CASE REPORT

How crisis management led to enduring collaboration in clinical education: a case report

Elsa Drevyn^1*, Judi Schack-Dugre², Robin Galley³, Laurie Neely⁴, Diane Roadarmel⁵, Stephanie Svoboda⁶, Jamie Dietrich⁷, Sabrina Wang⁸ and Donni Welch-Rawls⁹

¹Physical Therapy Department, University of Miami, Coral Gables, FL, USA; ²Department of Physical Therapy, University of Florida, Gainesville, FL, USA; ³College of Health Care Sciences, Nova Southeastern University-Tampa, Clearwater, FL, USA; ⁴Division of Physical Therapy, College of Health Professions and Sciences, University of Central Florida, Orlando, FL, USA; ⁵Physical Therapist Assistant Program, Keiser University, Fort Lauderdale, FL, USA; ⁶Department of Sports Health, Nicklaus Children’s West Kendall Outpatient Center, Miami, FL, USA; ⁷Rehabilitation Services, Tampa General Hospital, Tampa, FL, USA; ⁸Rehabilitation Services, UF Health – Jacksonville, Jacksonville, FL, USA; ⁹Department of Physical Therapy, University of North Florida, Jacksonville, FL, USA

Abstract

Rationale: Historical challenges in clinical education were intensified by the global health pandemic. This paper describes how clinical educators in Florida collaborated during the crisis to strategize to meet immediate clinical education needs of clinical sites and academic programs while creating a roadmap for sustainable future success.

Clinical education scenario: A task force of clinical educators was formed to assess the current state of clinical education and manage the evolving crisis. Two unique needs assessments were developed and disseminated to both academic and clinical educators. A descriptive research design was used. Quantitative findings were reported through descriptive statistics.

Outcomes: Obtaining objective data was crucial for decision-making and implementing solutions during this crisis. Data analysis informed a series of coordinated, phased, action items that were implemented. Not only opportunities for immediate support were identified, but also longstanding challenges within clinical education were confirmed. The study results led to informed crisis management, reduced competition, and enduring collaboration.

Discussion and implications: Without collaboration, the pandemic’s impact on clinical education could have been more severe. Implementing data-driven crisis management strategies mitigated challenges posed by the pandemic and improved processes, enhancing the future state of clinical education in Florida.

Keywords: physical therapy; clinical education; collaboration; COVID-19; partnership

 

 

Clinical education is integral to physical therapy education and comprises almost one third of the total curriculum for many programs.¹ Clinical education experiences (CEEs) provide students the opportunity to apply theoretical knowledge and develop clinical competence needed in the physical therapy profession.^2,3 The Commission on Accreditation for Physical Therapy Education’s (CAPTE) criteria requires students to manage patients/clients in various practice settings, across the lifespan and continuum of care. CAPTE requires that Doctor of Physical Therapy (DPT) programs include a minimum of 30 weeks of full-time CEEs, while Physical Therapist Assistant (PTA) programs contain 520–720 h of full-time CEEs.^4,5

The variability in DPT and PTA clinical education, combined with the rising number of new academic programs, increased student enrollment in current programs, and a dependance on volunteerism of clinical instructors (CIs) places significant strain on academic programs and clinical sites.^1,6–8 Often programs compete for practice settings needed to meet their curricular objectives.⁸ In addition, there is no standardized timing, sequencing, total number, or duration of CEEs across programs.^1,6,8 Inconsistency across academic programs, combined with clinical productivity demands and supervisory requirements, places a significant strain on clinical sites, which can lead to CI burnout, and hesitancy to host students.^3,6–9

COVID-19 exacerbated these issues, creating major challenges. Social distancing reduced the number of people allowed at clinical sites, while shortages of mandated personal protective equipment (PPE) and decreased CI availability due to illness, resignations, layoffs, and furloughs further strained sites. Increased telehealth service delivery that allowed providers to work remotely also reduced onsite CI availability.^10–12 Initially, academic programs were forced to terminate CEEs and remove students from clinical sites, while also facing cancellations for future CEEs.¹¹ The Florida Physical Therapy Association (FPTA) Board of Directors, prompted by the Program Directors (PDs) of DPT programs in the state, created a task force to assess the status and needs of clinical education in the state. This paper describes how a task force of five Directors of Clinical Education (DCE) and three Site Coordinator of Clinical Educations (SCCEs) objectively assessed and managed the changing needs of clinical education during the pandemic. The collaboration led to the creation and implementation of action items to improve clinical education in Florida during and after the crisis.

