PHYSIOTHERAPY CANADA

142 Physiotherapy Canada, Volume 72, Number 2 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 8:36:50 PM - IP Address:43.246.243.82 expressed interest in the study. Rounds 2 and 3 remained instances), removing the professionalism domain and its open for 2 weeks each, separated by a 2-week period. supporting competencies, and combining or replacing multiple supporting competencies with a single support­ Round 1 ing competency (7 instances). Renaming the baseline On the basis of the literature review, we identified 11 assessment domain and combining a number of domains and organizing them according to sub-headings was also domains (distinct components of suctioning) – baseline proposed. assessment, access to appropriate equipment, equipment preparation, patient preparation, suctioning procedure, In addition, nine new supporting competencies sug­ patient monitoring, post-suctioning care, post-suctioning gested by participants in Round 1 were rated. The rating assessment, infection control, communication with the scale does not meet expectations, meets expectations, ex­ health care team, and professionalism – and 69 support­ ceeds expectations received the highest mean score (2.4 of ing competencies (essential subcomponents). Consensus 3); 83% of the participants preferred a tool that enabled was achieved for all domains; however, it was borderline the rater to rate a physical therapist’s performance on for the professionalism domain (79% agreed or strongly each of the individual supporting competencies, and 87% agreed that it should be included). Multiple participants wanted a tool to include an item rating the individual’s suggested that it was redundant given that it is a global overall performance. A summary of the results for all requirement for all physical therapists and is not specific Round 1 and 2 items is available from the authors on to suctioning. Consensus was also achieved for 64 of request. the 69 supporting competencies; however, it was border­ line for 5 of these items, and 5 achieved no consensus. Round 3 Table 2 provides a summary of the results for the support­ After Round 2, 11 outstanding items were brought for­ ing competencies that achieved borderline or no consen­ sus. ward to the EAC for a final decision. The Round 2 results for these items, as well as the decisions from the EAC, are Round 2 provided in Table 3. The participants then rated the pre­ The participants’ comments and responses from liminary tool, and the results from the sensibility question­ naire are shown in Table 4. Seven of those 10 items had a Round 1 were used to generate 39 recommendations for mean score of 4 or more out of 5 and were therefore the participants to consider in Round 2. These recom­ deemed to be sensible; the remaining 3 items had a mean mendations included adding new examples under the score of less than 4 out of 5. Overall, the preliminary tool supporting competencies (4 instances), rewording or was deemed to be globally sensible with a combined mean modifying the content of the supporting competencies score for all items of 4 out of 5. The participants’ comments (10 instances), removing the supporting competencies (9 suggested that although the participants thought that the Table 2 Items That Achieved Borderline or No Consensus in Round 1 Percentage Domain and supporting competencies SD+D N A+SA Consensus Access to appropriate equipment (ensures that it is accessible and in working order) 3 18 79 Borderline Mask and goggles or face shield 21 18 62 Not achieved Sterile gloves for open-system suctioning 21 30 48 Not achieved Gown 21 74 Borderline A nasal–pharyngeal airway if frequent nasotracheal suctioning is being performed 6 15 74 Borderline Patient preparation 12 29 59 Not achieved Has informed consent for suctioning 12 41 50 Not achieved If not contraindicated, positions the patient in Fowler’s or semi-Fowler’s position Does not routinely perform hyper-inflation 9 21 79 Borderline 24 74 Borderline Suctioning procedure 0 Continuous suction is used during withdrawal of suction catheter for patients with an artificial airway 3 29 68 Not achieved Does not routinely instill saline 3 Domain: Post-suctioning care If hyper-oxygenation is performed, it is done for at least 1 min Note: Percentages may not total 100 because of rounding. SD+D = strongly disagree and disagree; N = neutral; A+SA = agree and strongly agree.

