy and Educatio 12. Gagne RM, Driscoll MP. Essentia wood Cliffs, NJ: Prentice Hall, 19 13. Abrams RG. Questioning in precl Educ 1983;47:599. 14. American Physical Therapy Ass Clinical Performance Instrument ican Physical Therapy Association

Annotated Bibliog

Brown LT, Collins A, Duguid P. Situa ing. Educ Res 1989;18:32. The au from complex, social interactions which it is developed. This work i ing theory and emphasizes the soc Graham CL. Conceptual learning pr Phys Ther 1996; 76:856. This stud ical therapy students in developi therapy. Graham describes a mo depicts conceptual learning as an able to the clinical learning situat

Scully RM, Shepard KF. Clinical teaching in physical therapy e Phys Ther 1983;63:349. This ethnographic study examines th of clinical education from the viewpoint of clinical teachers. Watts NT. Handbook of Clinical Teaching. New York: Churchi stone, 1990. Watts has contributed a practical handbook with advice to enable clinical teachers to build bridges between th and practice of clinical teaching. Each chapter includes exer feedback that provide an opportunity for the reader to refle information presented and begin to develop skill in application

Education Carol Jo Tichenor and Jeanne M. Davidson

When I came to the residency program, I wanted to different examination and treatment techniques so t have a "large bag of tricks" to use with my patient day over a year I had the opportunity to work with mentors. They challenged me to "think on my f respond to the emerging data from the patient. I lear conduct a focused examination, to systematicall problems for the difficult, multifactorial patient, treatment plan, and to reassess the effects of Although I came to the residency program to learn an advanced clinical specialty area, I also became ist." I strengthened my patient management skills i that will impact all types of patients. I learned how my patients and understand their perception of th dysfunction so that I could better judge their readin and their ability to change in response to my recomm It has changed the manner in which I listen and co in my professional as well as personal life. The cha manner in which I now practice physical therapy are my initial expectations. After this year of intens mentoring and didactic education, I feel that I have

200

POSTPROFESSIONAL CL

tools to continue to g confident that I am p vice delivery models throughout health ca

Chapter Objecti

After completing thi

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l. Discuss the history and ph 2. Identify key components o 3. Describe faculty characteri cal mentoring and resident cessful learning. 4. Describe various residency rationale for their use.

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Clinical Residen

The turn of the centu longer a distant goal for the future, get in the here and now. All health lenge to develop service delive providing cost-effective, clinically care. Physical therapists are being digm of practice, which focuses t patient. Instead, physical therapist ments to the needs of the health costly inefficiencies of practice. 1 T advanced patient management and therapists seek to stay competitiv What is the bottom line? Physical retical and clinical knowledge bas be confident practitioners who can tain respect from patients and othe Is the physical therapy profess ing clinical practice demands? No the past 2 decades, the physical pressing issues other than direct bled the number of physical ther professional and postprofessional

ated their desire for advanced clinical training. 3 Some therapists seek professional Master's degree studies but emphasis on advanced cli training is highly variable in existing programs. Others turn to the con ing education market. Physical therapists, frustrated by a piece approach to weekend continuing education courses, are rethinking thei fessional goals to establish a sound, cohesive professional plan for t selves-a plan that will have a major impact on their level of compe over time. 4 Postprofessional clinical residency education can assist phy therapists to achieve advanced clinical competence. This chapter focus approaches that are used in an orthopedic manual physical therapy res cy program. The concepts presented here are, however, applicable to m other advanced specialty areas within physical therapy, as well as to as of physical therapy professional curricula.

What is a Residency Program?

The APTA Task Force on Accreditation of Clinical Reside proposes the following definition of clinical residencies:

A clinical residency is a planned program of postprofess clinical education that is designed to significantly advanc graduate's preparation as a provider of patient care ser beyond entry level expectations in a defined area of cli practice. The program combines the opportunities for ong mentoring and formal and informal evaluation of knowle clinical performance, and competency over time, inclu didactic and practical examination. A residency also inc a foundation in scientific inquiry and coursework design provide a theoretical basis for the advanced education builds upon but is distinct from physical therapist profes al education. 5

In addition to medicine, which has had ambulatory care reside since the early 1870s,6 podiatry,? optometry,8 and psychology9 are amon

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many professions that have reco and confidence that can be atta into the profession and for sp established an accreditation pr therapy, the concept of residenc opment of the University Affil malized, interdisciplinary long 1970s, the lack of opportunities the United States led some Am countries as Norway and Aus advanced coursework. 4 Over the rorehabilitation, pediatric, and have also developed in various p bers increasing especially in the

Residency Mo

Various part-time United States. 4 In a full-time mo ic 20-30 hours per week, durin group (e.g., one-on-three) super laboratory practice in the advan icallectures, clinical seminars, c rophysiology, anatomy, biomec Applied science and research co by academic faculty from an a grams generally range from 1 to Part-time models generally residency clinic during weekda clinical supervision are given d clinical mentor or in blocks of t residencies are highly variable i

Philosophy of

It is impossible to many advanced specialty areas els. However, based on our com the country, key aspects that ar summarized. Residency educati opment of advanced clinical s

tic techniques, the core of residency curricula is the developmen systematic, clinical reasoning process. Finally, residency education ack edges that active listening skills are an integral part of effective patien agement and refinement of these communication skills is an essentia of confident, effective practitioners. The greatest challenge of residency education is that curricula foc the experienced clinician and developing strategies that will enab practitioner to achieve professional expertise. The progression to adv clinical performance does not occur in 1, 2, or 3 years of residency tr but is based on the development of a clinical reasoning process that o over subsequent years of experience and is linked with the concurren lution of the clinician's knowledge base. 13

Over the past 2 decades, various models for clinical reasoning hav researched in the health care professions. 13, 14 Clinical reasoning is the plex thought process used in the evaluation and management of patie One physical therapy clinical reasoning model, originally proposed by land,16, 17 was refined by Grant et aU 8 into a more formalized tea model. The model used a framework established by Barrows and Tamb It involves the systematic collection of subjective and objective data a recognition, based on knowledge and experience, of clinical patterns a variations that may occur. The clinical reasoning process also includ complex process of identifying, ranking, and reranking a working hypo to develop an "evolving concept of the patient's problem."ls This p involves the use of a systematic method for reassessing factors that vate or ease the patient's symptoms. Gale and Marsden20 point ou active interpretation and evaluative thinking processes occur throu the clinical reasoning process. Factors that influence the effectiven clinical reasoning include (1) presence of a sound knowledge base; (2 knowledge is stored, retrieved, and refined with repeated use 13 , 18,21; (3 experiences, values, and attitudes 22; and (4) ability to involve the pati cooperative decision making. 23, 24 Development of these skills is the fo the clinical supervision process. This development is facilitated as th ical mentor works collaboratively with the resident with multiple pa over an extended period of time.

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Development of experienc ical expertise is well described of skill acquisition. This mod strategies discussed below. Ben skill, the clinician passes throu beginner, competent, proficien levels of expertise reflects the skill performance: (1) movem rules to use of past concrete ex tion of and understanding of a compilation of equally relevan and complex whole); (3) shift f to intuitive judgment; and ( involved and fully engaged par According to Benner, the each situation and zeroes in o out wasteful consideration of noses and solutions. Capturin difficult, because the expert total situation." 25 In opposition to Benner, R tice of the expert may and sho several years of residency teac practitioner in a residency pro ciency as he or she advances in ate frustration for the experien faculty member. Recognition gies for the resident enables fac the program to achieve its cur in resident learning and strate cussed below.

Characterist Members an

A residency prog therapy clinical faculty memb cal training-including lecture clinical training area and supe py clinical faculty may be resi

also assist clinical faculty in curriculum design and evaluation and in a learning models. Communication between academic and clinical fac members is critical in creating a residency curriculum that truly integ theory with advanced clinical practice. For programs that are not adjace universities, use of technology-including audiotaping, videotaping, teleconferencing-can support such linkages. A minimum of 2 years of clinical experience in a relevant area of c cal practice is a frequent requirement for admission into many existing idency programs. Resident characteristics that lead to a successful resid experience are strong organization and time management skills, discipline, and mature communication skills. Other key ingredients for cess for a resident are openness, flexibility, and a strong desire to rec ongoing clinical feedback. As a resident once described to us, "You hav reach a certain level of frustration with your own clinical practice and the inadequacies of piecemeal weekend courses to develop a sincere mitment to receive supervision within a residency program."

General Strategies for Linking Academic and Clinical Curriculum Components

As described previously, the works of several authors rein the importance of the clinician's ability to effectively use knowl throughout the clinical reasoning process.l3, 18,21 OngOing critiques o signed readings from a broad range of peer-reviewed and non-peer-revie journals can be integrated with the daily curriculum schedule to expose idents to the problems and pitfalls of scientific literature in an adva clinical training area. Repeatedly, residents report that their ability to tique the literature substantially improves their confidence in commun ing with other health care professionals as they concurrently dev refinement in their clinical skills. Knowledge from the literature, however, does not always apply to patients. Of critical importance is facilitating development of the thin or reflective processes a clinician can use when the "textbook knowle

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just doesn't apply. Schon30 ca and argues that this knowledg frequently complex problems to solve the problems of prac not work, solving the problem and skills. A key characteristic of exp mon clinical presentations, wh cal reasoning and developmen assisting residents to recognize of formalized seminar papers. T mine clinical features of rele pathology of various syndrome agement, and research suppor papers can be critiqued in a sem Formalized seminar papers ies by the resident. The caseorganize patient data and to j current scientific literature. Th the resident presenting the pat mal demonstration. Benner an assist residents in achieving a state that the "interaction of ence, a turning point in unders point out, however, that man through case exercises or sim the centerpiece of residency e uncommon for residents to eas inar paper, or written case stud ing patient data and making ju quickly recognize clinical pa patient, and tailor their exami Ongoing clinical supervision e resident to think reflectively an edge and live practice. 29, 30

Direct Clinica "Reflection-in

Residents may ty residency training site with f

time may be used in part-time programs. Other part-time residencies ma require the resident to bring in a patient to demonstrate and receive feed back from the faculty and classmates or evaluate and treat patients who ar on the caseload of the faculty member at the residency clinic on a one-to one or small-group basis. With these latter supervision strategies, the res dent may not have the opportunity to receive ongoing mentorin throughout the course of the patient's treatment. Focused critique can b provided, however, by faculty during scheduled contacts with the residen and classmates. In the early phases of clinical supervision, it is worthwhile to focu feedback on the initial evaluation as accurate identification of workin hypotheses and prioritization of patient problems that will directly impac subsequent data collection 13, 15 and organization of follow-up care. Even fo residents with considerable experience, it is important to have the clinica mentor initially demonstrate many aspects of the examination process. Th clinical mentor is asking the resident to reflect-to rethink his or her entir clinical reasoning process, to break old interview and examination habits and to identify and refine aspects that are useful or successful. As describe previously, it is sometimes necessary for the proficient practitioner t return to earlier learning strategies when novelty is present. 25 As the resident progresses in his or her ability to perform a systemat ic examination process, greater emphasis can be placed on follow-up vis its. Residents are encouraged to bring back the same patient at specifie time intervals, so that the faculty member can assist the resident i treatment selection and progression. Residents commonly attempt to us too many treatment techniques at once or discontinue techniques with out reassessing the efficacy of each technique. Consolidation and finess in patient management come when the resident knows how to systema ically select treatment and reassess its value over an extended period, how to combine various treatment techniques with home exercise and func tional training, and how to vary the vigor of a technique according to th patient's condition. During the clinical mentoring process, the resident i challenged to think on her or his feet and to respond to emerging dat from the patient. I?

I

Communicatio

Clinical supervis poses complex and sometimes pists come to a residency bec obtain; however, working side times be very threatening, dep the faculty, the resident's expe performance anxiety, the abil clinical reasoning process to th of mentorship that the faculty tioner in a residency program b rience than a physical therapy experienced resident also has d perception as a professional, expertise in selected areas of p resident brings varying flexibi be supervised. Although residents are adu their learning needs as they ha sion before. The clinic coordin role in ensuring an effective an encouraging ongoing feedback recognizing the teaching stren in relation to the resident's lea

Tutorial Follow

The value of t enhanced through small group vide peer critique of docume treatment techniques in comb ever, the resident will focus p cient time to perfecting cl management skills. Role playi an invaluable avenue for reinf tion schema, and common clin ize that wise practice is the knowledge, clinical signs and standing the patient's perspect

ing strategies were derived from the clinical reasoning model develop Maitland,16, 17 which is described in the section on the philosophy o dencyeducation. Teaching methods may be the focus of a faculty-re discussion during or after initial evaluation and treatment. Common p of the novice practitioner are described below. The reader should not pret that these behaviors represent only the less experienced practit Rather, the term novice practitioner will be used to describe learning b iors through several stages of the practitioner's progression from adv beginner, to competent, to proficient. A common theme that underl strategies is teaching residents to reflect upon performance or to cont ly self-monitor practice during and after seeing patients. Accordi Cross,29 for any experience to have lasting meaning, it must be follow some appropriate distance by a period of reflection-mere involvem not enough. Schon30 referred to these actions as "reflection-in-action "reflection-about-action" and views self-correction, adaptation proces essential to development of expertise.

Developing Patient-Centered Interview Skills

Excellent observation and communication skills are accepted as attributes of effective health care practitioners. Jensen an colleagues31 describe the expert clinician's ability to "maintain focuse bal and non-verbal communication with the patient" as one of the attr that differentiate expert from novice clinicians. Benner32 reports th effective clinician integrates "the implications of (a patient's) illnes recovery into their lifestyle" and "most important, captures the pa readiness to learn." The expert's data-gathering process begins the mo the patient and therapist meet and includes careful observation o patient's overall appearance, facial expression, spontaneous posture manner of movement. The information gained from these early intera is used by the expert in recognizing subtle clinical patterns and in form ing an initial hypothesis as to the nature of the patient's problems and relevance to the patient's goals. In addition to role modeling, comm

tion, and observation skills, the the resident through the subjec dent learn to focus interview sk Subjective examination is obtained about the area of a pa mechanical behavior of the s patient's complaints; and the p cautions to the ensuing object tive exam is key to developme each phase of questioning, the nizable clinical patterns that sions or observations. 16, 17 The following case study extremity complaints. It is foll that the clinical mentor can us reasoning process through subj treatment planning.

J.T., a 31-year-old male hard

lower back pain and right k iliac crest and is distributed inches wide. He describes th varies in intensity to a shar mittent stiffness in the sam alized area around the whol feeling of stiffness with inte observation, the right knee ion. The patient states the l feel that the low back and ri be aggravated and eased ind does not feel one symptom The onset of his sympt into second base during a inflammatory medication, been put off work for 5 da knee or low back before. H that he is athletically activ times per week and plays s ball, skiing, bicycling, swim

ing biased questions, (2) asking more than one question at a time, ( ing assumptions as to the nature of the patient's problems, (4) fa allow or make use of the patient's spontaneous comments, (5) repe asking questions or pursuing responses that do not lend useful infor or (6) failing to pursue a response in sufficient detail. Table 6-1 p examples of questions and typical errors made by the novice whe viewing patients regarding areas of symptoms. An alternative ques style representative of the experienced clinician is presented in Ta Maitland!7 summarizes the importance of open-ended questioning, "the patient will tell the therapist what is wrong with him if the th will, in fact, listen!" When used selectively, the clinical mentor c model an effective, efficient questioning style by rephrasing quest interjecting a question that facilitates more useful dialogue with the In some cases, when persistent questioning yields no useful data, th cal mentor may urge the resident to "move on" and later explain w questioning was unnecessary.

Identifying Salient Subjective Information: Pattern Recognition

A key step in the clinical reasoning process is the ab identify salient subjective information when there are multiple sy areas. By salient, we mean clinically relevant data (i.e., informati taining to the provocation of the patient's symptoms or relief of sym pertaining to the patient's current problem, or affecting treatmen problem). Examples of salient subjective data for the lumbar sp knee are summarized in Table 6-2. Subjective data are listed in t hand column, and possible interpretations of this initial interview d listed in the right-hand column. Using this format, the faculty mem assist the resident to identify patterns in the patient's various fun activities that aggravate or ease symptoms. She or he can also as resident in determining whether mechanical or nonmechanical contribute to the patient's dysfunction.

questioning

Patient response

Error

What is your chief complaint?

What do you mean?

Use of medical jargon.

What's the problem that brings you to physical therapy?

I can't move around easily. My back hurts.

Where is your pain?

In my back mainly.

Biased question.

Where are you having trouble ?

In my back mainly.

Do you mean right in here? (touching patient's low back)

Yes, but over here too.

Making assumptions; biased question.

Show me where.

(Allows patient to outline area. Clarify and delineate region if needed.)

Do you have pain in your buttock or down your leg?

No, but my knee also hurts.

Asking more than one question at a time; biased question.

Do you have complaints anywhere else?

(Allows patient to answer spontaneously; then specifically clear area above/below.) My right knee also hurts.

Describe your pain; is it sharp or dull?

Both.

Asking more than one question at a time; biased question.

Describe how your low back feels .

There's always a dull ache. When I try to bend down, it's stiff and I get a sharp pain.

Is it constant or intermittent?

Oh, there'S always something there.

Use of medical jargon; incomplete data obtained.

(Allows spontaneous comments to emerge; then can clarify in more detail.)

experienced therapist

Patient response

Aggravating factors

Painful with sitting brief periods and with prolonged standing Painful/stiff rising from chair

Low tolerance for static axial loads in flexion more so than extension Difficulty transitioning to an erect posture

Easing factors

Lying down with legs extended Placing hands behind back

Eases with non-weight bearing; with spinal extension bias Eases with spinal extension biased pressure

Right knee symptoms Area of symptoms: whole knee

Multiple sources: tibiofemoral joint and soft tissues surrounding knee

Aggravating factors

Stiff to walk, go up/down stairs

Difficulty weightbearing in extension and flexion

Easing factors

Eased by lying down/elevation Eased by ice/ace wrap

Relief with unloading, passive drainage Relief by reducing swelling, supporting joint

L = lumbar vertebrae.

The faculty mentor plays a vital role in assisting the resident to identi fy subjective information that can be used to plan the objective examination and initial treatment. In the clinical reasoning process, this is called pattern recognition or forward reasoning. 33 For the mentor, the cues presented by the patient in the interview are recognized as fitting with a clinical pattern linked with a hypothesis or diagnosis. Novice practitioners often have diffi culty knowing what information to gather from the patient's current or prio history, and view all data as being of equal value. They also have difficulty

.

"

prioritizing what data are imp ment. The clinical mentor m resident to establish the relatio worst area of symptoms. Dete (e.g., "Does your knee pain in the resident identify how ma have. Determining the worst p the examination and treatmen ment sessions. In the above c back is his most troublesome rate problem areas, the low b symptom affects or causes th exam should be directed to th right knee. Another valuable teachin ment the evaluation concurr can role model concise, organ the resident may have intervi unclear or incorrect written tions (e.g., "You could have ner.. .. ") or additional question on a photocopy of the reside can provide specific strategie tioning style.

Objective Exa

The resident nee the next step in the process, w the subjective data, the reside the area of symptoms, joints tractile tissues under the are other structures that must be This thinking process trains t ing factors. Another importan soning skills is the ability to called backward reasoning. 33 few hypotheses in their patie hypotheses or a delay in deter Table 6-3 demonstrates ho assist the resident in identifyi

L4-L5, L5-S1 apophyseal joints Right tibiofemoral joint Right patellofemoral joint Right superior tibiofibular joint

Right hamstrings Right gastrocnemius (proximal heads)

Right knee ligame (collaterals, cruc ates, coronary, e Right knee bursae

SX = symptoms; L = lumbar vertebrae; S = sacral vertebrae; SLR = straight leg raise. Source: Adapted from forms developed by the School of Physiotherapy, University of South Australia and Curtin University of Technology, Perth, Western Australia.

6-3, the assessment suggests that there may be a neural tension compon

contributing to the patient's low back symptoms. Adverse neural tissue sion is a term used to describe any abnormal physiologic or mechan responses from the nervous system that limit the nervous system's nor mobility.34 The concept of adverse neural tension was originally develo by Elvey35 and further elaborated on by Butler.34 Straight leg-raise and pr knee-bend tests are among the clinical measures used to assess whe there may be problems with mobility in neural tissues. Salient subjective information (see Table 6-2) and the plan for objective examination form (see Table 6-3) are used to develop an in hypothesis of the patient's problem(s). The preliminary data in Tables and 6-3 suggest a possible subacute lumbar derangement syndrome3 addition to a right knee problem. According to McKenzie,36 some of key features of a lumbar derangement are (1) sudden onset of p (2) symptoms that are local, in the midline, or adjacent to the spinal umn and may radiate distally in the form of pain, paresthesia, and nu ness; and (3) symptoms that may be improved or further irritated follow certain repeated movements or the maintenance of certain positi McKenzie argues that the pain felt with a derangement syndrome occur as a result of a change in disc shape with malalignment of the in vertebral segment and its related abnormal stresses. This patient's sub

tive data support the key featu ment of the initial hypothesi gathering further objective ex

Identifying S Correlating S

The next step i the resident to correlate sub confirm or revise the initial w Selected objective examinati summarized here.

The objective findings at t limited and painful move was poor segmental unrol spinal flexion) at the fourt levels. Side trunk flexion symmetrical on the left degrees bilateral and limit was normaL Spinal palpat lumbar paraspinal muscle at the L4-L5 than the L5-S observed to be swollen an limited in flexion to 10 degrees. Manual muscle t indicated no presence of knee joint revealed warm joint but did not reveal fo

Following the objective ex analyze the findings and relat example, spinal motion is limi sagittal plane, which correlate forward to brush his teeth an suggests muscle tightness a directed posterior-anterior an L4-L5 intervertebral segment, identified by the patient. Knee joint testing reveals pattern of restriction, sugges

formed to assess for other possible structures involved, including ligaments, meniscal structures, or the patellofemoral joint.

Prioritizing the Patient's Problems

Ability to prioritize the patient's problems is a necessar in helping the resident to manage patients with increasingly difficult m factorial dysfunction. One method for helping the resident organize e nation data from a patient with more than one problem area is to use chart. The flow chart organizes the data in a meaningful way by req the resident to rank the symptom areas in order of importance. The also summarizes the patient's physical problems that may contribut limitation in function. The flow chart in Figure 6-1 is an example o ceptual mapping. Conceptual mapping assists the resident in thinking her or his thinking and analyzing clinical reasoning. 38

Treatment Selection

All practitioners entering a residency program have had rience selecting and progressing treatment. The challenge for clinic ulty, however, is to guide the resident to select and progress trea using a systematic clinical reasoning process. Through prior expe and training in advanced techniques in the residency curriculum, th dent has a broader repertoire from which to begin treatment. Some monly used treatments for J.T., the case study patient, may include mobilization; extension exercises; modalities; ergonomic recomm tions; and instruction in posture, body mechanics, and home exercise specific treatment methods depend on the patient population serve patient's goals, and the therapist's knowledge base, skill level, and history of successful outcomes. Having formulated reasonable hypotheses for the sources of the pa symptoms and prioritized the patient's complaints, the resident can easily decide where and how to initiate treatment. By using the flow of the patient's problems (Figure 6-11, the clinical mentor can guide th

Problem Area #1 Lumbar Spine

+

• limited spinal ROM (flexion, extension)

+

• L4-S1 paraspinal muscle spasm

+

• L4-S1 intervertebral hypomobility

+

• adverse neural tension (bilateral straight leg raise 70 degrees)

Further examination needed

Lower extremity muscle leng Trunk strength deficit? Faulty body mechanics? Ergonomic issues?

Figure 6-1 Flow chart used to id movement; L = lumbar vertebra

ident to devise a plan of treat ple, treatment for lumbar prob spinal range of motion. Such techniques, such as posterioras described by Maitland,I? described by McKenzie for lu two. If paraspinal muscle spas techniques, soft-tissue techniq Restrictions found in straight mobilization techniques descr a similar fashion to address t

Reassessment

The key to successful treatment of a patient's problem is sy tematic assessment and reassessment of the symptoms and signs throug out the entire process of examination and treatment. Through method reassessment of the salient subjective and objective data, the resident c (1) detect change in function, (2) reconfirm his or her hypotheses, (3) pro the efficacy of treatment, and (4) consider additional hypotheses or pla for future examination and treatment. The concept of reassessment is cornerstone of the Maitland 16, 17 approach to musculoskeletal examinatio and treatment. An example of how the assessment-reassessment process works can described using the case study presented in this chapter. Key lumbar exa findings include (1) limited spinal motion, (2) paraspinal muscle spasm (3) segmental hypomobility, and (4) restricted SLR with a possible neur tension component. McKenzie's36 application of repeated spinal extensi movements to reduce lumbar derangement and improve range of motio needs to be proven beneficial. Before and after application of repeated spin extension movements, the patient's response to each of the four findin identified above is reassessed. If lumbar spinal motion improves, and t paraspinal muscle spasms are decreased, then the need for treatment direc ed to the muscle spasms (e.g., modalities, soft-tissue techniques) is not ne essary. If segmental hypomobility at L4-S1 and restriction in SLR do n fully resolve, however, a treatment plan for joint mobilization may need be added. If, after applying mobilization techniques to the L4-S1 interve tebral segment, the spinal motion is full-range and pain-free and SL improves to within normal limits, then the proposed treatments for SL neural tissue mobilization are not necessary. Through consistent reasses ment of the salient data after each treatment applied, the value of the tec nique(s) and whether it needs to be continued, progressed, or discontinu can be determined. The clinical reasoning process continues throughout the resident's ma agement of the patient. Assessment and reassessment of the patient's sym

....,""

toms and signs by using hypo entire process of examination the salient subjective and obj in function, (2) reconfirm he treatment, and (4) consider ad nation and treatment. In summary, the clinica tern recognition (forward rea ward reasoning). The use of further developing their cl inquiry is central to the data ical data used in the evaluati is a continual reflective proc development and refinement

..-"

i.

Fonnal and

Residents are ev methods, including special p described. Practical examinat entire examination and treatm tors as (1) thoroughness and a justification of clinical hypo based, (3) selection and justi (5) time management, (6) tre and justify the patient's treat tions are established by indivi gram's graduation competen should be made to establish in ulty members for practical e Practical examinations may a dling techniques that are perf such areas as accuracy and co tion, and therapist body posit Use of written patient e resident's ability to assess w justify treatment. Analysis o test clinical reasoning skills. The key component of th gram is that faculty have the ing basis over an extended

Summary

PhYSical therapy describes itself as and prides itself on be clinical profession, yet the profession has fallen short in making oppor ties available for experienced clinicians to receive advanced clinical trai In postprofessional residency training, physical therapists can link th with clinical practice and receive ongoing clinical mentoring ove extended period of time. Postprofessional curricula are directed to teaching experienced practitioners examination and treatment strat that will enable them to continually monitor and critique their perform and develop clinical expertise over time. As stated by Rivett and Higgs achieve expertise .. .is to 'rise above mediocrity,' clinicians need to dev and practice relevant strategies to turn their experience into learning."4 The physical therapy profession is decades behind other professio acknowledging the value of residency training for entry into the profe and for specialization. The residency curriculum and teaching strategies sented in this chapter are derived from our knowledge of postprofess residency programs in orthopedic manual physical therapy throughou United States. We hope that the ideas in this chapter will stimulate a mic and clinical faculty to plan for the addition of extended internshi part of physical therapy professional curricula, the development of res cy programs for new graduates, and the expansion of residency program experienced clinicians. Health care changes are placing high demand novice therapists, who must IIhit the ground running" after graduating physical therapy school, and on experienced physical therapists, who assume new roles with greater responsibility and autonomy. In this environment, a commitment to clinical residency education is a com ment to clinical excellence. Residency education will be critical for the vival of the physical therapy profession in the twenty-first century.

References

1. Eddy D. Rationing resour 272:817. 2. Commission on Accredita itation Update (Vol 1). A Association} 1996. 3. American Physical Therap Association Membership Therapy Association, 1992 4. Tichenor CJ. Clinical resid sion? PT Mag 1995;3(1):49 5. American Physical Therap Clinical Residencies. Tas Alexandria, VA: American 6. Stoeckle JD, Leaf A, Gross ing outside the hospital an 7. Council on Podiatric Medi Guidelines for Approval o da, MD: American Podiatr 8. Council on Optometric Ed Handbook. St. Louis: Ame 9. American Psychological A ington, DC: American Psy 10. Long TM, Sippel K. A pedi 11. American Academy of Ort dards for Orthopaedic Ma Gulfport, MS: American Therapists, 1993. 12. American Physical Therap Clinical Residencies. Ale Association, 1994. 13. Elstein A, Shulman L, Spr retrospective study. Eval H 14. Higgs J, Jones M. Clinical R Butterworth-Heinemann, 1 15. Jones M. Clinical reasoning 16. Maitland GD. Peripheral M 1977. 17. Maitland GD. Vertebral M 1986;1.