Clinical education scenario

During the COVID-19 pandemic, DPT and PTA programs had to terminate clinical experiences. Restrictions and clinician shortages due to illness, resignations, or furloughs reduced student placement slots. Clinical sites were forced to cancel or limit their available slots,^10–12 and many could not confirm future placements due to the uncertainty of the situation. Academic sites aimed to advance students to avoid graduation delays maintaining compliance with programmatic and CAPTE requirements ensuring future employability. The shortage of clinical sites and CIs made this increasingly difficult for all clinical educators.

DPT program PDs in Florida requested the FPTA Board of Directors to organize a task force to investigate the clinical education issues and emerging pandemic needs. Clinical educators from academic programs and clinical facilities were recruited. These individuals were selected based on their clinical education expertise and their program’s geographical location.

The task force met virtually and determined that DCEs and SCCEs had differing perceptions of barriers and solutions in clinical education. A needs assessment was deemed essential to accurately capture the evolving situation.

The task force split into two subcommittees: DCEs and SCCEs. The DCE subcommittee developed a DCE needs assessment (academic survey). The subcommittee was composed of DCEs from five programs (DPT and PTA) across the state, and both private and public institutions of varying sizes and delivery modalities (resident and hybrid) were represented. The DCEs experience ranged from 6 to 12 years with a mean of 8.6 years. All DCEs also had experience as a CI or SCCE ranging from 8 to 23 years.

The academic survey was shared with the task force and PDs for feedback and revised until the DCEs reached 100% agreement. The survey strength was enhanced by the DCEs’ experience, the diversity of the institutions’ locations, program sizes, and instructional delivery. Due to the urgent situation, the survey was not piloted. Questions were designed for quick completion using mostly Likert scales, multiple choice, and select-all options (Supplementary Appendix A). The survey focused on the current state and evolving challenges related to student placements, including the confirmation status of future placements. It addressed the program’s demographics and the number of students expected to complete full-time and part-time CEEs in the Classes of 2021 and 2022 during the upcoming Fall, Spring, and Summer semesters. The survey queried the number of confirmed placements and how many had become tentative. Participants were asked to rank perceptions of confidence or likelihood related to student placement situations for the two cohorts, as well as clinical education modifications made by the program and concerns related to those modifications. Perceptions of placement barriers and challenges were also ranked. Open-ended questions were included in the survey but not analyzed due to the low response rate. Distribution was through email to the DCEs/Academic Coordinator of Clinical Education (ACCEs) of all CAPTE-accredited DPT and PTA programs in Florida. Contact information was retrieved from the CAPTE and FPTA websites.

A second needs assessment (clinical survey) was developed by the SCCE subcommittee¹² (Supplementary material B). This subcommittee included therapists from various clinical settings across the state. The SCCEs’ experience as CIs ranged from 8 to 26 years with an average of 15 and as SCCEs from 5 to 10 years with an average of 7. The clinical survey was developed based on task force discussions and review of literature.^12–17 The survey was shared with the task force and a small group of SCCEs for feedback, and consensus was reached with 100% agreement. This survey consisted of three sections. The first section included demographic information, the second section collected information on past students, while the third section collected data regarding the impact of COVID-19 on the clinical site’s clinical education program. Similar to the academic survey, the clinical survey included open- and closed-ended questions, with the majority of questions being multiple choice to enhance completion rates. Snowball sampling was implemented using the databases from several academic institutions and the Florida Consortium of Clinical Educators (FCCE) to disseminate the survey to SCCEs across the state.

Outcomes

The academic survey was distributed to all 51 accredited programs in Florida; 29 programs responded (14 DPT and 15 PTA) equaling a 56.86% response rate. The clinical survey had 48 respondents; the response rate was not calculated due to using snowball sampling. A variety of clinical settings were represented, including ambulatory care/outpatient hospital (35%), acute care/inpatient hospital (23%), acute inpatient rehabilitation (21%), outpatient private practice (7%), skilled nursing facilities (4%), corporate outpatient center (4%), and federal/state/county health, and homecare, school systems, and well/prevention programs were all less than 4%. Both surveys had respondents from across the state.

Descriptive statistics were used to analyze the data. The academic survey showed that programs made modifications to their CEEs (55% for the Class of 2021 and 24% for the Class of 2022), but these modifications varied. The two most common program modifications involved loosening the requirement for students to complete CEEs in diverse care settings and altering the duration of CEEs. This change was adopted by 38% of programs for the Class of 2021 and by 10% for the Class of 2022. Additionally, programs altered CEEs’ duration, 34% adjusting for the Class of 2021 and 10% for the Class of 2022.