Miller et al. Using Expert Consensus to Develop a Tool to Assess Physical Therapists’ Knowledge, Skills, and Judgement in Performing Airway Suctioning 143 Table 3 Summary of Items Presented to EAC after Round 2 Percentage https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 8:36:50 PM - IP Address:43.246.243.82 Item SD+D N A+SA Consensus EAC’s decision “Verifies the identity of the patient” should be included as a supporting competency. 13 17 70 Borderline Exclude “Ensures that hand sanitizer and soap/water are accessible” should be included as a supporting 20 23 57 Not achieved Exclude competency. 37 43 20 Not achieved Exclude “Verifies the expiration date on the package of the sterile suction catheter (for open system 10 20 70 Borderline Re-word suctioning only)” should be included as a supporting competency. “Sets the suction pressure to 150 mmHg or less” should be replaced by “Sets the suction 24 45 31 Not achieved Exclude pressure to 120 mmHg or less.” 27 30 43 Not achieved Exclude “If not contraindicated, the patient’s head is in a slightly extended position” should be 7 30 63 Not achieved Exclude included as a supporting competency. 3 37 60 Not achieved Exclude “Has informed consent for suctioning” should be excluded. 3 27 70 Borderline Exclude “If not contraindicated, positions the patient in Fowler’s or semi-Fowler’s position” should be 13 23 63 Not achieved Exclude excluded. “Does not routinely perform hyper-inflation” should be excluded. 3 33 63 Not achieved Exclude “Post-suctioning care: if hyper-oxygenation is performed, it is done for at least 1 minute” should be excluded. “Is able to demonstrate reflective thinking about the encounter” should be included as a supporting competency. The professionalism domain and its supporting competencies should be excluded. Note: Percentages may not total 100 because of rounding. EAC = Expert Advisory Committee; SD+D = strongly disagree and disagree; N = neutral; A+SA = agree and strongly agree. Table 4 Round 3 Sensibility Questionnaire Mean (max score of 5) Item 4.04 4.12 1. The tool is clear. 4.22 2. The tool would be easy to use. 3.60 3. The tool has identified all necessary related factors. 4.04 4. The tool does not include any redundant factors. 4.08 5. The tool is appropriate for assessing knowledge related to tracheal suctioning. 3.92 6. The tool is appropriate for assessing skills related to tracheal suctioning. 3.80 7. The tool is appropriate for assessing judgement related to tracheal suctioning. 4.16 8. The tool is acceptable in terms of its comprehensiveness and the amount of time it would take to complete. 4.16 9. You would use this tool as a resource for clinical practice or teaching. 4.01 10. Overall, this tool would be useful for physical therapists. Overall mean tool would be useful, they were concerned that it was a lit­ tool with four domains, six sub-domains, and 43 support­ tle long and included a number of redundant items. ing competencies, as well as a final item rating the indivi­ dual’s overall performance and a comments box. The Developing the final tool revised tool is included as the online Appendix. In an effort to make the tool clearer and more concise, DISCUSSION we revised the instructions for the tool, made minor We have described the development of a new tool to wording changes, moved examples under the supporting competencies to a glossary, collapsed three supporting assess physical therapists’ competence for performing competencies into other similar items, and removed suctioning with adults. Using consensus methods is not a three supporting competencies identified by the partici­ novel approach for developing assessment tools in physi­ pants as being redundant. These revisions resulted in a cal therapy.33–35 The Delphi method is particularly useful

144 Physiotherapy Canada, Volume 72, Number 2 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 8:36:50 PM - IP Address:43.246.243.82 in cases in which the information about a topic is incom­ equipment domain. The not applicable option was also plete,29 which is the case for the evidence on the optimal added to recognize that the appropriate suctioning proce­ performance of suctioning. Early clinical practice guide­ dure may vary according to the individual case, as well lines for suctioning found a complete absence of studies as the type of suctioning approach used and the practice on issues such as the optimal suctioning approach and context. This is in line with our goal to create a tool using an artificial airway (e.g., an oral airway or a nasal- that will apply in the different practice settings in which pharyngeal airway) for non-intubated patients, suction suctioning is performed (e.g., the intensive care unit, criti­ catheter diameter, suctioning frequency, optimal suction cal and acute care environments, long-term care, home pressure, the depth at which to apply suction pressure, care), as well as across suctioning approaches (e.g., endo­ use of continuous versus intermittent suction, catheter tracheal, orotracheal, nasotracheal, using a tracheostomy). rotation, and use of lubricating gel or water.26 Van Der Vleuten identified five variables to consider More recently, the evidence base for suctioning adults with regard to the utility of assessment methods for pro­ has improved; however, evidence to inform suctioning fessional competence: reliability, validity, educational practices on non-intubated individuals has remained impact, acceptability, and cost.40 Acceptance of the tool scarce, and the majority of studies have had small sample is critical.40,41 For that reason, our participants included sizes.12 Relevant clinical practice guidelines