ORIGINAL RESEARCH ARTICLE

Perspective in physical therapy education: creating a communication network to connect clinical education stakeholders

Janice Howman^1*, Tawna C. Wilkinson², Nancy F. Mulligan³, Kara L. Lardinois⁴ and Colette Pientok⁵

¹Associate Clinical Professor and Director of Clinical Education, Ohio University, Athens, OH; ²Associate Professor and Director of Clinical Education, A.T. Still University of Health Science, Mesa, AZ; ³Associate Professor and Director of Clinical Education, Regis University, Denver, CO; ⁴Clinical Instructor, Duke University Health System, Durham, NC; ⁵Education Manager/Site Coordinator of Clinical Education, Memorial System, Houston, TX

Abstract

Current issue: Collaboration among national, regional, and local physical therapy (PT) clinical education (CE) stakeholders is variable, creating fragmentation, duplication of efforts, and inconsistent lines of communication.

Perspective: A formalized network for effectively communicating across all CE stakeholders is needed to promote excellence in PT education. Whether centralized, decentralized, or blended, determining the best organizational structure to position the CE community for the future is critical. Participants at the 2018 National Consortium of Clinical Educators regional networking session envisioned the ideal network as a blended structure with shared leadership and centralized resources in either a bottom-up–top-down or circular configuration. A web of communication pathways connecting all CE stakeholders was also emphasized.

Implications for clinical education: Transforming the vision of CE partnerships from the narrow academic program–clinical site dyad to a broader, well-connected CE ecosystem is a prerequisite to develop a communication network. National, regional, and local stakeholders, including clinical representatives, must contribute to the development of the network. Information and communication technologies (ICTs) are critical for building efficient, bidirectional interorganizational communication. The time is right for national leadership to collaborate with local CE stakeholders to identify the best network structure and ICTs to move the profession forward in its pursuit of educational excellence.

Keywords: clinical education; communication; network

MeSH Terms: education, communication, organization

 

 

Numerous initiatives are underway in the pursuit of excellence in physical therapy (PT) professional education, including clinical education (CE).^1–5 To achieve this vision of excellence, it is important to engage stakeholders, regardless of their geographic proximity, in sharing perspectives and promoting best practices. Interactions among CE stakeholders can be considered on a national, regional, and local continuum. Currently, national, regional, and local stakeholders intermittently and randomly interact but consistent, widespread horizontal communication among stakeholders at the same level and vertical communication up and down the continuum is lacking. Lack of consistent communication has, at times, created fragmentation, variation, and duplication of efforts. Some top-down efforts to enhance coordination among stakeholders from the American Physical Therapy Association (APTA) have begun, but a broader CE communication network could engage and connect stakeholders at all levels.

The APTA includes two groups dedicated to professional education: the American Council of Academic Physical Therapy (ACAPT) and the Academy of Education (referred to as the Academy hereafter). Each group has a CE component, the National Consortium of Clinical Educators (NCCE), and the Clinical Education Special Interest Group (CESIG), respectively. To connect these stakeholders, APTA, ACAPT, and the Academy developed the Education Leadership Partnership (ELP) in 2016.⁶ The breadth of perspective provided by collaboration among all national stakeholders with an interest in professional education is foundational to advancing the ELP’s purpose of promoting excellence in PT education.⁷ Whether a result of this formalized partnership or not, communication among APTA and its component groups (ACAPT/NCCE and the Academy/CESIG) was perceived as strong by regional CE stakeholders when given rating choices of strong, less reliable, or nonexistent (Table 1). This same group of stakeholders noted less reliable lines of communication between ACAPT/NCCE and the Academy/CESIG, indicating that there is still room for improved horizontal communication among national-level CE stakeholders.

Table 1. Regional stakeholder perceptions of horizontal and vertical communication among various clinical education stakeholders at the national, regional, and local levels gathered during the 2018 National Consortium of Clinical Educators regional networking session (majority response reported)

Horizontal communication
Level	Perception
National level
American Physical Therapy Association (APTA) ←→ the Academy of Education/Clinical Education Special Interest Group (CESIG )	Strong
APTA ←→ American Council of Academic Physical Therapy (ACAPT)/National Consortium of Clinical Educators (NCCE)	Strong
the Academy/CESIG ←→ ACAPT/NCCE	Less reliable
Regional level
Regional consortia ←→ Regional consortia	Nonexistent
Local level
Clinic Site ←→ Clinic Site	Nonexistent
Academic Program ←→ Academic Program	Strong
Academic Program ←→ Clinic Site	Less reliable
Vertical communication
Level	Perception
National ←→ Regional	Mixed perceptions*
National ←→ Local	Nonexistent
Regional ←→ Academic program	Strong
Regional ←→ Clinic site	Less reliable
Abbreviations: ACAPT, American Council of Academic Physical Therapy; APTA, American Physical Therapy Association; CESIG, Clinical Education Special Interest Group; NCCE, National Consortium of Clinical Educators. *Stakeholder responses equally distributed among reports of strong, less reliable, and nonexistent communication.

