Clinical Performance Scores of Internationally Educated Physical Therapists during Clinical Education in a Bridging Programme

Abstract

Purpose: We describe the numerical ratings assigned by clinical instructors to the performance of internationally educated physical therapists (IEPTs) during their clinical internships while enrolled in a bridging programme. Method: We conducted a secondary analysis of the quantitative data for IEPT learners attending the Ontario Internationally Educated Physical Therapist Bridging Program using the Canadian Physiotherapy Assessment of Clinical Performance (ACP) tool. We extracted the scores from each IEPT’s ACP form at the midterm and final evaluations for two internships and conducted a descriptive analysis. Results: We obtained 318 data sets for 61 IEPTs. By the final point of the second internship, (1) items about communication pertaining to ethical professional relationships, conducting oneself within legal and ethical requirements, and respecting the individuality and autonomy of the client had high mean ratings; (2) most items rated achieved advanced intermediate performance and many indicated entry-level performance; and (3) most IEPTs (84%) either had high scores throughout or improved from lower scores to at least advanced intermediate performance. Conclusions: Items relating to professional conduct and effective communication in professional relationships were relatively high among the IEPTs. By the end of the second internship, most IEPTs in this bridging programme had improved their clinical performance toward or up to the entry-level standard for Canadian physiotherapists.

The success rate of internationally educated physical therapists (IEPTs) in Canada in both components of the Physiotherapy Competency Examination (PCE) – the Written Component and Clinical Component – is well below the national average for Canadian-trained first-time exam takers.¹ Low performance during the assessment of professional competencies is often the major reason why IEPTs fail the professional entrance exam of the country to which they have emigrated.^2–4 Canadian-trained physiotherapists acquire and develop professional competencies, to a significant degree, during their clinical internships in entry-to-practice education. It stands to reason that IEPTs have developed competencies and expertise specific to their source country of physiotherapy practice, and these competencies and expertise may vary from the competencies specific to the Canadian practice context. Thus, these deficiencies may affect their performance on the PCE.

Bridging programmes, also known as bridge training programmes, are occupation-specific programmes designed to help immigrants achieve success in the certification or licensure process needed to enter the labour market in their new country. The Ontario Internationally Educated Physical Therapist Bridging (OIEPB) Program is an educational bridging programme that offers both a refresher on theory and practice knowledge related to the Canadian context and two clinical internships for physiotherapists trained outside Canada. Its stated goal is “to enhance the IEPTs’ professional and clinical competencies to qualify for practice as an autonomous practitioner within the Canadian health care system.”⁵

The IEPTs admitted to the OIEPB Program are referred to as learners. As a mandatory component of the bridging programme, learners are expected to complete two full-time clinical internships of 4 and 5 weeks, respectively. Clinical Internship I provides learners with an opportunity to solidify fundamental clinical skills with hands-on practice and integration into a Canadian physiotherapy practice setting under the guidance of registered physiotherapists.⁵ Clinical Internship II gives learners the opportunity to consolidate physiotherapy clinical knowledge, skills, and professional behaviours required for autonomous practice in Canada.⁵ Learners select clinical internships in areas of practice that help meet their identified learning needs and build their professional network.⁵ For both internships, the supervising clinical instructor (CI) assesses the learners’ performance using the Canadian Physiotherapy Assessment of Clinical Performance (ACP), a competency-based assessment tool used in the majority of the entry-to-practice physiotherapy education programmes across Canada.

The ACP is a valid, reliable, and practical tool for assessing the performance of Canadian-educated students in physiotherapy clinical education experiences in Canada.^6–8 It is based on the roles and key competencies listed in the 2009 Essential Competency Profile for Physiotherapists in Canada (ECP).⁹ The ECP is a national document that describes the essential competencies (knowledge, skills, and attitudes) required by physiotherapists at entry to practice and throughout their physiotherapy career in Canada.⁹ It identifies seven roles of Canadian physiotherapists: expert, communicator, collaborator, manager, advocate, scholarly practitioner, and professional.⁹

Mori and colleagues⁸ demonstrated that the ACP had strong internal consistency; Cronbach’s α values for each role ranged from 0.94 to 0.99. The ACP was also shown to have good criterion validity because there were significant correlations (rs = 0.51–0.84) between its aligned items and the previously used tool (the Physical Therapist–Clinical Performance Instrument, or PT–CPI)¹⁰ and significant differences in levels of performance among the senior, intermediate, and junior physiotherapy students. In addition, Mori and colleagues⁸ demonstrated that the ACP was a practical measure: the majority of CIs indicated scores of agree or strongly agree for a series of six questions about the ACP’s feasibility and satisfaction.

It stands to reason that exposing IEPTs to the practice culture of their new country has the potential to increase their success rate on the licensure exams of their profession in the new country.^3,11 Preliminary evidence has shown that approximately 80% of IEPTs who attended the OIEBP programme passed both the written and the clinical components of the PCE.^12,13 We are not aware of any studies that have examined how IEPTs perform during clinical internships with respect to entry-level criteria for the profession in their new country. We had an opportunity to analyze the performance of IEPTs who were completing clinical placements in Canada in preparation for future professional practice. The purpose of this study was to describe the numerical ratings assigned by CIs to the performance of IEPTs during clinical internships while enrolled in a bridging programme.

