Conceptual learning processes in physical therapy students.

As the health care environment continues to change, increased pressure is being placed on physical therapy education programs to graduate clinicians who are prepared to adapt to the evolving nature of physical therapy practice. Physical therapy educators should consider how well students are being prepared to function in rapidly changing and complex clinical situations. Faculty and clinicians have observed that some students appear to "forget" information learned in the academic setting by the time they begin clinical affiliations.[1] What do we really know about the depth of conceptual knowledge these students possess and how students learn the concepts needed to practice physical therapy?

Assessment of learning outcomes can help to determine how well physical therapist students are being prepared to function in the changing world of health care. Recent changes in the accreditation process for physical therapy education programs have emphasized outcome measures of graduates' performance.[2] These outcome measures can provide information about employers' and consumers' perceptions of the competence of recent graduates. In-depth study of the learning processes used by physical therapist students may also provide information about learning strategies that enable students to gain conceptual knowledge and to apply this knowledge in the clinical setting.[3,4] The focus of this qualitative study was to investigate the processes used by physical therapist students in developing conceptual knowledge.

Trends in Physical Therapy Education

Physical therapy curricula, beginning in the 1920s, appeared early in the profession's history to be largely content-based and reflected the technical role of the physical therapist at that time.[5] As the role of the physical therapist began to expand, the curricula became increasingly rooted in the medical and behavioral sciences. During the 1960s, as physical therapy education programs began to move from certificate to baccalaureate programs, more programs were located in colleges and universities than in hospitals and other health care facilities.[5] Consequently, patients often were no longer readily available for demonstrations and the medical environment was no longer an integral part of the students' daily lives. These changes prompted further revisions in physical therapy curricula and a new consideration of transfer of learning from the academic setting to the clinical setting.

In the 1970s, the focus of some physical therapy curricula shifted toward competencies that new graduates were expected to demonstrate. Competency-based curricula focused on terminal competencies for entry-level performance and on criterion-referenced evaluation.[6] Curricula in the late 1970s and early 1980s emphasized the development of problem-solving skills. Curricula based on a problem-solving approach were organized around themes of physical therapy practice rather than around subject matter. Emphasis was placed on the process of problem solving and modes of inquiry rather than on the simple mastery of content.[7]

In the late 1980s and early 1990s, changes in the health care environment led physical therapy educators to begin to explore alternatives to existing curricula. Particular attention has been paid to the concept of problem-based learning, in which learning is structured around patient problems.[8] The use of group work and reflective activities has also been advocated by physical therapy educators in recent years.[9]

Trends in Learning Theory

The evolution of physical therapy curricula has, in many ways, followed changes in the thinking of learning theorists. Although a diversity of theoretical and philosophical frameworks for learning theory exist,[10-12] several trends in learning theory have occurred over the past few decades.

For many years, educators subscribed almost solely to behaviorist theories, such as operant-conditioning theories described by Skinner.[10] In this teaching and learning process, tasks are broken down into a series of discrete elements and responses are reinforced so that the probability that they will recur in the future is increased. Learned responses are behaviors that are overt and easily measured.[10] The early content-based curricula and competency-based curricula appear to be rooted in behaviorist learning theory.

According to cognitive learning theorists such as Bruner,[11] learning is an active process in which a person makes sense of facts and stimuli through the process of conceptualization and categorization. The process of concept attainment is seen as a series of decisions.[11] This emphasis on decision making and the process of learning provides the basis for physical therapy curricula that are oriented around the problem-solving process.

Recently, learning theories based on a constructivist perspective or world view have been developed.[12] Although more traditional learning theories are based on the belief that knowledge is transmitted from teacher to learner and that knowledge exists in objective reality, constructivist learning theory holds that learners actively construct reality as they develop knowledge.[12] The fundamental premise of constructivist learning theory is that knowledge is actively constructed by learners on the basis of each learner's experiences, beliefs, and biases.[13] Constructivist learning theory appears to underpin educational approaches such as problem-based learning and reflective learning.

