RESEARCH ARTICLE Open Access

Paediatric Physiotherapy curriculum: anaudit and survey of Australian entry-levelPhysiotherapy programsKaren Mistry, Emi Yonezawa and Nikki Milne*

Abstract

Background: No documented standard or core competencies exist for paediatric curriculum in entry-levelphysiotherapy programs in Australia. Consequently, extensive variability is thought to exist amongst Australianentry-level physiotherapy programs for preparing physiotherapists to work safely and effectively with children.The purpose of this study was to explore the landscape of paediatric curriculum in Australian entry-levelphysiotherapy programs and identify the paediatric content being covered, its perceived importanceaccording to university academics who teach paediatrics, the mode of delivery and assessment, and thestrengths, weaknesses, barriers and facilitators to implementing paediatric curriculum.

Methods: A web-based desktop audit and an online cross-sectional survey using closed and open-endedquestions was administered to all Australian universities offering entry-level physiotherapy programs inNovember 2017. Content coverage and perceived level of importance for paediatric content areas weredetermined using Likert scale responses. Open-ended responses were thematically analysed to identify keythemes for strengths, weaknesses and facilitators to implementation of paediatric curriculum.

Results: All (n = 20, 100%) entry-level programs used the terms lifespan, child and/or paediatrics somewherein at least one subject descriptor. Forty-five percent (n = 9) of universities did not use the terms lifespan,child or paediatric in their published learning objectives. Eight (40%) universities offered a paediatric stand-alone course. Sixty-five (13/20) percent of universities invited, responded to the survey. For paediatric conditions theperceived level of importance was predominately higher than its course content coverage for 19 of the 31 conditionssurveyed. Key barriers to implementating paediatric curriculum were: crowded curriculum, limited financial resourcesresulting in a lack of qualified staff, lack of prioritisation of paediatric curriculum and inadequate paediatric placementavailability. Facilitators for effective implementation of paediatric content were stand-alone paediatric subjects,demonstrated dedication to paediatric curriculum and having suitably qualified faculty members.

Conclusion: The results of this survey provide the physiotherapy community with the views of paediatric physiotherapyacademic educators regarding the content, perceived need to expand content delivery in identified clinical areas, and thebarriers and facilitators to implementing paediatric content in Australian entry-level physiotherapy programs. Furtherresearch exploring similar questions with paediatric physiotherapy clinicians would complement the findings of this study.

Keywords: Australian, Physiotherapy, Paediatric, Curriculum, Entry-level, University, Tertiary education, Allied health,Training

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

* Correspondence: nmilne@bond.edu.auFaculty of Health Sciences and Medicine, Bond Institute of Health and Sport,Bond University, Robina, QLD, Gold Coast 4226, Australia

Mistry et al. BMC Medical Education (2019) 19:109 https://doi.org/10.1186/s12909-019-1540-z

BackgroundPhysiotherapists in Australia received rights for beingfirst-contact practitioners in 1978 [1]. These rights wereaccompanied with expectations to complete an entry-level degree in physiotherapy to be deemed capable ofassessing and treating the general population throughoutthe lifespan. A guide for accreditation of entry-levelphysiotherapy programs published by the AustralianPhysiotherapy Council (APC) state that each universitymay design their own curriculum providing they meetthe Australian and Aotearoa New Zealand PhysiotherapyPractice Thresholds (2015) [2]. Additionally the APCstate that Universities should do so while preparing stu-dents to be safe, effective and efficient entry-level phys-iotherapists [2]. Although physiotherapy programs inAustralia prepare their own university-specific curriculumindependently of each other, there is no standardised con-tent that is expected or published for entry-level physio-therapy students to have covered in the field of paediatricphysiotherapy. Paediatric physiotherapists are health pro-fessionals who work with children and adolescents andhave a thorough understanding of child development andits relation to body systems and functions [3]. A paediatricphysiotherapist should also follow a family-centred careapproach that involves a decision-making process betweenfamilies and professionals in a healthcare setting [4].Approximately 19% of the Australian populations are

under the age of 15 years [5]. In 2012, 4.2 million peoplein Australia were reported to have a disability, of whichapproximately 7% were children between the ages 0–17years [6, 7]. Physiotherapy remains an area of increasingdemand on the Australian occupational list in themedium to long term [8]. With the growing require-ments of physiotherapists and increasing population ofchildren, it is expected that most therapists will encoun-ter children for therapy at some point in their career [9].As Australia moves fully into the National Disability In-surance Scheme (NDIS) funded care for persons (includ-ing children) with a disability, it will likely benefitchildren and the physiotherapy profession to includeand enhance paediatric curriculum in entry-level physio-therapy programs. The NDIS is a new model of caresupporting people within the community who have adisability, their families and carers and focuses on a life-time approach to enhance their future outcomes [10].The skills and knowledge required to treat a child arenot always transferrable from those learnt in adult con-texts, as children with developmental difficulties and dis-abilities require specific care that is unique to theirpresentation and life context [9]. Whist all students inAustralian physiotherapy programs will undertakeclinical placements in adult care environments and willbe assessed using a nationally standardised valid and re-liable assessment tool for their clinical competencies

[11–13], they may never undertake a clinical placementwith the same level of external assessment in paediatricsettings or with paediatric clients. Additionally, somestudents in Australia may graduate from their physio-therapy program having never been assessed for theircompetencies to safely and effectively assess and treatreal infants or children, yet directly after graduating theirprogram, they can become licenced to work independ-ently with infants and children. For this reason, it may beappropriate to develop a minimum set of standards re-garding paediatric-specific physiotherapy knowledge; skillsand attributes which could be used to develop curriculumand a tool to assess paediatric competencies at entry-levelto the profession, to better ensure that paediatric clientsand their families are being effectively, efficiently andsafely managed by physiotherapists across Australia.

Review of literatureTo understand issues surrounding paediatric content inphysiotherapy programs globally, a narrative review ofthe literature was undertaken. Internationally, mixedmethod studies have been carried out between 1983 and2017 utilising surveys, guidelines and opinions to deter-mine paediatric physiotherapy curriculum standards. Fif-teen studies investigating this topic have collectivelyinvolved 1700 participants; however, all studies wereconducted in the United States (US) of America. Threekey themes relating to paediatric physiotherapy curricu-lum have been identified in previously published litera-ture including the following; (i) paediatric content(conditions and science); (ii) mode of delivery and; (iii)barriers to the implementation of paediatric curriculum.A review and synthesis of previously published literaturesuggests that only a minimal amount of paediatric con-tent is covered within university curriculums in the US.Additionally, most US universities use a lifespan ap-proach in the delivery of content, however, the time allo-cated to paediatric populations and approaches to carefluctuate substantially between programs [9, 14]. Dis-crepancies exist in the level of knowledge and skills ofgraduating physiotherapists from entry-level programsin the US. Insufficient faculty [15–19], insufficient clin-ical placements [14, 16] and a lack of consensus regard-ing paediatric content to prioritise [15, 16], were reasonsprovided in previously published literature, to explainthe limited amount of paediatric content in US physio-therapy entry-level programs. In the development offirst-contact practitioners who are licensed to work withinfants and children, appropriate paediatric content de-livered within the curriculum is critical to prepare phys-iotherapists to have adequate skills and knowledge tomanage paediatric populations in a safe and effectivemanner. Considering the extensive variability in thepaediatric content delivered across universities in the