Methods

This was a secondary data analysis of the ratings on ACP items for learners in two successive cohorts participating in a bridging programme at a university in Canada. The ACP instruments were originally completed by the CIs supervising the learners for their two clinical internships. The CIs had assessed the learners’ clinical performance using the ACP at both the midterm and the final points of each internship. The completed forms were submitted to the Academic Coordinator of Clinical Education of the bridging programme. Each learner had four potential datasets: a midterm and a final evaluation for both internships. At the time of enrolment in the bridging programme, all learners had provided informed consent to allow the data to be used for research and evaluation purposes. In addition, ethical approval was obtained from the Queen’s University General Research Ethics Board and University of Toronto Health Science Research Ethics Board.

Participants and sampling decision

Participants were learners who had completed all components of the bridging programme. On applying for the bridging programme, learners had provided demographic information: age, gender, country of physiotherapy training, length of time in Canada, immigration status, proficiency in English, physiotherapy experience outside Canada, years since graduation from entry-level physiotherapy degree, and volunteer or work experience in the Canadian health care system in roles other than a physiotherapist. For the present analysis, the participants were all the learners registered in two cohorts of the bridging programme (N = 62). Scores from four points in time (midterm and final evaluations for both Clinical Internships I and II) were extracted for each learner.

ACP tool

The ACP tool has numeric scoring and open-ended comment sections. A student or learner is assessed on 21 items across seven roles; these items are rated based on the key and enabling competencies described under each role in the ECP. Each item is rated on a scale from 1 to 10, with anchor descriptors modified from the PT-CPI: version 2006.¹⁰ The anchor descriptors, which are detailed in the ACP, are beginner, advanced beginner, intermediate, advanced intermediate, entry-level, and with distinction; they correspond to levels 1, 3, 5, 7, 9 and 10, respectively. Levels 2, 4, 6 and 8 fall between two anchors and have no explicit description.

An entry-level physiotherapist is expected to perform at level 9 in all the key competencies.⁸ Each item on the ACP is rated twice, at both the midterm and the final evaluation during each internship. In addition to the rating scale, CIs have the option of indicating whether there are significant concerns with a learner’s performance in any of the roles. Comment boxes are open-ended sections placed at the midterm and final point of the ACP roles. For the present study, we extracted data only from the numerical scoring sections. We also recorded instances in which a CI checked any of the “significant concern” boxes.

Data analysis

All the data were compiled into a spreadsheet. When learners had more than one CI, with separate ACP records, we considered the records separately for the item-level analysis; thus, we had more records than there were learners. We used descriptive analysis to describe the patterns of the learners’ midterm and final scores for both internships (Clinical Internships I and II). Quantitative data were analyzed using Microsoft Excel 2016 (Microsoft Corporation, Redmond, WA). Baseline characteristics for the IEPTs were summarized using frequencies and percentages.

We examined the ACP score data for normality using skewness and kurtosis. We summarized the score data using frequency counts, including calculating percentages for how many scores achieved at least the benchmarks of advanced intermediate and entry-level. We plotted a progression graph of the learners’ mean midterm and final scores.

Role scores were calculated when multiple items were conceptually linked within a defined role, as described by Mori and colleagues.⁸ Role scores were calculated as the mean of all available scores for items within that role.

To describe learners’ individual performance, we plotted progression graphs of their ACP scores. For learners who had two CIs for an internship, we averaged the scores before plotting them. The progression graphs were used to illustrate the improvement of individual learners and to complement the analysis of the group mean scores. Because scores for most of the items were not normally distributed, the process of creating individual progression graphs and subsequently grouping them into patterns was intended to enable better understanding of performance profiles. We grouped the learners’ individual graphs into five categories: (1) high performance throughout, (2) highly improved performance within and across internships, (3) moderately improved performance within and across internships, (4) moderate performance with low change, and (5) low performance throughout.

Our initial categorization was based on visual impression; we subsequently developed explicit criteria in order to be rigorous and consistent. To be in Category 1, a learner must have achieved a score of 7 or more (advanced intermediate) in 12 or more of the ACP items at all points of both internships and must also have had a score of 9 (entry-level) or 10 (with distinction) in 17 or more of the final point ratings in their best internship. This category represented IEPTs who were performing at or near entry level. To be in Category 2, a learner must have shown an obvious improvement in at least 70% of the items in at least one internship; this improvement was from a low or moderate score at midpoint to a score of 9 at the final point. This category represented IEPTs who were not performing near entry level initially but who had improved.

To be in Category 3, a learner must have shown an obvious improvement, similar to what was described earlier for Category 2, except that the final point score had to be at least 7 (advanced intermediate) rather than 9. To be in Category 4, a learner must have shown an improvement in at least 50% of the items on the ACP, with at least 80% of the final term rating at 5 or 6. To be in Category 5, a learner must have had 80% of the items rated at 5 or less. The learners in Categories 4 and 5 were those who appeared to have had challenges achieving performance near entry-level during the course of their internships.

Results

We obtained data sets for 61 of the 62 learners in the two cohorts. The learners completed their clinical internships in the following areas of practice: musculoskeletal (n = 37; 30.3%), cardiopulmonary (n = 30; 24.6%), neurology (n = 28; 23.0%), geriatrics (n = 17; 13.9%), general practice (n = 6; 4.9%), oncology (n = 3; 2.5%), and paediatrics (n = 1; 0.8%). Demographic and other data are shown in Table 1. Because many learners had more than one CI for one or both internships, we had 79 data sets for Clinical Internship I and 80 data sets for Clinical Internship II.