Research on learning processes has been conducted in other disciplines,[3,4] but only one study in the literature focuses on physical therapist students' perspectives and strategies for learning. Van Langenberghe[14] investigated approaches to studying used by 179 first- and second-year physical therapist students in a problem-based physical therapy program. Results indicated that physical therapist students generally demonstrated an ability to define their own studying tasks, higher motivation, less reliance on memorization, and greater independence when their scores were compared with normative scores on the Short Inventory of Approaches to Studying. Although studies such as that of Van Langenberghe help to shed light on the study habits used by physical therapist students, little information has been obtained as to the actual learning processes used by the students.

This qualitative study focused on the following question: What strategies do students use to develop conceptual knowledge in physical therapy?

Method

I used qualitative research methods to pursue an understanding of the processes used by physical therapist students in developing conceptual knowledge. Qualitative methods were chosen because the purpose of the study was consistent with the descriptive and inductive nature of the qualitative research paradigm.[15] My primary interest in choosing this topic was to gain an understanding of how a small group physical therapist students developed conceptual knowledge. Because these processes were unknown to me, the classic qualitative question, "What's going on here?" seemed to be an ideal fit with the goals of this study.[15] My goals were to describe the learning processes used by the students and to induce or develop concepts and themes from the data collected.

Subjects

Subjects were 10 first-year students enrolled in the professional Master of Physical Therapy degree program at The University of Texas Medical Branch at Galveston. This program follows a "3+3" model in which students are required to complete a minimum of 90 hours of college prerequisites before applying to the program, and then to complete 90 hours of course work in the physical therapy curriculum. The first-year class was selected as the sampling frame because, based on my experience, important conceptual change occurs in the first year of the program as the students move from undergraduate to graduate professional course work.

After reviewing information in admissions records, the 44 students in the first-year class were placed in three categories: linear category (students who completed college prerequisites and immediately entered the physical therapy program), career change category (students who had worked in other careers and were returning to school), and intermediate category. Many of the students in the intermediate category had applied to physical therapy school in previous years and were working, either in physical therapy or in unrelated fields, during the reapplication process. Ten students were then randomly selected from the categories in the following manner: 3 students from the linear category, 3 students from the intermediate category, and 4 students from the career change category. A slightly larger number of subjects were selected from the career change category because of my interest in that subgroup.

The type of sample used in this study is a purposeful random sample.[16] The sample was purposeful in that first-year physical therapist students at one university who fit into the categories described were selected. Random selection from these categories was then used at the request of the program director to avoid problems with student sensitivity regarding inclusion in or exclusion from the study. According to Patton,[16] the goal of purposeful random sampling is credibility, not representativeness. This type of sampling is intended to remove any suspicion as to why certain subjects were selected, but it is not designed to be used for statistical generalization. Any generalizations made from this type of sample should be based on the extent to which readers believe that the sample and the setting studied apply to their own situation, a concept called reader generalizability or user generalizability.[17]

After the selection process was complete, written informed consent was obtained. Each participant chose a pseudonym to ensure confidentiality throughout the study. The final sample consisted of 5 female and 5 male students. Ages of the participants ranged from 21 to 34 years, with a mean age of 25.8 years (Table). Nine participants were white, and 1 participant was black. Six students had completed baccalaureate degree requirements prior to beginning the program. The students were asked whether they considered themselves to be nontraditional students, according to their own definition of the term "nontraditional." All students in the career change category and 1 student in the intermediate category identified themselves as nontraditional students. All 10 participants completed the study.

