Curriculum and Competency Evaluation in Respiratory Therapy Entry-to-Practice Programs

Abstract

BACKGROUND:

Essential skills for respiratory therapists extend beyond the traditional scope of therapy. Respiratory therapists are expected to communicate effectively, deliver bedside education, and practice within interprofessional teams. Respiratory therapy entry-to-practice program accreditation standards require evaluation of student competence in communication and interprofessional practice. This study aimed to determine if entry into practice programs include curriculum and competency evaluation for oral communication, patient education, telehealth, and interprofessional activities.

METHODS:

The primary objective was to identify the curriculum and method of competency evaluation. The secondary objective was to compare degree programs. Directors of accredited respiratory therapy programs were invited to complete an anonymous survey with regard to degree program type, oral communication, patient education, learning strategies, telehealth, and interprofessional activities. Degree programs were classified as associate's of science 2 year, associate's of science < 2 year, or bachelor's of science.

RESULTS:

Of 370 invited programs, respondents in 136 programs (37%) completed the survey. Oral communication competence was evaluated by 82%. Patient education curriculum and competency evaluation were reported by 86% and 73%, respectively. Telehealth was rarely included or evaluated. Interprofessional activities were included by 74%, of whom 67% evaluated competency. Bachelor's of science programs were more likely to include a specific patient education course (P = .004), evaluate oral communication competency with unpaid preceptors (P = .036), and evaluate interprofessional competence through formal interprofessional programs (P = .005). Associate's degree 2-year programs used laboratory proficiency for patient education competency evaluation more often than other programs (P = .01). associate's of science < 2-year programs were more likely to include simulation experiences that involved motivational interviewing (P = .01).

CONCLUSIONS:

Differences exist among program types for curriculum and competency evaluation. Telehealth was rarely included or evaluated at any degree level. Programs should evaluate the need for enhanced patient education and telehealth instruction.

Introduction

Essential skills for respiratory therapists (RT) now extend beyond the traditional scope of therapy.^1–4 Department leaders are under increasing pressure to hire appropriately trained staff, maximize orientation time, and positively affect patient outcomes. The RT is expected to communicate effectively, deliver bedside education, and practice within interprofessional teams.⁵ Essential non-clinical professional skills must be developed during preparation for professional practice. A gap frequently exists between knowledge obtained at the educational level and the requirements of bedside practice. An assumption is made that respiratory therapy students will demonstrate the requisite competence before graduation. The pedagogy and strategies programs use to reduce the knowledge – practice gap is important.⁶

Health professions education has undergone a shift from an entirely concept-based model to a more inclusive, comprehensive strategy of competency-based instruction and evaluation. Within the strategy are the core competencies expected of graduates for entry to practice, as reflected by the 2022 Commission on Accreditation Entry into Practice Standards.^3,6–11 This shift also applies to telehealth competency through clinical simulation.^12–17 Students are expected to follow a progressive evolution of non-clinical, professional attributes as they advance toward competence in clinical skills and preparation for practice as a registered RT.

As an allied health profession, respiratory therapy has led the way in competency-based clinical education, extending > 2 decades.^3,18,19 The Commission on Accreditation for Respiratory Care Entry into Practice Standards¹¹ outlines 4 core, non-clinical competencies that must be evaluated in each student's development: effective communication, critical thinking, interprofessional practice, and ethical behavior and professionalism. Furthermore, the American Association for Respiratory Care noted that competency in non-clinical professional attributes are essential for entry-level practice for safe, efficient, and effective care.¹ The trend is corroborated by the American College of Graduate Medical Education²⁰ core competencies for patient care, professionalism, and interpersonal and communication skills. Yesterday's soft skills are today's essential skills. Employers consistently communicate a preference for practitioners who are proficient in communication and working in interprofessional teams.^2,21–23 Indeed, these essential skills are the foundation for effective interprofessional practice.