Table 1.

Demographic Characteristics of the IEPTs Included in Our Analysis (n = 61)

Characteristic	No. (%)
Gender
Female	35 (57)
Male	26 (43)
Country of PT entry-level training
India	26 (43)
Philippines	14 (23)
Iran	4 (7)
Poland	3 (5)
Brazil	2 (3)
United States	2 (3)
Columbia	2 (3)
Other*	8 (13)
Year graduated from an entry level PT programme
Before 2000	10 (16)
2000–2005	19 (32)
2006–2010	24 (39)
After 2010	8 (13)
PT practical experience outside Canada, y
<1	10 (16)
1–5	31 (51)
>5	20 (33)
Length of time in Canada, y
<1	12 (20)
1–5	31 (51)
>5	18 (29)
Not practising after PT graduation, y
<3	28 (46)
3–5	15 (25)
>5	18 (29)
Experience in the Canadian health care system
Yes	41 (67)
No	20 (33)

^*Includes Chile, Ecuador, Egypt, Mauritius, Portugal, Ghana, Nigeria, and Hong Kong.

IEPT = internationally educated physical therapist; PT = physiotherapy.

Item levels

Descriptive statistics of the ACP scores at the midterms of Clinical Internship I and II and the final point of Clinical Internship I are presented in Appendices 1–3. The final point of the ACP scores of clinical internship II are presented in Table 2. The data were normally distributed at the final evaluation for Clinical Internship II for one item – “analyzes assessment findings” (1.3). All other items were negatively skewed, reflecting the clustering of ratings near the high end of the scale. In particular, all items in the Manager role, as well as items about conducting oneself within legal and ethical requirements (7.1) and respecting the individuality and autonomy of the client (7.2), were highly negatively skewed, indicating that the left tail was longer, with a greater concentration of scores at the high end of the distribution. The item about managing and supervising support personnel (4.2) had missing data in 30% of the records. This finding is unsurprising because this item is the only one for which the ACP instructions permit CIs to deem it as “not observed” when a learner is not interacting with any physiotherapy support personnel.

Table 2.

ACP Cl Final Point Item-Level Descriptive Statistics for Clinical Internship II

	Expert								Communicator			Collaborator		Manager			Advocate	Scholarly practitioner	Professional
Statistic	1.1	1.2	1.3	1.4	1.5	1.6	1.7	1.8	2.1	2.2	2.3	3.1	3.2	4.1	4.2	4.3	5.1	6.1	7.1	7.2	7.3
Mean	7.1	7.0	6.9	6.7	7.0	7.1	6.8	6.4	7.6	7.2	6.5	7.2	6.8	7.1	7.0	7.2	6.8	7.1	8.0	8.1	6.8
SD	1.9	1.9	1.9	1.9	1.8	2.0	2.0	2.3	1.9	1.9	2.3	2.1	2.1	1.9	2.0	2.1	2.2	1.9	1.8	1.7	2.4
Median	7	8	7	7	7	7.5	7	7	8	7	7	8	7	8	7	8	7	8	9	9	7
Mode	9	8	9	9	9	9	9	9	9	9	9	9	9	8	8	9	9	9	9	9	9
Maximum	9	9	10	9	9	10	9	9	10	10	10	10	10	9	10	10	10	10	10	10	10
Minimum	3	2	3	2	3	3	2	1	3	3	1	2	1	2	1	2	2	2	4	4	1
FC1	0	0	0	0	0	0	0	1	0	0	1	0	2	0	2	0	0	0	0	0	2
FC2	0	2	0	2	0	0	5	5	0	0	6	2	0	2	1	3	4	2	0	0	2
FC3	6	4	6	4	6	7	2	6	2	4	4	4	0	4	0	4	4	2	0	0	7
FC4	2	5	2	6	2	2	2	4	5	2	4	4	12	2	4	4	7	0	6	4	4
FC5	7	4	13	10	7	9	10	8	6	9	7	5	7	10	4	4	6	16	7	5	9
FC6	10	9	8	9	12	8	9	9	8	7	12	10	11	0	6	4	8	9	2	4	5
FC7	16	13	13	16	13	12	15	11	13	21	10	10	12	19	13	13	14	8	8	10	12
FC8	9	20	13	10	16	16	13	13	8	6	11	16	11	21	15	18	12	14	4	4	8
FC9	26	19	18	19	20	18	20	18	24	23	16	19	18	18	7	24	17	21	39	39	23
FC10	0	0	3	0	0	4	0	0	10	4	3	6	3	0	4	2	4	4	10	10	4
FC missing,* no.	4	4	4	4	4	4	4	5	4	4	5	4	4	4	24	4	4	4	4	4	4
FC missing,* %	5	5	5	5	5	5	5	6	5	5	6	5	5	5	30	5	5	5	5	5	5
Skewness†	−0.73	−0.97	−0.44	−0.52	−0.73	−0.61	−0.84	−0.62	−0.64	−0.56	−0.56	−0.77	−0.55	−1.07	−1.04	−1.09	−0.57	−0.58	−1.07	−1.12	−0.64
Kurtosis‡	−0.38	0.64	−0.76	−0.64	−0.32	−0.55	0.01	−0.72	−0.57	−0.39	−0.62	−0.17	−0.20	0.40	1.30	0.31	−0.64	−0.35	−0.11	0.27	−0.65
Responses, no.	76	76	76	76	76	78	76	75	76	76	74	76	76	76	56	76	76	76	76	76	76
Responses of 9 and 10, %	33	25	28	25	26	29	26	24	45	36	26	33	28	24	20	34	28	33	64	64	36
Responses of 7, 8, 9, or 10, %	67	68	62	59	64	66	63	56	72	71	54	67	58	76	70	75	62	62	80	83	62

^*Represents scores that are missing or where an item was deemed “not observed.”

