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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Library of Congress Cataloging-in-Publication Data

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

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 Contents
Contributing Authors vii

Foreword I 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 1
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
vi Contents

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 393

Index 397
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 health-
these 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 per-
II

ceptions 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 teacher-
patients and families, students participating in formal academic programs,
health care colleagues, community neighbors, and one's self.

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 learn-
ing to occur:

1. Teachers must know keenly the topics they are teaching and cease-
lessly 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 stimu-
lated by one's students. Reflecting on these experiences results in trans-
formation 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 teach-
ing, 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 aware-
ness and knowledge comes from listening to students speak-learning what
they understand as well as how they think and reason, through watching stu-
dents' 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
'} "How can these educational
experiences be effectively
organized?"
I Design
Decisions

t
Program OBJECTIVES
"What educational experi~
enees can be provided that
are likely to attain these
purposes?"

t
Program GOALS
Deliberation

t
Program and Institutional
PHILOSOPHY
} "What educational purposes
should the school seek
attain?"
to

Platform of Beliefs and Vision

Curricular Tyler's Fundamental Walker's Naturalistic

Design Questions 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. Ser-
vice to others, the importance of family life, the inalienable worth of each indi-
vidual 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 pre-
pares men and women in their professional disciplines with an emphasis on
moral values and service in order to develop competent graduates, who demon-
strate concern for human health. This mission is fulfilled by providing compre-
hensive 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 Has advanced knowledge of norma
and wellness across the life span 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 Integrates information from founda
coursework 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 Understands and believes in lifelon
academic institution 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 Has pride in and commitment to t
profession 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

j this may have on working with fami-

lies and their infants with neuromotor
impairments. "

h'r
Course ContentlLearning

Course Evaluation
E.G., Required Reading:
Lynch EW, Hanson MJ. Developing
Cross-Cultural Competence. Balti-
more: Paul H. Brooks, 1992.

E.G., take home exam case of a 10-

month-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 inter-
vention with this child, and what you
as a physical therapist can do."

Program Evaluation (Graduates) 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
 Physiology 3 and treatment
skills
MPT I/Spring Neuroanatomy 3 Critical Clinical 3 Clinical
analysis II kinesiology II educa
Basic evaluation 3 (4 wks
and treatment May)
skills
Clinical medicine 4
Basic exercise and 3
rehabilitation
MPT II/Fall Motor control 3 Critical 2 Musculoskeletal 3 Behavioral 2 Clinical
analysis III dysfunction I science II educa
Cardiopulmonary 3 Human devel- 2 (8 wks
dysfunction opment Jan)
MPT II/Spring Pharmacology 2 Research I 2 Musculoskeletal 3 Behavioral 2
and nutrition dysfunction II science III
Neurologic 3
dysfunction I
Neurologic 3
dysfunction II
Electrotherapy 3
 Foundation Clinical Behavioral Clinical
Year/Semester sciences SH Research SH sciences SH sciences SH practice SH

MPT III/Fall Research II 2 Musculoskeletal 2 Health care 2 Clinical 3

dysfunction III organiza- education III
Neurologic 2 tions I (8 wks, Aug-
dysfunction III Oct)
Orthotics and
prosthetics
Clinical
simulations I
MPT III/Spring Research III 2 Clinical 1 Health care 2 Clinical 3
simulations II organiza- education IV
Gerontology tions II (8 wks,
March-May)

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
/I

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.
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
Modeling of effective stress
management
Critical thinking considered inherent
in professional behavior
Modeling of effective, professional
behaviors
Expectations for lifelong learning
Respect for and trust in one's
colleagues
Openness to innovation
Respect for and sensitivity to patients
Expectations for lifelong service to
the profession
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.
Courses that receive scheduling p
for class time, location, and op
examination time
Faculty members· demonstrate c
resiliency in response to sudde
in class time, broken audiovisu
ment, no-show guest lecturers,
Faculty members critically analyz
mation, brainstorm ideas, and d
strate tolerance for ambiguity
Faculty members demonstrate an
of students courtesy, initiative,
for other viewpoints, and willin
act as moral agents
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
Faculty members demonstrate en
for team teaching and express f
tion with alternative viewpoin
Faculty members demonstrate res
other health care professionals
Faculty members encourage stude
explore alternative health care
phies and models of practice (e
puncture, Feldenkrais method,
method)
Faculty members refer to patients
viduals characterized by compl
unique physical, social, and beh
characteristics rather than by d
or body parts
Faculty members participate in co
and task forces and on boards a
state, and national levels of the
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 on-
visit 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 On-Site Visit and
Self-Study Preparation of Report
(ROSET)

\CMrn +
Program Response to
On-Site Report
Deliberation (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 on-
team for physical therapy programs and a two-member on-
team 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 "reflection-
than novice teachers. This is similar to experienced clinicians wh
know the right thing to do with patients with an ease and confi
 Teacher Institution Audience Class Size DatefTim
Philosophical + Learning Theory + Domain of Learning + Student Learning +
Orientation Style
('Yo) ('Yo) ('Yo) ('Yo)
_Cognitive Processing- _Behaviorism _Cognitive _Concrete Experience
Reasoning _GestaltIProblem- _Affective _Reflective Observation
_Academic Rationalism Solving Experience _ Psychomotor _Abstract-
_Technology _PiagetlCognitive _ Perceptual Conceptualization
_Social Adaptation Structure _Spiritual _Active
_Social Reconstruction Experimentation
_Personal Relevance

Teaching Aids + Formal of Delivery + Student Evaluation + Teaching Environment +

A. Audiovisual ('Yo) ('Yo)

_Computer Generated _Lecture _Practical Exam _Room Arrangement
_Blackboard _Laboratory _Written Short Answers _Room Environment:
_Overhead Projector _Seminar-Discussion _Written Essay temperature, light,
_Slides _Independent Study _Report or Project acoustics, cleanliness
_Videotape; film _Teacher Materials:
podium. chalk/pens,
B.~ 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/problem-
ing 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 2-n 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
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
 calculate calculate construct
Knowledge compute demonstrate categorize create
describe dramatize compare design
cite discuss employ contrast formulate
count explain examine debate integrate
define express illustrate diagram manage
draw identify interpret differentiate organize
list locate operate examine plan
name report practice inventory prescribe
record restate schedule question propose
relate review sketch test
repeat tell solve
underline translate use

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
codify (form
Responding accept discriminate doe
balance display
Receiving behave believe favor
complete defend judge
accept comply devote order
attend cooperate influence organize
develop discuss prefer relate
realize examine pursue systematize
receive obey seek weigh
recognize observe value
reply respond

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
Needs
Satisfactory 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
Recognizes and handles personal and
work-related frustrations in a nondis-
i:
ruptive 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. Perception: Distinguish among various maneuvers.