Regionally, many academic programs and clinic sites collaborate in well-established grassroots consortia with varying structures, processes, and outcomes.⁸ These consortia functioned primarily in isolation until 2016 when the NCCE began sponsoring annual regional networking sessions to facilitate collaboration among regional CE stakeholders.⁹ The 2018 regional networking session focused on effectiveness of CE communication to explore the need for developing a national network. During this session, most participants described horizontal communication between regional consortia as nonexistent (Table 1). The role of regional consortia in a national communication network was also explored. Although both positive and negative responses were reported, more favorable comments were noted.¹⁰ These favorable comments highlighted benefits of involvement in a national network, such as improved cohesiveness, strengthened partnerships, enhanced efficiencies, expanded uniformity, broadened transparency, and increased sharing.¹⁰ Participants who expressed reluctance about regions participating in a national communication structure focused on concerns related to grassroots organizations becoming embedded in a national structure.¹⁰ The most frequently noted concerns were competition, trust, equal representation, multiple layers of bureaucracy, and national oversight.¹⁰

Local CE stakeholders include organizations (academic programs and clinic sites) and individuals (Directors of Clinical Education, Site Coordinators of Clinical Education, Clinical Instructors, academic faculty, academic program and clinic site administrators and students). According to regional CE stakeholders, horizontal communication effectiveness at the local level varies by stakeholder group (Table 1). Strong lines of communication were perceived between academic programs while communication across clinic sites was considered nonexistent. Communication lines between academic programs and clinic sites were noted as less reliable.

In addition to horizontal communication among stakeholders at the same level, vertical communication is necessary to connect local and regional stakeholders with national leadership. The importance of engaging local or grassroots, community-based individuals, and organizations is evident in the public health sector where community mobilization is routinely employed.¹¹ From health promotion campaigns to infectious disease outbreaks, grassroots engagement has helped overcome social barriers, build trust, and maximize success while empowering grassroots volunteers.^12–15 In the context of a CE network, strong bottom-up connections are needed for grassroots stakeholders to provide input and feel engaged with national initiatives while top-down lines of communication are important for sharing information and fostering transparency. During the 2018 regional networking session, vertical communication channels were reported but their effectiveness varied (Table 1). For example, strong communication was perceived between regional consortia and academic programs, but less reliable lines of communication between regions and clinic sites were reported. Communication between the national level and clinic sites was unanimously described as nonexistent.

Perspective

The lack of strong, well-established lines of communication among all CE stakeholders affirms the need for development of a formal CE network. Formal interorganizational networks can result in positive outcomes at the partnership, community, and single organization levels.^16,17 Enhanced partnerships, problem-solving, innovation, quality of services, accessibility to services, worker satisfaction, organizational legitimacy, and circulation of best practices have been described as positive collaborative outcomes.^17,18 Shumate et al. also noted that collaboration breeds collaboration, stating ‘most successful large-scale interorganizational networks grew out of the fertile field of previous successful collaborating groups’¹⁸ (p. 19). Given that many of these outcomes are desirable in the pursuit of CE excellence and that pockets of collaboration already exist, it seems like the time is right for development of a national network.

There are multiple ways to configure an interorganizational network; therefore, structural characteristics and organizing principles, such as formalization, trust, and network management, must be considered to ensure successful collaboration.^16,19,20 Structurally, networks can be centralized with a hierarchical governance or decentralized with a flat or shared governance.¹⁹ Successful centralized networks have less formalization of policies and function, more informal relationships, and more network management; decentralized networks have more integration, less network management, more power sharing, and more formalization through contracts, agreements, and policies.^16,20,21 Trust is important in all network structures,²¹ but it must be stronger and broader in decentralized networks to facilitate cooperation and achieve outcomes.¹⁶ Many global business organizations are beginning to use a blended approach to realize the benefits of both centralization and decentralization.²² In a blended structure, employees or stakeholders maintain their autonomy while leadership centrally houses and shares resources to facilitate efficiency and consistency of performance.²²

During the 2018 networking session, regional stakeholders shared their perspectives on the ideal communication structure for connecting all CE stakeholders. Two types of interorganizational networks emerged from their visual representations: bottom-up–top-down and circular (Fig. 1). Most bottom-up–top-down communication networks showed shared leadership (decentralized) at the top of the hierarchy.¹⁰ In these models, leadership was either shared between national level stakeholders (APTA, ACAPT, and the Academy) or between national and regional level stakeholders.¹⁰ The circular communication structures connected stakeholders to a central organization that varied between regional consortia, NCCE, ACAPT, and a national database system.¹⁰ In both the bottom-up–top-down and circular structures, specific communication conduits were outlined, including ‘permeable’ channels of communication connecting all levels of stakeholders. Regional stakeholders also highlighted the need for centralized communication technologies, such as Facebook groups or Listserv structures, to ensure ‘one message’ to all stakeholders and centralization of resources through a ‘one-stop shop’.