22.

23. 24. 25. 26.

27. 28. 29. 30. 31.

32. 33.

34. 35. 36.

and clinicians: an explanation for diagnostic expertise. Med E 1987;21:92. May B1, Dennis JK. Teaching Clinical Decision-Making. In J Higgs Jones (eds), Clinical Reasoning in the Health Professions. Boston: B terworth-Heinemann, 1995;301. Higgs J. A programme for developing clinical reasoning skills in gra ate physiotherapists. Med Teach 1993;15:195. Payton OD, Nelson CE, Ozer MN. Patient Participation in Prog Planning: A Manual for Therapists. Philadelphia: FA Davis, 1990. Benner P. From Novice to Expert: Excellence and Power in Clin Nursing. Menlo Park, CA: Addison Wesley, 1984. Ruth-Sahd LA. A modification of Benner's hierarchy of clinical p tice: the development of clinical intuition in the novice trauma nu Holistic Nurse Prac 1993;73:8. Benner P, Wrubel J. Skilled clinical knowledge: the value of percep awareness. Nurse Educ 1982;7:11. Polanyi M. Personal Knowledge. London: Rutledge & Kegan Paul, 1 Cross V. Introducing physiotherapy students to the idea of "reflec practice." Med Teach 1993;15:293. Schon DA. The Reflective Practitioner. New York: Basic Books, 19 Jensen GM, Shepard KF, Gwyer 1, Hack LM. Attribute dimensions distinguish master and novice physical therapy clinicians in orthop settings. Phys Ther 1992;72:711. Benner P. Uncovering the knowledge embedded in clinical pract Image J Nurs Sch 1983;15(2):36. Patel V, Groen G. The General and Specific Nature of Medical Ex tise: A Critical Look. In KA Ericsson, J Smith (eds), Toward a Gen Theory of Expertise. New York: Cambridge University Press, 1991; Butler DS. Mobilisation of the Nervous System. London: Churchill ingstone, 1991. Elvey R. Treatment of arm pain associated with abnormal brac plexus tension. Aust J Physiother 1986;32:224. McKenzie RA. Mechanical Diagnosis and Therapy for Disorders of

37. 38.

39. 40.

41.

~l

L

C..': f:' {.." t.•.. ~

.

~.,

L

c:

42.

Low Back. In L Twomey, JR Back (2nd ed). New York: C Cyriax J. Textbook of Ortho Tissue Lesions (7th ed). Lon Tichen A, Higgs J. Facilitatin Clinical Reasoning. In J Hig Health Professions. Boston: Barrows HS. The Simulated Edwards H, Franke M, Mc Teach Clinical Reasoning. I in the Health Professions. B Vu NY, Barrows H, Marcy M cal, performance-based asse Southern Illinois University Rivett D, Higgs J. Experienc Zeal J Physiother 1995;Apri

Annotated Bib

Cross V. Introducing physiothera tice." Med Teach 1993;15(4): Higgs J. A programme for devel physiotherapists. Med Teac examples of methods for teac ical knowledge of physica include theory sessions, case These articles will assist the clinical reasoning concepts physical therapy curriculum Higgs J, Jones M (eds). Clinical R Butterworth-Heinemann, 199 er nationally and internatio clinicians to share theory an first section describes key mo literature. Section two exa researched, and describes mo apy, and occupational therap sions of teaching clinical rea technology, assessment, and vides a wealth of practical cl be easily incorporated into c

Physical Therapists Toward Patient Education * Lisa Chase, JulieAnn Elkins, Janet L. Readinger, and Katherine F. Shepard

INTERVIEWER: What do you think are your classic skills in patient What do you think you are very good at? TOM: I think I'm good at teaching them what to do and impressing on they have to do it. I never, never let them think that I'm going to them better. They have to make themselves better. All I can do their coach and their cheerleader. But, they have to play the game. don't think that the things that happen to them in here are making better. They don't come to therapy to get better. They come to how to get better. INTERVIEWER: How do you know when you've been successful? TOM: (Laughs.) The numbers tell me if they're better. I mean, thei strength is better, their range of motion is better, their job perform is better .... They're not coming to me with pain. They have pai they're not coming because they have pain. They're coming be their joint doesn't move and their arm doesn't work. Now, that's e measure. (Interview with a master clinician, 1990.)

'This chapter was adapted from a research report with the same ti authorship published in Physical Therapy 1993;73:787.

Chapter Obje

After completing

1. List the types of health cedures that physical th 2. Discuss patient educati therapists in clinical pra 3. Describe what professio most important to ensu 4. State at least five techn apist assistant can use effective. 5. Name the five most prev 6. Discuss what factors co ing skills useful in clini

Physical The Therapist As

t. (,

Patient education physical therapy education pr itation of Education Programs states that physical therapy p concepts of teaching and lear and evaluating learning experi dents, colleagues, and the c Accreditation of Educational states that physical therapist to "participate in the teaching families. II I From the patients' perspect teachers has been identified i defined several roles of the ph related to the patients' overa grams. 2 In their study of 245 p ing qualities, such as the abil favorable traits for a physical identify what characteristics o descriptive of the ideal physic

Results demonstrated that, in general, physical therapists had a strongly pos itive attitude toward teaching. Sotosky's study also indicated that the thera pists had a strong interest in learning more about teaching and fel inadequately prepared to perform the role of a teacher in the clinic. A similar study by May determined that 99% of a nationwide sample o physical therapists thought that teaching was an important skill in clinica practice. s Furthermore, 98% of physical therapists surveyed by May report ed that they participated in individual patient education. Only one-third o May's nationwide sample, however, had received instruction in teaching as part of their basic entry-level physical therapy education. The majority o her respondents reported that it would be beneficial to receive instruction in educational skills in both basic physical therapy education and continuing education courses. One of the problems encountered in studying patient education is lack o an appropriate instrument for assessing therapist involvement in patient edu cation. Sluijs developed and tested a 65-item checklist that she believes can be used to assess current patient education activities in physical therapy prac tice. 6 She suggested that the checklist could be used to determine whethe physical therapy programs include appropriate training in patient education. This chapter presents a descriptive research study that assessed practic ing physical therapists' perceptions of their involvement in patient educa tion. The purpose of the study was to learn the following: (1) what physica therapy procedures and activities are most often taught to patients, (2) wha methods or tools of patient education are most often used, (3) what physica therapist behaviors related to patient education physical therapists perceive are most important, (4) what techniques are used to assess the effectiveness of teaching, (5) what factors are barriers to delivering effective patient education, and (6) what factors contribute most to the development of teaching skills. For the purpose of this study, patient education is defined as "a planned learning experience using a combination of methods such as teaching counseling and behavior modification techniques that influence patients Knowledge andhealth behavior. / / 7

Method

The method section leagues was used as a model for thi we conducted a series of personal i naire based on data gathered durin ment consisted of three parts: (1) p of personal interviews, and (3) deve gathered during the personal interv

Instrument Deve

During interview tra Readinger individually interview regarding their involvement in pa were compared across the three in agreement for comparable intervie 75%. Each interview was videotap Based on this analysis, additional t vided by chapter author Shepard. The next step was to gather in physical therapists practicing in the were used to choose this purposeful half of his or her work week in dire ed a proportional distribution of ph and gender in accordance with prel Physical Therapy Association (APT To design a questionnaire that views were conducted to determine pists had to the six areas of patient e discussed earlier in the chapter. Th mation retrieved from practicing phy gathered solely from a literature approach, we tried to obtain an insid experiencesj in this case, how he or Interview protocol was designed wi mat (nomoutine ordering of quest open-ended and, when appropriate, f The authors then aggregated t Conjoint responses given by the ph and were included in the questionn

egory of not applicable. For each question, respondents were asked to the items that were most important to them. Demographic data were lected from each respondent. A panel of 15 physical therapists who had p ticed 5 or more years and were considered experienced in patient educa stated that the questionnaire was content valid and gave suggestions for torial refinement. Following questionnaire revisions as a result of input f the panel, a pilot study of 12 physical therapists from a variety of health settings was conducted. Input from the pilot study was used to ensure un standable formatting of the final questionnaire to increase reliabilit responses. We were, however, unable to directly examine the reliabilit the responses gathered by questionnaire.

Sample

The questionnaire was distributed by mail to 300 APTA mem bers who were selected from a random sample of the 1991 APTA Membershi Directory. Two-hundred fifteen (72 %) of the 300 questionnaires distribute nationwide were returned. After the first mailing, 177 questionnaires (59% were returned, and after the second mailing, 38 (13%) more questionnaire were returned. Fifteen of the returned questionnaires were excluded from analysis-nine respondents were considered ineligible because they were no longer involved in direct patient care, four respondents did not meet the deadline for questionnaire return, and two respondents did not complete the questionnaire. Thus, 200 questionnaires, or 67% of the eligible responses, were used in the analysis. The modal respondent was a woman (80%) who held a baccalaureate degree (83%) and spent greater than half of her work week in direct patient care (83%). Thirty-four percent of the respondents reported that they worked in private practice, which included outpatient orthopedic, sports medicine, acute care, rehabilitation, and pediatric centers, as well as prepaid health care and physicians' offices. Twenty-nine percent of the respondents worked in acute care hospitals, which included inpatient, outpatient, and pediatric units. Ten percent of the respondents worked in a rehabilita-

Table 7-1 Areas of Patient Care

Rationale for treatment Home programs Strengthening Range 'of motion, stretching Postural awareness Basic safety precautions Prevention, risk factors Body mechanics Functional mobility

-..

Signs and symptoms of complications

(J

Positioning

~. ­

r~

'-'.,

Pain management Anatomy and biomechanics of complications

.

Etiology of diagnosis \

L , ,~

l ...

•

u C..

Simulating home and occupationa situations

Equipment needs and maintenance Education of family and caregiver by the patient Medical terminology Psychological adjustments to medical condition Surgical procedures Skin care, wounds Breathing techniques Sexual capabilities and activities

Demonstration

97.5

2.5

0.0

Patient-specific instruction sheets with sketches

79.9

16.1

4.0

Patients working with only one therapist

74.4

18.1

7.5

Moving the body passively through the desired activity

53.0

38.5

8.5

Assuming different roles toward the patient (e.g., teacher, supporter, parent, disciplinarian)

52.3

28.6

19.1

Quiet atmosphere

44.0

44.0

12.0

Other professional support staff

38.5

45.5

16.0

Charts of skeleton, muscles, nerves, and so ort

36.2

43.7

20.1

Educating family or caregivers to educate the patient

33.0

37.0

30.0

Three-dimensional models of joints, skeleton, and so on

26.1

35.7

38.2

Creating situations in which patient actively solves problems

22.5

46.0

31.5

Prepublished booklets and pamphlets

21.2

57.1

21.7

Premade checklist of patient care objectives

14.1

21.7

64.1

Group classes with patients with similar disabilities

10.5

18.6

70.8

Textbooks (e.g., anatomy)

7.5

46.2

46.2

Videotapes or slides

7.5

21.6

70.8

Using other patients to provide patient education

7.5

36.7

55.8

Having patients work with many therapists

6.5

25.1

68.4

Using biofeedback equipment

3.0

25.6

71.3

Demonstrations with dolls

1.5

7.0

91.5

Table 7-3 Importance of Physica to Patient Teaching (n = 200)

Developing a trusting relationship with the patient

Developing concrete goals that correlate with the patient's perceptions and desires Developing active listening skills Keeping directions simple and in layperson's terms

Continually assessing one's own effectiveness as a teacher throug patient response <~

Being sensitive to the amount of information the patient is capab of receiving

Demonstrating flexibility by approaching each patient differe

(J

•.U. , -"

&l:::

LJ

( ..

Maintaining communication with other professionals Understanding that nonverbal communication influences the patient's response Not assuming other professionals educate the patient Determining the learning style of the patient Using input from family

tion hospital, which included tation units. The smallest ca early intervention, military, in a traveling physical therapist. half of the respondents repor reported 10 or more years.

Developing objective standards for assessing patient improvement

75.5

16.0

8.5

Assessing results of function in a taskoriented manner (e.g., reaching for a cup)

71.5

23.5

5.0

Having the patient explain what has been taught (to the instructor or to others)

59.0

36.5

4.5

Asking other professionals working with your patient about how the patient performs tasks

43.0

37.5

19.5

Using a checklist to ensure that patient care objectives have been met

30.5

28.5

4l.0

6.5

12.0

8l.5

Analyzing performance via videotapes

The demographic profile of this sample was comparable to the APTA Membership Profile in the areas of gender (74% women in the p compared with 80% women in this study), primary employment setting number of years in practice. Regarding employment setting, the diffe between the 1990 APTA reported data and the data reported in this stud not exceed 3%. In the area of total number of years in practice, the A similarly reported that 50% of members responding have more tha years' experience. Based on these comparisons, the demographic prof our sample closely resembles the APTA nationwide membership pr Consequently, the results of our study may be a good indication of the of patient education as it exists in the APTA clinical membership at la

Data Analysis

Response frequencies were compiled into tables by rank of response. Hypothesis-generating chi-square analyses were perform determine whether there were significant relationships between d graphic data (i.e., primary employment setting, number of years in pra number of years as a clinical instructor, and percentage of the work

Table 7-5 Barriers to Delivering P

Patient attitudes about illness or dis

Patient's passive role and attitude to therapy

Patient attitudes or expectations reg ing physical therapy outcomes Patient's cognitive status Patient's emotional status Shortage of staff Lack of trust in therapist

<:. ('" . J!

C·..'

Lack of time allotted for treatment session Lack of participation by family and caregivers in educational efforts Patient's physical status Distractions in treatment area

C!

•.

t.J

Architectural layout for practicing f tional activities

~:::

Ineffective participation by family a caregivers in educational efforts ( overprotection)

lJ

Limited resources (money, equipme

(

English is not the patient's first lang

~

..

Sensory deficits Patient's level of education

Inconsistency in teaching among pr fessionals and support staff Length of inpatient stay

Philosophy of department or institu toward patient education Therapist has a "bad day"

Interaction with colleagues

85.9

12.6

1.5

Continuing education courses

76.2

20.2

3.6

Clinical instruction within physical therapy program

76.0

17.1

6.3

Interaction with patients' families

63.8

23.8

12.4

Experience in teaching aside from patient education (e.g., lecturing, presenting in-services, and so onl

62.0

27.1

10.9

Academic education outside physical therapy program

57.3

31.8

10.9

Academic education within physical therapy program

52.8

35.8

11.4

Department in-services

42.5

45.1

12.5

spent in direct patient care) and the highest response frequency it (starred) in each question in the survey. Any relationships found to be nificant could be used to generate hypotheses for future study.

Results

More than 90% of the physical therapists reported teac their patients about treatment rationale, home programs, strengthening, range of motion most of the time or nearly always. See Table 7-1 for o information and activities that were most commonly taught to patien well as information and techniques that physical therapists in this sam rarely taught patients. In regard to how often certain methods or tools of patient educatio used, more than 95% of physical therapists surveyed used verbal discus or demonstration most of the time or nearly always. Using written ins tions with sketches and having patients work with only one therapist also popular methods that were used to promote patient education.

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Table 7-2 for an extensive list education that physical therap All of the respondents re physical therapist behaviors rel the respondents indicated that respond to were "most import list of these behaviors. Nearly oping a trusting relationship w tant behavior related to patien In regard to how often cer tiveness of clinical teaching, 96 strate what was taught. Thera standards for assessing patient task-oriented situations (72%) effectiveness are listed in Table Few respondents thought t of the time a barrier to the deli the respondents, however, indi ness or disability, assuming a p tus, attitudes or expectations cognitive status were barriers the reader with a list of barrier physical therapists in this sam time, or rarely. Nearly 95% of the respon most important for the developm considered interaction with co clinical instruction within the tant factors in developing skills their academic education was contributing to development of Of 28 chi-square analyses, cant. A significant relationshi ting and the four most imp functional mobility, body mec 40.06 and p..:;, 0.05). A significa in extended care facilities and n most important as compared tings. A significantly greater health agencies checked home with respondents in other em

(43%) reported assessing function in task-oriented situations as a technique for assessing their teaching skills. A higher percentage of re dents from private practice settings (29%t as compared with acute car pitals (18.6%), rehabilitation hospitals (17%), and home health ag (7%), indicated that use of objective standards was a most useful tech for assessing their teaching skills. Likewise, a relationship existed between primary employment s and factors that become barriers to delivering effective patient edu (i.e., patients' attitudes about illness or disability, assuming a passiv regarding therapy, attitudes or expectations regarding physical therap come, and cognitive status) (X2 = 30.01 and p~ 0.05). A greater percent respondents employed in schools (57%), extended care facilities and n homes (38'}H and rehabilitation hospitals (33%) considered cognitive to be the most problematic barrier in delivering patient education as pared with respondents in other settings.

Discussion

This study supports previous findings demonstratin physical therapists believe that patient education is an important of patient care and that they act on that belief. Physical therapists reported the use of technological equipment or prepared materia teaching in the clinical setting. Instead, the respondents reported r on methods and tools, such as patient-specific instruction sheets sketches, verbal discussion, and demonstrations, that afforded the opportunity to individualize patient education plans. Further res would be helpful in determining which methods are the most eff in delivering a high quality of patient education, and whether methods of patient education assist in improving the overall healt tus of patients. A high percentage (66-100%) of respondents perceived a num interpersonal and task-oriented physical therapist behaviors rela patient teaching as most important or very important in delivering eff patient education. This finding suggests that physical therapists use

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ety of behaviors to adapt thei research, however, is warranted adapt their behavior to deliver o Barriers that were considere tive patient education were pat gests that when delivering patie of psycho emotional issues on p has described a teaching approac nosis to address psychological b diagnosis is defined as the iden edge, attitudes, motivation, fea negatively influence desired pat ables leads the clinician to strategies to meet the goal of im to Chapter 8 for ideas regarding ily education. Nearly 95% of all physical with patients to be very importa ing skills. Only slightly more th reported that academic educati contributed most to developing Sotosky4 and MayS determined prepared for patient teaching. Th on developing patient teaching s The significant relationship areas of patient care taught, tech ing, and barriers to delivering pa of health care the patient is und diagnostic and treatment phase a She suggests that in the diagno information regarding their dise During the follow-through phase information regarding home care of reoccurrence or complication may have different priorities wit clinical problems patients presen insight into the process of patien delivery settings. Chapters 8, 9, skills that can be used by physi tants in patient and family educ

ing, what patient education barriers they perceive as problematic, an physical therapists perceive themselves as acquiring teaching skills. S cant differences in perceptions among physical therapists were no occur with respect to primary employment setting. This study identified several areas in which additional research i cated to gain more insight into the actual process of patient educ Results from such studies could be incorporated into physical therap ricula and continuing education courses, with the intent of imp patient teaching skills and thereby improving overall patient care.

References

1. Commission on Accreditation in Physical Therapy Education. E tive Criteria for Accreditation of Education Programs for the Pr tion of Physical Therapists and Physical Therapist Assis Alexandria, VA: American Physical Therapy Association, 1993. 2. Anderson HE, Aldredge HP, White BC, Wroe Me. The roles of the ical therapist: their importance to the patient. Phys Ther 1965;4 3. Grannis CJ. The ideal physical therapist as perceived by the e patient. Phys Ther 1981;61:479. 4. Sotosky JR. Physical therapists' attitudes towards teaching. Phy 1984;64:347. 5. May BJ. Teaching a skill in clinical practice. Phys Ther 1983;63: 6. Sluijs EM. A checklist to assess patient education in physical th practice: development and reliability. Phys Ther 1991;71:561. 7. Bartlett EE. At last, a definition. Patient Educ Counsel 1985;7:32 8. Ballin AI, Breslin WH, Wierenga KAS, Shepard KF. Research in ph therapy philosophy, barriers to involvement, and use among Cal physical therapists. Phys Ther 1980;60:888. 9. American Physical Therapy Association. 1990 Active Membership Report. Alexandria, VA: American Physical Therapy Association, 1 10. Morse JM. Critical Issues in Qualitative Research Methods. Tho Oaks, CA: Sage, 1994;166.

11. Goetz JP, LeCompte MD

cational Research. Orlan 12. Bartlett E. Behavioral di tion. Patient Educ Coun 13. Redman B. The Process 1993;16.

Annotated B

Refer to the Annotated Biblio

Receptivity to Chang Teaching for Treatment Adherenc

Gail M. Jensen, Christopher Lor and Katherine F. Shepard

This is a brief story of a physical therapist resident, wor a clinical residency program with an expert clinical tutor.

A resident with 5 years of clinical experience is w hard to be more systematic in musculoskeletal assessme is evaluating a woman with persistent neck and arm pa lowing a long course with upper quarter problems afte accident 2 years ago. The patient has not worked sin accident. The resident sees this patient as a potentially case and performs an initial evaluation, which takes th dent more than the allotted 45 minutes. After three visi the patient, the resident is stumped and frustrated. He isolate any problems and is convinced that perhaps this has another agenda and, after any litigation is complet symptoms will disappear. The resident decides to consult the mentor about thi cult case. The mentor skillfully does a quick reassessm getting the patient to distinguish between the major a pain. He asks questions that focus not just on the pa report of symptoms relative to where they are on th chart but how they relate to activities in the patient's li

mentor then has the p has lost because of th becomes a major goa toward with the inte mentor performs the patient with her m patient's report of cha and steady movement if the patient is fully resident and mentor begin a slow-paced e ments aimed at givin program is connected

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What does this story tell abou Therapists identify the role of ed their overall role. When asked abou vention, therapists are likely to f patient's goals, their working hypo diagnosis and trying to manage the its. Although they mention consid talk about doing any specific asses behaviors as they relate to a funda interventions-exercise. This is li examining a map to identify the di rienced therapists may talk about patients." But what does that mean and intervention that are part of co patient, or is there more to it?

Chapter Objecti

After completing this

1. Discuss the central role of p of the therapeutic process. 2. Identify the primary factors characteristics, disease varia practitioner relationship var 3. Discuss and apply your exp physical therapy practice.

The goal of this chapter is to provide therapists with practical ap tion of theoretical concepts aimed at enhancing patient learning and vation to follow treatment. The patient-therapist interaction, whic fundamental aspect of the therapeutic process, is the focus of many practical strategies discussed in the chapter. It is out of this inter that patient and therapist learn about each other, which helps when ing what actions to take. The therapeutic process is more than asses and treatment of musculoskeletal impairment. It involves the thera understanding and mediating the patient's belief system with the pist's own. A process of collaborative problem solving and nego between the therapist and patient is necessary to find mutually acce treatment goals and treatments. This may seem unimportant to comfortable prescribing treatment and expecting the patient's d adherence, but treatment adherence data suggest that patients a quently not dutiful. Patients often do more or less than prescribed, puts them at risk for treatment side effects, slow progress, or no pro By involving patients in the treatment decision making, patient le becomes self-interested. In his writing on the role of behavioral diagnosis in medicine, Ba says the following:

Few physicians would think of prescribing a medication out first diagnosing the probable cause of the illness. Y same clinicians, when confronted with the problem of ior change, frequently do not realize that the influen behavior are multiple and complex. Instead, when conf with patient nonadherence, they tend to assume th patient either does not understand or is not motivated do not realize that knowledge and motivation are only many variables that can influence behavior.

Therapists are involved on a daily basis in teaching or facil patient learning, whether it be use of proper body mechanics, imp

posture, teaching exercise, or ad aspect of teaching patients invol their health. 3, 4 This is one of th ence or cooperation has been sug because of the connotation of pa expert's advice. 5 Enhancing patie essential aspect of the therapi return to maximal function in t take for granted that the patient tend to label the patient as unm ing if the treatment regimen is connotations that are not helpfu the therapist and provide little g barriers to exercising. Low patient compliance or n a wide range of diseases, in all s tice settings. Compliance range medical regimens. 5- 7 Factors rel sonal and disease factors as we relationship variables (Table 8-1 therapy about patient adherenc physiotherapists and patients i factors related to nonadheren encounter, lack of positive feedb helplessness. 9 Turk, a well-kno summarizes the need for physic

Physical therapists ing compliance as cise regimen. They influencing the pat their behavior. II

Physical therapists know th cooperation or adherence when t tive about the condition and it unique interpretation that incorp tive factors, which determine th patient's perspective and the proc to the teacher-student model in w vessel" into which the teacher (

Apathy and pessimism Previous history of nonadherence Failure to recognize need for treatment Health beliefs Dissatisfaction with practitioner Lack of social support Family instability Environment that supports nonadherence Conflicting demands (e.g., poverty, unemployment) Lack of resources Disease variables Chronicity of condition Stability of symptoms Characteristics of the disorder Treatment variables Characteristics of treatment setting Absence of continuity of care Long waiting time Long time between referral and appointment Timing of referral Absence of individual appointment Inconvenience Inadequate supervision of professionals Characteristics of treatment Complexity of treatment Duration of treatment Expense Relationship variables (patient-practitioner) Inadequate communication Poor rapport Attitudinal and behavioral conflicts Failure of practitioner to elicit feedback from patient Patient dissatisfaction

Source: Reprinted with permission from D Meichenbaum, DC Turk. Facilitatin Treatment Adherence. New York: Plenum, 1987.

knowledge. For example, exercise is a therapists often want their patients an vessel metaphor as the model of the pat vides knowledge (i.e., gives the patie written materials or classes about his o clude that if a patient does not improv until the vessel is filled with the right edge does not necessarily lead to a cha Following a treatment plan requires (2) know when to do the plan, (3) hav the plan, and (4) remain motivated t resolves. Thus, while treatment and k tant, the patient's initial and long-term understand these, therapists must u Therapists are more likely to facilitate iors by understanding the patient's bel and based on culture, past experiences This ability to effectively underst increasingly important as the changes of shrinking health care resources, the sure to set priorities and maximize res sure to demonstrate that the treatm outcome. 13 The pressure on therapist smaller number of visits will increase. with the highest likelihood of patient an essential factor in assessing patient needs and demands, increased empha and health promotion are found in fede guidelines of the American Physical T

Explanatory Mode

Every therapist has one when he or she works with patients. Th ing about the patient's wants and nee patient's receptivity to change, and ho at home. Just as a patient comes to the dition, its immediate and long-term c ment that have and have not helped, explaining the cause of the patient's co treatment. That is, the therapist has a

90-50212. Washington, DC: U.S. Department of Health and Human Services, GPO, 1990.

through prevention of dise disability. Priority areas Broad categories, such as hea motion (changes in behavi choices), health protection ( in the environment), and c preventive services (access screening, immunization, counseling).

Commission on Accreditation in Physical Therapy Education, American Physical Therapy Association. Evaluative Criteria for Accreditation of Education Programs for the Preparation of Physical Therapists. Alexandria, VA: American Physical Therapy Association, 1991.

Graduate outcome objectives Design a comprehensive phy therapy plan of care that i recognition of: (1) the influ biological, psychological, co social, and cultural factors o pliance and achievement o and (2) concepts of health tenance and promotion an vention of disease and disa

Evaluative Criteria for Accreditation of Education Programs for the Preparation of Physical Therapist Assistants. Alexandria, VA: American Physical Therapy Association, 1992.

The program graduates: Interact with patients and fa in a manner that provides desired psychosocial suppo including the recognition cultural and socioeconom differences. Participate in the teaching o health care providers, pati and families.

American Physical Therapy Association Education Division. Coalitions for Consensus. Normative Model of Physical Therapist Professional Education (4th rev). Alexandria, VA: American Physical Therapy Association, 1996.

Practice expectation: health pro Professional skills Identify and assess the hea needs of individuals, gro and communities, inclu screening, prevention, a wellness programs. Promote positive health be and potential for life ch

Table 8-2 continued

Source

American Physical Therapy Associa A guide to physical therapist prac Phys Ther 1995; 75:717.