2. Set: Position oneself to engage in each maneuver.
3. Guided response: Duplicate the maneuver a skilled perfor
4. Mechanism: Adjust the maneuver to the needed respon
5. Complex overt response: Coordinate various maneuver
plish successful play or task.
 adjust develop
demonstrate
copy build supply
Perception maintain
determine illustrate
adjust indicate operate
approach discover
distinguish duplicate manipulate
hear locate mix
place imitate
see inject set up
smell position
prepare repeat
taste
touch

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
 Experimentation Reflective
Observation

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. Demonstrate clinical decisi

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

'I '
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

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
.::! 'I.~ blank questions are more difficult
I:
.,,1 ... cient, but not overabundant, amou
one- or two-word response.
-I;'
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
'-
consider working to change to avoid physical therapist-physic
assistant conflict.
e Think about grading quick checks as "excellent," "good," or
t.
If the student receives a try again, he or she can do just that-t
1- in another response within the week. When the second response
~, the student's grade may be moved up to a good or a good-
l, method of grading avoids the stress of a one-shot pop quiz and p
e on students grappling with ideas and transforming knowledge. Q
e are easy to grade quickly and give the instructor information abo
,f vidual students are absorbing the information presented.

Evaluation Methods that Promote Ref

1-
One of the central themes of this book is the role
e in facilitating the development of "reflective practitioners." De
e reflective thinking as a state of doubt or perplexity in which th
s nates and a process of inquiry begins that is aimed at finding wa
s the doubt or problem. 28 Schon, in studying several different prof
1-
ognized reflection as an important vehicle for acquiring all typ
sional knowledge. 6 More than a decade of research, dialogue, and
.t
transpired since Schon's Educating the Reflective Practitione
1-
educational community. One recurring element is the use of
~.
promote reflection, such as the use of portfolios and journals. 29
e

Evaluation Methods that Promote

s Reflection in Students
I-
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
s nents of their portfolios (e.g., must include papers, reflective jou
Ie 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
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
I ,lor:

References
1. Brophy J. Teachers' Knowledge
Practice. Greenwich, CT: JAl P
2. Grossman PL. The Making
Teacher Education. New York:
III rt~
3. Reynolds A. What is competen
.;\..... erature. Rev Educ Res 1992;62
4. Irby D. What clinical teacher
~.mll~

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
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
.1 ...1'"
of instructional objectives and their
, t"
. .'
'~
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 REFLECTIVE EVALU
(preparing, selecting, and (teacher and student
adapting teaching materials) 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
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
i
information in the area but also understand how the key conce
t
are connected, as well as the ways in which new knowledge is
validated.! Using the previous sketch, remember that the instruct
t
1-
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
e
ing the clinical skills of measurement (i.e., goniometry and man
e
1-
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
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
.~ .1 11 ~ .
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

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 ini-
tial 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 pro-
vide 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 follow-
ing 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 (cogni- Cognitive
tive domain) requirement
Knowledge Recall information

Comprehension Understanding (quest

can be answered by
restating material i
a literal manner)

Application Solving (questions in-

volve problem solv
in new situations)

Analysis Exploration of reason

dIll
(questions require
student to break th
idea into its compo
parts)
Synthesis Creating (questions re
.,, ~ I students to combin
ideas into a statem

Evaluation Judging (questions m

judgment about so
" , '~, I
" II
thing by making th
judgment principle

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
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
"\'1
ing, or reflection on practice.
"knowing how"-that is, kno
.:; :: ~:' :
second category of profession
knowing about things. In prof
L:il 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
 !
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

Practical Examin
'1'1 11

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

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. Stu-
dents need to experience that knowledge is not transferred from one
's head to another, but that knowledge is a consensus among mem-
bers 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 dis-
cussed earlier. Small groupwork is another teaching strategy to engage stu-
dents in large classes in active learning. In any small-group process, there
will always be issues of leadership, individual performance, and communi-
cation. Therefore, the use of small groups requires the same careful prepara-
tion 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. Aware-
ness 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 par-
ticipation. Having students learn about working toward equal participa-
tion 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:

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
"" " . ,
.. :.. .. ,/,
.,," Ii

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.
"".. . I~
~'i
.,1:',

Group Expert Techn

The group expert t
t. ~.
that builds confid,ence and coll
:'J: 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
Peer teaching is
learning experiences already
Lt be classified into five areas: (
=-_:A. 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

The greatest American philosophe

many contributions to education. Perha
butions was his writing about thinking-
Dewey 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
)1'"
provide students with a more engaged
- . !~'I'
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
-'J" facilitating this process-the use of case
~ . ~'
~':~ ,..

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
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
~

- :"-, 01""1'
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
_ " 0 r ciprofloxacin hydrochloride (Cipro
~, . ~. ,;""
coagulant), ethambutol hydrochlo
conazole (antifungal agent), trazod
(Marinol; appetite stimulant), mo
dine (AZT)/ddi (antiviral).
Lt 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 Hip f
Triceps 4/5 Hip e
Biceps 4/5 Knee
Hands 5/5 Ankl
Ankle planter flexors 2/5
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, Generate a problem list. How would you go a
early intervention, or en- establishing a ther
vironmental adaptations peutic relationshi
minimize functional lim- with this patient?
itations?
What other health care pro- What is the working Identify any cultural
fessionals might this hypothesis(ses)? variations that ma
patient benefit from have an effect on
working with? interaction with t
patient and caregi
List your short- and long- What specific verbal
term functional goals. 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

/
Patient goals Movement problems/ambulation
needs
ROM

Goniometry
Strength

I
Dynamometer
""
Joint swelling

Circumference
measure
Home
environment
Joint dysfunction
I
NMT

Work Evidence of components that con-

environment tribute to dysfunction Imeasures of
strength, range, swelling, compared to
other knee; weight bearing during
ambulation; posture; balance)

Figure 3-5 A comparison of clinical instructor and student concept maps for an evaluation of a
patient with a total knee replacement. (ROM = range of movement; NMT = neuromuscular
tension.)
 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 pre-
sentations.