The expanding role of RTs into disease management and patient education creates a need for formal patient education training as part of entry-to-practice programs. Training programs and curriculum models exist to assist respiratory therapy programs in preparing graduates to deliver patient education.²⁴ The models include curricular outlines and assessment methods for core competencies health literacy, cultural competence, domains of teaching and learning, telehealth, and evaluative rubrics.^8,14,24–28 The literature related to telehealth seems to be focused almost exclusively on practice, with research related to curriculum in health professions programs lagging behind but emerging.^25,29–32 A recent literature search did not identify any publications that specifically differentiated respiratory therapy curriculum or evaluation practices by comparing various program types or length. Our objective was to discover how distinct degree programs incorporate communication, patient education, telehealth, and interprofessional practice in the curriculum; identify related student experiences; and determine how competence is evaluated.

QUICK LOOK.

Current Knowledge

Essential skills for respiratory therapists have evolved beyond the traditional scope of providing care at the bedside in the hospital. Many respiratory therapists now participate in patient education, help prepare patients for discharge, and practice in the out-patient clinic setting. Respiratory therapists are expected to communicate effectively and work within interprofessional teams.

What This Paper Contributes to Our Knowledge

Most programs evaluated competency in oral communication, patient education, and interprofessional activities. Telehealth was rarely included or evaluated. There were differences among respiratory entry-to-practice programs for curriculum and competency evaluation. An opportunity exists for programs to incorporate curriculum for telehealth.

Methods

The primary aim of the study was to determine if respiratory therapy entry-to-practice programs include specific curriculum for oral communication, patient education, telehealth, and interprofessional activities other than clinical rotation. The secondary aim was to identify the methods of competency evaluation and compare degree programs. A questionnaire was developed to address the aims. The survey domains were degree program type, oral communication, patient education, learning strategies for patient education, telehealth, interprofessional activities, use of laboratory or simulation experiences, and method of competency evaluation.

Surveys included a maximum of 32 items, depending on branching logic. Degree program options were associate's degree, bachelor's degree, and master's degree. Program types were differentiated at the associate's degree level into programs at least 2 years in length (Associate 2 year) and those < 2 years long (Associate < 2 year). We did not differentiate associate's degree type. For convenience, the designation associate's degree refers to an associate's degree of any type. No assumption was made that associate's 2 year programs conferred the associate of science degree, or that associate's < 2 year programs conferred the associate's of applied science degree. The questionnaire was piloted with local respiratory program educators for accuracy and understanding of survey items. Survey questions are included as a supplementary file (see the supplementary materials at http://www.rcjournal.com).

The institutional review board at the University of Arkansas for Medical Sciences determined that the study was not human subject research. Directors of respiratory therapy entry-to-practice programs were invited by e-mail to anonymously complete the questionnaire via a link to the survey. Inclusion criteria were programs accredited by the Commission on Accreditation for Respiratory Care. The survey was conducted from February to March 2021. Responses were collected electronically in the Research Electronic Database Capture application.³³ Descriptive statistics, including frequency and percentage, were used to summarize results. To determine if the frequency of responses differed among the programs, chi-square or Fisher exact tests (when cells had expected counts of < 5) were used to compare program types. P < .05 was considered statistically significant. Analyses were performed using SAS version 9.4 (SAS Institute, Cary, North Carolina).

Results

Three hundred and seventy accredited respiratory therapy programs were invited to complete the survey. Surveys were returned from 136 respondents (37%), which represented 141 different degree programs. Respondents of 6 programs reported having more than one type of degree. The majority of degree programs represented were associate's degree 2-year programs (94, 67%), followed by bachelor's of science (26, 18%), associate's degree < 2 years (16, 11%), and master's degree (5, 4%). Due to the small number of master's degree respondents, master's degree programs were excluded from extensive analysis.