DCE/ACCEs’ concerns over the consequences of these modifications included decreased self-confidence (31% concerned or very concerned), delayed graduation (28% concerned or very concerned), and viability of employment (38% concerned or very concerned). Another concern was that a lack of inpatient slots would lead to inadequate inpatient preparation upon graduation. DCE/ACCEs’ perceptions of limiting factors regarding available clinical sites included staffing shortages, decreased patient volume, administrative restrictions at the site, and social distancing (Table 1).

 

Table 1. Perceived barriers in clinical education during the pandemic

DCE/ACCE perceptions
Staffing cuts at clinical sites	66%
Reduction/change in patient volume	72%
Social distancing guidelines	69%
Administration restricts at the site	72%
SCCE perceptions
Changes in the number of CIs available	56%
Constraints of adhering to social distancing guidelines	54%
Management placing student program on hold	33%
Changes in patient census	31%
Limited supply of PPE	23%
No limiting factors	10%
CI: Clinical Instructor; PPE: Personal Protective Equipment; SCCE: Site Coordinator of Clinical Education.

The clinical survey results outlined barriers to hosting students, including a decrease in available CIs, social distancing requirements, and administrative restrictions on student programs (Table 1). To overcome these barriers, SCCEs indicated they would be more likely to host students if academic programs added COVID-19 prevention to the curriculum (52%), provided students with PPE (40%), and decreased the length of CEEs (15%). Ten per cent of respondents indicated that there was nothing the academic institutions could do to help the site host students. Key recommendations identified in both surveys are summarized in Table 2.

 

Table 2. Summary of key perceptions and recommendations

Summary of academic survey
Perceptions limiting placement PTs being laid off Decrease in patient volume Administrative restrictions on hosting students Social distancing guidelines limiting capacity
Challenges faced by academic programs during the pandemic Placing students in a variety of settings Confirming full-time clinical placements Availability of full-time slots
Concerns for the students following graduation Finding employment Graduating with enough experience to practice competently in all settings
Academic program needs during the pandemic and beyond More inpatient opportunities More clinical slots in general
Recommendations made by academic faculty Work with inpatient settings to encourage increased participation in clinical education Modify part-time/integrated clinical experiences to include simulation Increase the use of telehealth options for clinical experiences
Summary of clinical survey
Perceptions of ongoing difficulties in the SCCE role Volunteer role with minimal time allotted for student program Discrepancy on view of the role and ability to fulfill the role
Perceptions of clinician motivation to become a CI Volunteers who may be working towards promotion as incentive Qualified based on willingness to serve and years of experience
Preparation and readiness needs for students and clinical faculty Need for improved student preparation via hands-on practice of tasks specific to setting Need for CI development Limited space and time for students
Recommendations from clinical faculty to academic programs Increase support to the SCCEs and CIs via training and provision of CEUs Clinical skills refresher course for students just before starting CEEs with CI input Add COVID-19 training to the curriculum
PT: Physical Therapist; SCCE: Site Coordinator of Clinical Education; CI: Clinical Instructor; CEU: Continuing Education Units; CEE: Clinical Education Experience.

Action items implemented (Table 3) in response to the evolving situation included an initial email (June 2020) encouraging Florida clinical partners to prioritize Florida students for placements. The task force created an online calendar accessible on the FPTA website that included the timeframes of all CEEs, providing an overview of placement needs for all Florida DPT programs. The calendar highlighted variability in timing, sequencing, and duration of CEEs and elucidated areas of overlap.

 

Table 3. Outcomes from task force action items

Task force action item	Clinician and site benefit	Academic institution benefit
Immediate action during pandemic
Recommendation letter from task force requesting sites prioritize Florida schools for CEE	Increased awareness of the critical CEE needs in Florida	Presented a unified approach to communicate the critical needs of Florida’s DPT and PTA programs
Shared CEE calendar of Florida DPT programs on FPTA website	Provided easy access to SCCEs to simultaneously view the timing of CEE needs for Florida programs	Allowed academic programs access to the CEE dates of other programs to collaborate for placement needs
Infomercial for FPTA conference	Increased awareness of the critical CEE needs in Florida	Presented a unified approach to communicate the critical needs of Florida’s DPT and PTA programs
Implementation of SCCE survey recommendations	Prepared students for COVID-19 considerations in the clinic via educational training Prepared students for the acute care setting via simulation-based learning	Prepared students for COVID-19 considerations in the classroom via educational training
Post pandemic action
Professional development continuing education presented by the FCCE and various academic institutions	Provided clinicians with free continuing education credit for licensure	Supported CAPTE requirement standard 4O4
Implementation of SCCE survey recommendations	Provided support and training via sponsorship of FCCE membership and APTA’s CCIP Prepared students for the acute care setting via simulation-based learning and hospital observations by some academic institutions	Supported CAPTE requirement standard 4O4
Scholarship opportunities	Task force clinicians received mentorship on research dissemination	Strengthened scholarly agendas
CEE: Clinical Education Experience; PTA: Physical Therapist Assistant; DPT: Doctor of Physical Therapy; FPTA: Florida Physical Therapy Association; SCCE: Site Coordinator of Clinical Experience; FCCE: Florida Consortium of Clinical Educators; APTA: American Physical Therapy Association; CCIP: Credentialed Clinical Instructor Program.