Sources: American Physical Therapy Phys Ther 1995;75:717; National Hea Healthy People 2000. DHHS Publicat Department of Health and Human Se in Physical Therapy Educaiton, Amer teria for Accreditation of Education P Alexandria, VA: American Physical T Accreditation in Physical Therapy Ed Evaluative Criteria for Accreditation cal Therapist Assistants. Alexandria,

patient and the provider. Kleinman defined Ems as "the notions pa families, and practitioners have about a specific illness episode.,,18 models represent the patient's attempt to make sense out of the from "ease" to "disease." These beliefs often incorporate an attempt patient to self-disprove and ascribe a course to the condition. The pa diagnosis and casual beliefs bring into play beliefs about the likely quences of the condition, the time before the condition resolve treatments (home remedies and prescribed). Kleinman l8 and othe speculate that the effectiveness of clinical communication and the pa health care outcome may be a function of the extent of discr between the patient's explanatory model and the provider's expla model. For example, if a patient comes to physical therapy with the tation that the therapist will fix his or her problem and will provide massage for his or her sore muscles, while the therapist expects to g patient on a home exercise program in one visit, there is likely to be flict in their interactions or disappointment when either realizes that he is not getting what was expected. The dominant explanatory model shared by many practitioners biomedical model, which focuses on pathology and disease process, p symptoms that are a result of the disease process, and the medical in tion that will fix those physical symptoms and the problem. 20 While the deficiencies of this model as a way of thinking about practice are b ing increasingly apparent. Because of recent discussions in physical t about the critical importance of patient outcome, more emphasis i placed on addressing the patient's functional needs and health status, than just documenting changes in physical impairment measures (e.g of motion or strength) and assuming those changes will result in a p functional outcome in patients' lives. 21 , 22 Such emphasis puts the th in touch with part of the patient's perspective, because it requires t therapist know the patient's functional goals. However, this em ignores the other elements of the patient's explanatory model th affect treatment adherence. Another example of an explanatory model is a disablement schem as the International Classification of Impairments, Disabilities, and

DISABLEMENT PROCESS

Pathology

Impairment

ORGAN AND BODY SYSTEM

Figure 8-1 Disablement concepts

model displayed, assists the ther the disease affects the patient's b A Jette. Physical disablement con tice. Phys Ther 1994;74:380.)

caps.21 A model like this prov think more deeply about the fu a patient who has a disease lik disease and a subsequent lower of impairment as a result of the ments, such as loss of range of m be measured and documented. tionallimitations in the patien activities. Over time these chan to changes in his or her ability would be considered a handi process affects individuals not personal and social levels. Phy patient movement and enhanCi physical, personal, and sociaPl apist explore the patient's tr determine possible treatment b

A Patient-Practitioner Collaborative Model

We propose that a patient-practitioner collaborativ can be used to help physical therapists and physical therapist as focus their interventions on patient need and improve the patient' ence to treatment. This model integrates concepts from several oth els in medicine and physical therapy (Figure 8_2).6,8, 12,20 At the c the model is the patient in the context of his or her life. This inclu patient's beliefs, attitudes, skills, and feelings shaped by a lifetime her disease, others' diseases and illnesses, and his or her support sy is useful to distinguish two conceptualizations of ill health-dise illness. Disease represents what went wrong with the body as a m whereas illness represents the person's experience of the disease o her life. Patients come to physical therapists with many beliefs abo illness experiences. Such beliefs mayor may not be scientifically Diseases, on the other hand, are diagnosed by the therapist using medical model. The focus of most practitioners' evaluative proc finding out the diagnosis or diagnoses: The patient's illness ex may not be explicitly understood by the practitioner. As a conse the patient's and therapist's goals and explanations are disconnecte necting with the patient means developing a relationship that allow ing the patient's beliefs as the first step of negotiating a treatm argue here that understanding disease and illness is a critical a therapeutic intervention. Essential to the therapist's role as a prof is understanding not only the context of the patient's life and th care system but also how these contexts influence manifestation patient's disease and illness. Finally, through the process of per education, and support, therapists need to teach patients how to disease or relapse and promote health. The model we propose h phases: (1) establishing the therapeutic relationship, (2) diagnosing mutual inquiry, (3) finding common ground through negotiati (4) intervening and following up. This model can easily be integra the physical therapy evaluation process. Table 8-3 demonstrates a centered approach compared to a provider-centered approach to eva

Communicate respect and care via: Positive verbal and nonverbal interactions Active listening Responsive touch

CONTEXT: Family system and health care system

Physical and movement diagnosis Begin behavioral diagnosis process Identify disease beliefs Identify treatment beliefs Identify valued activities Identify potential barriers to treatment

INTEGRATE: Prevention and health promotion

INTERVENTION AND FOLLOWUP: TEACH AND PROBLEM SOLVE Teach performance skills, provide knowledge of how to implement and monitor self-treatment, design reminder strategies Evaluate for treatment effect Evaluate for adherence Problem solve to eliminate barriers to adherence Modify success indicators as patient progresses

NEGOTIATE COMMON GROUND Continue with behavioral diagnosis Identify best treatment patient is likely to follow Link to valued activity Identify specific barriers to treatment Assess self-efficacy Make a mutual agreement for long- and shortterm goals

Figure 8-2 Examples of key concepts that are part of the physical therapist's work with patients in facilitation of exercise or other self-management strategies.

chart as evaluation begins. Collecting data and recording on clipboard.

ing gentle palpa the most acute patient sits on t Engaging in perso logue and findin area of common with the patien

Focusing on gathering data on the joints involved, including the activities that make the symptoms worse and better. Assessing the irritability of the patient's condition (moderate), so that the therapist is able to perform a good physical assessment and localize the involved thoracic joints.

Diagnostic process of mutual inquiry.

Identifying the are racic spine whe mary symptom Discovering the p intense fear of f from the osteop Identifying that th patient's primar to pick up grand Finding out that t walks in the ma group of friends week.

Establishing that joint mobilization, grades I and II, will be the appropriate place to start. Discussing with the patient the prognosis that the manual therapy along with an exercise program should eliminate the symptoms in 2-3 weeks.

Negotiate common ground.

Identifying that pa most likely to e along with her walking. Setting mutual sh goals with patie become proficie her exercise pro Setting the long-t for the patient t to pick up her g Performing an ini ment of self-eff shows that the fear of fracture be addressed.

Table 8-3 continued Provider-centered approach: professional as expert Intervention. Proceeding with joint techniques; reassessment shows increase in movement. Giving patient a sheet of home exercises that include trunk extension and beginning mobility exercises for the trunk. Writing on the sheet for the patient to do each exercise five times twice a day.

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Followup. Noting patient complaints of difficulty in doing exercises. Reviewing the exercises, performing another session of mobilization, and adding two self-mobilization exercises. Telling the patient that you will see her in 2 weeks.

Establish the T

The concept of the of therapeutic evaluation and in with establishing a therapeutic during the interview. This is cru revealing his or her beliefs and f Verbal and nonverbal behaviors some may think that these behav are focused on gathering evaluat

Clarifying the patient's needs Nonverbal Facing the patient Making eye contact Leaning toward patient Displaying an open posture Using nonverbal cues to acknowledge active listening Behaviors that impede the therapist's connection with patients Acting busy Reading notes Doing tasks Using medical jargon Cutting off patient's story Responding only to disease information Failing to give feedback Showing little empathy Not asking about the patient's concerns

Sources: D Meichenbaum, DC Turk. Facilitating Treatment Adherence. N Plenum, 1987; GM Jensen, C Lorish. Promoting patient cooperation with programs: linking research, theory and practice. Arthritis Care Res 1994;7 R Carkcuff. The Art of Helping (7th ed). Amherst, MA: Human Resources 1993.

toms, they are often unaware of their verbal and nonverbal interac example, when under pressure to get the needed evaluative data, a b apist may not make eye contact or may cut off a patient's story a only disease data and not ask about the patient's concerns. The m the patient is that the condition is important, not the patient. The reduced to the facts about his or her symptoms. Table 8-4 pro overview of key behaviors that facilitate and impede the therapist' tion with the patient. 8, 24 Consistent and timely use of behaviors t tate connection has a great deal to do with whether the patient re or his beliefs and becomes a willing partner in treatment.

Diagnostic Proce

Some form of the dia a physical therapy evaluation. This therapist meet. The process usual the patient and begins the physic with inquiring about the moveme pist should begin to do an explici adherence or cooperation by beginn This information is crucial for und treatment. Typical barriers include to do the treatment; not being con treatment; having beliefs or values having the time, equipment, or sup Assessing what the patient kno and treatment is a good place to star of the patient's beliefs about the c tion, and what treatments he or sh needs to identify the patient's belie quences of the disease or condition Sample questions for this asse

How would you describe the p therapy? What do you think caused the Why do you think this happen

The therapist must also find ou Some sample questions about the p

What things can you no longer of your condition? What daily activities do you n How do others who you live w How does your body tell you t causes these changes?

The therapist will also want to k including past treatment, home tre pist should also identify any potent ment by asking questions like:

Why is it so important to identify these patient beliefs? The ans questions like these reveal much about what the patient knows and d know about her or his condition, what activity he or she wants to that can motivate treatment adherence, and what alternative treatm patient may be doing in addition to the prescribed treatment. Physic apists are ultimately interested in facilitating patients' self-care in t their movement problems. Exercise is likely to be one of the health iors that is part of the treatment regimen carried out at home. As th pist asks the patient to reveal more about his or her understan the condition and what possible treatment she or he is likely to the patient is also gaining information about the therapist by ob and responding to the questions and developing or modifying about the therapist's competence and trustworthiness. 6, 20 By inquirin the patient's beliefs, the therapist shows interest in the patient's and the disease process.

Finding Common Ground Through Negotia

As the therapist continues the evaluation and beh diagnostic process, she or he is negotiating treatment goals w patient. The essential question here is not just what is the best tre for this condition, but what is the best treatment that this patient ly to follow. To answer this question, the therapist must contin the behavioral diagnosis and find out more specifically abou potential barriers (e.g., physical, sociocultural, and psychologic were not revealed by the other questions. I, 8 To discover these b the therapist should begin by acknowledging that many patients difficult to follow an exercise program (Table 8-5). The therapist then ask the patient: What problems do you anticipate? What are your beliefs about exercise? What are the worst things about exercise and what are the best

Table 8-5 Typical Positive and Ne Negative consequences

Boring Takes too much time Too complicated Increases symptoms Takes too much energy Forget to do them Exercises have no purpose Positive consequences

More limber More energy Can do more valued activities Exercise with friends Feel stronger More independent Family is supportive

A central aspect of the behav the patient's motivation to imp patient has some important acti ment goal to motivate treatmen what activity the patient wants m wants most to control or elimina of self-efficacy /i.e., the state of b behavior) is a good predictor of m is more likely to follow the trea high likelihood that the treatm goal. The patient's belief that th come can be developed by referen cess experience with the treatme her or his ability to perform the performing the treatment must the patient's motivation are:

What is the most important What symptoms do you wish How confident are you in yo Do you think these exercises important activities?

Teaching and Problem Solving During Intervention and Followup

Instruction about the treatment regimen is critical,3, haps one of the most common mistakes is making the treatmen men too complex (i.e., giving the patient too much to do with little sp instruction).l,6 While the therapist may believe that doing all 10 exercises is critical to a rapid change and that the patient can refer exercise handout, the likelihood of a patient being able to succes do all the exercises is probably quite low. If home exercise is part intervention, then patients should receive specific instruction psychomotor aspects of the exercise, clear written instructions on to do, specific tailoring of the exercise to the patient's lifestyle an ued activities, and, if necessary, reminder strategies to perform the cise. The therapist should find out about social support and tea family or significant others the exercises if necessary. The foll questions are helpful for assessing the patient's understanding treatment regimen:

Can you tell me what you are supposed to do? (Includes exercise quency, duration, and intensity.) Can you demonstrate the exercise(s)? What problems do you anticipate fitting the treatment into your activities? Do you have the necessary equipment? Do you have a place where you can do the exercise(s)? What should you do if the exercises are not working or causing a tive change in symptoms?

When the patient returns for followup, the therapist should evalu patient not only for change in physical impairment measures and fu but also for treatment effect-present and future. The therapist wi want to do some specific assessment for adherence to the regimen. S questions for assessment of adherence to the regimen include:

Table 8-6 Problem-Solving Skills

Key problem-solving steps 1. Define the problem in behav 2. Encourage the patient to sub do something with a specific 3. Generate possible solutions 4. Evaluate the positives and n least practical to most practi 5. Try out the solution. Stay fle 6. Reconsider the problem. Can about the problem?

Ideas for problem-solving methods l. Talk to others. 2. Recall what things have wor 3. Imagine how someone else m 4. Think of the future and pote 5. Practice coping by rehearsin 6. Look for a support system th 7. Use coping skills instead of

Source: Adapted from D Meichenba ence. New York: Plenum, 1987.

Can you perform the exerci What changes have you not change? Were there any negative co How many times did you fo did you have? What has happened with pr How long before you expec condition?

Followup with the patient i solving. This is necessary becau intervention. What was motiva because of the patient's contin ment. The therapist will need t adherence. If necessary, she or h indicators (if the patient has pr ment to the goals. Table 8-6 pro be used when working with a v

a problem adhering to the intervention, the physical therapist will explore barriers to following the treatment. The therapist may also find ways to adapt or change the treatment goal and the time line to modate barriers that cannot be changed. Lorig and coworkers3 outline sion chart that can be used by the therapist for exploring with the how to improve adherence (Table 8-7). For example, if a patient can why he or she is not doing the exercises, the therapist may need t problem-solving steps as tools to get at the patient's belief system. Th apist may begin by defining the problem, evaluating the positive an tive aspects of exercising, having the patient recall what has worked past, identifying a support system, assisting the patient to focus on with the barriers, and not giving up (see Tables 8-6 and 8-7).

Role of Self-Efficacy

Several of the areas for exploration, renegotiation, and p solving with the patient have to do with the concept of self-e Remember that self-efficacy is a person's belief that she or he can plish a behavior. 3, 25 There are four central areas to focus on to enhance a patient's s cacy. The first is skills mastery, which is where therapists usually making sure the patient can perform the exercise. Often a task can ken down into smaller tasks. The patient needs feedback about his performance of the exercise to increase the likelihood of mastery of th See Chapter 9 for more information on effective feedback strategie setting or contracting is another method of providing feedback. 3, 25 Modeling is another strategy for increasing self-efficacy. In one patient care, often the therapist is the model. In group education s the model should be most like the patient, matching as many char tics as possible (e.g., age, sex, ethnic origin, socioeconomic statu therapist may consider having another patient with a similar co demonstrate. One reason why group educational intervention can b ful is that patients are modeling to each other and, therefore, enh their own self-efficacy.3, 25

Table 8·7 Suggestions for Impro Problem

P r

Can the patient tell you why he or she is not doing the exercises? Does the patient believe that adherence to the regimen will help the problem? Does the patient understand the exercise program? Does the patient have the skills to do the exercises?

Does adherence with the exercise program have negative consequences for the patient? Does nonadherence have positive consequences for the patient? Does the patient forget to do the exercises? Does the patient believe that he or she cannot do the exercises? What if the patient does not want to adhere to the regimen?

Source: K Lorig (ed). Patient Educa Oaks, CA: Sage, 1996.

Two other strategies for en of physiologic signs and sympt physiologic signs and sympto First, you must find out what p they interpret their present sym

encouragement in exercise. As a last resort, the therapist should emph to the patient the negative consequences of not doing the exercise. strategy of emphasizing what a patient might lose should be used with and only after some initial problem solving has been done. Although therapists may quickly focus on sharing their knowledge with the pa by telling him or her all the bad things that could happen, initial foc the positive consequences of treatment is an important aspect of pa practitioner collaboration. 3, 25

Self-Efficacy Patient Cases

This chapter discusses the central importance of collabo with patients and working together with them in designing a trea intervention that is likely to be followed. The following three case grounded in the collaborative model and demonstrate specific applicat concepts from self-efficacy theory. The reader should try to identify th efficacy concepts being used in each case.

Case Study One Bill is a 34-year-old man who came to physical therapy fo ing surgical repair of knee, which he hurt during a pickup bask game. He currently works as a plumber. He was given a home ex program. He found the exercises hard to do because they caused pain. During his last visit, he said that he did not think exercis doing him any good and wanted to quit and just get pain medic from the doctor.

What now? First, attempt to understand more about Bill and ex more of his current life circumstances. When you probe more specif about his home life, his family, and his financial status, you find that afraid of not being able to hold his job as a plumber because of his problem. He and his wife have a 2-year-old child and another baby o way. He believes that his knee will not get better through exercise be he associates exercise with pain. His concerns about potential unem

ment, failure to fulfill his role as of exercise with pain are all con exercise therapy. You identify the barriers to and his belief that exercise doesn' specific times per day to exercise of these times he exercises at wo exercise program so that the pain porary and reteach Bill the exerc You also work with Bill on rein quence of exercise. You teach hi duce the use of ice for pain relief.

Case Study Two Helen has worked w her lO-year course of rheumat she does the exercise for a wh specific shoulder problem, b Helen really needs more supp being involved in a regular fit sibilities with her, she immed health club. She says that she

You arrange at the next visit f arthritis and participates in the a community pool to come and tal the program, discusses her contin time to take Helen to the next c decided not to be a role model for Calling on this friend seemed to what she could do.

Case Study Three Mr. Runningbear is experienced a mild stroke. strength and increasing numb physical therapy for a home You find out in exploring wi stroke that he is quite concer ishment for past events in hi

you decide to enlist others to assist in persuasion and perhaps some re pretation of your patient's physiologic symptoms.

Summary

Although little research has been done in physical th regarding patient-centered communication, there have been several st in medicine investigating whether patient-centered communication m any difference to the patient and health outcome. There is strong evi that more patient-centered communication does lead to enhanced p satisfaction and more positive outcomes. 26-29 In effective use of the pa centered approach, the physician does the following:

1. Asks questions about the patient's complaints, concerns, under

standing of the problem, expectations, impacts, and feelings. 2. Shows support and empathy. 3. Allows the patient to express himself or herself completely. 4. Allows the patient to perceive that a full discussion of the prob has taken place. S. Allows the patient to ask more questions. 6. Uses information and educational materials for patients. 7. Is willing to share decision making with patients.

We have presented a model for patient-practitioner collabor that hopefully can be useful in clinical practice. Chapter 10 provide reader with many examples of how to use this patient-practit collaboration model in designing specific educational intervention patients and families. We firmly believe that attention to and gration of adherence procedures should be part of every physical t pist's and physical therapist assistant's therapeutic interactions wi patients. The following treatment adherence guidelines, suggest Meichenbaum and Turk, 6 provide a good summary of the key ide this chapter:

Guideline 1 Guideline 2

Anticipate no Consider the patient's pers Guideline 3 Foster a colla Guideline 4 Be patient-ori Guideline 5 Customize tr Guideline 6 Enlist family Guideline 7 Provide a sys Guideline 8 Make use of o munity resou Guideline 9 Repeat everyt Guideline 10 Do not give u

References

1. Bartlett EE. Behavioral diag tion. Patient Couns Health 2. American Physical Therap practice. Phys Ther 1995 j 7 3. Lorig K (ed). Patient Educa sand Oaks, CA: Sage, 1996 4. Redman Klug B. The Proc Mosby, 1984 j 21. 5. Haynes R. Ten-year upda Educ Couns 1987 j lO:107. 6. Meichenbaum D, Turk D York: Plenum, 1987. 7. Slujis EM, Knibbe J. Patie retical approaches to sho Educ Couns 1991 j 17:191. 8. Jensen GM, Lorish C. Prom grams: linking research, 1994j 7:181.

9. Slujis EM, Kok GJ, van der physical therapy. Phys The 10. Jette AM. Improving patie mens. Arthritis Rheum 19 11. Turk D. Correlates of exe mentary). Phys Ther 1993 j

15. Commission on Accreditation in Physical Therapy Education, Am can Physical Therapy Association. Evaluative Criteria for Accredit of Education Programs for the Preparation of Physical Therap Alexandria, VA: American Physical Therapy Association, 1991. 16. Commission on Accreditation in Physical Therapy Education, Am can Physical Therapy Association. Evaluative Criteria for Accredit of Education Programs for the Preparation of Physical Therapist A tants. Alexandria, VA: American Physical Therapy Association, 19 17. American Physical Therapy Association, Education Division. C tions for Consensus: A Normative Model of Professional Educa Alexandria, VA: American Physical Therapy Association, 1995. 18. Kleinman A. The Illness Narratives: Suffering, Healing and the Hu Condition. New York: Basic Books, 1987. 19. Levanthal H. The role of theory in the study of adherence to treat and doctor-patient interactions. Med Care 1985;23:556. 20. Stewart M, Brown 1, Weston W, et al. Patient-Centered Medi Transforming the Clinical Method. Thousand Oaks, CA: Sage, 19 21. Jette A. Physical disablement concepts for physical therapy rese and practice. Phys Ther 1994;74:380. 22. Jette A. Outcomes research: shifting the dominant research paradig physical therapy. Phys Ther 1995; 75:965. 23. Selker 1. Human resources in physical therapy: opportunities rapidly changing health system. Phys Ther 1995;75:31. 24. Carkcuff R. The Art of Helping (7th ed). Amherst, MA: Hu Resources Press, 1993. 25. Bandura A. Social Foundations of Thought and Action: A Social C tive Theory. Englewood Cliffs, NJ: Prentice-Hall, 1986. 26. Evans B, Kiellerup F, Stanley R, et al. A communication skills gramme for increasing patient satisfaction with general practice sultations. Br J Med PsychoI1987;60:373. 27. Kaplan S, Greenfield S, Ware J. Assessing the effects of physi patient interactions on the outcomes of chronic disease. Med 1989;275:5110.

28. Roter D, Hall J. Doctors Talk Doctors. Dover, MA: Auburn 29. Levinson W. Physician-Pat 1994;272:1619.

Annotated Bibl

Bandura A. Social Foundations of Theory. Englewood Cliffs, NJ social learning theory and self well-known theory. The book menting various aspects of th standing all aspects of self-effi Glanz K, Lewis FM, Rimer B. He Francisco: Jossey-Bass, 1990;3 excellent foundation materia health behavior. The book ad health behavior as well as gro Kleinman A. The Illness Narrati Condition. New York: Basic trist and anthropologist who medical anthropology. He is between the patient and the models is used by many. Lorig K (ed). Patient Education: A Oaks, CA: Sage, 1996. This is able with lots of examples. Th theory and other simple beha The book contains a number cation programs for groups. Meichenbaum D, Turk DC. Faci tioner's Guidebook. New York sic. The book is the most enhancing patient adherence guidelines and techniques fo issues of nonadherence. The b the health professions. Stewart M, Brown J, Weston W, forming the Clinical Method text, although written from w

Diane E. Nicholson

Shortly after starting my first job as a physical therapist treated a young woman named Nancy who had a left hem paresis secondary to stroke. For the first few days immedia ly after her stroke, Nancy had minimal, if any, act movements in her left arm and leg and she required moder to maximal assistance for most functional activities. Fo months after the stroke, I helped Nancy learn bed mobili transfers, and gait. Gradually her active movements and fun tional abilities increased, and on hospital discharge, Nan was walking independently with a straight cane. Six mon after her hospital discharge, Nancy had thrown away her ca and she was running.

Why did Nancy do so well? How much of her rehabilitation could ph ical therapy account for? Was her physical therapy program efficient? Cou she have reached a higher level of function with a different treatment p gram or with a shorter hospital stay? The focus of most teaching in physical therapy clinical settings is optimizing motor performance-that is, the enhancement of daily functio al activities. An understanding of motor learning principles (content know edge) is as important to the practitioner in physical therapy as are t elements of didactic teaching (pedagogical knowledge) presented in Chapt 2, 3, 8, and 10. The primary purpose of this chapter is to present variab related to motor learning that therapists can manipulate to facilitate cli acquisition of psychomotor skills.

2

Chapter Object

After completing th

1. Differentiate between mot 2. Describe the following pro and motor learning: attent motor memories, exempla retrieval of memories, lear peripheral constraints. 3. Describe Adams', Schmidt 4. Discuss Fitts' and Posner's motor tasks taxonomy. 5. Describe person, task, and formance and motor learni 6. Manipulate the following learning: prepractice variab scheduling and timing of a discovery learning and gui interference, part- and who and audience effects. 7. Adapt motor learning pri populations.

Distinction Bet and Motor Perf

Motor learning is a rience that results in a relatively ity of performing skilled action process, motor learning cannot b ated indirectly most often by me example, in physical therapy, mo ing change in a client's performan up-and-go-test. " However, at any point, moto other than motor learning. Table 9 or permanent effects on perform result in relatively permanent cha of separating the permanent effect changes across days or weeks inste

Guidance Fatigue Stress Boredom Pharmacologic agents

practice

Practice and learning

transfer

fective when one is attempting to measure learning in pediatric and elder populations because maturation can result in physical changes over days weeks in children and older adults. To separate maturation and practi influences on performance in these populations, comparisons of practice a nonpractice groups are usually necessary. For example, several studies ha used two group experimental designs to separate performance changes d to maturation and participation in early intervention programs. 2, 3 Temporary factors, such as motivation, physical or verbal guidanc fatigue, stress, and boredom from long therapy sessions, also influen performance. During my initial years as a therapist, I essentially ignor these temporary effects. However, I now recognize that temporary a permanent effects of these variables can have remarkably different effec on performance. To measure motor learning, the effects of temporary factors on perfo mance should be minimized. The most common method used to reduce t temporary effects of variables on performance is to allow a rest interv between the practice and the evaluation session. In physical therapy s tings, the effects of temporary factors can be minimized by evaluating client's performance after he or she rests or by evaluating performance at t beginning of a subsequent therapy session. Separating the effects of temporary and permanent factors on perfo mance is critical for documentation. During the first 10 years of my clinic

practice, I mistakenly document mance I observed in therapy. T influenced by the temporary ef facilitation techniques). Now I in permanent effects of variables. I by evaluating performance at the ument client performance durin permanent effects of practice. Goals of practice include cap time and capability to modify a p a different environment, at a diff gait training might include the velOCities; on tile, carpet, grass, way. Often the physical therapy ments that clients will encounte The field of motor learning ticed and new environments. Ev ing a practice or therapy sess evaluation in a different environ sion is termed a transfer test. Fo tile during therapy, he or she wo ed on tile and a transfer test whe fer tests are used for measures of performers learn practiced tasks ers learn to generalize learning t

Overview of th

At least two major of motor learning. First, learnin processes, not specific movemen therapists should understand the Second, practice conditions that problem solve (i.e., process infor memory retrieval processes) are m ditions in which solutions are pr that clients in physical therapy s production of their movements b Instead of performing therapy o solutions, therapists should act a problems. The processes of moto

chunking).

5. The capability to detect and correct errors enhances learning. Error detectio and correction occurs on-line, or during, slow, positioning movements. It occurs after the movement in fast, timing tasks.

6. Exemplar and generalized sensory and motor memories are thought to be st in memory. 7. Retrieval practice enhances learning more than repetitive drills. 8. Instead of focusing on individual elements of a functional task, performers should focus on the goals of the task.

9. Actions become more efficient when performers learn to exploit the biomec anics of a task.

10. Categorizing tasks based on task goals and environmental and performer co texts can enhance understanding of task requirements.

Stages of Learning

In 1967, Fitts and Posner proposed three sequential stag motor learning: (1) the cognitive stage, (2) the associative stage, and (3 autonomous stage. 4 During the cognitive stage, performers focus on un standing a task goal and developing strategies to most efficiently ach a goal. Because this stage is characterized by rapidly improving and able performance, it is thought to require cognitive processes, suc attention. Teaching techniques and strategies are probably most usef this stage of learning. A classic example of the cognitive stage is the first few month learning to drive a car. My personal performance at this stage consiste gripping the steering wheel, being unable (or at least unwilling) to rem my visual focus from the road, and having difficulty engaging in a con sation with another passenger or resetting the radio station. All of attention was directed at trying to understand the relationships betw the steering wheel, the gas pedal, and the brake pedal and keeping the on the right side of the road and not in a ditch. In essence, driving dem ed all my attention.

Each time I attempt a new mo snowboarding), and often when I quently practiced environment (e skiing down a steeper hill than I learning. I often observe clients go are in therapy. After a total knee performing a straight-leg raise. Ye they can often perform three or fou limiting factor for their first strai that their muscles were not perf that clients need to think about a action goal, "raise my leg," and th goal. After the cognitive stage of le stage of learning. Here the goal i the focus is on how to produce t cognitive stage, this stage is chara and reduced variability. Most mo stage of learning. To continue the previous exa drive an automobile represent the learned to smoothly accelerate and smoothly change gears using the g ciative stage is represented in phy to increase the safety or efficienc with an above-knee amputation le tion from taking a few uncoordina floor represents the associative st time to enhance her or his perfor and home exercise programs can b practice time of clients in the asso The autonomous stage of lear Relative to the first two stages, pe attention and information processi rent driving style characterizes changing the radio station, holdin monitoring children in the back physical therapy setting, the auton apparent when clients are trying strategies for producing movemen uses and constraint-induced facil

mation. Therefore, automaticity occurs due to a reduction in the amount o original information processing. An alternative view states that the amoun of information processing remains constant, while the speed of processing increases. 8 This view is most often explained by taking several sequentia segments of an action and putting them together to form a larger unitj this is termed chunking. An example would be taking several individual letter and putting them together to form a word. Learners are thought to proces the word as a whole unit and not as individual letters. Processing a whole unit is thought to take less time than processing each component separate ly. Thus, by putting information into larger units, information processing i faster and automaticity occurs.