^†Acceptable limits = ±0.5; moderately skewed = −1 to −0.5 or +0.5 to +1; highly skewed = < −1 or > + 1.

^‡Kurtosis: acceptable limits = ± 2.¹⁴

ACP = Canadian Physiotherapy Assessment of Clinical Performance; Cl = clinical instructor; FC = frequency count, for each anchor.

The modal score was at entry level for 18 of 21 items. Notably, the items about communication pertaining to ethical professional relationships (2.1), conducting oneself within legal and ethical requirements (7.1), and respecting the individuality and autonomy of the client (7.2) had 45%, 64%, and 64% of learners, respectively, at entry-level or with-distinction performance. The three items with a modal score lower than entry level concerned collecting assessment data relevant to a client’s needs and physiotherapy practice (1.2), managing individual practice effectively (4.1), and supervising support personnel (4.2). The bottom row of Table 2 shows that more than half of the ratings on all 21 items was 7 or more for learners at the final point in Clinical Internship II.

Role scores

Descriptive statistics of the ACP mean role scores at the midterm and final points, for both Clinical Internships I and II, are presented in Table 3. Overall mean role scores for Clinical Internship I were normally distributed across learners for the communicator, collaborator, and scholarly practitioner roles at both midterm and final points. Overall role scores for expert, manager, and advocate showed moderately positive skew at midterm, although they were normally distributed at the final point. The role score for professional was normally distributed at midterm and showed moderately negative skew at the final point. The overall mean role scores for Clinical Internship II were normally distributed at midterm for all roles and only for advocate at the final point. The scores for other roles showed negative skew at final: moderately skewed for expert, communicator, collaborator, and scholarly practitioner and highly skewed for manager and professional. There were increases in the overall mean scores in each of the roles from midpoint to final point.

Table 3.

ACP by Cl Role Score: Descriptive Statistics for All Data and for Both Internships

	Midpoint							Final point
Statistics	Expert	Communicator	Dollaborato	Manager	Advocate	Scholarly practitioner	Professional	Expert	Communicator	Collaborator	Manager	Advocate	Scholarly practitioner	Professional
No. of items	8	3	2	3	1	1	3	8	3	2	3	1	1	3
Clinical Internship 1
Overall mean	3.7	4.7	4.2	3.9	3.3	4.5	5.5	5.5	6.0	5.8	5.4	4.7	5.7	6.5
Overall SD	2.4	2.5	2.7	2.5	2.4	2.5	2.9	2.3	2.3	2.4	2.5	2.66	2.3	2.7
Overall max	9	9	10	9	9	10	10	9	9	9	9	9	10	10
Overall min	1	1	1	1	1	1	1	1	1	1	1	1	1	1
Overall missing values, no.	14	4	4	32	2	2	6	0	2	0	15	0	0	0
Overall missing values, %	2	2	3	16	3	3	3	0	1	0	7	0	0	0
Overall skewness*	0.67	0.26	0.41	0.58	0.85	0.45	−0.24	−0.18	−0.44	−0.36	−0.34	0.15	0.16	−0.81
Overall kurtosis†	−0.67	−1.12	−0.95	−0.78	−0.37	−0.84	−1.23	−0.84	−0.57	−0.78	−0.87	−1.20	−0.93	−0.57
Clinical Internship II
Overall mean	5.0	5.9	5.2	5.1	5.0	5.6	6.2	6.9	7.1	7.0	7.1	6.8	7.1	7.6
Overall SD	2.2	2.4	2.4	2.3	2.4	2.4	2.4	2.0	2.1	2.1	2.0	2.2	1.9	2.1
Overall max	10	10	9	10	9	10	10	10	10	10	10	10	10	10
Overall min	1	1	1	1	1	1	1	1	1	1	1	2	2	1
Overall missing values, no.	31	12	8	39	4	4	12	33	13	8	32	4	4	12
Overall missing values, %	5	5	5	19	5	5	5	5	6	5	15	5	5	5
Overall skewness*	−0.07	−0.27	−0.02	−0.06	−0.22	−0.45	−0.35	−0.71	−0.68	−0.65	−1.07	−0.57	−0.58	−1.04
Overall kurtosist	−0.76	−0.74	−1.03	−0.90	−0.96	−0.58	−0.93	−0.38	−0.25	0.26	0.55	−0.64	−0.35	0.18

^*Acceptable limits = ±0.5; moderately skewed = -1 to −0.5 or +0.5 to +1; highly skewed = < −1 or > +1.

^†Acceptable limits = ±2.¹⁴

ACP = Canadian Physiotherapy Assessment of Clinical Performance; Cl = clinical instructor.

