break out of your silo: collaborations to achieve core competencies€¦ · core competencies kim...

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Break Out of Your Silo: Collaborations to Achieve

Core CompetenciesKim Levenhagen PT, DPT, WCC

Saint Louis University

Sara Alhajeri MPT, GCS

Caitlin Rosentreter, DPT

Barnes Jewish Hospital, Saint Louis, Missouri

Objectives

By the end of this educational session the participant will:

• Recall the Core Competencies for Entry-Level Practice in Acute Care Physical Therapy, the APTA Core Values and behaviors identified in the evidence that reflect acute care practice.

• Identify methods to integrate acute care practice behaviors into the didactic curriculum.

• Determine methods for various clinical education models to increase numbers of students in the acute care setting.

• Create a win/win scenario to maximize excellence and professional duty among students and physical therapists/physical therapists assistants.

Minimum Required Skills of Physical Therapist Graduates at Entry Level

• Screening– Systems review for referral– Recognize scope of limitations

• Examination/Re-examination– Medical Records– Imaging– Lab Values– Medications– Home environment– Each system

• Integration

• Evaluation– Clinical reasoning and evidence

• Diagnosis– Identify and prioritize impairments

and activity limitations, participation restrictions

• Prognosis– Recognizing barriers

• Plan of Care– Goal setting– Coordination of care– Discharge

DOISY COLLEGE OF HEALTH SCIENCES

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Minimum Required Skills of Physical Therapist Graduates at Entry Level

• Interventions– Airway clearance– Assistive devices– Movement (gait, functional mobility)– Safety– Collaboration– Communication across settings

• Outcome Assessments• Education

– Patients/families– Colleagues

• Practice Management– Billing– Documentation– Direction and supervision– HIPPA/Patient rights

• Professionalism• Consultation• Evidence Based Practice


Minimum Required Skills of Physical Therapist Assistant Graduates at Entry Level

• Plan of Care Review‒ Review of physical therapy

documents‒ Identification of role in patient care‒ Identification of items to be

communicated to the physical therapist

‒ Identify when the directed intervention are either beyond the scope of work or personal scope of work of the PTA

• Provision of Procedural Interventions

• Patient Instruction‒ Application of principles of learning

‒ Use of variety of teaching strategies

‒ Clarity in instructions

‒ Assessment of patient response

• Patient Progression‒ Competent patient progression

‒ Communication of patient information

‒ Clinical problem solving


Minimum Required Skills of Physical Therapist Assistant Graduates at Entry Level

• Data Collection– Competent date collection– Interview skills– Accurate and timely– Clinical problem solving– Ability to modify techniques– Documentation and communication

• Documentation– Select relevant information– Accuracy– Ability to adapt

• Safety, CPR and Emergency Procedures

• Reads and understands the healthcare literature

• Educate colleagues and other health care professional about the role, responsibilities and academic preparation and scope of work of the PTA

• Ensure ongoing communication with the physical therapist for optimal patient care.


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A Normative Model of Physical Therapist Professional Education: Version 2004

“Consistently define and describe entry-level physical therapist professional education that is reflective of a contemporary and forward looking perspective of practice, is responsive to physical therapy practice and the health care environment, and that incorporates the elements for the profession's vision.”

– Guide to Physical Therapist Practice– Core competencies for area of practice– Movement System


Core Competencies for Entry Level Practice in Acute Care Physical Therapy (2015)

Kristin Greenwood, PT, DPT, EdD, MS, GCS | Chair

Eric Stewart, PT, DPT

Erin Milton, PT, DPT, NCS

• Clinical decision making• Communication• Safety• Patient management• Discharge planning

Melissa Hake, PT, DScPT

Lauren Mitchell, PT, DPT

Babette Sanders, PT, DPT, MS, FAPTA

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Core Competencies for Entry Level Practice for Physical Therapist Assistants in Acute Care Settings (2017)

Jeremy Foster, LPTA | Chair

Michele Biernacki, PTA, ACCE

Holly Clynch, PT, DPT, MA, GCS

Chrissy LaMastus, MPT, BSN, RN

• Communication

• Safety

• Patient Management‒Medical review and documentation

• Contributions to discharge recommendations

Amanda Rausch, PTA

Christina Schiel, PT, DPT

Deanna Smith, PT

Movement System (APTA 2017)• PTs provide a unique perspective on

purposeful, precise, and efficient movement across the lifespan based upon the synthesis of their distinctive knowledge of the movement system and expertise in mobility and locomotion.