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

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
l!'i'"
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
-.: ji
Slides
t. t "
- · '~. I"
In teaching som
~~: 1~ 1"
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
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
.. .
. . -1<
~

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.
- ..· .1
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

t. t . , pendence-that is, socia
-'-i''..:,,'
~~.,,,
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
 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.
~.,:---_ ., . 11
29. Fields E. Use of debate form
". __ 7 ~PI "

-" 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.
f.. i " 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 intro-
duction 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 plan-
ning 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 educa-
tional technology. There is an excellent chapter on the use of instruc-
tional 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 chap-
ter 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 pro-
vides 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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 Settings
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Undertaking New Challenges: Preparation for Teaching in Clinical Settings

(Calvin and Hobbes © 1995 Watterson. Distributed by Universal Press Syndi-
cate. Reprinted with permission. All rights reserved.)

1
 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
.-' ", - II, copy of the academic pr
~.-. '1 111
tives, dates of the clinic
coordinator of clinical ed
--' to'
. used to assess the stude
experience. In addition,
was written in the stu
illegibly, that indicated
and housing and parkin
!. t"" 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
Imagine education
pist assistants occurring solely i
clinical practice as an integral pa
fession's conception, clinical pra

-
~J!

-_
"'- ~-.

..

..
_., ;
I II

} :
been and continues to be of para
dents' educational experiences. O
students' progression through th
does this by bridging the worlds
f;-:.-::: world" laboratory lessons that ca
~? i ,~."

ducing students to the peculiarit

---. ! -'I I
fession, and refining basic knowl
~-- •• ""t. ~
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
 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
~L~' :.';I als. Students and patients are as
represent the cultural needs of so
....~- -;I' ~

""'"', , ,, students and teachers and patie

services to persons of all custom
ers and practitioners in physical
t=-, '-~::~
incumbent on the profession to
~i!" ."'" can prepare future generations to
..--. ,,"III and demands of a multicultural
" Many similarities between
described. Closer examination o
academic and clinical educatio
between the two environments.
L.L,

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
 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
f-~",_ .,. . ,1" Because learning occurs withi
,., = .- ]: 1;
~ .. 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
•
-'-"" ' ''- ~ I ''
by posing questions to herself or
;=-- ·· '· r
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.
'¥- : :1
~ "" ~." .;

Roles and Res

Students, and th
clinical learning experiences, p
zational structure. The true m
Students provide feedback to
~l" ' "
system. Given the configurat
~· · .· · I ~
heavy burden, because learning
i
tion received from academic p
rate in relation to perceived l
their needs to the CIon a dai
bility for their learning if they
LL" dents ultimately will be held
1Jr:i"'.::: 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.
 4. Educating and empoweri
I 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
~ 1 11. Determining whether stu
~ .. -
learning objectives for th

--
=" -f'~~
continued progression th
12. Obtaining feedback abou
curriculum to assist in o
~,_ ,_,,' k sions.43, 44, 46
,.r I· "
=3iIIIIi" ' . o/ t~

Additional activities that the

ticipation in consortia activities (
clinical educators that sponsor
related activities, (3) curriculum
research, (5) management of budg
LL.! and (6) coordination of clinical
=i~.::: 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. Experience as a practitioner.
2. Ethical professional behaviors.
3. Experience in providing clinical education to professional stud
4. Interest in providing quality learning experiences.
 5. Good interpersonal and commun
6. Knowledge of the clinical facilit
7. Capability to consult in the eva
8. Administrative, organizational,
9. Knowledge of contemporary issu
management, clinical education

If the CCCE is a physical therapy p

t 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
-==.-- ··~'n.
~ _ -..I
=·........ _,, 1' 1. Obtaining administrative suppo
program by providing clinical si
nale and evidence for developme
2. Determining clinical site readin
3. Contacting academic programs t
"'~ I '. ., ",
- __ ... .1
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
 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

t 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
~ t.. ,"
il
';;,...... ,
Therapist Professional Education, which
of what the physical therapy professio
.,.-
...
; ~!;

~;" level practice expectations, content, an

physical therapist professional educatio

c~ ~.:: :!
Skills and Qualifications o
~.~~~! In general, CIs' roles are m
behaviors, such as facilitating, supervis
~ .."'
--'="' '; ,,", , ,,, teaching, evaluating, counseling, advisi
i" I
and socializing. Before serving as a C
_"' -~.'.' J.
competence should be demonstrated
C-.J::: dimensions:
Lt~J
-j~::::
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
Patient referral and taking a patient P
history

Performing initial patient evaluation A

and problem identification

Determining long-term goals mutually S

with the patient

Defining short-term patient goals D

~
~"'~ "'"
t H Clarifying patient treatment plan D
=-.
~
~·r".,
, j.
~_.,. "

Performing patient re-evaluations and P

",
~.:.
J:-:,a
.. assessing the level of progression

Performing patient outcomes assess- P

ment and discharging patients
from physical therapy

i '-~.','"
, Source: Adapted from The New England Cons
~'·-'"'-·: d~
cal Education, Inc. The Role of the Clinician a
~~J::: land Consortium of Academic Coordinators of

ety, talented staff, a variety of educatio

for the students to explore their own ob

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.
 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

.
~~.,",t:

~~
- ..
...•e."",, \ .. ,

.... -, 4l

4:-.1 .::
~
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
Lt_. J~
education and feedback rather than so
~j~~:::
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
 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
~-1 '~ I
...... - c~
Development of effective comm
skills should also be included as part
-: .~ .. " content to be addressed includes comp
~ ,~. j tion; ways of improving interpersonal,
.." ~"I"N munication; sources of conflict in th
~ ~ ~ .• ,.:f
"r identifying, managing, and resolving c
=-,.. I~ "~
-... ,.:j,j
Fundamental components of clini
standing of the roles, characteristics,
~1-· ' "'' ' '
'u,
----="'-.;;!,~
organizational structure of clinical ed
; , -~, ',~
and management of the clinical env
~
..-=:o""-,'j~
within that environment. 96, 97 Manage
.c~J:~~'

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.
 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
L:~ ]
.~
~-
~ ;~ " Student Objectives
-..

