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Research Report
Karen W Hayes
Gail Huber
Jean Rogers
Babette Sanders
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653
KW Hayes, PhD, PT, is Assistant Professor of Physical Therapy and Curriculum Coordinator, Programs in Physical Therapy, Northwestern
University Medical School, 645 N Michigan Ave, Suite 1100, Chicago, IL 60611 (USA) (k-hayes@nwu.edu). Address all correspondence to Dr
Hayes.
G Huber, PT, is Instructor in Physical Therapy, Programs in Physical Therapy, Northwestern University Medical School.
J Rogers, PT, is Assistant Professor in Physical Therapy and Academic Coordinator of Clinical Education, Programs in Physical Therapy,
Northwestern University Medical School.
B Sanders, PT, is Instructor in Physical Therapy, Programs in Physical Therapy, Northwestern University Medical School.
Concept and research design were provided by Hayes, Huber, Rogers, and Sanders, with initial assistance from Jennifer Kamm, PT; data collection,
by Rogers, Huber, and Sanders, with assistance from Bill Healey, PT, GCS, who helped with interviews; data analysis, by Hayes, Huber, Rogers, and
Sanders, with assistance from Mary Ziomek, PT, who provided blinded classification of behaviors, and Kathleen Shean, who double-checked the
classification of behaviors and data entry; writing, project management, and fund procurement, by Hayes; and subjects, by Rogers. Facilities,
equipment, institutional liasons, and clerical/secretarial support were provided by Sally C Edelsberg, PT. Katherine Shepard, PhD, PT, FAPTA,
provided consultation (including review of manuscript prior to submission).
This study was approved by the Institutional Review Board of Northwestern University.
This study was supported in part by a grant from the Chicago Area Clinical Educators Forum.
Parts of this article were presented at the Combined Sections Meeting of the American Physical Therapy Association, February 14, 1997, Dallas,
Tex, and at the Scientific Meeting and Exposition of the American Physical Therapy Association, May 31, 1997, San Diego, Calif.
This article was submitted October 10, 1997, and was accepted March 8, 1999.
654 . Hayes et al
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Figure 1.
Original conceptual framework indicating presumed factors contributing to unsafe or ineffective delivery of physical therapy services by
students.
Hayes et al . 655
Table 1.
Information Obtained From Participants About Themselves and the Students and Incidents About Which They Were Reporting
Information About Participants
Age
Sex
Race
First professional (entry-level) physical therapy degree
Highest academic degree
School and year of graduation
Clinical facility
Number of years as a clinical instructor
Number of students supervised in the clinic
Number of students supervised who performed at level
not appropriate to their education
Age
Sex
Race
Type of professional program in which the student was enrolled
Amount of experience of clinical instructor at time of incident
How long ago the incident occurred
Manner in which the reporter learned of the incident
Description of the setting in which the incident occurred
Type of environment (eg, size of facility, location of patient treatment)
Time at which the incident occurred
People involved in the incident
Conditions or context for the incident
Activities occurring during the incident
Outcomes for the patient, facility, and student
Whether incident was a sole occurrence or one of a series of incidents
Subjects
Eligible subjects were CIs who were physical therapists
working in approximately 250 facilities with clinical
education contracts with any of the professional physical
therapist education programs in Illinois in 1995. Any
physical therapist from one of these facilities would be
considered qualified if he or she had worked with or had
the opportunity to observe at least one physical therapist
student who had problems functioning effectively in the
clinic. The students with whom they had worked could
be from any education program in the country, not just
those in Illinois. Clinical instructors were recruited
through advertisements placed in professional publications, announcements at clinical education meetings,
and requests by academic coordinators of clinical education (ACCEs) from Northwestern University at facilities during clinical contacts. Although the sample was
one of convenience, efforts were made to establish
geographic diversity within the sample.
656 . Hayes et al
Procedure
We defined provision of physical therapy services as
independent patient evaluation, treatment planning and
implementation, and interactions with patients, families,
and other health care providers by students. This definition predated the publication of the Guide to Physical
Therapist Practice,21 but we believe it is consistent with the
intent of the definitions used in that publication. The
specific problem in the study was unsafe and ineffective
delivery of physical therapy services by students.
In the interest of gathering rich data, group and individual interviews were conducted to gather information
about the critical incidents from CIs. Most group interviews were face-to-face; one group interview was conducted by conference call. Two individual interviews
were conducted when a group was not available.