from the physical therapists who were likely to use the tool in the American Association of Respiratory Care and Chaseling future (e.g., practising clinicians and educators). Overall, and colleagues continue to highlight ongoing gaps in the the preliminary tool was deemed to be globally sensible, literature, providing mainly weaker strength practice re­ and this assessment provides preliminary evidence of its commendations.1,25 In the current study, we systematically face and content validity. Future studies will explore the gathered and consolidated expert opinion to supplement utility of the revised tool, including an assessment of its the existing relevant literature as we developed the tool. reliability and validity for use with physical therapists in the Canadian health care context. Checklists and global rating scales (GRSs) are two common assessment methods. When using checklists, The assessment tool we developed represents only one clinicians evaluate individuals against a list of specific possible method of assessment. A single assessment predefined behaviours, using a binary scale to indicate method is likely not sufficient to capture the complex array whether they are at or below the standard.8 In contrast, of information needed to make an informed judgement GRSs provide a more global impression of an individual’s about successfully delivering services in health care.42 This overall performance or performance on relevant sub- tool is also not intended to replace the judgement of skilled tasks.36 Checklists have been criticized for rewarding evaluators or provide a definitive or stand-alone judge­ thoroughness rather than expertise, and the psychomet­ ment of a physical therapist’s clinical competence for suc­ ric properties of GRSs are commonly thought to be more tioning. Individuals using this tool in the future should robust.37–39 A recent systematic review of the validity evi­ consider how it fits within broader assessment frame­ dence for checklists compared with GRSs in simulation- works, including multiple assessment approaches and as­ based assessments in health care generally supported sessments across multiple points in time. both, but the authors did convey the additional impor­ tant benefits of GRSs, including the fact that they poten­ This study had several limitations. Although we met or tially applied across multiple tasks and could better exceeded our target sample size in all rounds and the capture subtle differences in performance expertise.36 sample included participants from six Canadian pro­ vinces, experts from Ontario accounted for the majority During Round 2, the majority of our participants indi­ of the study participants. In addition, nearly all the prac­ cated a preference for a tool that would enable a rater tising physical therapists who participated identified to rate performance on each supporting competency. their primary practice setting as acute care. The results Although this preference aligns more closely with a may therefore have been biased to more strongly reflect checklist-based approach, the participants did support the relevant opinions and practices of Ontario-based including an item at the end of the tool that would pro­ physical therapists and those working in acute care envir­ vide a more global assessment of performance. More­ onments, as opposed to reflecting a broader national per­ over, a three-level rating scale was selected, allowing for a spective. Finally, although our study questionnaires were greater appreciation of variation in performance com­ available only in English, we attempted to partially miti­ pared with a binary scale. gate this issue by allowing participants to provide written comments in French when they requested it. Of note is the fact that the scale included in the tool is a modification of the scale selected by the study partici­ CONCLUSIONS pants. In consultation with the EAC, we realized that the Using a modified Delphi methodology, we developed scale initially selected did not align well with a number of items in the tool. For example, it would not be possible a new tool to assess physical therapists’ clinical compe­ for an individual to exceed expectations on items in the tence for performing airway suctioning with adults. The

Miller et al. Using Expert Consensus to Develop a Tool to Assess Physical Therapists’ Knowledge, Skills, and Judgement in Performing Airway Suctioning 145 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 8:36:50 PM - IP Address:43.246.243.82 final-round sensibility questionnaire provided initial evi­ 11. Sullivan GM. A primer on the validity of assessment instruments. J dence of the tool’s face and content validity, but the par­ Grad Med Educ. 2011;3(2):119–20. https://doi.org/10.4300/jgme-d­ ticipants expressed concerns that the tool included 11-00075.1. Medline:22655129 redundant factors and was a little long. The tool was re­ vised accordingly, and in the next phase of developing 12. Overend TJ, Anderson CM, Brooks D, et al. Updating the evidence- the tool, we will further assess its utility. base for suctioning adult patients: a systematic review. Can Respir J. 2009;16(3):e6–e17. https://doi.org/10.1155/2009/872921. KEY MESSAGES Medline:19557211 What is already known on this topic 13. Lexico.com. Knowledge [Internet]. Oxford (UK): dictionary.com, Airway suctioning is an important but potentially dan­ Oxford University Press; n.d. [cited 2018 June 28]. Available from: https://en.oxforddictionaries.com/definition/knowledge. gerous intervention performed by health care profes­ sionals, including physical therapists. Given the high-risk 14. Nutter D, Whitcomb M. The AAMC project on the clinical education nature of this technique, it is important to assess the clin­ of medical students: clinical skills education [Internet]. Washington ical competence of the health care professionals who per­ (DC): Association of American Medical Colleges; n.d. [cited 2018 form it. Previous tools have been developed for this June 28]. Available from: https://www.aamc.org/download/68522/ purpose, but they are not relevant to current physical data/clinicalskillsnutter.pdf. therapy practice. 