Table.
Participant Characteristics

                Age                           Self-Identified
Participants    (y)   Gender   Category       Status

Sara            21    Female   Linear          Traditional
Jan             22    Female   Linear          Traditional
Tye             23    Male     Linear          Traditional
Elizabeth       24    Female   Intermediate    Nontraditional
John            24    Male     Intermediate    Traditional
Donna           25    Female   Intermediate    Traditional
Darrell         27    Male     Career change   Nontraditional
Dot             28    Female   Career change   Nontraditional
Jim             30    Male     Career change   Nontraditional
Kevin           34    Male     Career change   Nontraditional

Procedure

A two-credit kinesiology course was chosen for data collection because of the conceptual nature of the content. The course consisted of 23 hours of lecture and 16 hours of laboratory sessions. A 6-hour-lecture, 9-hour-laboratory biomechanics unit was also included as a source of data collection. Data were collected over the 15-week length of the course and after a 2-week clinical education experience that followed the course. Three data-collection methods were used: open-ended interviews, journals, and observation in lecture and laboratory sessions.

Open-ended interviews of approximately 1 hour each were conducted with each participant at three intervals. All interviews were audio taped with the students' permission. The first interview took place during the 4th or 5th week of the course; the second interview took place during the 9th or 10th week of the course; and the third interview took place approximately 1 month after the conclusion of the kinesiology course, after the semester break and after the students had completed a 2-week clinical affiliation. The interviews focused on strategies used by the students in learning concepts in kinesiology. During the third interview, how students applied information learned in the classroom to patient care situations in the clinic was also discussed.

The students were asked to keep journals throughout the kinesiology course and during the 2-week clinical affiliation to record their thoughts and reactions to the course and to reflect on learning strategies and concept development during the course. The journals were collected at the second interview session and after the clinical affiliations.

I observed approximately 14 hours of lecture sessions and 16 hours of laboratory sessions during the kinesiology course and biomechanics unit. The focus of the observations was on the types of questions asked by the students during lecture sessions and the problem-solving and reasoning processes used by the students in addressing laboratory assignments.

Data Analysis

Data analysis was continuous throughout the data-collection period, using the constant comparative method.[15] As I transcribed the first set of interviews, I made notes about potential categories and trends. After the transcriptions were complete, I read each transcribed interview several times. I then coded the data to identify emerging categories and trends. The second set of interviews focused on the trends that emerged from the first set of interviews. This process continued through the final set of interviews. The previously collected data were compared with the newly collected data to identify emerging or changing trends. In this way, existing trends were refined or discarded as new trends developed.

The journals were reviewed shortly after they were collected at the second interview session and after the clinical affiliations. I read the journals and documented information that either supported or refuted the existence of emerging themes identified from other data sources. The possibility of new themes was noted. Some information obtained from the journal review after the second interview session was used as the basis for questions for participants during the third interview.

The data obtained from observation of classroom and laboratory sessions were also analyzed during the course of the study. I documented information from data that either supported or refuted the existence of themes identified from other data sources or data that appeared to suggest that a new theme existed. Data from the observations were also used as a basis for questions for subsequent interviews.

Finally, data and emerging themes from all sources were reviewed. Triangulation of the data occurred as each emerging theme was considered in terms of confirmation or lack of confirmation from each of the three sources of data. Triangulation, or comparison of multiple sources of data, is a commonly used strategy for establishing validity in qualitative research.[17] When lack of confirmation of a theme occurred, this theme was reconsidered and reconceptualized. During the final stages of data analysis, member checks were performed. Each participant was asked for input as to the accuracy of emerging themes from the study. Member checks provide a mechanism for seeking feedback from the participants to ensure that the results are accurate and credible.[17] This input was used to further refine the themes.

Reliability in qualitative research refers to the dependability or consistency of the results.[17] In addition to the use of triangulation, which is a mechanism for strengthening reliability,[17] peer review of the data was performed throughout the data-collection period. A colleague read the interview transcripts, journal entries, and observation notes and provided input on theme construction. This input was also used to refine and reconceptualize themes.

Results

Three major themes related to the process of conceptual development emerged during data analysis: use of discussion, use of visualization, and use of experience.

