Geographical challenges for physical therapy continuing education: preferences and influences.

Key words: continuing education, Influences, Physical therapy, Preferences.

Continuing education (CE) may be defined as a systematic effort to provide education beyond formal education and initial entry into a profession.[1] Continuing education implies that some form of learning occurs to advance the learner's level of competence.[2] Continuing education becomes particularly important during periods of rapid increases in knowledge such as when mastery of new knowledge is necessary for continued competency.[2]

We believe that the organization and implementation of successful CE programs require a thorough knowledge of the needs and preferences of the population targeted for CE programming. Few efforts have been made to collect CE data for physical therapists. Some research has been conducted in the United States and western Canada to determine factors influencing levels of physical therapist participation in CE activities,[3-6] as well as the motivations behind their participation.[7,8] Preferences related to program design have also been identified.[4,6] Little information, however, is available on the effects of geographic location on preferences for program design and its influences on CE participation.[9]

A potential concern for CE program planners is the geographically isolated physical therapist.[9,10] In many countries that have developed physical therapy professions, geographical isolation is a major concern. For physical therapists in outlying areas, there has been less opportunity to participate in CE and to influence program planning.[9,10] Access to CE opportunities is important because of the location of physical therapists across vast geographical areas within states, provinces, or countries. Other barriers to CE participation for isolated physical therapists include scarcity of academic faculty and resources, decreased access to experts, a small number of participants to support CE programs, and travel and financial restrictions imposed by distance.[9]

Continuing education program planners in the province of Ontario, Canada, face geographic challenges that are similar to those experienced by their counterparts in the United States.[10] For example, Ontario has approximately 10 million people inhabiting an area about five times the size of Texas. Most of the population lives in a narrow band above the Great Lakes and the St Lawrence River in the southern part of the province. Northern Ontario comprises approximately 86% of the province's total area but is home to just 7% of the population. Outside the major population centers, the population can be as sparsely distributed as one person for every 6.3 [km.sup.2]. Furthermore, in many northern areas, the population size is decreasing due to changing employment patterns. Given the geography and demography of this area, the educational needs of physical therapists from northern Ontario may be quite different from those of their southern counterparts.

The purpose of our study was to compare program design preferences and influences on CE programs for physical therapists in sparsely and densely populated areas of Ontario. Because this study was exploratory in nature, there was no basis for predicting the outcomes. We anticipated that differences would be found because the number of therapists in each region and the geography of the province varied greatly. The information gathered can provide knowledge that CE providers can use in the development of programs, particularly in large nonurban areas.

Method

Population and Sample

The research design was a cross-sectional survey. All licensed physical therapists residing in Ontario on February 1, 1994, comprised the target population. The 4,502 potential subjects were divided into northern and southern strata (as defined by the French River) prior to sampling. Simple random sampling without replacement was used to sample 470 subjects from southern Ontario.[11] Due to the small population, survey instruments were sent to all 314 physical therapists in northern Ontario.

Questionnaire

The first section of the questionnaire contained closedended questions to elicit responses about program design preferences. A pretest of convenience samples of 10 physical therapists in southern Ontario and 5 physical therapists in northern Ontario was conducted to identify ambiguous items and missing content. A cover letter and a draft of the survey instrument were mailed to each participant. In summary, the participants found the draft of the survey instrument to be well thought out, salient to their needs, and relevant to the current issues in the physical therapy profession. Response categories, therefore, should have been exhaustive. An "other" option was included in case the therapists thought that there were missing categories.

The second and third sections asked therapists to indicate their perceptions on influences on participation in CE and their preferences for a variety of learning methods. The learning methods chosen reflect shortterm formal and informal methods, but do not include longer-term methods such as postprofessional degree programs and residencies. Seven-point Likert scales were used to measure the strength and direction of opinions. Seven-point scales were chosen over threeor five-point scales to allow more variability in responses for the purposes of data analysis. A middle category was included to allow for no preferences. The final section of the questionnaire measured demographic characteristics.