• PTs examine and evaluate the movement system (including diagnosis and prognosis) to provide a customized and integrated plan of care to achieve the individual's goal-directed outcomes.

• PTs maximize an individual's ability to engage with and respond to his or her environment using movement-related interventions to optimize functional capacity and performance.


What do the students say?• What I learned in the classroom is not real life

– Line management– Ventilators

• Complex patients on paper not the same as the hospital– Clinical reasoning is not always black/white– Difficult to apply classroom knowledge to patients in the clinic

• Some clinicals too short• Not enough acute care choices

– May not have a rotation in level 1 trauma center• Some time since my acute care rotation and starting my job


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Student Feedback Regarding Preparedness• I did not feel under‐prepared for this experience in the sense that we had not learned certain material yet. However, I did have to look a few things up that we had already learned just for a quick refresher!

• Finding different motivation techniques to encourage patients to participate in therapy when they refuse.

• One suggestion would be to team up with the OT program for a lab and co‐treat a patient so students can learn how to work together efficiently, while also playing a balancing act seeing how both therapies overlap yet do not cross boundaries.

• I felt unprepared for ventilator management, IV/leads management, walking patients with multiple medical devices (IV poles, etc.), pharmacology and its implications for PT, discharge disposition.


Reviewing the Evidence (Baybar 2003)

• Case study presentation

• Group discussion

• Patients in class• Patients in clinic

• Problem solving videotape

Reviewing the Evidence

Jette 2007

• Knowledge

• Clinical skills

• Safety

• Clinical decision making

• Self directed learning

• Interpersonal communication

• Professional demeanor

Masley 2011

• Continual Dynamic Assessment

• Complex– Communication to gain information

– Collection and analysis of medical information

– Communication to provide information

– Application of specialized physical therapy knowledge


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Nationwide Acute Care Physical Therapist Practice Analysis Identifies Knowledge, Skills and Behaviors that Reflect Acute Care Practice (Gorman 2010)

Foundational SciencesFoundational Sciences

Clinical diagnostic proceduresClinical diagnostic procedures

LeadershipLeadership

Risk managementRisk management

Professional developmentProfessional development

Social responsibilitySocial responsibility

Examination/EvaluationExamination/Evaluation

Diagnosis/PrognosisDiagnosis/Prognosis

InterventionIntervention

OutcomesOutcomes

Bridging the Gap


• Weaving inpatient care into the curriculum– Pathology clinical examples

– Basic Procedure

– Multisystem Management

• Labs

• Integrative clinical experiences

• Seminars

Acute Care Threaded Throughout Curriculum

Survey of Disease, Lab Studies/ Imaging, Basic Procedures, Pharmacology • Integrative Project• Patients in lab• Assist devices

Multisystem Management, Cardiopulmonary, Neuro, Patient Management, Communication • Patients in lab• ICE• Integrative Project• Sim Lab• Collaboration with

nursing

Seminars, Patient Management, Business Administration, InterprofessionalTeam Seminar, Clinicals• Complex evaluation

in clinic• Cases w/ IP

therapists• Collaboration w/

PTA Program• Interprofessional

interactions

PY 1

PY 2PY 3

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Project: Survey of Disease, Pharmacology and Lab Studies/Imaging

Example of Lab: Integrative Clinical Experience

• Chart Review• Subjective Interview• Objective Examination

– Cognition – Gross muscle screen– Dermatome/Light touch – Vital signs– Balance (sitting/standing)– Outcome measures – Movement assessment (bed mobility, sit to stand to sit, ambulation)


Example of Lab: Integrative Clinical Experience

• Assessment•Identify impairments and activity limitation and participation restrictions.•State why patient requires skilled physical therapy.•Describe intervention or education provided during this treatment session.

• Plan•Determine frequency for therapy sessions during hospital stay.•Document 3 short term goals for the patient (met by discharge).•Establish a discharge plan.


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Example of Lab Integrative Clinical ExperienceDiscuss 3 relevant findings from the chart review with anticipated

presentation (signs and symptoms and implications with examination. At least one must include an abnormal lab value.

Include clinical implications for 3 pharmacological agents the patient is

currently taking in the hospital.

Discuss how CI adapted the examination secondary to

current and past medical history.

Explain your clinical reasoning for your discharge recommendation.

Given the patient’s findings today, name 2 interventions and 2 follow‐

up examinations you want to perform on the next visit.

Collaborative Learning in Nursing Sim Lab


An interprofessional experience through structured communication

tools such as SBAR provide context for application in an acute care

environment.