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US, the Section on Paediatrics (SoP); a special interestgroup of APTA (American Physical Therapy Associ-ation) carried out an Education Summit in July 2012[20]. An objective of this summit was to recommendstrategies for academic institutions to assist in develop-ing paediatric education to prepare entry-level physio-therapy students. Rapport, et al. [20] highlighted thedecision-making process during the summit that re-sulted in a consensus on five core competencies thatwere referred to as essential knowledge base for allentry-level physiotherapy graduates regardless of the in-tent or interest to provide services to children upon com-pletion of the program. The identified core competencieswere: [1] Human development, [2] Age-appropriate pa-tient/client management, [3] Family-centered care for allpatient/client and family interactions, [4] Health promo-tion and safety, and [5] Legislative policy and systems.Additionally, the SoP, APTA [20] endorsed a list of paedi-atric conditions that are considered appropriate for inclu-sion in US entry-level physiotherapy programs.Whilst paediatric core competencies exist in the US,

there is currently no documented standard for universitycurriculum or competencies relevant to paediatric physio-therapy in Australia for which the Australian Physiother-apy Council (APC) can hold programs accountable. Whilethe APC commonly reviews subject outlines and descrip-tors as well as assessment items during accreditation cy-cles [2], historically there has not been a consistentrequirement to detail the paediatric curriculum of a pro-gram. This is despite there being a common acknowledge-ment of very limited paediatric placement experienceswhere external assessment is available. Subsequently witha lack of available evidence, the accreditation panels maybe certifying universities to graduate first-contact,entry-level physiotherapists who may not have the skillsor knowledge to work safely and effectively with childrenyet, can become registered to do so. Now that the NDIShas been implemented across Australia it is a critical pointin time where Australian physiotherapy program accredit-ation panels could review their expectations regardingpaediatric curriculum, including content, delivery andachieved competencies. To become a NDIS provider,registration can be completed online following a checklistapplication process ensuring providers understand thisscheme and its role within the community. Providers withthe intention to treat children aged between zero - sixyears have to register as an Early Childhood Early Inter-vention (ECEI) provider through the NDIS. To become anECEI provider evidence of previous engagement with chil-dren (0–6 years) is required for registration. However, ap-proval to become a standard NDIS provider to treatchildren over the age of seven years, requires no verifiedproof of paediatric experience, knowledge or competency[21]. Furthermore, private practice physiotherapists are

not required to provide evidence of competencies to workwith children of any age or ability. Therefore, a registeredphysiotherapist could potentially be providing care to chil-dren within the community without any history of previ-ously assessing or treating real-life children in a safe,effective and efficient manner and this is also an areaworthy of further consideration at an accreditation level.The exploration and documentation of current paedi-

atric curriculum in entry-level physiotherapy programsin Australia, may be a useful mapping process for uni-versities as a bench-marking opportunity. This processmay assist universities to become more accountable fordeveloping in students, the knowledge and skills re-quired of entry-level, first-contact practitioners to prac-tice with children and infants. Therefore, the objectiveof this prospective cross-sectional study was to investi-gate the landscape of paediatric physiotherapy curricu-lum in entry-level physiotherapy programs in Australiausing two methodological steps. The first preliminarystep was to undertake a desktop-audit, with the aim ofquantifying publicly available information (e.g. subjectoutlines / course descriptors) regarding paediatric-specificlearning objectives and assessment items published onuniversity websites for entry-level physiotherapy pro-grams. Secondly, the research team undertook a nationalsurvey with the aim of identifying:

(i) The paediatric curriculum content covered inentry-level physiotherapy programs and to whatextent;

(ii) The perceived importance of paediatric content byuniversity academics who teach or convene coursesinclusive of paediatric content in entry-levelprograms, including differences in responses basedon program level (i.e. bachelor versus entry levelmasters +/− extended);

(iii)The mode of delivery of paediatric curriculum andassessment in entry-level programs;

(iv) Strengths, weaknesses, barriers and facilitators, tothe implementation of paediatric courseworkcurriculum in entry-level programs.

MethodsParticipantsDetails for all universities offering entry-level physiother-apy programs throughout Australia (n = 20 universities)were sourced using the Australian Health PractitionerRegulation Agency (AHPRA) website [22]. All Australianentry-level physiotherapy programs were eligible to beincluded in this study. A list of names, emails and phonenumbers for staff members teaching directly into thephysiotherapy curriculum at respective universities werecollected using publicly accessible university websites.Twenty universities were identified and from these

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universities, thirty-one possible participants were in-vited to participate in the research study, with the ex-pectation of having one person per university programparticipate in the study to share information about theiruniversity curriculum.

Research design (desktop audit and survey)A web-based desktop audit of university entry-levelcurriculum and a mixed method cross-sectional surveywas concurrently carried out to review each university’s(n = 20) curriculum for paediatric content as it was pub-lished on their university website at the time of theaudit. The inclusion criteria for both research designswere as follows: [1] University or Institution of highereducation located in Australia, [2] Offering an entry-level physiotherapy program (i.e. bachelor, masters bycoursework, extended masters). Institutions offering onlya diploma or certificate of trade in the area of physio-therapy were excluded. The desktop audit captured theprogram type (i.e. bachelor, masters by coursework, ex-tended masters) for each university, and included thecourse description, learning outcomes, syllabus and as-sessments for each subject that included the terms child,paediatric or lifespan, if available. The desktop auditswere categorised into three groups for analysis: i) all uni-versities, ii) survey respondents and; iii) non-survey re-spondents. Upon reviewing information about eachcourse as it was published on the web, four main ques-tions were answered to explore paediatric contentcovered in universities. Responses to questions werescored 0 or 1 (0 = No and 1 = Yes). The questions ad-dressed in the desk-top audit were: (i) are any of theterms - child, lifespan or paediatric used in the publishedcurriculum? (ii) did the course description use termssuch as child, lifespan or paediatric but did not use theseterms in the learning objectives? (iii) was there clearlydocumented paediatric specific assessment in thecurriculum? and (iv) was a stand-alone paediatriccourse/subject offered?A mixed method cross-sectional study including quan-

titative and qualitative methods was used to collect data.Ethical approval was obtained from the Human ResearchEthics committee at the host University (HREC approvalnumber: 16162). An online cross-sectional survey wasdeveloped in three stages; (i) an extensive review ofexisting literature assisted the research team in draftingthe survey; (ii) local paediatric physiotherapists (n = 3)with higher education teaching experience were con-sulted to pilot the survey and provide feedback on thecontent, themes, structure and assist with identifyingany question ambiguity; (iii) the survey was modifiedbased on feedback before circulation of the survey linkto potential study participants using Survey Monkey.The final survey design consisted of six themes including

the following; (i) paediatric teaching staff demographic;(ii) curriculum relating to (ii.a.) knowledge of typicaldevelopment; (ii.b.) paediatric diagnoses (atypical devel-opment); (iii) paediatric examination/assessment; (iv)paediatric intervention and; (v) strengths, weaknesses,barriers and facilitators to implementation. A five-pointLikert scale was used to quantify the content covered in theuniversity’s curriculum at the time of the survey (0 = notcovered at all, 5 = covered very well) and the teaching staffs’perceived importance in covering that content (0 = stronglydisagree with its importance, 5 = strongly agree with itsimportance). Questions using dichotomous answers (Yes /No) were employed to explore barriers to implementingpaediatric curriculum. Open-ended questions wereemployed to identify facilitators to implementing paediat-ric curriculum within entry-level physiotherapy programsand to explore strengths and weakness’ in the paediatriccurriculum. (See Additional file 1 for copy of survey).

ProcedureThe chief investigator sent an e-mail invitation to allpersons (n = 31) identified as suitable to participate inthe study including a link to Survey Monkey where theparticipant information sheet and consent form wereaccessible. After providing consent, participants wereasked to complete the online survey (taking approxi-mately 30 min). A fortnightly e-mail was sent out as areminder to participate in the study. On completion ofthe survey, the results of the university desktop auditwere emailed to the relevant universities. To validate theresponses from the survey when ambiguous answerswere provided, participants were provided an opportun-ity to update the details from the desktop audit for theiruniversity’s paediatric curriculum. This step was under-taken by sending a Word document file, (containing theextracted paediatric content from the university website)via email to the participants at the relevant universities.

