Competencies in Physical Therapy by hijuney4

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									Competencies in Physical Therapy
A Resource for Written Self-Assessment and Clinical
Performance Evaluation and a Component of a
Department's Quality Assurance Program


             This article was written to demonstrate how clinical competence in ultrasound
             administration can be reviewed. A team of two members of the Minnesota
             Competency Consortium developed two tests: 1) a written examination that
             could be used as a tool to assess the knowledge of physical therapists in
             physical therapy departments and 2) a skills-mastery check list to assess
             ultrasound treatment skills. Both tests followed the competency hierarchy of
             Competencies in Physicai Therapy: An Analysis of Practice. As one component
             of a physical therapy department's quality assurance program, the tests also
             were used to identify educational needs in order to develop programs to meet
             those needs.

             Key Words: Education, continuing; Physical therapy; Quality of health care.

   The task of analyzing practice can be approached                     The American Physical Therapy Association made
by professionals in many ways. The American Phys-                    a commitment to providing and promoting quality
ical Therapy Association's Competencies in Physical                  services in its 1977 Philosophical Statement and Plan
Therapy: An Analysis of Practice (the Red Book) offers               for Implementation.3 In recent years, the ways in
a method of analyzing practice that presents various                 which competence is assessed have changed.4 A de-
competencies (tasks) that physical therapists and                    mand for accountability has arisen from professional
physical therapist assistants perform in their work                  organizations, legislatures, the courts, and consumers.
settings. (Competencies are defined as skillfully per-               The Red Book is an attempt to identify critical knowl-
formed, work-related activities.1) This method is                    edge, skills, and characteristics of individual compe-
based on the idea that every competency has an                       tence that are necessary to provide physical therapy.
identifiable set of less complex component skills and                The competency hierarchy describes each component
knowledge that must be mastered to perform the                       of a task, outlining specific conditions and standards.
higher-level task successfully. The competencies are                 Because a comprehensive program of quality assur-
structured in a hierarchical format, and supporting                  ance must include a method of assessing all of the
subtasks and knowledge are detailed.                                 physical therapy tasks encountered in the practice
   In this article we will describe the development of               setting, the analysis of these task components can be
a written, cognitive self-assessment examination and                 helpful in designing a plan for evaluating the quality
a skills assessment of the performance of an ultra-                  of physical therapy services.
sound treatment using Competency 2.3.6 from the
Red Book, "Administer Ultrasound." This test dem-                    BACKGROUND
onstrates ways in which the Red Book can serve as a
resource in evaluating clinical competence and in                      The Minnesota Competency Consortium (the Con-
developing a clinic's quality assurance program                      sortium) was organized in April 1978 and supported
(QAP).2                                                              by the Allied Health Project Grant 1D12AH9001902
                                                                     (Department of Health, Education and Welfare) with
   Ms. Eilingham is Assistant Professor and Academic Clinical Co-
ordinator, Course in Physical Therapy, University of Minnesota,      the specific purpose of educating and encouraging
Minneapolis, MN 55455 (USA).                                         physical therapists in the use of the Red Book. The
   Ms. Fleischaker is Director, Rehabilitation Services, Methodist   core group of the Consortium was formed by four
Hospital, St. Louis Park, MN 55426.
   This article was submitted March 16,1981, and accepted November   physical therapy educators from three physical ther-
23,1981.                                                             apy and one physical therapist assistant programs in