Error Detection

The capability to detect errors is another process that i thought to develop with learning. Error-detection capabilities are thought to require memory of sensory feedback from previously performed actions Adams, in his 1971 closed-loop theory of learning, argued that performer accumulate memories of sensory feedback associated with each previously performed motor outcome. Storage of a memory for every action performed is termed an exemplar memory. Adams called these exemplar memories per ceptual traces. 9 Schmidt, in his 1975 schema theory of learning, argued that performers develop a recognition schema during practice. 1O These schema consist of a memory of initial environmental conditions, sensory feedback, and moto outcomes. In contrast to Adams' theory, in which every action is stored in memory, Schmidt suggests information from individual actions is kept only long enough to develop or update a generalized memory. (See Table 9-3 and Appendix C for summaries of Adams', Schmidt'S, and Newell's theories o motor learning.) In summary, Adams states that a memory is stored for every action tha is performed, whereas Schmidt states that only a few generalized memories are stored. For example, in the functional task of transferring from a chair to standing, Adams' theory suggests that a sensory memory trace would be

Table 9-3 Summary of Theories of M

Adams' theory 1. Focuses on slow, positioning task 2. Sensory feedback is required for 3. Exemplar (or individual) sensory action is performed. 4. Enhancing sensory feedback will 5. Errors will always interfere with 6. Emphasizes practicing tasks to b specificity of learning).

Schmidt's theory 1. Focuses on fast, timing tasks. 2. Defines a class of tasks as action amplitude. 3. Generalized sensory and motor m 4. Novice actions should be perform same class of tasks. 5. Errors can enhance learning. 6. Emphasizes benefits of practicing variability in practice).

Newell's theory 1. Emphasizes performer, task, and 2. Emphasizes relationships betwee (action) strategies. 3. Emphasizes relationships betwee

stored for each transfer that is att only one sensory memory would "composite" memory of all previou Regardless of whether exem (schema) memories are stored, Ad error detection is possible due to th ories. The memories that enable er ferently for slow-positioning and fa In slow-positioning tasks, sens to its endpoint. Thus, performers action matches the memory of sen fast-timing tasks, performers are u action on-line, or during an action to detect errors after the action has

a fast-timing task. A movement such as this is too fast for sensory feedbac to be used during the movement. Sensory feedback can be used only after th movement to determine the accuracy of the action-that is, the person i holding the glass or looking at a puddle on the floor. Several practice variables are thought to enhance the development o error-detection processes. These include allowing performers time to thin about an action before feedback is provided by a therapist, asking perform ers to estimate their own errors before feedback is provided, and withhold ing therapist feedback on some practice trials (especially near the end o practice). Several studies demonstrate that increasing the amount or qualit of sensory feedback during practice enhances performance. Expert coache are thought to stress the development of error detection with the idea that performers learn error detection, they will learn to evaluate their own per formances and can then continue to practice without the presence of a ther apist or coach. For more detail on the effects of practice variables on erro detection see Swinnen et al. 12

Motor Memories

In addition to storing generalized memories of sensory infor mation, Schmidt lO proposed that performers store generalized memories o motor information. He named this process the recall schema. This memor includes an abstraction or generalization of initial conditions, response spec ifications (time and amount of muscle activity used), and outcomes. In con trast, Adams 9 suggested that exemplar memories of individual actions ar retained. An example of the difference between the two models can be see with the functional task of chair-to-stand transfers. For this task, schem models suggest that only one generalized motor memory of chair-to-stan transfers is stored, and this memory is a composite of all previous attempt at this transfer. On the other hand, exemplar models suggest that moto traces from all previous chair-to-stand transfers are stored in memory Results from several studies, however, have led many motor behaviorists t believe that exemplar and generalized memories are stored in memory. 13

Forgetting and R

A main goal of prac memories or to retard forgettin occur because of trace decay and passive process in which a memo ference is an active process in w one another. Little evidence exis learning. Thus, most forgetting decay, with the amount forgotten example, forgetting is minimal f ing, walking, running, ice skatin discrete tasks, such as transfers rests, and bed mobility. Ideally, performers will deve for actions during practice. Howe performers must be able to retrie ory. Thus, a goal of practice is le term memory.14 For example, if problems-multiply four times th four times three-you will most from long-term memory. Howeve problems-multiply four times three-you can probably supply a using short-term memory witho term memory. Similar scenarios a ple, clients with left hemiparesi assist moving the left arm during to perform the tasks roll from sup roll from supine to right sidelying to right sidelying and back to s required to retrieve items from l trast, if the tasks are presented i sidelying, transfer from right side to left sidelying, clients should re ory on every trial. Retrieval practice can be enh practice on a trial-by-trial basis (te using drills or practicing the same practice). Blocked and random pra

Figure 9-1 Child with cerebral palsy learning to ride a tricycle.

the label of contextual interference or practice schedule, which is d later in this chapter.

Focusing on Actions, Not Movements

Many motor behaviorists argue that memories fo ments focus on task goals. IS There is little evidence that perform and retrieve memories for individual segments of an action (e.g the elbow, open the fingers, close the fingers, then grasp an object) regard for the task goal or the environment. This principle sugg patients should practice tasks or actions, not individual movem example, Figure 9-1 shows a child with cerebral palsy learning to r cycle. The therapy goal is to enhance interlimb coordination betw legs. During practice, the therapist and child focus on an outco

(moving the tricycle as fast as p limb coordination.

Learning to Ex

Increased consiste occurs with practice. Performer the passive inertia properties of tice, performers demonstrate in because they have learned to o requirements of a task. Physical therapists and phy help clients exploit biomechani most often teach a force-control strategy is relatively safe, a mom Cook and Woollacott 17 advocat strategies for transfers to have over efficiency, they may choose the primary goal, a momentum

Gentile's Task

What processes a attempted to answer this questio that the sensory, motor, and co task goals and environmental an Table 9-4 lists Gentile's taxo one of four environmental conte tionary, the environment is stab last two categories, termed mot task is being performed. In the fi variability, the environment rem ond and fourth categories, term changes from trial to trial. Exam (1) Getting out of bed at home, chair in the downstairs hallway with no intertrial variability (i.e. change from one repetition to th out the house on hardwood floo glass or a mug; or walking with examples of stationary tasks wit