Because this study required the development of a new instrument, reliability and validity were both addressed as part of instrument construction. Although the 29-item list that measured the influences on participation in CE was similar to that used in Craft and colleagues' study of nurses, which was shown to have excellent alternateform reliability (r = .98),[12] internal consistency reliability of the questionnaire's subscales was assessed using Cronbach's alpha coefficient. Acceptable standardized alpha values were defined as those greater than .60. These reliability values suggest that items within each subscale were measuring the same construct (Tab. 1). Face and content validity of the questionnaire were addressed using the literature and five content experts in the fields of survey research methodology, physical therapy, and education. One expert was chosen to represent each of the following: (1) the national professional association, (2) the provincial professional association, (3) the provincial licensing body, (4) academia, and (5) clinical practice.

Table 1.
Description of Factor Subscales and Explained Variance From
Principal-Component Analysis

Factors                                        Loadings

Timing
  Time of day                                    .8242
  Time of week                                   .8559
  Time of year                                   .7552

Presentation quality
  Published objective                            .6254
  Reputation of presenter                        .7563
  Qualifications of presenter                    .7860
  Profession of presenter                        .6762

Work-related cost
  Loss of pay                                    .7864
  Loss of vacation                               .8035
  Loss of personal time                          .6412

Course-related cost
  Registration fee                               .7359
  Reduced fee for member or employee             .6863
  Financial support from employer                .6062
  Cost for food, lodging, and transportation     .5288

Socialization
  Opportunity for social activities              .7580
  Opportunity to network with peers              .7986

Program content
  Content pertinent to current practice          .8358
  Courses available in area of interest          .8435

Total

                                               Explained
Factors                                        Variance (%)

Timing                                            19.1
  Time of day
  Time of week
  Time of year

Presentation quality                               9.0
  Published objective
  Reputation of presenter
  Qualifications of presenter
  Profession of presenter

Work-related cost                                  7.0
  Loss of pay
  Loss of vacation
  Loss of personal time

Course-related cost                                5.9
  Registration fee
  Reduced fee for member or employee
  Financial support from employer
  Cost for food, lodging, and transportation

Socialization                                      4.5
  Opportunity for social activities
  Opportunity to network with peers

Program content                                    4.2
  Content pertinent to current practice
  Courses available in area of interest

Total                                             49.7

                                               Standardized
Factors                                        Alpha

Timing                                              .82
  Time of day
  Time of week
  Time of year

Presentation quality                                .74
  Published objective
  Reputation of presenter
  Qualifications of presenter
  Profession of presenter

Work-related cost                                   .75
  Loss of pay
  Loss of vacation
  Loss of personal time

Course-related cost                                 .70
  Registration fee
  Reduced fee for member or employee
  Financial support from employer
  Cost for food, lodging, and transportation

Socialization                                       .61
  Opportunity for social activities
  Opportunity to network with peers

Program content                                     .71
  Content pertinent to current practice
  Courses available in area of interest

Total

Data Collection

On March 1, 1994, study questionnaires were mailed to all chosen subjects, with a cover letter explaining the purpose of the study. To encourage responses, prestamped return envelopes were included. Identification numbers were placed on both the questionnaires and the return envelopes to facilitate identification of nonrespondents for more efficient follow-up mailings. Our address and the requested return date were printed at the end of the questionnaire to assist returns in the event of misplaced prestamped envelopes or information letters. Data collection was discontinued on September 15, 1994.

Procedures to Maximize Response

Follow-up procedures were used to encourage the highest response rate possible, thereby minimizing response bias. To further increase the response rate, an announcement that preceded the first follow-up was published in the March issue of the provincial professional association's monthly newsletter.