~ -:
0-

of Clinical Learning
Designing a clinical educa
structural framework, or road map, for
experience meets the expected perform
, ......HI
demic program must determine, in the
~ , . ~.,. , ..'"' experiences will, in conjunction with t
i-
-_ . ~
.,.
the curricular performance outcomes
practice. Although at times the. road ma
4::j ::
clinicians, and academic faculty can c
Ll.. J, learning and performance outcomes, th
-1"" '.
~"'1I 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
 their values and attitudes about thei

I 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
~ t '1
~ .....A1
analysis, synthesis, and evaluation. T
:i2* ~ ,~ "
~-"'~

-~-" degree to which students are able to s

--. ;~ ,
..c: . ~, formance for entry into practice .
~L i Effective clinical educators use g
~ +fO: .... objectives describe the broader, more
~_ ~ .... r
dent performance, while behavioral o
further define each incremental learn
-,-.'W," objective in the psychomotor doma
"...;;oo-~"... " Ii_
able to evaluate a patient." A speci
~" " this global objective might state, 1/ ••
......,.. __ -.:1 " patient with complex shoulder patho
.c:j ::
approach substantiated by the literat
LL.£ ioral objectives should lead to achiev
=:1::. 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 circum- Following a patient demo
stances under which stration ...
the objective will be Given a skeleton ...
achieved and the meth-
ods used
Criterion Describes the level of Student completes an ev
acceptable performance tion of the shoulder w
10 minutes.
Student completes an ev
tion thoroughly.
Learner or audience Focuses on the learner or The student will ...
audience rather than The learner will...
the instructor
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 Appropriate exa

I Learner centered vs
teacher centered
The student will pe
goniometric mea

Outcome oriented The student will co

vs process oriented articles on cystic

Outcome oriented The student will ev

vs merely stating biomechanics of
the material to be
addressed

:.~ .... r •.•

Describes only one The student will co
~~-,~ outcome vs de- patient interview
..-- .i
scribing multiple
"'" . '"
outcomes
~ -':"n
~, •.•f Specific vs general The student will ac
<..() perform manual
testing on the an

....
J."
"..;;oo',;,1f/t

__ . ~ -J
,,*,

•
Observable and
measurable vs
not observable
The student will p
rationale for the
delivered based o
and quantifiable
Source: Adapted from The New England Acad
Inc. The Role of the Clinician as Clinical Edu
tium of Academic Coordinators of Clinical Ed

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

Design Strengths
One CI to one Allows the CI to main
student (tra- greater control of th
ditional design) learning experience
Can easily monitor st
performance
Familiar student learn
design
One CI to two Fosters collaborative
or more stu- learning through pe
dents (collabor- interactions
ative-peer de- Enhances clinical com
sign)1l6-125,142,143 tence related to clin
judgment
~:-J
Develops greater self-
---.
~
~-

~~.-
.....
reliance, independen
and interdependenc
~ "!
~~,..b
.' Teaches students to u
~-" . and maximize limit
~ .... ~" resources
~_.r

<.() Allows the CI to facil

and guide the learni
experience
-r."
~"'"
Fosters student proble
~- . solving and critical-

c:....",
~ __ ','fiI!: thinking skills
:...a ••
Makes orientation les
costly and time con
U .,.i suming
=r.:, 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 (super- Enhances understandi
visor-delegator the roles and respon
design) II 4 bilities of the PTA
 tion between PT and PTA strengths, and limitations so
students that they can learn from each
Maximizes clinical site re- other
sources and minimizes
competition for limited
numbers of clinical sites
when PT/PTA programs
provide the student clin-
ical education con-
currently
One CI to two Same as one CI to two or Same as one CI to two or more
students more students design students design
paired from Allows the experienced stu- Can be problematic if students
the same pro- dent to develop supervisory are not compatible in their
gram at diff- skills learning styles or interperson
erent clinical Allows students to use each al interactions
levels (stu- other as a resource and ac- Requires alternative leadership
dent-peer cept feedback more easily design situations in which on
mentor Allows the experienced stu- student is the leader and the
designJl27-129 dent to orient the inexper- other the aide, and vice versa
ienced student when be-
ginning times are staggered
Allows the experienced stu-
dent to serve as the lead in
situations in which the in-
experienced student has
not completed the didactic
content
Is useful in situations in which
the inexperienced student
has a shorter clinical experi-
ence
Two part-time CIs Maximizes opportunities for Requires excellent communica-
or two CIs on dif- part-time personnel to be in- tion between CIs
ferent rotations volved as CIs (often experi- Can confuse students if expecta
to one or more enced clinicians) tions of the CIs differ
students 13O,144 Increases opportunities for Requires additional planning an
clinical sites with part-time organization
clinicians to participate in Requires greater coordination
 Table 4-4 (continued)
Design Strengths
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
~:z .... ; Increases CI productivit
comparison with clin
that are not involved
Reduces supervisors' dir
tient-related responsib
-,-,r,..
~ ,
Decreases the number of
ficial questions posed
1--
--.:.'
~4.~:' Two CIs (one high-
students
Provides a mechanism to
UJ; ly experienced tor and develop an ine
and one less ienced CI through rol
=r.:, experienced) to modeling and teachin
two or more Allows students to learn
students parallel processes as i
(teacher-mentor perienced CIs
designj123, 131, 132 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 Permits solo practice se
single practices to network with othe
offering collab- to provide student cli
orative clinical experiences
learning experi- Provides a support syste
ences (coopera- clinical teachers in ru
 rural and solo practices
Augments student learning ex-
periences through interac-
tions with multiple clini-
cians who provide care in
different clinical settings
One or more CIs Provides a learning model that
to one or more teaches collaborative team
students from learning among different
different disci- disciplines
plines (interdis- Gives students a better under-
ciplinary/co- standing of the roles and re-
operative de- lationships between different
sign)133, 136, 137 disciplines in real practice
Teaches students team leader-
ship 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
CI = clinical instructor; PT = physical therapist; PTA = physical therapist as
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

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
 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
~ , t!
~,.. . ...\
, one another, and to provide social
~
OE ..t:..,.._• •

~"-"
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
I-~.' 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
 ed at the beginning of this chapter m
preferred approach for preparing fut
clinical teaching have been shown to

t 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
-C ~::;
ship should be made available to sp
~- ..
----- :.1 ~
~ , .. clinical educators.
.~ ,!
~';;',.._I
~ 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
~ .....
.1=--• Students should also learn how to
~-

~J~~
.. learning experiences, and routinely
their growth and development throu
LL.1 They should also begin to develop an
=.c 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.

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4~.
~' .~ ; frequency of clinical teaching be
~,~- ~,

~,~,-" 56. Emery MJ, Wilkinson CPo Percei

-=#" .~

'---
#,-,
~-'
ical teaching behaviors: surveys
center coordinators of clinical e
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•
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2:1 student-instructor education
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1991;5:78.

Annotated Bibliog
~.~ "I American Physical Therapy Associati
~ .... ...;.