Group interviews were limited to no more than 4 participants to enable the group to remain cohesive and
complete its task in a reasonable period of time.20
Interviews were conducted at clinical facilities in combination with on-site clinical meetings, at a Chicago-Area
Clinical Educators Forum meeting, at a meeting of the
Illinois Consortium for Clinical Education, and at a
Combined Sections Meeting of the American Physical
Therapy Association (APTA). Some groups included
participants from several facilities, and other groups
were composed of participants from a single facility. All
participants were assured of anonymity and protection
of their rights as subjects and gave informed consent
granting permission to record and use their information. Participants were asked to complete a questionnaire requesting the information shown in Table 1.
Interview facilitators were members of the investigation
team and an additional ACCE from Northwestern Uni-
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Table 2.
Information Identified From Transcripts by Investigators
Actual student behavior
Inferences generated by the reporter (Sometimes reporters
described a category of behavior or an attribution of cause.
Because the investigators were interested only in the actual
behavior, this inference was identified and discounted by
investigators.)
A preliminary category for the behavior
Consequences of the behavior
Whether feedback was given to the student
Whether the behavior changed
Outcomes for the students education
Data Analysis
From the questionnaires, the transcripts, and the classification process, one investigator coded the participants,
students, and incidents and entered the data into a
database for later analysis. The numerical code indicated
the number of the participant first, then the number of
the student specific to that participant, and finally the
number of the incident specific to that student. For
example, the first incident reported about the 27th CIs
second student would be coded 27.2.1.
While the interviews were proceeding, the members of
the team of investigators independently reviewed the
initial transcripts and identified the information listed in
Table 2. A first classification was performed independently by each investigator; that is, each team member
reviewed the incidents from the initial transcripts and
identified and named categories of her choosing related
to reasons for unsafe and ineffective delivery of physical
therapy services. Knowledge and skills and some noncognitive factors were expected based on the initial framework, but the exact nature of those factors emerged
from the data. The investigative team initially identified
61 behaviors and discussed the behaviors, the generated
categories, and their relationship with the original categories in the initial framework. Pairs of team members
then independently classified the 61 behaviors as a check
on whether categories were mutually exclusive. The
original 3 categories from the initial framework were
revised by combining inadequate knowledge and inadequate psychomotor skill because they were not mutually
exclusive and by identifying 2 noncognitive categories
(ie, poor communication and unprofessional behavior).
Based on our findings and a review of other studies,2,5,22
we defined the first categoryinadequate knowledge
and skillsas consisting of behaviors that demonstrated
inadequate command of the scientific basis of physical
therapy, the inability to perform physical therapy procedures, or the inability to apply knowledge and skills to
the safe and effective identification and management of
Hayes et al . 657
Table 3.
Sex (n, %)
Male
Female
5
28
(15.2)
(84.8)
Race (n, %)
White
Nonwhite
26
4
(86.7)
(13.4)
1
27
3
(3.2)
(87.1)
(9.7)
21
9
1
(67.7)
(29.0)
(3.2)
17
11
4
(53.1)
(33.3)
(12.1)
(16.7)
(26.7)
(40.0)
(3.3)
(0.0)
(3.3)
(10.0)
(87.1)
(12.9)
26
4
Clinical Instructors
Thirty-three CIs contributed to the study. Their characteristics are summarized in Table 3. In age, sex, race,
entry credential, and highest degree obtained, they
reflected the 1994 and 1996 APTA membership profiles.24,25 They were from 1 eastern state, 1 western state,
and 4 midwestern states. Two thirds of the group had
supervised 6 to 20 students in clinical education, and
most participants (87.1%) had had no more than 2
students not performing up to expectations. The majority of the participants worked in rehabilitation or acute
care settings. Only 4 CIs worked in outpatient clinics. Of
the 33 CIs participating, 32 were able to provide information about specific incidents. The participant who was
unable to provide information about incidents had
misunderstood the instructions and had come to the
interview with a list of precategorized concerns collected
from co-workers. She did not report the specific examples from which her categorized information was drawn.
Due to reporting, taping, and transcription errors, complete information was not available for all participants
and students. Two CIs who participated in telephone
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Table 4.