The results and recommendations of this study were shared with the FCCE during a virtual meeting in January of 2021. A second letter (March 2021) outlining current critical and longstanding needs of clinical education was disseminated to all Florida physical therapy clinical sites academic institutions through the FCCE, academic listservs, and was included in the FPTA newsletter. The letter suggested that academic programs consider more diversity in what constitutes a CEE, including simulation, decreasing CEE duration, and flexibility in programmatic practice setting requirements. Clinical sites were again asked to prioritize Florida students.

To reach a broader audience, a brief infomercial video produced by the task force was utilized. The infomercial used a skit-story approach containing the same information as the second letter from the task force. The infomercial was automatically played during the 2021 FPTA Virtual Spring Conference. Participants had to watch the video before gaining access to each virtual session. This infomercial provided the opportunity to reach a wider audience including administrators, other faculty members, and students, amongst others.

The online calendar continues to serve as a resource during the student placement process for both academic institutions and clinical sites (Table 3). In addition to the calendar, other long-term strategies were implemented. Some Universities began sponsoring SCCE or CI memberships to the FCCE to increase clinician engagement. Also, more CIs were sponsored by academic programs to the American Physical Therapy Association Credentialed Clinical Instructor Program to assist with professional development. Additional outcomes from various institutions included free webinars, newsletters highlighting evidence-based articles, and professional development training for CIs and SCCEs. Standardized inpatient simulations and hospital visits during didactic courses were also added to DPT curriculums in several universities. The task force collaboration provided a scholarship opportunity for its members with the outcomes disseminated at local, regional, and national levels, therefore increasing awareness of clinical education needs.

Discussion and implications

Many of the action items implemented have been advocated by previous task forces to build stronger academic–clinical partnerships.^6–8 Understanding the state of clinical education from different perspectives during the COVID-19 pandemic was essential. The management of students from an anecdotal knowledge base is not a standard of best practice¹⁸; therefore, the task force obtained data to guide the decision-making processes during an unprecedented time. Decisions were best organized by a system-level support network versus each program working in isolation. This collaboration has remained vital to Florida’s approach to clinical education. A non-competitive environment that shares resources is the foundation for advancing clinical opportunities for students in Florida.

The challenges identified and exacerbated by COVID-19 were not all new problems in clinical education.^19,20 The need for a contemporary approach to addressing and managing these issues became clear. Previous studies have found that DCEs experience deficits of sufficient offers in acute care settings, similar to what was experienced by the DCEs/ACCEs in Florida.^7,20 In 2021, Rindflesch et al.⁷ also suggested academic institutions consider curriculum changes as well as training and support for SCCEs, which mirrors the results of the task force.

Future research should be performed to assess academic program outcomes following this time period to determine if these changes had any impact on student placement and performance such as first time National Physical Therapy Examination pass rates and employment rates. Equally important is to continue to have clinical educators support each other and develop relationships that are transparent, meaningful, and collaborative. This enhanced relationship was the silver lining for this task force’s experience. Sharing of resources relieved stress among DCEs/ACCEs while allowing students to meet programmatic needs for graduation.

A limitation of this study was a reduced response rate from the PTA programs (45%) as compared to DPT programs (93%). PTA programs were not included in the calendar development, which would directly impact representation of student placement needs. Another limitation is the low response rate from clinical sites. Future recommendations include increased individual PTA membership in the FPTA and PTA program participation in the development of a CEE calendar.

In conclusion, through unprecedented challenging times, these clinical educators were able to combine efforts to identify problems, to develop and implement solutions, and to position clinical education for success in the state of Florida during and beyond the pandemic. The process implemented by the task force can also serve as a model of response in future emergency events. With a data-based approach, mutual understanding of each other’s needs and barriers is obtained, a crisis was overcome, and processes were implemented and improved to enhance the future of clinical education in the state of Florida.

Ethical approval

IRB Protocol Exemption #: IRB-20-0513.