V:;Z

Manipulation

>."!:: Variable

~~~ s::; ..... ...c Motionless .... til .....o ...... .... g ~ ~ > Body stability V:;.El 'tdC Consistent 'J:: .:.=: ..... ..... .... ...c

Variable

Variable

Motionless

Motionless

Motionless

Body stability Manipulation

Body transport

Body transport Manipulation

Consistent

Consistent

Consistent

Motion

Motion

Motion

'.0

.S ~ 00> Body stability :::EZ

Body stability Manipulation

Body transport

Body transport Manipulation

>- Open ."!:: ...... ........... Variable ~ os::; .;S ~ . 1:: ~ Motion ~ > Body stability :::E.El

Open

Open

Open

Variable

Variable

Variable

Motion

Motion

Motion

Body stability Manipulation

Body transport

Body transport Manipulation

II) os::; ....,

til

'.-1

.-1

o

• .-4

Motion

Manipulation

Variable

Source: Adapted from AM Gentile. Skill Acquisition: Action, Movement and Neuromotor Processes. In J Carr, R Shepherd, J Gordon, et al. (edsl, Movement Science: Foundations for Physical Therapy in Rehabilitation. Rockville, MD: Aspen Press, 1987;93.

is stationary, yet it may change from trial to trial). (3) Stepping on to a moving walkway at airports, selecting food off of a cafeteria conveyor belt, or walking through a revolving door at the front of a hospital are examples of a motion environment with no intertrial variability (i.e., the environment is moving, but the movement does not change from trial to trial). (4) Maintaining balance on a moving bus, walking in a crowded mall, and catching a falling cup of juice are examples of a motion environment with intertrial variability (i.e., the environment is moving and the movement changes between trials). As shown in the top of Table 9-4, tasks with little or no variation that are performed in a stable environment are termed closed tasks. These tasks

require consistent patterns of mo with little attention). Tasks that formed in a changing environmen Table 9-4). These tasks require a information processing. Examples ing a familiar flight of stairs and t mat. Examples of functional ope corridor and maintaining balance With the columns, Gentile s contexts. In the two categories on focuses on maintaining a posture. body transport, the person focu another location. In the first and the person focuses on one task, e.g or herself to another location. In manipulation, the person is requ e.g., holding a posture and manipu herself to another location while in each category are as follows: (1 are examples of body stability with while sitting and opening a kitch body stability with manipulation with two feet are examples of body ing and talking simultaneously or to the kitchen table are examples How does Gentile's taxonom quently performed in physical th categories. Then these categories processes required for different processes that a client is success cient exercise program based on a she would like to perform, and (4) of tasks and processes that are saf

Variables That

Considerable resear kinesiology, physiology, and eng influence skill learning. Informat that findings from experiments in populations. Although this gene

multiple-limb actions that coaches and therapists attempt to help clien learn or relearn. Second, the tasks and environments in most motor learni studies have been held constant. Thus, there is very little motor learni research under conditions with changing tasks or environments. Stud using changing tasks, environments, or both have typically focused motor control mechanisms and not motor learning effects. Third, the majo ity of motor learning studies have focused on persons without cognitiv affective, or physical impairments (i.e., a normal population). Very few stu ies have focused on motor learning in therapeutic environments. However, the few motor learning studies performed with clinical po ulations suggest that the principles of motor learning are similar for pop lations with and without physical impairments. l9 , 20 Several therapists wi expertise in motor learning have made the assumption that motor learni principles and results from experiments of motor learning provide a the retical basis and suggestions for therapeutic interventions used by the pists. 2l - 23 Further research focusing on persons with physical impairmen is needed to confirm the effectiveness of motor learning variables in the peutic settings. The purpose of this section is to provide readers with information how to apply motor learning principles to clinical situations. As shown Table 9-5, prepractice and practice variables are covered. This section intended to be solely a summary of variables found to influence learning. F a more comprehensive review, readers should see Schmidt l or MagilP4

Prepractice Variables

Therapists can manipulate several motor learning variab even before practice begins. These prepractice variables include motivatio goal setting, ensuring that clients understand task goals, modeling, a demonstrations. Clients and their families should be included in goal form tion. Goals should be motivating and challenging, yet clients should be a to learn to achieve the set goals. Goals should be objective and measurab (e.g., walk independently without losing balance for 80 meters in 1 minut The goal" do the best you can" should be avoided, as it has been shown to

Table 9-5 Variables That Influence Lea

Prepractice variables Goal setting Understanding task goals Understanding critical sensory cues an Modeling, demonstration

Practice variables Amount of practice Rate of improvement and over practice Frequency of feedback (100% or reduce Scheduling of feedback (faded, bandwid Timing of feedback (instantaneous or d Types of feedback (KR or KP) Videotape feedback Discovery, learning, and guidance Variability in practice (several variation Contextual interference effects (random Part- and whole-task practice Speed-accuracy trade off Audience effects KR = knowledge of results; KP = knowledge

less effective for learning than objectiv be on the action or task level (e.g., wa be asked to perform motions (e.g., ben Before beginning practice or in t should ensure that performers unde achieving a task. Therapists should al mation and changes in sensory inform gested by modeling or demonstratin demonstrations can be achieved by w ing a therapist model the desired actio

Practice Variables

Amount of Practice and The amount of practic directly related. Therefore, therapists practice. This can be achieved by in formed in a therapy session or by givi practice outside of therapy sessions.

However, therapists and third-party payers should also co learning effects of continued practice after a goal has been achi tinuation of practice after a criterion level of performance has be is termed over learning or over practice. Over practice is expensi effects of over practice are thought to retard forgetting. In a cla Melnick had performers practice a balance task on an unstable sur the goal criterion was to maintain standing balance for at least 28 Four practice conditions were used: Subjects in the criterion (e) received no further practice after they reached the criterion C-50%, C-100%, and C-200% conditions performers practiced 5 and 200% more trials, respectively, after they reached the crit Each subject participated in a retention session 1 week or 1 month tice. The balance time on the first retention trial and the numb tion trials required to reach 28 seconds of standing balance we measures of amount learned. Results of both retention trials were similar. The averag achieve standing balance during the first retention trial was reli for groups with over practice than for the (e) group. In addition, number of trials required to reach 28 seconds of standing balanc ably less for the C-200% group than the criterion group. These r gest that practice conditions that include over practice are more e learning than conditions in which performers practice until they terion goaL These beneficial learning effects are thought to be potent when, after some time interval without practice, the first a response is critical, such as to avoid falls or accidents. To balanc and benefits of practice beyond criterion levels, Magill24 sugges formers practice 100% beyond criterion levels. In summary, the amount learned is usually directly rela amount of practice. Therefore, clients should be encouraged to inc practice time by using home exercise programs or by participatin practice sessions. These extended practice sessions should be esp eficial for safety and for generalizing skills to novel situations.

Augmented Feedba Secondary to the am often considered to be the most ing. 27,28 Information feedback, pr information that informs perform of an action. Intrinsic informatio vided by sensory systems, wherea not readily available in a task, is augmented information that has results (KR). KR is defined as ext relationship between an action a occur when performers are told meaning that they need to decrea respectively, to achieve a goal. Investigators have altered nu temporal location, or the precisi attempts to understand the princ frequency and scheduling of info large research effort. Frequency of KR is most ofte formers practice the same numbe after every action and other group and Schmidt3° compared 100%-K 100%-KR condition, augmented f action, whereas in the 50%-KR co ed after 50% of the practice trials tive days, performers in both gr minutes and 24 hours after the e mance during the practice sessio the 50%-KR group demonstrated group on the lO-minute retention the 24-hour retention session. T feedback on some practice trials ing augmented feedback on every Several schedules can be us some practice actions. Winstein studies of KR frequency, presente each practice session and less oft is termed a faded feedback sche feedback were manipulated, the effects of feedback frequency and

and Schmidt experiment.3D During practice and in the lO-minute session, there were no reliable group performance differences. group differences in performance emerged during the 24-hour rete sion, where gradually increasing the frequency of feedback acros degraded performance, and gradually decreasing the frequency of across practice enhanced it. These results suggest that a faded schedule is more effective for skill learning than a constant feedba ule or a reverse-faded feedback schedule. Similar results have been found using bandwidth feedback du tice. In bandwidth feedback conditions, precise quantitative feedba sented when performance lies outside a bandwidth of co surrounding a target and withheld when performance is within a b of correctness. Because errors are typically large early in practic mance is frequently outside the bandwidth of correctness resulti quent feedback. As practice continues, errors typically becom resulting in performances within the bandwidth of correctness, so is frequently withheld. Relative to practice with feedback on ev practice with bandwidth feedback is beneficial for learning. 32, 33 Augmented feedback can be presented instantaneously after co an action or it can be delayed by some time intervaL Swinnen et subjects practice for 2 days using instantaneous- or delayed-feedba tions. In the instantaneous-feedback condition, KR was presented liseconds after performers completed an action: In the delayed condition, KR was presented 3.2 seconds after performers com action. Relative to practice with instantaneous augmented feedba holding KR for as little as 3.2 seconds after completing an action performance during long-term retention sessions even after 4 mon out practice. These results suggest that delaying the presentatio mented feedback for a few seconds after each practice action effective for learning than providing feedback instantaneously a practice action. Closely related to KR is knowledge of performance (KP). KP is d extrinsic feedback providing kinematic information about an ac

example of KP occurs when pe extension in the terminal swing performance and learning effect ples of KR and other forms of ex In summary, findings from tions with augmented extrins delayed for a few seconds after a practice conditions with freque ed instantaneously after an acti for these findings. 34, 35 One reaso taneously on every practice trial vented) from attending to thei strong relationship between sen all, why should performers exp when the consequences of action second explanation is that f retrieval practice. Because frequ ing subsequent actions, perform tions from long-term memory. A augmented feedback late in prac actions based primarily on rando to unstable neuromuscular proc late in practice is less effectiv withheld on some trials. The learning effects of freq not been incorporated into equi peutic settings. In fact, just the that their equipment has the cap back. Therapists need to be wa may enhance performance duri term retention.

Video Feedbac

In 1976, Rothstei effects of videotape feedback. 37 C back were skill level and the us fited from videotape feedback r contrast, to be effective for lear to focus their attention to pertin

Videotape replay was used during therapy for Nancy, the client p stroke who was described in the sketch at the beginning of this chapter. D ing the terminal swing phase of gait, Nancy lacked full knee extens which resulted in a flexed knee on initial contact, a shortened stride len and reduced gait velocity and function. I filmed a sagittal view (left and r sides) of Nancy walking, and then Nancy and I watched her video as we a video of an individual without any known physical impairments. watched the videos at regular speed (60 frames per second) and at s speeds focusing on the knee joint in terminal swing and initial cont Nancy was able to visually see and understand how a lack of full knee ex sion in terminal swing interfered with stride length and velocity. She t was able to provide her own solution for this problem.

Discovery Learning and Guidance

Discovery learning consists of providing performers wi challenging yet achievable problem and encouraging them to discover t own solutions. Guidance, usually considered the opposite of discovery le ing, consists of verbal guidance, physical guidance, or both used to ach the goal with minimal, if any, errors. In 1983, Hagman38 examined the effects of guidance versus disco learning. Compared with practice with discovery conditions, practice w guidance conditions demonstrated reliably large errors on a 24-hour re tion session. Similar results have been found in children and older adult formers, suggesting that discovery practice is more effective for reten than guidance practice conditions, regardless of the performer's age. Winstein and colleagues compared the effects of physical guidance frequent KR on skill learning. Practice with physical guidance on every (frequent KR) resulted in small errors during acquisition and large errors ing retention. This suggests that frequent on-target performance, achie via physical guidance, is detrimental to learning. Although frequent mented feedback and guidance should be avoided, the effects of phys guidance appear to be especially ineffective for learning.

Nancy, the client described in chapter, provided a nice example working on increasing knee extens watched videotapes of herself and a ments, she attempted to recognize knee was extended and slightly fl perform approximately five gait cy and then she would try and identif rect knee positioning. Then she wa back. Nancy was determined to hav of her footwear; thus, she perform and sneakers. She discovered rela and knee positioning and between knee positioning.

Variability in Pract

Variability in practice r versions of a task; specifically at lea overall force amplitudes, or both. Co solely one version of a task-that is Schmidt's schema theory states that, rion speed, variability in practice enh by allowing rule formation. lO Studie support for Schmidt's hypothesis. Ho ers consistently show that practice v a criterion speed than practicing sole able practice usually results in more sessions when performers are practic formers' ages. These effects have be tasks, including badminton and forea ticing a task at several speeds enhan ing to generalize the task to a new g see Shapiro and Schmidt. 40 Functional tasks practiced in the rion speed. For example, my average different from my average gait spee from studies of variability in practice practice several speeds of functional tiple environments.

practice, which was presented earlier in this chapter. Results from several studies on contextual interference dem that blocked practice is more effective than random practice for acq of a task, blocked and random practice produce equivalent perform blocked retention tests, and random practice is more effective fo mance on random retention tests than blocked practice. 41 These res gest that, relative to practicing the same task over and over, interm different tasks throughout practice is beneficial for learning. Thes have been generalized to several real-world tasks, including verbal l badminton serves, and wiring diagram tasks used in industry. Contextual-interference effects are attributed to storage of mor rate memory patterns41 , 42 and retrieval practice 14 associated with practice conditions. It is interesting to note that no major theory o learning can explain the effects of contextual interference on perf and learning. However, Magill and Hall provide an extensive review textual interference effects. 43

Part- and Whole-Task Practice

To optimize learning, should functional tasks be tau whole or should individual segments of a task be taught separately a combined to form a whole action? The answer to this dilemma dependent.44 When the item to be learned is the timing between segmen whole-task practice enhances learning. For example, when learning gears in an automobile, it is easy to learn to depress the clutch and the gear stick from one gear to another. The difficult part of the ta coordination of depressing the clutch while changing gears. Becaus nation (or timing) is the item to be learned, practice sessions should the whole task. Coordination of segments is often the focus of con tasks, such as walking, swimming, and driving, suggesting that wh practice should be performed for these actions. Physical therapy task

whole-task practice is recommend tum transfers. When the item to be learn coordination, part-task practice whole-task practice. For exampl town therapy location requires tions. The focus is on learning making appropriate left and rig information processing is the i should be on learning segments to the freeway, directions for fr the freeway exit to the therapy the focus of serial tasks, includ line activities. Part-task practic task practice is also efficient w tively simple segments. In such difficult segments without needi of a task.

Speed-Accurac

Physical therapy go racy and speed when performing usually results in decreased spa accuracy trade off. Because spee pists may choose to work on sp Bobath45 argues that therapy in speed should be increased only a several lines of research suggest t components of a task, both shou In one experiment, performe practice (60 repetitions of a task ually increased across practice ( increasing to 60 repetitions pe throughout practice was more minute action than gradually inc Malouin et al. and Richards e gait-training program in clients w program included speed training training (via the use of a limbdemonstrated that an intensive

Audience Effects

The presence or absence of an audience can have drama effects on performance. 49 When a skill is well learned and an audience h little evaluation potential, performance is usually enhanced by an au ence. When a skill is poorly learned or the audience has a relatively lar evaluation potential, or both, performance is usually degraded by an au ence. For example, although I am a novice singer, I enjoy singing. My b singing performances occur when I have the house to myself and I am the shower. At a recent business party, to my surprise, the host announc that I was going to sing a song for the guests. I was very embarrassed a nervous, and during the performance my voice cracked several times. T audience interfered with my novice singing capabilities. Similar scenar occur in physical therapy when therapists ask clients to demonstr motor skills in the presence of their families. For example, imagine a 5 year-old man poststroke who is an inpatient in a rehabilitation setting. has successfully accomplished the tasks of bed mobility and sit-to-sta transfers and is just beginning to take a few steps with close supervisi for balance and safety. His wife is healthy, but she is concerned that s may not be able to care for her husband at home. She is concerned tha he lost his balance she would be unable to catch him, and therefore she debating long-term institutional care. To help the wife make an educat decision about placement, you invite her to observe her husband pract ing in physical therapy. Her husband performs bed mobility and supinesit transfers faultlessly and his wife smiles and relaxes. Then, as attempts to transfer from sit-to-stand, he loses his balance and falls ba onto the mat. His wife becomes tense, she sits on the edge of her chair a starts offering verbal and nonverbal suggestions (i.e., "be careful"). T client attempts another sit-to-stand transfer, but this time his movemen are guarded and tense. He is successful with his transfer but he decides is too uncomfortable to take any steps. One explanation for this scena is that the client's performance was degraded because sit-to-stand transfe and gait were poorly learned tasks and his wife had evaluation potentia am not suggesting that families be excluded from therapy sessions, b

rather that therapists evaluate and audiences on performance.

Special Considera and Older Adults

Adult, pediatric, and o processes for learning, suggesting th similar for all three populations. The populations appear to be in the rate o to perform tasks. Children and older adults dem movement times when performing ta is exaggerated further when they are ing specialists suggest that neither im motor systems is the primary cause o Rather, slowness of central informat control in pediatric and older adult p tions take longer than average to ma suggest that therapists and coaches processing by requiring clients to ma ing practice and to increase the durat The previous section of this ch learning suggested several variable encourage problem solving. In addit found to be almost as effective as p tal and physical practice should be variability in practice has been sho than constant practice, suggesting variations of a task. 40 Unfamiliar un back can be confusing for children be avoided.

Summary

Motor learning princip ical therapy interventions. Many mot trol of therapists and can easily be in challenge for therapists is to test the ciples to actions performed by person

A common trend that emerges from the guidance, KR, and con interference literature is that practice conditions that encourage (or force) performers to engage in sensory encoding and retrieval proce more effective for learning than practice conditions that frequently solutions. Possibly, a therapist's role is to provide several tasks, seve ations of each task, and several environments that encourage info processing. Information processing should be enhanced by providin sional, not frequent, guidance or KR or by intermingling tasks thro the therapy session rather than completing one task before beginni tice on a second task. Certainly drills, where performers repeat th movement over and over to memorize a normal movement pattern be avoided. At least three major themes emerge from motor learning studie temporary and permanent effects of variables can have remarkabl ent effects on performance. Second, learning is process specific: P ers remember processes, not specific movement patterns. Third, conditions that encourage (or possibly force) performers to proces mation or engage in sensory encoding and memory retrieval pr are more effective for learning than practice conditions that prov quent solutions.

References

1. Schmidt RA. Motor Control and Learning: A Behavioral Empha ed.) Champaign, IL: Human Kinetics, 1988. 2. Resnick MB, Eyler FD, Nelson RM, et al. Developmental inter for low birth weight infants: improved early developmental o Pediatrics 1987;80:68. 3. Turnbill JD. Early intervention for children with or at risk of palsy. Am J Diseases Children 1993;147:54. 4. Fitts PM, Posner MI. Human Performance. Belmont, CA: Broo 1967. 5. Wolf SL, Lecraw DE, Barton LA, et al. Forced use of hemipleg

6. 7.

8. 9. 10. 11.

12.

13. 14. 15. 16.

17. 18.

19. 20.

extremItIes to reverse the stroke and head-injured patie Taub E, Miller NE, Novack motor deficit after stroke. Ar Schmidt RA. The Acquisitio ception-Action Relationship (edsl, Perspectives on Percep 1987;77. Keele SW. Attention and Hu Goodyear, 1973. Adams JA. A closed-loop 1971;3:11l. Schmidt RA. A schema theo Rev 1975;82:225. Schmidt RA, White J1. Evid motor skills: a test of Ad 1972;4:143. Swinnen S, Schmidt RAJ Nic skill learning: instantaneous ing. JExp Psychol Learn Me Lee TD, Hiroth TT. Encodin memory for movement exten Lee TD, Magill RA. The locu acquisition. J Exp Psychol Le Bernstein N. The co-ordinat England: Pergamon Press, 19 Kelso JAS, Holt KG, Kugler Structures as Dissipative S gence. In GE Stelmach, J R Amsterdam: North-Holland, Shumway-Cook A, Woollaco Applications. Baltimore: Wil Gentile AM. Skill Acquisit Processes. In J Carr, R Sheph ence: Foundations for PhYS MD: Aspen Press, 1987;93. Swanson LR, Lee TD. Effect results on motor learning. G Merians A, Winstein C, Sull skill learning in older heal Neurol Rep 1995;19:23.

24. 25.

26. 27. 28.

29. 30.

31.

32. 33.

34. 35.

tanooga Group, 1991. Magill RA. Motor Learning: Concepts and Applications (3rd ed) Dubuque, IA: WC Brown, 1989. Newell A, Rosenbloom PS. Mechanisms of Skill Acquisition and th Law of Practice. In JR Anderson (ed), Cognitive Skills and Their Acqui sition. Hillsdale, NJ: Erlbaum, 1981;1. Melnick MJ. Effects of over learning on the retention of a gross moto skill. Res Q Exerc Sport 1971;42:60. Bilodeau 1M. Information Feedback. In EA Bilodeau (ed), Acquisition o Skill. New York: Academic, 1969;255. Newell KM. Knowledge of Results and Motor Learning. In J Keough, RS Hutton (eds), Exercise Sport Science Review. Santa Barbara, CA: Journa of Publishing Affiliates, 1976;195. Ho L, Shea JB. Effects of relative frequency of knowledge of results o retention of a motor skill. Percept Mot Skills 1978;46:859. Winstein CJ, Schmidt RA. Reduced frequency of knowledge of result enhances motor-skill learning. J Exp Psycho I Learn Mem Cogn 1990 16:677. Nicholson DE, Schmidt RA. Scheduling Information Feedback t Enhance Training Effectiveness. Proceedings of the Human Factor Society 35th Annual Meeting. Santa Monica, CA: Human Factors Soci ety, 1991;1400. Sherwood DE. Effect of bandwidth knowledge of results on movemen consistency. Percept Mot Skills 1988;66:535. Lee TO, White MA, Carnahan H. On the role of knowledge of results i motor learning: exploring the guidance hypothesis. J Mot Beha 1990;22: 191. Salmoni AW, Schmidt RA, Walter CB. Knowledge of results and moto learning. A review and critical reappraisal. Psychol Bull 1984;95:355. Schmidt RA. Frequent Augmented Feedback Can Degrade Learning Evidence and Interpretations. In GE Stelmach, J Requin (eds), Tutorial in Motor Neuroscience. Dordrecht, Germany: Kluwer Academic Pub lishers, 1991;59.

36. Nicholson DE. Information F Ph.D. diss., University of Cali 37. Rothstein AL, Arnold RK. Br videotape feedback and bowli 38. Hagman JD. Presentation- a retention of distance and loc 1983;9:334. 39. Winstein CJ, Pohl PS, Lewthw knowledge of results on mo hypothesis. Res Q Exerc Spor 40. Shapiro DC, Schmidt RA. Th Developmental Implications. opment of Movement Contr 1982;113. 41. Shea JB, Morgan RL. Contextu retention, and transfer of a 1979;5:179. 42. Shea JB, Zimny ST. Context E ment Information. In RA Ma Amsterdam: North-Holland, 1 43. Magill RA, Hall KG. A review motor skill acquisition. Hum 44. Naylor J, Briggs G. Effects of the relative efficiency of part choI1963;65:217. 45. Bobath B. Adult Hemiplegi Oxford, England: Heinemann 46. Sage GH, Hornak JE. Progress ous motor skill. Res Q Exerc 47. Malouin F, Potvin M, Prevost gait training program in a seri accidents. Phys Ther 1992;72 48. Richards CL, Malouin F, Woo therapy for optimization of ga Phys Med RehabilI993;74:61 49. Singer RN. Effect of an audien Behav 1970;2:88. 50. Welford AT. Motor Performan book of the Psychology of Ag 1977;3.

in New Orleans in 1990. Theoretical and clinical articles related cacy of physical therapy interventions in children with cerebra were written on several topics, including rate of motor develo improving postural control, neurophysiology and motor contro ries, promoting family functioning and functional independenc role of the physical therapist in family stress and coping, and phys beliefs in the efficacy of physical therapy. Carr HJ, Shepherd RB, Gordon J, et a!. Movement Science: Foundati Physical Therapy in Rehabilitation. Rockville, MD: Aspen Press This book was designed to demonstrate how basic science pri from the field of neuromotor control and learning could be app physical therapy practice. It consists of four chapters, one e assumptions underlying physical therapy interventions, Carr and herd's motor learning model, skill acquisition, and recovery of fu after brain injury. Harrow AJ. A Taxonomy of the Psychomotor Domain. New York: McKay, 1972. Educators in classroom and clinical situations use B taxonomy to develop cognitive and affective objectives, practice ties, and evaluation items. Harrow developed a taxonomy fo chomotor skills that can be used in classroom and clinic situatio taxonomy consists of seven hierarchical levels: (1) perception, (3) response, (4) mechanism, (5) complex overt response, (6) adap and (7) origination. Lister MJ (ed). Contemporary Management of Motor Control Problem ceedings of the II Step Conference. Alexandria, VA: Foundation fo ical Therapy, 1991. This publication is based on a conference, spo by the American Physical Therapy Association Neurology and Pe Sections and the Foundation for Physical Therapy, in Norman, homa, in 1990. Twenty-eight papers focus on new information field of motor control, development and learning, issues that cha current physical therapy approaches, and suggestions for how

control, development, and l cal therapy practice. Magill RA. Motor Learning: Co IA: WC Brown, 1989. This course in motor learning. It c on motor learning principle environments. It focuses on variables while providing a b ing phenomena. Schmidt RA. Motor Control and Champaign, IL: Human Kin graduate course in motor le sections on motor behavior ry. It contains hundreds of re erature. It is essentially an e Winstein CT, Knecht HG. Mov Physical Therapy Associatio tributions published in the issues of Physical Therapy. in the field of movement sc application and for applicati

Interventions for Patients and Families Maureen T. Nemshick

I've learned that it is impossible to teach without learning something yourself. -Live and Learn and Pass It On copyright ©1991, 1992 b H. Jackson Brown, Jr., and reprinted by permission of Ru ledge Hill Press.

When I was a staff therapist working in the Northwest, gentleman was referred to physical therapy for patient edu tion and home instruction for a neck problem. He appeare be a "typical" patient I was used to instructing. Part of the sion was spent going over a neck-care booklet that had instr tions and photographs. After the first page, his nonve behavior made me think, "I don't believe this gentleman read. I'd better emphasize information using the photograp I couldn't ask him point-blank if he could read, and I wa fast enough on my feet to figure out how to ask for his in mation in an indirect way. (Now I would ask him, "Do think you will find it easier to follow words or pictures to h you remember how to take care of your neck?") Up until that time, I had assumed all English-speak adults were literate. Drawings, diagrams, or photographs home instruction materials are helpful for the "typical" ph

cal therapy patient If I had not picked my emphasis, my inappropriate and Physical Therapy E

The process of preparing for cussed at length in previous ch in response to the patient's beh all of the factors influencing the ter uses those ideas as a backgro interventions for patients and fa and learning environment for including practical approaches families in the clinic. Other a physical therapist's and physic family education, the preparat ways to teach different popula teaching, implementation of te patient-family education proces

Chapter Objec

After completing t

1. Understand the rationale and family needs, beliefs ing strategies as they rel 2. Identify four motivationa member motivation for l 3. Define three domains of design and implementati 4. Understand how and wh tional materials effective 5. Discuss specific educatio patient populations thro 6. Discuss ways to determi sions are indicated. 7. Identify 12 teaching stra education more efficient

In preparation for effective teaching and learning, it is impo tant to consider assessment of the family's response to illness, patient an family beliefs, patient and family needs, and the coping strategies of patien and family members or support persons.

Family System and Response to Illness

It is important for physical therapists or physical therapi assistants to explore the family system in the process of determinin information that will be helpful for patient and family education plan Rolland, in his Family Systems-illness Model,l describes four basic domain of family functioning to consider during family assessment: (1) famil structural and organizational patterns, (2) communication processe (3) multigenerational patterns and family life cycles, and (4) famil belief systems. When assessing family structural and organizational patterns, it important for the therapist to consider those members that are part of th family and support system. These can include health care professional friends, and caregivers. Physical therapists need to be sensitive to the fa that conflicts may arise during a crisis between relatives of the patient an the support system they have chosen. Issues to be considered involve th reorganization of the family if the illness requires it, a change in famil roles and responsibilities, whether the changes in family organization a realistic and at an appropriate level, whether the family is flexible in mak ing changes, and how the family expectations match the expectations of th physical therapist and health care team. In assessing the family unit, on can determine how connected family members are and if there is a willing ness among the members to work through differences. Physical therapis can also explore family boundaries or the rules within the family about th members' responsibilities. l

Another component that should be assessed is the communicatio processes. Does the family communicate only to convey messages, or d they also discuss feelings and opinions? Assessing communication als

includes looking for nonverbal whether the family can discuss ly members' comfort zone. Th members express their emotions these emotions. l In this assessm er information about how she o members of the family. When assessing the multige physical therapist assesses how generations involved in the respo to determine the member(s) who split between members of differ tional or reversed as a result of determine whether there is a bal members are dysfunctionaL An e change roles within the family. I assumes more responsibility and these new roles. 1 During patient education, assistants usually try to respond tems and health behaviors. Goa stand their medical problems an that might prevent or change the to structured questions can help family's beliefs and anticipate o may exhibit throughout the edu The following structured qu to discover information about pa

1. What do you think cause

2. Why do you think it star 3. If you have an illness, wh How does it work? 4. How bad do you think yo think it will last a long ti 5. What kind of treatment w 6. What are the most impor therapy sessions? 7. What are the chief proble 8. What do you fear most ab

of an illness. 3 A patient's inability to learn a skill, such as a self-care ac ity, can be affected by the family's difficulty watching the patient strug with new challenges presented by a disability. The family might inhibit patient's learning by doing the activity for the patient, rather than let the patient struggle. In such cases, the family thinks that they are help the patient and are usually unaware of the consequences of their actio Family meetings with the health care team or with the patient's psych gist or sessions of family teaching can be helpful to redirect families help them cope with the changes in their lives. They can learn to help patient become more responsible for his or her own care. It is also important to consider the provider-patient relationship. If physical therapist considers the patient and family member's goals, dynamics between them occur in a team atmosphere where everyone wo together, and not a parent-child atmosphere, in which the therapist i charge and directs the learning experience. 2 The physical therapist sho ask the patient or support person what his or her goals are and as whether they are in line with the goals being set for the patient's recov As a team, all members can work out the best plan so that all will be in ested in carrying it out.

Cultural Influences on Patient and Family Education

Cultural differences between the therapist and the patient family members are important to consider. The key components of cul that should be considered are communication and cultural norms. W communicating with patients or family members of a different culture, physical therapist or physical therapist assistant should be concerned w language barriers, nonverbal communication, an awareness of perso space, and the use of interpreters. Patients and family members of different cultures may have a differe in language or in the style in which it is conveyed. For example, in some tures, being assertive is not acceptable because it is viewed as disrespect

It is also important not to assum based on his or her inability to s ferent cultures interpret gestures Gestures that are not offensive in another. Personal space is anothe a different culture. Some cultures sonal space while others prefer space. It is important for the the family member some basic comm tations from both parties can be with another employee or someon background if there is no family interpreter, the therapist should b the patient. He or she needs to k consider asking the interpreter to when a misunderstanding is poss Cultural norms are also imp private and their members may fe with a health care provider. Some tiny affect their health status. Ot ties, compared with what is cons status, their roles within the fam and family members may also hav apist and may verbally agree with follow through with the recomme When considering all of these important to remember the follow 1. 2. 3. 4.

Be honest. Be yourself. Examine your own biases. Demonstrate tolerance of Be careful when interpreti quick to label the patient 5. Consider discussing cultu they are complex or migh 6. Ask questions. Try to lear beliefs if they are willing tion about your culture w

Information about cultural no the family belief system. If the ph

the assessment of the family's response to illness.

Patient and Family Needs

What is the most effective and efficient way of providing ed cation to patients and family? As discussed earlier in this chapter, findin out what the patient needs to learn is a key component in the preparatio for effective teaching and learning. The best time to find out about th patient's needs is throughout therapy sessions. There are a variety of sourc from which the therapist can obtain information about the patient's need Before the initial evaluation, the therapist should look at the patien chart for information that may have been given to other members of th health care team. Basic information about the patient and the family may written in the patient's history. Reviewing the chart first, if it is availabl can help the therapist avoid repetitive questioning, which is tiring for th patient. Also, the therapist may wish to network with other members of th team, such as the occupational therapist, physician, nurse, speech therapis or others, casually or in a team meeting to get as much information as po sible about the patient and family.

Observation of Patient and Family Members

Casual observation of the patient and family members w provide the physical therapist with a great deal of information about th patient's needs for education. The therapist needs to watch for non-verb signals to determine things that may be regarded as unimportant, painfu difficult, or confusing. The therapist should watch patients using piec of equipment or performing certain exercises independently. It will helpful to observe a patient and family member(sl when they are visitin in the lobby, the patient's room, or in a recreational area to see their inte actions and observe their follow through with strategies learned in phy ical therapy. A great deal of information about how much the patient h learned can be gained by watching the patient's and family's action When the therapist watches patients interact with their families

friends, it is also possible to de the person who provides the received during observation m therapist assistant make adjust patient learn more effectively.

Patient-Family

When interviewin the patient's medical history, about their living situation, w goals for physical therapy, an them from reaching those goal ficial for the physical therapi friends, and the patient. Ther can be asked of the patient an bilitation to assist in plannin time to ask questions, especial assistance from a family memb tions may be very helpful:

1. Who will be the primar activities? 2. What is that person's sch or she is not at home? 3. Tell me about the set up your bedroom, bathroom as the entrances and exi 4. Do you have any medica 5. What are your personal r household chores? Descr need and want to do in y 6. What are your work obli that you need to do at yo 7. What is your main type work, too?

Before asking any of these the information that is needed f sider other questions, such as th determining a behavioral diagno

Physical Therapist's and Physical Therapist Assistant's Role

The physical therapist and the physical therapist assista play a vital role in patient and family education. Patient education is continuous activity, which takes place throughout most of the treatme sessions in physical therapy. Physical therapists need to develop skills assessing patient motivation, planning, goal setting, evaluating materia and preparing for the teaching process, as well as carrying out teachi plans. This section includes information to help develop those skills.

Motivation for Learning

As discussed above, answers to questions about family belie can provide ideas about how the patient really feels and what types treatments or learning experiences might be motivational for him or he Information about motivation is very important when planning for patie and family education. Redman states, "motivation is a more relevant id than considered previously in changing behavior and learning." 2 Becau changing behavior or establishing new behaviors is often the goal patient and family teaching, physical therapists and physical therap assistants need to look closely at motivation. The therapist may wish discuss with the patient some of her or his past experiences in whi behavior was changed. What motivated the patient to make this chang What strategies were used to achieve his or her goal? PhYSical therapis and physical therapist assistants need to find out what the patient, fami member, or friend is most ready and motivated to learn as well as t patient's desired degree of independence. When thinking about motivation, it is important to understand th internal motivation is stronger than motivation brought on by extern rewards. 2 If patients have input and set out to accomplish goals that me the most to them, they are more likely to participate. The patient or fam ly member must be ready to learn, or the educational activity may unsuccessful. Success in itself is motivating. If the session focuses on to

