ORIGINAL RESEARCH ARTICLE

Professional quality of life and organizational support: a survey of physical therapists with experience as clinical instructors

Andrea C. Mierau, PT, DPT, EdD^*

College of Graduate Health Studies, A.T. Still University College of Graduate Health Studies, Kirksville, MO, USA
Department of Physical Therapy, School of Health Professions, Augustana University, Sioux Falls, SD, USA

Abstract

Purpose: The purpose of this study was to determine the professional quality of life (ProQoL) of physical therapists (PTs) with experience as a clinical instructor and identify factors associated with compassion satisfaction, burnout, and secondary traumatic stress.

Methods: This study used a cross-sectional design and survey methodology. Participants were clinician PTs who have been clinical instructors, and completed an online survey that included the ProQoL scale, the eight-item Survey of Perceived Organizational Support, and demographics.

Results: Of the 259 participants who completed the survey, the majority experienced average to high levels of compassion satisfaction and low levels of burnout and secondary traumatic stress. Chi-square tests of independence indicated high ratings of compassion satisfaction were associated with the uppermost years licensed as a PT, years of clinical teaching experience, and age. Participants aged 26–35 or with less than 5 years of clinical instruction experience correlated with low ratings of compassion satisfaction. Participants with more than 25 years of experience as PTs correlated with low ratings of burnout. High levels of compassion satisfaction were associated with high levels of perceived organizational support.

Conclusion: Findings may assist clinical sites and site coordinators of clinical education in selecting and training clinical instructors.

Keywords: physical therapists; quality of life; compassion fatigue; clinical education; clinical instructors; workplace

 

 

Professional quality of life (ProQOL) encompasses both compassion satisfaction, the positive dimensions of the work experience, and compassion fatigue, the negative facets of the professional role.¹ Compassion satisfaction is the satisfaction of performing work duties despite fatigue or hardship, while compassion fatigue is a diminishing ability to nurture.¹ Studies have identified compassion fatigue across various healthcare disciplines, with recent investigations highlighting varying degrees within the rehabilitation profession.^2–4 According to the ProQOL model, compassion fatigue is conceptualized as the combined experience of burnout and secondary traumatic stress.¹ Burnout, in particular, has prompted dedicated attention from the American Physical Therapy Association, recognizing the need to address and mitigate burnout among physical therapists (PTs).⁵ The demanding and empathetic nature of physical therapy contributes to burnout and compassion fatigue susceptibility. Recognizing and understanding ProQOL aspects are vital for fostering a supportive work environment and ensuring well-being in rehabilitation professionals.

An inquiry into the ProQOL of the physical therapy workforce in Alabama unveiled encouraging results, with moderate to high levels of compassion satisfaction and moderate to low levels of compassion fatigue among participants.² Similarly, a separate study focusing on new graduate PTs reported comparable levels of compassion satisfaction and lower levels of compassion fatigue and burnout. Despite these positive findings, both studies emphasize the significance of even low levels of compassion fatigue and burnout including diminished quality of care, compromised work relationships, and attrition rates within the profession.^2,4,6 Recognizing that any degree of compassion fatigue and burnout can impact the well-being of healthcare professionals and the quality of care they provide, these studies underscore the importance of addressing and mitigating these challenges in the field of PT.

The organizational environment influences ProQOL.¹ Healthcare professionals, including PTs, face complex demands in an overburdened healthcare system.^2,7–9 Occupational stressors such as heavy workload, productivity quotas, insufficient resources, and organizational support contribute to burnout among PTs.^2,10 Conversely, a supportive work environment has the potential to promote resilience and enhance the quality of life for healthcare professionals.¹¹ Studies indicate that meaningful workplace recognition correlated with reduced compassion fatigue and predicts higher levels of compassion satisfaction, whereas a lack of recognition predict elevated compassion fatigue.¹² These findings emphasize the role of organizational support and recognition in mitigating occupational stressors and promoting the well-being of healthcare professionals.