15. Cambridge Dictionary. Judgment [Internet]. Cambridge (UK): What this study adds Cambridge University Press; n.d. [cited 2018 June 28]. Available from: This study describes how we used expert consensus to https://dictionary.cambridge.org/dictionary/english/judgment. develop a comprehensive up-to-date tool to guide the 16. Hsu CC, Sandford BA. The Delphi technique: making sense of objective assessment of physical therapists performing consensus. Pract Assess Res Eval [Internet]. 2007 [cited 2018 Jan 30]; airway suctioning. This process resulted in the creation of 12(10). Available from: https://pareonline.net/pdf/v12n10.pdf. a tool that study participants thought would be useful to physical therapists. The revised tool is provided in the 17. von der Gracht HA. Consensus measurement in Delphi studies. online Appendix, and we plan to conduct further studies Technol Forecast Soc Change. 2012;79(8):1525–36. https://doi.org/ to assess its utility. 10.1016/j.techfore.2012.04.013. REFERENCES 18. Boulkedid R, Abdoul H, Loustau M, et al. Using and reporting the Delphi method for selecting healthcare quality indicators: a 1. American Association for Respiratory Care. AARC clinical practice systematic review. PLoS One. 2011;6(6):e20476. https://doi.org/ guideline: endotracheal suctioning. Respir Care. 2010;55(6):758–64. 10.1371/journal.pone.0020476. Medline:21694759 2. Regulated Health Professions Act, 1991, SO 1991, c. 18 [Internet]. 19. Humphrey-Murto S, Varpio L, Wood TJ, et al. The use of the Delphi Ottawa. [cited 2018 Sept 29]. Available from: https://www.ontario. and other consensus group methods in medical education research: ca/laws/statute/91r18. a review. Acad Med. 2017;92(10):1491–8. 3. Physiotherapy Act, 1991, SO 1991, c. 37 [Internet]. Ottawa. [cited 2018 20. Duong M, Bertin K, Henry R, et al. Developing a physiotherapy- Sept 29]. Available from: https://www.ontario.ca/laws/statute/91p37. specific preliminary clinical decision-making tool for oxygen titration: a modified Delphi study. Physiother Can. 2014;66(3):286– 4. College of Physiotherapists of Ontario. How to roster for controlled 95. https://doi.org/10.3138/ptc.2013-42. Medline:25125782 acts [Internet]. Toronto: The College; 2018 [cited 2018 Jan 21]. Available from: https://collegept.org/members/rostering. 21. Thompson L. Suctioning adults with an artificial airway: a systematic review. Adelaide (SA): Joanna Briggs Institute for Evidence Based 5. College of Physiotherapists of Ontario. Standard for professional Nursing and Midwifery; 2000. practice: performing controlled acts and other restricted activities [Internet]. Toronto: The College; 2018 [cited 2018 Jan 21]. Available 22. Pederson CM, Rosendahl-Nielsen M, Hjermind J, et al. Endotracheal from: http://www.collegept.org/Standards/Controlled_Acts. suctioning of the adult intubated patient – what is the evidence? Intensive Crit Care Nurs. 2009;25(1):21–30. https://doi.org/10.1016/j. 6. Epstein RM, Hundert EM. Defining and assessing professional iccn.2008.05.004. Medline:18632271 competence. JAMA. 2002;287(2):226–35. https://doi.org/10.1001/ jama.287.2.226. Medline:11779266 23. Wang CH, Tsai JC, Chen SF, et al. Normal saline instillation before suctioning: a meta-analysis of randomized controlled trials. Aust Crit 7. Brosky Jr JA, Scott R. Professional competence in physical therapy. J Care. 2017;30(5):260–5. https://doi.org/10.1016/j.aucc.2016.11.001. Allied Health. 2007;36(2):113–8. Medline:27876258 8. Kak N, Burkhalter B, Cooper M. Measuring the competence of 24. American Association of Respiratory Care. AARC clinical practice healthcare providers. Operations Research Issue Paper. Bethesda guideline: nasotracheal suctioning – 2004 revision & update. Respir (MD): US Agency for International Development; 2001. Care. 2004; 49(9):1080–4. 9. Brooks D, Solway S, Graham I, et al. A survey of suctioning practices 25. Chaseling W, Bayliss S-L, Rose K, et al. Suctioning an adult among physical therapists, respiratory therapists and nurses. Can ICU patient with an artificial airway: a clinical practice Respir J. 1999;6(6):513–20. https://doi.org/10.1155/1999/230141. guideline. Version 2. Chatswood: NSW Agency for Clinical Medline:10623788 Innovation; 2014. 10. Miller E, Beavers L, Mori B, et al. Assessing the clinical competence 26. Brooks D, Anderson CM, Carter MA, et al. Clinical practice of health care professionals who perform airway suctioning with guidelines for suctioning the airway of the intubated and adults. Respir Care. 2019;64(7):844–54. https://doi.org/10.4187/ nonintubated patient. Can Respir J. 2001;8(3):163–81. https://doi. respcare.06772. Medline:31138738 org/10.1155/2001/920160. Medline:11420592 27. National Physiotherapy Advisory Group. Essential competency profile for physiotherapists in Canada. Ottawa: The Group; 2009. 28. Akins RB, Tolson H, Cole BR. Stability of response characteristics of a Delphi panel: application of bootstrap data expansion. BMC Med Res Methodol. 2005;5(1):37. https://doi.org/10.1186/1471-2288-5-37. Medline:16321161 29. Skulmoski GJ, Hartman FT, Krahn J. The Delphi method for graduate research. J Inf Technol Educ: Res. 2007;6:1–21. https://doi.org/ 10.28945/199.













































