Analysis of dataSurvey Monkey data was retrieved as an Excel file andcoded before importing into SPSS version 24 [23] foranalysis and storage. Descriptive statistics were used toderive percentages and frequencies for demographic in-formation, barriers to the implementation of paediatriccurriculum and results from the desktop audit. Medianand mean responses with standard deviations were cal-culated for all questions using a Likert scale. Tests fornormality were performed and assumptions explored toidentify the appropriate analyses to undertake. Afterensuring that all relevant assumptions were met,Mann-Whitney U tests were undertaken as a secondaryanalysis to identify if significant differences in medianresults existed between bachelor level programs andentry-level master programs (+/− extended) for content

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delivered and perceived importance of content in pro-grams. A p-value of < 0.05 was considered significant.To examine the impact of non-paediatric therapistresponses to the median scores, a sensitivity analysis wasundertaken where the responses of non-paediatric phys-iotherapists (n = 2) were removed from the raw data toidentify potential differences in median values comparedto initial analyses. Two forms of thematic analysis were ap-plied to open-ended questions. Open coding was used toidentify themes for strengths and weaknesses of the cur-riculum concerning paediatric content [24]. Surface analysis[24] of frequently used words were utilised to identifythemes for facilitators to the implementation of paediatriccurriculum and inter-professional education [24].

ResultsPaediatric teaching staff demographicFrom the 31 possible participants from 20 Australianuniversities with entry-level physiotherapy programs, 16physiotherapists who were involved with paediatric cur-riculum across Australian universities initially agreed toparticipate (response rate 65%). Of the survey re-sponders eight bachelor and six master (+/− extended)programs were represented in this study. One personwithdrew their consent after identifying that they didnot have the required paediatric curriculum experienceto complete the survey. Among the remaining 15 partici-pants, most were females (n = 14) with an average of sixyears of teaching experience (ranging from 1 to 12 years)and an average of 22 years of clinical experience (rangingfrom 9 to 38 years) as a registered physiotherapist.Eighty-seven percent (n = 13) of survey respondentsundertook their physiotherapy entry-level training inAustralia with the remaining participants completingtheir physiotherapy training overseas (n = 2, 13.3%). Thehighest level of academic degree completed by partici-pants was a PhD (n = 7, 46.7%), with others completingdegrees in, bachelor +/− honours (n = 3, 20%) and mas-ter level degrees (n = 6, 40.0%). Additionally, some par-ticipants had completed post-graduate training in avariety of fields including paediatrics (n = 7, 46.7%), edu-cation (n = 4, 26.7%), cardiopulmonary (n = 3, 20.0%)and neurodevelopmental therapy (n = 2, 13.3%). Someparticipants also completed additional training in otherfields including musculoskeletal (n = 1, 6.7%), sports(n = 1, 6.7%), rural and remote physiotherapy (n = 1,6.7%), aquatic physiotherapy (n = 1, 6.7%) and leadership(n = 1, 6.7%). Sixty-seven percent of participants (n = 10)were in a part-time position averaging 0.56 full-timeequivalent (FTE) (ranging from 0.4 to 0.8 FTE). Theother 33% (n = 5) of the participants were employed in afull-time position as a paediatric academic staff member.Ten participants (66.7%) were employed at an academiclevel of Lecturer, four as Senior Lecturer (26.7%) or

equivalent and one respondent was employed at the As-sociate Professor level (6.7%).

Desktop audit of Paediatric content in entry-levelPhysiotherapy programsPublicly available information was recorded and synthe-sized for each entry-level physiotherapy program inAustralia. All (n = 20, 100%) entry-level programs atthe time of this study were noted to use the terms ‘life-span’ and/or ‘child’ and/or ‘paediatrics’ somewhere in atleast one of their subject descriptors. Forty-five percent(n = 9) of the universities did not use the terms ‘life-span, child or paediatric’ in their published learning ob-jectives and four of these universities did not respondto the survey invitation. Fourteen (70%) universities ei-ther did not specify or did not make publicly availableitems of assessment for paediatric specific learning.Eight (40%) universities offered a paediatric stand-alonecourse and six of these universities were surveyresponders.

Survey responses for knowledge of typical developmentTable 1, outlines response rates relevant to content cov-ered in programs and the perceived importance of thecontent areas relevant to typical development. Most con-tent areas were reported to be ‘somewhat’ to ‘very well’covered except for ‘knowledge of prenatal developmentand birth’, ‘when a child should provide consent’ and‘milestones in social-emotional, speech and language do-mains’ where the majority of responses were ‘not verywell’ or ‘not at all’ covered in the curriculum. Most ofthe responses for questions relating to the perceived im-portance of knowledge relevant to typical developmentwere ‘agreed’ to ‘strongly agreed’. There was one ‘dis-agree’ response for ‘develop foundation knowledge forprenatal development and birth’ and four ‘neutral’ re-sponses, including ‘childhood development and learning’(n = 1), developmental motor milestones (n = 1) andmilestones in social-emotional, speech and language do-mains (n = 2).

Survey responses for paediatric diagnosis (atypicaldevelopment)Fig. 1 (a, b and c) illustrates the median responses (con-tent covered and perceived importance) for questionsabout paediatric specific diagnoses. Perceived import-ance responses were equal to or more than one valuehigher on the 5-point Likert scale than responses to con-tent covered for 19 of the 31 conditions surveyed. Re-sponses for ‘cancer’ and ‘failure to thrive’ revealed thatthe median response for content covered was in the ‘notvery well’ range [1] but the median response for per-ceived importance was ‘agree’ [3], therefore revealing a2-point difference on a five-point scale. Content coverage

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and perceived importance values were equal for 10 of thesurveyed conditions. Mann-Whitney U tests revealed nosignificant differences between bachelor and master levelprograms for content coverage except for neurodevelop-mental conditions covered (e.g. specific learning disorder,ADHD – Attention Deficit Hyperactivity Disorder, DCD– Developmental Coordination Disorder, ASD – AutismSpectrum Disorder) which were reported to be covered inmore detail in bachelor programs (Mdn bachelor = 3.0,Mdn master = 2.0, U = 10.00, p = 0.025) and Spina Bifidawhich was reported to be covered more in master levelprograms (Mdn bachelor = 3.0, Mdn master = 4.0, U = 6.5,p = 0.008). For the perceived importance of curriculumareas, there were no significant differences between bach-elor and master level programs, other than forgrowth-related injuries (Mdn bachelor = 3.0, Mdn master= 4.0, U = 9.00, p = 0.014) and sports and overuse injuries(Mdn bachelor = 3.0, Mdn master = 4.0, U = 6.0, p = 0.005)where in both cases, the master level programs felt theywere more important. When two responders who werenot paediatric physiotherapists were removed in the sensi-tivity analysis the median perceived importance in paediat-ric curriculum for ‘cardiomyopathies’, ‘traumatic brain andspinal cord injury’, ‘cancer’ and ‘failure to thrive’ decreased

from ‘agree’ [3] to ‘neutral’ [2] for each condition.Additionally, the significant difference between the bach-elor and master level programs for content covered rele-vant to neurodevelopmental conditions was no longerapparent (Mdn bachelor = 3; Mdn master = 2, U = 8.50,p = 0.06). However, the significant differences noted forthe perceived importance of covering growth-relatedinjuries (Mdn bachelor = 3, Mdn master = 4, U = 7.50,p = 0.034) and sports and overuse injuries (Mdn bach-elor = 3, Mdn master 4, U = 5.0, p = 0.014) in the cur-riculum remained significantly different betweenbachelor and master level programs.