Clinical educators in healthcare face numerous challenges while balancing the demands of student learning and patient care.⁹ The quality of professional life, as measured by the ProQOL, is influenced by the organizational environment, including the support received.¹ Drawing from insights in clinical practice literature, it becomes evident that institutional support for clinical teaching may also influence the ProQOL of clinical educators. Research by Coleman-Ferreira et al. highlights the connection between a PT CI’s ability to develop competence and a supportive work environment with access to resources and mentorship.¹³ Moreover, Davies et al. emphasize the significance of the healthcare institution’s culture, specifically its explicit valuation of clinical education, as a crucial factor for CIs when considering student placement requests.¹⁴ These studies suggest interconnectedness between organizational support and effective teaching practices. Taken together with clinical practice literature that underscores the multifaceted challenges confronting clinical educators in healthcare, these factors collectively may contribute to shaping the ProQOL for CIs.

As clinical education constitutes approximately 23% of the curriculum in physical therapy education,¹⁵ clinician CIs become instrumental in fulfilling teaching needs and thereby influencing the clinical education quality.¹⁶ The role of a CI is acknowledged to be time-intensive, with studies indicating a perceived increase in stress and additional responsibilities added to the clinician’s workload.^9,17 Novice CIs, in particular, face challenges in balancing patient care and student responsibilities as they build confidence in their role as clinical educators.¹⁸ The heightened responsibility, coupled with the known relationship between organizational support and ProQOL in healthcare, might place CIs at a higher risk of experiencing compassion fatigue and an overall decreased ProQOL.^2,10–12

This study advances previous research by examining the ProQOL, specifically focusing on compassion satisfaction and compassion fatigue in PTs who have served as CIs. CIs hold a pivotal role in the success of a physical therapy clinical education curriculum, yet there is a notable gap in the literature concerning the ProQOL of PTs with CI experience. The primary objective of this study was to understand the levels of compassion satisfaction and compassion fatigue in clinicians with CI experience, spanning various levels of expertise.

The researcher utilized the ProQOL scale, a 30-item self-report scale, to assess compassion satisfaction and compassion fatigue, measured through the combined experience of burnout and secondary traumatic stress.¹ Results were reported as individual subscale scores or cut scores indicating low, moderate, or high levels of CS and compassion fatigue. Additionally, the study explored personal and professional factors influencing the ProQOL of PTs, such as age and years of experience both as a PT and as a CI.

A secondary objective of the study was to investigate the potential relationship between compassion satisfaction and perceived organizational support in PTs with experience as CIs. Organizational support influences ProQOL in healthcare settings, yet the relationship specific to ProQOL in PTs involved in clinical education appears to be a gap in the literature. The Survey of Perceived Organizational Support (SPOS), an eight-item tool, was employed to measure self-reported perceived organizational support, providing scores categorized as low, medium, or high.

In summary, this research contributes valuable insights into the ProQOL of PTs who have served as CIs, including the potential influence of organizational support on compassion satisfaction.

Method

Design

This study used a cross-sectional design using survey methodology, conducted from August 26 to September 22, 2022 and approved by the IRBs at A.T. Still University and Augustana University.

Subjects

The sample population comprised 300 United States-based PTs who also served as CIs, with 259 meeting the inclusion criteria of having primary evaluation responsibilities for Doctor of Physical Therapy (DPT) students in the past year. It is unclear whether participants were supervising a student at the time of survey completion. Fourteen participants had incomplete survey responses; therefore, only their completed subscales were included in the data. The sample size was determined using G*Power software¹⁹ for significant correlation using an alpha level set at 0.05, an effect size set at medium or r = 0.3,²⁰ power set at 0.8,²¹ and 5 degrees of freedom. An estimated 143 participants were needed to obtain adequate statistical power to avoid a Type II error.

The participants were recruited through convenience sampling using Exxat Prism (Warren, NJ). Approximately 4,550 email addresses were exported to Excel and randomized using random number generation. The first 1,430 email addresses were selected for contact, assuming a 10% response rate. Recruitment emails included the link to digital informed consent, which, once signed, allowed access to the anonymous web-based survey in Qualtrics (Provo, UT). An additional batch of 1,430 emails was sent the following day in the order of the random number generator, as a 13% bounce rate occurred. The recruitment email was also sent through the APTA Academy of Education listserv.