An initial follow-up letter and a duplicate survey instrument were sent to all nonrespondents 3 weeks after the initial mailing. A self-addressed, stamped envelope was included in this follow-up package. A second follow-up was done on April 15, 1994, consisting of a reminder letter encouraging nonrespondents to complete their survey instrument and to return it to the research center by May 1, 1994. Recipients of this letter who had not received either of the first two questionnaire packages were asked to contact the principal investigator in order that a copy could be mailed to them. This third mailing should therefore have minimized the effects of lost or misdirected packages.

Data Analysis

Descriptive statistics were used to characterize the sample obtained with respect to demographics. Because simple random sampling was used for physical therapists in southern Ontario, each respondent from this region represented approximately nine licensed physical therapists. In northern Ontario, however, each respondent represented one licensed physical therapist. To yield accurate point estimates, expansion weights were used so that each case would be represented proportionally to the likelihood of being sampled.[13]

Population ultimates for program design preferences were determined using proportions, and regional differences were tested with the chi-square test. Population estimates for learning method preferences were determined using means and standard deviations, and regional differences were tested with independent t tests. For each item, missing values were replaced with the mean score calculated from respondents who had provided responses. A Bonferroni correction ([Alpha]/[Kappa]) was used to adjust for inflated Type I error due to multiple comparisons. The initial alpha level was set at .10 to compensate for the known loss of power in Bonferroni's procedure.[14] The ultimate alpha levels used for determining differences in program design and learning method preferences were .009 and .0125, respectively.

Population estimates for the factors influencing participation in CE were determined using means and standard deviations. Missing values were replaced with mean scores. A principal-components factor analysis was then conducted on the 29-item scale as a means of reducing the total number of items and to determine whether influencing factors could be grouped into discrete subscales.

Results

Response Rates

Of the 784 mailed questionnaires, 8 questionnaires were returned unopened due to recent changes in respondents' addresses. Of the 776 remaining questionnaires, 636 questionnaires were received by the cutoff date, for an overall response rate of 82%. Response rates by strata at each step in data collection are presented in the Figure, together with nonresponse rates.

[Figure ILLUSTRATION OMITTED]

Demographic Characteristics

To assess representativeness of the sample to the target population, sample demographic characteristics were compared with December 31, 1995, human resources data obtained from the provincial licensing board. There were no substantive differences in demographic characteristics between the sample and the target population for the following variables: place of residence, clinical area of practice, employment setting, and type of practice (eg, clinical, teaching, administrative).

Of the 636 respondents, 265 respondents (42%) were from northern Ontario and 371 respondents (58%) from southern Ontario (Tab. 2). The majority of the respondents were female (87%), and nearly two thirds of the respondents were under the age of 40 years. About two thirds of the respondents had received their professional education through a degree program and were working in full-time positions, most often providing direct patient care. Over half of the respondents had been in practice for more than 10 years. The physical therapists worked primarily in orthopedic (45%) and general (23%) clinical areas and were employed to a large degree in general hospitals (32%) and private practice settings (28%).

Table 2.
Demographic Characteristics of Respondents (Weighted)[a]

                                Total          Northern Ontario

                                n       %      n     %
Age (y)
  20-39                         2,321   58.4   183   69.1
  40-60                         1,430   39.8    80   30.1
  >60                              65    1.8     2    0.8

Employment status
  Employed part-time              948   26.4    57   21.5
  Employed full-time            2,345   65.2   194   73.2
  Leave of absence                131    3.6     5    1.9
  Other                           171    4.7     9    3.4

Area of responsibility
  Administration                  220    6.2    13    5.0
  Direct patient care           2,934   82.8   225   87.2
  Teaching                         56    1.6     2    0.8
  Administration/patient care     138    3.9    12    4.6
  Other                           195    5.5     6    2.4

Clinical area of practice
  Cardiorespiratory               113    3.8     5    2.2
  General--all areas              672   22.7    87   38.3
  Gerontology                     208    7.0    10    4.4
  Neurology                       222    7.5     6    2.6
  Orthopedics                   1,334   45.2    92   40.5
  Pediatrics                      168    5.7    15    6.6
  Rheumatology                     97    3.3     7    3.1
  Other                           140    4.8     5    2.1

