The influence of pre-professional curricula on components of the Physical Therapist Clinical Performance Instrument

Background and Purpose: The purpose of this study is to investigate any association between pre-enrollment curricula and clinical performance in physical therapy professional schools. Specifically, does the type of undergraduate institution (as defined by Carnegie classification type) influence performance on components of the Physical Therapist Clinical Performance Instrument? Methods: The study methods include a retrospective quantitative review of student educational records from the Duke Doctor of Physical Therapy (DPT) classes of 2013 to present. Kruskal-Wallis tests were used to determine significance of the dependent variables. Results: Results indicated that when the Carnegie Classifications were consolidated to five categories, there was only a significant difference in score for one of the 108 possible scales in the CPI (Professional Behavior, Final 3). Students who attended an undergraduate institution with a professional focus (category 5) scored significantly (p=.033) higher on this Professional Behavior scale than did students who attended an undergraduate institution with an arts and sciences focus (category 1). When the Carnegie Classifications were consolidated to four categories, two scales showed significant results (Professional Behavior, Final 3; Accountability, Final 3). Conclusions: The study fails to confirm the hypothesis that the type of undergraduate institution influences performance on components of the Physical Therapist Clinical Performance Instrument. There is virtually no difference on clinical performance based on undergraduate institution type. INTRODUCTION Future clinicians, including physical therapists, need to treat the entire patient, not just a disease or injury. Understanding preenrollment factors that may predispose or enhance a physical therapy student’s ability to be best suited to meet all the needs of the patient is of interest. Limited literature exists that links baccalaureate level curricula and ultimate affective and clinical ability. As American tertiary education moves to skill-based or competency-based curricula, we want to examine the role of liberal arts undergraduate education in developing future clinicians’ requisite affective dispositions. The value of a liberal arts education has received a lot of recent attention in the media. Liberal arts, in the context of this study, is defined as a major in a discipline in the sciences, the humanities, or the social sciences (not a pre-professional undergraduate track). Employers often equate liberal arts graduates with enhanced critical thinking skills, heightened intellectual curiosity, abilities to work in teams and better communication skills.1 While some question the contemporary role of this education framework, empirical studies continue to demonstrate the sustained value of liberal arts training. A recent report sponsored by the National Center for Higher Education Management Systems (NCHEMS) and the Association of American Colleges and Universities (AAC&U;) discusses these issues.2 In an analysis of the report authors noted, "Whatever undergraduate major they may choose, students who pursue their major within the context of a broad liberal education substantially increase their likelihood of achieving long-term professional success."3 This study looks at the association, if any, between attending an undergraduate institution that emphasizes the liberal arts and ultimate professional success in physical therapy. While columnists in popular media publications and state-level politicians – including former North Carolina Governor Pat McCrory – remain critical of liberal arts education because of the perceived inability of liberal arts majors to gain and to maintain gainful employment, current research does not uphold this claim.4 CEOs and major employer satisfaction surveys report the The Influence of Pre-Professional Curricula on Components of the Physical Therapist Clinical Performance Instrument 2 © The Internet Journal of Allied Health Sciences and Practice, 2017 immediate need for employees who can think critically, calculate logically, and communicate effectively; as such, the call for liberal arts graduates remains.5 Not only are liberal arts skill sets in demand, but employers are willing to compensate workers with these skill sets. The NCHEMS/AAC&U; study found liberal arts majors earn more than professional majors at peak earning ages. According to the report analysis, At peak earnings ages (56 to 60 years) workers who majored as undergraduates in the humanities or social sciences earn annually on average about $2000 more than those who majored as undergraduates in professional or pre-professional fields. These data include all college graduates working full-time, including those with only a baccalaureate degree and those with both a baccalaureate and graduate or professional degree.3 The interest in students with liberal arts training is true not only in the ultimate workplace, but also in professional schools. Janeksela states, “The liberal arts contribute to professional programs by demonstrating the connections between the liberal arts