Volume 62 / Number 6, June 1982                                                                                       845
Fig. 1. Physical Therapy Competency Analysis 2.3.6—Administer Ultrasound.
Minnesota and four clinical instructors from those              sent to emergency room (ER) of local hospital;
programs. The group was divided into teams, each                seen by ER physician who instructed patient to
composed of a clinician and an educator. These teams            return home and limit activity, to keep leg
studied and developed ways to apply the task analysis           elevated, and to return in one week.
format found in the Red Book to clinical and edu-               Wednesday—Patient returned to ER because
cational settings.                                              of increased swelling, discoloration, and severe
   We were one of the teams and had a common                    pain.
interest in the clinical application of ultrasound.             Thursday—Surgery performed to repair com-
While producing an ultrasound educationalfilm5two               plete evulsion of quadriceps tendon; evidence
years earlier, we had found that few clinics had                of necrotic tissue present in a 4" X 4" area
defined procedures for 1) the application of ultra-              anterior and superior to patellar surface of knee.
sound as a therapeutic modality, 2) the maintenance              Sensation (superficial and deep) absent in area
of ultrasound equipment, and 3) the use of this mo-              surrounding necrotic tissue.
dality in accordance with research finding in the                  Surgery: left quadriceps tendon repaired and
literature. We sought to apply the Red Book analysis               debrided; left leg immobilized—long-leg cyl-
to the development of these procedures.                            inder cast with window applied. Orders: pa-
                                                                   tient to receive gait training for nonweight
ULTRASOUND TECHNIQUE ASSESSMENT                                    bearing on the left foot and for partial
                                                                   weight-bearing after two weeks.
   Two forms of evaluation were used to assess clinical   2. Patient is a physical therapist and needed minimal
competence in ultrasound technique.6 To assess the           instruction and supervision for gait training and
knowledge of the therapists, a written self-assessment       follow-up program.
test was developed with questions on each compe-          3. Order by physician.
tency task, subtask, and basic knowledge. Assessment         Patient to report to PT for whirlpool, ultrasound,
of skills needed to perform ultrasound was done by           exercises (active, isometric, and active-assistive),
observation, using a skills-mastery check list that          and prolonged stretch as tolerated. Initial stretch-
followed the hierarchy of the Red Book's ultrasound          ing—weight of extremity only.
competency. Both the knowledge test and the skills           Exceptions: None.
test were based on recognized textbooks7,8 and cur-          Precautions: Sensation changes and ulcer.
rent literature on ultrasound.                            4. All pertinent evaluative data present as stated in
Written Self-Assessment Test                              5. Treatment goals:
                                                             a. Increase range of motion of knee.
   The outline for the test followed the hierarchy of        b. Clean wound to promote healing.
the ultrasound competency analysis. In the Red Book,         c. Relieve pain.
competencies are structured in levels consisting of          d. Re-educate and increase muscle strength of
overall tasks that are further divided into subtasks             quadriceps femoris muscle.
and knowledge content. Mastery of the subtasks en-        6. Selection of ultrasound equipment from that avail-
ables the practitioner to perform the overall tasks          able in clinical setting.
(Fig. 1).                                                 Standard: Appropriate to
   Test questions were designed to assess knowledge       1. Neurophysiologic status of patient—sensation def-
of all necessary information and to reflect current          icit must be well-defined to determine tolerance of
literature on the use of ultrasound. Because the hier-       administration of ultrasound to right leg.
archy concept is difficult to follow in test form, the    2. Body part to be treated—left knee.
test was designed in topic form. To make the test         3. Treatment goals—as listed in Given, above.
clinically relevant, the following patient problem was
presented in the introductory information.                Test Format

Patient History Used in Test                                Following is the written test developed for one task
                                                          area of the ultrasound competency, that of Determin-
Given:                                                    ing Dosage (Fig. 1, Task 3). In the actual test, the
1. A specific patient problem                             entire competency was covered. We tested for specific
   • Patient with admitting diagnosis of left evulsed     knowledge because we thought it was important that
     quadriceps tendon with a traumatic onset.            therapists know isolated facts reflecting current re-
   • 65-year-old woman, employed full time.               search and literature. The following are the Givens,
   • Week 1:                                              Standards, and Test Items developed for the task of
      Sunday—sudden onset (fell leaving church);          determining dosage:

Volume 62 / Number 6, June 1982                                                                              847
3. Determine Dosage                                          T F I attempt to educate physicians who believe
Given:      1. Patient whose plan of care includes               that every patient should receive ultrasound
               ultrasound                                        at 1 W/cm2 for three minutes.
            2. All pertinent information.                  Process and Results
            3. Treatment goals.
            4. Predetermined method.                          The test was given on several occasions and each
Standard: 1. Optimum for condition to be treated.          test group was reviewed separately. About 150-200
            2. Comfortable.                                therapists took the written exam when they attended
            3. Safe.                                       our presentation at the Minnesota APTA State Meet-
Questions:                                                 ing. The written test was also given during three in-
   T F The size of area to be treated is important.        service presentations to groups of 10-20 therapists.
   T F The speed at which the soundhead is moved              Test results of over 200 written tests given to prac-
         is critical and definitely influences the dos-    ticing physical therapists showed that basic skills and
         age.                                              knowledge of the current ultrasound literature need
   T F Circular motions with the soundhead make            to be routinely reviewed.
         it more difficult to control the amount of
                                                           STAFF PERFORMANCE EVALUATION
         energy without overheating the part.
                                                           CHECK LIST
3.1 Determine depth of target
   3.1.1 Anatomy                                              The ultrasound competency was useful in devel-
   T F The greater the tissue content the higher the       oping a total staff development program. The test was
         intensity can/should be.                          given to a physical therapy staff to indicate individual
3.2 Determine chronicity/acuteness                         areas of weakness common to the entire group. Ultra-
   3.2.1 Clinical Sciences: evaluate immediate,            sound application technique was first demonstrated
         short-term, and long-term patient responses       by a staff member. The group then used the perform-
         to ultrasound.                                    ance evaluation check list to test psychomotor skills
   T F Diathesis is a contraindication for the use of      of the therapists (Fig. 2).9 Criteria for evaluation
         ultrasound because of the inability to heat       followed the tasks and subtasks. The level of accom-
         the tissues safely, adequately, and selec-        plishment on the performance evaluation necessary
         tively.                                           for subjects to achieve was 80-85 percent.2 The tech-
3.3 Apply power/dosage calculation rules                   niques of applying ultrasound used by the therapists
   T F I am up-to-date in reviewing the literature.        were varied because the techniques had been learned

                            ULTRASOUND PERFORMANCE CHECK LIST
                                                                            YES              NO    COMMENTS