Employment setting
  Academic facility               110    3.1     2    0.8
  Community agency                112    3.2    13    5.0
  Extended care facility          175    5.0     4    1.5
  General hospital              1,141   32.2   115   44.4
  Home care program               325    9.2    28   10.8
  Pediatric facility              204    5.8    15    5.8
  Private practice                991   28.1    55   21.2
  Rehabilitation facility         266    7.5    14    5.4
  Other                           212    6.0    13    5.0

Gender
  Female                        3,152   87.4   218   82.3
  Male                            452   12.6    47   17.7

Level of education
  Diploma                       1,070   29.8    62   23.4
  Degree                        2,281   63.4   184   69.4
  Postgraduate                    175    4.9    13    4.9
  Other                            69    1.9     6    2.3

Years of practice
   0-5                            835   23.2    97   36.6
   6-10                           620   17.3    44   16.6
  11-30                         1,801   50.1   109   41.2
  31-50                           338    9.4    14    5.3

                                Southern Ontario

                                n       %
Age (y)
  20-39                         1,917   57.6
  40-60                         1,350   40.6
  >60                              63    1.8

Employment status
  Employed part-time              891   26.8
  Employed full-time            2,151   64.6
  Leave of absence                126    3.8
  Other                           162    4.7

Area of responsibility
  Administration                  207    6.3
  Direct patient care           2,709   82.5
  Teaching                         54    1.6
  Administration/patient care     126    3.8
  Other                           189    5.7

Clinical area of practice
  Cardiorespiratory               108    4.0
  General--all areas              585   21.5
  Gerontology                     198    7.3
  Neurology                       216    7.9
  Orthopedics                   1,242   45.5
  Pediatrics                      153    5.6
  Rheumatology                     90    3.3
  Other                           135    5.0

Employment setting
  Academic facility               108    3.3
  Community agency                 99    3.0
  Extended care facility          171    5.2
  General hospital              1,026   31.3
  Home care program               297    9.1
  Pediatric facility              189    5.8
  Private practice                936   28.6
  Rehabilitation facility         252    7.7
  Other                          198     6.1

Gender
  Female                        2,934   87.9
  Male                            405   12.1

Level of education
  Diploma                       1,008   30.3
  Degree                        2,097   63.0
  Postgraduate                    162    4.9
  Other                            63    1.9

Years of practice
   0-5                            738   22.1
   6-10                           576   17.3
  11-30                         1,692   50.7
  31-50                           324    9.7

[a] Expansion weights were applied to reflect the sampling fraction in the southern stratum. Actual n = 371 for southern respondents.

Program Design Preferences

Program design preferences are presented in Table 3. Differences between the respondents from northern Ontario and those from southern Ontario were noted for the following program design preferences: time of day, day of week, format, maximum fee, travel distance with costs shared, and travel distance with costs not shared.