and the professions, by preparing students who have transferable knowledge and skills, and by preparing graduates who can provide leadership in the workplace and for the profession.”6 Increasingly, professional schools are looking for liberal arts graduates to populate their incoming classes. The Medical College Admissions Test (MCAT) recently added questions from the social sciences and humanities to the exam, exemplifying this shift. Other clinically-based professions also require skill sets typically associated with liberal arts training. Physical therapy is one such example. Admission to health sciences professional training programs requires prerequisite coursework that emphasizes the basic sciences. As part of the application process to Doctor of Physical Therapy programs in the United States (DPT), applicants are required to fulfill a set of prerequisite courses.7 Though each school may have slight differences in their list of required prerequisites, there are consistent trends that indicate a strong preference for science coursework. For the 2015-16 application cycle, the Physical Therapy Centralized Application Service (PTCAS) released statistics indicating that greater than 92% of the programs required at least one prerequisite course to be taken in each of the following: anatomy and physiology, chemistry, physics, and behavioral science.8 Additionally, 87% of programs required applicants to have taken at least once additional course in biological sciences, separate from their anatomy and physiology. In contrast, only 21% of programs required one prerequisite course in English composition or writing. Communication courses were required by only 9% of programs. Only 6% of programs required a non-communications humanities course. Fewer than 3% of programs required an ethics course prior to admission.7 This disconnect between employers’ calls for liberal arts graduates and the coursework required to gain acceptance to professional physical therapy programs merits further study. Following admission and matriculation into a DPT program, students spend on average 123 weeks to earn a doctoral degree in physical therapy.9 The curricula in DPT programs is not limited to clinical sciences. The Commission on Accreditation in Physical Therapy Education (CAPTE) requires the following major areas of instruction for all DPT programs necessary for entry level practice: 1) foundational sciences (e.g. biological sciences, physical sciences, movement sciences); 2) social and behavioral sciences (e.g. communication, ethics, values, management, finance, teaching, clinical reasoning); 3) clinical sciences (i.e. management of patients with musculoskeletal, neuromuscular, cardiovascular, metabolic, or integumentary concerns); and 4) practice skills and knowledge.10 Though each DPT program must demonstrate that it possesses a curriculum that sufficiently instructs students in all of these areas, CAPTE is not prescriptive about the amount of time a program emphasizes any individual level. The ultimate measure of a successful curriculum is its students’ ability to successfully pass the National Physical Therapy Examination (NPTE). This examination, required for licensure in any state in the United States, covers all of the same aspects of knowledge described in the CAPTE requirements above. However, less than 2% of the questions are related to topics similar to preparation in the social sciences, ethics, or humanities. The Federation of State Boards of Physical Therapy (FSBPT) indicates that 2% of the questions on any NPTE may fall under “professional responsibilities” defined as “the responsibilities of health-care providers to ensure that patient/client management and health-care decisions take place in a trustworthy environment.”11 With this in mind, it is important to examine the relationship between liberal arts exposure and training at the undergraduate level and professional school outcomes. This study seeks to investigate any association between pre-enrollment curricula and clinical performance in professional physical therapy school. Specifically, we hypothesized that the type of undergraduate institution (those with arts and sciences curricular foci compared to professional curricular foci) influences performance on components of the Physical Therapist Clinical Performance Instrument.12-14 The Influence of Pre-Professional Curricula on Components of the Physical Therapist Clinical Performance Instrument 3 © The Internet Journal of Allied Health Sciences and Practice, 2017 METHODS This study was a retrospective quantitative review of student educational records from the Duke Doctor of Physical Therapy (DPT) classes of 2013 to 2016. The students all enrolled in the DPT program in Durham, NC. The study was approved for exemption by the Duke Medicine Institutional Review Board (Pro0006938). Admissions records and final Clinical Performance Instrument (CPI) internship scores of the students in the classes of 2013-2016 were included for a total 247 students. Records of those students who completed a degree beyond a baccalaureate (n=12) or those who had not completed the academic program (n=2) were excluded from analysis. The total subject records analyzed following exclusions was 