Clinical Commentary on Kalu et al.

The demand for physiotherapy (PT) services in Canada is increasing by 3.8% per year, and the unemployment rate for physiotherapists in 2014 was 0.3%.² About 700 students graduate from Canadian PT programmes every year,³ and the capacity to increase programme enrolment is limited. Internationally educated physiotherapists (IEPTs) who immigrate to Canada to practise must meet credentialing standards, meet a language requirement, and complete a health systems course and two licensing exams.⁴ Bridging education is a mechanism that assists IEPTs in transferring their PT practice to Canada, but these programmes are limited, costly, and time intensive.

There are five PT bridging programmes in Canada, four of which offer clinical internships. Ontario offers two clinical internships that total 9 weeks, Alberta offers 6 weeks, and the two Quebec programmes offer 8–12 weeks. All PT master’s programmes require a minimum of 1,025 clinical hours, which represents approximately 40% of a 24-month programme. The IEPTs in this study had 338 clinical hours, which reflects about 48% of their 10-month part-time programme hours. Clinical internships help IEPTs consolidate theory, and there really is no replacement for this on-the-job learning. The Canadian Physiotherapy Assessment of Clinical Performance (ACP)⁵ is based on the Essential Competency Profile for Physiotherapists in Canada⁶ and is used to evaluate performance during internship.

Kalu and colleagues¹ set out to study the performance of 61 IEPTs over two internships, as reported by clinical instructors using the ACP. The IEPTs whose scores were examined were required to have a language score of 7.0 (based on the International English Language Testing System) and to pass a full-day admissions test consisting of 100 multiple-choice questions, a 2-hour objective clinical exam, six mini interviews, and an essay. They had also completed 18 weeks of the part-time programme before their first internship and 10 more weeks before their second internship.

Kalu and colleagues¹ collected the midterm and final ACP scores over these two internships, which provided four time points for analysis. They categorized the diversity of scores on the basis of the percentage of items on which learners improved. To understand the performance patterns, they grouped learners’ individual graphs into five categories: 1 (high performance throughout), 2 (highly improved performance in and across internships), 3 (moderately improved performance within and across internships), 4 (moderate performance with low change), and 5 (low performance throughout). The results indicated an overall graduated improvement over the four time points and achievement of high to entry-to-practice competency at the end of the two internships. It is important to note that these findings are similar to those of Mori and colleagues with PT students in Canadian programmes.⁶

Most interesting was the fact that the competencies on which these 61 IEPTs performed highest were communication in the professional relationship, conducting oneself according to legal and ethical guidelines, and respecting the individuality and autonomy of clients. Kalu and colleagues admitted that they had expected the IEPTs’ competence in communication would be low,¹ assuming that they would have difficulty because English was their second language. However, communication is complex and entails far more than the spoken word.

IEPTs are skilled clinicians working to adapt from their source countries to a new health care culture, and they understand the value of the professional, therapeutic relationship and embrace client-centred care. They have taken a risk in immigrating and recognize the need to adapt their skills to the Canadian context. The Ontario Internationally Educated Physical Therapy Bridging Program has identified this need to “integrate their perspectives into the Canadian health care context” in an adult learning environment.⁷ The clinical education component of this programme assigns a clinical practice facilitator to each student to further enrich his or her internship, thereby influencing Kalu and colleagues’ positive findings of communication competency.

Kalu and colleagues¹ provided information on the IEPTs’ diverse backgrounds; most had graduated about 10 years before the study commenced and had come to Canada 1–5 years earlier after practising for 1–5 years. The majority (66%) had immigrated from India and the Philippines. Factors such as the year in which they had graduated, how recently they had practised, and how long they had been in Canada suggest that these individuals were older than students in the master’s programmes. Perhaps this maturity was also reflected in their strong communication competencies – encompassing tone, expression, and body language – in developing the therapeutic relationship.

Kalu and colleagues reported that one major limitation of their study¹ was the inability to report on ACP ratings as a subset of country of origin. Although statistics are a wonderful tool, sometimes it is better to leave a diverse group as just that. I have been working with IEPTs for 7 years, and I suggest that their success is more likely based on their hard work and resilience and has less to do with their country of origin. Of note, the Canadian Alliance of Physiotherapy Regulators website provides a list of schools by country that indicates which schools – not countries – meet its standards on the basis of curricula and supervised clinical practice hours.

A small subset of IEPTs did not achieve final entry-to-practice ratings. The results of Kalu and colleagues’ study are similar to those of Mori and colleagues’ study,^1,3 so a next step could be investigating the correlation of admissions scores to internship ratings, including both bridging and master’s programmes. Admission processes strive to identify individuals with character traits indicative of their capacity to develop therapeutic relationships. How can an admissions process effectively identify individuals who are less able to engage in a professional, therapeutic relationship?

In conclusion, Kalu and colleagues demonstrated that IEPTs improve under the supervision of a clinical instructor and show strength in the competencies of communication and professionalism.¹ It is clear that clinical internships are essential to graduate strong and competent physiotherapists, and all physiotherapists should play a role in providing these critical learning opportunities. Bridging programmes that offer clinical internships enable physiotherapists to transfer their skills across cultures. Facilitating success for our internationally trained colleagues is essential for the growth of the PT profession. There are many opportunities and emerging roles for physiotherapists in this health care environment – the profession must ensure that we have the personnel and diversity to fill these roles.