“This was a good learning experience for me because I now know that I need to make my SBAR statement more clear and concise in

the future. I especially want to improve upon my "assessment portion" of the SBAR in establishing why the patient might be

experiencing various symptoms.”“It was good to have nursing there and interact with them as well but I found it difficult to cut off my interview and quickly gather my thoughts

to give the SBAR to the nurse in front of the patient.”

A HFHS patient scenario with emerging data provided a safe

environment for learning.

“Overall, I liked to experience and I have a better idea of what kinds of communication skills and inpatient skills I can improve upon in the future. The experience was unique and not one that we usually get to receive in school so I really liked to opportunity to see my strengths

and weaknesses in that situation.”

“This was a great experience. It was very helpful to be able to collaborate with the nurse following the interview. It was a good way to get out first time jitters with experiences like this. I was prepared

with a lot of questions to complete a full interview but due to the significant changes in BP and heart rate and presents of redness,

swelling, and tenderness in her L calf I had to stop short.”

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Capacity vs Quality

WHAT IS YOUR PRIMARY CLINICAL EDUCATION

CHALLENGE?

Capacity or Quality

Professor Clinician Clinical Instructor SCCE

OUR SILOS

ADDRESSING QUALITY: FROM THE CLINICAL SITE

PERSPECTIVE

ORIENTATION & COMMUNICATION

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HOW DO WE MANAGE ALL OF THIS ORIENTATION?

IT TAKES A VILLAGE

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Structure similar to employee orientation

Components

of Our Student Orientation Program

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EXAMPLES OF ASSIGNED STUDENT PROJECTS

Create/Update Patient Handouts

Analyze Evidence for Outcomes Measures

Update Existing Documents

With Current NormsCreate Videos - For Student

Orientation,

Transfer Training, etc

Update Student Orientation Materials

Bring Evidence To Staff

Case Studies and Journal Clubs

Archive Students’ Projects For Future Use

FEEDBACK FROM SLU STUDENTS

• The student program at Barnes (Jewish Hospital) is great! They are very open to teaching you as much as possible and exposing you to the way the hospital system operates.

• Doing the case study/inservice was helpful to learn more about inpatient PT and different interventions to provide.

• All of the training and orientation was very helpful for succeeding on this clinical.

• I thought the student program was structured very well. I learned so much on this rotation and was able to get a great understanding of what PT's role is in acute care.

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ADDRESSING QUALITY: FROM THE

ACADEMIC PERSPECTIVE

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ADDRESSING CAPACITY:FROM THE

ACADEMIC PERSPECTIVE

ADDRESSING CAPACITYFROM THE

CLINICAL SITE PERSPECTIVE

SCCE COMMUNICATION WITH CLINICAL INSTRUCTORS

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Culture

Experts

Lifelong Learners

Role Models

Student

New Employee

Clinical Instructor

Role Model

CLINICAL EDUCATION MODELS

1 Student:

1 Instructor

2 Students:

1 Instructor1 Student:

2 Instructors

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1 Student:

1 Instructor

PT or PTA Student ICE


1 Student:

2 Instructors

Split Clinical Between 2 Full Time Therapists

Full Time Student Shared Between 2 Part Time Therapists


2 Students:

1 Instructor

2 PT/PTA Students

PT Student/ PTA Student

PT Student/

ICE StudentPT Student/

Student LabsStudent

Labs

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POLICIES AND REGULATIONS:STUDENT SUPERVISION

Barriers

Student

Quality of Clinical

Divided CI Attention

Generalized Feedback

Treat Together Comparison to Student

Instructor

Too Much Time

2x Documentation

Review

2 CPI!!

Increased Stress

Students at Different Levels

Decrease Productivity at

Beginning

2:1 CLINICAL MODEL

Benefits

Student

Increased Collaboration

Improve Knowledge

Security Foster Independence

Get Comfortable with

Uncomfortable

Instructor

Lifelong Learner

Experience

Expert

Increased Productivity

Larger Caseload

Less Stress

2:1 CLINICAL MODEL

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PT STUDENT & PTA STUDENT:INSTRUCTOR MODEL

PT Student

PTA Student

Increased Collaboration

Direction and Supervision

Teamwork

Increased Communication

Scope of Practice

Education

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INSTRUCTOR ROLE MODEL

RESOURCESTO EXPLORE

Specialty Sections and Special Interest Groups (Education Section of APTA)

Education Leadership Conference

American Council of Academic Physical Therapy (ACAPT)