 1.   Select instrumentation/method
 2.   Determine mode (continuous/pulsed)
 3.   Determine medium/medium temperature
 4.   Select soundhead size/temperature
 5.   Prepare patient for treatment
 6.   Position patient
 7.   Prepare area to be treated
 8.   Drape patient
 9.   Explain procedure
10.   Apply rules regarding movement of soundhead
11.   Apply safety rules/precautions
12.   Determine depth of target
13.   Apply power dosage calculation rules
14.   Determine chronicity/acuteness of condition
15.   Identify all control switches
16.   Describe sequence of operation
17.   Utilize correct soundhead application technique
18.   Apply rules regarding application of soundhead
19.   Efficient

                         Fig. 2. Basic outline for staff performance evaluation check list

848                                                                                          PHYSICAL THERAPY

in various physical therapy schools and practiced in             performance evaluation check list, a continuing edu-
clinical settings. The techniques used in the test were          cation program was developed and initiated for cor-
based on the theory and application of skills as de-             recting identified problems. Changes in administra-
scribed by Lehmann.7                                             tion policies and procedures were made as the result
   The written pilot instrument was tested in several            of testing and staff review.10 The ultrasound compe-
clinics during in-service presentations on ultrasound.           tency was used in one department's QAP as the
Additionally, one staff member observed a fellow                 predetermined criteria for concurrent and retrospec-
staff member perform an ultrasound treatment and,                tive documentation review. Collected data were ana-
using the check list evaluation instrument, evaluated            lyzed, and appropriate corrective actions were taken.
the performance. A similar written pilot presentation
was used at the Minnesota APTA State Meeting,                    CONCLUSION
except that the ultrasound educational film developed
earlier by the authors was shown to demonstrate                     The written test for the competency "Administer
technique, because the size of the group would have              Ultrasound" (2.3.6) can serve in a clinical setting both
made it difficult to see one person apply ultrasound.            as a resource for a self-assessment process and as a
Based on the results of all test sessions, the team              tool to review current philosophies of technique and
discussed and modified its educational programs.                 knowledge of ultrasound. The test is also useful in
                                                                 showing areas of need for continuing education. This
STAFF DEVELOPMENT IN A QUALITY                                   test involves applying techniques of basic sciences
ASSURANCE PROGRAM                                                and identifying areas of weakness in knowledge and
                                                                 skills defined by the subtasks in the ultrasound com-
  As part of a department's QAP, the peer review                 petency presented in the Red Book. The ultrasound
and problem-solving processes are essential. The re-             competency could also be used as part of a depart-
sults of the performance evaluation of one depart-               ment's QAP. We believe an appropriate system of
ment's peers were useful in determining staff in-ser-            quality appraisal includes a written self-assessment
vice training needs for ultrasound administration.               by staff, a performance evaluation of skills, and an
Using the written self-assessment test questions, pre-           evaluation of the process and outcome of care. Using
determined criteria for outcomes were developed and              the competency "Administer Ultrasound" and eval-
a concurrent, retrospective-focused audit was done               uating the staff process and patient outcomes by the
through chart review.                                            measures described in this article is one way to ana-
   Based on the results of a review of patient docu-             lyze practice objectively through quality review based
mentation, the written self-assessment test, and the             on a predetermined standard for performance.

 1. Competencies in Physical Therapy: An Analysis of Practice,         neapolis, MN, Department of Physical Medicine and Reha-
    ed 3. Washington, DC, American Physical Therapy Associa-           bilitation, University of Minnesota, 1976
    tion, 1981                                                    6.   Morgan M, Irby D: Evaluating Clinical Competence in the
                                                                       Health Professions. St. Louis, MO, The C V Mosby Co, 1978,
 2. Block JH: Mastery Learning Theory and Practice. New York,          pp 3 3 - 5 1 , pp 1 3 9 - 1 5 0
    NY, Holt, Rinehart & Winston, Inc. 1971, p 70                 7.   Lehmann JF: Diathermy. In Krusen FH, Kottke FJ, Ellwood
                                                                       PM (eds): Handbook of Physical Medicine and Rehabilitation.
 3. Quality Assurance Program: Plan for Implementation. Wash-
                                                                       Philadelphia, PA, W B Saunders Co, 1973, p 3 0 3
    ington, DC, American Physical Therapy Association, 1977
                                                                  8.   Lehmann JF: Ultrasound therapy. In Licht S (ed): Therapeutic
 4. Pottinger P, Goldsmith J: Defining and Measuring Compe-            Heat and Cold, ed 3. Baltimore, MD, Waverly Press Inc.
    tence. San Francisco, CA, Jossey-Bass Inc. Publishers,             1965
    1979, p 35                                                    9.   Treece E, Treece J: Elements of Research in Nursing. St.
                                                                       Louis, MO, The C V Mosby Co, 1973, pp 1 0 1 - 1 9 6
 5. Ultrasound: Therapeutic Treatment, Techniques and Care of    10.   Davis CM, Anderson MJ, Jagger D: Competency: The what,
    Equipment, film. Ellingham C, Fleischaker K, Baum B: Min-          why, and how of it. Phys Ther 59:1088-1094, 1979

Volume 62 / Number 6, June 1982                                                                                              849

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