No significant concerns were reported by CIs about any of the learners during their internships.

Overall pattern of the scores

The pattern of the overall mean ACP scores for the midterm and final evaluations of the two clinical internships is presented in Figure 1. There were improvements in all the mean scores in each role from midterm to final, but the improvement was specific to each internship and not continuous across the two internships: that is, learners’ mean midterm scores in Clinical Internship II were lower than their mean final scores in Clinical Internship I. Communication pertaining to ethical professional relationship (2.1), conducting oneself within legal and ethical requirements (7.1), and respecting the individuality and autonomy of clients (7.2) had higher scores than other items, and they showed less improvement across all four time points.

Figure 1.

ACP mean scores at midterm and final point by internship.

ACP = Canadian Physiotherapy Assessment of Clinical Performance.

Individual patterns of the scores

We graphed 57 of the 61 learners’ complete data sets. The remaining 4 had a missing data set for one time point. Five (8.8%) of the learners’ graphs were classified as Category 1 (high performance throughout), and 18 (31.6%) were classified as Category 2 (highly improved). The greatest number of graphs (n = 25; 43.9%) were classified as Category 3 (moderately improved), and 7 (12.3%) were classified as Category 4 (moderate throughout). Only 2 (3.5%) individuals’ graphs were classified as Category 5 (low performance). An example of each of these graphs is shown in Figure 2.

Figure 2.

Examples of one graph in each of the five categories.

From top to bottom: Category 1 = high performance throughout (n = 5); Category 2 = highly improved (n = 18); Category 3 = moderately improved (n = 25); Category 4 = moderate throughout (n = 7); Category 5 = low performance (n = 2).

Discussion

We had near-complete data for the performance of the bridging programme’s two cohorts of learners in the clinical internships. The areas of practice for the internships in our study reflect the practice patterns of Canadian-trained physiotherapists,^2,8 specifically in Ontario,¹⁵ Alberta,¹⁶ and Saskatchewan.¹⁷ It is not surprising that physiotherapists trained in India were the highest subset of IEPTs by country because India has been the most common country of physiotherapy training among IEPTs applying for credentialing in Canada every year from 1997 to date.^1,4

Most learners achieved at least advanced intermediate performance on all items by the end of the second internship; these results correspond with the rating for the intermediate level reported for physiotherapy students in Canadian programmes.⁸ Moreover, a substantial proportion of ratings were at entry level or with distinction. The individual progression graphs and categorization showed that the majority of these IEPTs (48 of 57; 84.2%) were either near entry level or showed improved performance toward entry level over the course of the two short internships. The finding of improvement by almost all IEPTs implies that Canadian physiotherapy programmes would do well to develop more clinical internship opportunities for IEPTs. It also seems that clinical internships promote IEPTs’ ability to perform closer to the entry-level standard for Canadian physiotherapy practice than they could before starting the internships. Further research with a larger data set should explore the associations between ACP scores and some demographic variables, such as country of entry-level physiotherapy programme, years of entry-level physiotherapy education graduation, and years of practice of physiotherapy outside Canada. In addition, there is value in considering the findings of our study in relation to the findings reported in the literature for the clinical performance of students in Canadian entry-level-to-practice physiotherapy programmes and what the implications may be for the integration of the IEPTs into the Canadian workforce.

Our findings for the distribution of scores were generally consistent with those reported in the original studies about the ACP. Consistent with the study by Mori and colleagues,⁸ the midterm scores were normally distributed in all items in Clinical Internship II. In contrast with Mori and colleagues,⁸ however, the final evaluation scores were not normally distributed for any items in Clinical Internship II. All the items were moderately or highly negatively skewed, meaning that many learners were rated at or near entry-level performance at the end of Clinical Internship II.

The high percentage of missing values for Item 4.2 was not surprising. As noted earlier, it is the one item on the ACP that may be left unscored if it does not apply because working with support personnel is not practised in all settings. Mori and colleagues⁸ reported a similar finding, and both Norman and Booth¹⁵ and Proctor and colleagues¹⁷ reported a high percentage of missing values for the analogous item on the PT–CPI.

The percentage of learners was higher at or near the entry-level score for almost all items at the final point of both internships compared with the midpoint; this indicates general improvement in clinical performance during the internships. The pattern of the mean scores we found was similar to the pattern reported for junior and intermediate students in Canadian physiotherapy education programmes.⁸ Although this may indicate that the learners were not able to perform at entry level, the caseload associated with the descriptors in the ACP may have been the determining factor as to why many learners achieved scores at or near advanced intermediate. Specifically, the description of advanced intermediate includes the maintenance of approximately 75% of a full-time physiotherapist’s caseload. Consequently, CIs who rated the learners strictly according to the ACP instructions would have considered scores of 5–7 to be the appropriate maximum. Thus, the learners were performing at the expected level in practice contexts that may have been highly novel to them.

This novelty includes not only the local details of the practice site but also the wider context of potentially large differences in scope of practice, professional expectations, and health care culture compared with the context in the learners’ country of physiotherapy education. Moreover, the learners generally showed improvement from midterm to final evaluations. Because the internships are short, it is possible that ongoing improvement in entry-level scores could have been achieved by most learners across all criteria if the internships had been a few weeks longer.