Table 3.
Percentage of Respondents Reporting Program Design Preferences

                                         Total   Northern Ontario

Location preference
  Academic institution                    6.6           6.8
  Health care facility                   18.7          19.8
  Hotel or convention center             12.1          12.9
  No preference                          62.6          60.5
Time-of-day preference
  Morning                                 9.5           5.4
  Afternoon                               3.4           1.2
  Evening                                10.3           5.0
  Full day                               76.8          88.4
Day-of-week preference
  Sunday                                  5.2           1.9
  Monday/Tuesday                         12.0           6.0
  Wednesday                               7.6           3.4
  Thursday                                4.4           2.3
  Friday                                 25.8          26.1
  Saturday                               36.6          52.3
  Other                                   8.4           8.0
Time-of-year preference
  January-March                          32.8          30.3
  April-May                              27.0          27.0
  June-August                             4.8           3.9
  September-December                     35.4          38.8
Cost preference
  Paid by physical therapist              7.2           9.5
  Shared between physical therapist
    and employer                         52.2          57.8
  Paid completely by employer            19.8          12.9
  Free to CPA(b) members                 14.3          10.3
  Paid by physical therapist,
    employer, and CPA                     2.0           2.7
  Other                                   4.5           6.8
Travel distance/costs shared
  0-100 km                               34.7           9.2
  101-200 km                             19.5           7.2
  201-400 km                             18.7          24.8
  401-600 km                              6.6          24.4
  >600 km                                13.3          34.4
Travel distance/costs not shared
  0-100 km                               57.4          30.6
  101-200 km                             23.4          16.5
  201-400 km                             10.8          24.1
  401-600 km                              3.8          14.2
  >600 km                                 4.6          14.6
Maximum fee preference
  $10/h                                  17.9          14.0
  $20/h                                  44.4          38.8
  $30/h                                  19.9          29.8
  $40/h                                   5.7           7.4
  $50/h                                   2.0           1.9
  Depends on course                       1.9           4.6
  Other                                   8.2           3.5
Format preference
  Conferences/workshops                  70.0          75.0
  Short lectures/in-services             17.7           8.8
  Visual-based instruction                4.4           6.9
  Written materials                       3.0           3.5
  Other                                   4.9           5.8
Topic preference
  Management                              5.6           4.2
  Marketing/public relations              2.2           2.7
  Practical instruction                  26.4          27.2
  Theory-based instruction                2.8           4.6
  Practical/theory-based instruction     59.4          60.9
  Physical therapy professional issues    3.6           0.4

                                           Southern Ontario    P(a)

Location preference
  Academic institution                          6.6            .945
  Health care facility                         18.6
  Hotel or convention center                   12.0
  No preference                                62.8
Time-of-day preference
  Morning                                       9.9
<.001
  Afternoon                                     3.6
  Evening                                      10.6
  Full day                                     75.9
Day-of-week preference
  Sunday                                        5.4
<.001
  Monday/Tuesday                               12.5
  Wednesday                                     7.9
  Thursday                                      4.6
  Friday                                       25.8
  Saturday                                     35.3
  Other                                         8.5
Time-of-year preference
  January-March                                33.0            .713
  April-May                                    27.0
  June-August                                   4.9
  September-December                           35.1
Cost preference
  Paid by physical therapist                    7.0            .041
  Shared between physical therapist
    and employer                               51.8
  Paid completely by employer                  20.3
  Free to CPA(b) members                       14.6
  Paid by physical therapist,
    employer, and CPA                           2.0
  Other                                         4.3
Travel distance/costs shared
  0-100 km                                     36.7
<.001
  101-200 km                                   28.3
  201-400 km                                   18.2
  401-600 km                                    5.2
  >600 km                                      11.6
Travel distance/costs not shared
  0-100 km                                     59.5
<.001
  101-200 km                                   23.9
  201-400 km                                    9.8
  401-600 km                                    3.0
  >600 km                                       3.8
Maximum fee preference
  $10/h                                        18.2
<.001
  $20/h                                        44.8
  $30/h                                        19.0
  $40/h                                         5.6
  $50/h                                         2.0
  Depends on course                             1.7
  Other                                         8.7
Format preference
  Conferences/workshops                        69.6            .010
  Short lectures/in-services                   18.4
  Visual-based instruction                      4.1
  Written materials                             3.0
  Other                                         4.9
Topic preference
  Management                                    5.7            .076
  Marketing/public relations                    2.2
  Practical instruction                        26.3
  Theory-based instruction                      2.7
  Practical/theory-based instruction           59.3
  Physical therapy professional issues          3.8

(a) Probability value for chi-square test, unadjusted for repeated tests.

(b) C.P.A = Canadian Physiotherapy Association.

