RESEARCH REPORT
Experiential Learning Enhances Physical Therapist
Student Confidence in Management of Neurologically
Involved Adults and Children
Kristen Barta, PT, PhD, DPT, NCS, Megan Flores, PT, MPT, PCS, and Anna Edwards, PT, DPT, MA, MBA
Introduction. Clinical experiences are an
integral part of professional physical ther-
apist (PT) education programs. Hands-on
engagement helps foster the critical think-
ing skills necessary to successfully navigate
the complexity of clinical practice during
a PT student’s final clinical internships. As
PT students advance through an entry-
level professional program, their clinical
decision-making skills improve; however,
they lack self-confidence in working with
both adult and pediatric patients present-
ing with neurological impairments. e
purpose of this study was to explore the
effect of experiential learning using com-
munity volunteers (both adults and chil-
dren) with activity and participation
restrictions as a result of neurological in-
sult or developmental delay on PT student
perceived self-confidence.
Methods. A convenience sample of 128
students currently enrolled in a PT
education program were recruited. A
pretest–posttest survey assessed the stu-
dents’ self-perceived confidence in the
Kristen Barta is an assistant professor at the
University of St. Augustine for Health Sciences,
5401 La Crosse Avenue, Austin, TX 78739
(kbarta@usa.edu). Please address all correspon-
dence to Kristen Barta.
Megan Flores is an assistant professor at the
University of St. Augustine for Health Sciences,
Austin.
Anna Edwards is an assistant professor at the
University of St. Augustine for Health Sciences,
San Marcos.
e authors declare no conflicts of interest.
Received January 30, 2018, and accepted
February 27, 2018.
Supplemental digital content is available for this
article. Direct URL citations appear in the
printed text and are provided in the HTML and
PDF versions of this article on the journal’s Web
site (www.aptaeducation.org).
Copyright © 2018 Academy of Physical erapy
Education, APTA
DOI: 10.1097/JTE.0000000000000040
Vol 32, No 3, 2018
Copyright ª 2018 Academy of Physical Therapy Education, APTA. Unauthorized reproduction of this article is prohibited.
evaluation and treatment of a neurologi-
cally involved individual across the life-
span. e students completed 4 weeks of
experiential learning with one adult and
one pediatric community volunteer with
a neurological condition in small groups.
e four sessions included an initial eval-
uation, two treatment sessions and one
discharge reassessment. An exploratory
factor analysis was completed to validate
the tool and to determine the factors that
make up the survey. Qualitative data
(open-ended questions) were analyzed
using a grounded theory approach.
Results. On average, students reported
more self-perceived confidence in the
posttest survey than in the pretest survey.
is difference was significant t(127) =
213.841, P < .001.
Conclusion. Students expressed that
more exposure and increased time spent
with neurologically involved adults and
children could improve their confi-
dence. is study supports the use of
experiential learning in PT education
programs.
Key Words: Experiential learning, Confi-
dence, PT student, Clinical experience,
Clinical reasoning.
INTRODUCTION
Clinical experiences are an integral part of
professional physical therapist (PT) educa-
tion programs, and PT students value the
opportunity to engage with real patients in the
classroom during their didactic curriculum.1
rough a variety of methods, many entry-
level professional PT education programs
weave clinical experiences throughout the
curriculum. Hands-on engagement helps
foster the critical thinking skills necessary to
successfully navigate the complexity of
professional practice during a PT student’s
clinical internships and prepares students for
entering the workforce.2
As PT students advance through an entry-
level professional program, their clinical
Journal of Physical Therapy Education
decision-making skills improve.3 However,
they lack self-confidence in working with
both adult and pediatric patients who pres-
ent with neurological impairments.4 One
solution to improve PT students’ self-
confidence with this population is the addi-
tion of experiential learning opportunities
with adults and children with neurological or
developmental impairments, including ac-
tivity and participation restrictions.5 Expe-
riential learning uses direct student
interaction with community volunteers to
simulate real-world clinical application of
didactic material. Recently, Schreiber et al6
advocated for “inclusion of experiential
learning with children with participation
restrictions as a component of professional
education for all PT students.” is method
of introducing a clinical experience into the
curriculum can be an especially powerful
teaching tool when used with community
volunteers across the lifespan who are lim-
ited due to neurological or developmental
deficits.