Use of Discussion

Use of discussion emerged as a key strategy in the process of developing conceptual knowledge in kinesiology. All subjects used some form of verbalization of the concepts as a critical phase of conceptual development. As the study progressed, it became evident that the methods used by the students in the process of developing conceptual understanding took on several forms, including discussion with peers, the course instructor, Clinical Instructors, or another listener (such as a family member) and self-dialogue (ie, self-verbalization or "thinking aloud").

The form of discussion most often used by the students was with peers. A trend was noted in that many students who studied individually at the beginning of the semester began to study with another student or in groups as the semester progressed. Some students found one-on-one interactions with a classmate to be the most beneficial form of discussion. Both students who preferred the one-on-one interactions and those who participated in study groups usually studied individually to a certain point before engaging in discussion with peers. Based on student report, it was important to the students to attain a basic level of comprehension of the material before beginning discussions with peers.

I think things click when I'm talking with someone about it, but it's a

building-up process. I have to start out by myself first, and then I'll

be able to talk about it. I have to have enough knowledge to talk

about it. (Dot, interview #2)

Another form of discussion used by the students in developing conceptual knowledge was with Clinical Instructors during the 2-week clinical affiliation that followed the kinesiology course. Several students who had the opportunity to engage in extensive discussions with Clinical Instructors believed that these discussions helped build connections between what was learned in the classroom and application of the information in patient-care situations.

Some students, particularly those who did not have easy access to peers or to study groups, used discussion with another listener, usually a friend or family member, as part of the process of learning concepts. This form of discussion was often one-way in that the other party was not able to give feedback to the student in terms of the accuracy of the concept. Therefore, the emphasis of this form of discussion was on verbalization or the oral nature of the learning process.

Several students used self-verbalization or communication with themselves to attain conceptual understanding. This strategy was particularly used by those students who did not usually engage in group or peer learning situations. either by preference or by lack of accessibility to a group. Again, this form of discussion emphasized the importance of verbalizing the concept, even if no other party was present to give feedback.

One of the primary benefits of discussion articulated by the students was that it helped them to grasp concepts at a high level of understanding. The students stated that they were able to expand their understandings of concepts by engaging in the various forms of discussion. Several students were able to articulate the difference in the level of understanding they could reach individually versus that attained after participating in discussion. In this case, discussion with peers served as a mechanism to expand the student's understanding of concepts:

I can get to a pretty high level on my own. But my feeling is, in

order to get to a ... well, I can even quantify it. I think I can get a 90

on my own, but in order to get 100, I think I need some feedback

with my peers as to what's really going on, because it gets me

thinking. I don't know, it takes me to a little bit of a higher level to

really drive it home. (Kevin, interview #2)

An important aspect of attaining a higher level of understanding was the opportunity to gain multiple perspectives on concepts during discussion with other students. Most students felt that, after reaching a basic understanding of the concepts, it was helpful to hear other students' viewpoints on the concepts and to try to reach a more holistic understanding through discussion and integration of the various viewpoints.

The students emphasized the need to obtain feedback on or reinforcement of conceptual understandings. That is, some mechanism was needed by which the students could gauge the accuracy and thoroughness of their understandings. Use of one of the forms of discussion provided this mechanism for every student in the study. As the semester progressed, several students realized that individual study was not as effective for them

Use of Visualization

A strong theme throughout the study was the students' use of visualization in the development of conceptual knowledge in kinesiology. Early in the study, it became evident that the students needed to be able to picture a working model of the concept, either mentally or on paper, before a complete understanding of the concept was attained. The visualization process did not occur naturally for the students. Instead, all of the students in this study made a concentrated effort to visualize the concepts, often during class sessions. In most instances, once an accurate visualization of a concept was made, the student was able to internalize the concept without further study.