Survey responses for mode of delivery and assessment ofpaediatric learningOnly five (33.3%) responders reported that they did notuse written exams or quizzes to assess paediatric learn-ing outcomes. Practical exams (Objective StructuralClinical Examination (OSCE) or Viva) and seminar/oralpresentations were used by 62.5 and 53.3% of re-sponders, respectively. Seven (46.7%) of respondersstated that clinical placements were used to assess paedi-atric learning outcomes for all students in their program.Eighty-seven percent (n = 13) of participants reported

Table 1 Content covered and perceived importance reported for the knowledge of typical development

n = 15 Content covered Perceived Importance

0Notatall(%)

1Notverywell(%)

2Some-what(%)

3Well(%)

4Very-well(%)

Median Mean(SD)

0Stronglydisagree(%)

1Disagree(%)

2Neutral(%)

3Agree(%)

4Stronglyagree(%)

Median Mean(SD)

Develop foundationknowledge of prenataldevelopment and birth

1(6.7)

1(6.7)

3(20.0)

5(33.3)

5(33.3)

3 (well) 2.80(1.21)

– 1 (6.7) – 8(53.3)

6 (40.0) 3 (agree) 3.3(0.80)

Develop foundationknowledge of thetheories of childhooddevelopment andlearning

– – 4(26.7)

4(26.7)

7(46.7)

3 (well) 3.20(0.86)

– – 1 (6.7) 5(33.3)

9 (60.0) 4(stronglyagree)

3.5(0.64)

Demonstrate knowledgeof developmental motormilestones

– – 2(13.3)

4(26.7)

9(60.0)

4 (verywell)

3.5(0.74)

– – 1 (6.7) 2(13.3)

12 (80.0) 4(stronglyagree)

3.7(0.59)

Understand theimportance oftherapeutic play withindiverse family, cultural,community and societalcontext

– – 1 (6.7) 6(40.0)

8(53.3)

4 (verywell)

3.5(0.64)

– – – 2(13.3)

13 (86.7) 4(stronglyagree)

3.9(0.35)

Understand when a childshould provide consentand gaining parent/ carerconsent

– 1(6.7)

1 (6.7) 6(40.0)

7(46.7)

3 (well) 3.3(0.88)

– – – 2(13.3)

13 (86.7) 4(stronglyagree)

3.9(0.35)

Demonstrate knowledgeof developmentalmilestones in the social-emotional, speech andlanguage domains

– 1(6.7)

5(33.3%)

6(40.0)

3(20.0)

3 (well) 2.7(0.88)

– – 2 (13.3) 3(20.0)

10 (66.7) 4(stronglyagree)

3.5(0.74)

SD Standard Deviation

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A

B

C

Fig. 1 a. Median responses to questions about content covered and perceived importance for musculoskeletal conditions. b. Median responsesto questions about content covered and perceived importance for neurological conditions. c. Median responses to questions about contentcovered and perceived importance for cardiorespiratory and other conditions

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that paediatric content was provided to students throughlectures and tutorials. Problem/case-based learning (n = 10,66.7%), independent study (n = 10, 66.7%), online content/modules (n = 10, 66.7%) and clinical placements (n = 10,66.7%) were other popular modes of delivery for paediatriccurriculum. Some programs also reported using workshop/practical classes (n = 9, 60%), simulated learning (n = 9,60%), flip classes (n = 4, 27.7%) and site visits (n = 3, 20.0%)in the delivery of paediatric content. Eleven (73.0%) of the15 responders indicated that paediatric curriculum in theirprogram was delivered across different subjects as a lifespanapproach and nine (60%) responders stated that their pro-gram had a stand-alone paediatric subject.

Survey responses for paediatric examination/assessmentTable 2 outlines the responses relevant to paediatric assess-ment and examination. The data revealed that all contentwas covered ‘somewhat’ (score = 2) to ‘very well’ (score = 4)with the exception of ‘ergonomic and body mechanics’,‘orthotic, protective and supportive devices’, ‘reflex integ-rity’, ‘ventilation and respiration / gas-exchange’ and ‘car-diorespiratory fitness’ which were covered ‘not very well’(score = 1) or ‘not at all’ (score = 0). Most responses re-garding the perceived importance of assessment/examina-tions were ‘agree’ (score = 3) to ‘strongly agree’ (score = 4)except for ‘ergonomics and body mechanics’, ‘motor skills’,‘neuromotor and sensory assessment’, ‘orthotic, protectiveand supportive devices’, ‘range of motion’ and ‘ventilationand respiration / gas-exchange’ which received ‘neutral’(score = 2) responses. Mann-Whitney U tests revealed nosignificant differences between bachelor and masters levelresponses. After removing the non-paediatric physiothera-pists in the sensitivity analysis, the median value for con-tent covered for ‘reflex integrity’ reduced from 3 (well) to2 (somewhat) and for ‘outcome measures’ increased from3 (well) to 4 (very well). Additionally, the sensitivity analysisdid not reveal any significant differences between bachelorand master level programs for content covered and per-ceived importance of paediatric examination / assessment.

Survey responses for paediatric interventionsTable 3 outlines the responses related to contentcoverage and perceived importance of paediatric inter-ventions. More than half of surveyed paediatric interven-tions resulted in equal median scores when comparingcurriculum content coverage (‘well’ to ‘very well’) and itsperceived importance (‘agree’ to ‘strongly agree’). Fiveintervention types were perceived as more importantthan what was currently being covered in the curriculum(based on perceived important median scores being onepoint higher than the median score for the same contentarea coverage). Electrotherapeutic and mechanical mo-dalities as well as behaviour management strategies werereported to be only ‘somewhat’ [2] covered in paediatric

curriculum and electrotherapeutic and mechanicalmodalities were perceived to be only ‘somewhat’ [2] im-portant to cover. Mann-Whitney U tests revealed no sig-nificant differences between responses for bachelor andmasters level programs for survey responses to contentcovered or perceived importance. After removing non-paediatric physiotherapists from the dataset in thesensitivity analysis the perceived importance of ‘thera-peutic exercises’ increased from 3 (agree) to 4 (stronglyagree) and the content covered for ‘prescription and ap-plication of equipment devices’ reduced from 3 (well)to 2 (somewhat). The sensitivity analysis did not revealany significant differences between bachelor and masterlevel programs for content covered and perceived im-portance of any paediatric interventions.

Survey responses for paediatric curriculum strengths,weaknesses, facilitators and barriersFigs. 2 and 3 outline the thematically analysed responses(n = 15) to open-ended survey questions regardingstrengths and weaknesses of curriculum with paediatriccontent. Three key themes relevant to paediatric cur-riculum strengths emerged from this thematic analysisincluding: i) background paediatric/development know-ledge; ii) paediatric treatment skills and; iii) mode of cur-riculum delivery. Sixty-seven percent of participants(n = 10) highlighted one of their greatest paediatriccurriculum strengths to be teaching their students com-mon paediatric conditions along with clinical reasoningskills that equip students to treat a wide paediatric case-load (see Fig. 2). The thematic analysis of weaknessesrelevant to paediatric curriculum revealed two keythemes: i) internal organisation structural limitationsand ii) external limitations (see Fig. 3). Forty percent ofparticipants (n = 6) identified ‘limited time allocated’ tolearning paediatric skills and content, as the greatestweakness of the paediatric curriculum, which wasthemed under internal organisation structural limita-tions. The external limitations highlighted by 40% of theparticipants (n = 6) were ‘inadequate placement availabil-ities’, resulting in students having limited hands on ex-perience with the paediatric population (see Fig. 3).Surface thematic analysis of participants’ most frequently

reported responses to open-ended questions regarding ‘fa-cilitators to implementation and development of paediatriccurriculum’ revealed three key themes which are outlinedbelow with example responses supporting the themes:

(i) Stand-alone course

“would benefit from embedding the main paediatriccontent within one subject instead of it being spreadout over 4 years.”

Mistry et al. BMC Medical Education (2019) 19:109 Page 8 of 18

Table

2Con

tent

coveredandpe

rceivedim

portance

repo

rted

forpaed

iatricexam

ination/assessmen

t

n=15

Con

tent

covered

PerceivedIm

portance

0no

tat

all

1no

tvery

well

2 somew

hat

3well

4very

well

Med

ian

Mean

(SD)

0strong

lydisagree

1 disagree

2 neutral

3 agree

4strong

lyagree

Med

ian

Mean

(SD)

Client/paren

tinterview

––

1(6.7%)

5 (33.3%

)9 (60.0%

)4(very

well)

3.5

(0.64)

––

–1 (6.7%)

14(93.3%

)4(stron

gly

agree)

3.9

(0.26)

Physicalassessmen

t–

–1(6.7%)

6 (40.0%

)8 (53.3%

)4(very

well)

3.5

(0.64)

––

–2 (13.3%

)13

(86.7%

)4(stron

gly

agree)

3.9

(0.45)

Ergo

nomicsandbo

dymechanics

–1(6.7%)

9(60.0%

)2 (13.3%

)3 (20.0%

)2 (som

ewhat)

2.5

(0.92)

––

2 (13.3%

)7 (46.7%

)6(40.0%

)3(agree)

