Clinical Instructors’ Perceptions of Internationally Educated Physical Therapists’ Readiness to Practise during Supervised Clinical Internships in a Bridging Programme

Abstract

Purpose: The purpose of this study was to describe clinical instructors’ (CIs) comments on the Canadian Physiotherapy Assessment of Clinical Performance (ACP) that reflect areas of strength and areas requiring improvement among internationally educated physical therapists (IEPTs) during supervised clinical internships in a bridging programme. Method: We reviewed the assessment records of 100 IEPTs’ clinical performance during two internships each for three successive cohorts of learners in a Canadian bridging programme. We extracted the CIs’ text from 385 comment sections of the ACP completed during these internships and analyzed them using qualitative content analysis. Results: The iterative deductive coding process resulted in 36 subcategories: 14 for areas of strength and 22 for areas requiring improvement. We merged the 36 subcategories to produce nine categories: four areas of strength (subjective assessment, treatment, patient confidentiality, and professionalism) and five areas for improvement (objective assessment, clinical reasoning, establishment of treatment goals, communication, confidence, and time management). We then grouped these categories into two broad themes: professional practice and professional conduct. Conclusions: The CIs commended the IEPTs for their clinical competence in subjective assessment, treatment, patient confidentiality, and professionalism. The areas requiring improvement typically required more complex clinical decision-making skills, which may have been challenging for these IEPTs to demonstrate as competently during a short internship.

Internationally educated physical therapists (IEPTs) who emigrate to countries that require professional regulation and licensure face challenges obtaining their license and integrating into the physical therapy (PT) workforce of those countries.^1–3 These challenges may be a result of differences in cultural practices, specific professional language proficiency, application of clinical skills, intra- and inter-professional and team-based skills, and epistemology of practice.⁴

In Canada, bridging programmes have been designed to enable IEPTs to succeed in the licensure process required to enter the PT workforce.^5,6 The Ontario Internationally Educated Physical Therapy Bridging (OIEPB) Program offers a review of theory and practice in the Canadian health care context during two clinical internships. The programme’s goal is “to enhance the internationally educated physical therapists’ (IEPTs’) professional and clinical competencies to facilitate success as an autonomous practitioner in the Canadian health care system.”⁷

In their first clinical internship, learners aim to solidify their fundamental clinical skills by using hands-on practise and integrating theory into practice; in the second, learners further consolidate the PT clinical knowledge, skills, and professional behaviours required for autonomous practice in Canada.⁷ During both internships, the supervising clinical instructor (CI) uses the Canadian Physiotherapy Assessment of Clinical Performance (ACP) to assess learners’ performance. All supervising CIs are familiar with the ACP because it is used for students in Canadian PT education programmes. Also, clinical internships include regular continuing education and debriefing sessions on the use of the ACP.

The ACP is a reliable, valid, competency-based tool for assessing students’ clinical performance during their clinical internships in PT programmes in Canada.⁸ The ACP is based on the 2009 edition of the Essential Competency Profile for Physiotherapists in Canada, which categorizes physiotherapists’ competencies into seven roles: expert, communicator, collaborator, manager, advocate, scholarly practitioner, and professional.⁹ The ACP uses numeric scoring for 21 items and has nine open-ended comment sections – three for the Expert role (which is broken into Assessment, Analysis, and Intervention) and one for each of the six other roles. CIs use the ACP to assess students at both the mid- and final points of an internship. Mori and colleagues have reported a detailed description of the ACP’s development and structure.^8,10,11

Although published studies on assessing PT clinical education are based entirely on the numerical data from clinical performance tools,^8,12–16 researchers and clinical educators are increasingly interested in expanding the assessment of learners beyond numerical rating to incorporate qualitative comments during clinical internships.^17,18 To this end, researchers have evaluated whether the qualitative data (written comments) are consistent with the numerical scoring. The results have been mixed.