~.~
(Vol I). Alexandria, VA: American
~,

~-:~Ji-"
This resource is a collection of 79
~
physical therapy literature that
~ ... ,
dimensions in clinical education.
~- ulty (ACCEs, CCCEs, and CIs),
~
£i".J design of clinical education, ev
resources. This is an excellent ref
-,- education because relevant litera

••..
~,..

tion. Volume II of this publicat

--.I
• updates the physical therapy liter
c:"J- and includes articles from other d
1.11 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
t
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.
-~
~
310 .... ~~
_

--.* New Directions for Continuing Educat

~~~
~ volumes in this series of quarterly
~ .. :~
~..,.t
.;
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
, 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

CLINICAL INSTRUCTOR: Jeff is a

eager to learn. I know this is o
he hasn't had all of his classroom
¥c -.-"l
-==------, I've really tried to spend time te
Cc_ ·~ a student. My CI just let me go
~~;
but I would have liked to have h
zIi-
--: 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
 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
~1f
~-­
~~~
student to develop patterns of l
~ off observation for students are o
~---#F­
~. a busy clinical practice where p
_ ::i
--'~
little time for teaching and prac
~~

~-
enter the clinic setting and inte
.~
to start. They must come with t
60 ing and doing with a patient.
What does a student need t
-r-
,~-
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 University
Assignmen
Time and l
Internal Departmen
Assignmen
Health req
Clinical teacher Preparation
Value judg
Source: Adapted from RM Scully. Clinic
Clinical Education. Ph.D. diss., Columbi

~ .. ~..;o

~ Consider the examples of Nat

~ students assigned to a pediatric cli
.4£--
~~ programs. Student assignment or p
~~
~ the method used varies from pro
Cz-' 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
• 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
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
eel stated, "education is not an affair of 'te
L~ constructive process."ll Successful cli
make meaning of knowledge in a clini
::; ing when providing physical therapy s

--
~

~
C'-) Student Ownership
The clinical education
despite the fact that it will occur in t
• c. 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 with recommendations
experiences to meet student needs
Instructional strategies Routine Challenging
Extrinsic rewards Encouraging deep and ric
and incentives mental processing
Feedback and evaluation Clinical instructor Available but infrequent
dominates and controls from external sources, e.
student behavior the clinical instructor
Institutional and personal Emphasize conformity Emphasize creativity, inn
premiums 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

t 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

Roles of the Clin

----
~l
~-~

~~
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
rID specific enabling acts used by good
throughout this discussion.
~--=j 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:

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:
CD I felt I needed to push her to ge
She did say that this was rea
~~:a 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 opportu-
nity to review the enclosed materials, please write down your goals and objectives for this experi-
ence. 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 Recall of facts or p
Translation Demonstrate unde
Excogitative Challenge the stud
making skills
Evaluation Require the stude
ideas, solutions,
Source: Adapted from RG Abrams. Ques
tion. JDent Educ 1983;47:599.

=!
.~.~
~
understanding of the student's abiliti
~ See Table 5-5 for a brief description o
~
~;

-
-~

~-
;'....1
1. Knowledge questions are dire
or principles. This information may
'lID 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 self-
efforts 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

l. Discuss the history and ph

2. Identify key components o
3. Describe faculty characteri
cal mentoring and resident
,"" cessful learning.
,·r
4. Describe various residency
rationale for their use.
~,

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
 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.
 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
il
( 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
 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 case-
organize 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 experienced therapist Patient response
What is your chief What do you mean? Use of medical What's the problem that brings I can't move around easily. My
complaint? jargon. you to physical therapy? back hurts.
Where is your In my back mainly. Biased question. Where are you having trouble ? In my back mainly.
pain?
Do you mean right Yes, but over here too. Making assump- Show me where. (Allows patient to outline area.
in here? (touching tions; biased Clarify and delineate region if
patient's low back) question. needed.)
Do you have pain in No, but my knee Asking more than Do you have complaints (Allows patient to answer spon-
your buttock or also hurts. one question at anywhere else? taneously; then specifically
down your leg? a time; biased clear area above/below.) My
question. right knee also hurts.
Describe your pain; Both. Asking more than Describe how your low back There's always a dull ache.
is it sharp or dull? one question at a feels . When I try to bend down, it's
time; biased stiff and I get a sharp pain.
question.
Is it constant or Oh, there'S always Use of medical jar- (Allows spontaneous comments
intermittent? something there. gon; incomplete to emerge; then can clarify in
data obtained. more detail.)
Aggravating factors
Painful with sitting brief periods and
with prolonged standing
Painful/stiff rising from chair
Easing factors
Lying down with legs extended
Placing hands behind back
Right knee symptoms
Area of symptoms: whole knee
Aggravating factors
Stiff to walk, go up/down stairs
Easing factors
Eased by lying down/elevation
Eased by ice/ace wrap
L = lumbar vertebrae.
Low tolerance for static axial loads in
flexion more so than extension
Difficulty transitioning to an erect
posture
Eases with non-weight bearing; with
spinal extension bias
Eases with spinal extension biased
pressure
Multiple sources: tibiofemoral joint
and soft tissues surrounding knee
Difficulty weightbearing in extension
and flexion
Relief with unloading, passive drainage
Relief by reducing swelling, supporting
joint

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 Right hamstrings Right knee ligame
apophyseal joints Right gastrocnemius (collaterals, cruc
Right tibiofemoral (proximal heads) ates, coronary, e
joint Right knee bursae
Right patellofemoral
joint
Right superior
tibiofibular joint
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 posterior-
as 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.
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Alexandria, VA: American
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Gulfport, MS: American
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13. Elstein A, Shulman L, Spr
retrospective study. Eval H
14. Higgs J, Jones M. Clinical R
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15. Jones M. Clinical reasoning
16. Maitland GD. Peripheral M
1977.
17. Maitland GD. Vertebral M
1986;1.
 and clinicians: an explanation for diagnostic expertise. Med E
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22. 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.
23. Higgs J. A programme for developing clinical reasoning skills in gra
ate physiotherapists. Med Teach 1993;15:195.
24. Payton OD, Nelson CE, Ozer MN. Patient Participation in Prog
Planning: A Manual for Therapists. Philadelphia: FA Davis, 1990.
25. Benner P. From Novice to Expert: Excellence and Power in Clin
Nursing. Menlo Park, CA: Addison Wesley, 1984.
26. 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.
27. Benner P, Wrubel J. Skilled clinical knowledge: the value of percep
awareness. Nurse Educ 1982;7:11.
28. Polanyi M. Personal Knowledge. London: Rutledge & Kegan Paul, 1
29. Cross V. Introducing physiotherapy students to the idea of "reflec
practice." Med Teach 1993;15:293.
30. Schon DA. The Reflective Practitioner. New York: Basic Books, 19
31. 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.
32. Benner P. Uncovering the knowledge embedded in clinical pract
Image J Nurs Sch 1983;15(2):36.
33. 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;
34. Butler DS. Mobilisation of the Nervous System. London: Churchill
ingstone, 1991.
35. Elvey R. Treatment of arm pain associated with abnormal brac
plexus tension. Aust J Physiother 1986;32:224.
36. McKenzie RA. Mechanical Diagnosis and Therapy for Disorders of
 Low Back. In L Twomey, JR
Back (2nd ed). New York: C
37. Cyriax J. Textbook of Ortho
Tissue Lesions (7th ed). Lon
38. Tichen A, Higgs J. Facilitatin
Clinical Reasoning. In J Hig
Health Professions. Boston:
39. Barrows HS. The Simulated
40. Edwards H, Franke M, Mc
Teach Clinical Reasoning. I
in the Health Professions. B
41. Vu NY, Barrows H, Marcy M
cal, performance-based asse
Southern Illinois University
~l 42. Rivett D, Higgs J. Experienc
L Zeal J Physiother 1995;Apri