Mori et al. Designing, Implementing, and Evaluating a Practice Tutor Internship Model during an Acute Care Clinical Internship 181 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 8:36:50 PM - IP Address:43.246.243.82 Case presentations in small groups One-on-one session with practice tutor Discharge planning/impression practice Prioritization/PTA assignment Suctioning SIM session Oxygen equipment and titration Breath sounds tree Chest assessment (IPPA) ABGs and lab values Transfers and falls prevention Orientation to charts and documentation 012345678 Very valuable Valuable Not very valuable Figure 2 (CaI)s’CaIsn’danstdud(be)nststu’ dpeenrctse’pptieorncsepotfiothnes voafltuheeovfatlhue porfatchteicpertaucttoicresetustsoior nsse.ssions. CI = clinical instructor; PTA = physiotherapy assistant; SIM = simulation; IPPA = inspection, palpation, percussion, auscultation; ABG = arterial blood gases. two, compared with the traditional model or when no that, compared with previous internships, the students students were present in the programme (see Figure 4). were more prepared and the teaching and learning with students during the internship was more effective: “I Focus group and open-ended survey results never had to review charting with her, I never had to During the analysis of the FG transcripts and the open- review anything with her after the sessions, she seemed to get her questions answered there [at practice tutor ses- ended survey questions, we noted common themes in sions] and move on” (CI FG). The CIs noted in the FGs each of the data sources. Therefore, we have presented that the students had performed well during their intern- these data together in this article. Four themes were iden- ships. tified: benefits, tensions, critical logistics, and unforeseen blind spots. The main points for each theme are summar- Students reported a greater sense of camaraderie ized in Table 1. among them with this model, stating that conversations about the clinical practice continued beyond the practice Benefits tutor sessions. Several benefits of the practice tutor model were And I think it was an unintended side effect that there are noted. Both the CIs and the students communicated that so many of us, but we’re also naturally talking more about the practice tutor model had fostered critical thinking. these kinds of things at lunch. So, having the practice tutor One student said, “I found it caused me to think a little facilitated us to start talking about those things, and once bit more critically about my actions because I was com- we did, it extended. (Student FG) ing to a group and having to talk about what we were doing with our patients” (Student FG). The CIs noted Four of eight (50%) CIs reported that they had more time to get stuff done:

182 Physiotherapy Canada, Volume 72, Number 2 Case presentations in small groups https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 8:36:50 PM - IP Address:43.246.243.82 1:1 session with practice tutor Discharge planning/impression practice Prioritization/PTA assignment Suctioning SIM session Oxygen equipment and titration Breath sounds tree Chest assessment (IPPA) ABGs and lab values Transfers and falls prevention Orientation to charts and documentation 01234567 Very valuable Valuable Not very valuable Figure 2 CIs’ and students’ perceptions of the value of the practice tutor sessions. (Continued). I liked having a little bit of time to just get something else tutor] sessions, so, I don’t know if that helped or hindered, done while they [the students] were gone, so it just freed but maybe by the end he could have actually been seeing up my day a little bit to get other things done on caseload, more patients because he would have had the extra hour or other projects.. . . It helped in the first 2 weeks when or two initially. (CI FG) they had the daily session so I could count on having 1–2 hours to get whatever I needed done. (CI FG) Another tension reported by CIs related to the duplica- tion of teaching: Tensions Both the CIs and the students noted several tensions Transfers [practice tutor session] is good, but I still went through [it] with them.. . . I want to know what to expect throughout the internship. Time that the students spent from him so that it’s safe for everybody . . . it gives me with the practice tutor represented less time they could peace of mind, and so it’s one of those things I’m going to spend on the clinical unit, and both the students and the do on my own again. (CI FG) CIs reported this as a concern. For example, one student said, In addition to flagging the duplication of teaching, stu- dents reported that differences in the clinical practice Your CI can’t just wait around for you to come up and methods presented by the practice tutor and the CI on then start your day, so it forces them to do the work for the clinical unit caused confusion in learning. Both of you that you should be practising, like reviewing everyone, these tensions had the potential to result in decreased screening everyone, and scheduling out the day. It makes teaching efficiencies. your CI have to do that and then you don’t get the opportunity. (Student FG) Although the students described the ability to learn with and from each other as a positive aspect of the prac- Similarly, a CI reported, tice tutor model, in the focus group one student men- tioned feeling intimidated by the group context and in I think it was tough because I felt like I had to hold back discussions in which they perceived that a peer’s perfor- on his caseload sometimes because he had the [practice mance exceeded their own.