3.3

(0.70)

Gait,locomotionandbalance

––

4(26.7%

)6 (40.0%

)5 (33.3%

)3(well)

3.1

(0.80)

––

–4 (26.7%

)11

(73.3%

)4(stron

gly

agree)

3.7

(0.46)

Jointintegrity

andmob

ility

––

4(26.7%

)8 (53.3%

)3 (20.0%

)3(well)

2.9

(0.70)

––

–9 (60.0%

)6(40.0%

)3(agree)

3.4

(0.51 )

Motor

controland

motor

learning

––

4(26.7%

)5 (33.3%

)6 (40.0%

)3(well)

3.1

(0.83)

––

–4 (26.7%

)11

(73.3%

)4(stron

gly

agree)

3.7

(0.46)

Motor

skills

––

1(6.7%)

5 (33.3%

)9 (60.0%

)4(very

well)

3.5

(0.64)

––

1 (6.7%)

2 (13.3%

)12

(80.0%

)4(stron

gly

agree)

3.7

(0.59)

Musclepe

rform

ance

(stren

gth,po

wer,

endu

rance)

––

1(6.7%)

11 (73.3%

)3 (20.0%

)3(well)

3.1

(0.52)

––

–7 (46.7%

)8(53.3%

)4(stron

gly

agree)

3.5

(0.52)

Neuromotor

andsensoryassessmen

t(develop

men

tandintegration)

––

5(33.3%

)4 (26.7%

)6 (40.0%

)3(well)

3.1

(0.88)

––

1 (6.7%)

6 (40.0%

)8(53.3%

)4(stron

gly

agree)

3.5

(0.64)

Ortho

tic,p

rotectiveandsupp

ortivede

vices

1 (6.7%)

2(13.3%

)8(53.3%

)4 (26.7%

)–

2 (som

ewhat)

2 (0.85)

––

2 (13.3%

)8 (53.3%

)5(33.3%

)3(agree)

3.2

(0.68)

Posture

––

4(26.7%

)7 (46.7%

)4 (26.7%

)3(well)

3 (0.76)

––

–9 (60.0%

)6(40.0%

)3(agree)

3.4

(0.51)

Rang

eof

motion(m

uscleleng

th)

––

1(6.7%)

10 (66.7%

)4 (26.7%

)3(well)

3.2

(0.56)

––

1 (6.7%)

8 (53.3%

)6(40.0%

)3(agree)

3.3

(0.62)

Reflexintegrity

–1(6.7%)

6(40.0%

)6 (40.0%

)2 (13.3%

)3(well)

2.6

(0.83)

–1(6.7%)

2 (13.3%

)7 (46.7%

)5(33.3%

)3(agree)

3.1

(0.88)

Ventilatio

nandrespiratio

n/gasexchange

–1(6.7%)

3(20.0%

)8 (53.3%

)3 (20.0%

)3(well)

2.9

(0.83)

––

2 (13.3%

)7 (46.7%

)6(40.0%

)3(agree)

3.3

(0.70)

Cardiorespiratory

fitne

ss–

1(6.7%)

3(20.0%

)8 (53.3%

)3 (20.0%

)3(well)

2.9

(0.83)

––

–8 (53.3%

)7(46.7%

)3(agree)

3.5

(0.52)

Outcomemeasures(AIMS,NSM

DA,G

MFC

S,BO

T-2,MABC

2,TG

MD2)

––

1(6.7%)

7 (46.7%

)7 (46.7%

)3(well)

3.4

(0.63)

––

–5 (33.3%

)10

(66.7%

)4(stron

gly

agree)

3.7

(0.49)

Clinicalreason

ingtools(IC

F)–

––

2 (13.3%

)13 (86.7%

)4(very

well)

3.9

(0.35)

––

–2 (13.3%

)13

(86.7%

)4(stron

gly

agree)

3.9

(0.35)

Und

erstanding

theroleof

themem

bersof

the

interprofessionalp

aediatric

team

––

–6 (40.0%

)9 (60.0%

)4(very

well)

3.6

(0.51)

––

–3 (20.0 %

)12

(80.0%

)4(stron

gly

agree)

3.8

(0.41)

SDStan

dard

deviation,

AIMSAlberta

Infant

Motor

Scale,NSM

DANeu

rosensoryMotor

Develop

men

talA

ssessm

ent,GMFC

SGross

Motor

Functio

nClassificatio

nScale,

BOT-2Bruinink

s-Oseretsky

Test

ofMotor

Proficiency

2ndEd

ition

,MABC

2Mov

emen

tABC

2ndEd

ition

,TGMD2Test

ofGross

Motor

Develop

men

t2n

dEd

ition

,ICF

Internationa

lClassificatio

nof

Functio

nDisab

ility

andHealth

Mistry et al. BMC Medical Education (2019) 19:109 Page 9 of 18

Table

3Con

tent

coveredandpe

rceivedim

portance

repo

rted

forpaed

iatricinterven

tions

n=15

Con

tent

covered

PerceivedIm

portance

0no

tat

all

1no

tvery

well2 Some-

what

3well

4very

well

Med

ian

Mean

(SD)

0strong

lydisagree

1 disagree

2 neutral

3 agree

4 strong

lyagree

Med

ian

Mean

(SD)

Manualthe

rapy

orpo

sitio

ning

andhand

ling

–1(6.7%)

4 (26.7%

)7 (46.7%

)3 (20.0%

)3(well)

2.8

(0.86)

––

–10 (66.7%

)5(33.3%

)3(agree)

3.3

(0.49)

Family/patient-cen

teredcare

––

–4 (26.7%

)11 (73.3%

)4(very

well)

3.7

(0.46)

––

–2 (13.3%

)13 (86.7%

)4(stron

gly

agree)

3.9

(0.35)

Therapeutic

exercises

–1(6.7%)

2 (13.3%

)10 (66.7%

)2 (13.3%

)3(well)

2.9

(0.74)

––

2 (13.3%

)6 (40.0%

)7(46.7%

)3(agree)

3.3

(0.72)

Play-based

exercises

––

1(6.7%)

9 (60.0%

)5 (33.3%

)3(well)

3.3

(0.59)

––

–3 (20.0%

)12 (80.0%

)4(stron

gly

agree)

3.8

(0.41)

Functio

naltrainingin

self-care

andin-hom

emanagem

ent

––

5 (33.3%

)6 (40.0%

)4 (26.7%

)3(well)

2.9

(0.80)

––

1 (6.7%)

6 (40.0%

)8(53.3%

)4(stron

gly

agree)

3.5

(0.64)

Functio

naltrainingforusein

scho

olor

play,inthe

commun

ityandleisureintegration/

re-in

tegration

––

4 (26.7%

)6 (40.0%

)5 (33.3%

)3(well)

3.1

(0.80)

––

1 (6.7%)

5 (33.3%

)9(60.0%

)4(stron

gly

agree)

3.5

(0.64)

Prescriptio

nandapplicationof

equipm

entandde

vices

(assistivede

vices,orthotics,prosthetics)

–3 (20.0%

)4 (26.7%

)8 (53.3%

)–

3(well)

2.3

(0.82)

–1(6.7%)

2 (13.3%

)8 (53.3%

)4(26.7%

)3(agree)

3.0

(0.85)

Airw

ayclearancetechniqu

es–

–2 (13.3%

)10 (66.7%

)3 (20.0%

)3(well)

3.1

(0.59)

––

2 (13.3%

)8 (53.3%

)5(33.3%

)3(agree)

3.2

(0.68)

Electrothe

rape

uticandmechanicalm

odalities

4 (26.7%

)2 (13.3%

)6 (40.0%

)3 (20.0%

)–

2 (som

ewhat)

1.5

(1.13)

2(13.3%

)2 (13.3%

)8 (53.3%

)3 (20.0%

)–

2 (som

ewhat)

1.8

(0.94)

Behaviou

rmanagem

ent

2 (13.3%

)3 (20.0%

)6 (40.0%

)3 (20.0%

)1 (6.7%)

2 (so m

ewhat)

1.9

(1.13)

––

3 (20.0%

)11 (73.3%

)1(6.7%)

3(agree)

2.9

(0.52)

Und

erstanding

theroleof

themem

bersof

the

interprofessionalp

aediatric

team

––

3 (20.0%

)6 (40.0%

)6 (40.0%

)3(well)

3.2

(0.77)

––

–4 (26.7%

)11 (73.3%

)4(stron

gly

agree)

3.7

(0.46)

Use

ofgo

alsettingfortreatm

entplanning

––

5 (33.3%

)10 (66.7%

)4(very

well)

3.7

(0.49)

––

–3 (20.0%

)12 (80.0%

)4(stron

gly

agree)

3.8

(0.41)

SDStan

dard

Deviatio

n

Mistry et al. BMC Medical Education (2019) 19:109 Page 10 of 18

Fig. 2 Thematic analysis for open-ended responses related to strengths of curriculum covering paediatric content

Mistry et al. BMC Medical Education (2019) 19:109 Page 11 of 18

(ii) Demonstrated dedication to implementation of apaediatric curriculum

“staff members covering paediatric subjects are verypassionate about emphasising the paediatriccomponent in the course and making it as relevantand engaging as possible for students.”