For example, Richards and colleagues and Durning and colleagues reported that comments were usually consistent with the scores assigned.^19,20 In contrast, Tsuda and colleagues, Ginsburg and colleagues, and Frohna and Stern found that the comments were not usually consistent with the scores assigned, revealing areas requiring improvement that the scores had not identified.^21,22,23 Moreover, written comments in a clinical performance assessment tool may detect specific or latent student behaviours that numerical scoring may not detect, thereby offering formative feedback to improve future performance.^24–27

We were interested in examining CIs’ written comments on the ACP regarding IEPTs’ performance during their clinical internships in the OIEPB Program as a means of further understanding IEPTs’ readiness to practise in Canada. Therefore, the primary purpose of this study was to analyze and categorize CIs’ comments on the ACP into areas of strength and areas requiring improvement among the IEPTs they had supervised.

Methods

The data we extracted for this study were CIs’ written comments about IEPTs from their midterm and final evaluations for each of the nine areas of the ACP: Expert–Assessment, Expert–Analysis, Expert–Intervention, Communicator, Collaborator, Manager, Advocate, Scholarly Practitioner, and Professional. Therefore, for each student, we had four sets of comments across two internships. We conducted a secondary analysis of the data, which were originally collected for educational purposes. When they enrolled in the bridging programme, each learner provided informed consent to allow their data to be used for research and evaluation purposes.

The Queen’s University General Research Ethics Board and the University of Toronto Health Sciences Research Ethics Board approved this study. The OIEPB Program faculty and staff provided anonymized demographic data for the learners.

Participants

The participants were learners from three cohorts (n = 100) who had completed the two clinical internships in the OIEPB Program. The learners provided certain demographic information on admission to the programme: age, gender, country of entry-level PT training, time in Canada, immigration status, English language proficiency score (if applicable), PT experience outside of Canada, years since graduation, and years of experience in the Canadian health care system (Table 1).

Table 1 .

Demographic Characteristics of IEPTs (N = 100)

Characteristic	No. of participants
Gender
Female	61
Male	39
Country of entry-level PT training
India	45
Philippines	20
Iran	6
Brazil	6
Poland	3
United States	2
Colombia	2
Chile	2
Egypt	2
United Kingdom	2
Other*	10
Year of graduation from an entry-level PT program
Before 2000	20
2000–2005	31
2006–2010	39
Since 2010	10
PT practice experience outside Canada, y
< 1	12
1–5	51
> 5	37
Length of time in Canada, y
< 1	18
1–5	52
> 5	30
Length of time not practising after PT graduation, y
< 3	46
3–5	24
> 5	30
Experience in the Canadian health care system?
Yes	68
No	32

^*Pakistan, Ecuador, Ghana, Mauritius, Portugal, Jamaica, China, Romania, Czech Republic, and Nigeria.

IEPT = internationally educated physical therapist; PT = physical therapy.

Data analysis

We followed the framework of Hsieh and Shannon for content analysis²⁸ – specifically, the eight steps described by Zhang and Wildemuth.²⁹ These eight steps are as follows: preparing the data, defining the unit of analysis, developing categories and the coding scheme, testing the coding scheme on a sample of text, coding the entire text, assessing the coding consistency, drawing conclusions from the coded data, and reporting methods and findings.

First, we copied all the comments verbatim into a spreadsheet. Then, we adopted an iterative deductive approach to determine the emerging themes associated with each role in the ACP. The unit of analysis was any group of sentences for one learner within one role that described a specific area of strength or weakness. Two reviewers independently identified the units and classified them as areas of strength, areas requiring improvement, or unable to categorize. A third reviewer independently reviewed the uncategorized statements before discussing them with the previous two reviewers. We grouped each statement (unit of analysis) within the roles to form subcategories and then merged the subcategories across the roles to form categories. Subsequently, we merged the categories to form themes (see Figure 1 and the Appendix for subcategories within the roles).

Figure 1 .

Steps in the coding process.

Notes: Light grey indicates categories and themes for areas of strength; dark grey indicates categories and themes for areas requiring improvement.