Mori et al. Designing, Implementing, and Evaluating a Practice Tutor Internship Model during an Acute Care Clinical Internship 183 12 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 8:36:50 PM - IP Address:43.246.243.82 10 Average number of patients seen per day 8 Practice tutor 6 Students, no tutor No students 4 2 0 CI 1 CI 2 CI 3 CI 4 CI 5 CI 6 CI 7 Figure 3 Average number of patients seen per day by each CI over the entire internship. CI = clinical instructor. So, coming to those sessions and hearing that people were students’ smooth transition from their practice tutor ses- already prioritising and putting their patients in, it was sions to their clinical activities. overwhelming because I was like, oh my gosh I’m so far behind, how am I going to be at that level? (Student FG) In delivering this practice tutor model, we were fortu- nate that the practice tutor was a former employee of the Critical logistics clinical site who had worked on a cardiorespiratory ser- The participants described the logistics and manage- vice. Therefore, she knew the hospital, programmes, and care models very well. This was found to be a critical lo- ment of the practice tutor model as being critical to its gistical factor and one that was viewed as positive by effectiveness. Initially, when the CIs were consulted both the students and the CIs. about the scheduling of the sessions, they chose to vary the times of the practice tutor sessions so as not to disad- Yeah, and I had more faith in what the practice tutor was vantage any one programme. In doing so, sessions were teaching because [she] had previously been an employee scheduled inconsistently – in the morning, around lunch, here.. . . And so [she] knew all of us, and so [she] knew our or at the end of the day. All of the participants said that patient populations, and [she] knew [she] could customise this had an impact on their clinical care and the schedul- it to us. (CI FG) ing of their activities, as demonstrated in these quotes from the student FG transcript: Although I found that sometimes that [practice tutor familiar with CIs] helped; if she hadn’t known my CI at all, Sessions that were [at] 10:00 or 9:00 to 10:00, you would go it wouldn’t have been the same. She knew exactly what to in the morning and you wouldn’t have enough time to see tell me because she knows me, she knows my CI, and she a patient and then you would have to come here [other was able to give me advice about that and how to interact, building]. And by the time you get back, you only have an so that was helpful. (Student FG) hour to see your morning patients and that, split up right in the middle, made it difficult to schedule your day. Unforeseen blind spots (Student FG) Although having a practice tutor who was familiar Probably if I had to pick a time, 3:00–4:00 at the end of the with the site and staff was considered advantageous, the day would be best. (Student FG) students also considered that she might share informa- tion with the CIs. They thought that this could affect the The location of meeting rooms and clinical units was a safe learning environment she developed. factor that the students and CIs thought constrained the So, you second-guess yourself if you say something to her [practice tutor] about how you’re approaching your care

184 Physiotherapy Canada, Volume 72, Number 2 10.0 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 8:36:50 PM - IP Address:43.246.243.82 8.0 Average number of patients seen per day 6.0 Practice tutor Students, no tutor 4.0 No students 2.0 0.0 Week 2 Week 3 Week 4 Week 5 Week 1 Figure 4 Average number of patients seen per day in each week for all CIs. CI = clinical instructor. and then she goes to speak to your CI. I don’t know if Dedicated time to planning and delivering the practice tutor anything really came up, but I think the conflict of interest internship model is in terms of the power dynamic. (Student FG) To develop the practice tutor internship model, a The students also thought that the fact that the roles of novel experience for both the university and the intern- practice tutor and ACCE faculty member were filled by ship site, we used several resources. We developed a lead- the same person might represent a conflict of interest. ership opportunity for a final-year physiotherapy student so that she could take on a part-time (3 d/wk) adminis- My student said, if he had an issue, he would feel not trative position for her final internship at the site (KN). As comfortable as much to talk to her because [of] the position a component of the internship, she attended four team she is in right now.. . . Because [it] kind of felt very strange, meetings to plan the practice tutor internship model and like, you have an issue, I’m going to the person who is also created the manual (15 h total). finding me the internships, is that going to affect . . .? (CI FG). Before the internship started, the practice tutor was involved in reviewing and editing the manual. She kept a A similar perspective was shared during the student FG: log of the responsibilities and time commitment involved “You can’t always be that honest and then a day later go in facilitating the student sessions before, during, and to her for help for finding the next internship, kind of after the internship; it took a total of 30.5 hours (group thing” (Student FG). Table 1 Main Points of the Four Themes Benefits Tensions Critical logistics Unforeseen blind spots Fostered critical thinking; more Time on the unit vs. time in Consistent scheduling is key; Students perceived practice tutor variety for students; students were practice tutor session; learning practice tutor sessions need to be being the same person as the better prepared; discussions among from others vs. doubt about your close to the unit; it is beneficial for university clinical education lead as students happened outside practice own knowledge or practice base; practice tutor to be part of the either a conflict of interest or tutor sessions; camaraderie; CIs CIs waited for content to be institution and know about the beneficial; practice tutor sharing had time to “get stuff done”; more covered in practice tutor session service and details of the site. information with CIs could either efficient teaching; students vs. discussing that concept now affect the safe learning environment performed well. with the student; practice tutor and developed by the practice tutor or be CI used different methods. beneficial. CI = clinical instructor.