References

1.	CAPTE. Aggregate program data [updated 1 March 2024]. Available from: https://www.capteonline.org/globalassets/capte-docs/aggregate-data/capte-2023-pt-fact-sheet.pdf [cited 15 June 2024].
2.	Christensen N, Jones MA, Edwards I, et al. Helping physiotherapy students develop clinical reasoning capability in clinical reasoning in the health professions. 3rd ed. Amsterdam: Elsevier; 2008, pp. 389–96.
3.	Rodger S, Webb G, Devitt L, et al. Clinical education and practice placements in the allied health professions: an international perspective. J Allied Health (2008) 37(1): 53–62.
4.	Standards and required elements for accreditation of physical therapist education programs [updated 8 September 2022]. Available from: https://www.capteonline.org/globalassets/capte-docs/capte-pt-standards-required-elements.pdf [cited 20 June 2024].
5.	Standards and required elements for accreditation of physical therapist assistant education programs [updated 8 September 2022]. Available from: https://www.capteonline.org/globalassets/capte-docs/capte-pta-standards-required-elements.pdf [cited 20 June 2024].
6.	Jette D, Nelson L, Palaima M, et al. How do we improve quality in physical therapy education? Examination of structures, processes, and outcomes. J Phys Ther Educ (2014) 28(1): 6–12. doi: 10.1097/00001416-201400001-00004
7.	Rindflesch A, Flom-Meland C, McCallum C, et al. Toward standardization of the placement process used in full-time clinical education experiences: findings and recommendations of the placement process task force. J Phys Ther Educ (2021) 35(3): 171–81. doi: 10.1097/JTE.0000000000000193
8.	McCallum C, Mosher P, Howman J, et al. Development of regional core networks for the administration of physical therapist clinical education. J Phys Ther Educ (2014) 28: 39–47. doi: 10.1097/00001416-201400001-00008
9.	Layman EJ, Bamberg R. Coping with a turbulent health care environment: an integrative literature review. J Allied Health (2006) 35(1): 50–60.
10.	Impact of COVID-19 on the physical therapy profession over one year a report from the American Physical Therapy Association; 2021. Available from: https://www.apta.org/contentassets/15ad5dc898a14d02b8257ab1cdb67f46/covid-19-impact-report.pdf [cited 6 March 2023].
11.	Hyland N, Vore ME, Chan C, et al. COVID-19 impact on students in physical therapist and physical therapist assistant education programs in New York and New Jersey: Key issues and recommended responses. J Phys Ther Educ (2021) 35: 279–85. doi: 10.1097/JTE.0000000000000205
12.	Svoboda SM, Kostrna J, Pabian P. The impact of COVID-19 on physical therapy clinical education experiences in Florida. J Phys Ther Educ (2023) 37(3): 220–6. doi: 10.1097/JTE.0000000000000286
13.	Recker-Hughes C, Padial C, Becker E, et al. Clinical site directors’ perspectives on clinical education. J Phys Ther Educ (2016) 30: 21–7. doi: 10.1097/00001416-201630030-00005
14.	Silberman N, LaFay V, Zeigler S. Practices of exemplary leaders in clinical education: a qualitative study of director and site coordinator of clinical education perspectives. J Phys Ther Educ (2020) 34: 59–66. doi: 10.1097/JTE.0000000000000119
15.	Timmerberg JF, Dungey J, Stolfi AM, et al. Defining the role of the center coordinator of clinical education. J Phys Ther Educ (2018) 32: 38–45. doi: 10.1097/JTE.0000000000000017
16.	American Physical Therapy Association. Reference manual for site coordinators of clinical education. 2018. Available from: https://assets-002.noviams.com/novi-file-uploads/apta-aoe/Resources/Clinical_Educator_Resources/2018-SCCE-Manual-FINAL.pdf [cited 23 August 2022].
17.	American Physical Therapy Association. Physical therapist student evaluation: clinical experience and clinical instruction [updated 27 December 2010]. 2010. Available from: https://www.apta.org/for-educators/assessments [cited 23 August 2022].
18.	Litvaj I, Ponisciakova O, Stancekova D, et al. Decision-making procedures and their relation to knowledge management and quality management. Sustainability (2022) 14(1): 572. doi: 10.3390/su14010572
19.	Triggs NM, Shepard KF. Physical therapy clinical education in a 2:1 student-instructor education model. Phys Ther (1996) 76(9): 968–81. doi: 10.1093/ptj/76.9.968
20.	Coleman J, Knott K, Jung B. Impact of physical therapy and occupational therapy student placements on productivity: a scoping review. Can Med Ed J (2021) 12(4): 98–110. doi: 10.36834/cmej.69298