Procedures

The online survey included three sociodemographic questions. The first two questions asked participant’s age and years of experience in clinical practice. The third question asked for years of experience as a CI; however, it did not specify the average or typical number of students taken per year, leaving the degree of experience unknown. Participants completed the eight-item SPOS²² and the ProQOL scale.¹ The SPOS assesses perceived organizational support with eight questions using a 7-point Likert-type scale (0 = strongly disagree to 6 = strongly agree). Cronbach’s alpha ranges from 0.90 to 0.93^23,24 and has significant convergence validity with the other SPOS measures (36-item and 16-item). Construct validity was demonstrated with item-total correlations ranging from r = 0.70 to 0.84.^23,24 The ProQOL comprises 30 items scored on a 5-point Likert-type scale (0 = never to 5 = very frequently) and is scored over three subscales: compassion satisfaction, burnout, and secondary traumatic stress. The ProQOL has demonstrated good construct validity and discriminant validity (r < 0.70) and good internal consistency (α = 0.75 – 0.88).^1,2,25 Cronbach’s alpha for the ProQOL was 0.88 and ranged from 0.75 to 0.88 for individual subscales.¹

Analysis

The researcher identified data sets that did not have complete answers on either the ProQOL subscales or the eight-item SPOS and removed the incomplete responses. Specifically, there were 253 complete SPOS responses, 250 complete secondary traumatic stress ProQOL subscale responses, 248 complete burnout ProQOL subscale responses, and 253 complete compassion satisfaction ProQOL subscale responses. The remaining data had complete entries, n = 245. Three participants omitted responses on age or years licensed as a PT while one did not provide information on years of experience as a CI.

Univariate descriptive statistics were calculated, including the mean, standard deviation, and interquartile range of participants’ sociodemographic characteristics. The raw data from the ProQOL were summed and compared against ProQOL cut scores.¹ Univariate descriptive statistics were calculated for each subscale.

Chi-square tests of independence were performed to explore associations between participants’ sociodemographic characteristics and individual ProQOL subscale scores and between SPOS and compassion satisfaction subscale. Due to the number of responses in the low category of compassion satisfaction (n = 2) and the high levels of burnout (n = 0) and secondary traumatic stress (STS)(n = 0), the researcher dichotomized responses into high and average/low categories for compassion satisfaction for further analysis and to meet assumptions of Chi-square testing. All expected cell frequencies were greater than five, except the Chi-square test conducted between participant age and secondary traumatic stress, which had one cell with an expected frequency of 3.40. Post hoc testing using adjusted standardized residuals was used to determine, which characteristics contributed to significant associations.

Results

A post hoc power analysis revealed a power of 97.7% with a sample of 259, an effect size of 0.3, a precision level of ±5%, and five degrees of freedom. The mean age of participants was 38.44 (SD 8.46) years, ranging from 26 to 69 years old. The mean number of years licensed as a PT was 12.44 (SD 8.7) years, and participants ranged from new graduates with 1 year of experience to experienced PTs with nearly 50 years of experience. The average experience in clinical instruction was 9.57 (SD 7.71) years, ranging from new CIs to experienced CIs with more than 30 years of teaching experience. Table 1 presents the participants’ complete sociodemographic information.

Table 1. Sociodemographic characteristics of participants

Characteristic	n	%
Age  26-35  36-45  46-55  56+	112 99 31 14	43.8 38.7 12.0 5.5
Years Licensed as PT  <5  6-10  11-15  16-20  21-25  >25	58 78 45 27 23 25	22.7 30.5 17.6 10.5 9.0 9.8
Years of Experience as CI  <5  6-10  11-15  16-20  21-25  >25	106 60 41 27 12 12	41.1 23.3 15.9 10.5 4.7 4.7
PT, physical therapist; CI, clinical instructor.

The individual ProQOL subscale results are in Table 2. Each subscale was summed and categorized as low (≤ 22), average (23–41), or high (≥ 42),¹ except for compassion satisfaction, where data were condensed into high and low/average categories for compassion satisfaction. Compassion fatigue was low to average per the burnout and STS subscales. The average burnout subscale score was 22.32 (SD 5.25), between low and average. The average STS scale score was 19.30 (SD 4.72), considered low. Compassion satisfaction was an average score of 41.4 (SD 5.63), between average and high.