The progression graphs for individual learners showed that the majority had either highly or moderately improved performance in their clinical internships, which suggests that most learners improved throughout their internships. It also suggests that clinical internships have a positive influence on clinical performance by these IEPTs, making it possible for many of them to achieve near entry-level performance.

Among the learners, all the mean ACP scores at the midpoint for Clinical Internship II were higher than the corresponding scores at the midpoint of Clinical Internship I. This finding could imply that there was a carry-over of skills developed from the first internship to the second. Nevertheless, we can see that the mean scores at the midpoint of Clinical Internship II were almost all lower than the scores at the final point of Clinical Internship I; this is understandable because the learners needed to familiarize themselves with the new area of practice and new clinical setting of the second internship. Moreover, learners are encouraged to select the clinical internship area of practice and setting that they have identified as their greatest learning need and, therefore, those in which they wish to gain experience while being embedded in a supported learning environment.

One might expect, based on the evidence, that the communicator items would show relatively low ACP scores because of the evidence that effective communication skills are integral for IEHPs to successfully integrate into their new country.^11,18–20 For the learners in this study, one communicator item and two professional items demonstrated better mean scores than items in other roles; this may reflect the admission requirement of high language proficiency scores on standardized tests. This finding supports the idea that factors beyond communication present challenges for IEPTs, but it does not rule out the possibility some IEHPs lack the nuanced communication skills specific to Canadian health care culture, thereby limiting their ability to demonstrate entry-level performance in other roles.^11,21 It is of interest that this study indicates that communication may not be the major problem for most IEPTs in an area of Canada in which English is the dominant language. This finding implies that IEPTs who succeed at the credentialing process in Canada, a necessary prerequisite for entry into the bridging programme, have largely adequate basic language skills. Factors that may pose a greater challenge are unfamiliarity with Canadian health care culture, the time needed to adjust to a new environment, or other factors, although all these require further investigation.

No CIs checked the “significant concerns” box for any of the learners. However, a small proportion of the learners did not achieve the ACP ratings that one would expect from an entry-level physiotherapist, even in the context of a novel practice setting with a reduced caseload. Perhaps the CIs did not feel the need to flag areas below the expected standard because there was open, targeted, and direct communication with the OIEPB Program throughout the internships.¹⁵ Although these learners form a small subset, their low ratings warrant further investigation; this was beyond the scope of this study. In addition, the OIEPB Program may want to examine its admission criteria to determine whether they can identify prospective learners who would be unlikely to achieve entry-level performance for a physiotherapist in Canada.

The strength of this study is that it is the only report on ACP scores beyond those determined by the initial developers.^6–8 Nevertheless, there is one major limitation. Some of the demographic data points (age, number of years of physiotherapy practice outside Canada) about the learners were obtained in a categorically variable format from the original source, and there was overlap between categories; therefore, we further merged the overlapping categories. Consequently, we were unable to run an inferential analysis to determine whether country of physiotherapy education or any other demographic variable had an association with the ACP scores or score patterns. It is possible that some Canadian standards of physiotherapy practice may pose a particular challenge for IEPTs from some countries.

Conclusion

Clinical internships in a bridging programme appear to promote the ability of IEPTs to perform at, or close to, the entry-level standard for Canadian physiotherapy practice, as judged by the ACP scores rated by their CIs. The IEPTs’ mean scores were highest on three items: (1) develops, builds, and maintains rapport, trust, and ethical professional relationships through effective communication (communicator role); (2) conducts self within legal and ethical requirements (professional role); and (3) respects the individuality and autonomy of clients (professional role). Among individual IEPTs, a large majority (84.2%) showed either entry-level performance almost immediately or improvement in performance toward entry level across the two internships. The substantial improvement in the IEPTs’ clinical performance indicates that clinical internships are an effective approach to developing and demonstrating the essential competencies required for entry-level practice in Canada.

Key Messages

What is already known on this topic

The Canadian Physiotherapy Assessment of Clinical Performance (ACP) developed by Mori and colleagues^6–8 is now used throughout Canada to assess performance in clinical education of students in Canadian physiotherapy programmes.

What this study adds

This is the only study that describes the pattern of ACP scores during clinical education among internationally educated physical therapists (IEPTs) in a bridging programme. Most IEPTs showed a progressive improvement in their clinical performance. One item in the communicator role and two in the professional role were, on average, the most highly rated items, indicating that communication skills pertaining to professional ethical relationships are relative strengths for IEPTs in a bridge training programme.

Appendix 1: ACP Cl Final Point Item-Level Descriptive Statistics for Clinical Internship I