Literature Review/EBP

Online Links: Balance Testing, Stroke Education, ECG Knowledge, etc

APTA Learning Center

AcuTEACH Forum in AACPT

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BREAK DOWN THE SILO: IMPROVING CAPACITY AND QUALITY

Academic Wins Clinic Wins

Increasing student placements Teaching opportunities for staff

Advancing current practice: Awareness of current trends in clinical practice

Advancing current practice: In-service on topicsrelevant to your practice (Student or faculty)

Building relationships with facilities/sites (Recruiting lab assistants/adjunct faculty)

Building relationships with academic institutions (Opportunities: lab assistant, email list for CEUs)

Preparing students for entry level practice/Normative Model

Increasing efficiency of new hire for orientationand productivity when previously a student at that site

Improving application of curriculum content because of hands on experience

Completing projects: Students can do these too

Refining students inter-professional communication

Improving employee retention (Educated decision when applying for position)


REFERENCES• APTA A Normative Model of Physical Therapist Professional Education: 2004.• Guide to Physical Therapist Practice 3.0. Alexandria, VA: American Physical Therapy

Association; 2014. Available at: http://guidetoptpractice.apta.org/. Accessed 11/1/17.• APTA Professionalism in Physical Therapy: Core Values BOD P05-04-02-03

[AM E N D E D BOD 08-03-04- 10] http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/Judicial_Legal/ProfessionalismCoreValues.pdf Accessed on 3/6/2017.

• Core Competencies for Entry-Level Practice in Acute Care Physical Therapy. APTA Academy of Acute Care Physical Therapy Minimum Skills Task Force; 2015.

• Gorman SL, Wruble Hakim E, Johnson W, et al. Nationwide acute care physical therapist practice analysis identifies knowledge, skills, and behaviors that reflect acute care practice. Phys Ther. 2010; 90 (10): 1453-1467. Doi: 10.2522/ptj.20090385

• Masley PM, Havrilko CL, Mahnensmith MR, et al. Physical therapist practice in the acute care seting: A qualitative study. Phys Ther. 2011; 91(6), 906-922. Doi: 10.2522/ptj.20100296.

• Delany C, Bragge P. A study of physiotherapy students' and clinical educators' perceptions of learning and teaching. Med Teach. 2009 Sep;31(9):e402-11.


REFERENCES• Dunfee HJ. Clinical Education: Past, Present, and Future. Journal of Physical Therapy Education.

2008;22(3):3‐6.• Plack Margaret M. The Learning Triad: Potential Barriers and Supports to Learning in the

Physical Therapy Clinical Environment. J of Physical Therapy Education. 2008;22(3):7‐18.• Rosenwax L, Gribble, N, Margaria, H. GRACE: An Innovative Program of Clinical Education in

Allied Health. Journal of Allied Health. 2010;39(1):e11‐e16.• Giberson Tomas R, Black Beth, Pinkerton, Eric. The Impact of Student‐Clinical Instructor Fit and

Student‐Organization Fit on Physical Therapist Clinical Education: Experience Outcome. Journal of Physical Therapy Education. 2008;22(1):59‐64.

• Smith PM, Seeley J. A review of the evidence for the maximization of clinical placement opportunities through interprofessional collaboration. J Interprof Care. 2010 Nov;24(6):690‐8.

• Jette D, Brown R, Collette N, Friant W, Graves L. Physical Therapists’ Management of Patients in the Acute Care Setting: An Observational Study. Phys Ther. 2009;89(11):1158‐1181.

• APTA student supervision chart http://www.apta.org/Payment/Medicare/Supervision/. Accessed 11/27/17.


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REFERENCES

• Jette D, Bertoni A, Coots R, Johnson H, McLaughlin C, Weisbach. Clinical Instructors’ Perceptions of Behaviors That Comprise Entry Level Clinical Performance in Physical Therapist Students: A Qualitative Study. Phys Ther. 2007; 87:833-843.

• Silberman N, Panzarella K, Melzer B. Using Human Simulation to Prepare Physical Therapy Students for Acute Care Clinical Practice. Journal of Allied Health. 2013; 42(1): 25-32.

• Pabian P, Dyson J, Levine C. Physical Therapist Productivity Using a Collaborative Clinical Education Model Within an Acute Care Setting: A Longitudinal Study. Journal of Physical Therapy Education. 2017;31(2): 11-17.

• Ohtake PJ, Lazarus M, Schillo R, Rosen M. Simulation experience enhances physical therapist student confidence in managing a patient in the critical care environment. Phys Ther. 2013;93:216-228.


REFERENCES

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