Table 2. Summary of ProQOL scores

ProQOL Subscale	n	M (SD)	Median	IQR	Low (10-22)	Average (23-41)	High (42-50)
n(%)
CS	257	41.40 (5.63)	42.00	6	2 (0.8)	122 (50.2)	119 (49.0)
BO	252	22.32 (5.25)	22.00	7	133 (52.8)	119 (47.2)	0 (0)
STS	253	19.30 (4.72)	19	6	192 (75.9)	61 (24.1)	0 (0)
ProQOL, professional quality of life; CS, compassion satisfaction; BO, burnout; STS, secondary traumatic stress.

Table 3 presents the results of the chi-square tests of independence, showing associations between participants’ sociodemographic characteristics and ProQOL subscale scores. Compassion satisfaction had a significant, moderate association with age, x²₃ = 15.6, P = 0.001, years licensed as a PT, x²₅ = 16.6, p = 0.005, and years of experience as a CI, x² ₅ =13.1, p = 0.023. Table 4 presents post hoc testing using adjusted standardized residuals. Older age (>56), greater years of experience as a PT, and more years of experience as a CI (>25 years) revealed a higher likelihood of scoring high in compassion satisfaction. Younger participants (26–35) and those with less than 5 years of experience as a CI were more likely to score low/average in compassion satisfaction. Age was the only factor significantly associated with the burnout subscale, x²₃ = 11.1, p = 0.011. According to post hoc testing, participants >56 years of age were more likely to report low levels of burnout than other age groups. No factors were significantly associated with the STS subscale.

Table 3. Relationship of sociodemographic and professional characteristics with ProQOL subscale scores

Characteristics	n (%)	CS Subscale*			BO Subscale *			STS Subscale *
		Low/Avg n(%)	High n(%)	x2	Low n(%)	Avg n(%)	x2	Low n(%)	Avg n(%)	x2
Age
26-35	112 (43.8)	65 (25.6)	46 (18.1)	15.591†	52 (20.8)	58 (23.2)	11.105‡	80 (31.9)	31 (12.4)	5.748
36-45	99 (38.7)	44 (17.3)	55 (21.7)		49 (19.6)	47 (18.8)		71 (28.3)	24 (9.6)
46-55	31 (12.0)	12 (4.7)	18 (7.1)		18 (7.2)	12 (4.8)		25 (10.0)	6 (2.4)
56+	14 (5.5)	1 (0.4)	13 (5.1)		13 (5.2)	1(0.4)		14 (5.6)	0 (0.0)
Years Licensed as PT
<5	58 (22.7)	34 (13.4)	24 (9.4)	16.575‡	27 (10.8)	30 (12.0)	9.032	39 (15.5)	18 (7.2)	6.771
6-10	78 (30.5)	42 (16.5)	35 (13.8)		36 (14.4)	39 (15.6)		54 (21.5)	21 (18.2)
11-15	45 (17.6)	22 (8.7)	23 (9.1)		23 (9.2)	23 (8.4)		34 (13.5)	11 (10.9)
16-20	27 (10.5)	9 (3.5)	18 (7.1)		13 (5.2)	14 (5.6)		21 (8.4)	5 (2.0)
21-25	23 (9.0)	11 (4.3)	11 (4.3)		12 (4.8)	10 (4.0)		19 (7.6)	4 (1.6)
>25	25 (9.8)	4 (1.6)	21 (8.3)		20 (8.0)	5 (2.0)		23 (9.2)	2 (0.8)
Years of Experience as CI
<5	106 (41.1)	61 (23.8)	45 (17.6)	13.067‡	47 (18.7)	56 (22.2)	9.002	70 (27.7)	34 (13.4)	9.897
6-10	60 (23.3)	28 (10.9)	31 (12.1)		33 (13.1)	25 (9.9)		49 (19.4)	9 (3.6)
11-15	41 (15.9)	15 (5.9)	25 (9.8)		22 (8.7)	19 (7.5)		31 (12.3)	9 (3.6)
16-20	27 (10.5)	14 (5.5)	13 (5.1)		13 (5.2)	14 (12.8)		20 (7.9)	7 (2.8)
21-25	12 (4.7)	3 (1.2)	9 (3.5)		8 (3.2)	3 (1.2)		11 (4.3)	1 (0.4)
>25	12 (4.7)	2 (0.8)	10 (3.9)		10 (4.0)	2 (0.8)		11 (4.3)	1 (0.4)
CS, compassion satisfaction; BO, burnout; PT, physical therapist; CI, clinical instructor; STS, secondary traumatic stress.
* Categories based on subscale scores: low less than or equal to 22, moderate, equal to 23 to 41, high, greater than or equal to 42.
†p = .001
‡p < .05