233. Variables The variable of interest in this study were performance scores on the Clinical Performance Instrument (CPI). This instrument, a standardized and validated tool, requires the students' clinical instructor to assess the students' performance on 18 performance criteria that relate to quality of patient care (see Table 1).12-14 The CPI is a nationally normed instrument that is used by most physical therapy programs across the country. The CPI is a series of 21-point rating scale items, designed to reflect a continuum of performance, that were broken into six anchor definitions that range from "beginning performance" (1) to "beyond entry level" (21). The CPI was administered during students' three 12-week clinical internships during their final year in the academic program. Midterm scores in each of the 18 performance criteria were aggregated across the three internships. Likewise, final CPI scores were aggregated. Table 1. Physical Therapist Clinical Performance Instrument 18 Performance Criteria Criterion Number Performance Criterion 1 Safety 2 Professional Behavior 3 Accountability 4 Communication 5 Cultural Competence 6 Professional Development 7 Clinical Reasoning 8 Screening 9 Examination 10 Evaluation 11 Diagnosis and Prognosis 12 Plan of Care 13 Procedural Interventions 14 Educational Interventions 15 Documentation 16 Outcomes Assessment 17 Financial Resources 18 Direction and Supervision of Support Personnel The independent variable in the study is “Type of Undergraduate Institution” operationalized by the Carnegie Undergraduate Instructional Program Classification system.15 The researchers used the Carnegie Classifications because they are standard in the field of education research, and because this classification schema can serve as a proxy for exposure to a liberal arts curriculum.16 Admissions records were reviewed for the undergraduate institutions of all subjects included in the study revealing 150 different institutions. The Carnegie “Institution Lookup” was used to identify the undergraduate instructional program type revealing study participants graduated from programs of 14 different classifications out of the 22 possible assigned by Carnegie. (see Appendix 1).17 Statistics For the purposes of analysis, the 14 classifications were first consolidated into five categories (see Appendix 1) arts and sciences focused (input variables 8-10) (n = 15); 2) arts and sciences plus professions (input variables 11-13) (n=45); 3) balanced arts and sciences/professions (input variables 14-16) (n=96); 4) professions plus arts and sciences (input variables18-19) (n=63); and 5) professions focus (input variables 21-22) (n=5). In order to increase the sample size in the professions-focused classifications, further consolidation was performed to four categories. These are: 1) arts and sciences focused (input variables 8-10) (n = 15); 2) arts and sciences plus professions (input variables 11-13) (n=45); 3) balanced arts and sciences/professions The Influence of Pre-Professional Curricula on Components of the Physical Therapist Clinical Performance Instrument 4 © The Internet Journal of Allied Health Sciences and Practice, 2017 (input variables 14-16) (n=96); 4) professions focus (input variables 18-22) (n=68). Kruskal-Wallis tests were used to determine significance of the independent variables, as Kruskal-Wallis is useful for determining significant differences between two or more groups of an independent variable when studying an ordinal dependent variable.18 Researchers used pairwise comparisons to view post-hoc analyses following the discovery of significant results from the KruskalWallis tests. All analyses were performed using IBM SPSS Statistics for Windows version 22.0 (IBM Co., Armonk, NY, USA). RESULTS When the Carnegie Classifications were consolidated to five categories, there was only a significant difference in score for one of the 108 possible scales (18 criteria x 6 evaluations per criterion) in the CPI (Professional Behavior, Final 3) (see Table 2). Students who attended an undergraduate institution with a professional focus (category 5) scored significantly (p=.033) higher on this Professional Behavior scale than did students who attended an undergraduate institution with an arts and sciences focus (category 1). There were no significant differences between students who completed their undergraduate degree at various institution types on any other CPI scale. The p-values in Tables 2-3 indicate the overall significance of the difference between any of the five categories at that time point; the p-values delineated below each table refer to the results of the post hoc analysis and are limited to the significance of the difference between the two noted samples. Table 2: Five Carnegie Groups Asymp. Sig. CPI Indicator Midterm 1 Final 1 Midterm 2 Final 2 Midterm 3 Final 3 Safety 0.875 0.654 0.925 0.977 0.800 0.271 Professional Behavior 0.304 0.721 0.986 0.941 0.941 .027*^ Accountability 0.054 0.615 0.755 0.661 0.925 0.075 Communication 0.351 0.668 0.648 0.804 0.628 0.234 Cultural Competency 0.366 0.859 0.783 0.968 0.776 0.230 Professional Development 0.807 0.736 0.529 0.827 0.792 0.246 Clinical Reasoning 0.613 0.703 0.981 0.380 0.113 0.475 