More than one half of all entry-to-practice programs included in the analysis required oral communication as a prerequisite (70, 51%). Most programs without a prerequisite requirement included an oral communication–specific course or separate unit or module (47, 35%). Eighteen programs (13%) did not identify any oral communication requirements or curriculum, whereas one program respondent noted that it was not a criterion for admission but was required for graduation. Laboratory and simulation center experience for oral communication was reported by respondents of 86 (63%) and 73 (54%) programs, respectively. The majority of programs evaluated oral communication competence (112, 82.3%) with oral presentation, which represented the most common type of competency evaluation (102, 75%) (Table 1).

Table 1.

Oral Communication

Curricula for patient education was included by respondents of 117 programs (86%) through either a specific course (26, 19%) or a separate unit or module (91, 67%). Bachelor's of science degree programs (11, 42.3%) had designated patient education courses more often than associate's degree programs (15, 13.6%). More programs included laboratory experience for patient education (104, 76%) compared with simulation center experience (68, 50%). The teach-back method was the most used learning strategy (108, 79%). Competency evaluation of patient education was reported by respondents of 99 programs (73%), with laboratory proficiency identified as the most used method (66, 49%) (Table 2).

Table 2.

Patient Education

Of the respondents of programs who reported use of learning strategies for patient education, the majority of programs included a separate course, unit, or module for the teach-back method (96/108, 89%), teach-to-goal method (48/54, 89%), and motivational interviewing (29/31, 94%). Laboratory experience was most common for the teach-back method (85/108, 79%) and the teach-to-goal method (36/54, 67%). More than half of all the respondents of programs that used learning strategies confirmed that competency assessment was included for the teach-back method (60/108, 56%) and teach-to-goal method (33/54, 61%). The simulation center experience was less common for all strategies (Table 3).

Table 3.

Learning Strategy Content

A specific course for telehealth was reported by 3 respondents and only 34 (25%) included a separate unit or module. Competency evaluation for telehealth was infrequent (6, 4%) (Table 4). Seventy-four percent (n = 101) of all programs included interprofessional activities other than clinical rotations, of which the majority evaluated competency (91, 67%). The most common method of competency evaluation for interprofessional activities was academic/clinical faculty clinical evaluation (62, 46%) (Table 5).

Table 4.

Telehealth

Table 5.

Interprofessional Activities Other Than Clinical Rotations

Few statistically significant differences among the programs were identified. Although not significant, a larger percentage of bachelor's of science programs (18, 69%) required an oral communication prerequisite compared with associate's degree programs (associate's degree < 2 year, 9, 56%; associate's degree 2 year, 43, 46%) (P = .09). Bachelor's of science degree programs were more likely to evaluate oral communication competency with clinical evaluation by using unpaid preceptors (P = .036), to include a specific course for patient education (P = .004), and to evaluate interprofessional competence through completion of a formal interprofessional program (P = .005).

Associate's degree 2-year programs used laboratory proficiency for competency evaluation of patient education more often than did other programs (P = .01). Associate's degree < 2-year programs included simulation center experience for motivational interviewing more than other programs (P = .01). Five master's degree programs were excluded from the overall analysis due to the small number of programs. One master's degree program respondent identified his or her program as a post-professional master's level program rather than entry-to-practice program. It is unknown if the other master's degree programs were entry level or post-professional due to the anonymous nature of the survey. All the respondents of master's degree programs reported that patient education was included in the curriculum either through a specific course (3, 60%) or a separate unit or module (2, 40%). Respondents of 4 master's degree programs (80%) reported having a separate unit or module for telehealth. All 5 programs (100%) incorporated interprofessional activities other than clinical rotations, of which 4 (80%) evaluated student's ability to work in interprofessional teams.

Discussion

This survey of curriculum and competency evaluation in respiratory entry-to-practice programs identified differences among the program types. This finding may be due to the number of academic terms allotted for degree attainment, state mandated requirements for the bachelor's of science degree, or available financial and physical resources. Bachelor's degree programs at academic medical centers or traditional colleges with multiple programs may be able to better support a variety of opportunities for interprofessional collaboration as a result of enhanced resources. Associate's degree 2-year programs were more likely to rely exclusively on laboratory evaluation for patient education competence. Evaluation approaches among the programs varied widely, without clear consensus on preferred or more-effective methods.