I have to visualize it in my mind. Like when it [the lecture] had to

do with torque and she [the instructor] is talking about the

humerus coming up into a flexed position, I have to see it. I have

to draw arrows and see a picture of the axis of rotation and such

like that. At those times when I can really get a good picture and it

comes time to study, I don't really have to study it because I read

it and see the picture. Then I put it in my own words and read

what I wrote to make sure that my words kind of reflect what it

says. (Jim, interview #1 )

The visual nature of the learning process in the kinesiology course was also evident during my observations of class sessions. Students were very frequently observed moving and manipulating their limbs while the instructor explained concepts in the lecture sessions.

Use of Experience

The students used several types of experience as a context for learning new concepts in kinesiology. Students frequently drew on past clinical experiences in physical therapy, everyday life experiences, the experience gained in the kinesiology laboratory sessions, and current clinical experiences in developing conceptual knowledge in kinesiology.

Several students reflected on clinical experiences they had had as volunteers or aides prior to entering physical therapy school that served as context or background as they began to learn concepts in kinesiology. Clear connections were formed between the students' current learning and their past clinical experiences. In a sense, the students were able to engage in a form of discussion between the old and new experiences.

I was in the clinic one day and they had the patient on the

Biodex* [an isokinetic exercise machine]. He was doing knee

flexion and knee extension, and the physical therapist was saying,

"Wow, look at that torque." And I was wondering, what in the

world is torque? So every time she [the course instructor] talks

about torque, my mind flashes back to the clinic where that patient

was on the machine and I can see the torque. So I just try to take it

out of the school setting and put it to something that I've seen

before. (Sara, interview #1)

One strategy that students frequently used in learning concepts was to attempt to connect what was being learned to something encountered in everyday life. Again, this strategy was used to provide a context for learning the new concepts. Several students generated examples from everyday life experiences that, although not directly related to physical therapy, were close approximations of the way the concept is used in kinesiology. For example, one student related open and closed kinetic chain movements to the activities of a running back in football.

The kinesiology course included 16 hours of laboratory experiences in which the students participated in various activities designed to apply kinesiological concepts in practical and clinical situations. Many students spoke of the value of this laboratory experience in attaining conceptual knowledge.

In lab, you have to be able to do it and explain it, whereas in

lecture, you just sit there and sponge it in. So, in lab is where I

know I understand the concepts. In class, I don't have to give any

feedback. So it's like I don't have to know it right now because I

don't have to do anything but write. But labs are instant feedback.

When you don't know how to do it, then obviously you didn't

learn something in lecture. If you can't explain it, there's something

you missed. So the labs kind of gauge your progress. (Dot,

interview #1)

My observations of lecture and laboratory sessions corroborate the students' comments about learning during laboratory sessions. I observed that the students were fairly quiet and passive in lecture sessions and that most of the questions asked were for clarification of information. During laboratory sessions, however, the students were very engaged in the learning process. The questions asked during the laboratory sessions were more conceptual in nature. The students also tended to generate their own examples of concepts during laboratory sessions rather than asking the instructor for examples.

Even though the 2-week clinical experience occurred after the kinesiology course, the students commented that the clinical experience was useful in reinforcing or expanding their conceptual knowledge. The value of applying knowledge and skills in patient situations was emphasized by several students.

The clinical definitely reinforced the concepts, and it expanded

them to the point where I realized there is no definitive way to do

things. Ideally, we get taught the best way [in the classroom], but

you've got to be able to improvise. To me, that's where things got

expanded in the clinic. Here's the hard-and-fast rule, but there are

situations where you're going to have to think of alternatives.

(Kevin, interview #3)

Discussion

The physical therapist students in this study used an active, experiential approach to learning that included a reliance on the senses during the learning process. The students repeatedly used words such as "talking," "seeing," "hearing," "feeling," and "doing" as they described their learning processes during the kinesiology course. A constructivist view of learning was supported by the results of this study because conceptual development was seen as an active, evolving process in which the students used their past and current experiences as a context for learning.[13] To facilitate this type of learning process, physical therapy educators may find it beneficial to use educational methods that are based on constructivist learning theory, such as collaboration/group learning, situated cognition/authentic contexts, cognitive apprenticeship, and whole-part-whole learning.