Overall, physical therapists preferred full-day attendance at CE offerings held on Fridays or Saturdays. Approximately three quarters of respondents indicated conferences or workshops as the preferred format for CE, and more than 40% considered $20 per hour to be the maximum reasonable fee. With respect to travel distances, a third of the respondents would not travel farther than 100 km (about 60 miles). Therapists from northern Ontario were generally more willing than their southern counterparts to travel farther distances, regardless of whether costs were shared. A preference for more limited travel distances was noted for both regions when costs were not shared.

In general, physical therapists from southern Ontario were twice as likely as those from northern Ontario to prefer (1) morning, afternoon, or evening sessions, (2) weekday (Monday-Thursday) offerings, and (3) short lectures or in-services. Physical therapists from northern Ontario, however, were more likely to prefer weekend courses (Friday or Saturday), and nearly a third of the respondents would pay $30 per hour, compared with only 19% of therapists from southern Ontario.

There were no regional differences for location, time of year, cost, and topic preferences. About two thirds of the respondents expressed no preference for location, but the respondents preferred fall or winter months and a practical or theory-based method of instruction. Three quarters of the physical therapists expected costs to be shared between themselves and their employer, or to have the costs completely covered by their employers.

Results of independent t tests on preferences for learning methods are presented in Table 4. There were only two differences between northern and southern Ontario physical therapists for learning method preferences. Physical therapists from southern Ontario were more interested in short lectures and in-services (P [is less than] .001), whereas physical therapists from northern Ontario preferred teleconferencing (P [is less than] .001). Overall, the most preferred learning method was conferences or workshops and the least attractive methods were computerassisted instruction followed by audio-based instruction.

Table 4. Means and Standard Deviations for Learning Method Preferences for Total Sample and by Region(a)

                                                    Northern
                                  Total (N=636)     Ontario (n=265)
Learning Method                     X       SD        X       SD

Audio-based instruction           3.21     1.63     3.27     1.56
Computer-assisted instruction     3.20     1.65     3.29     1.66
Conferences/workshops             6.09     1.07     6.26     0.92
Short lectures/in-services        5.98     1.17     5.61     1.27
Teleconferencing                  3.34     1.57     3.83     1.72
Visual-based instruction          4.81     1.47     4.97     1.41
Written materials                 5.39     1.34     5.28     1.34
Multidisciplinary workshops       5.44     1.33     5.27     1.39

                                  Southern
                                  Ontario (n=371)
Learning Method                  X        SD       P(b)

Audio-based instruction         3.20     1.63      .599
Computer-assisted instruction   3.19     1.65      .456
Conferences/workshops           6.07     1.08      .023
Short lectures/in-services      6.01     1.16     <.001
Teleconferencing                3.30     1.56     <.001
Visual-based instruction        4.80     1.48      .155
Written materials               5.40     1.35      .284
Multidisciplinary workshops     5.45     1.33      .098

(a) 1 = not at all interested; 7 = extremely interested.

(b) Probability value for mean difference by t test, unadjusted for repeated tests.

Influencing Factors

A 29-item list addressed the factors important to physical therapists in choosing which CE offerings to attend. Respondents rated each item on a seven-point Likert scale. Table 5 lists the 29 items and their respective means and standard deviations. The 2 items related to course content were ranked highest as influencing factors for CE: content pertinent to current practice (X = 6.54, SD = 0.78) and courses available in the respondent's area of interest (X = 6.57, SD = 0.73). These items were rated higher than any cost-related, time-related, or presenter-related items. The least important factors were availability of child care, opportunities for social activities, and the facility in which the CE offering was being held.