Results

For the 100 IEPTs, 385 of the possible 400 comment sections were available for analysis. Every comment box had at least one sentence and frequently included multiple sentences. The IEPTs completed their two clinical internships in the following areas of practice: musculoskeletal (n = 59; 30.4%), cardiopulmonary (n = 48; 24.7%), neurology (n = 39; 20.1%), geriatrics (n = 24; 12.4%), general practice (n = 18; 9.3%), oncology (n = 4; 2.1%), and paediatrics (n = 2; 1.0%).

Subcategories, categories, and central themes

The iterative deductive coding process resulted in 36 subcategories, 14 for areas of strength and 22 for areas requiring improvement. We merged these subcategories to produce nine categories: four areas of strength and five areas for improvement. These categories were grouped into two broad themes: professional practice and professional conduct (see Figure 1).

Areas of strength

We identified four areas of strength: subjective assessment, treatment, patient confidentiality, and professionalism.

Subjective assessment

Many CIs commended the IEPTs for continuously improving how they took patient histories and as for their ability to collect and review the background information relevant to a patient’s health from the clinical record or other health care professionals or sources.

Able to review all aspects of a patient’s chart independently, including medical notes, labs, nurses’ notes, and previous notes. Also, checks with RN [registered nurse] prior to seeing [patient] to get an up-to-date status. Also, beginning to determine when other collateral information is needed (i.e., calling care facility, using a language service) and does so without guidance from a clinical instructor. (CI-2)

Many CIs commented that the IEPTs had initially struggled to obtain informed consent from patients. However, over time, they improved, bringing themselves up to the level expected for independent PT practice in Canada.

He [IEPT] is becoming more efficient at obtaining formal consent at the beginning and during an assessment. (CI-3)

Treatment

On many ACPs, the CIs commended the IEPTs for effectively delivering a treatment protocol or treatment generally.

[He] performs interventions such as exercise prescription with FITT [Frequency–Intensity–Type–Time], and basic transfers well. (CI-4)

The CIs often praised the IEPTs’ effective body mechanics while handling patients. As the IEPTs came to the end of their clinical internship, they had also come to understand how to position their patients and ensure their comfort when they were delivering treatment.

[IEPT] … has become more comfortable and consistent with applying safe body mechanics and now clean[s] and clear[s] the treatment areas. (CI-5)

[IEPT] … is clearly thinking about how to streamline his approach (e.g., [patient] positioning, order of [assessment] for efficiency and [patient] comfort. (CI-6)

The CIs frequently praised the IEPTs’ ability to prescribe exercise for their patients.

[IEPT] showed great improvement in prescribing exercise. Initially, [IEPT] could prescribe exercise but often struggle[d] to state or document the FITT parameters. However, towards the end of the internship, he was able to prescribe and document exercise using the FITT format without being reminded. (C1-10)

Patient confidentiality

The CIs’ commended the IEPTs’ ability to maintain patient confidentiality, even in the early stages of the clinical internship. This is one of the skills for which almost all the IEPTs received praise.

She was able to abide by the practices of informed consent, weighing risks and benefits and confidentiality, even at the early stage of this placement. (CI-13)

Professionalism

The IEPTs were able to maintain professional therapeutic relationships with their patients and other team members and to demonstrate sensitivity to individual characteristics.

[She] always presents herself in a professional manner with patients and staff. She is always respectful of [patients’] opinions (e.g., Mr. P) while providing [patients] with the necessary education to optimize safety. (CI-14)

The CIs emphasized the IEPTs’ professional behaviour during clinical meetings, their ability to understand the professional relationship with other health care professionals, and the fact that patients often commended the IEPTs on their skills as professionals.

Patients have purposely taken the time to comment on [IEPT’s] communication and professionalism. (CI-15)

Areas requiring improvement

We identified five areas requiring improvement: objective assessment, clinical reasoning and setting patient-centered treatment goals, communication, confidence, and time management.

Objective assessment

The CIs reported that the IEPTs needed to improve their ability to perform an objective assessment. Goniometry and manual muscle testing were frequently cited examples of procedures for which IEPTs required cueing when performing.