Collaboration/Group Learning

The emphasis on use of the various forms of discussion by the students in this study provides strong support for educational methods that promote some type of verbalization or discussion during the learning process. The results of my study support Vygotsky's[18] theories on the role of social interaction in the development of higher intellectual processes. A zone of proximal development, described by Vygotsky as "... the distance between the actual developmental level as determined by independent problem solving and the level of potential development as determined through problem solving under adult guidance or in collaboration with more capable peers,"[18(p86)] was clearly evident as the students spoke of the benefits of discussion in attaining a higher level of understanding of the concepts.

Problem-based learning is one example of an approach to physical therapy education that promotes discussion among students.[19] When this approach is used, students are usually placed in small tutorial groups with a faculty facilitator. The groups are then presented with a patient problem and are asked to construct an explanation of the underlying processes (physical, biological, and psychosocial) depicted in the patient problem. The patient problem is addressed through discussion with the tutorial group members and the faculty facilitator and through other resources or learning methods determined by the students. In addition to promoting discussion and elaboration of knowledge among students, problem-based learning also supports the use of prior knowledge in learning because students are encouraged to reflect on existing knowledge as they process new information.[19]

Other ways to promote discussion within physical therapy curricula may include the use of tutorial groups in selected courses; provision of opportunities to engage in collaborative learning efforts with one or more peers, clinicians, or faculty members throughout the curriculum; and allowing time for one-on-one or group discussions during class time. Students should be encouraged to participate in the form of discussion they find most beneficial. Some students may resist a change in study methods because they have been successful in individual study prior to entering the physical therapy program. For these students, discussions with second- or third-year students may be helpful in encouraging a change in study habits.

Situated Cognition/Authentic Contexts

Throughout this study, the students emphasized the benefits of learning from experience in laboratory sessions and on the clinical affiliation. In addition, students often reflected on previous experiences and everyday life experience to provide a context for learning. Brown et al[20] believe that knowledge is situated in that it results from an interaction of the activity, context, and culture in which it is developed. That is, the development of knowledge involves "complex social negotiations"[20(p33)] in the situations in which it is used. The fundamental principle of situated cognition is that no learning is context-free.

In physical therapy education, integrated clinical experiences throughout the academic curriculum provide opportunities for the students to learn in authentic contexts. Within the didactic portion of the curriculum, however, even though case studies and simulated problems may be used, students generally have few opportunities to learn in truly authentic contexts. Thus, students learn in simulated contexts and then are expected to transfer or apply this knowledge in the authentic context of the clinical setting.

Authentic contexts can be incorporated into the didactic portion of the curriculum by collaboration with clinical facilities to use actual patient cases and provide opportunities for interaction with patients. This may be logistically difficult in some cases because physical therapy class sizes can exceed 60 students. An alternative may be to bring patients to the classroom or laboratory setting and allow students to interact with the patients in large or small groups, depending on the goals of the learning experience. Authentic contexts can also be incorporated into the didactic curriculum by using students' actual experiences as the context for learning experiences.

Cognitive Apprenticeship

Another aspect of situated cognition is learning through cognitive apprenticeship. This learning method incorporates both discussion and experience, which were major components of the learning processes used by the students in this study. The goal of cognitive apprenticeship is to enculturate students into authentic practices of the field or discipline.20 This goal is accomplished through activity and social interaction with practitioners in the field, in a manner similar to craft apprenticeship.

In physical therapy education, clinical experiences provide an opportunity for students to enter into cognitive apprenticeship with practicing physical therapists. In my study, those students who had opportunities to engage in extensive discussions with their Clinical Instructors during the 2-week clinical affiliation commented on the benefits of these discussions in helping to bridge the gap between academic learning and application of skills and knowledge in the clinical setting. Conversely, those students who did not have the opportunity to engage in extensive discussion with their Clinical Instructors did not reap the same benefits from the clinical experience.