many activities in which neith ceed, goals may appear to be i ensue. Therefore, the therapist patient or family member can ties in the same session. A person's motivation may such that the patient can accom example, it makes sense to tea move the patient forward in th teaching all of the steps require is also helpful to end each educ that all of the people involved w sions. As the physical therapist to support the patient's and fam their behaviors and learn throug belief that the therapist affiliate on common goals. 2 If patient an should guide them toward more the way in which the patient's There are also times when assistants may try other motiv process more meaningful and m gies might include learning con

Learning Contrac The learning con physical therapist and the patie and provides guidelines for the tional sessions. 5 Watts explains ing a person make difficult cha the person slowly learn compo specific rules for creation of a c

1. 2. 3. 4. 5.

Identify something you Be realistic. Specify. Write it down. Check it daily.

Learning contracts are he need more structure and more

into the process and the goals to be achieved. The person's agreement an commitment is exhibited by his or her signature on the contract. See Fi ure 10-1 for an example of a learning contract between a physical therapi and a patient.

Behavioral Learning Contract Another type of contract, a behavioral learning contract, ca be used with patients to give them an incentive to achieve goals and pa ticipate in therapy sessions (Figure 10-2). Behavioral contracts includ incentives and rewards for patient's participation in educational sessions These should be used with caution because some patients may chang their behavior in a certain way only to receive the reward. 5 If learning education is the goal, using external rewards may only result in a patient change in behavior due to the reward but not due to learning. For exampl the therapist might reward a patient for asking for assistance in getting u and walking to the bathroom at night by allowing him or her to watch rented movie. While receiving the reward, the patient may be successf and consistent with the behavior. However, the behavior may not demo strate that the patient has learned asking for assistance is the more appr priate and safer process. If the reward is removed and the patient does n ask for assistance during the night, it may show that the patient w responding to the reward and not necessarily learning the informatio related to safety.

Domains of Learning

When addressing the goal of patient and family education, th physical therapist or physical therapist assistant should consider that lear ing occurs in the cognitive, affective, and psychomotor domains,4 whic were discussed in Chapter 2. Unlike the classroom, in which a specific ed cational session may be addressing one of the domains of learning, the phy ical therapist or physical therapist assistant often teaches in a combinatio of all three domains simultaneously. The following are some examples teaching in different domains in patient education.

Leam

TIlis is an agreement between Mary Was

1. Goal: James will independently manage all of the c arm rests, and foot rests without any help from

Plan of ActiOD: James will attend therapy on a daily basis and will demonstrate his knowledge to nursing w needed. He will keep a log of successful dem

Mary will teach the management skills to the has resources for reinforcement. She will rev

COMMENTS:

TARGETDATE:,________

2. Goal: James will independently perform his home ex instructions and pictures two times/day.

Plan of Action:

James will be responsible for a complete indep learning the exercises. He will then maintain and discuss it with Mary at the beginning of ea

Mary will be responsible to teach James the ex performance. Mary will be responsible to rem of the first three sessions to get the program st

COMMENTS:

TARGET DATE:_________

DAT

Both Mary and James set and agreed to these toward the goals. Progress will be documente

Mary Washington, PT

Figure 10·1 A learning contract.

for assistance before she gets up to walk around and wait until the staff or a family member assists her. The staff and family member who witnesses the behavior will document it in Susan's log book

John will practice this procedure and discnss the safety component of this behavior with Susan on a daily basis in her physical therapy session. Reward: If Susan follows through with this procedure for a 5-hour period she gets to rent a movie of her choice the following evening.

TARGET DATE: _ _ _ __

DATE COMPLETED: _ _ __

COMMENTS:

Both John and Susan have set and agreed to these goals. They agreed to work TOGETHER toward the goals. Progress will be documented on this contract in the comments section.

JohnYu, PT

Susan Smith

Figure 10-2 A behaviora11earning contract.

1. When physical therapists or physical therapist assistants prov patients with written information about exercise, precautions, patholo anatomy, or any other topic, they are teaching in the cognitive domain. Follo up in this domain can be performed by having discussions or asking qu tions about the material presented to test the patient's recall a understanding of the topic. As the physical therapist or physical therap assistant progresses to instructing the patient to perform the exercise, she he is combining teaching in psychomotor and cognitive domains. 2. Physical therapists or physical therapist assistants address the aff tive domain when they determine that the patient's decreased motivat

toward participating in therapy is ities. The physical therapist or decide to change the educational going outside to practice transfers pist or physical therapist assistant steps of transfers, and may even be a new skill because of his or her in an idea may not be the most conv much more realistic and useful to more motivating for a patient bec patient has had this experience, it practice the skill in other situatio 3. Many of the things that th psychomotor domain, or physica climbing, exercises, bed mobility domain does not happen in isolat cessful physical activity, the patie about the activity. For example, t teaching them why they are meas they can put on their lower extre selves from potential injuries with learning session. The information the physical practice of the skills more successful results.

Teaching in a particular doma or task that the patient will be l learning domain, but this preferen or task that is being learned. For very willing to learn information about it, attending a lecture, or st uninterested in learning exercise function. On the other hand, th involved in physical activities an ested in the knowledge and info activity. It is unlikely that a pers time, but it is helpful for the phy tant to assess the patient's prefer use that information when plan should ask the patient or suppor learning experience. It would als

5. What makes you avoid learning?

The physical therapist or physical therapist assistant might also experimenting by teaching in certain domains and evaluating the perso ability or interest in learning. Often, it is necessary to combine many diff ent experiences that try to teach the same information. For example, wh teaching a patient about exercises for the low back, it is helpful and app priate to provide written information about the exercise and expec results, demonstrate the exercises, have the patient practice the exerci with coaching, and then have the patient demonstrate the exercises in pendently. This approach makes the teaching more effective by provid reinforcement. It also helps to ensure that the patient is receiving the inf mation. In summary, to set up a successful learning experience, the teac must consider the domain of learning most appropriate to teaching the ta or information, the preferred way in which the patient learns, and a vari of ways to teach the same information.

Planning

After the physical therapist has gathered information abo the patient and family's needs, beliefs, motivation, learning preferences, a current physical status, he or she can begin to make a teaching plan. All the factors discussed earlier in this chapter can limit a person's ability learn. The therapist should plan sessions for family teaching ahead of ti and try to spread out the learning of difficult tasks. It is helpful to plan w other team members, so that teaching too many things at one time may avoided and reinforcement teaching can take place. It is most helpful for the therapist to plan visits with the patient's fa ily or support person to avoid conflict with other responsibilities, but, always, it is necessary to be flexible in a busy clinical setting. Even the b of plans may have to change due to unexpected events. As a physical the pist or physical therapist assistant, there are often times when a support p son arrives at the therapy session unannounced because he or she beca

available to visit and observe. If ties to other patients or supervis for therapists to initiate teaching has not specifically addressed pla or he will be challenged to do so may accompany the patient to on apist has formalized an educatio ing to assist with interventions the patient is not in physical the tunity to spend time in teachin The session may not be formal opportunity to address some edu During any treatment sessio ed request or be motivated to le about something related to ph increased motivation, this woul switch gears and teach somethi likely improve, because the patie process. Again, flexibility is an tional goals.

Goal Setting

It is important to tized, realistic, achievable, and d and achievable within the desire any length of time between on weeks. Long-term goals are var therapy intervention. If the pati cast, and is to be discharged the s activities the patient needs to patient does not have to climb during the session, he or she ma physical therapist teach stair clim sidering activities that a patient outside the health care setting a or her to know. For example, a p transferring the patient from wh however, for the patient's son t These exercises could be taught not time to teach them in an inp

representative or case manager. It is essential that physical therapists consider innovative ideas regard ing goals and treatment plans. Planning traditional treatments and usin time frames that have been used in the past are not enough in the changin health care environment. Some ideas that demonstrate innovation are to se a pediatric patient intermittently for patient and family education and hol those therapy sessions on a playground to achieve play skills. Montgomery7 mentioned that this change in plans and goals can be very effective, and pos sibly even more effective than interventions physical therapists have used in the past (e.g., gym therapy three times a week without much parenta involvement or responsibility). Physical therapists must be advocates. They must take the time an energy to share their plans and goals with case managers so that eac patient's plan of treatment can be individualized. They must also demon strate the outcome effectiveness of their interventions. If beneficial out comes cannot be demonstrated, patients will receive less intervention. Goals should be documented in the patient's initial evaluation or reeval uation and be addressed by activities in the treatment plan. It is very impor tant to document the goals and achievement because they are an importan part of assessment and intervention. Reimbursement for education will no be possible if there is no mention of the teaching process in physical thera py documentation. Written goals should include the following: 1. The task to be achieved. 2. The level of supervision or assistance to be attained. 3. Any equipment to be used in the task. 4. The amount of time it will take to achieve the goal.

The following are a few examples of goals for patient and famil education: 1. Patient will understand benefits of exercise program and follow written exercise program I (3 weeks).

2. Patient will know three t examples of restricted ac 3. Patient's son will transfe moderate assistance to pa 4. Patient's sister will posit prone positions (2 weeks) 5. Patient will instruct care 6. Patient will engage in thr (3 weeks). 7. Patient will identify thre problems and state ways occur (1 week).

It is helpful to provide the pa planned for teaching sessions. T be understood by the recipient. with the patient and family so addressed. Goal setting is a very impo interventions for patients and fa tically, the goals will effectively al interventions.

Preparation of

The therapist shou cific to each patient's learning ne ponents of this preparation.

Evaluation and Ada Due to time const care system, physical therapists lenged to be creative, cost-effe issues and materials related to teaching materials in a teaching them thoroughly and make adap them. 8 The therapist should mak

• Clear • Readable • Simple

use, the patient may be confused. If the information given is not in large enough print, it will be difficult to read for patients with visual impairments. Materials that include humor, such as comic strips or funny pictures, will be more entertaining and interesting for the patient. When considering the purchase of prewritten materials, the therapist should thoroughly review the information and make decisions about cost, usefulness, organization, and reproducibility. There are many written resources available that address common educational topics for physical therapy patients. There are also computer software programs related to patient care activities and exercises available. See Figure 10-3 for a resource list of educational materials. Often, physical therapists use their own written materials as an adjunct to patient education. In preparing these materials, it is again important to consider the time needed to portray the information clearly, simply, and creatively. One of the advantages therapists experience in creating their own materials is that they can more easily address unique patient care needs. Information can be presented in a way that parallels verbal and interactive teaching (e.g., the same phrases and steps in a sequence can be used). The primary disadvantage is that each time the therapist writes a new set of instructions, a significant amount of time is spent on the endeavor. It is helpful for the therapist to have a resource with good pictures of activities or exercises that can be copied and added to different sets of written instructions (Figure 10-4). Using a computer or word processor to write patient instructions can also be very helpful and improve efficiency. There are computer software programs available that provide photos and standard instructions, the ability to individualize instructions, and the ability to import pictures and create examples with instructions (Figures 10-5 and 10-6). With a computer, the basic information is available, and you can quickly make adaptations for each patient. If the therapist combines written information with a variety of pictures to create effective educational tools, the tools can be shared with colleagues so that each member of the team does not have to recreate the same information. As a group, the therapist and

Aspen Publishers, Inc. PO Box 990 Frederick, MD 21705-9782 800-638-8437 Helios Therapy Resources do Warehouse West Grant Road Tucson, AZ 85745 Home Care for the Stroke Patient: Living in a Pattern (Clip-ex software) Churchill-Livingstone, Inc. PO Box 3188 Secaucus, NJ 07096-9927 Homex: The Handbook of Illustrated Exercises Homex Westfield Place Kingsport, TN 37664 Krames Communications Grundy Lane San Bruno, CA 94066 800-333-3032 PhysioTools Ltd. PO Box 175 Francis House Sir William Place St. Peter Port, Guernesey GYI 4HQ Channel Islands Telephone: int + 44-1481-700 602 Phys-X 2.0 Arena Health Systems 800-265-1950

PTEX 211 Manchonis Road Wilbraham, MA 01095-9913 800-653-2510 Saunders' Exercises Et Cetera The Saunders Group, Inc. 4250 Norex Drive Chaska, MN 55318 800-654-8357 Stretching RA Anderson and JE Anderson Shelter Publications Inc. Bolinas, CA Copyright 1980

Figure 10-3 Reference list of prew

Tucson, AZ 85733 800-866-4446

educational tools.

VHI Exercise and Rehabilitation Prescription Kit VH1 PO Box 44646 Tacoma, WA 98444 800-356-0709

Variety of exercise cards with duplication ability. Provides the patient with an individualized, clear, and illustrated exercise routine.

Hlp Abduction-Active Lie on ___ side with bottom knee bent. Raise top leg. Keep knee straight and toes pointed forward. Do not let hip roll backward. Hold counts. Repeat _ _ times. Progress to __ Ibs. at thigh/ankle.

Figure 10-4 Example of a prewritten resource that can be copied. (From Progressive Individualized Exercises. Copyright © 1989 by Therapy Skill Builders a division of The Psychological Corporation. Reproduced by permission. All rights reserved.)

Per

YOUR LOGO

Provided for : Mar

Provided by : July A Sitting.

Tilt your head towar side. Using your han approx. _ sees. R Repeat _

times.

Ii> PhysioTooIs LId

Figure 10·5 Example of a computeriz from PhysioTools. Helsinki, Finland:

Sample PTEX Printout LaserJetlInkJet Format Patient: Kate Knaplund Therapist: Jeff Coppersmith

1. Ankle Pumpinq, 30 reps

Increase ROM and circulation by toes downward, then up,

fir~

in a slow st

Repeat 30 times.

Tailor the instructions t your patient's exact nee

2 . P1antarf1exion, Elastic Resistanc

Sit on the floor with an elastic loo as shown. Press down as far as possi

resistance. Slowly return to the sta

Repeat 30 times.

QuickJy .set exercise set reps. seconds. and poun

Figure 10-6 Example of a computeriz reps = repetitions.) (Reprinted with p Wilbraham, MA: PTEX Systems, 199

comprehension and reading levels. If the level of reading required to und stand written material is not considered, the patient and support person m not benefit from material issued to address their educational needs. Ma authors have examined the readability of patient education materials to if they compare to the level of comprehension of their recipients. It has be found that many of the materials are written at a level much higher th many people's reading levels. 9 In a study testing adults in a public hospi it was found that 40% of those tested read below a sixth-grade level. lO P ple may also be found to be at a reading level that is different from their le of education, because their ability may be affected by aging, mental stre or emotional stress related to their illness. ll When assessing written mate als, physical therapists and physical therapist assistants must be aware the possibility of poor reading skills of patients and family memb involved in the process. There is a way to analyze the readability of written materials by us the Fog Index sM Formula (Figure 10-7) created by Gunning.12 This meth can easily be used when assessing materials by examining the vocabul and sentence structure and determining the grade level at which they written. A person is considered literate when he or she can read at a fif grade leveI.9 By taking into consideration this standard, if documents written at or near this grade level, the materials will have better readabi and the average patient will have a better ability to comprehend the inf mation. (See a comparison of instructions for an exercise written at t grade levels in Figure 10-8.) The Fog formula provides a quick, sim method of estimating the grade level of the written material. It can applied to purchased written materials or materials created by the physi therapist. There are also a variety of computer software programs availa that measure readability.4, 9

Addressing Illiteracy In addition to varying levels of readability, it is also import to consider that not all patients are literate. To determine literacy, the th apist should be fair and considerate and ask the patient in private. This w avoid patient embarrassment and will allow the patient to give helpful inf

1.

Count 100 words in successio several samples of 100 words average the results.

2.

Count the number of comple

the middle of a sentence, incl becomes S in the formula. 3.

Divide the words (100) by the

4.

Count the number of words h

count (1) verbs ending in "ed" syllable, (2) capitalized words as "butterfly."

s.

Apply the formula to calculat

GL ~ [(W/S) + (

where GL is the grade level, W

the number of sentences, and more syllables.

Figure 10-7 Fog IndexsM formula by

Kallan. How to Take the Fog Out o 1994. The Fog Index scalesM is a ser munication Consultants by D. Mue

When assisting someone with increasi or maintaining range of motion, be su that you read the instructions carefu and follow the pictures for proper ha placement. For instance, when you a helping the person to stretch out his or h shoulder, first, support the upper extrem ty at the elbow and wrist joint. Turn t hand so that the thumb is facing forwa and raise the arm slowly over the perso head until you reach the point of res tance. Once you have reached resistanc hold the arm in that position for 10seconds and then return to its starti position. Repeat this exercise 10 times. Grade Level

~

11.14

Figure 10-8 Comparison of written

A

B

c

The pivot transfer from a wheelchair to a bed.

Figure 10-9 A sequence of pictures used to demonstrate an activity. (Reprinte

with permission from R Tronson-Simpson. Caring for People with Multiple Disabilities. San Antonio: Therapy Skill Builders, 1991;15.)

mation in a confidential setting. The patient may not answer direct because of the social stigma attached to illiteracy. The therapist must b sensitive to the patient's feelings about this issue, make changes as neede in teaching methods, and make referrals to a literacy program if the patie or family member expresses an interest. 4 If it is determined that a patient has a low literacy level, it is necessa for the therapist to make adaptations to teaching strategies. As the patie and support person will often rely on verbal communication, the followin guidelines can assist in making the teaching effective. The therapi should be careful to keep the language simple and use short sentences. Sh or he should repeat information in the same sequence accompanied b visual demonstration if possible. For these patients and their support pe sons, observation may be the most effective way to learn. In addition verbal communication, it is important to consider additional props to a as learning aides. 13 For example, the therapist may use pictures or sequence of pictures that demonstrate an activity (Figure 10-9). The ther pist may also use photographs of the physical therapist assistant an patient or the patient and family member to make a poster of the activi being taught. This poster will help cue the patient and the family membe An example of this would be to take several photographs of steps in th sequence of transferring a patient from his or her bed to a wheelchair or steps for putting on a leg brace. Another way to improve comprehension verbal information might be to use a doll to demonstrate certain activiti

before trying them on the patient. literacy skills may require more in from increased practice of activiti effective, the therapist may also co as an adjunct to teaching. 13 It is also important to conside cultures. It is helpful to determine comprehend verbal and written in physical therapist assistant's nati preter, special arrangements shoul a volunteer who speaks the langu tion session. FolloWing the same literacy skills may help improve t ability to learn.

Considering Spe

Because the physical have strong teaching roles in thei design their teaching experiences to ulations they work with. Physical interactions with a variety of patie cents, young adults, adults, geriatri nitively impaired. As there are diff within these groups, special strat tional interventions for patients an

Pediatrics

The pediatric popula their ability to pay attention when task, and their ability to enjoy the l ical therapist or physical therapi must schedule the sessions for a s of fun are often needed throughout uses play to demonstrate the idea teach the pediatric patient. For ex catch with a colorful ball, and thi child's standing balance. If the phy tant places a child prone on a scoo to propel around the room, the ch

Figure 10-10 Examples of fun activities with pediatric clients. (From Pediatr Strengthening Program. Copyright © 1989 by Therapy Skill Builders, a divisi

of The Psychological Corporation. Reproduced by permission. All rights reserved.)

coordination and strength in his or her upper extremities. The pediat patient needs time to learn information and praise and emotional suppor reinforcement in the learning process. It also may be helpful to have the patient's parents present during session for emotional support. During the session, the parents can le strategies for reinforcement in the home environment. 4 The therapist m also consider holding a separate meeting for parental teaching, so that parents are not distracted and the pediatric patient does not become restl while the parents are trying to learn. If the educational environment is a p itive experience for the child, it will encourage more learning and incre the motivation to learn.

Adolescents

Adolescents should be considered differently than childr They want to be treated more like adults, and they like to be independe When designing an educational experience for adolescents, the therap should keep in mind that adolescents are very conscious of their bo appearance and their peers' opinions of them. They often oppose their p ents' ideas and do not want them present during educational sessions. 8 If physical therapist or physical therapist assistant can take the role of an ad cate rather than a parent, there will be increased trust and the relations between the patient and the physical therapist or physical therapist assist will be more successful. The therapist should always be honest and dir with adolescents and use simple, clear instructions.

Adolescents should be taught in The therapist needs to engage them in want and need to learn. For example, learning how to get in and out of a ca out with friends. They are also often exercises to build up their upper bod admired by their peers. The physical tant should try to help them achieve may also wish to combine things the things that they are motivated to l should give the adolescent responsibi (e.g., information to read, videos to w pendently). As they are given more r evaluate their performance and give t ment. The therapist should always b avoid embarrassment and allow them appearance when possible. s For examp shaved for a surgical procedure, the th one of her favorite hats. It may also he to wear his or her favorite sports clo exercises and physical activities. Parents and family members, as w to allow the adolescent to be as indep for them to provide assistance to the planned to include only those activi involved in the teaching session, it is physical therapist assistant to discuss limits with the adolescents, ideas ab related to safety and progression, and that are helpful with this patient. 4 F tant for a parent to know the adoles tine, if the adolescent has had a spina the parent can reinforce and remind providing pressure relief and can he remain in one position.

Adults

There are some differen ing educational interventions for adul with new increased responsibilities,

Adults as patients or support persons will have a more successfu ing experience if they have been given the opportunity to give input an the things that will be taught in the education session. For example adult is most concerned with being able to access the bathroom and independently, this goal should be addressed as soon as the person's p condition allows. Adults should be partners in goal setting and also s ideas for accomplishing those goals. The physical therapist or physic apist assistant can then provide education and guidance and assist achievement of those goals. As an educator, it is important to investigate the support that i able to the adult and identify things that might cause stress in the p life. For example, giving an adult additional exercise responsibilities he or she already has a very busy schedule and little support, may re noncompliance and frustration. However, if the exercise program is porated into his or her normal routine (e.g., something that can b while on a stretch break at her or his desk or while watching the news pliance may be higher (Figure 10-11). Information about the patient's ties and routine will help in designing a realistic educational program, will meet the patient's scheduling needs, and may help to cont amount of stress, which can be a barrier to learning. Approaching without judgment and with respect for their input and ideas will b beneficial in this educational process. 4

Geriatrics

There are different considerations to be made when ning educational interventions for the geriatric population. People population may need to have sessions designed so that informa introduced more slowly, allowing the patient or support member t absorb the information or skill. It is also helpful to keep educatio sistent, in a familiar or constant environment, and on a similar sch Changes or new information added to an educational program sho made slowly.8 Independence is very important to this population,

Figure 10-11 Example of an exercise

with permission from K Lorig. Patie hoe, Australia: Fraser Publications,

is very helpful to focus on teachi atric patient can do independentl and only has a bedroom and bath very interested in learning how dently. The educational focus of can mean the difference between a temporary bedroom and comm and the patient using his or her p tioning independently. Sometimes geriatric patient solve and share their experiences tion is experiencing more loss i health), and the group setting ma physical therapists and physical observe and assess the patient to to learn due to social, mental, grams that focus on educational patient's strengths. 4

who are terminally ill the opportunity and the right to make decisions regarding their health and their future. Also, there is an increased need for emotional support of the patient and support persons throughout the educational process. 8 The most effective way to design educational interventions is to do so with the patient and the family members. They are the guiding group. They have ideas about their needs and wants, and the program should be designed to reach as many of their goals as possible. Patients with terminal illnesses may have different goals than other patients. Often their concerns are comfort, safety, and basic functions (e.g., rolling or positioning themselves in the bed, transferring to the commode or a chair, or walking short distances to the bedroom and bathroom). Their focus may not be on participating in an exercise program to increase their strength and endurance, unless it is related to returning to a function that seems realistic to them. The physical therapist or physical therapist assistant can provide guidance and encouragement in goal setting and patient and family education so that it is an effective process.

Cognitively Impaired

There are no age limits to the cognitively impaired population. When considering education of the cognitively impaired, the therapist focuses on the education of the caregiver and includes the patient when possible. This caregiver can be the parents, a spouse, a friend, a neighbor, or any other support person. For example, when working with a patient with memory deficits who has had a total hip replacement, the patient's support person will need to be educated in all of the steps required for maintaining hip precautions and prescribed weight bearing. The support person can then assist the patient in remembering the important steps to preventing further injury and possible rehospitalization. If the patient is involved in the educational process, the therapist should keep the written and verbal information simple and use demonstrations and pictures. The therapist may use a patient log book to assist the patient who has a memory deficit. This log book could help the patient remember daily schedules and other important information about his or her medical status and list a contact number for the support person, impor-

tant things to remember, and othe unnecessary harm. The caregiver's e or her involvement, abilities, and patient's care. The educational pro learning needs and accomplish goal

Choosing Group

There are times whe more effective than individual tea the group members support each o patients volunteer to attend an ed excellent for learning. Support an much more meaningful from pers from someone who is knowledgeab ence. It is important for the physic who is leading the group to be an achieve the educational goals. 14 A group might also be used to resources, such as time or money, tion of patient education from the tion to individual teaching may b support persons, and patients, be help, and support each other while and tasks. Individual teaching is indicat information is specific to the pati people. This may also include priv bladder function. Patients and fa things that might embarrass them evoke anxiety and block the learni an individual session when the the learn. Learning assessment is not e patient is less likely to respond an honor patient privacy in relation t is also indicated if a patient or fam to learn because of the presence of be overshadowed by their support p in the learning situation. 8 Sometim because they are afraid that they w

environment needs to be informal and comfortable to facilitate the sharing of information. Group dynamic techniques such as placing group members in a circle, having everyone introduce himself or herself, and serving snacks can be very helpful in establishing an informal environment. Another guideline is that there should be a group facilitator. In programs that address physical therapy issues, the facilitator is often the physical therapist. The group facilitator's responsibilities are l4 : • • • • • • • •

Setting up the informal and comfortable environment Stating the purpose of the meeting Assisting the group in setting goals for the meeting Establishing guidelines for group behavior Leading the group discussion Encouraging participation of group members Acting as a resource person Summarizing learning and achievements at the end of the session

Research to evaluate the effectiveness of group learning demonstrates mixed results. Some studies show that group learning is less effective, while others show that it is more effective. IS-I? Often, the quality of the group experience and the design of the educational experience should be considered more carefully than the group factor itself. It is important for physical therapists to carefully consider the responsibilities of group teaching and evaluate the indications for individual teaching before deciding that group teaching is the most effective method. Often, a combination of the two methods is used to facilitate the delivery of the variety of information that needs to be taught throughout the patient's physical therapy intervention.

Implementation of Teaching Techniques Certain strategies will often make implementing teaching ideas more effective and efficient by saving the physical therapist or physical therapist assistant time in the educational process. The following teach-

ing tips3 are strategies to keep in ing teaching in physical therapy:

1. Be concise. Do not ove with too much information overa 2. Make the written mater readability and the patient or su new information. Also consider th you can adapt the material to th prewritten materials for patient e cational tools. 3. Keep the educational in easy to understand, break the inf the sequencing of information, an 4. Give feedback througho should point out successes, as w should be given as close to the b build confidence and competence provide a more positive learning the patient or support person, a "never" and try to organize the offered before negative feedback. I ient may not hear the positive fe in mind with regard to feedback hurtfu1. 1s Examples of hurtful and

• Hurtful: "You are being un your wife. You might hurt • Helpful: "The first two step before you move your wife will have less stress on you

When considering feedback, learning process, it is helpful to w their performance. In this way, th cal therapist's cueing and will Salmoni et al.,IS it was recognize formance, but when this feedback addition, Schmidt found that al might improve performance, it c term retention. 19 His studies ind

5. Be as specific and clear as possible. When providing the patient an support person with educational information give them examples, sugges tions, and rationale to increase their understanding and enhance learning. 6. Use repetition to improve learning and understanding. Whe demonstrating or delivering an important point, repeat the process severa times. Watch the patient and support person's facial reactions to see if the reveal understanding, enlightenment, confusion, or boredom. Have them highlight important points they have learned or repeat the task they hav learned without cueing. This will give you a better idea of their understand ing of the information. 7. Be practical during the educational session. Discuss realistic infor mation with regard to time, equipment, or people that are available o involved. 14 Use diagrams, visual aids, or demonstrations whenever possibl to enhance comprehension. Provide feedback and comments about thing that can be changed. For example, it would be helpful to determine if ther are two people available to assist in transferring a patient using a Hoyer lift if this is the way the patient and family are trained in the hospitaL If th patient and family cannot obtain a Hoyer lift for home use, the education th physical therapist or physical therapist assistant provides must be adapted t reflect what is possible to carry out in the home setting. 8. Consider prior preparation of the patient and family for educationa sessions. Try to have the patient and support person read information, watc educational videotapes, or listen to educational audiotapes before a sched uled educational session. This will save time by providing initial informa tion that can be reviewed and reinforced in the educational session. 9. Stay flexible. Be aware that opportunities for teaching patient and support persons can occur at any time. Teach the patient throughou all physical therapy sessions by providing rationale and information an by answering the patient's questions. 14 It is sometimes difficult to sched ule all educational sessions ahead of time. When an opportunity for teach ing appears unexpectedly, take advantage of it! It is also helpful to b flexible when considering the amount of information to be shared becaus it is essential to teach at the pace appropriate for the patient and the sup port person.

10. It is important to rememb this chapter, use the chart for doc support person and keep an additi bursement, and it provides good assists in better carryover by the p son and will be available in case misplaced. In addition to the do patient's and the support person's or their refusal to participate if ne 11. Try to coordinate patien the health care team. Discuss th meeting or in patient-family meet a universal plan to achieve goals. sistent and efficient because all sequence that is logical, practical 12. Remember to consider h preparing an inpatient for dischar education can be provided more e the atmosphere and the people av of the patient's ability or learning mation. When referring a patient rent educational progress and ed therapist, because this will help home physical therapy plan.

Evaluation of t Education Proc

Methods of Eva

Evaluation of patie component of the educational pr the physical therapist or physica patient and determine whether t are ways that a physical therapis ate the learning that has taken pl

1. The therapist should ask ended questions about the inform this way, the patient or support p

replacemen t? "

2. Another method of evaluation is for the patient or the suppor to identify the place at which he or she reached a block in the task or understand the information. The therapist should have the patient port person provide a rationale for actions and involve him or her in p solving. The therapist can do this by saying: • • • •

"Tell me where you got stuck in the process." "What information didn't you understand?" "Why did you do it that way?" "What would happen if... ?"

3. Demonstrations and questions can also be used to evaluate th ing of the patient or family member. The therapist should ask the pa support person to demonstrate the learned task without any feedbac she or he has finished the demonstration, the physical therapist or p therapist assistant will be able to focus additional teaching on com of the task that could not be completed correctly. Inviting the pati family to ask questions about the educational sessions helps the p therapist or physical therapist assistant focus on the information tha to be included in additional teaching. 4. It is also helpful to test the learning that has occurred in the tional sessions. The therapist could test transfer skills learned in t environment by asking the patient to transfer in alternative enviro such as a transfer to a couch, a bed, or another chair. The therapist n ask the family who has completed inpatient family teaching to tes safe environment, such as an activities of daily living suite. This pro be used as a test run before discharge to the home environment. It p the patient and family the opportunity to problem solve together, de more questions, identify a problem list that needs to be addressed, a tice all of the things they have learned, while members of the hea team are available to help in an emergency. This is a great opportu

patients and families who have lea mation and skills that have to be ca

Feedback from th

As part of the educati and their families about the educat ful. The physical therapist or phy variety of ways to obtain informati and the areas in which he or she n develop an informal list of question in person, such as:

• What information did I provid • Do you have any suggestions regard to teaching? • What sources of informatio learning new materials le.g., lectures, practice sessions)? • Did the educational informa before our implementation o needs were not addressed? • Do you have any other quest

In evaluating the education pro therapist assistant retrieves subject tionnaire, survey, or a feedback grou tion retrieval is not important as lo therapist assistant has feedback in s apist's future educational strategies setting related to professional grow

Self-Appraisal

It is a good idea for th pist assistant to appraise his or her and family education, along with a tions presented in the above section ily can be asked of the physical the also might be helpful for the therap depth about the process, especially

a larger group about the effectiveness of education for research and fo evaluation, it is necessary for the therapist to develop or use a valid s dardized test instrument. The therapist should especially consider approach in a research environment and when trying to retrieve accu data about outcomes and effectiveness of intervention.

Conclusion

This chapter presents information and identifies strategie assist physical therapists and physical therapist assistants in designing e tive educational interventions for patients and families in the physical th py environment. The process of patient and family education is ong throughout physical therapy intervention and includes informal and fo educational sessions. The essence of the physical therapy profession is dem strated when physical therapists and physical therapist assistants a patients in achieving their goals and increasing their functional abilities. Teaching patients and families can be very complex at times bec therapists are challenged to be evaluative, creative, supportive, and effe within shorter time limits. The joy of successfully teachi~g a patient t something large or small cannot, however, be overshadowed by the c lenge. The patient's and family member's successful learning will a them each day in achieving goals related to increased function, incre safety, increased strength, decreased pain, and so on. The educational pro offers the physical therapist and physical therapist assistant many oppo nities to be creative and make a difference in people's lives.