Performing [range of motion] and [manual muscle testing] requires a great lot of cueing from [CI]. (CI-7)

Needs a lot of cueing selecting and performing most appropriate outcome measures (e.g., goniometry measurement) on assessment and discharge reassessments. (CI-8)

Clinical reasoning and setting patient-centered treatment goals

Other areas in which the IEPTs needed to improve were the ability to apply clinical reasoning principles to analyze their objective and subjective assessment findings and to subsequently set patient-centered treatment goals that were specific, measurable, action-oriented, realistic, and time-limited (SMART).

[IEPT] is beginning to determine indications for chest physiotherapy and when alternat[ive] treatments would be appropriate (i.e., dangle with Mr. B). He has continued to improve on guiding/educating patients to develop function-specific goals (i.e., walk without aid vs. walk to a coffee shop to meet friends). (CI-11)

[IEPT] requires guidance in creating SMART goals specific to the patients. (CI-9)

This need for cueing also affected the IEPTs’ ability to decide when to discharge a patient who might not benefit from a specific therapy or to propose alternative management options.

[IEPT] was not able to determine when a [patient] who had been declining physio 90 percent of the time for the past few weeks should be discharged or be given suggestions for another option like exercise programs in the community. (CI-12)

Communication

Communication could be mapped across virtually all areas, and comments about communication appeared in many areas beyond those associated with the communicator role. The CIs’ concerns about the IEPTs’ communication skills were diverse – for example, their tone and choice of culturally situated language.

[IEPT] needs to understand the terms that are appropriate for each group of patients you see on a daily basis. I encourage you [the IEPT] to be language sensitive. (CI-16)

Another area requiring improvement related to communication as a collaborator. The CIs commented that some IEPTs found it difficult to communicate or even speak up during team rounds. Other IEPTs were either rushing their sentences or were not able to clearly communicate their point to the other team members.

Some misunderstandings in terms of communication between different team members. Learn to ask clarifying questions from [patients] and colleagues when you are not understanding the conversations. For example, whether the MRI was done, the doctor was not going to discharge [patient] and why. (CI-17)

Some IEPTs did not communicate very well with patients during assessment and treatment and gave the patients unclear instructions. The IEPTs seemed to have difficulty identifying patients’ non-verbal gestures and communicating with patients non-verbally.

Needs to stay consistent with looking for non-verbal signs of discomfort when performing manual therapy, e.g., mobilization. Not all patients will inform you if they are in discomfort even though you have asked them to, so keep watching. (CI-18)

The CIs reported that the IEPTs needed to improve their written communications (clinical documentation), especially in a care setting with an electronic charting system.

He is becoming comfortable with electronic charting. Still, he requires some cueing to remember to chart some information he observed during treatment/reassessment, as well as correction of spelling and grammar. (CI-19)

Confidence

Lack of confidence appeared to underpin many of the areas deemed to require improvement. IEPTs who were able to perform certain assessments seemed to display a lack of confidence communicating their findings during team rounds or to the patients. The IEPTs also lacked confidence when giving instructions to the PT assistants. Their lack of confidence also appeared to affect their ability to advocate for their patients with other health care professionals.

Always increase confidence in communicating with patients/family members/team on the importance of participating in physiotherapy to promote independence. Ensure screening of all [intensive care unit] patients and determine if those patients, not already referred for physiotherapy, might benefit from physiotherapy intervention at an early stage. Use critical judgment and liaise with the nurses on the appropriateness of a referral. (CI-20)

Time management

Time management during patient assessment, treatment, and documentation was one of the areas in which the IEPTs were frequently reported to need improvement.

Ensure that you manage your time very well by being able to determine and set priorities during assessments and treatments. In Canada, there are so many patients waiting, and in order for you to be able to carry the caseload required of you during practice, you should learn how to manage your time. (CI-21)

Two central themes

These areas of strength and areas requiring improvement were merged into two central themes: professional practice and professional conduct. We defined professional practice as the physiotherapists’ performance skills during direct patient care, heavily characterized by the expert role’s key and enabling competencies. We defined professional conduct as the complementary actions required to ensure that professional practice skills were efficient, effective, and patient centered.