“supportive program director and strong representationof paediatric staff”

(iii)Having suitably qualified faculty members.

“strong clinicians from a variety of paediatricspeciality areas are involved in both curriculumdevelopment and teaching.”

Two major themes were identified through thematicanalysis of open-ended questions regarding ‘facilitatorsof inter-professional education and training implementa-tion in paediatrics’:

Fig. 3 Thematic analysis for open-ended responses related to weaknesses of curriculum covering paediatric content

Mistry et al. BMC Medical Education (2019) 19:109 Page 12 of 18

(i) dedication to implement a multidisciplinary teamapproach in teaching

“key staff that understand the importance ofinterprofessional education are dedicated to see moredevelopment within programs.”

(ii) maintaining relationships with multidisciplinaryteams (MDTs) within the university and externalpartners.

“Have good links and a number of subjects that arerun interprofessionally with the occupational therapyand speech pathology department at our university.”

Crowded curriculum (n = 12, 80.0%) was identified as aprimary barrier to the implementation and developmentof paediatric physiotherapy curriculum. Limited financialresources (n = 6, 40.0%) and lack of prioritisation of cur-riculum space for paediatric content (n = 6, 40.0%) werealso identified as barriers. Regarding the implementationand development of Interprofessional health Education(IPE) and training for students in the field of child healthand development the following barriers were identified; (i)timetabling challenges (n = 14, 93.3%), (ii) crowded cur-riculum (n = 10, 66.7%) and; (iii) organisational structureof the institution of higher education (n = 9, 60.0%).Additional comments regarding paediatric curriculum

in entry-level programs were offered by seven partici-pants and two responses that were otherwise not repre-sented in previous results are provided below.

“I think now is a crucial time to push the importanceof minimum level standards upon graduation, giventhe introduction of NDIS.”

“Always need to stretch the creativity on how to assessentry-level practitioners in a standardised way forsafety and efficacy to practice in paediatrics. Basicpractice standards really need to be updated andfinalised by the APA, so curriculums can align tothese.”

DiscussionMajor findingsThis study is the first to investigate the paediatricphysiotherapy curriculum in entry-level physiotherapyprograms in Australia. In relation to Australian physio-therapy entry-level programs, the preliminary step

undertaken was a desktop-audit, with the aim of quanti-fying the publicly available information regardingpaediatric-specific learning objectives and assessmentitems published on the university website. Through a na-tional survey, this study identified; (i) paediatric curricu-lum content covered and to what extent; ii) theperceived importance of academic content by universityacademics teaching or convening subjects inclusive ofpaediatric content, including differences in responsesbased on program level (i.e. bachelor versus entry levelmasters +/− extended); iii) the mode of delivery ofpaediatric curriculum and assessment; (iv) barriers and/or facilitators to the implementation of paediatriccoursework. The major findings of this study suggestthat most paediatric content outlined in the present sur-vey was reported as being covered ‘well’ in Australianuniversities with very few topics being covered ‘verywell’. Additionally, the perceived importance for paediat-ric content coverage was greater for most topics sur-veyed when compared to the level of actual coveragereported in the programs. Whilst curriculum deliveryand assessment modes reported in the survey differedacross universities, the desktop audit revealed that justunder half of Australian universities did not use theterms lifespan or paediatric in their published learningoutcomes, suggesting that learning specific to paediatriccaseloads were not targeted outcomes. Limited time al-located to paediatric content was the most commonlyreported weakness of paediatric curriculum withcrowded curriculum being identified as the primary bar-rier to the implementation/delivery of paediatric content.Further, the most commonly reported facilitators to theeffective implementation of paediatric curriculum washaving a stand-alone paediatric subject and having bothchampions for implementation of paediatric content andsuitably qualified physiotherapists on staff to teach thecontent. Whilst these themes clearly arose from the sur-vey analysis, further work is required to assist with de-termining how much time should be dedicated topaediatrics and what modes of delivery best meet theneeds of new graduate physiotherapists to safely and ef-fectively service paediatric clients. The US based educa-tion summit carried out in 2012 by SoP, APTA [20]discussed the number of hours to be devoted to teachingpaediatrics but were unable to reach a consensus due tothe lack of available evidence at the time. The SoP,APTA determined that each educational program couldcontinue making their own decisions about hours andmode of delivery as so long as a variety of learning strat-egies were used. With relation to mode of delivery theexperts attending the SoP, APTA summit highlighted thetwo most common approaches for content delivery wereintegrated or a stand-alone approach. The integrated ap-proach would require the education programs to deliver

Mistry et al. BMC Medical Education (2019) 19:109 Page 13 of 18

paediatric content across the curriculum by providingfoundation knowledge relevant to paediatrics in the firstyear of study and as the years progress to build on thisknowledge through the different topics in the physio-therapy curriculum. A unique challenge identified withthe integrated program was the difficulty in pulling allpaediatric concepts together and collaborating withother faculty members to effectively convey the paediat-ric content [20]. In the Australian program accreditationguidelines published by the APC [2] the key areas whichmust be covered in an entry-level program include mus-culoskeletal, neurological, cardiorespiratory and electro-physical agents across all ages from acute to communitycontexts [2]. These guidelines, do not provide detailedguidance on the depth of content and skill developmentthat is suitable for students to develop paediatric corecompetencies, potentially leaving graduates of somephysiotherapy programs with a taste of paediatrics ineach integrated subject without developing competenciesrelevant to paediatric clients in the particular clinicalarea. It is commonly understood by Australian physio-therapy program accreditation panels that there are notenough 5-week paediatric placement experiences for allphysiotherapy students to have a paediatric placementexperience assessed using the APP. Consequently,accreditation panels accept alternate models of practicalexperience compared to those in the clinical areas ofneurological, musculoskeletal and cardiorespiratoryphysiotherapy which are typically undertaken in adult-oriented settings. The lack of detailed curriculumguidelines in this difficult to source placement area (i.e.paediatrics) means that the quality control for paediatriccompetencies compared to the more adult-orientedcompetencies in Australian physiotherapy programs isreduced. Currently, the APC accreditation standard 3.3 -The quality and quantity of clinical education is suffi-cient to produce a graduate competent to practise acrossthe lifespan in a range of environments and settings, ap-pears to be left open to interpretation for paediatrics asthere is no defined expectation for coursework curricu-lum or practical experience. Whilst the authors of thispaper are not suggesting that the APC mandate a setnumber of clinical placement hours or an exact syllabus,to ensure that programs are producing graduates com-petent to practise across the lifespan and to safeguardpaediatric clients, further scrutiny in this area is war-ranted. It may be advantageous to have Australian guide-lines available detailing minimum standards forpaediatric curriculum and practical experience thatphysiotherapy programs could be benchmarked againstby accreditation panels. A mandated bench-markingprocess for paediatric curriculum may also assist theuniversities to share and learn about new and innovativeways to develop paediatric specific skills and knowledge

and this may be particularly helpful for programs whodo not have paediatric physiotherapists on staff.A stand-alone paediatric course was the second most