In a study conducted on cost-effectiveness of clinical education, short-term clinical affiliations were found to be less cost-effective than long-term affiliations.[21] Based on the results of my study, however, I believe that the time spent by Clinical Instructors during the early, short-term affiliations is very valuable in helping to bridge the gap between academic learning and clinical practice. The value of the time spent by the Clinical Instructors during these early affiliations should be given strong consideration in evaluating the overall effectiveness Of short-term clinical experiences.

Opportunities for use of the cognitive apprenticeship model also exist in the didactic component of physical therapy education. In the cognitive apprenticeship model, the instructor serves as a role model for the students by demonstrating thought processes or by verbalization during problem solving. This process serves to demystify the acquisition and use of knowledge in the discipline being studied.[20]

Opportunities for cognitive apprenticeship in physical therapy education include student observation and interaction with faculty members during treatment of a patient or problem solving through an authentic case study, and use of case studies from the faculty member's current or past practice to share thinking processes as the case is discussed. The cognitive apprenticeship model can be used in the classroom setting when the instructor is asked a question during class. Sharing thought processes by a response such as, "This is what I'm thinking," could be very effective in demystifying the problem-solving process.

Whole-Part-Whole Learning

An additional method that may help students to develop a context for learning, even when they do not have experiences in the area, is whole-part-whole learning.[13] Constructivist learning theory holds that learning proceeds from whole to part to whole.[13] The learner begins with general ideas about the concept as a whole, then learns specific details, then returns to the concept as a whole again. This progression of conceptual understanding suggests that students should begin the conceptual development process with a holistic understanding of the context in which the concept will be applied. Students may bring this holistic understanding based on past experience to the classroom situation, or they may be dependent on the instructor to provide the context. Instructors should, therefore, determine whether students have experience with the concept. This provides an ideal opportunity for instructors to engage in discussions with students about their past experiences and to provide clinical examples from their own experience, if necessary.

Whole-part-whole learning also encourages a holistic understanding of concepts rather than a focus on memorization of the details. Because of the emphasis placed on functional application by the kinesiology course instructor in this study, students who attempted to memorize details without understanding the larger context of the material generally found that they were unsuccessful. Use of whole-part-whole learning strategies may help to lessen the emphasis on memorization of details and facilitate a greater understanding of the context in which the concepts will be used in the clinical setting. The students in this study often used visualization as a method of gaining a holistic understanding of the concept without memorizing the details.

Limitations

This study was conducted to gain an understanding of the processes used by students in developing conceptual knowledge in physical therapy. The results are limited by the size and nature of the sample. The conceptual development processes identified in this study may be specific to this sample of first-year physical therapist students from one "3+3" model professional Master of Physical Therapy degree program, who were in the early stages of learning a new content area. It is hoped that this study will provide a starting point for further research in the area of conceptual learning.

Further Studies

An expanded study of conceptual learning processes in physical therapy students, using a larger and more representative sample, is needed to determine the generalizability of the results of this type of study. Further research is needed to study the impact of various types of teaching strategies on both the learning processes used by students and the outcomes of physical therapy education. Studies comparing the impact of the type of teaching methods supported in this study, such as problem-based learning, and more traditional teaching methods would provide important information regarding the relationship between teaching methods and learning processes. Further study is also needed to explore differences in learning processes with regard to students' age and experience levels.

Conclusion

This study provided an in-depth description of the learning processes of a small sample of physical therapist students. The students in this study demonstrated an active, experiential approach to learning that focused on the use of discussion, visualization, and experience. These learning processes may be facilitated by the type of educational methods described in this article.

Acknowledgment

I thank Dr L Adrianne Bonham of Texas A & M University for her assistance in revising this manuscript and for her dedication and wisdom throughout my doctoral studies.

(*) Biodex Medical Systems, Brookhaven R&D Plaza, Box 702, Shirley; NY 11967.