C..': Annotated Bib

f:' Cross V. Introducing physiothera
tice." Med Teach 1993;15(4):
Higgs J. A programme for devel
{.." physiotherapists. Med Teac
t.•.. ~ examples of methods for teac
.
~.,
ical knowledge of physica
include theory sessions, case
L These articles will assist the
c: 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
Patient education
physical therapy education pr
itation of Education Programs
states that physical therapy p
concepts of teaching and lear
and evaluating learning experi
t. 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 edu-
cation, 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 teach-
ing 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 dead-
line for questionnaire return, and two respondents did not complete the ques-
tionnaire. 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 pre-
paid health care and physicians' offices. Twenty-nine percent of the respon-
dents 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

. \
L , ,~
Etiology of diagnosis
Simulating home and occupationa
l ... situations
•
Equipment needs and maintenance
u Education of family and caregiver
C.. 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 79.9 16.1 4.0
with sketches
Patients working with only one 74.4 18.1 7.5
therapist
Moving the body passively through 53.0 38.5 8.5
the desired activity
Assuming different roles toward the 52.3 28.6 19.1
patient (e.g., teacher, supporter,
parent, disciplinarian)
Quiet atmosphere 44.0 44.0 12.0
Other professional support staff 38.5 45.5 16.0
Charts of skeleton, muscles, nerves, 36.2 43.7 20.1
and so ort
Educating family or caregivers to 33.0 37.0 30.0
educate the patient
Three-dimensional models of joints, 26.1 35.7 38.2
skeleton, and so on
Creating situations in which patient 22.5 46.0 31.5
actively solves problems
Prepublished booklets and pamphlets 21.2 57.1 21.7
Premade checklist of patient care 14.1 21.7 64.1
objectives
Group classes with patients with 10.5 18.6 70.8
similar disabilities
Textbooks (e.g., anatomy) 7.5 46.2 46.2
Videotapes or slides 7.5 21.6 70.8
Using other patients to provide 7.5 36.7 55.8
patient education
Having patients work with many 6.5 25.1 68.4
therapists
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 per-
ceptions 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
Maintaining communication with
(J
other professionals

•.U.
-"
,
Understanding that nonverbal
communication influences the
&l::: patient's response
LJ 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 75.5 16.0 8.5
assessing patient improvement
Assessing results of function in a task- 71.5 23.5 5.0
oriented manner (e.g., reaching for a cup)
Having the patient explain what has been 59.0 36.5 4.5
taught (to the instructor or to others)
Asking other professionals working with 43.0 37.5 19.5
your patient about how the patient
performs tasks
Using a checklist to ensure that patient 30.5 28.5 4l.0
care objectives have been met
Analyzing performance via videotapes 6.5 12.0 8l.5

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
Lack of time allotted for treatment
session
<:.
('" Lack of participation by family and
. J!
caregivers in educational efforts
C·..'
Patient's physical status
Distractions in treatment area
Architectural layout for practicing f
C! tional activities

•.
t.J
~
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 76.0 17.1 6.3
therapy program
Interaction with patients' families 63.8 23.8 12.4
Experience in teaching aside from 62.0 27.1 10.9
patient education (e.g., lecturing,
presenting in-services, and so onl
Academic education outside 57.3 31.8 10.9
physical therapy program
Academic education within 52.8 35.8 11.4
physical therapy program
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.
 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
Cl the respondents, however, indi
F" ness or disability, assuming a p
~.ii.
tus, attitudes or expectations
cognitive status were barriers
the reader with a list of barrier
tJ physical therapists in this sam
,•..
LJ
, time, or rarely.
Nearly 95% of the respon
most important for the developm
II considered interaction with co
C.., 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
 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
L~
ing, and barriers to delivering pa
C... 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

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
L~,
patients." But what does that mean
Coo. 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.
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 Associa-
tion, 1991.
Evaluative Criteria for Accreditation of
Education Programs for the Preparation
of Physical Therapist Assistants.
Alexandria, VA: American Physical
Therapy Association, 1992.
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.
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).
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
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.
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: Physical and movement diagnosis
Positive verbal and nonverbal Begin behavioral diagnosis process
interactions Identify disease beliefs
Active listening Identify treatment beliefs
Responsive touch CONTEXT: Family system and Identify valued activities
health care system Identify potential barriers to treatment

INTEGRATE: Prevention and

health promotion

INTERVENTION AND FOLLOWUP: NEGOTIATE COMMON

TEACH AND PROBLEM SOLVE GROUND

Teach performance skills, provide knowledge of Continue with behavioral diagnosis

how to implement and monitor self-treatment, Identify best treatment patient is likely to follow
design reminder strategies Link to valued activity
Evaluate for treatment effect Identify specific barriers to treatment
Evaluate for adherence Assess self-efficacy
Problem solve to eliminate barriers to adherence Make a mutual agreement for long- and short-
Modify success indicators as patient progresses term 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. ing gentle palpa
Collecting data and recor- the most acute
ding on clipboard. patient sits on t
Engaging in perso
logue and findin
area of common
with the patien
Focusing on gathering data Diagnostic process Identifying the are
on the joints involved, of mutual racic spine whe
including the activities inquiry. mary symptom
that make the symptoms Discovering the p
worse and better. intense fear of f
Assessing the irritability of from the osteop
the patient's condition Identifying that th
(moderate), so that the patient's primar
therapist is able to per- to pick up grand
form a good physical Finding out that t
assessment and localize walks in the ma
the involved thoracic group of friends
joints. week.
Establishing that joint mobil- Negotiate common Identifying that pa
ization, grades I and II, will ground. most likely to e
be the appropriate place to along with her
start. walking.
Discussing with the patient Setting mutual sh
the prognosis that the goals with patie
manual therapy along with become proficie
an exercise program should her exercise pro
eliminate the symptoms in Setting the long-t
2-3 weeks. 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: E
professional as expert
Intervention. In
Proceeding with joint tech-
niques; reassessment shows Te
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.
Followup.
Noting patient complaints
of difficulty in doing
exercises.
Reviewing the exercises, per-
forming 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
P
Problem 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 con-
sequences for the patient?