common approach for curriculum delivery reported inour survey. This method of delivering paediatric content,if inclusive of case-based learning and laboratory experi-ence, was recently recommended as the most effectivemethod of teaching paediatric physiotherapy core com-petencies in a US based curriculum [25]. The desktopaudit in the present study revealed that a stand-alonepaediatric course (subject) was offered in only eight ofthe 20 universities audited. A potential reason for uni-versities not having a stand-alone paediatric coursecould be due to limited time and prioritisation of paedi-atric content within the curriculum, which was reportedas a barrier by multiple researchers in previous US-based literature [14–16, 19]. In the present study mostparticipants recognised that offering a stand-alone paediat-ric course was a facilitator for adequately covering paediat-ric content. Universities and accreditation authorities couldconsider these findings when planning, developing andaccrediting paediatric professional education to ensure thatknowledge and skills relevant to a paediatric caseload(birth-18 years) are adequately covered and assessed.The findings of this investigation are particularly im-

portant to consider with the Australian health-caremodel now introducing the NDIS funded care across thecountry. Historically, families of children requiring carefor developmental or disability-related conditions wereguided to apparent child-related services that employedsuitably trained and or experienced paediatric physio-therapists with supervision and mentoring arrangementsin situ. With the NDIS, the general population can nowmake an autonomous choice on the therapists they visitfor their child’s disability support. The providers theychoose to visit (either NDIS registered or private practi-tioner) may not necessarily have the level of skills andknowledge to treat a paediatric caseload (aged over 7years). Additionally, physiotherapists servicing childrenmay not have a supervision framework in place, as iscommonly the case in publicly funded paediatric facil-ities (e.g. Hospitals and community health centres). Thisposes the question as to whether entry-level physiothera-pists should be able to provide care to paediatric clients,without further training or supervision.The SoP, APTA during the US education summit in

2012, identified five core competencies and endorsed ashort list of common paediatric conditions for inclusionin US entry-level physiotherapy programs where evi-dence existed for physiotherapy interventions and theseincluded; ASD, brachial plexus injury, Cerebral Palsy,congenital limb deficiencies, Cystic Fibrosis, DCD, devel-opmental delay, Down Syndrome, Muscular Dystrophy,Myelomeningocele +/− with or without hydrocephalus

Mistry et al. BMC Medical Education (2019) 19:109 Page 14 of 18

and Torticollis +/− Plagiocephaly [20]. The results fromthe present survey demonstrated that Australian paediat-ric academic educators also perceived these conditionsto be important for inclusion in entry-level physiother-apy curriculum. Additionally, three of the five corecompetency areas including human development,age-appropriate client management and family-centredcare were considered important elements for inclusionby Australian academic educators. The final two corecompetency areas in the SoP, APTA curriculum guide-lines [20] were not included in the present study and re-quire further investigation in Australian contexts. Theresults of the present study have further validated thecollective findings from previous US literature on thistopic [9, 16, 20, 26, 27] and have contextualised these re-sults to be relevant to the Australian higher educationsector and physiotherapy profession. Consequently, thefindings from this study could be used as a resource forAustralian physiotherapy programs when developing orteaching paediatric physiotherapy content.

Secondary findingsThe Mann-Whitney U test revealed some significant dif-ferences between bachelor and master level programsfor four paediatric conditions surveyed, but after con-ducting sensitivity analysis on the same results the dif-ferences were no longer apparent. The only differenceobserved was that masters level programs perceivedgrowth-related injuries and sports and overuse injuriesas slightly more important to cover in a program. As thisdifference was only observed in two out of the 31 condi-tions surveyed, it could be stated that most programsperceive it important to cover the documented paediat-ric conditions despite the level of the program (i.e. bach-elor and masters). Our study also found that most of thepaediatric content was delivered through lectures andtutorials and was assessed using written exams and quiz-zes. This suggests that a gap may exist in the practicalassessment of paediatric competencies for physiotherapystudents and this is likely due to the limited number ofpaediatric placement opportunities available in Australia.This was evidenced in addressing our fourth study aim,where a lack of paediatric-specific placements was notedas a barrier to many program’s paediatric curriculum.Half of the participants in the present study reportedthat they provided all students the opportunity to attendclinical placement in the field of paediatrics, howeverthe length of time or expected learning outcomes fromthe placement (e.g. observation verses competencies) isunknown. If universities were mandated to benchmarktheir paediatric curriculum, universities who are under-represented in paediatric placements, would have theopportunity to see how some universities manage toplace all students in paediatric clinical experiences and

assess their competencies for working safely and effect-ively with children. With the NDIS now active acrossAustralia, it may be appropriate to consider new oppor-tunities for paediatric placements, outside of hospitalsettings. Supervised visits to childcare and school envi-ronments, paediatric placements with private practicesworking with NDIS funded clients, university interpro-fessional paediatric clinics, simulated learning, inaddition to the more commonly utilised communityhealth and hospital environments, should all be consid-ered as rich learning environments where physiotherapystudents could develop paediatric specific competencies.Additionally, universities may need to look beyond trad-itional 5-week full time 1:1 supervised placement blocks,yet still offer adequate time and supervision for studentsto develop safe and effective skills that will serve chil-dren, infants and their families well.Previous, research suggests that hands on experience

assists in consolidating information and skills learnt atuniversity [17]. Without all students undertaking place-ment experiences with paediatric clients, due to theidentified lack of clinical placement availabilities, it ispossible that only some students are being adequatelyprepared to manage a paediatric caseload as anentry-level physiotherapist. The lack of paediatric place-ment experiences for some students is likely to continuewith growing cohort numbers in physiotherapy pro-grams across Australia. Furthermore, in Australia,students attending placement types such as musculo-skeletal, cardiorespiratory and neurological physiother-apy are consistently being examined by physiotherapistsexternal to the university using the Assessment ofPhysiotherapy Practice (APP) [13] to ensure adequateknowledge and practical skills are being attained. With-out all students undertaking a paediatric clinical place-ment assessed using the APP or another appropriateassessment tool, there is a risk that some physiotherapystudents may graduate without assurances that they pos-sess the skills, knowledge and attitudes to safely and ef-fectively work with children. When placements areunable to be achieved, universities need to develop in-novative and appropriate learning opportunities, includ-ing practical experiences within their curriculum toensure that all students learn skills relevant to becomingsafe, effective and efficient to work with paediatric popu-lations and their families.Limited financial resources were an identified barrier

to the implementation of paediatric curriculum in ourstudy and this barrier was also noted in previously pub-lished US-based literature [16, 19]. If universities whodo not have permanent faculty members trained inpaediatrics are indicating financial barriers, then it ispossible that the same financial barriers may prohibit‘buy-in’ of sessional paediatric staff to appropriately

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teach and assess the curriculum, bringing into questionthe quality and appropriateness of the paediatric contentdelivered and raises concerns that paediatric contentmay not be adequately included in program curriculumdue to unavailability of qualified faculty. A stand-alonepaediatric subject would potentially increase the likeli-hood of a paediatric physiotherapist being employed as apermanent staff member rather than short-term buy-inof staff occurring. Furthermore, if programs do not havestaff appropriately trained to teach and assess paediatriccontent and skills, it is possible that this area of curricu-lum would become a low priority and potentially be-come diluted or even lost from subjects that are taughtby physiotherapists with adult-based knowledge andskills only. Moreover, if a qualified faculty member withpaediatric skills is employed on staff, development andquality control of a paediatric curriculum across the pro-gram and/or across a designated subject may be morelikely to occur, as sessional staff members are unlikely torequest information regarding the detailed scope ofpaediatric curriculum in a program, unless they areemployed to do so. Further research is warranted to ex-plore this area.