At the University of St. Augustine for
Health Sciences, experiential learning is
administered through a structured 4-week
Patient-Oriented Integrated Neurological
Treatment (POINT) lab. Students interact
with one adult and one child each week,
both of whom have neurological impair-
ments. e purpose of this study was to
explore the effect of experiential learning
using community volunteers (both adults
and children) with activity and participa-
tion restrictions as a result of neurological
insult or developmental delay on PT student
perceived self-confidence. It was hypothe-
sized that PT students would perceive
greater levels of confidence in their patient
management skills for neurologically in-
volved patients across the lifespan after the
4-week POINT lab.
REVIEW OF LITERATURE
As they advance through the professional
education program, PT students begin to
transition from a self-centered focus toward
improved reflection and integration of
295
situational awareness.3 One study found that
while third-year PT students used sophisti-
cated strategies, first-year students used sim-
ple strategies when evaluating and treating
a simulated patient case.7 Because adults and
children with neurological deficits or de-
velopmental delay present with complex re-
habilitation issues, PT students are best
equipped to handle these cases toward the end
of their didactic coursework. For clinical
reasoning and patient-safety purposes, it was
determined that POINT lab would be most
successful if integrated into neuromuscular
and pediatric classes just before students
embark on their final internships.
ere is ample evidence to suggest that
practice-based learning is important for fos-
tering clinical reasoning and advanced critical
thinking skills in PT students.1,2,8-13 Multiple
methods of practice-based learning have been
recently explored, including assessment of
clinical skills using a standardized patient
scenario.14 In this model, an actor who is
trained to reproduce appropriate patient
symptoms and responses interacts with health
care students while instructors assess their
clinical skills. Although useful early in a pro-
fessional education program, the patient sce-
narios become more complex as students
advance through the program, making re-
alistic portrayals by an actor difficult.14
e resources and time needed for actors
to accurately portray complex standardized
patients is often unreasonable for many PT
professional education programs. A system-
atic review of simulation learning experiences
for professional PT education programs by
Mori et al12 found that these experiences can
augment student learning. However, Sabus
et al15 suggest that although simulation in PT
education may be beneficial when learning
about patient safety and interprofessional
practice, it is often time-consuming and cost-
prohibitive. Additionally, use of actors or
mannequins does not adequately simulate
pediatric or adult patients with true neuro-
logical impairments or developmental delay.
Some evidence exists to suggest that PT
student’s self-confidence improves through
a practice-based learning approach.5,16
Ohtake et al16 found that PT student’s self-
confidence increased when managing a criti-
cal illness patient by using a mannequin
simulator and real medical professionals after
a one-time (15 minutes) intensive care unit
patient simulation. Additionally, Lubbers and
Rossman5 reported an increase in nursing
student self-confidence after a pediatric sim-
ulation using community-based observation.
Likewise, Mai et al17 found that student’s self-
confidence improved when they were exposed
to an integrated clinical experience. However,
in a study examining PT student’s self-
296
Copyright ª 2018 Academy of Physical Therapy Education, APTA. Unauthorized reproduction of this article is prohibited.
confidence after an online interactive sce-
nario, Johnston et al18 discovered no additional
benefit to using scenario-based technology to
simulate patient care.
Although the literature reveals mixed
results when assessing student self-confidence
with practice-based learning, few studies ex-
plore true “hands-on” experiential learning in
the classroom. Clearly, as stated by Schreiber
et al,6 there is an “absence of evidence that
definitely supports the effectiveness of expe-
riential learning opportunities with children
for professional PT students.” is absence of
evidence also extends to adults with neuro-
logical impairments. It seems that experiential
learning with pediatric and adult patients
with neurological or developmental impair-
ments is an understudied learning method
that needs to be explored.
METHODS
Subjects
A convenience sample of students enrolled in
a doctor of PT program was recruited for this
study. Initially, 130 students with ages that
ranged from 20 to 50 years were recruited
over the course of three semesters, but only
128 students (63 male and 65 female)
completed both the pretest and the posttest
surveys. e PT students recruited for the
study were those who had completed all
didactic work in the neuromuscular and pe-
diatric curriculum and who were about to
leave on their final internships. Students were
excluded from participating if they did not
complete the initial pretest survey before the
start of POINT labs.
Design
e study was a one-group pretest–posttest
design using a survey to assess the students’
self-perceived confidence in the evaluation
and treatment of a neurologically or de-
velopmentally impaired individual across the
lifespan. e survey asked students to rate
their self-confidence in the evaluation and
treatment of people with activity and partic-
ipation restrictions from birth to geriatric.