Does nonadherence have pos-

itive 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 Anticipate no
Guideline 2 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

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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
practice Practice and transfer
Fatigue
learning
Stress
Boredom
Pharmacologic
agents

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 Manipulation
>-
."!:: Variable Variable Variable Variable
~~~
s::; ..... ...c Motionless Motionless Motionless Motionless
.... g
.... til
.....o ......
~ ~ > Body stability Body stability Body transport Body transport
V:;.El Manipulation Manipulation
'tdC Consistent Consistent Consistent Consistent
'J:: .:.=:
..... .....
.... ...c Motion Motion Motion Motion
os::; ....,
II) til
'.-1

'.0 .S ~
00> Body stability Body stability Body transport Body transport
:::EZ Manipulation Manipulation
>- Open Open Open Open
."!::
......
........... Variable Variable Variable Variable
~
os::; .;S
~ . .-1
1:: ~ Motion Motion Motion Motion
o
• .-4

~ >
Body stability Body stability Body transport Body transport
:::E.El
Manipulation Manipulation

Source: Adapted from AM Gentile. Skill Acquisition: Action, Movement and Neuromo-
tor Processes. In J Carr, R Shepherd, J Gordon, et al. (edsl, Movement Science: Founda-
tions 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 mov-
ing 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) Main-
taining 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 limb-
demonstrated 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 supine-
sit 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
 extremItIes to reverse the
stroke and head-injured patie
6. Taub E, Miller NE, Novack
motor deficit after stroke. Ar
7. Schmidt RA. The Acquisitio
ception-Action Relationship
(edsl, Perspectives on Percep
1987;77.
8. Keele SW. Attention and Hu
Goodyear, 1973.
9. Adams JA. A closed-loop
1971;3:11l.
10. Schmidt RA. A schema theo
Rev 1975;82:225.
11. Schmidt RA, White J1. Evid
motor skills: a test of Ad
1972;4:143.
12. Swinnen S, Schmidt RAJ Nic
skill learning: instantaneous
ing. JExp Psychol Learn Me
13. Lee TD, Hiroth TT. Encodin
memory for movement exten
14. Lee TD, Magill RA. The locu
acquisition. J Exp Psychol Le
15. Bernstein N. The co-ordinat
England: Pergamon Press, 19
16. Kelso JAS, Holt KG, Kugler
Structures as Dissipative S
gence. In GE Stelmach, J R
Amsterdam: North-Holland,
17. Shumway-Cook A, Woollaco
Applications. Baltimore: Wil
18. Gentile AM. Skill Acquisit
Processes. In J Carr, R Sheph
ence: Foundations for PhYS
MD: Aspen Press, 1987;93.
19. Swanson LR, Lee TD. Effect
results on motor learning. G
20. Merians A, Winstein C, Sull
skill learning in older heal
Neurol Rep 1995;19:23.
 tanooga Group, 1991.
24. Magill RA. Motor Learning: Concepts and Applications (3rd ed)
Dubuque, IA: WC Brown, 1989.
25. 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.
26. Melnick MJ. Effects of over learning on the retention of a gross moto
skill. Res Q Exerc Sport 1971;42:60.
27. Bilodeau 1M. Information Feedback. In EA Bilodeau (ed), Acquisition o
Skill. New York: Academic, 1969;255.
28. 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.
29. Ho L, Shea JB. Effects of relative frequency of knowledge of results o
retention of a motor skill. Percept Mot Skills 1978;46:859.
30. Winstein CJ, Schmidt RA. Reduced frequency of knowledge of result
enhances motor-skill learning. J Exp Psycho I Learn Mem Cogn 1990
16:677.
31. 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.
32. Sherwood DE. Effect of bandwidth knowledge of results on movemen
consistency. Percept Mot Skills 1988;66:535.
33. 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.
34. Salmoni AW, Schmidt RA, Walter CB. Knowledge of results and moto
learning. A review and critical reappraisal. Psychol Bull 1984;95:355.
35. 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. Be honest. Be yourself.
2. Examine your own biases.
3. Demonstrate tolerance of
4. 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. Identify something you

2. Be realistic.
3. Specify.
4. Write it down.
5. 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 impair-
ments. Materials that include humor, such as comic strips or funny pic-
tures, 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 writ-
ten resources available that address common educational topics for phys-
ical 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 cre-
ating 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 writ-
ten 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 educational tools.
800-866-4446

VHI Exercise and Rehabilitation Variety of exercise cards with duplication ability. Provides
Prescription Kit the patient with an individualized, clear, and illustrated
VH1 exercise routine.
PO Box 44646
Tacoma, WA 98444
800-356-0709

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 Pro-
gressive 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 fir~

toes downward, then up, 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 10-
seconds 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 regard-
ing their health and their future. Also, there is an increased need for emotion-
al 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 bed-
room and bathroom). Their focus may not be on participating in an exercise
program to increase their strength and endurance, unless it is related to return-
ing to a function that seems realistic to them. The physical therapist or phys-
ical 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 sup-
port 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 guide-
line is that there should be a group facilitator. In programs that address phys-
ical 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 consid-
ered 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 physi-
cal 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 con-
temporary 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 pro-
fessionals 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 pro-

grams 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 precon-
templation to action, from action to maintenance, and from main-
tenance 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 Applying co
to guide behavior 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 Adequate s
and social environ- equipme
ment couragem
form the
behavior
Readiness to change
Stages of change Not thinkin
thinking
ing, or qu
desired b
Individualization
Program accommo- Variation in
dation 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

Phase 2: program implementation
Programs to move precontemplators and
contemplators to action
Programs to move from action to
maintenance
Programs to prevent relapse
Phase 3: evaluation
Step 1: specify expected positive
and negative program outcome goals
and measures
Step 2: specify program activities
that contribute to positive and negative
outcomes and measures
Step 3: collect data to determine
progress in achieving goals
Step 4: revise program goals, activities,
or both
exercise video