References 1. Rolland

J. Families, Illness, and Disability. New York: Basic Bo

1994j 64.

2. Redman BK. The Process of Patient Education (7th ed). St. L Mosby, 1993 j 24. 3. Hansen J, Rowe P, Watson J. A timesaving guide to better patient te ing. Nursing 1987 j 17(1l):129.

4. Falvo DR. Effective Patient E s. Watts NH. Handbook of Cl ingstone, 1990;104. 6. Lorig K. Patient Education. Oaks, CA: Sage, 1996; 111. 7. Woods EN. APTA Progress delivery. PT Magazine 1995; 8. Rankin S, Duffy K. IS prob tions. Nursing 1984;14/4):67 9. Doak C, Doak L, Root J. Te Philadelphia: Lippincott, 19 10. Glazer-Waldman H, Hall K, hospital. Nurs Res 1985;34:1 11. Stephens ST. Patient educa Nurs Forum 1992;19:83. 12. Gunning R. The Technique 1968;38. 13. Barnes LP. The illiterate cli Care Nurs 1992:17;127. 14. Hanson 1, Rowe P, Watson J. ing. Nursing 1987;17/11):129 IS. Kosik SL, Reynolds PJ. A nu group preoperative teaching Staff Dev 1986;2/1):18. 16. Barnason S, Zimmerman L. A among post~perative corona Cardiovasc Nurs 1995;10/4): 17. Stankovic R, Johnell O. Con Spine 1990;15/2):120. 18. Salmoni AW, Schmidt RA, W learning: a review and critic 19. Schmidt RA. Motor Contro Champaign, IL: Human Kin 20. Winstein CJ, Schmidt RA. R enhances motor learning. J E 21. Fodor J, Dalis GT, Giarran Application. Malvern, PA: W

There are many nursing examples provided in the book, but they can be useful in assisting other health care professionals to develop their patient teaching skills. Falvo DR. Effective Patient Education. Rockville, MD: Aspen, 1994. A contemporary text that provides the reader with many concepts related to patient education. There are numerous nursing examples provided to support the concepts presented. This text addresses the issues of patient education across the lifespan and various cultures. An excellent resource with practical information that can be applied in patient education in the health care professions. Lorig K. Patient Education. A Practical Approach (2nd ed). Thousand Oaks, CA: Sage, 1996. This book provides the reader with practical information about setting up effective patient education programs. The text is very readable and provides information about planning, implementation, and evaluation of health education programs. The author presents many physical therapy examples to support her descriptions of educational strategies. This book is enjoyable and helpful in teaching health care professionals how to develop successful patient education programs. Redman BK. The Process of Patient Education (7th ed). St. Louis: Mosby, 1993. A comprehensive book that addresses patient education in the field of nursing. This classic text provides the reader with practical and theoretical information. An excellent resource for those teaching and learning about patient education in the health care arena.

for Change Christopher Lorish Imagine the following scenario between a therapist, Ms. veau, and her supervisor:

Ms. Nouveau's supervisor, who has been at the clinic a time, calls Ms. Nouveau into her office unexpectedly. H no idea what the supervisor wants but having no reason concerned, Ms. Nouveau enters confidently. She is told the administrator for an independent living center reque physical therapist to speak at the residents' meeting this end. The supervisor asks Ms. Nouveau to do it. Althoug official request is stated in a way that it can be declined Nouveau infers from her supervisor's stare and lowered to voice that she is telling her to do it. Ms. Nouveau is pro being asked because of the older patients she is seeing because she has yet to do any community education. Ms. Nouveau came into her supervisor's office calml with confidence, she now feels uneasy about the idea of s ing in front of a group to give a talk. Later, she anxiously ders out loud what she will say, what she will do, wh audience is, what they really want, if she knows anythin will be useful to them, if she can overcome her anxiety speaking to groups, and if she will make a fool of hersel useless information that is poorly presented.

Like Ms. Nouveau, physical participate in planning or implem grams, especially as the empha increases. Such participation va example, involvement in a large community-wide impact and inv within a community represent t community intervention is the intensive, community-wide pu implemented to reduce cardiova pists are involved in programs i are often involved with an esta American Heart Association, th Lung Association, in planning o exercise program to prevent com or injury or to minimize the ris dation's land and water exercis examples of targeted, preplanne help implement (Figure 11-1). It with clinic patients, a therapist education program, a support g phone service sponsored by the therapists often become involve programs. Occasionally, therapi the print or electronic media for have expertise. A consistent theme through ical therapists and physical th chapters have addressed the patients, and families. Health p do more with less time and fewe address the issues of health pro preceding chapters, a patient improving patient knowledge, w oping skills, is a core aspect of challenged to find ways to eff and families. These methods m settings. This chapter provides the community.

Figure 11-1 A community water exercise program. (Courtesy of the Arthritis Foundation.)

Chapter Objectives After completing this chapter, the reader will be able to:

1. Identify the differences between community health education programs that emphasize "awareness" versus "knowledge to solve problems." 2. State the three-factor model of behavior determinants and apply it to a group's health behavior. 3. State the cognitive determinants of behavioral intention that need to be considered in planning a program to encourage desired health behavior. 4. State the stages of change and explain how these concepts might b used in planning tailored health education programs. 5. Describe at least one method for facilitating change from precontemplation to action, from action to maintenance, and from maintenance to relapse prevention.

Figure 11-2 A community group edu

Foundation.)

6. Define and apply the conce program. 7. State the common characte ning model and the Plannin model.

This chapter builds on what assessing and treating patients. Th apists use to plan and implement extensions or elaborations of th principles firmly rooted in a the patient presents with a problem; help determine the cause and to p pist then applies, evaluates, and p quent visits. The process of pl health education is much the sa makes similar assumptions.

approaches. The first approach attempts to inform community me about a health topic with the hope that the newly informed recipien use the knowledge to prevent health problems or to respond appropria a health problem occurs. A clinical analogy is the therapist's explanat the patient's musculoskeletal dysfunction. The second approach attem affect the public's self-initiated behavior-that is, to influence the per adopt healthy behavior and stop unhealthy or accident-promoting beh The clinical analogy to this is teaching patients how and when to do home programs so that they will follow the programs at home. Each of approaches makes assumptions about knowledge, behavior, a person's ness to change, and individual differences that need to be explored 11-1). These assumptions affect the planner's decisions about program poses and methods.

Knowledge Assumption

One assumption made by community health educ programs that disseminate information is that knowledge is a suff condition for desired behavior (i.e., a person's behavior will change the person is adequately informed). The corollary is that if behavio not change or the problem remains, the person does not know en and needs more information. This is a tenuous assumption, as illu ed by smokers who do not quit despite knowing smoking's ha effects or physical therapists who do not exercise despite knowin health benefits. Programs with goals of helping participants know or be aware of an issue result in a better informed public but not n sarily a healthier one. The reason, it is argued later in this chap probably due to participants' readiness to change and other det nants of behaviors that are not necessarily affected by information. so, the right information at the right time can trigger behavioral c in some people.

Table 11·1 Assumptions of Commu Assumption

Defin

Knowledge Knowing about x

Knowing fa formatio

Knowing " if-then" rules to guide behavior

Applying co behavior treatmen

Three-factor model of behavior determ Motivation

Beliefs that the likeli desired b

Performance skills

The psycho ability to the desir

Supportive physical and social environment

Adequate s equipme couragem form the behavior

Readiness to change Stages of change

Not thinkin thinking ing, or qu desired b

Individualization Program accommodation

Variation in goals and accommo difference readiness

One reason for the relative imp behavior is that persons may lea standing of how to apply it to cha knowing the facts of addition, subt ing how to solve word problems. stage for future behavioral change, health problem they may have or can occur.

they should slow down the activity until the heart rate is Y to avoid pr lem Z. This rule serves as a guide to doing exercise appropriately wh minimizing the risk of harm. To use this rule, persons would have to taught the meaning of the concept heart rate, develop skill in monitor their heart rate under conditions of rest and exercise, and correctly ap the rule during exercise to produce behavior consistent with the rule. T importance of the use of knowledge to solve problems concept to comm nity health programs is that if persons are not given instruction and pr tice to apply the therapist's treatment rules to situations, they will ap their own to solve problems or respond to new situations. This can res in disastrous effects. Even programs that work to develop a participa capability to assess and solve problems may not be successful in doing The initiation and continuation of new behavior, like correct posture patients with back pain, involves considerations other than the acquisit of knowledge and problem-solving skills.

Determinants of Behavior Assumption

A second assumption is focused on the determinants behavior. This assumption comes into play with community progra that more directly attempt to maintain or increase healthy behavior decrease unhealthy habits. Implicit in the second goal is the assumpt that the behavior of individuals in a community can be changed throu attempts to modify the determinants of behavior. A three-factor mode behavior determinants is proposed (Figure 11-3). These factors inclu (1) the motivation to initiate or continue healthy behavior, (2) the kno edge and performance skills required by the new behavior, and (3) a s portive physical and social environment. Community health progra must first promote participants' motivation to change, then teach the p formance skills and knowledge needed to perform the desired behavi The programs can finally reduce any physical, social, and environmen barriers to engaging in the behavior. Since the configuration of these determinants is different for every co munity group, the content and methods to address them may be differe

Motivation

Knowledge and Skills

Physical and Social Environment

Figure 11-3 Three-factor model of be

One important function of progr behavior determinants of a group, s ing any that are barriers to the desi knowledge and skill, and environm ities are probably best focused on de change, before teaching participa attempting modifications to the phy the new behavior. Even so, constrai a program's activities attend to all t If the goal of a community hea moting increased exercise or eating nant that should be addressed is behavioral concepts that have been problems like smoking and weight c apists for program planning. Cognitive behavior theories ha son's cognitions and emotions (i.e. behavior. More important, these th ioral change can be influenced by at beliefs. The most influential of thes ing theory,3 Becker's health belief m soned action,S and Prochaska and D a Centers for Disease Control-spon

difficult or impossible for the behavior to occur; (3) the presence o knowledge, problem-solving skills, and psychomotor skills to perfor behavior; (4) the belief that positive consequences of the behavior are g than negative consequences of the behavior and greater than positive c quences of competing alternatives, like taking medication; (5) the belie there is more social support to perform the behavior than not to perfo (6) the belief that performing the behavior is consistent with the pe standards or self-image; (7) an emotional reaction to performing the b ior that is more positive than negative; and (8) the belief that the perso the abilities to execute the behavior (i.e., the person has confidence in her ability to perform the behavior). While these eight concepts can be grouped into the three-factor mo behavior determinants, the specific beliefs that make up the motivatio tor provide useful insight (see Figure 11-3). Drawing from Fishbei Ajzen's theory of reasoned action,S a person's intention to do something exercise) can be nonexistent, weak, or strong. According to their theory intention can be influenced by beliefs about positive and negative c quences of the behavior, the person's beliefs about what significant think about the behavior, the consistency of the behavior with the pe self-image, and the person's confidence in his or her ability to perfor behavior correctly. For example, for a person to start exercising there w first have to be an intention to do so. The intention to exercise is deter by the person's belief that more positive consequences than negative c quences will come from doing exercise, the person's belief that signi others are more supportive of doing exercise than not, the person's dence in her or his ability to perform the exercise correctly (which is mined primarily by knowing what to do and by skill practice), and the that doing exercise is consistent with how the person views himself o self. All of these motivational beliefs are potentially modifiable by e tion, persuasion, and reflection on experience. Stimulating others to c their behavior is often more complex than these concepts suggest. How the three-factor model of behavior determinants provides a useful f work for planning health education programs. Thus, community edu programs that provide practice opportunities that develop only the p

mance skills (e.g., learning a water ex the participant's motivation and social support continued involvement in the behavior as when all three factors are

Readiness to Chang

A third assumption has ticipant's readiness to change. Any g lecture on a health issue is probably m something new immediately after th cautious approach, and some who are mote changed behavior. The assum grams can influence an individual's DiCIemente6 have investigated the when making a change like losing we (Figure 11-4). The first stage, precon thinking about or considering making is not in his or her consciousness, changing. The second stage, contem thinking about making a change. Th and cons of the change or thinking taking action. The third, preparation thinking about the change but has a attempts, like purchasing shoes for w what it is like. As the person reco quences of the new behavior, the int fourth stage. The fourth stage, action to do the activity and is doing it. Aft ed into the person's routine, she or h which the challenge is to continue t behavior and returns to the state be relapse stage. Following relapse, a per contemplative and repeat the cycle. If, as is often the case, a commun stages, the goals of health education plators and contemplators to the acti stage as long as possible, and (3) work behavior. Prochaska and colleagues' s person from one stage to the next in nants previously discussed. In fact, a

Figure 11-4 Stages of health behavior change.

change stages is in terms of how a perso oped and maintained. To promote movement from pre co preparation and action, information evaluation and personal awareness are mass media awareness campaigns, rol and observation of others who have increase awareness of a health problem are focused on changing the motivatio ment from preparation to action can b mote decision making and public c identifying workable alternatives tha needs, and behavioral contracts. Ensur ties that maximize the rewards and m such as when a supportive group enga and rewards are set, or variation in the d boredom. Activities that prevent re rehearsing strategies to deal with situ behavior to stop (e.g., going on vacatio responses to occasions when the desired lead to feelings of failure and demorali Prochaska and DiClemente's work be applied to community health educat ties are needed to respond to persons in gram is starting in the same stage, sp maintain that stage or move the progra gram does not match the audience's st program's goals is greatly diminished. F templative stage is not likely to be res an exercise. Such instruction would be the preparatory or action stages. Third, stages several times over the years, ma and resources needed to support change

Individualization As

The fourth assumption, i recognition that people are different, treatment prescriptions, are usually m are recognized and program goals and ences. 9 Accommodation refers to plan

what participant characteristics need accommodating. When impo characteristics are identified and accommodated by the program by pro ing variations in the program's goals, materials, and methods or the needed to achieve the goals, the program has been individualized. Other ilar terms include tailoring, matching, and adapting. In community health education, program planning should attem reduce the heterogeneous community members into more homogen groups to whom health programs can be more effectively targeted. One sibility has already been suggested in the previous discussion in the r ness to change section. Program planners probably need to imple different programs for those in the contemplation, action, or relapse s of change, because those who are not thinking about changing a behavio not as likely to respond to the program as those in the preparation s Other possibilities commonly seen are exercise programs that accommo differences in exercise experience, age, gender, disease, exercise typ modality, and sport. Multiple characteristics can be accommodated by a gram. For example, a water exercise program could be tailored to el women with osteoarthritis of the knees. The process of individualizing a program is intuitively understood b practicing therapists in a general outpatient clinic. Each patient typi undergoes an assessment that results in a prescription in which treat goals and methods are tailored to the patient's specific needs. Even if a eral outpatient clinic reduced the heterogeneity of problems presente patients by specializing in one kind of problem, like low back pain, treat goals and methods will still vary (albeit within a narrower range) based o therapist's assessment of each patient's signs and symptoms. While ac modating patient differences in formulating treatment goals and metho the current practice standard, community health education programs cally deal with groups. Individualizing for groups involves selecting ch teristics that most effect the outcome and identifying clusters or subgr of relatively similar persons on one or more of those characteristics. On of characteristics that could be assessed to cluster members of a group i members' readiness to change and behavior determinants. This assess could result in planned variations of the program to accommodate differe

in readiness stage and behavior dete community health education take a s

Community Healt Planning Models

Arguably, the most influential m the PRECEDE-PROCEED model dev CEDE stands for "predisposing, reinf diagnosis and evaluation," while PR and organizational constructs in ed ment." These acronyms represent tw tematic community health educat program outcomes based on an analy its causes, and the organizational an the program. The definition stage is and evaluation. To stress the sequent Kreuter lO describe six phases that se program implementation to solve the the program's success and needed cha sist of the following:

Phase 1 Examination of the qu defined by the members of a commu focus groups and surveys. This phas larger community into groups so tha Phase 2 Identification and ran tribute to the quality-of-life problem plished by using available data on m risk factors, and other epidemiologic in the community or specially colle phase 2 is selecting one or more resources will be focused. This phas on the basis of health problems and s Phase 3 Analysis of the enviro physical, social, and economic influen control but can be modified to reduc behavioral determinants of the health such indicators as the frequency, rang ior, compliance, consumption pattern clinic, this phase is similar to the asse

of health-promoting behavior that affect whether the behavior is conti The program planner decides which of these factors in the three categ will be the focus of the program, much like a therapist would prio symptoms and treatment options to address the higher priority sympt Phase 5 Assessing organizational and administrative capabilities ed to implement the program. The program's content and methods em from the analysis of what needs to be done (the health problem) and w feasible to do given organizational resources and constraints. The progr then implemented at the appropriate site (e.g., the entire community, sites, schools, churches, health care facilities). The clinic analogy is the apist's attempt to integrate information about resources or other ba that exist in the patient's home environment into a treatment program is feasible and effective. For example, a walking program is less likely prescribed if the therapist determines that the patient cannot affor appropriate footwear. Phase 6 Evaluating the program's effects by collecting data that cate if changes in the health problem and its environmental and beha causes have occurred as expected. Failure to achieve those objectives result in a change in the program. The program's potency or objective be changed if judged unreachable. This phase is similar to the evaluat a patient's therapeutic progress and problems at a follow-up visit tha result in a revision of the treatment.

This brief overview of the PRECEDE-PROCEED model reveals it tematic, sequential, and comprehensive nature and, perhaps more im tantly, two of its key assumptions. In their model, Green and K assume correctly that health problems have multiple causes that c identified. Once identified, efforts to modify these causes most likely to occur at the behavioral, environmental, social, and organizational levels. The reader may have noticed the similarity between the thre tor model of behavior determinants and the phase 4 assessment. important difference between what a therapist does with a clinic p and someone planning a community program is not in the process

assessment, treatment, and evaluatio (i.e., individuals compared with gro emphasized in the assessment). Th Kreuter's phases helps ensure that being planned is as homogeneous as In this way, a more targeted program While Green and Kreuter have dev ing community health education, th potentially being overwhelming in it intimidating to the practicing thera inaccessible to the therapist, there respond to requests to become invol The reader is strongly encouraged to on the PRECEDE-PROCEED model a health education. 10- 13 As an alternative to PRECEDE, process will be developed (Table 11-2) typical request made of physical thera groups within a community who shar step is to identify the most importan increased incidence of hip injuries from Next, the specific behaviors to reduce and the behavioral determinants of t The content of the program usually behavior determinants. Such assessm more similar in their stage of change targeted goals and activities can be of

Process of Commu

Planning and assessmen program, including a community he phase, information is obtained to mak the alternative desired behavior, the desired behavior, the instructional decreasing deficiencies in behavior d and any characteristics that affect th phase is program implementation, dur engaged in one or more instruction desired behavior. The third phase is e effects of the program and modifying

exercise video Phase 2: program implementation Programs to move precontemplators and contemplators to action

Persuasive talk from person similar to group who overcame back pai

Programs to move from action to maintenance

Exercise program that ensures psychosocial and physical rewards with low barriers

Programs to prevent relapse

Group discussion of ways to handle situations that lead to quitting

Phase 3: evaluation Step 1: specify expected positive and negative program outcome goals and measures

50% increase in back and abdomin strength and endurance (Le., a change in the number of exercise performed)

Step 2: specify program activities that contribute to positive and negative outcomes and measures

Attendance three times per week a group exercises at a local church

Step 3: collect data to determine progress in achieving goals

Examining attendance and exercise records

Step 4: revise program goals, activities, or both

Increase in social rewards to maintain participation

activities based on the results. It should be noted that, except for the size the target group, this process is applicable to clinic patient education a community education. When applied to Ms. Nouveau's situation as described at the beginni of the chapter, a key difference has to do with planning for an individu clinic patient versus planning for a diverse group whose only commonali at this point is that they are elderly and the administrator believes they ne more exercise. If Ms. Nouveau develops a presentation without doing furth assessment and planning, her fears may be realized.

Phase 1: Planning

Assessing the Health Pr Planning is a process o sions about the why, what, how, an questions about what is needed and health problem to be addressed and program's goal. Desired health behav from the common health needs of a by polling the group to discover the group, by reviewing health records severity of health problems (e.g., ho soliciting the opinions of informed information about health problems tions about health needs, which bett than public records or an informed experts may identify a health probl templative. Once the desired behav gram's goal, data should be collecte the individual's readiness to change tional characteristics that may affec sions about the appropriate content largest number of persons in the gro geneous subgroups. While there are for deciding which of these characte one approach is to survey the pote many are in each stage (e.g., the per action). Next, the barriers to moving ing an action stage, or preventing r problem of reducing physical and behavior can be addressed. When applying this process to M mined that she should first ask the a lem the administrator wishes her t administrator knows it is a problem. able, because exercise is not a healt responses to an undisclosed health pr veau might reveal that the administr experiencing an accelerated decline i cating that residents' probable funct

regular group activities for the residents. A replacement has not been foun so residents are left with no planned activities to structure their time. T administrator concludes that the residents need to hear a talk about t importance of exercise and a demonstration of some simple ones. The adm istrator hopes that the talk will stimulate the residents to be more act and reduce functional loss. Agreeing with the administrator that continu inactivity puts the group at risk of functional loss and that it is likely th residents will continue to be inactive, Ms. Nouveau asks if residents ha ever expressed concerns about losing function or a desire to do exercis The administrator admits that she had heard none. While it would have been easy for Ms. Nouveau to develop a talk exercise and lead a practice session of exercises that would please the adm istrator, the problem analysis revealed little knowledge of the group's sali behavior determinants or educational characteristics needed to plan speci content or methods. Ms. Nouveau realized that further analysis was need if the goal of engaging residents in regular exercise was to be achieved. The fact that none of the residents expressed a concern about the l of function or exercise raises the strong possibility that the residents w precontemplative, at worst, or contemplative, at best. This impression w checked out by a brief survey of residents to determine the distribution precontemplators, contemplators, and residents in the action stage change to help determine the kind of program needed. The residen answers to questions about how many were exercising regularly (act stage), were thinking about it (contemplative), had not thought abou in the last 6 months (precontemplative), or had recently quit exercis (relapse) were sufficient to classify the group members. As most were p contemplators or contemplators, Ms. Nouveau needs to think of ways affect those behavior determinants to move them closer to the action sta Activities that include information, persuasion, and self-awareness c affect motivation. In PRECEDE model terms, Ms. Nouveau accomplish the first three phases through her discussion with the administrator, b she needs to collect still more information on the behavior determinants exercise among this group.

Assessing Behavior Deter Assuming that the analy cussion with the administrator has ide gram's goal (maintain function) and (insufficient exercise) and the distribut then data must be obtained on identify ing and maintaining daily exercise fo model as elaborated by the consensus tion can be obtained from the residen observation, or any combination of the current knowledge and skills to do ap tional beliefs concerning (1) the pos exercise, (2) their confidence in their a other residents are supportive of the ex violates any strongly held standard of b cise"), and (5) whether previous exercis tions that might recur. In addition, an a environments is needed to ensure adeq tion, safety, and support from others a ment will give Ms. Nouveau and the ad the strengths that can be capitalized on sent barriers to change that need to be To conduct the assessment, Ms. N residents complete a survey. The surve were supportive of each other during importantly, it shows that most resid long-term positive effects of exercise o and functional decline. While a few we enced benefits, a few others believed t do them any good. In addition, Ms. No that there was adequate space, time, staff at the facility. From the survey r even though the residents did not know all had the requisite psychomotor and exercises. Thus, in addition to the fact contemplative about doing regular exer the absence of motivational beliefs abo cise as the significant barrier to movin or action stages. Ms. Nouveau is confident that she (including the rules for when and when

consequences of inactivity. Thus, as she does in her practice, Ms. Nou analyzes the predominant health behavior change stage and the exe behavior determinants needing modification. She must now decide the way to use information, persuasion, or self-awareness activities to m more of the group to the preparation and action stages. Before final decis are made regarding program activities and instructional materials, Ms. N veau must do an instructional assessment.

Instructional Assessment Decisions about how to teach something depend on the o tives of the activity and the characteristics of the group that affect ability to learn. As discussed above, individualization involves accom dating differences as far as practicaL In groups this means organizing groups that are more homogeneous regarding the program's goals, materials and instructional methods used, or the time dedicated to ach the program's goals. For example, some may prefer to come for weekly sions to listen to a speaker, while others may prefer a guided discussion mat. Other characteristics need to be assessed to aid decisions regar materials and methods. These are characteristics that, if ignored, diminish the learning of program participants. The first of these chara istics is reading literacy and cultural beliefs. A simple but useful stra for estimating literacy is determining the distribution of the numbe years of schooling received. Then, select the cluster of answers that in porates the largest number and lower the reading level from the clus midpoint grade by two grade levels. If this cannot be done, and wr materials are used in the program, a fairly safe approach is to make sure they are written at a sixth-grade level as measured by a reading diffi index, such as the Fog Index sM formula or SMOC14 (see Chapter 10). I educational level is generally lower than sixth grade, any written mat should be more cartoon-like or heavily illustrated, with more white s and simple words. A better idea is to use video or audiotapes, because a tory vocabulary is usually higher than reading vocabulary. Culturally related beliefs that affect motivation or willingness to ticipate in an educational activity need to be identified by interv

expert opinion, or survey.15 For examp that involve sharing feelings or admitti to select their most preferred methods ideas for instructional activities acc related beliefs and behavior peculiar to to be identified and accommodated. A ing, and movement impairments amo situation in which the hearing impaire the visually impaired are asked to read out special accommodations. Other important factors that can af the patient's current pain, energy level affected by existing disease, injury, and with persons with inflammatory arthri modate participants' pain and fatigue. about pain, energy, mood, vision, hea Nouveau reveals that three members o have hearing aids and two have osteoar its their movement. These questions sh no questions to determine presence o assess the degree of impairment. In su reveals that the health problem is the f ity. The program goal is therefore to pre goal, Ms. Nouveau needs to engage the and strengthening exercises. However found to be precontemplative or contem of the personal benefits of exercise or h some have arthritis that limits motion taught to them. Given the stages of cha residents have to move to the action sta also knows that her best approach is t needed to support exercise and to try to group as possible for the exercises.

Phase 2: Program Im

This chapter assumes th education programs can do more than i ence persons to reduce unhealthy beha behaviors by systematically addressing tively homogeneous groups. The follo

of the motivational deficiencies of the group, specifically salient beli influence members' intentions to change. Given that informatio method is to distribute an informative booklet, audiotape, or video the group members that addresses the motivational issues. This is a l approach that, if followed up with meetings to discuss the details of gram, can be sufficient to move some to the preparatory stage. A p problem with this approach is that the group members must be wi read, watch, or listen to the material. It is possible that if frequent at is called to availability of the material, word-of-mouth influence ma more to use it as time passes. This contagion effect can be enhanced itive testimonials from group members. Of course, negative testi that are spread by word-of-mouth can kill the program. Another approach involves capitalizing on the persuasive influe credible source, like a physical therapist or physician, who most lay would believe initially because of their trust in the position and ex Thus, Ms. Nouveau could give a lecture in which she presents all t tive consequences of doing exercise and the negative consequence doing exercise that are likely to be important to the group to whom talking. As reinforcement of the message that would facilitate the d ment of positive outcome expectancies for doing exercise, she coul testimonials of its benefits from the few in the group who exercise larly. In this way, she could increase the message's credibility and pr vicarious source that builds the participants' confidence in their abili exercise. The challenge for Ms. Nouveau is to identify those conseq that will most likely affect individuals' intentions. That is, she must the motivational switch. One way of doing this is to have each grou ber indicate in a meeting, interview, or survey the functional activit he or she would most like to retain or recover. With this informati Nouveau could tailor the discussion of exercise consequences to ho cise can help retain or recover these functional activities. Coming credible source and reinforced by testimonials, this can be a persuasi sage that can cause some to move to the next stage closer to action.

A message's influence derives no ery, which can promote self-reflectio lectures physical therapists hear in grams are not to be emulated, becau mit information rather than stimul members most likely occurs when tions or personal challenges of rele technique is to use group activities respond to a relevant problem (e.g., th then share their thoughts with the re Activating an audience by stimu oratorical skills that not all speakers niques that are possible for most. Firs tends to transfer to the audience, oft the presentation. Second, nonverbal communicate respect and interest in ence's identification with and accepta nonverbal behaviors include frequen gestures, and body posture (e.g., leani er wishes to make physical contact) understood by having a few key poin the group. The message should also b easily understands. A common mista technical terms with a lay audience, To capitalize on the energy and audience members could be given t mitment to taking the next step in attending a planning meeting in whi the exercise program. Thus, the nex sentation and made easily accessibl dents part of the planning, member and commitment to the program. T here, but a good model to consider is gious conversions.

Action to Maintenance Once commitment is members must learn how to perform rules for its use (e.g., when to stop or ing a behavior goal, and (3) the indica tion, mechanisms for minimizing n

a group. Support groups that provide encouragement for new behavio can provide ideas for solving problems are the model here.

Maintenance to Relapse Prevention After a behavior is established as a habit, different rew may need to be identified as initial rewards lose their value. The group be used to identify new reward mechanisms, as well as to problem solve barriers. Even so, people relapse most typically because of changes to daily routines that break up the habit, negative emotions (e.g., anx depression, or boredom), interpersonal conflicts with friends and fa members, and negative social pressure from the unconverted. 16 Anticip planning and practice can help counter these influences. Group mem must first be taught to identify the situations that place them at greate for relapse. Before encountering those situations, rehearsing respons them not only provides a relapse-preventing response but also helps dev confidence in their ability to successfully cope with the situation. An im tant aspect of this coping is agreement by group members not to interpr a failure an occasion in which the behavior is missed. These occa instead are interpreted as a "slip," from which the person is expect immediately get up and resume the new behavior. Finally, the program need to help its members learn alternative coping responses to perv stress factors (e.g., relaxation techniques) and use them at each session they become habit. In the event that a member does relapse, the ch cycle will repeat in time.

Phase 3: Evaluation

While the topic of educational program evaluation is cov in many books, including those by Como and Snow9 and Green Lewis,I7 most therapists may not have the time or resources to condu evaluation that more definitively determines program effects. How there are two fundamental issues that the therapist should attem resolve. The first is determining what is different as a result of the prog These differences may be changes in the frequency of the desired beha

reductions in the health problem, or move into the preparatory, action, or o positive, attention should be paid to attributable to the program. For examp other residents are jealous that the exe the television watchers, and that the je the participants. Injuries caused by the only for safety but also to minimize t may do more harm than good. Periodic vation of typical participant behaviors rent stage or exercise frequency, or a session can be used to document posit The second issue focuses on proce is in documenting what is most likel outcomes or why the expected effects amount desired. Typical possibilities in program goals that are needed to achi increases in exercise activity would no of the participants moved into the acti to ask would be why no changes in approach would be to have a person un ticipants in an interview, focus group, o exercises or, if they have, why they ar would be useful for identifying parts of and need modification. The evaluation purpose and methods of follow-up visit mine the patient's status relative to res sufficient progress is not being made, th ment goals, changing the treatment, o therapist collects during the followup mended. Both the logical process of coll for the lack of change and identifying th same in the clinic and community edu

References

1. Fortmann SP, Taylor CB, Flora JA,

health education on plasma chol Five-City Project. Am JEpidemioI

6. Prochaska JO, DiClemente Cc. Stages of Change in the Modificat Problem Behaviors, Progress. In M Hersen, RM Eisler, PM Miller Behavior Modification. Sycamore, IL: Sycamore Press, 1992. 7. Fishbein M, Bandura A, Triandis H, et al. Factors Influencing Beh Change. Final Report-Theorist's Workshop. Washington, DC: Ce for Disease Control, 1991. 8. Prochaska JO, DiClemente CC, Norcross Jc. In search of how p change: applications to addictive behaviors. Am Psychol 47:1102. 9. Como L, Snow RE. Adapting Teaching to Individual Differences. Wittrock (ed), Handbook of Research on Teaching. New York: Ma lan, 1986. lO. Green LW, Kreuter MW. Health Promotion Planning: An Educa and Environmental Approach (2nd ed). Mountain View, CA: Ma Publishing, 1991. 11. Bates IT, Winder AE. Introduction to Health Education. Palo Alto Mayfield, 1984. 12. Greenberg JS. Health Education: Learner Centered Instructional S gies. Dubuque, IA: WC Brown, 1987. 13. Ewles L, Simnett I. Promoting Health: A Practical Guide to Health cation. New York: Wiley, 1985. 14. Doak CC, Doak L, Root JH. Teaching Patients With Low Li Skills. Philadelphia: Lippincott, 1985. 15. Randall-David E. Strategies for Working With Culturally Diverse munities and Clients. Washington, DC: Association for the C Children's Health, 1989. 16. Marlatt GA, Gordon JR. Relapse Prevention: Maintenance Stra in the Treatment of Addictive Behaviors. New York: Guilford 1985. 17. Green LW, Lewis FM. Measurement and Evaluation in Health E tion and Health Promotion. Palo Alto, CA: Mayfield, 1986.

Annotated Bibli

Doak CC, Doak L, Root JH. Teac Philadelphia: Lippincott, 1985 dealing with one of the endur education, the low literacy lea instructional materials for poo Marlatt GA, George WH. Relapse mal Health. In SA Shumaker, book of Health Behavior Chang George have done the most th their old behavior, and how th anticipatory education. This c thesis of theory and research o Prochaska JO, Norcross JC, DiClem W. Morrow, 1994. The most r applications of stages of change ested in influencing change fro it is in clinic or community co Redman BK. The Process of Patie 1993. A comprehensive, readab for patient education. While th techniques and theory are app programs. Useful appendices meta-analytic studies on the ef interventions for changing hea Shumaker SA, Schron E, Ockene Change. New York: Springer, behavior theories and their app programs. Thus, it provides a how programs can be designed health behavior of participants