Before the first POINT lab session, each co-
hort of students who agreed to participate was
informed as a group about the purpose of the
study and the time commitment needed to
complete the study and a description of the
survey. All students were informed that par-
ticipation in the survey was voluntary and
that each person was allowed to discontinue
the study at any point in time. ose students
who were interested in participating signed an
informed consent before the pretest survey
and were issued a unique identification
number. e lead instructors (who were also
Journal of Physical Therapy Education
the study investigators) for each course did
not participate in administration of surveys,
and all data collected contained only the
unique identification number to ensure ano-
nymity of the student. e investigators were
permanently blinded as to which students
participated in the study.
e survey focused on items needed to
evaluate, develop a plan of care, and effectively
treat a client in clinical practice. In addition,
the students completed a demographic sheet
that asked about age, gender, grade point av-
erage, experience in a neurological setting
before starting their PT education, and their
clinical interest after graduating.
e pretest survey contained 10 rating
questions and two short-answer questions for
the students to define their self-confidence in
the context of PT and what contributes to
their level of confidence. e first 10 questions
were rated on a 4-point Likert scale: 1 = not
confident, 2 = somewhat confident, 3 = con-
fident, and 4 = very confident. is scale was
based off a similar questionnaire published by
Ohtake et al16 that measured student’s confi-
dence. e questions assessed the skills of
evaluation, plan of care development, treat-
ment, safety, patient and family interaction,
and home exercise prescription. e pretest
survey took approximately 15 minutes to
complete (Appendix A, Supplemental Digital
Content 1, http://links.lww.com/JOPTE/A27).
Within a week of completing the pretest
survey, the students started the first of four
POINT lab sessions involving an adult com-
munity volunteer with a neurological condi-
tion, and the first of four POINT lab sessions
involving a pediatric community volunteer
with a neurological condition or de-
velopmental delay. During the POINT labs,
the students were divided into small groups
(3–5 members) and worked with the same
volunteers each week. Over the course of 4
weeks, the student groups completed one
adult and one pediatric session each week,
giving them equal time with both age cate-
gories. All sessions were supervised by an
experienced, licensed clinician.
e week before the start of the experiential
learning experience, the student groups were
given the community volunteer’s medical di-
agnosis. During the first week of POINT lab,
the groups completed an initial PT evaluation
of the volunteer. is involved taking a full
history, completing a systems review, mobility
assessment, and administering appropriate
tests along with outcome measures.
Weeks 2 and 3 consisted of students
implementing the created plan of care that
addressed the community volunteer’s goals
for POINT lab. ese two intervention ses-
sions required the students to not only treat
the client according to the established goals
Vol 32, No 3, 2018
but also simulated real-life clinical situations
that require a clinician to think on their feet
and modify a plan if necessary. e groups
were required to have an alternate plan in the
event that a regression or progression of
a particular activity was necessary.
e final week was a continuation of the
previous intervention sessions and also in-
cluded a reevaluation of outcome measures
and goals. Students were required to measure
all necessary outcomes from the initial eval-
uation to document progress over the month.
Additionally, over the course of the POINT
labs, the student groups developed a home
exercise program. Each community volunteer
was educated and issued a home exercise
program handout during the last session.
After completing each session, the student
groups submitted written documentation
within 48 hours. Students documented the
evaluation on a template typical of clinical
practice, including the history, systems re-
view, test and measures, outcome measures,
assessment summary, and patient goals. e
intervention sessions also involved docu-
mentation of a PT treatment note to record
intervention details and the group’s assess-
ment and plan. At the end of the treatment
note, each group was required to provide
evidence-based peer reviewed articles that
supported their interventions, including a ci-
tation and brief rationale. e final session
involved a discharge treatment note, sum-
mary of progress toward the goals, and a copy
of the issued home exercise program. e
student groups received feedback from the
course instructor for improving documenta-
tion before the next lab. ey also got verbal
feedback about their session from a licensed
clinician.
Once the students completed the final
adult and pediatric POINT labs, a posttest
survey was given. e posttest survey in-
cluded the same 10 rating questions assessing
self-perceived confidence and 3 different
short-answer questions. e open-ended
short-answer questions targeted student
perception on what contributed to their
confidence in the evaluation and treatment
of a neurologically involved patient. e
posttest survey took approximately 10
minutes to complete (Appendix B, Supple-
mental Digital Content 1, http://links.lww.
com/JOPTE/A27).
Data Analysis
Quantitative Analysis. Data from the 10
rating questions were analyzed using IBM
SPSS Statistics (Armonk, NY).19 An explor-
atory factor analysis, informed by eigenvalues
and scree plots, was completed to validate the
tool and to determine the factors that make up
Vol 32, No 3, 2018
Copyright ª 2018 Academy of Physical Therapy Education, APTA. Unauthorized reproduction of this article is prohibited.
the survey. A factor loading cutoff of 0.40 was
used to determine those items to retain in
a factor. Next, a paired sample t-test was used
to analyze the difference between the pretest
and posttest results.