	Expert role								Communicator			Collaborator		Manager			Advocate	Scholarly practitioner	Professional
Statistic	1.1	1.2	1.3	1.4	1.5	1.6	1.7	1.8	2.1	2.2	2.3	3.1	3.2	4.1	4.2	4.3	5.1	6.1	7.1	7.2	7.3
Mean	6.0	5.7	5.5	5.4	4.9	5.7	5.4	5.3	6.9	6.0	5.1	5.8	5.7	5.4	4.6	6.1	4.7	5.7	7.1	7.5	4.8
SD	2.2	2.3	2.3	2.3	2.4	2.3	2.3	2.3	2.1	2.2	2.3	2.3	2.5	2.1	2.7	2.4	2.6	2.3	2.2	2.1	3.0
Median	6	6	5	5	5	6	5	5	7	6	5	6	6	6	5	6	5	5	7	9	5
Mode	5,7	5	5	5	5	5	4	7	9	6	5	5,7	7	6	1	9	5	5	9	9	1
Maximum	9	9	9	9	9	9	9	9	9	9	9	9	9	9	9	9	9	10	9	10	9
Minimum	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1
FC1	4	4	4	4	7	7	5	5	2	2	8	4	8	4	16	6	12	2	2	2	23
FC2	0	5	5	5	8	2	4	6	2	4	5	5	0	5	0	4	9	2	2	2	0
FC3	6	8	9	10	8	4	6	8	2	6	7	2	9	4	6	5	12	12	4	2	8
FC4	9	4	6	8	9	4	14	10	0	5	5	10	9	13	9	4	0	10	3	0	0
FC5	15	18	22	14	18	18	13	14	16	13	19	15	12	13	7	6	18	16	4	8	19
FC6	10	9	7	12	5	17	6	7	7	19	12	8	3	14	6	15	6	9	6	3	0
FC7	15	9	2	6	7	9	13	15	17	8	7	15	18	12	10	15	6	8	20	17	9
FC8	6	11	15	11	10	4	11	4	4	6	11	6	6	7	5	8	7	4	4	4	6
FC9	14	11	9	9	5	14	7	10	29	16	3	14	14	7	5	16	9	13	34	36	14
FC10	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	3	0	5	0
FC missing,* no.	0	0	0	0	2	0	0	0	0	0	2	0	0	0	15	0	0	0	0	0	0
FC missing,* %	0	0	0	0	3	0	0	0	0	0	3	0	0	0	19	0	0	0	0	0	0
Skewness†	−0.35	−0.26	−0.07	−0.10	0.05	−0.40	−0.20	−0.09	−0.86	−0.30	−0.26	−0.35	−0.34	−0.23	−0.02	−0.64	0.15	0.16	−1.15	−1.35	0.01
Kurtosis‡	−0.44	−0.86	−0.95	−0.94	−0.97	−0.34	−0.86	−0.90	0.33	−0.59	−0.77	−0.64	−0.90	−0.54	−1.23	−0.53	−1.20	−0.93	0.63	1.48	−1.44
No. of responses	79	79	79	79	77	79	79	79	79	79	77	79	79	79	64	79	79	79	79	79	79
Responses of 9 & 10,%	18	14	11	11	6	18	9	13	37	20	4	18	18	9	6	20	11	20%	43%	52%	18%

^*Represents scores that are missing or where an item was deemed “not observed.”

^†Acceptable limits = ±0.5; moderately skewed = -1 to -0.5 or 0.5 to 1; highly skewed = < -1 or > 1.

^‡Acceptable limits = ±2.¹⁴

ACP = Canadian Physiotherapy Assessment of Clinical Performance; Cl = clinical instructor; FC = frequency count, for each anchor.

Appendix 2: ACP Cl Midpoint Item-Level Descriptive Statistics for Clinical Internship I

	Expert role								Communicator			Collaborator		Manager			Advocate	Scholarly practitioner	Professional
Statistic	1.1	1.2	1.3	1.4	1.5	1.6	1.7	1.8	2.1	2.2	2.3	3.1	3.2	4.1	4.2	4.3	5.1	6.1	7.1	7.2	7.3
Mean	3.9	3.6	3.6	3.5	4.3	4.0	3.6	3.4	5.3	4.4	4.5	4.2	4.2	3.8	3.3	4.3	3.3	4.5	6.0	6.6	3.8
SD	2.3	2.2	2.4	2.4	2.6	2.4	2.3	2.4	2.5	2.4	2.4	2.6	2.7	2.4	2.5	2.5	2.4	2.5	2.5	2.3	2.9
Median	3	3	3	3	4	3	3	3	5	4	4	4	4	3	2	3	2	4	6	7	3
Mode	2	3	2	1	2	3	1	1	5	3	2	1	1	3	1	3	1	5	9	9	1
Maximum	9	9	9	9	9	9	9	9	9	9	9	10	10	9	9	9	9	10	10	10	9
Minimum	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1
FC1	7	14	17	21	11	14	18	25	6	6	8	19	21	14	19	11	27	9	4	2	32
FC2	21	13	17	10	14	9	16	8	6	11	14	5	4	13	7	9	12	11	6	6	0
FC3	15	22	15	18	12	17	11	14	10	21	12	11	13	16	5	19	8	15	5	0	8
FC4	4	2	6	6	9	6	6	6	8	5	7	11	2	10	2	2	6	4	4	4	2
FC5	12	8	2	2	9	13	6	8	13	12	13	7	15	6	10	10	10	18	14	17	19
FC6	6	6	2	6	4	4	12	8	6	4	7	6	2	6	2	6	4	0	7	3	2
FC7	6	6	10	8	5	6	2	2	8	4	4	10	12	2	0	12	2	8	11	12	0
FC8	0	5	7	3	8	4	3	0	10	8	9	0	0	7	3	2	5	4	6	10	2
FC9	6	1	1	3	7	4	3	6	10	6	5	7	7	3	3	6	3	7	19	22	12
FC10	0	0	0	0	0	0	0	0	0	0	0	1	1	0	0	0	0	1	1	1	0
FC missing,* no.	2	2	2	2	0	2	2	2	2	2	0	2	2	2	28	2	2	2	2	2	2
FC missing,* %	3	3	3	3	0	3	3	3	3	3	0	3	3	3	35	3	3	3	3	3	3
Skewness†	0.76	0.66	0.72	0.74	0.45	0.53	0.68	0.85	−0.06	0.52	0.34	0.43	0.38	0.72	0.86	0.34	0.85	0.45	−0.39	−0.66	0.059
Kurtosis‡	−0.34	−0.65	−0.88	−0.62	−1.07	−0.66	−0.57	−0.13	−1.14	−0.89	−1.03	−0.87	−1.00	−0.49	−0.27	−1.05	−0.37	−0.84	−0.92	−0.46	−0.94
No. of responses	77	77	77	77	79	77	77	77	77	77	79	77	77	77	51	77	77	77	77	77	77
Responses of 9 & 10, %	8	1	1	4	9	5	4	8	13	8	6	10	10	4	6	8	4	10	26	30	16