The variety of respiratory therapy program types (master's, bachelor's, associate of science, and associate of applied science degrees), academic settings, degree requirements, and length of enrollment time (2 years vs < 2 years) make identification and adoption of uniform instructional methods a noteworthy challenge. Program length has the potential to impact every aspect of a program's structure and processes, including prerequisite requirements, educational resources, curriculum design, the time available for content instruction, and clinical exposure. Ensuring development and evaluation of competence in interprofessional communication and patient education skills is an added challenge, especially for programs with limited faculty resources and a compressed academic timeline for degree completion. Literature related to how respiratory therapy programs at various degree levels teach or evaluate these skills, either individually or collectively, is limited and fragmented.^{19,22,27,34,35}

Most programs included oral communication as part of a patient-encounter module or unit of study on communication and patient assessment. The survey respondents among all program types commented about building interprofessional communication skills, and patient rapport is emphasized throughout the programs. Approximately half of all associate's degree programs required an oral communication prerequisite compared to 69% of bachelor's of science degree programs. A majority of all degree programs assessed oral communication through competency evaluation. Regardless of program type, competence was often assessed through oral presentations and laboratory proficiency testing. These techniques were generally in alignment with the rate of competency evaluation for patient education among all the programs, although there was no evidence that the 2 evaluations were related or conducted simultaneously.

At least 30% of the programs relied entirely on evaluations completed by unpaid preceptors, and bachelor's of science degree programs had the highest rate. The difference in program resources, faculty work load, and curricular strategy may account for these differences. Preceptor evaluation occurs in the clinical setting where most patient education and interprofessional practice occur. However, the practice highlights the need for preceptors to be trained for evaluation of essential competencies.

All program types offered training and evaluation in patient education as part of the curriculum in either classes or laboratory sessions. More than 82% of programs included a unit, module, or entire course for patient education. Bachelor's of science degree programs had designated patient education courses more often than did associate's degree programs (P = .004). The difference among the degree programs that offered patient education courses may be due to program length, the time afforded for additional non-professional coursework, and degree credits required by the conferring institution or state agency. Associate's degree 2-year programs evaluated competence in patient education by laboratory proficiency more often than in other program types. Respondents commented that evaluation of competence in patient education was frequently incorporated into regular, clinical proficiencies. The appropriateness of not having a separate evaluation system for patient education and the impact this approach has on student confidence requires further investigation.

The most frequent method for evaluation was clinical evaluation by preceptors and clinical faculty. Sixty-five percent of bachelor's of science degree respondents indicated that competency in patient education was evaluated by written quizzes and evaluations compared with 80% of the associate's degree <2-year and 47% of associate's degree 2-year programs. Written examinations to assess knowledge may be useful but neglects demonstration of ability or progression of competence in a patient care setting. The pedagogy and value of objective structured clinical examination, clinical simulation, and 360 evaluation has been well established for assessing clinical competence.^6,36–38 Use of simulation-based learning in entry-to-practice respiratory programs was previously found to be widely used but with limited faculty training.¹²

A sizeable difference in the methods used for patient education was noted. The teach-back method was referenced more frequently than the teach-to-goal method or motivational interviewing. Bachelor's of science degree programs were more likely than both associate's degree program types to include motivational interviewing but less likely to address the teach-to-goal method. The rates of inclusion of the teach-back method among the programs was very similar, with no significant statistical differences noted. The similarity among the programs is likely due to the familiarity with the teach-back method, its straightforward approach, and frequency with which it is used in clinical practice.³⁶ Motivational interviewing was addressed much less frequently and may be due to the lack of initial training or exposure to effective techniques, which is also acknowledged in nursing practice.^39,40 Faculty familiarity and regional preferences may also contribute to the technique(s) emphasized in the program.