Inadequate Knowledge and Skill: Subcategories and Examples of Behaviors
Subcategory
Example
10
When I asked him if the cane was adjusted correctly, he answered that it was, and I said,
Are you sure? What would be the proper height? He said, Well, it should be almost to the
waistline. (9.1.3)
16
The student tried to evaluate the strength of her upper extremities and couldnt figure out
where to place her hands to test elbow flexion versus elbow extension. She kept changing
her hands back and forth, and when I asked her exactly what she was trying to test, she
wasnt even able to tell me. (10.1.1)
She had a lot of trouble keeping track of her schedule . . . . She couldnt keep to her
schedule at all. (23.1.6)
15
He had the assignment to assess this child [with cerebral palsy], identify major problems, and
[develop the] treatment plan, and he supposedly did all this and came up with nothing more
than range of motion, and thats what he proceeded to do. (3.1.2)
12
The student was asked to spot one of my patients on a treadmill. This patient was status post
knee replacement about 3 or 4 months and was very short in stature, about 4 ft tall, and
very nervous. I was at the controls of the treadmill. The patient had on the gait belt. My
student was behind the patient, so I started the treadmill. The patient became fearful and lost
her balance; I grabbed her by the gait belt and the hips. I was holding her up in the air,
and I turned around, and my student was at the bottom of the treadmill, kind of snickering, I
think, and I said, Hit the stop button. I was screaming, Hit the stop button, and the
manager of the department had to come over and hit the stop button. (8.1.2)
Behaviors
A total of 134 behaviors were identified by the CIs. These
incidents occurred between 1971 and 1994, with 73% of
the incidents occurring during 1993 and 1994. Interviews were conducted from March 1995 through March
1996, so most incidents had occurred within 1 to 3 years
of the report. Behaviors fell into 3 categories: inadequate
knowledge and skills, poor communication, and unprofessional behavior. Inadequate knowledge and skills was
the largest category, with 43.3% (n558) of the behaviors. We identified 5 subcategories: inability to recall
information, inability to perform a skill, inefficiency in
task completion, poor problem solving, and unsafe
judgments or actions (Tab. 4). Thirty-seven of the behaviors fell into the poor communication category and
involved primarily inappropriate nonverbal behavior,
inappropriate interactions with patients and colleagues,
and inappropriate response to feedback (Tab. 5). Thirtynine behaviors were classified into the unprofessional
behavior category. These behaviors were related to problems with stress management, work ethic, accepting
responsibility, commitment to learning, recognition of
limits, and common sense (Tab. 6).
Students
The incidents provided by the CIs involved 40 students.
The characteristics of the students as reported by their
Hayes et al . 659
Table 5.
Poor Communication: Subcategories and Examples of Behaviors
Subcategory
Example
10
Her eyes would dart around a lot. She wouldnt look at the patient. She wouldnt
focus on what he was doing. (16.1.2)
15
She got so mad [at a patient who had had a cerebrovascular accident] that she just
screamed at the woman . . . just screamed at her and told her that she wasnt
cooperating. (23.3.1)
12
I said, You need to get in close to the patient, and you may want to put a gait belt
on the patient, and he just nodded his head, and then the next time just did it the
way he had been doing it. (25.3.1)
Table 6.
Unprofessional Behavior: Subcategories and Examples of Behavior
Subcategory
Poor stress management
Poor work ethics
N
5
12
Example
She got very nervous. The 2 arms of the goniometer would be shaking so furiously that
she couldnt even read what the measurement was. (28.1.3)
I was approached by another therapist who told me, Your student has been on the
phone for 3 hours in the nurses station, her financial aid records spread across the
desk, and is having a telephone conference. She was supposed to be treating
patients. (33.2.1)
He had set his patient up in the cervical traction mode and then had left without telling
anyone where he was going and had actually left the building and didnt come back
until a significant amount of time later. (6.1.1)
When I suggested that she consult, that night, her manual muscle text so we could
discuss it the next day, she told me that she really didnt have time to do that. You
know, social friends. (2.1.2)
The physician had ordered diathermy for this patient. She felt that diathermy was not
appropriate because the patient was slightly heavy, and even after consulting with
her clinical instructor and the text was unable to find information that really
supported her claim. When the clinical instructor was off, she proceeded to ask
several other therapists and the director of the department if this was an appropriate
order. They told her Yes based on the physical findings. At that point, she
proceeded to tell the patient that she felt the physician made an error and was
incorrect in ordering this modality as well as documented this in the chart. (25.1.1)
She was observing our clients, but she failed to notice that people were having a
difficult time passing in the corridor where she was standing in the middle. (30.1.4)
10
Her boyfriend had come on site. We have a gym thats an inside gym and then we
have an outside quad area that has windows to patients rooms, administrative
rooms, and other health care professionals looking onto this quad area. Anyway,
she was out there with her boyfriend lying down, making out on the mat. (27.1.1)
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Table 7.
Characteristics of Students (as Reported by Clinical Instructors)
(n540)a
Characteristic
26
4
5
1
2
Sex (n, %)
Male
Female
17 (41.5)
24 (58.5)
Race (n, %)
White
Nonwhite
33 (86.8)
5 (13.2)
0 (0.0)
26 (68.4)
12 (31.6)
(68.4)
(10.5)
(13.2)
(2.6)
(5.3)
Hayes et al . 661
Figure 2.