References

[1] Sanders B. Are we teaching what we say? Educational outcomes and accreditation. Presented at the Combined Sections Meeting of the American Physical Therapy Association; February 2-7, 1993; San Antonio, Tex.

[2] Commission on Accreditation in Physical Therapy Education. Evaluative Criteria for Accreditation of Education Programs for the Preparation of Physical Therapists. Alexandria, Va: American Physical Therapy Association; 1993.

[3] Entwistle N, Marton F. Knowledge objects: understandings constituted through intensive academic study. Br J Ed Psychol. 1994;64:161-178.

[4] Renstrom L, Andersson B, Marton F. Students' conceptions of matter. J Ed Psychol. 1990;82:355-569.

[5] Pinkston D. Evolution of physical therapy practice in the United States. In: Scully RM, Barnes ML, eds. Physical 'Therapy. Philadelphia, Pa: JB Lippincott Co; 1989:2-30.

[6] May BJ. Competency-based evaluation of student performance. J Allied Health. 1978;7:232-237.

[7] Barr JS. Problem-solving curriculum design in physical therapy. Phys Ther. 1977;57:526-529.

[8] Morris J. An overview of and comparison among three current approaches to medical and physiotherapy undergraduate education. Physiotherapy. 1993;79: 91-94.

[9] Gandy J, Jensen G. Group work and reflective practicums in physical therapy education: models for professional behavior development. Journal of Physical Therapy Education. 1992;6:6-10.

[10] Skinner BF. About Behaviorism. New York, NY: Alfred A Knopf Inc; 1974.

[11] Bruner JS. Beyond the Information Given: Studies in the Psychology of Knowing. New York, NY: WW Norton & Company Inc; 1973.

[12] Guba KG, Lincoln YS. Fourth-Generation Evaluation. Newbury Park, Calif: Sage Publications Inc; 1989.

[13] Poplin MS. Holistic/constructivist principles of the teaching/learning process: implications for the field of learning disabilities. Journal of learning Disabilities. 1988;21 :93-106.

[14] Van Langenberghe HVK. Evaluation of students' approaches to studying in a problem-based physical therapy curriculum. Phys Ther 1988;68:522-526.

[15] Bogdan RC, Biklen SK. Qualitative Research for Education: An introduction to Theory and Methods. 2nd ed. Needham Heights, Mass: Allyn and Bacon: 1992.

[16] Patton MQ. Qualitative Evaluation and Research Methods. 2nd ed. Newbury Park, Calif: Sage Publications Inc; 1990.

[17] Merriam SB. Case Study Research in Education: A Qualitative Approach. San Francisco, Calif: Jossey-Bass Inc Publishers; 1988.

[18] Vygotsky LS. Mind in Society: The Development of Higher Psychological Processes. Cambridge, Mass: Harvard University Press; 1978.

[19] Albanese MA, Mitchell S. Problem-based learning: a review of literature on its outcomes and implementation issues. Acad Med. 1993;68:52-81.

[20] Brown JS, Collins A, Duguid P. Situated cognition and the culture of learning. Educational Researcher. 1989;18:32-42.

[21] Graham CL, Catlin PA, Morgan J, Martin E. Comparison of 1-day-per-week, 1-week, and 5-week clinical education experiences. Journal of Physical Therapy Education. 1991;5:18-23.

CL Graham, PhD, PT, is Associate Professor, Department of Physical Therapy, School of Allied Health Sciences, The University of Texas Medical Branch at Galveston, 301 University Blvd, Galveston, TX 77555-1028 (USA) ([e-mail]). This work was conducted in partial fulfillment of the requirements for her Doctor of Philosophy degree at Texas A & M University, College Station, TX 77843.

This study was approved by the institutional review boards at The University of Texas Medical Branch at Galveston and Texas A & M University.

This article was submitted July 18, 1995, and was accepted April 25, 1996.