Fewer than 10% of programs at the associate's degree and bachelor's of science degree levels included telehealth or evaluated telehealth competency. Several comments reflected that telehealth was omitted entirely from the program curriculum. Other programs reported a brief introduction to the topic or a newly implemented module. Methods for telehealth instruction were infrequently listed but included techniques such as workshops and observation in the clinical setting. For some programs, telehealth was incorporated into student rotation but not evaluated. The results reflect a need for increased formal training in telehealth. The literature related to inclusion of telehealth in health professions programs is limited but growing.^{14,17,25,29,41,42} No systematic approach to the delivery of telehealth or evaluation of competence is apparent.²⁵ This gap is also corroborated in nursing education literature.^31,33,43

Use of technology for patient interaction is growing rapidly, which leaves the educational preparation lagging behind clinical experience and employer expectations. In some cases, telehealth experiences are not widely available, which creates difficulty in establishing a suitable teaching environment. The use of clinical simulation is an appropriate and rapidly growing technique for teaching telehealth competencies in an interprofessional setting.^{17,26,31,32,43} The COVID-19 pandemic demonstrated the value of telehealth and highlights the need for strategic program implementation and student exposure during clinical rotations. Roberts et al¹⁶ implemented a tele-ICU rotation during the pandemic when many clinical sites did not allow students on site. The rotation increased student confidence in patient assessment and knowledge related to COVID-19.¹⁶

Every program type acknowledged interprofessional activities in the clinical arena. Evaluation was reported to be conducted overwhelmingly by clinical preceptors, clinical faculty, and academic faculty. Programs of all types reported interprofessional activities outside of clinical rotations. A large proportion of interprofessional experiences being evaluated occurred during clinical simulation, which is reflected in recent literature.^15,44,45 A wide distribution of responses was noted relative to how interprofessional experiences were evaluated. Respondent comments indicated that communication is a frequent area of inter-professional education (IPE) exploration. Most of the IPE experiences were found to be a product of regularly scheduled clinical rotations rather than separate pre-arranged formal IPE activities. Bachelor's of science degree students were more likely to complete a formal interprofessional education program.

Although there were only 5 respondents with master's degree level programs in the survey, this number represented 41.6% of all Commission Accreditation for Respiratory Care accredited master's degree programs. Very strong responses (100% of master's degree programs) that indicated the inclusion of patient education and interprofessional education in addition to clinical activities reflect a forward trajectory for the profession and a heightened focus on patient-centered holistic care. Incorporation of telehealth above that of associate's degree and bachelor's of science degree programs (master's degree 80%, bachelor's of science 35%, associate's degree 25%) may be a consequence of the low number of master's degree programs reported. However, it may be an accurate reflection of how telehealth is prioritized in higher level curricula and the emerging role for master's degree graduates to extend the scope of practice to disease management and telehealth.

Limitations

Several limitations are acknowledged. The survey was original to the investigators. Although pilot tested with faculty from 3 different program types, strict validity and reliability cannot be guaranteed. The response rate was satisfactory, but the results reflect a modest convenience sample of program directors who chose to participate. Because some program directors oversee more than one program, surveys may have been completed for multiple locations, which could slightly increase the response rate. Convenience participation in the survey may disproportionally represent high-quality, well-resourced programs with highly engaged program directors who were motivated to respond. The survey did not address how a program's culture, program type, clinical opportunities, faculty size, or faculty background may influence the elements surveyed or the responses from survey respondents. The number of contact hours allotted to particular competencies was not explored. Respondents' interpretation of terms (although defined in the survey) cannot be guaranteed.

Conclusions

Differences exist among program types for patient education courses and interprofessional activities in respiratory entry-to-practice programs. Telehealth was rarely included or evaluated at any degree level. Programs should evaluate the need for enhanced patient education and telehealth instruction, and consider partnering with clinics and affiliates for increased exposure to telemedicine. More research related to the development and evaluation of essential professional competencies and telehealth in respiratory care programs is needed to establish best practices. Further investigation of the individual elements of this study is warranted.