Table 4. Crosstabulation of participant characteristics and ProQOL subscales

Characteristic	CS Subscale*		BO Subscale*
	Low/Avg n†	High n†	Low n†	Avg n†
Age
26-35	65 (3.0)	46 (-3.0)	52 (-1.6)	58 (1.6)
36-45	44 (-0.9)	55 (0.9)	49 (-0.4)	47 (0.4)
46-55	12 (-0.9)	18 (0.9)	18 (0.8)	12 (-0.8)
56+	1 (-3.2)	13 (3.2)	13 (3.1)	1 (-3.1)
Years Licensed as PT
<5	34 (1.8)	24 (-1.8)	—	—
6-10	42 (1.4)	35 (-1.4)	—	—
11-15	22 (0.1)	23 (-.1)	—	—
16-20	9 (-1.6)	18 (1.6)	—	—
21-25	11 (0.2)	11 (-0.2)	—	—
>25	4 (-3.4)	21 (3.4)	—	—
Years of Experience as CI
<5	61 (2.6)	45 (-2.6)	—	—
6-10	28 (-0.1)	31 (0.1)	—	—
11-15	15 (-1.5)	25 (1.5)	—	—
16-20	14 (0.4)	13 (-0.4)	—	—
21-25	3 (-1.6)	9 (1.6)	—	—
>25	2 (-2.2)	10 (2.2)	—	—
ProQOL, professional quality of life; CS, compassion satisfaction; BO, burnout.
*Only subscales with significant associations included in post hoc testing and table.
†Adjusted residuals appear in parentheses beside observed frequencies. Bold indicates a cell significantly deviates from independence by >2 or 3 standard errors

Mean SPOS score categories include low, medium, and high levels of perceived organizational support, with total scores ranging from 0 to 6.²² Most participants (63.2%) reported medium levels of perceived organizational support. Only 9.3% of participants reported a high perception of organizational support based on the SPOS. Table 5 presents results from the chi-square test of independence between the SPOS score and compassion satisfaction subscale. A statistically significant and moderately strong association existed between the SPOS and compassion satisfaction subscale scores, x²₂ = 29.429, p ≤ 0.001.

Table 5. Relationship of SPOS score with compassion satisfaction subscale

SPOS category	n(%)	CS subscale		x2
		Low/Average n*	High n*
Low (≤2)	68 (26.8)	48 (4.4)	20 (-4.4)	29.429†
Medium (>2–4)	163 (64.2)	71 (-1.7)	92 (1.7)
High (>4)	23 (9.1)	2 (-3.9)	21 (3.9)
CS, compassion satisfaction; SPOS, survey of perceived organizational support.
*Adjusted residuals appear in parentheses beside observed frequencies. Bold indicates a cell significantly deviates from independence (>2 or 3 standard errors).
†p < .001.

Discussion

The findings highlight the potential benefits of accumulated experience and emphasize the significance of organizational support for PTs involved in clinical education. The significant associations found between compassion satisfaction and age, years licensed as a PT, and years of experience as a CI indicate that these factors may influence a PT’s level of compassion satisfaction. Older PTs and those with extensive experience as clinicians and CIs were more likely to report higher levels of compassion satisfaction. Age was the only factor significantly associated with burnout, with participants over 56 reporting lower burnout levels than their younger counterparts. These findings suggest that accumulated experience may foster an overall positive ProQOL in physical therapy. However, it is crucial to approach the relationship between years of experience as a CI and compassion satisfaction cautiously. The demographic survey question asked for ‘years of experience as a clinical instructor’, which may not necessarily reflect a CI’s actual level of involvement. For example, some CIs may only mentor a student once every few years, while others may take on multiple students annually. Consequently, this metric may not significantly differentiate from years of licensed PT experience.