^*Represents scores that are missing or where an item was deemed “not observed.”

^†Acceptable limits = ±0.5; moderately skewed = −1 to −0.5 or 0.5 to 1; highly skewed = < −1 or > +1.

^‡Acceptable limits = ±2.¹⁴

ACP = Canadian Physiotherapy Assessment of Clinical Performance; Cl = clinical instructor; FC = frequency count, for each anchor.

Appendix 3: ACP Cl Midpoint Item-Level Descriptive Statistics for Clinical Internship II

	Expert								Communicator		Collaborator		Manager		Advocate		Scholarly practitioner		Professional
Statistic	1.1	1.2	1.3	1.4	1.5	1.6	1.7	1.8	2.1	2.2	2.3	3.1	3.2	4.1	4.2	4.3	5.1	6.1	7.1	7.2	7.3
Mean	5.1	4.9	4.9	4.7	4.8	5.1	4.9	5.4	5.7	5.5	6.5	5.3	5.1	4.8	5.1	5.4	5.0	5.6	6.5	6.7	5.3
SD	2.3	2.3	2.1	2.2	2.1	2.3	2.2	2.2	2.4	2.3	2.2	2.4	2.5	2.1	2.3	2.3	2.4	2.4	2.2	2.3	2.4
Median	5	5	5	5	5	5	5	6	6	6	7	5	5	5	5	5.5	5	5	7	7	5
Mode	5	4	4	4	4	7	6	7	3	7	7	6	3	6	7	7	7	5	9	9	7
Maximum	9	9	9	9	9	10	9	9	10	10	10	9	9	8	10	9	9	10	9	10	10
Minimum	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	2	2	1
FC1	7	9	5	7	7	5	9	2	5	5	1	7	7	5	5	3	9	8	0	0	7
FC2	7	4	7	5	7	8	4	8	0	5	4	2	3	8	0	6	6	2	2	5	0
FC3	0	6	6	11	3	6	6	9	12	5	4	11	16	11	7	12	7	3	10	2	17
FC4	13	17	16	14	17	12	12	8	9	11	5	10	9	11	8	6	8	8	2	7	4
FC5	20	11	13	10	13	12	9	10	10	9	8	9	8	8	8	11	10	18	15	13	13
FC6	4	8	11	9	8	8	15	11	12	10	12	12	8	14	7	5	11	2	2	2	4
FC7	14	12	11	13	16	16	14	13	6	17	15	8	11	8	9	18	17	14	13	13	19
FC8	4	2	2	4	2	4	3	9	10	5	11	10	4	11	0	8	3	17	13	11	5
FC9	7	7	5	3	3	3	4	7	10	7	11	7	10	0	3	7	5	2	19	18	5
FC10	0	0	0	0	0	2	0	0	2	2	5	0	0	0	2	0	0	2	0	5	2
FC missing,* no.	5	4	4	5	4	4	4	3	4	4	4	4	4	4	31	5	4	4	4	4	4
FC missing,* %	5	5	5	5	5	5	5	4	5	5	5	5	5	5	39	5	5	5	5	5	5
Skewness†	−0.15	0.04	0.05	0.01	−0.15	0.00	−0.26	−0.16	−0.11	−0.22	−0.49	−0.14	0.09	−0.09	0.10	−0.19	−0.22	−0.45	−0.46	−0.49	−0.08
Kurtosis‡	−0.65	−0.72	−0.53	−0.83	−0.68	−0.70	−0.74	−1.03	−0.88	−0.70	−0.38	−0.94	−1.07	−1.11	−.28	−1.11	−0.96	−0.58	−1.06	−0.81	−0.87
No. of responses	76	76	76	76	76	76	76	77	76	76	76	76	76	76	49	76	76	76	76	76	76
Responses of 9 & 10, %	9	9	7	4	4	7	5	9	16	12	21	9	13	0	10	9	7	5	25	30	9

^*Represents scores that are missing or where an item was deemed “not observed.”

^†Acceptable limits = ±0.5; moderately skewed = −1 to −0.5 or 0.5 to 1; highly skewed = < −1 or > 1.

^‡Acceptable limits = ±2.¹⁴

ACP = Canadian Physiotherapy Assessment of Clinical Performance; Cl = clinical instructor; FC = frequency count, for each anchor.