Clinical relevance of study findingsThe findings of this study are relevant to the APC, Aus-tralian university programs, curriculum developers,placement providers, the physiotherapy profession andthe wider public community since the findings from ourstudy provides the first published insights into thecurrent landscape of paediatric curriculum in entry-levelphysiotherapy programs in Australia. With the informa-tion provided from this study, the program accreditationbodies or paediatric education interest groups could usethis information to assist with developing or support thedevelopment of a minimum standards guideline forpaediatric curriculum requirements for which univer-sities could be held accountable. Universities can alsouse these study findings to compare and identify gapswithin their curriculum and consider opportunities forbenchmarking and ways to make appropriate changes totheir program syllabus and staff resourcing. In support-ing universities to produce safe entry-level physiothera-pists, this research may help to increase the awarenessof placement providers, that universities see a lack ofpaediatric placements as a barrier to the implementationof paediatric content. Therefore, placement providers inthe future could increase available placement offers forstudents to practice and consolidate their knowledgeand skills relevant to working with paediatric popula-tions. Additionally, placement providers could work withuniversities to consider innovative and appropriatemodels of practical experience that provide learning and

assessment opportunities in paediatrics for all studentsin Australian physiotherapy programs.The collective contribution of accreditation bodies

(e.g. APC), university representatives and paediatric cli-nicians, is needed to develop a minimum standard cur-riculum and assessment guideline, aimed at enhancingthe skills and knowledge of entry-level physiotherapistsfor safe and effective practice with paediatric popula-tions. If this can be achieved, the physiotherapy profes-sion will be better able to assure the public thatAustralian physiotherapy graduates are adequatelyskilled to work as first-contact practitioners with chil-dren and their families.

Limitations of this studyA limitation of this study relates to having a small sam-ple size, due to the limited number of universities offer-ing entry-level physiotherapy programs within Australiacompared to larger countries such as the US. Non-re-sponders may have been discouraged from completingthis survey due to time commitments involved with par-ticipation. Another limitation was the potential biaswithin the results as lecturers invested in overlookingpaediatric curriculum were the only participants re-quested to complete the survey from each university. Asmost of our participants were paediatric physiotherapiststheir perception of importance for covering paediatriccontent may have been inflated to favour inclusion ofmore paediatric content within a curriculum comparedto non-paediatric staff. For this reason, the future re-search in this area should involve a wider representationof clinicians and potentially stakeholders such as thepublic community. When using the Likert scale to inves-tigate the content covered and its perceived importance,no clear definition or classification of the scoring systemwas provided. This may have resulted in a subjective in-terpretation of the scale and may have decreased the ac-curacy of the results, as documented in previouspublished literature [28]. An additional limitation to thisstudy was the design of the question regarding the useof paediatric placements to assess paediatric learningoutcomes for students in their program. Almost half ofrespondents stated that a clinical placement was used toassess paediatric learning outcomes of all students intheir program, however, national APP data does not sug-gest that there are adequate 5-week paediatric place-ments to validate these findings [29] suggesting that theplacements may be atypical in length of time. The designof our survey limited the ability to determine if theseplacements were i) externally assessed using the APP oran alternate tool and ii) if the placement occurred over afull-time five-week duration or a shorter timeframe.At the time of the analysis for this study, there were

no responses providing further validation of the content

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in the desktop audits therefore the desktop audit datawas analysed with publicly sourced information only.This is likely to be related to the increased time commit-ment to provide further detailed information, howeverthere is a possibility that further paediatric content is be-ing delivered and assessed that is not represented in thepublished subject outlines and therefore not representedin our desktop audit findings.

Suggestions for future researchAs this research was the first of its kind in Australia, thepaediatric physiotherapy profession could build on this pre-liminary study with future investigations focusing on carry-ing out a similar survey with paediatric physiotherapyclinicians working within hospitals and the community.The findings from future research could complement thefindings of the present study and help consolidate curricu-lum topics considered important for coverage in universityprograms. The wider physiotherapy profession and thepublic could also be surveyed to identify their perspectiveon the level of knowledge an entry-level physiotherapist hasor should have to work with paediatric populations andsuch information could complement the findings of thepresent survey to contribute towards the development ofminimum standards for paediatric curriculum. Additionally,future research should investigate the details of paediatricassessment in clinical practice to explore if paediatric com-petencies are being assessed in a valid manner after com-pletion of clinical placement experiences. This may assistwith ensuring graduates from Australian programs are safe,effective and efficient to work therapeutically with childrenand their families. Our study together with future comple-mentary research could provide findings that may assistwith developing minimum standards for paediatric curricu-lum and assessment in entry-level physiotherapy programsand consequently better assure the public of the knowledge,skills and attributes that all physiotherapists possess rele-vant to working with paediatric populations after graduat-ing from an Australian physiotherapy program. To developminimum standards for Australian entry-level physiother-apy paediatric curriculum (including clinical experiences)the recommended research above, must first be undertakento fully understand the expectation of key stakeholders re-garding paediatric physiotherapy curriculum. With this in-formation, paediatric teaching leads may then collaboratethrough targeted workshops or Delphi style consensusmethods [30] to achieve consensus on what should be in-cluded in Australian minimum standards for pediatricphysiotherapy entry-level curriculum.

ConclusionAs no documented standard or core competencies existfor paediatric curriculum in Australia there is extensivevariability amongst Australian entry-level programs for

preparing physiotherapists to work safely and effectivelywith children. The results of this study suggest there arecommonly agreed imperative paediatric curriculum con-tent areas to be covered in training entry-level physio-therapists. Most universities surveyed stated theperceived importance of many paediatric content areasto higher than the level it was being covered in theirprogram. The main barriers to the implementation ofpaediatric curriculum included; crowded curriculum, lim-ited financial resources and inadequate paediatric place-ments. Findings from this study may help inform thedevelopment of minimum standards for paediatric-specificknowledge, skills and attributes for students in entry-levelphysiotherapy curriculum across Australia.

Additional file

Additional file 1: Copy of Survey titled Paediatric PhysiotherapyCurriculum: An audit of Australian physiotherapy entry-level programs.(PDF 1496 kb)

AbbreviationsAHPRA: Australian Health Practitioner Regulation Agency; APC: AustralianPhysiotherapy Council; APP: Assessment of Physiotherapy Practice; ECEI: EarlyChildhood Early Intervention; IPE: Interprofessional Health Education;NDIS: National Disability Insurance Scheme; OSCE: Objective StructuredClinical Exam; SD: Standard Deviation; US: United States of America

AcknowledgementsThe authors would like to acknowledge the contributions of Cherie Zischke,MPhty, and Kirstin Macdonald, BPhty for their assistance with piloting thesurvey for this study and Dr. James Furness, BPhty, PhD, for consultativesupport throughout the research.

FundingNo financial support was obtained for this study.

Availability of data and materialsCurrently data for this study remains stored on a locked password protectedfile in the organisation approving the study protocol as this was arequirement of the approving ethics committee. Although informed consentwas obtained from staff overlooking paediatric curriculum that participatedin the study, they were notified that the data would be reported ascollective findings only (e.g. means, standard deviations and ranges) and thatno individual’s data would be published. Some de-identified data may beused as quotes to support the thematic analysis carried out in the study. Thedatasets used and/or analysed during the current study are available fromthe corresponding author on reasonable request.

Authors’ contributionsAuthors contributions included: NM: original concept, supervising protocoldevelopment, study selection, data collection, analysis of data, statisticaladvice and analysis, manuscript writing and editing; KM: protocoldevelopment, study selection, data collection, analysis of data, interpretationof results, manuscript writing and editing; EY: protocol development, studyselection, data collection, analysis of data, interpretation of results,manuscript writing. The study manuscript adheres to the InternationalCommittee of Medical Journal Editors (ICJME) (http://www.icmje.org/)definition of authorship. All authors read and approved the final manuscript.

Ethics approval and consent to participateEthical approval was provided by Bond University Human Research EthicsCommittee; experimental protocol number (RO16162). All participantsprovided informed written consent obtained from Survey Monkey prior totheir participation in the study.

Mistry et al. BMC Medical Education (2019) 19:109 Page 17 of 18

Consent for publicationInformed consent was obtained from staff overlooking paediatric curriculumparticipating in this study. Consent was not obtained to publish anyindividual person’s data, details, images or videos and are therefore notbeing considered for publication in this manuscript.

Competing interestsThe authors declare that they have no competing interests.

Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.

Received: 20 January 2019 Accepted: 2 April 2019

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