Table 5. Means and Standard Deviations for Factors Influencing Participation in Continuing Education(a)

                                                 Total (N=636)
Influencing Factors                                X      SD

Courses available in my area of interest         6.57   0.73
Content pertinent to my current practice         6.54   0.78
Reputation of presenter                          5.78   1.13
Qualifications of presenter                      5.76   1.15
Method of presentation                           5.69   1.02
Registration fee                                 5.68   1.25
Prior availability of course information         5.45   1.53
Loss of pay                                      5.41   1.64
Distance from home                               5.40   1.32
Length of program                                5.37   1.18
Financial support from employer                  5.31   1.73
Profession of presenter                          5.19   1.48
Time away from work                              5.17   1.55
Reduced fee for member or employee               5.12   1.56
Loss of vacation days                            5.00   2.04
Gaining knowledge in professional issues         4.99   1.35
Time of week                                     4.91   1.59
Cost for food, lodging, and transportation       4.91   1.69
Published objective                              4.82   1.44
Time of year                                     4.78   1.59
Oral or written recommendation by others         4.50   1.48
Loss of personal time                            4.47   1.76
Time of day                                      4.44   1.69
Opportunity to network with peers                4.42   1.45
Sponsoring organization                          3.36   1.62
Type of facility in which course is to be held   2.68   1.54
Attending with a friend/colleague                2.55   1.69
Opportunity for social activities                2.41   1.38
Child care provided                              1.87   1.51

                                                 Northern Ontario
                                                 (n = 371)
Influencing Factors                               X      SD

Courses available in my area of interest         6.53   0.72
Content pertinent to my current practice         6.58   0.74
Reputation of presenter                          5.63   1.10
Qualifications of presenter                      5.64   1.12
Method of presentation                           5.49   1.11
Registration fee                                 5.53   1.26
Prior availability of course information         5.33   1.45
Loss of pay                                      5.05   1.74
Distance from home                               5.28   1.32
Length of program                                5.31   1.23
Financial support from employer                  5.07   1.76
Profession of presenter                          5.10   1.31
Time away from work                              5.11   1.51
Reduced fee for member or employee               5.06   1.50
Loss of vacation days                            4.84   1.98
Gaining knowledge in professional issues         4.82   1.37
Time of week                                     5.08   1.58
Cost for food, lodging, and transportation       5.24   1.57
Published objective                              4.80   1.21
Time of year                                     4.93   1.46
Oral or written recommendation by others         4.62   1.36
Loss of personal time                            4.10   1.80
Time of day                                      4.40   1.73
Opportunity to network with peers                4.65   1.41
Sponsoring organization                          3.23   1.58
Type of facility in which course is to be held   2.51   1.47
Attending with a friend/colleague                2.61   1.68
Opportunity for social activities                2.55   1.42
Child care provided                              1.76   1.35

                                                  Southern Ontario
                                                  (n = 371)
Influencing Factors                               X       SD

Courses available in my area of interest         6.57   0.73
Content pertinent to my current practice         6.54   0.79
Reputation of presenter                          5.79   1.13
Qualifications of presenter                      5.77   1.15
Method of presentation                           5.71   1.01
Registration fee                                 5.69   1.25
Prior availability of course information         5.46   1.54
Loss of pay                                      5.44   1.63
Distance from home                               5.41   1.32
Length of program                                5.37   1.18
Financial support from employer                  5.33   1.73
Profession of presenter                          5.19   1.49
Time away from work                              5.17   1.56
Reduced fee for member or employee               5.13   1.57
Loss of vacation days                            5.01   2.05
Gaining knowledge in professional issues         5.00   1.35
Time of week                                     4.89   1.59
Cost for food, lodging, and transportation       4.88   1.70
Published objective                              4.82   1.46
Time of year                                     4.77   1.60
Oral or written recommendation by others         4.49   1.49
Loss of personal time                            4.50   1.76
Time of day                                      4.45   1.69
Opportunity to network with peers                4.40   1.46
Sponsoring organization                          3.48   1.62
Type of facility in which course is to be held   2.69   1.55
Attending with a friend/colleague                2.55   1.69
Opportunity for social activities                2.39   1.38
Child care provided                              1.88   1.52