Among the four areas of strength, two were related to professional practice and two were related to professional conduct. Among the five areas requiring improvement, two were related to professional practice and three were related to professional conduct. These areas are illustrated in Figure 2.

Figure 2 .

Descriptive synthesis of the areas of strength and areas requiring improvement identified for internationally educated physical therapists.

Notes: The upper half indicates areas of strength (light grey), and the lower half indicates areas requiring improvement (dark grey).

All these elements are shown in the context of the Canadian health care system, with a complex patient at its core. The complex patient was a construct that the CIs often referred to in their comments, and it influenced both the IEPTs’ professional practice and their professional conduct. “For example, when the IEPTs were faced with complex patients, they often struggled to demonstrate areas that had been identified as strengths” (CI-16).

This issue is described in the following comment from one CI:

At the end of the internship, [IEPT] improved in all areas and [has] achieved the desired skills as an entry-level physiotherapist practice in Canada; however, [she] requires cueing when assessing and managing complex patients, such as older adults with comorbid conditions. (CI-14)

Hence, a complex patient is considered to be a construct that influences competence among IEPTs during their clinical internships in the bridging programme. The Canadian health care system is another critical construct in this synthesis. The CIs documented the IEPTs’ strengths and weaknesses in the context of Canadian health care settings. They might not reflect the extent of their strengths and weaknesses in their source countries, where they had trained or practised as physiotherapists.

Discussion

In this study, we sought to examine the areas of strength and areas for improvement for IEPTs enrolled in a PT bridging programme by analyzing the comments written on their performance evaluation forms. During the IEPTs’ clinical internships, CIs documented the IEPTs’ strengths as subjective assessment, treatment of patients, patient confidentiality, and professionalism. They documented areas for improvement as skills in objective assessment, clinical reasoning and goal setting, communication, confidence, and time management.

These areas of strength and areas requiring improvement could be used as a framework for other IEPTs in Canada who are not in a bridging programme; they would help them self-assess their readiness to practise. This applicability is supported by the fact that the study population is representative of all IEPTs applying for credentialing with the Canadian Alliance of Physiotherapy Regulators.^30,31 However, our findings are most relevant to those IEPTs in Canadian PT bridging programmes, notably the OIEPB Program.

The areas of strength and areas requiring improvement identified in our study are consistent with those reported in the broader literature about internationally educated health professionals (IEHPs). For instance, Sullivan and colleagues reported that internationally trained medical doctors in Australia were good at clinical clerking but lacked detailed logical judgment in using clinical diagnostic tools.³² Their findings are similar to our results in that the CIs commended the IEPTs for their excellent skills in subjective assessment but had concerns about their ability to conduct an objective assessment of patients using specific protocols and outcome measures. The difficulties inherent in objective assessment seemed to influence IEPTs’ ability to clinically reason and develop patient-oriented goals for appropriate treatment strategies.

Time management, one of the areas in which the IEPTs in our study required improvement, has not, to our knowledge, been explicitly explored in the literature. The closest evidence reported is related to internationally trained doctors practising in New Zealand who said that they needed further training in patient management (management decisions, response to calls, emergency care) to enhance their productivity in practice.³³

Researchers have consistently identified communication as an area that requires improvement among IEHPs^34–36 – specifically, details of communication styles, tone, verbal and non-verbal skills, and use of colloquial vocabulary. Our findings are consistent with a report that the choice of colloquial words was the main constituent of the communication barrier faced by internationally trained occupational therapists in the United States.³⁵ Communication style is often culturally mediated.³⁷ Therefore, word meanings might differ between the country in which the IEPTs were trained and their new country. This could be one of the reasons for the communication issues noted among IEPTs. In addition, contextual differences in communication style might affect the IEPTs’ confidence in speaking up during rounds or in communicating their assessment findings to their patients, the team, or both. The problem of confidence has consistently been cited as an area in which IEHPs need to improve.^32,38

Although anyone’s skills would logically be challenged in a complex patient situation, we speculate that differences in practice culture may have contributed to the IEPTs’ lack of confidence in performing certain entry-level skills and clinical reasoning in these complex situations. Consequently, exposing IEPTs to the complexity of PT practice patterns, health care systems, and related services in Canada is likely to help them succeed in licensure and integration into the Canadian PT workforce.