Screening 0.380 0.430 0.423 0.968 0.325 0.495 Examination 0.849 0.882 0.694 0.848 0.141 0.261 Evaluation 0.608 0.658 0.697 0.580 0.691 0.595 Diagnosis and Prognosis 0.665 0.339 0.876 0.630 0.531 0.601 Plan of Care 0.373 0.779 0.964 0.421 0.264 0.362 Procedural Intervention 0.154 0.732 0.953 0.503 0.619 0.644 Educational Intervention 0.201 0.749 0.829 0.819 0.312 0.474 Documentation 0.224 0.661 0.865 0.624 0.880 0.783 Outcomes Assessment 0.423 0.768 0.380 0.361 0.253 0.237 Financial Resources 0.229 0.822 0.892 0.861 0.155 0.154 Direction and Supervision of Personnel 0.189 0.880 0.609 0.926 0.437 0.575 * p<.05; ^sample1selectivity of undergraduate institution is a compounding variable that ultimately impacts professional behavior andaccountability. Again, since the differences by undergraduate institution type are manifested in the final CPI evaluation, perhapsthe difference is due to a disparity in social or cultural capital that are exacerbated over time rather than being impacted byundergraduate institution type. There are additional limitations to this study. Clinical student data was used from only oneinstitution so results may not be generalizable across all physical therapy programs. The study only analyzed student data inthe aggregate due to the sample sizes available. Additional research is needed to analyze the impact of undergraduate institutiontype on various student sub-populations (including gender, race, ethnicity, selectivity of school, and others). References1. McNutt MI. There is Value in Liberal Arts Education, Employers Find. 2014. Available at:http://www.usnews.com/news/college-of-tomorrow/articles/2014/09/22/there-is-value-in-liberal-arts-education-employers-say. Accessed December 15, 2016.2. Humphreys D, Kelly P. How liberal arts and sciences majors fare in employment: A report on earnings and long-termcareer paths. 2014. Available at: http://www.augusta.edu/provost/documents/38-how_liberal_arts_and_science_majors_fare_in_employment.pdf. Accessed June 27, 2016.3. Association of American Colleges & Universities. New Report Documents That Liberal Arts Disciplines Prepare Graduatesfor Long-Term Professional Success. 2014. Available at: https://www.aacu.org/press/press-releases/new-report-documents-liberal-arts-disciplines-prepare-graduates-long-term. Accessed June 27, 2016.4. Strauss V. North Carolina governor attaches higher ed, proposes funding colleges by graduates’ jobs. The WashingtonPost. February 7th, 2013.5. Shinn LD. Liberal education verses professional education: the false choice. 2014. Trusteeship Magazine.January/February ed2014.6. Janeksela GM. The value of a liberal arts education. Academic Exchange Quarterly. 2012;16(4):37-41.http://rapidintellect.com/AEQweb/5192NEW.pdf7. American Physical Therapy Association. PTCAS. Summary of course prerequisites for programs in PTCAS: 2015-2016.2015. Available at: http://www.ptcas.org/ProgramPrereqs/. Accessed November 25, 2015.8. Physical Therapist Centralized Application Service. Physical Therapist Centralized Application Service 2014-2015Applicant Data Report. 2015. Available at: http://www.ptcas.org/About/. Accessed November 25, 2015.9. Commission on Accreditation in Physical Therapy Education. Aggregate Program Data: 2014-2015 Physical TherapistEducation Program Fact Sheets. 2015.10. Commission on Accreditation in Physical Therapy Education. PT standards and required elements. 2015. Available at:http://www.capteonline.org/Faculty/AccreditedPrograms/. Accessed November 25, 2015.11. Federation of State Boards of Physical Therapy. NPTE-PT test content outline, effective January 2013. 2013. Available at:https://www.fsbpt.org/Portals/0/documents/free-resources/ContentOutline_2013PTT_201212.pdf. Accessed November25, 2015.12. American Physical Therapy Association. Physical Therapist Clinical Performance Instrument. Alexandria, VA: AmericanPhysical Therapy Association. 2006.13. Roach K, Gandy J, Deusinger SS, et al. The Development and Testing of APTA Clinical Performance Instruments. PhysTher. 2002;82(4):329-53. [PMID: 11922850]14. Roach KE, Frost JS, Francis NJ, Giles S, Nordrum JT, Delitto A. Validation of the Revised Physical Therapist ClinicalPerformance Instrument (PT CPI): Version 2006. Phys Ther. 2012;92(3):416-28. [PMID: 22135710]15. The Carnegie Classification of Institutions of Higher Education. Undergraduate Instructional Program Classification. 2015.Available at: http://carnegieclassifications.iu.edu/lookup/lookup.php. Accessed February 21, 2016.16. Altbach PG. The Carnegie Classification of American Higher Education: More—and Less—Than Meets the Eye.International Higher Education. 2015(80):21-3.17. The Carnegie Classificiation of Institutions of Higher Education. Institution Lookup. 2015; Available at:http://carnegieclassifications.iu.edu/lookup/lookup.php. Accessed February 21, 2016.18. AERD Statistics. Kruskal-Wallis H Test using SPSS Statistics. 