Fig. 1.  Examples of regional stakeholders’ communication structures for a clinical education network showing a bottom-up-top-down structure with shared leadership and a circular structure with permeable channels of communication.

Overall, a blended approach emerged as the ideal network structure with shared leadership and centralization of resources. The importance of vertical and horizontal communication among all stakeholders was also noted. Based on this information, regional stakeholders appear to be interested in a blended network that connects all levels of stakeholders, allows for open access of resources, and shares a consistent message through efficient use of information and communication technologies (ICT).

Implications for clinical education

Developing a framework for academic–clinical partnerships has emerged as a common theme in several strategic initiatives^4,23 and in the current ELP and ACAPT strategic plans.^6,24 In fact, academic–clinical partnerships comprise one of the four work categories in ELP’s long-term strategic planning process and was one of the subgroup topics at the CE strategy meeting in 2018.²⁵ While most discussions about academic–clinical partnerships focus on individual-level relationships between academic programs and clinic sites, discussion at the CE strategy meeting began considering CE stakeholder partnerships more globally with the subgroup reporting ‘excellence in clinical education partnership promotes multi-level [emphasis added] relationships devoted to collaboration, accountability, capacity, and mutual benefits’²⁵ (p. 24). If the profession wants to foster innovation and best practices in CE, developing this vision of academic–clinical partnerships on a broader level would be an important step forward.

Moving from the narrow dyad (academic program, clinic site) view of CE stakeholders to a broader view of interconnected stakeholders in a CE ecosystem will better position the profession to achieve educational excellence. Like the service ecosystem described in marketing literature,²⁶ a CE ecosystem would enhance value for all stakeholders through communication and sharing since no single stakeholder has all the necessary resources to provide quality CE in isolation. An ecosystem conceptualization also emphasizes the importance of the broad web of interactions needed among stakeholders to adapt and survive in a constantly changing environment,²⁰ such as today’s healthcare and higher education environments.

To achieve the vision of a well-integrated CE ecosystem with equal representation of academic and clinical stakeholders at all levels, the profession must investigate both academic and healthcare environmental factors that can affect the development of an interorganizational communication network (Fig. 2). For example, rapid expansion of PT and physical therapist assistant programs^27,28 combined with challenges in the current healthcare environment contribute to increasing demand and competition in CE.²⁹ This competitive environment can cause some hesitation for development of a national CE network, as noted by some regional stakeholders, especially if communication lines are nonexistent. It also emphasizes the importance of building and maintaining stakeholder trust when moving toward a national communication structure.¹⁶ Fostering trust will facilitate initial network development and can increase the likelihood of successful outcomes.¹⁶ Other examples of environmental factors needing consideration are also displayed in Fig. 2.

Fig. 2.  A clinical education ecosystem with an interconnected web of communication and collaboration between all clinical education stakeholders in the current academic and healthcare environment.

The next step would be to facilitate network development. Fostering interaction within and among all levels of stakeholders will enhance resiliency and sustainability of a CE ecosystem,²⁶ but connecting such a broad network of diverse and autonomous stakeholders is no easy task. The complexity of bidirectional communication across multiple organizations and multiple levels must be considered.¹⁸ Knowing that communication can be supported by the proper use of communication technologies,³⁰ it is not surprising that regional stakeholders emphasized their desire for a streamlined technology infrastructure that facilitates communication in all directions when envisioning their ideal structure.¹⁰ Currently, APTA Communities³¹ and ACAPT discussion boards³² attempt to facilitate bidirectional, open communication using ICT but efficient, broad use of these platforms is limited because users must seek out information or member login may be required. With only about 30% of practicing PTs being members of APTA,³³ requiring member login can significantly reduce access to resources. While necessary, it must also be recognized that ICT-assisted interorganizational communication can be hindered by system incompatibly, limited infrastructure, poor design, and improper tools.^18,30 Therefore, designing an infrastructure that is efficient, bidirectional, and accessible to all stakeholders and also user-friendly will require collaboration with experts in the ICT industry.

Broader input from national and local stakeholders, including clinicians, is also needed. The 2018 regional networking session revealed support and provided foundational information for development of a national CE network, but the participant demographics lacked breadth. The uneven distribution of academic (74%) and clinical (26%) educators minimized the clinical viewpoint. In addition, the clinical educators who were present may not represent the majority of clinical educators. Barriers to clinician participation must be overcome to ensure that this crucial group of stakeholders is engaged. Trialing small-scale communication efforts to reach local clinical stakeholders is a necessary first step to engage, empower, and gain the trust of these integral members of the ecosystem.

It is time for the NCCE and CESIG, as national leaders in CE, to engage regional and local stakeholders in identifying best structure and ICT to create a broad communication network connecting our CE ecosystem to achieve excellence in PT education.

Ethics statement

No IRB/Ethical board approval required. A portion of content was published in a report to ACAPT and NCCE.

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