Relationship among categories of inadequate behaviors, use of feedback from the clinical instructors, presence of change by the student, and the
outcomes of the student clinical experience. The shaded boxes underscore the invariability of a positive outcome for the clinical experience if behavior
changed with or without feedback.
662 . Hayes et al
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Hayes et al . 663
Subjects
The clinical participants in this study typify the general
membership of the professional association. Their profile provides no reason to suspect that CIs who have
students with problems differ from CIs whose students
do not have problems. It is possible that the CIs who
volunteered to share their educational experiences may
have more interest in clinical education than CIs who
did not volunteer or than physical therapists who do not
serve as CIs.
Students
There were more male students than expected based on
the profile of student enrollment in professional physical therapist programs at the time of most of the
incidents.26 The data in this study cannot explain the
high proportion of male students. One possibility might
be related to the practice settings represented in this
study. Based on unpublished data, the areas of clinical
practice with the largest concentration of 1994 male
graduates were orthopedic and sports practices ( Jody
Gandy, personal communication, 1996). This type of
practice is usually an outpatient facility. Most of the
incidents in this study took place in inpatient and
rehabilitation facilities. The incidents involving only 5 of
40 students took place in outpatient facilities. If a
students interest in a particular type of clinical practice
were mismatched with the clinical assignment, inappropriate behaviors could result.
Other investigators have detected sex differences in
various phenomena in physical therapy. Stith et al28
found that male physical therapist students are less
satisfied with their clinical experiences than female
students. We do not know whether dissatisfaction might
be reflected in cognitive and noncognitive problems.
Learning preferences have been shown to differ between
the sexes.29 A mismatch between student learning style
and CI teaching style might lead to behavioral problems.
Because most CIs are women, more men might be
expected to experience mismatches. Further study is
necessary to determine whether student or CI sex factors
into clinical performance evaluation.
The number of nonwhite students among those with
negative outcomes, including dismissal, also seemed
higher than might be expected (2 of 8 students with
664 . Hayes et al
Behaviors
The categories of behaviors generated in this study of
factors that related to inadequate clinical performance
were inadequate knowledge and skills, poor communication, and unprofessional behavior. These categories of
behaviors are remarkably similar to those proposed by
other authors.2,5,22 Communication, professionalism,
commitment to learning, clinical judgment, communicating medical information, recognition of limits, interpersonal skills, and dealing with emergency situations
have been supported as relevant to clinical competence,
in addition to several cognitive items. All 10 of the
generic abilities proposed by May and colleagues5 are
included in the 3 categories generated in this study.
Commitment to learning, professionalism, responsibility, and stress management are included in our unprofessional behavior category. Interpersonal skills, communication skills, and use of constructive feedback appear
in our poor communication category. Effective use of
time and resources, problem solving, and critical thinking are represented in our inadequate knowledge and
skills category. The data from this study strongly support
these generic abilities.
All of these previous investigations included noncognitive elements of clinical competence. In this study,
noncognitive behaviors (poor communication and
unprofessional behavior) comprised 56.7% of the behaviors that alerted CIs to unsafe and ineffective performance, yet they accounted for only 35.0% of behaviors
that were associated with a negative outcome. We believe
that this element of competence is valued by clinicians
but infrequently used as a reason for recommending
that a students learning experiences be extended or
terminated.
The prevalence of noncognitive factors in assessing
clinical competence was observed by Cross and Hicks32
in their study of clinical educators constructs of good
and bad students. Eight constructs emerged in their
study; those given the greatest weight and that were most
discriminating between types of students were commitment, communication, and general disposition. These
clinical educators weighted noncognitive factors as more
important than cognitive factors in assessing student
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Hayes et al . 665
666 . Hayes et al
Limitations
Outpatient facilities may have been underrepresented in
our study even though invitations to participate were
issued to CIs at outpatient clinics. The data do not
explain this apparent underrepresentation. Perhaps
physical therapists in outpatient facilities find it difficult
to be away from the clinic in order to participate in a
study such as this one. Alternatively, perhaps fewer
students have difficulties in outpatient clinical
experiences.
The information from this study is admittedly limited by
having no information from the students described or
their ACCEs and no opportunity to follow up on the
careers of those who graduated. Such a study would be
valuable, though difficult to perform without breaching
the confidentiality of the students.
Conclusions
Physical therapist student behaviors and characteristics
that concerned CIs about student clinical performance
were studied. Behaviors of concern fell into the catego-
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Hayes et al . 667
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