Qualitative Analysis. Qualitative data (open-
ended questions) were analyzed using
a grounded theory approach. Student respon-
ses were transcribed and grouped by pretest
and posttest question. Line-by-line coding was
independently performed by two authors (K.B.
and M.F.) to identify codes. Axial coding by all
three authors was used to assign the codes to
categories and identify emergent themes.
RESULTS
A principal access factor analysis was con-
ducted on the 10-item questionnaire with
an oblique rotation (direct oblimin). e
Kaiser–Meyer–Olkin (KMO) measure varied
the sampling adequacy for the analysis,
KMO = 0.876, and all KMO values for in-
dividual items were >0.790. An initial analysis
was run to obtain eigenvalues for each factor
in the data. Two factors had eigenvalues over
Kaiser’s criterion of 1, and in combination
explained 57.36% of the variance. e scree
plot clearing indicated inflections that would
justify retaining two factors. erefore, we
retained two factors based on information
from the scree plot and Kaiser’s criterion.
Table 1 shows the factor loading after rotation.
Looking back at our initial questionnaire, we
determined factor 1 (items 1, 2, 9, and 10)
represented evaluation competencies and
factor 2 (items 3–7) represented the pro-
fessional behaviors taught in an entry-level
PT education program.
e evaluation competencies of the survey
(factor 1) had high reliability, with Cronbach’s
a = 0.839. However, the professional behav-
iors subscale of the survey (factor 2) had good
reliability, Cronbach’s a = 0.748.
A paired samples t-test was run to assess
the difference between the mean values of the
pretest and posttest total scores. e pretest
maximum score was 40 and the minimum
score was 13. For the posttest, the maximum
score was 40 and the minimum score was 16.
e paired sample t-test revealed that, on
average, students reported more self-
perceived confidence in the posttest survey
in the evaluation and treatment of the neu-
rologically involved individual (mean = 30.67;
SE = 0.52), than in the pretest survey (mean =
22.77; SE = 0.41). is difference, 27.91, BCa
95% confidence interval (28.98 to 26.75),
was significant t(127) = 213.841, P < .001, and
represented a large sized effect, d = 1.70.
To assess students’ perception of confi-
dence before POINT lab, students were asked
what would improve their confidence in the
Journal of Physical Therapy Education
evaluation and treatment of a neurologically
involved client. Five categories were identified
from the coded transcript: experience, expo-
sure, practice, observation, and feedback.
From these categories, three themes emerged:
1. Self-confidence can improve with expo-
sure to neurologically involved clients.
2. Preparation through practice and expe-
rience is necessary for self-confidence.
3. Self-confidence increases with guid-
ance through feedback from and
observation of experienced clinicians.
e posttest questions asked students to
reflect on their didactic and POINT lab ex-
perience to identify strengths and weaknesses
in their self-confidence. From the coded
transcript, three categories were identified
as strengths for self-confidence: team
work, curriculum, and patient exposure. Five
categories were identified as areas that needed
to be addressed to improve self-confidence:
more exposure to people with neurological
involvement, longer POINT labs, more lab
practice, wider variety of patients during
POINT lab, and no additional preparation
needed. From these categories, three themes
emerged:
1. Students value feedback from experi-
enced PTs and peers.
2. Patient-Oriented Integrated Neuro-
logical Treatment labs give students
the exposure and preparation they
need to improve their confidence.
3. Increased time in POINT labs would
further improve self-confidence, as
would exposure to a wider variety of
patients
DISCUSSION AND CONCLUSION
Although PTstudents are exposed to a wealth
of didactic material in their professional
education programs, they lack exposure to
real-life situations regarding patient care. e
students at the University of St. Augustine for
Health Sciences expressed decreased self-
confidence in the evaluation and treatment of
people with neurological conditions across
the lifespan before the experiential learning
exposure through POINT labs. e utiliza-
tion of an integrated clinical experience
within a curriculum-based course facilitated
an improvement in students’ self-confidence
in the assessment and treatment of this
population.