2013. Available at: https://statistics.laerd.com/spss-tutorials/kruskal-wallis-h-test-using-spss-statistics.php. Accessed May 21, 2016. The Influence of Pre-Professional Curricula on Components of the Physical Therapist Clinical Performance Instrument7 © The Internet Journal of Allied Health Sciences and Practice, 2017Appendix 1: Carnegie Classification Descriptors and Model GroupingsCarnegie ClassificationDescriptionInputVariableCode forModel 1Code forModel 2 Associate's Colleges: HighTransferThese institutions awarded associate'sdegrees but no bachelor's degrees with fewerthan 30% of awards (degrees and certificates)in career & technical programs.1 Associate's Colleges: MixedTransfer/Career & TechnicalThese institutions awarded associate'sdegrees but no bachelor's degrees with 30-49% of awards (degrees and certificates) incareer & technical programs.2 Associate's Colleges: HighCareer & TechnicalThese institutions awarded associate'sdegrees but no bachelor's degrees with morethan 50% of awards (degrees and certificates)in career & technical programs.3 Special Focus Two-YearInstitutionsThese institutions awarded associate'sdegrees but no bachelor's degrees withtypically more than 75% of awards in a singlecareer & technical program.4 Special Focus Four-YearInstitutionsThese institutions awarded bachelors andhigher degrees with typically more than 75% ofdegrees in a professional program.5 Tribal CollegesColleges and universities that are members ofthe American Indian Higher EducationConsortium, as identified in IPEDS InstitutionalCharacteristics.6 Baccalaureate/Associate'sCollegesThese institutions awarded both associatesand bachelor's degrees, but the majority ofdegrees awarded were at the associate's level.7 Arts & sciences focus, nograduate coexistenceAt least 80 percent of bachelor's degreemajors were in the arts and sciences, and nograduate degrees were awarded in fieldscorresponding to undergraduate majors.811 Arts & sciences focus, somegraduate coexistenceAt least 80 percent of bachelor's degreemajors were in the arts and sciences, andgraduate degrees were observed in up to halfof the fields corresponding to undergraduatemajors.911 Arts & sciences focus, highgraduate coexistenceAt least 80 percent of bachelor's degreemajors were in the arts and sciences, andgraduate degrees were observed in at leasthalf of the fields corresponding toundergraduate majors.1011 Arts & sciences plusprofessions, no graduatecoexistence60–79 percent of bachelor's degree majorswere in the arts and sciences, and no graduatedegrees were awarded in fields correspondingto undergraduate majors.1122 Arts & sciences plusprofessions, some graduatecoexistence60–79 percent of bachelor's degree majorswere in the arts and sciences, and graduatedegrees were observed in up to half of thefields corresponding to undergraduate majors.1222 Arts & sciences plusprofessions, high graduatecoexistence60–79 percent of bachelor's degree majorswere in the arts and sciences, and graduate1322 The Influence of Pre-Professional Curricula on Components of the Physical Therapist Clinical Performance Instrument8 © The Internet Journal of Allied Health Sciences and Practice, 2017degrees were observed in at least half of thefields corresponding to undergraduate majors. Balanced arts &sciences/professions, nograduate coexistenceBachelor's degrees awarded were relativelybalanced between arts and sciences andprofessional fields (41–59 percent in each),and no graduate degrees were awarded infields corresponding to undergraduate majors.1433 Balanced arts &sciences/professions, somegraduate coexistenceBachelor's degree majors were relativelybalanced between arts and sciences andprofessional fields (41–59 percent in each),and graduate degrees were observed in up tohalf of the fields corresponding toundergraduate majors.1533 Balanced arts &sciences/professions, highgraduate coexistenceBachelor's degree majors were relativelybalanced between arts and sciences andprofessional fields (41–59 percent in each),and graduate degrees were observed in atleast half of the fields corresponding toundergraduate majors.1633 Professions plus arts &sciences, no graduatecoexistenceAccording to the degree data, 60–79 percentof bachelor's degree majors were inprofessional fields (such as business,education, engineering, health, and socialwork), and no graduate degrees were awardedin fields corresponding to undergraduatemajors.1744 Professions plus arts &sciences, some graduatecoexistence60–79 percent of bachelor's degree majorswere in professional fields, and graduatedegrees were observed in up to half of thefields corresponding to undergraduate majors.1844 Professions plus arts &sciences, high graduatecoexistence60–79 percent of bachelor's degree majorswere in professional fields, and graduatedegrees were observed in at least half of thefields corresponding to undergraduate majors.1944 Professions focus, no graduatecoexistenceAt least 80 percent of bachelor's degreemajors were in professional fields (such asbusiness, education, engineering, health, andsocial work), and no graduate degrees wereawarded in fields corresponding toundergraduate majors.2054 Professions focus, somegraduate coexistenceAt least 80 percent of bachelor's degreemajors were in professional fields, andgraduate degrees were observed in up to halfof the fields corresponding to undergraduatemajors.2154 Professions focus, highgraduate coexistenceAt least 80 percent of bachelor's degreemajors were in professional fields, andgraduate degrees were observed in at leasthalf of the fields corresponding toundergraduate majors.2254