Mori et al. Designing, Implementing, and Evaluating a Practice Tutor Internship Model during an Acute Care Clinical Internship 185 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 8:36:50 PM - IP Address:43.246.243.82 teaching sessions, 11 h; case discussions, 3 h; chart stimu- for applying the science of learning to health professional lated recall discussions, 5 h; one-on-one student session, education: create learning spaces that are psychologically 1.5 h; preparation time and communicating with the phy- safe, attend to the social nature of learning, and create siotherapists for 2 h each week, 10 h). authentic experiences for workplace learning.23 This is what we tried to do by implementing the practice tutor The CIs who participated in the practice tutor intern- internship model – engage learners in their setting to ship model spent approximately 3 hours preparing for enhance their clinical reasoning and development and the internship; this included four team meetings, inde- become independent practitioners. Considering the data pendent time to review drafts of the manual, and discuss- from the surveys and focus groups, the practice tutor ing and agreeing on the practice tutor sessions and the model contributed to beneficial learning for most stu- final version of the manual. dents and CIs. DISCUSSION Overcoming the perceived barriers of offering a clinical The purpose of this study was to implement and eval- internship uate a practice tutor model of clinical education during a Physiotherapy clinicians reported several barriers physiotherapy student internship with a cardiorespira- noted previously when considering student supervision. tory physiotherapy team. Specifically, the research team The practice tutor internship model aimed to minimize wanted to determine the stakeholders’ satisfaction with the duplication of teaching over the course of the intern- the model in terms of the quality of the teaching and ship by streamlining common teaching elements. For the learning experience, the effect on patient attendance re- most part, this was achieved and reflected in the data, cords, and the feasibility of developing and delivering it. which showed that physiotherapy patient attendance Moreover, we anticipated that recommendations for was somewhat higher in the latter 4 weeks of the 5-week future implementation of this model could be made on internship, which can be interpreted as CIs having more the basis of our findings. time for patient care activities rather than spending time on teaching. In addition, half of the CIs reported having Teaching and learning benefits more time to complete other roles and duties when the The practice tutor model was perceived to facilitate students were attending the practice tutor sessions. the students’ clinical reasoning and learning experience. Other studies have reported similar improvements in Students prepared for practice tutor discussion sessions, productivity during student internships.24,25 It is thus and this group interaction eventually extended beyond conceivable that an internship model that decreases the the group context, encouraging peer discussion and col- perception of the time burden could increase the capac- laborative learning. The CIs thought that the students ity for clinical education. Productivity in this practice who engaged in this model of clinical education demon- tutor model could be further increased if the practice strated better preparation for internship, and the stu- tutor were available to spend more one-on-one time with dents described having more ideas for discussion with the students in the clinical environment. In our model, their CI. This feedback is supported by the literature on only one such session occurred, even though it had been clinical reasoning and social constructivist learning.17,18 offered to students. This requires consideration in future The practice tutor sessions used a case-based approach; research. similar to problem-based learning.19 This approach en- courages a tutor to facilitate the integration of theoretical Selecting the practice tutor knowledge and clinical reasoning skills by helping stu- Our findings suggest that selecting the appropriate dents identify and pursue their own objectives rather than by giving out information; this is the approach de- practice tutor (from either the acute care facility or the scribed by Maudsley.20 The practice tutor consciously academic institution) was critical to the model’s success. used these behaviours during the session. The fact that the person we chose was a practising clini- cian with educational experience and was also familiar These teaching behaviours are also reported to with the hospital and the physiotherapy education pro- improve clinical reasoning, as described in the review by gramme was viewed as an important and critical factor Rochmawati and Wiechula.17 Mann has suggested that by all participants. In some variations of the practice the learning network community (which can be the tutor model,15,16 the practice tutor is also involved in as- health care setting in this context) and the learners in the sessing students. This additional educational perspective community are important resources for learning.18 Sup- could be advantageous to both the CIs and the students ported by social cognitive theory and situated learn- because it would enhance the reliability of the student ing,21,22 these frames of reference suggest that learning clinical performance assessment process and divide the approaches that maximize learner participation and responsibility for it, thus reducing the burden on the CIs, build on the community can improve learning.18 Gooding who are responsible for assessing the students on their reflected these recommendations in several of her tips own.

186 Physiotherapy Canada, Volume 72, Number 2 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 8:36:50 PM - IP Address:43.246.243.82 The literature has also reported that a safe learning model, but it could be advantageous to have two per- environment is very important to students; a second spectives when the assessments are being completed. opinion from a member of staff with educational experi- The one-on-one sessions might be more valuable if they ence could add to this aspect of workplace-based learn- occurred near the beginning of the internship, when the ing.26 We believe that improved communication at the students are still orienting to the environment. They start of the internship about the role and advantages of might also be more valuable if a student was experien- the practice tutor, conveying the ultimate goal of sup- cing difficulty during the internship. porting students’ learning, can mitigate the students’ per- ceived disadvantage of CI–practice tutor communication. As a result, we think that this model is feasible to plan and implement. Scheduling the practice tutor sessions Students attended the practice tutor sessions in a Recommendations for future iterations of the practice tutor model location other than the clinical unit. This created ten- sions for some students because they sometimes missed On the basis of our evaluation of the practice tutor clinical opportunities for learning. Tension may also have model, we make the following recommendations: been created by the scheduling of these sessions, as ac- knowledged by participants, and it requires further atten- • Clearly communicate the purpose of the model, includ- tion if this model is used again. ing the roles and expectations for students, CIs, and the practice tutor. At the University of Toronto, students’ performance during clinical internships is assessed using the Canadian • Establish explicit guidelines with those involved about