In their responses to the open-ended
questions, the students linked self-confidence
to clinical reasoning, which is necessary before
a clinician can make a sound decision on the
most appropriate action to take with a client.
is cognitive process is dependent on the
297
Table 1. Summary of Exploratory Factor Analysis Results for the Patient-Oriented Integrated Neurological Treatment Lab Self-
confidence Survey (n = 128)a

Item Evaluation Competency Professional Behaviors

1. Complete a full age-appropriate evaluation of 0.21 0.47
a neurologically involved patient
2. Perform appropriate screen to determine need for 0.25 0.48
PT for a neurologically involved patient
3. Choose an appropriate outcome measure for the 0.28 0.28
neurologically involved patient
4. Develop a plan of care for a neurologically involved 0.73 0.06
patient
5. Write realistic, age-appropriate measurable goals 0.67 0.06
for a neurologically involved patient
6. Implement the developed treatment plan for 0.70 20.04
a neurologically involved patient
7. Develop an appropriate home exercise program for 0.82 20.08
a neurologically involved patient
8. Complete reassessment and discharge summary for 0.69 0.07
a neurologically involved patient
9. Interact with the neurologically involved patients 20.10 0.66
and families in a supportive manner
10. Practice in a safe and effective manner for the 0.01 0.77
neurologically involved patient
Eigenvalues 4.55 1.18
Percent of variance 45.54 11.82
Cronbach’s a 0.839 0.748

Abbreviation: PT = physical therapist.

a
Factor loadings over 0.40 appear in bold.

specific context of each decision as it is made
and executed. It has even been defined as an
“interactive phenomenon.”20,21 Even as they
progress through a PT education program,
students’ strategies used for clinical reasoning
change. Gilliland7 found that first-year stu-
dents tended to use unsuccessful strategies for
clinical reasoning, whereas the third-year
students used strategies more similar to nov-
ice practitioners in simulated patient cases.
e complexity of clinical reasoning stems
from the fact that decisions need to be made
after incorporating not only cognitive knowl-
edge but also affective and psychomotor skills
while simultaneously reflecting on the
patient’s response to these actions.3 It has been
suggested that a person transitions to an ex-
pert clinician when the application of skill and
knowledge can vary according to patient’s
response.22
Students in the current study also reported
that processing information in real-time re-
garding appropriate test, outcome measure,
and intervention selection was beneficial. is
could be because students were required to
assess the community volunteer’s response
after evaluation and treatment interventions
and modify as needed. e hands-on en-
gagement of POINT lab facilitates using
critical reasoning necessary to translate
knowledge into practice.
Additionally, the students reported that
feedback from instructors was helpful
throughout the POINT lab experience. da
Beer and Mårtensson23 found students in an
occupational therapy education program re-
ceived higher grades on practical examina-
tions when given more corrective feedback
from licensed clinicians during fieldwork.
During POINT labs, the constructive feed-
back given to the groups regarding the plan of
care, execution of interventions, and docu-
mentation may have contributed to their
increased level of confidence in this population
as they were able to use this information and
improve during the following sessions.
Every student had their own working
definition of self-confidence, with most de-
fining it as feeling prepared and knowledge-
able. One student defined self-confidence as
the “ability to trust your clinical reasoning
skills.” Students expressed that more exposure
and increased time spent with neurologically
involved adults and children could improve
self-confidence. ey also identified the need
for preparation through increased practice
with evaluation and treatment of this pop-
ulation. As a whole, the students in the study
demonstrated a significant increase in self-
perceived confidence after the completion of
POINT labs in all items of the survey.
is study had several limitations. e
students who agreed to participate in this
study volunteered to fill out the pretest and
posttest survey, but they were all required to
participate in POINT lab as part of their
neuromuscular and pediatric classes. is
poses a threat to internal validity because
there was no control group. Also, the survey
used was based only on a previous pilot study.
Although the survey was not a valid tool used
in previous literature, we did find good re-
liability through Cronbach’s a. Another lim-
itation was that all students who participated
in this study were from the same university. A
more robust study would implement POINT
labs and survey students across several uni-
versities. Additionally, there was no objective
assessment of student participation in the
POINT labs. Although students were required
to participate, they evaluated and treated the

298 Journal of Physical Therapy Education Vol 32, No 3, 2018

Copyright ª 2018 Academy of Physical Therapy Education, APTA. Unauthorized reproduction of this article is prohibited.
community volunteer in teams of three to
four students each. Group dynamics usually
have a leader and at least one member who
does not contribute as much as the others.
Despite the limitations of this study, in-
troducing a clinical experience into the cur-
riculum can be an especially powerful
teaching tool when used with community
volunteers across the lifespan who have par-
ticipation restrictions due to neurological or
developmental deficits. is study supports
the use of experiential learning in PT educa-
tion programs.
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