the Future: One More Word Geneva Richard Johnson

"One more word" implies that others have preceded what be said. Indeed, that is so. Some have heard those words as subtle exho tions to consider the implications of plunging ahead into an undef future. Others have heard a strong plea to look before they leap into unknown without a coordinated plan for action. In either case, the fu cannot be avoided. As professionals, physical therapists and physical th pist assistants can create and choose a future that will allow the profes to use special knowledge and skills in meeting the health care need diverse populations in the United States and other nations. I cannot say when the urge to think about the future struck me. know that the opening of a new world in physical therapy occurred for m one of those rare moments that left me feeling like a light bulb had b flashed in my unsuspecting brain. At a conference of academic administra in 1959 las an invited guest before I was eligible to join their ranks), I o heard a snatch of conversation between Catherine A. Worthingham, for director of the National Foundation for Infantile Poliomyelitis, and Hele Kaiser, founding director of the physical therapy programs at Duke Univ ty, that changed forever my concept of physical therapy and the role of p ical therapists in health care. The encounter was fleeting but the revela of a truth was instantly clear. The precise words overheard in that mom are in my deepest memory and not easily dredged up. What mattered m about that event is the freedom that came with the instant realization t must create a new future for myself. Obstacles to the creation of that fu

were temporary interruptions-deto some goals, but have usually been ove About 1970, the faculty I was par tal ball to help the process of divining . beauty catches the sunlight, sparkles, but no meditation or prolonged gazing of things to come in physical therapy. Some solitary thinking, lots of d other people who are not physical ther and news magazines, listening to news reading, reading, reading-all of those shaped my dreams for physical therapy For me, thinking about the future painting of a mural that is never quite takable theme but variations are notic acters are added. The mural depicting time. Occasionally, a segment represe ed out, replaced by another represent tion is RC14-79 adopted by the Am (APTAI House of Delegates in 1979. 1 ment to the postbaccalaureate degre physical therapy education. Further, preparing the physical therapist for pr degree programs by December 1990. T of the deadline for transition has left In 1996 in the United States, 153 i physical therapy, 110 offered the mas degree, and three offered a doctorate i programs, 29 will offer a master's deg mission on Accreditation in Physical T Therapy Association. Personal commu the bachelor's degree programs are bec one master's degree program has ma physical therapy.

Reflections on the

Like the mural, my refle py show a theme that says, "we hold th hearts to be whatever we dream. The h

From the Past

In my past as a clinician the most important words I h from patients were, "You listened. You heard what I said. You comforte by your touch." As we transform our vision of the future into the real the future, we must take care to retain the intrinsic values that have tained and distinguished us since the early part of the twentieth cen The characteristics attributed to physical therapists are caring, dedica and competence. Competence in practice is extremely important but ca stand without caring and dedication. The laying on of hands is the potent intervention at our disposal, and the least costly. In the following excerpts from 1984, I describe the role of the phy therapist as multifaceted and comment on what is required of the p tioner in any setting:

Some of the facets of the role can be identified as clin generalist, clinician specialist, teacher, consultant, patient advocate, researcher, political activist, negotiator, mark manager, supervisor, and administrator. Other facets will em as health care changes. The physical therapist who is in an a care setting must be a highly skilled communicator, pro solver, teacher, negotiator, consultant, patient advocate, h care planner, collaborator with colleagues, and an e clinician.

To compete successfully in any setting, the physical ther must be an astute business manager and marketer as well expert manager of patient care. To be a patient advocate physical therapist must understand and participate in political process. When faced with decisions about the al tion of time and personnel to provide services, the phy

therapist must be prepar issues involved in reachi

The role of the physic described as fluid. All ph position, function in mu another as the situation

In the present form of th ician generalist, clinician istrator, consultant, educ

The physical therapist i patient and family; a pol and the profession; a ma representative to comm needs in service, research in professional organizat tributor to new knowledg

The following comments on the r an earlier time:

The role of the practition disappear to be replace include the responsibiliti sional. I see the physical entist-a full and equal p

The physical therapist of tional settings of the ho tings where physical ther those environments, the on new and different dim

The emphasis on physic individual to develop his tain the functional level function. In this expande of evaluation-evaluatio ness or crisis care, evalu

increasing array of highly sophisticated and sensitiv ment. Some of that equipment will be used in evaluati cle strength and joint range of motion and the de spasticity, tightness, flexibility, or rigidity in a part. T itoring of physiological responses during treatment or tion will give precise information on which to b progression and intensity of treatment procedures. progress in research in neurophysiology will help to p scientific basis for the selection of physical therapy pro to meet individual needs.

Among the other functions in the enlarged role of the therapist will be those of teaching, consultation, supe and research. Although these functions are being perfo some physical therapists today, in the future all physi apists must share in those responsibilities.

Teaching has been a major activity in physical therapy, efforts have been concentrated largely on instructing p family members, supportive personnel, students in therapy, and colleagues. As we assume increasing resp ity in health care, the teaching function must exten general public as well. The physical therapist of tom therefore, will have responsibility for the dissemin information to the public on the prevention of impaire function, maintenance of function, growth, and deve of motor function throughout the life span.

As a consultant, the physical therapist will be availabl leagues in other health sciences, personnel in health ca cies, community planners, business, and industr consultative function may differ for the various groups

focus will remain cons therapy services to the i meet the health care ne will be an important c related to motor ability a

The theme of an expanding role constant among my public words. Wh Without a doubt the answer is "whate In 1967, I was discussing a propos therapy with Dr. John D. Millis, Ch Reserve University. He studied the pro plan was to create a new kind of phy new kind of physical therapist." With time, I hoped for a physical therapist with a high degree of competence, wi with willingness to make decisions, ta for those actions. I continue to hope fo

For the Future

My hopes for physical practitioners who will be primary care the entry point into the health care experience, and willingness to provide cal therapists and physical therapist as tions that they have allowed others in will be added. Among those added wi systems as a requisite for referral to o viduals and groups on health care; a health care services, including preven the life span, and maintenance of gain a personal plan for development. The physical therapist will be an supporting enactment of legislation a the benefit of the public. Another fun care services for individuals, groups, a ar, the physical therapist will collect about the efficiency and social benefit where, how, and what of services to

health care counselor; a political and community activist; and an advo for individuals, the community, and the profession.

Education for Practice

The demands, challenges, and opportunities for physical apy place us in an advantageous position. The same could be said of any od in our history. What makes this era different is that any limits cla are self-imposed. The remedies to barriers, perceived or real, may not be ular but are available. "They won't let me" is an excuse for indecision, tion, and tole~ting unreasonable restraints, but it is not a valid reaso accepting those restraints.

From the Past

In searching for words to describe education for the futu found that these from 1972 have not lost their significance:

Educational programs must be based on the role of the p cal therapist and the nature of the responsibilities tha implicit in that role. Because the role of the physical ther will be broadened, education for that role must include op tunities for learning which are not at this time an integral of all of our curricula. To accept the responsibility of inde dence in the community, the physical therapist must be pared through education and experience to make impo decisions about the services to be provided, the distributi those services, and the selection of services which enhance the motor function of any individual receiving sical therapy. 4

The following are words from 1974 that are as pertinent for today for the future:

If we are to control our today for those unkno less, exciting opportu because of the unique from the sciences and h all of the facets of phys colleagues and the pu health care needs of so

Directions for the 1970s and fo mural in 1984:

Preparation of the phy ethics, logic, philosoph ing, political science, t ation. Development of and problem-solving s preparation of the phys

To compete successful must be an astute busin expert manager of pati physical therapist mus ical process. When face time and personnel to must be prepared to d involved in reaching th

For the Future

Words for the future answers rooted in the past and pres in science and technology in the pa the future must take those advance tion for change on the roads that ph tions for the connected, but rarely options to consider for uncharted roa We are told by some philosoph solutions to problems are floating in plucking one or many of those idea Choosing one or more futures on

Physical Therapy and the Physical Therapist in the Future Education

The future must begin with education. In 1985, 20 year early discussions on the subject, I called for at least 50 physical therap grams to be at the doctoral level by the year 2000. 6 No matter how we that dream is unlikely to come to fruition. However, I remain convince in a few years the doctor of physical therapy will be chosen by the prof as the first professional education needed for practice. A clinical doctoral program will be expected to prepare physical pists to respond with competence, confidence, and compassion to the care needs of a complicated, diverse population in the United Stat other nations. To prepare a sufficient number of physical therapists doctoral level, the welfare of the public and the profession must recei highest priority. This means sharing of resources, especially faculty, a established programs. As the doctor of physical therapy degree is accepted and expected initial professional education for practice, those institutions una unwilling to face the challenge of the future will face decreased enrollm loss of financial support, and a reduction of positions for faculty. The will be an increase in the number of seats, faculty, and other resources able in stable institutions and development of separate schools of ph therapy with their own deans who speak for physical therapy to the ul decision makers in educational institutions. Another option for the future is development of several stron standing institutions dedicated to physical therapy education. These m supported by area educational institutions, which retain the right to own admission and graduation requirements and award of the degr will collaborate in the educational process. Centralizing the educa process in a single geographic location and functioning under a body resentatives from the member institutions of a consortium will be a nificent opportunity to offer the best learning and research resour students and faculty. The major benefactor of this collaboration will

public, who will have access to the se educated physical therapists prepared a

Experiential Profess

In the future, the physic tioner or as a specialist, will have resp ential professional activities beyond th service delivery. Opportunities must be ues, knowledge, and skills related to th and physical therapist assistants must and in different practice environments The current model of clinical e approach that focuses on the realities the physical therapist described in thi not given attention in most curricula. labeled this segment of the educatio activities. Under that heading, oppor classroom and laboratory will include specific objectives in state and annual professional organizations, (2) structure ment communities as a mechanism fo munication skills, (3) observation of caregivers and recipients of services in (4) survey of public facilities (e.g., hote accessibility, (5) participation in legisla levels, and (6) evaluation of chairs, sof protection of the back. These few ex options with sufficient variation to me Apart from the community experi ferent world, a group of students can b and service in another country with a faculty guidance and supervision, gro could plan together to share the exper activity could occur in selected areas i

Continuing Educati

The new graduate in the advised, to complete at least 1 year of s ance of a preceptor. Sites will be chose

development of materials can be a lucrative source of income.

Environments for Practice

Physical therapists today work in diverse settings in the co munity. They work in hospitals, prisons, educational institutions, indus all branches of the military, education, and treatment facilities in fore countries. In short, they work everywhere. The future for the delivery of vices will be in expanded coverage for all underserved areas-rural, urb and suburban. The focus will be on all age groups, with concern for con uing development throughout the life span, prevention of injury and illne maintenance of a healthy state, and restoration of lost or diminished mo ability as a result of injury or illness. Although this approach to the deliv of services is practiced now by many physical therapists, assuming resp sibility for primary care will make that approach mandatory for alL Beca the physical therapist will provide services wherever they are needed (e.g. the client's home, on the basketball court, in a store-front clinic, in a scho the potential for services has no limit.

Foreign Service

Other environments that will capture the attention of phys therapists are outside the United States. Establishing service and educati al programs in nations with limited resources is a professional responsib ty that physical therapists and physical therapist assistants cannot igno The monetary reward will not compare with salaries or income from pr tice in the United States, but the satisfaction derived from organizing guiding the development of those valuable services for others will outwe the monetary loss.

Research

As the number of scholarly and professional graduate p grams has increased, the quality, quantity, and variety of research

increased markedly. Advancement enhanced the research capabilities leagues. Clinical research has rece reimbursement for physical therapy clinical research in a speech to an in following words:

Justification for the co tinct profession rests o of our present and pot of society. Therefore, tively simple questio doing it? What results ting? How can we acco what we are doing?6

Technology will continue to en titioners and students. Major ques therapy interventions remain a chal Research is the responsibility regardless of the employment sett pists and physical therapist assista accurate data for analysis and t researchable questions. A concerted effort must be mad mance of graduates in a variety of en practice, and a host of other issues ical therapists can learn how to des duce a practitioner who will have expected of the primary care provid

Technology

Technology will be put exists allows learners and faculty to as partners in planning objectives. E increase so that no one will live in materials will multiply rapidly in th body of educational resources availab Through computer networks, s ized portion of the world's library

able about physical therapy as a profession, employment opportunities financial rewards of practice; and will have completed at least a baccalau degree. Physical therapy often will represent a second or third career cha Undergraduate preparation for entry into physical therapy educati a minimum must include the humanities (e.g., philosophy, ethics, logic eign languages, literature, and history), communication skills, and a bal between the sciences (e.g., natural, behavioral, social). An important a of undergraduate education is the expectation that the graduate will completed study in depth in a major field that requires analysis and as ment of information, evidence of competence in written and oral comm cation, and the ability to make decisions.

The Learning Environment

The learning environment in the future will encou learners to accept responsibility for their own 'learning, to be collabor with faculty in the learning process, and to participate in activities promote their own development and that of other learners. Integ opportunities for learning will be designed that develop (1) critical th ing and decision-making skills, (2) teaching and other communic skills, (3) caring and competence in the delivery of physical therapy vices, (4) understanding of the factors that influence the delivery response to health care services by clients, and (5) understanding o responsibilities of professional practitioners. Continued initiation refinement of problem-based learning curricula will provide opportun for learners to be self-directed and for faculties to be facilitators, gu and resources in the learning process.

Challenge of the Future

A retired, respected hospital administrator told me tha thinks physical therapy has reached its peak and will go downhill from

on. He was challenged immediately b the future of physical therapy is more than at any time in our history. The w ment is challenge. I choose challenge because the ea will fulfill the prediction of the adm few laurels on which to rest; challen deserve our special touch and the ser lenge because we have hardly begun t intrepid founders. As a profession, I th ity, and the dedication to accept the health care.

References

1. American Physical Therapy Asso Minutes. Alexandria, VA: Ame June 1979. 2. Johnson GR. Physical Therapy E Closing the Gap. Presented at th Administrators, sponsored by the tion, Department of Education. A 3. Johnson GR. Physical therapy 1974;54:37. 4. Johnson GR. What's the answer? 5. Johnson GR. Great expectations Ther 1985;65:1690. 6. Johnson GR. Clinical Research Physical Therapy. In Proceedings ical Therapy, Seventh Internatio eration for Physical Therapy, 197

Training Exercise: Broken Circles Instructions

Step 1. Divide the class into small groups (three to six persons per grou Give each person an envelope with different pieces of a circle. Step 2. The goal is for each student to put together a complete circle. T this, students must exchange some of the pieces. Step 3. Rules of the game include:

1. No talking. The game is done in complete silence. 2. A student may not point or signal any other player with his or h hands. 3. The focus of the game is giving. Students may give pieces one a time. They may not place a piece in another person's circle. Stu dents can hand a piece to a player or place it beside the other pi in front of him or her. 4. Students must complete their own puzzle. Step 4. This is a group task. Each group has 15-20 minutes.

After the time is up, the class should discuss the game using th lowing questions: 1. What do you think the game was about? 2. How did you feel as a group member? 3. What things helped your group be successful in solving the problem? 4. What things made it harder? 5. What could the group do differently?

Directions for making materials for pla Advanced Broken Circles

1. Make a set from heavy cardboar diameter. Each set of six circles ters and numbers marked on th cate group size and letters indic 2. Cut circles into pieces with the 180,210,240, and 270 degrees. S circles for a group of six. (Reme

Circle

Piece label A B

C 2

A B

3

A

4

5

C 3-C 4-D S-E 6-F D 4-C SoC 6-C E

SoD 6-D S-E 6-F 6

F

6-E

Degree angle for pie

120 120 120 120 240 120 180 60 60 60 60 270 90 90 90 ISO ISO ISO 60 60 210 ISO

Sources: Broken squares game developed by A Bavelas. The five squares probleminstructional aid in group cooperation. Stud Personn PsychoI1973;5:29. Broken cir game developed by T Graves, N Graves. (Game) Santa Cruz, CA: 1985. May be pu by writing Graves, 136 Library St., Santa Cruz, CA 95060. Average class would ne to eight sets. Directions for preparation of game reprinted by permission of the pub from EH Cohen. Designing Groupwork: Strategies for the Heterogeneous Classroo ed). New York: Teachers College Press, © 1994 by Teachers College, Columbia Un ty. All rights reserved.

B

Cooperativ Training Ex Esptein's F Rocket

Group Activity

This training exercise involv topic that will generate interaction with d is given a topic to discuss. As an example: discuss the role of research in physical the role be? Consider you are a task force of mendations to the faculty. Identify the dr make a list of recommendations. Decide w of project (e.g., proposal only, project, or experience in the curriculum, and whethe pendent projects or group projects.

Ground Rules

There will be four stages and practice these skills at each stage.

1. Conciseness. Select a timekeeper keep time for the group. The time person talks for only 15 seconds. D

her. (The peson who spoke before must nod his or her head to ind if the repetition is correct.) Do this for 4 minutes. 4. Everyone contributes. Select a new timekeeper. All previous apply. In addition, no one may speak a second time until ever in the group has spoken. Do this for 4 minutes.

Observers

The teacher can assign one or two observers to record e ples of group members' skills for each of the four stages (conciseness, li ing, reflecting, and contributions by all).

Debriefing Session

Following the discussion, have the groups debrief using th lowing list of group behaviors as a structure for discussion.

Group Behavior and Process Skills Work Behaviors: Skillful Members • • • • •

Have new ideas for the group Ask for or give information Help explain better Pull ideas together Find out if the group is ready to decide what to do

Helping Behaviors: Helpful Members • • • • •

Get people together Bring in other people Show interest and kindness Are willing to change own ideas if someone makes a good argum Tell others in a good way how they are behaving

Troublesome Behaviors:

• • • • • • • •

Attack other people Refuse to go along with sugges Talk too much Keep people from discussing be Show that they do not care abo Let someone boss the group Do not talk and contribute to i Tell stories and keep the group

Source: Adapted from C Epstein. Affective S Sex and Drugs. Scranton, PA: Intext Educati

Learning

In this appendix three well-known theories of motor learni (those of Adams, Schmidt, and Newell) are briefly described and suggestio given for their application to physical therapy practice. The assumptions a predictions of these theories can also be found in Table 9-3.

Adams' Closed-Loop Theory

In 1971, Adams published a closed-loop theory of motor lear

ing.l Adams proposed that memory consists of perceptual and memory trace

The memory trace is used to select the direction of movement and to ini ate an action. The perceptual trace, consisting of sensory feedback for intended action, serves as a reference of correctness and is developed duri practice. Any mismatch between ongoing sensory feedback and the perce tual trace is detected as error. Adams hypothesized that performers co tinue to move until ongoing sensory feedback matches the stored perceptu trace. This theory predicts that sensory feedback is a requirement for mov ment and learning, learning is directly related to the strength of the perce tual trace, practice without errors will strengthen the perceptual trace a enhance learning, practice with errors will weaken the perceptual trace a degrade learning, and previously practiced actions will be performed bett than unpracticed actions (termed specificity of practice and learning). A strength of Adams' theory is its predictions for slow, positioni actions. A weakness of the theory is that it is unable to account for mov ment and conditioned learning without sensory feedback. In 1968, Taub a Berman2 demonstrated that conditioned learning can occur in primates aft deafferentation. Recent research has revealed several other weaknesses Adams' theory. For example, practicing several variations of a task by chan ing the overall amplitude or duration (termed variable practice) is at least

3

effective, or more effective, for learning ation of a task (termed constant practice There are at least three ways that A cal therapy. First, it outlines the proces ments. Physical therapists can use the perform slow actions. Second, because making sensory feedback more accurate advocates the use of many facilitation te back. Third, this theory argues for sp Clients should practice the tasks they w they should practice them in an environ the post-therapy environment.

Schmidt's Schema T

In 1975, Schmidt3 publishe ing, where performers learn schema an Schmidt argued that instead of storing in performers store generalized rules about that a generalized motor program and tw recognition (sensory) schema to evalua schema to produce actions. The general vague terms. Schmidt stated that it consi without specifics. Recognition and recal tion on processes of learning in Chapter The recognition and recall schemes outcome feedback. Any variables that s schemes should enhance learning; thus, e hinder, learning. Because traces of indivi predicts that novel actions will be perfor ments within the same class of actions. actions occurs by altering the overall dur Strengths of Schmidt's theory are its its prediction of variability in practice ef tion in Chapter 9 on variables that inf practice effects seems to be especially because children have less practice than amount of practice, they may have exper ing to an experimental situation. Weakn ure to explain how generalized motor pro

ing on one surface at a single speed (which may be all that a client in nursing home is required to perform), clients should practice walking on s eral surfaces (e.g., tile, carpet, grass, cement, and gravel) at several spee (e.g., slow, self-chosen, and maximal). Third, Schmidt argued that errors c enhance learning. Thus, clients should be allowed to make errors so th they can distinguish between correct and incorrect perceptual feedback a motor actions to achieve a goal.

Newell's Theory

In 1991, Newell4 suggested that instead of learning motor p grams, practice leads to a stronger coupling between perception and actio Newell argues that learning consists of developing optimal strategies solve an action problem for a given task and environmental constrain Newell defined two work spaces-perceptual and motor. During learni performers explore their work spaces to identify critical perceptual cues a motor strategies for performing efficient actions. Because Newell's theory is relatively new, few studies have been p formed to test it. Its strength is in its focus on the relationship between s sory and motor processes. The major weakness is that it is essentially untested theory. Physical therapists can apply this theory by helping clie understand the critical perceptual cues and motor strategies of a task.

please refer to the Annotated Bibliography and References in Chapte for more information regarding these and other theories of motor learnin

References

1. Adams JA. A closed-loop theory of motor learning. J Mot Beh 1971;3:111. 2. Taub E, Berman AJ. Movement and Learning in the Absence of S sory Feedback. In SJ Freedman (ed), The Neuropsychology of Spatia Oriented Behavior. Homewood, IL: Dorsey Press, 1968.

3. Schmidt RA. A schema theory of di Rev 1975;82:225. 4. Newell KM. Motor skill acquisition

Academic coordinator of clinical education (ACCE), 127 activities of, 130 challenges for, 131 role and responsibilities of, 129-131 Academic rationalism, 42 Accreditation for physical therapist assistant programs, 28-33 for physical therapist programs, 28-33 process of, 29-30 purposes of, 29 self-study report for, 30-33 Acculturation, 179-180 Adams' closed-loop theory, 277-278, 393-394 Adolescent patients, teaching of, 329-330 Adult patients, teaching of, 330 American Physical Therapy Association (APTA), 2, 6, 39, 374 Bandura's social learning theory, 352 Becker's health belief model, 352 Behavior cognitive, 352-353 determining types of, 351-354, 364-365 interactional with patients, 255 learning theories, 46 readiness to change, 354-356

Behavioral learning contract, 313, Bloom, Benjamin, 50 Bobath, Berta, 42 Bobath, Karl, 42 Brainstorming, 103 Brunnstrom, Signe, 42

Canfield Learning Styles Inventory CAPTE. See Commission on Accre tion in Physical Thera Education (CAPTE) Case studies, teaching using, 106-1 Center coordinator of clinical educ (CCCE),127 activities of, 132-133 future concerns of, 133 personal attributes of, 131-132 role and responsibilities of, 131-133 Children biological development of, 48 psychomotor skills of, 296 teaching, 328-329 CI. See Clinical instructor (CI) Classroom environment creating a supportive, 84 grading systems in, 87-89 Clinical education context of, 171-176 continuing programs in, 141 educators' accountability in, 154-155

Clinical education-continued environmental conditions in, 173-176 future prospects of, 382 importance of, 169-170 instructors in. See Clinical instructor ICI) organizational structure of, 127-142 pre-experience planning for, 184-186 role and responsibilities of academic coordinators in, 129-131 center coordinators in, 131-133 clinical instructors in, 133-142 students in, 128-129 student objectives in, 142-145 behavioral, 144, 145, 146 factors in determining, 143-144 global, 144-145 purposes for, 143 supervisory patterns in, 145-153 teaching techniques in, 169-197 vs. academic education, 172-173 Clinical instructor ICI), 127 challenges for, 138 communication skills of, 136-137 developing expertise as, 142 enabling acts of, 183 personal qualities of, 135-138 preparing to be, 138-139 role and responsibilities of, 133-142, 182-195 skills and qualifications of, 134-135 student evaluations of performance, 190-191, 194-195 readiness abilities, 182, 184-191 self-assessment vs. demonstrated abilities, 187-190 student interaction with, 170, 174-175, 177-181, 184, 187, 190, 191, 192 student orientation by, 186 student supervision by, 147-153, 193-194 success factors of, 138 training for, 139-142 Clinical laboratory teaching deliberative processes in, 94-95 demonstrations in, 93 developing/assessing clinical practice skills in, 89-98

between resident and patient, 209-217 definition/description of, 201-202 education in, 199-224. See also Clinical reasoning challenges of, 203 linking academic and clinical curriculum components to, 205-208 philosophy of, 202-204 treatment selection in, 217-220 faculty, 204--205 models of, 202 supervision and mentoring in, 206-207 tutorial follow-up of, 208 Clinical training programs, 140-141 Cognitive processes, development of, 41--42 Cognitive structure, 48--49 Collaborative learning, 98-105, 114. See also Learning, collaborative Commission on Accreditation in Physical Therapy Education (CAPTEI, 29, 30, 31, 32 Commission on Recognition of Postsecondary Accreditation (CORPAI,29 Community health education, 345-372 assessing behavior determinants in, 364--365 health problems in, 362-363 assumptions in, 349-358 behavior and, 350, 351-354 individualization of, 350, 356-358 knowledge and, 349-351 readiness to change and, 350, 354--356 evaluating, 369-370 implementing, 367-369

Contextual interference paradigms, 293 Contracts, learning, 312-313, 314 behavioral, 313, 315 CORPA. See Commission on Recog tion of Postsecondary Accreditation (CORPAI Council on Postsecondary Accredita (COPAI, 29, 30 Cultures, influences of, 307-309 Curriculum, 1-35 accreditation of, 28-33 for physical therapist assistan programs, 28-33 for physical therapist program 28-33 process of, 29-30 purposes of, 29 self-study report for, 30-33 designing a, 3 developing a, 3-20 educational experience needed in 9-12 evaluating a, 17, 18 explicit, 11, 20-21 goals of, 4--9, 11 implicit, 11,21-23 in liberal arts vs. physical therap programs, 25-28 linking academic and clinical com nents of, 205-208 matrix, 15-16 micro environment in, 6--9 mission statement and, 9 null,23-25 organizing educational experienc and,12-17 preparing a course syllabus and, 61--62 problem-based,41 program philosophy and, 4--9, 10 Customer service, 123-124

Debates, 103-104 Deductive process, 81 Dervitz, Hyman L., 39 Dewey, John, 33, 47, 106 Dickinson, Ruth, 39 Discovery learning, 291-292 Domains of learning. See Learning domains Education academic vs. clinical, 124-127 clinical context of, 171-176 continuing programs in, 141 educators' accountability in, 154-155 environmental conditions in, 173-176 future prospects of, 382 importance of, 169-170 instructors. See Clinical instructor (CI) organizational structure of, 127-142 pre-experience planning for, 184-186 student objectives in, 142-145 supervisory patterns of, 145-153 teaching techniques in, 169-197 clinical residency and, 199-224 challenges in, 203 linking academic and clinical curriculum components in, 205 philosophy of, 202-204 treatment selection in, 217-220 community health and, 345-372 assessing, 364-366 assumptions about, 349-358 evaluating, 369-370 implementing, 367-369 phases of, 360-370 planning models in, 358-360 conflicts between professional and liberal arts, 25-28 continuing, 382-383 future of, 380-382 global environment of, 6 higher education vs. health care environments, 122-124 objectives of, 7

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short answer questions and, 63-65 true or false questions and, 64 Exercise, 321, 367 consequences related to, 258 training broken circles, 387-389 Esptein's four-stage rocket, 390-392 Expert panels, 105 Explanatory models. See Models, explanatory Faded feedback schedule, 288 Feedback augmented, 288 effective, 336 from patient/family, 340 positive, 336 video, 290-291 Fishbein and Ajzen's theory of reasoned action, 352, 353 Fog Index formula, 325, 326, 365 Ford, Patrick, 25 Gagne, Robert, 48 Games, 105 Gentile's task taxonomy, 282-284 Geriatrics, teaching, 331-332 Gestalt psychologists, 46 Grading systems, 88-89 classroom teaching, 87-89 competency-based, 88 contract, 89 criterion-referenced, 88 norm-referenced,88 peer-grading, 89 self-grading, 89 Groupwork, 98-102. See also Learning, collaborative; Learning, cooperative Harris, Irene, 5

Knott, Maggie, 42 Knowledge, transformation, 76 Knowledge of performance (KP), 289-290 Knowledge of results (KR), 288

Learning active, 77 categories of, 313, 315-317 clinical, 176--182 ability to perform effective actions in, 178-179 acculturation in, 179-180 bridging theory with practice in 178 critical analysis of competence 180 lifelong reflective practice and, 182 other-assisted to self-assisted, 1 outcomes of, 181-182 problem selection for students and, 191-193 process of, 176--180 questions in, 188-190 students and, 176-177 collaborative, 98-105, 114 brainstorming in, 103 debating in, 103-104 expert panels in, 105 games and simulations in, 105 group expert technique in, 100-101 in clinical setting, 152-153 peer teaching in, 102-103 role playing in, 104--105 rules for groups and, 100 seminars in, 10 1-102 small groups process and, 98-10 successful, preparing for, 99-100 tutorials in, 102 cooperative, 152-153

in a clinical setting, 152-153 training exercises for, 387-392 discovery, 291-292 motivation for, 311-313 motor error detection in, 277-279 exploiting biomechanics in, 282 focusing on actions not movements in, 281 forgetting and retrieval practice in, 280 Gentile's task taxonomy of, 282-284 measuring, 273 memories in, 279 processes of, 274-284 stages of, 275-277 autonomous, 276-277 cognitive, 276 themes in, 297 theories of, 393-395 Adams' closed-loop, 277-278, 393-394 Newell's, 278,395 Schmidt's schema, 278, 292, 394-395 vs. motor performance, 272-274 phases of skill in, 91 Learning contracts, 312-313, 314 behavioral, 313, 315 Learning domains, 5~56 affective, 52-54,315-316 cognitive, 5~52, 315 perceptual, 55 psychomotor, 54-55,316 relationship between philosophici;ll orientations, learning theories and, 56 spiritual, 55-56 Learning environment, of the future, 385 Learning styles, 56-58 Learning theories, 45-50 Adams' closed-loop, 277-278, 393-394 Bandura's social learning, 352 behaviorism, 46 cognitive structure, 48-49 Fishbein and Ajzen's, of reasoned action, 352, 353

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instruction surrounding treatment and, 259 patient negotiation process and, 257-259 patient-practitioner collaborative, 251 PRECEDE-PROCEED, 358-360 teaching, 75-78 comprehension of, 77-78 concepts for, 77 instruction and, 77 knowledge of subject matter and, 75-76 reflective evaluation with, 77-78 transformation phase and, 76 Motor learning. See Learning, motor Motor performance measuring, 273 vs. motor learning, 272-274 Neil, A.S., 44 Newell's theory, 278, 395 Nieland, Virginia, 32 Outcome objectives, 60--61 Patient education, 225-240 barriers to delivering, 234 behavioral learning contract and, 313,315 coping strategies in, 307 cultural influences on, 307-309 determining literacy of individual and, 325, 327-328 evaluating with feedback from patient/family,340 methods of, 338-340 with self-appraisal, 340-341 family system and, 305-306 guidelines for, 247-248 illness and, response to, 305-306

226-227 questionnaire and data analysis for, 233 design of, 229 development of, 228 discussion of, 237-238 response to, 229, 232-233 results of, 235-237 skill development in, 235 teaching, 311-328 of adolescents, 329-330 of adults, 330-331 categories of learning and, 315-317 choosing group or individu 334-335 of cognitively impaired, 33 of geriatrics, 331-332 goal setting in, 318-320 materials for, 320-328 motivation for learning, 311-313 of pediatrics, 328-329 physical therapist assistant in, 311 physical therapist's role in, planning for, 317-318 preparation for, 305-311 techniques for, 335-338 of terminally ill, 333 Patient examinations diagnostic process in, 256-257 evaluation approaches for, 253 formal and informal evaluatio 220-221 identifying problem areas in, 2 interviews and, 209-217 objective of, 214-216 prioritizing problems with, 21 subjective, 211 Patients case studies of, 263-265

Patients--continued establishing a therapeutic relationship with, 254-255 evaluation approaches with, 253-254 facilitating recovery of, 252 interactional behaviors toward, 255 interviewing, 209-217 obtaining cooperation from, 244 self-efficacy of, 261-265 treatment of. See Treatment understanding, 241-269 Pediatrics, 328-329 Peerteachin& 102-103 Performance, motor measuring, 273 vs. motor learning, 272-274 Physical therapist assistants accreditation of, 28-33 program philosophy, 20 Physical therapists accreditation of, 28-33 muscle performance examinations by, 173 Physical therapy applications of to foreign service, 383 to research, 383-384 curriculum. See Curriculum future prospects of, 373-374, 378-379,380-386 historical perspective of, 375-378 mission and practice of, 8 philosophy of, 10 Piaget, Jean, 48 Plato, 45 Portfolios faculty, 69-70 student, 67-68 Practitioners, roles of, 136 Preactive teaching, 39-40 grid for, 40-61 PRECEDE-PROCEED model, 358-360 Problem-solving experience, 46-48 Problem-solving objectives, 59-60 Psychologists, gestalt, 46 Psychomotor skills, 90-93 of children, 296 demonstrations of, 93 of elderly, 296 learning phases of, 91

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dency evaluating, 62-63, 67-70 clinical readiness abilities, 182, 184-191 peer reviews, 68-69 performance, 190-191, 194-195 self-assessment vs. demonstrated abilities, 187-190 using student journals, 68 using student portfolios, 67-68 interaction with clinical instructor, 170,174-175,177-181,184, 187, 190, 191, 192 learning styles of, 56-58 motivation principles of, 177 orientation to clinical setting for, 186 responsibility of in clinical setting, 176 roles and responsibilities of, 128-129 supervising, 193-194 in clinical setting, 145-153 Syllabus, 61-62 Teaching. See also Education; Lectures in academic settings, 73-118 academic vs. clinical, 172-173 adolescent patients, 329-330 adult patients, 330 case reports/studies and, 106-109 challenges of, 114 in classroom settings, 87-89 clinical laboratory. See Clinicallaboratory teaching in clinical settings, 119-167. See also Clinical education concept mapping and, 109 curriculum. See Curriculum domains of learning, 50-56 affective, 52-54,315-316 cognitive, 50-52,315 perceptual, 55

theories materials for assessing readability level,325 chalkboards, 112 computers, 111,321 evaluating, 320-325 films, 112 for patient education, 320-3 overhead transparencies, 112 reference list of, 322 slides, 112 using educational technolog for, 109-113 videotapes, 112 written, 321 objectives of, 58-61 behavioral, 58-59, 61 outcome, 60-61 problem-solving, 59-60 patient education. See Patient education philosophical orientation of, 41 academic rationalism, 42 course development and, 44 development of cognitive pr cesses, 41-42 personal relevance of, 43-44 social adaptation in, 43 social reconstruction in, 43 technology and, 42-43 preactive, 39-40 grid for, 40-61 preparing for, 37-72 course syllabus, 61-62 preparing examinations and, 63-67 essay questions, 66 free format questions, 64 grading systems, 88-89 multiple choice questions, 6

relationship between philosophical orientations and learning theories and, 49-50 domains of learning and, 56 student learning styles and, 56-58 Teaching models, 75-78. See also Models, teaching Technology, 42-43,384-385 computer, 109-111 educational, 109-113 traditional instructional, 111-113 Tests. See Examinations Theories Adams' closed-loop, 277-278, 393-394 Bandura's social learning, 352 behaviorism, 46 bridging with practice, 178 cognitive structure, 48-49 Fishbein and Ajzen's, of reasoned action, 352, 353 gestalt/problem-solving experience, 46-48 learning, 45-50 Newell's, 278, 395 relationship between philosophical orientations and, 49-50 domains of learning and, 56 Schmidt's schema, 278, 292, 394-395 Thorndike, E.1., 46

conceptual, 249-250 diagnostic process and, 256-257 disablement concepts, 250 dominant, 249 establishing therapeutic relationships and, 254-255 follow-up visits and, 259-261 instruction surrounding treatment and,259 patient negotiation process and, 257-259 patient-practitioner collaboration in, 251 facilitating exercise programs, 252 improving patients adherence to, 262 nonadherence of patients to, 245 problem-solving skills for determining, 260 reassessing, 219-220 removing barriers to, 261-265 selecting, 217-219 Tutorials, 102 Tyler, Ralph, 2, 3 Video feedback, 290-291 Visual teaching aids, 112-113 Walker, Decker, 2, 17 Worthingham, Catherine A., 373

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