It is important to note that the comments we analyzed reflected descriptions of performance during internships that lasted only up to 5 weeks. Some areas requiring improvement – for example, communication and confidence – may simply be areas in which any practitioner new to a practice location would need improvement, and improvement would logically occur as the individual became familiar with the particular health care team and practice culture. Others have noted that clinical decision making becomes more sophisticated as physiotherapists or other practitioners become more experienced, familiar, and confident in a context.^39,40

We may consider that taking subjective histories and executing treatment, although demanding, are relatively simple clinical skills. Still, they are necessary in the treatment of any patient, as is essential professionalism, and these IEPTs may have practised them very well. However, the processes that occur in between – namely, selecting the most appropriate objective examination procedures, interpreting findings, setting goals, and designing a treatment plan – are clinical decision-making skills that are less likely to be performed well by any practitioner in a novel context.^39,40

In addition, the ACP instructions specifically cue CIs to describe areas requiring improvement; thus, not all their comments may have represented competence below the entry-to-practice level. Moreover, in a separate analysis we conducted of the ACP score data from most of the same internships, we found that, by the end of their second internship, most IEPTs were being rated by their CIs as performing at or near entry level for most competencies.⁶

Although our findings provide insight into the areas of strength and weakness for IEPTs attending a bridging programme, this study has a few limitations. First, our findings are not necessarily generalizable to other similar learners: they are specific to the learners assessed in these three cohorts and to the CIs who supervised their clinical internships. The learners in the OIEPB Program are selected through a competency-based admission process targeted to those IEPTs who are “bridging ready.” Individuals who are bridging ready should demonstrate fundamental, theoretical knowledge of PT, PT clinical skills, and communication skills and have enough motivation to complete the bridging programme. Second, our coding process, grounded in the roles on which the ACP is based, may have omitted important ideas that did not fit into these roles.

Third, we would be more confident in the trustworthiness of the categories and themes if we had carried out member checking with the CIs, IEPTs, and programme instructors regarding the areas of strength and weakness. However, we did take steps to maintain rigor. Two reviewers undertook the coding, rather than just one. These reviewers held debriefing sessions with the other authors during the coding process to ensure that everyone agreed on the definitions of the units of analysis, the linkages of the statements to roles, and how the statements were classified. Second, we maintained detailed documentation of the subcategories developed during data processing (see the Appendix).

Conclusion

The CIs commended the IEPTs in this Canadian bridging programme for their clinical competence in subjective assessment, treatment, patient confidentiality, and professionalism. When the CIs recommended a need for improvement, it was frequently in the areas of objective assessment of patients, SMART goals, clinical reasoning, communication, confidence, time management, and patient safety. These findings are generally consistent with the challenges reported by others for IEHPs attempting to enter practice in a new country, and they may at least partly reflect a response to practising in novel contexts during relatively short clinical internships.

Key Messages

What is already known on this topic

The Canadian Physiotherapy Assessment of Clinical Performance (ACP) developed by Mori and colleagues^9,10 is now used throughout Canada to assess physical therapy (PT) students’ performance in clinical education. Cultural differences in professional practices are a major contributor to the challenges of integration among internationally educated health professionals (IEHPs).

What this study adds

This is the only published study that has analyzed the contents of the ACP’s comments sections to assess the clinical performance of internationally educated physical therapists (IEPTs) or any other PT learners. Poor time management during assessment and treatment have not been explicitly identified as an area requiring improvement among IEHPs. Our findings highlight the need for clinical placement for IEPTs when they migrate to a new country.

APPENDIX: Canadian physiotherapy assessment of clinical performance roles and their subcategories

Notes: Light grey indicates categories and themes for areas of strength; dark grey indicates categories and themes for areas requiring improvement.

* Time management in assessment and treatment.

SMART = specific, measurable, achievable, realistic, time limited; SOAP = subjective, objective, assessment, and plan; PTA = physiotherapy assistant; OTA = occupational therapy assistant.