The results of this study are consistent with prior research in the field of physical therapy. It was observed that PTs and PT assistants in Alabama who had been licensed for over 15 years were more likely to report elevated levels of compassion satisfaction compared to their counterparts in the earlier stages of their careers.² The findings align with numerous studies conducted across various healthcare professions, including nursing and physical therapy, suggesting that younger clinicians are more susceptible to compassion fatigue and burnout.^8,26–28 In this sample, an inverse relationship was identified between older age and burnout levels, as opposed to any significant association between younger age and burnout.

Perceived organizational support emerged as a factor related to compassion satisfaction levels among PTs who have been CIs. Most participants reported medium levels of perceived organizational support, while only a small fraction perceived high levels of support. The moderately strong association between perceived organizational support and compassion satisfaction underscores the relationship of organizational factors in promoting ProQOL among PTs who have been CIs. The results align with a meta-analysis of compassion satisfaction and compassion fatigue in nurses, where organizational support emerged as a predictor of elevated compassion satisfaction,¹² and a study of PTs where job satisfaction, demands, and resources were associated with burnout.²⁹ Aligning with previous research, the perception of organizational support correlates with the compassion satisfaction of PTs and may extend to the role of the CI. According to the ProQOL model, nurturing and positive work culture contributes to compassion satisfaction and elevated ProQOL.¹

In this sample, PTs who have served as CIs displayed compassion fatigue levels ranging from low to average, while their compassion satisfaction levels varied from average to high. According to the ProQOL model, most PTs in this sample maintain a positive outlook regarding their effectiveness in their professional environment. It’s crucial to note that the inclusion criteria specified active involvement as a CI within the past 12 months, whereas the ProQOL scale assessed experiences within the last 30 days at work. Therefore, while these overall ProQOL findings may specifically relate to the role of a CI, it’s essential to interpret them within the broader context of their day-to-day responsibilities as practicing PTs.

Relevance to clinical education

These findings offer insights into factors influencing the well-being of PTs engaged in clinical instruction, with the study exploring age, professional experience, and perceived organizational support in the context of ProQOL, which may extend to the CI role. This is especially relevant for novice CIs managing patient care and student mentoring responsibilities. Additionally, the study establishes a link between perceived organizational support and increased compassion satisfaction among clinicians who have been CIs, emphasizing the role of a positive work culture and organizational factors in promoting the well-being of PTs involved in clinical education.

This study exhibits two strengths. Firstly, it leverages well-established, reliable, and validated instruments. Secondly, the study has a moderately large sample size (n = 259), supported by a post hoc statistical power analysis of 1.0.

Acknowledging limitations is crucial for interpreting the results. The ProQOL assesses the quality of life over the past 30 days, while inclusion criteria focused on student supervision in the past 12 months. This time frame misalignment may not have captured recent clinical instruction experiences on the survey as anticipated. Strengthening data collection methods by asking about timeframe of recent supervision and emphasizing answering the ProQOL questions from a clinical instructor’s perspective would enhance clarity. Adding a question on the frequency of student supervision per year in the demographic survey would provide insight into experience levels. Limitations also include the subjective nature of ProQOL and SPOS measures and potential influences beyond the study’s scope, such as tenure or specific clinical settings. Self-selection bias in self-reported questionnaires and the focus on CIs in physical therapy may impact external and internal validity, respectively, limiting generalizability to other groups within the profession.

Conclusion

In conclusion, the capacity for experiencing compassion satisfaction and mitigating compassion fatigue is higher in PTs who have been CIs who are older and accumulated professional experience. These findings may extend to the clinical education role and experience. Perceived organizational support is related to elevated compassion satisfaction among clinicians who have been CIs, supporting the importance of cultivating a positive work culture and optimizing organizational factors to foster a supportive environment. These findings offer practical implications for clinical sites and SCCEs, including assessing perceived organizational support to identify areas where CIs might benefit from additional support and guidance.

Ethics and consent

IRB Protocol: 45CFR46.104 (d)(2)(i)

IRB Approval Number: AM20220815-001

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