Persuasive talk from person similar
to group who overcame back pai
Exercise program that ensures psy-
chosocial and physical rewards
with low barriers
Group discussion of ways to handle
situations that lead to quitting
50% increase in back and abdomin
strength and endurance (Le., a
change in the number of exercise
performed)
Attendance three times per week a
group exercises at a local church
Examining attendance and exercise
records
Increase in social rewards to main-
tain 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 Degree angle for pie

A 120
B 120
C 120
2 A 120
B 240
3 A 120
C 180
3-C 60
4-D 60
S-E 60
6-F 60
4 D 270
4-C 90
SoC 90
6-C 90
5 E ISO
SoD ISO
6-D ISO
S-E 60
6-F 60
6 F 210
6-E ISO
Sources: Broken squares game developed by A Bavelas. The five squares problem-
instructional 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 Clin-
ical reasoning
challenges of, 203
linking academic and clinical cur-
riculum 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 Physi-
cal Therapy Education
(CAPTEI, 29, 30, 31, 32
Commission on Recognition of Postsec-
ondary 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 p
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 instruc-
tor (CI)
organizational structure of,
127-142
pre-experience planning for,
184-186 p
student objectives in, 142-145 Eisn
supervisory patterns of, 145-153 Elde
teaching techniques in, p
169-197 t
clinical residency and, 199-224 Eva
challenges in, 203 p
linking academic and clinical cur-
riculum 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 s
implementing, 367-369
phases of, 360-370 t
planning models in, 358-360
conflicts between professional and
liberal arts, 25-28 Exa
continuing, 382-383 a
future of, 380-382 e
global environment of, 6 f
higher education vs. health care envi- g
ronments, 122-124
objectives of, 7
 short answer questions and, 63-65 Knott, Maggie, 42
true or false questions and, 64 Knowledge, transformation, 76
Exercise, 321, 367 Knowledge of performance (KP),
consequences related to, 258 289-290
training Knowledge of results (KR), 288
broken circles, 387-389
Esptein's four-stage rocket, Learning
390-392 active, 77
Expert panels, 105 categories of, 313, 315-317
Explanatory models. See Models, clinical, 176--182
explanatory ability to perform effective
actions in, 178-179
Faded feedback schedule, 288 acculturation in, 179-180
Feedback bridging theory with practice in
augmented, 288 178
effective, 336 critical analysis of competence
from patient/family, 340 180
positive, 336 lifelong reflective practice and,
video, 290-291 182
Fishbein and Ajzen's theory of reasoned other-assisted to self-assisted, 1
action, 352, 353 outcomes of, 181-182
Fog Index formula, 325, 326, 365 problem selection for students
Ford, Patrick, 25 and, 191-193
process of, 176--180
Gagne, Robert, 48 questions in, 188-190
Games, 105 students and, 176-177
Gentile's task taxonomy, 282-284 collaborative, 98-105, 114
Geriatrics, teaching, 331-332 brainstorming in, 103
Gestalt psychologists, 46 debating in, 103-104
Grading systems, 88-89 expert panels in, 105
classroom teaching, 87-89 games and simulations in, 105
competency-based, 88 group expert technique in,
contract, 89 100-101
criterion-referenced, 88 in clinical setting, 152-153
norm-referenced,88 peer teaching in, 102-103
peer-grading, 89 role playing in, 104--105
self-grading, 89 rules for groups and, 100
Groupwork, 98-102. See also Learning, seminars in, 10 1-102
collaborative; Learning, small groups process and, 98-10
cooperative successful, preparing for, 99-100
tutorials in, 102
Harris, Irene, 5 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 move- L
ments 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 L
behavioral, 313, 315
Learning domains, 5~56 L
affective, 52-54,315-316
cognitive, 5~52, 315 M
perceptual, 55 M
psychomotor, 54-55,316 M
relationship between philosophici;ll M
orientations, learning theo-
ries and, 56
spiritual, 55-56
Learning environment, of the future,
385 M
Learning styles, 56-58 M
Learning theories, 45-50
Adams' closed-loop, 277-278,
393-394
Bandura's social learning, 352 M
behaviorism, 46
cognitive structure, 48-49
Fishbein and Ajzen's, of reasoned
action, 352, 353
 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/fami-
ly,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 lea
establishing a therapeutic relation-
ship 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 mo
muscle performance examinations
by, 173 tea
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 Ratio
Portfolios Recal
faculty, 69-70 Refle
student, 67-68 Refle
Practitioners, roles of, 136 Resid
Preactive teaching, 39-40
grid for, 40-61 Roger
PRECEDE-PROCEED model, Role
358-360 Rood
Problem-solving experience, 46-48
Problem-solving objectives, 59-60 Schm
Psychologists, gestalt, 46
Psychomotor skills, 90-93 Schon
of children, 296 Semi
demonstrations of, 93 Simu
of elderly, 296 Socia
learning phases of, 91 Socia
 dency theories
evaluating, 62-63, 67-70 materials
clinical readiness abilities, 182, for assessing readability
184-191 level,325
peer reviews, 68-69 chalkboards, 112
performance, 190-191, 194-195 computers, 111,321
self-assessment vs. demonstrated evaluating, 320-325
abilities, 187-190 films, 112
using student journals, 68 for patient education, 320-3
using student portfolios, 67-68 overhead transparencies, 112
interaction with clinical instructor, reference list of, 322
170,174-175,177-181,184, slides, 112
187, 190, 191, 192 using educational technolog
learning styles of, 56-58 for, 109-113
motivation principles of, 177 videotapes, 112
orientation to clinical setting for, 186 written, 321
responsibility of in clinical setting, objectives of, 58-61
176 behavioral, 58-59, 61
roles and responsibilities of, 128-129 outcome, 60-61
supervising, 193-194 problem-solving, 59-60
in clinical setting, 145-153 patient education. See Patient
Syllabus, 61-62 education
philosophical orientation of, 41
Teaching. See also Education; Lectures academic rationalism, 42
in academic settings, 73-118 course development and, 44
academic vs. clinical, 172-173 development of cognitive pr
adolescent patients, 329-330 cesses, 41-42
adult patients, 330 personal relevance of, 43-44
case reports/studies and, 106-109 social adaptation in, 43
challenges of, 114 social reconstruction in, 43
in classroom settings, 87-89 technology and, 42-43
clinical laboratory. See Clinicallabo- preactive, 39-40
ratory teaching grid for, 40-61
in clinical settings, 119-167. See also preparing for, 37-72
Clinical education course syllabus, 61-62
concept mapping and, 109 preparing examinations and,
curriculum. See Curriculum 63-67
domains of learning, 50-56 essay questions, 66
affective, 52-54,315-316 free format questions, 64
cognitive, 50-52,315 grading systems, 88-89
perceptual, 55 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 Mod-
els, 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 relation-
ships 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 determin-
ing, 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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