Physiotherapy Assessment of Clinical Performance.27 if, what, how, and why information will be shared This assessment form has a rating scale that is linked to among the students, CIs, and practice tutor, and clearly the student’s caseload. Time away from the clinical unit communicate this with all parties involved. could be seen as less time for the students to develop and manage their caseload, potentially resulting in a lower • Involve the CIs and students in identifying the topics performance rating. Scheduling more practice tutor ses- and timing of the practice tutor sessions as well as the sions to take place in the first half of the internship might anticipated need for the one-on-one session. provide a solution to this problem because it would enable the students’ learning in the latter half of the • Schedule physiotherapy sessions at a time of least dis- internship to focus exclusively on the clinical unit. The ruption to clinical care (end of the day was the overall scheduling and location of the practice tutor sessions as recommendation). well as the time spent away from the clinical unit likely contributed to the value that the students placed on the • Locate the physiotherapy sessions close to the clinical sessions and their overall satisfaction with their experi- care unit to minimize the students’ travel time. ence. • Establish good communication links between the CIs Resources required to develop and implement the practice tutor and the practice tutor about their interactions with the model students and the students’ performance. The resources required to implement the practice • Schedule the practice tutor sessions at the beginning of tutor model were primarily the people and time needed the internship to give the students greater clinical expo- to develop and deliver it. We spent approximately 12 sure during the rest of the internship, providing further hours consulting with the CIs on scheduling and topics, physiotherapy sessions if students need them. creating the practice tutor model, and writing the man- uals. The practice tutor used 30.5 hours over the 5 weeks. • Ensure that the practice tutor is involved in clinical These data can help other interested academic centres supervision throughout the internship as required by estimate their costs. Having a space that allowed us to the students and CIs. deliver the teaching sessions and case discussions was important, so booking rooms with access to a computer • Ensure that the practice tutor does not have a faculty and display screen was required. One of the sessions also role that requires them to be involved in assessing stu- took place in the simulation centre and was rated very fa- dents on the curriculum when they complete their in- vourably by the students, so if simulation technology and ternships. resources are available, it would be beneficial to include them in the model. In this article, we have described the development, implementation, and evaluation of a novel practice tutor Having the practice tutor involved in more one-on- internship model in an acute care teaching hospital on a one teaching with the students on the clinical units cardiorespiratory service. Our study had a number of would require allocating more time and resources for this potential limitations. Our results and recommendations are based on one implementation of this model using seven students and eight CIs, which may limit transfer- ability to other settings. The students who indicated an interest in being at this site, using this internship model, and the CIs who participated may have had more interest in this education model and setting than a random group

Mori et al. Designing, Implementing, and Evaluating a Practice Tutor Internship Model during an Acute Care Clinical Internship 187 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 8:36:50 PM - IP Address:43.246.243.82 of physiotherapy students and CIs. Nonetheless, the allo- KEY MESSAGES cation of this internship was consistent with our current allocation system. What is already known on this topic Clinical education is an important component of the The institution at which we chose to implement the practice tutor model has a strong focus on education and entry-to-practice physiotherapy degree programme. Vari- therefore was very supportive of this initiative. This might ous models exist for delivering clinical education. Several not occur in all environments, hence the recommenda- perceived barriers to offering clinical internships have tion for early interaction with potential clinical sites been reported by physiotherapists in the literature. when considering this model of clinical education. What this study adds Although the principal investigator for this study was On the basis of our pilot of the practice tutor clinical on sabbatical during the development, implementation, and evaluation of this internship, she was known to all internship model in an acute hospital on a cardiorespira- the students involved, so they may have had an inherent tory service, we believe this model has the potential to bias to positively evaluate the model. When we delivered positively affect both teaching and learning during a clin- the practice tutor model for this study, the practice tutor ical internship. Most of the students and clinical instruc- was also the ACCE for the university, a role that has tors enjoyed learning and teaching in this model. responsibility for developing clinical sites to host stu- Incorporating our recommendations can improve this dents, preparing and matching students for their intern- model and potentially minimize the perceived barriers to ships, and supporting students during their internships. offering a clinical internship. As a result, the students might not have felt comfortable sharing their difficulties with her. REFERENCES Moreover, the practice tutor selected to implement 1. Physiotherapy Education Accreditation Canada (PEAC). PEAC this model had been a clinician, which may also have accreditation standards: 2012 including essential concepts [Internet]. affected both the CIs’ and the students’ perceptions of London (ON): PEAC. 2012 [cited 2018 Nov 28]. Available from: the model. 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Medline:21155869 APPENDIX 1: PRACTICE TUTOR MODEL INTERNSHIP STRUCTURE Wk Activities Intent 1 and Daily sessions (60–90 min) that covered a variety of topics Efficiently provide students with essential knowledge for their 2 considered essential to cardiorespiratory physiotherapy practice (e.g., internship, thereby increasing both clinician productivity during the first documentation, orientation to charting, breath sounds, transfers, 2 weeks and earlier student independence. 3 chest X-rays, interpreting lab values). No structured sessions were planned with the practice tutor. She was Included in the model to help develop strategies to support a student in 4 available to work one-on-one with the students in the clinical difficulty and provide a second, objective perspective for the midterm 5 environment. evaluation. Each student presented a case study of one of their patients to the Provided an opportunity for the students to deepen their clinical group of students and the practice tutor. reasoning and engage in shared problem solving. Time was allocated for the students to engage in a chart stimulated Reviewed a patient’s chart in detail to facilitate the students’ rationale recall: students spent ~20 min one on one with the practice tutor to for care decisions (a practice commonly completed with the College of review the rationale for their clinical decisions on the basis of their Physiotherapists of Ontario during a Practice Assessment of a written documentation. Physiotherapist).