(a) 1 = not at all important; 7 = extremely important

To reduce the total number of items and to determine whether influencing factors could be grouped into discrete subscales, principal-components factor analysis of the scale items was performed. Following Varimax rotation, nine factors with an eigenvalue of 1.0 or greater were identified. Of the nine factors identified, only the first six factors were interpretable. These factors were (1) timing, (2) presentation quality, (3) work-related cost, (4) course-related cost, (5) socialization, and (6) program content. As shown in Table 1, these six factors accounted for 49.7% of the total scale variance, with the timing factor alone accounting for 19. 1% of the explained variance. Eleven of the original 29 items were deleted, as they either had loadings below .50 or loaded onto factors seven through nine.

Discussion

Program Design Preferences

The primary objectives of this study were to determine the factors that influence participation in CE and to determine the program design preferences for physical therapists in both geographical regions. The majority of respondents preferred full-day offerings held on Fridays or Saturdays in the fall or winter months. Physical therapists generally preferred (1) a conference or workshop format of instruction, (2) to have costs shared with their employer, (3) to pay no more than $20 (Canadian currency) an hour, and (4) to partake of practical or theory-based instruction. A preference for more limited travel distances was noted for both regions when costs were not shared. Other researchers[4-6] have previously noted preferences for conferences or workshops held on weekends. The findings of our study also support the preferences of the respondents in Karp's study[6] for day of week, time of year, cost, and maximum fee.

Differences between regions were found in program design preferences for time of day, day of week, travel distance (regardless of whether costs are shared), maximum fee, and format. A smaller number of physical therapists in northern Ontario may have preferred half-day offerings due to the increased time that may be necessary to travel to a CE activity. Because fewer 3- to 5-day conferences and workshops are available to northern physical therapists who preferred this method of instruction, it is reasonable that they would invest greater financial resources to travel to other regions to participate in a wider variety of CE activities. It is also logical that northern physical therapists would pay more for CE opportunities, because fewer subsidies exist when courses are held in northern Ontario and the cost of using high-profile speakers is greater.

The southern Ontario physical therapists' preferences for shorter travel distances, regardless of whether the costs of attending a CE offering were shared, support their interest in a delivery system that requires less travel. They generally expressed a greater preference for short lectures or in-services than did physical therapists from northern Ontario. This finding is also supported by the finding that physical therapists from southern Ontario appeared to be more interested in this learning method. This finding may be reflective of the fact that physical therapists from this region are simply more accustomed to shorter travel distances. Many of the large population centers in southern Ontario are within 2 or 3 hours of each other by car.

Few physical therapists from southern Ontario preferred Friday or Saturday courses. Because physical therapists in this region generally commute farther distances to work and are more involved in weekend coverage, they may feel that weekends should be set aside for leisure activities that permit them to get away from city life. Furthermore, because a wider variety of course topics and methods of instruction are available in southern Ontario and because travel distances are generally shorter, physical therapists in this region may expect the ability to attend CE activities on weekdays.

Learning Method Preferences

Physical therapists were most interested in using conferences or workshops and short lectures or in-services as methods of instruction, with multidisciplinary workshops ranking third and written materials ranking fourth. These findings are similar to those of Karp,[6] who found that physical therapists were most interested in conference/seminar and lecture/slide instruction. Although physical therapists identified written materials as one of their most frequently used learning methods (over 80%), they were not as interested in this method as they were in conferences or workshops, which was the method used by about two thirds of respondents. One explanation for this finding is that reading materials cost less than attending conferences or workshops.

Although distance from home ranked as an important influence on the use of CE, physical therapist seemed interested in delivery systems that may require travel. The main implication of this finding is that CE providers should focus on decreasing the costs of CE activities so that physical therapists may choose the types of instruction that are of greatest interest to them. Furthermore, the conference or workshop should continue to be used as a primary vehicle for the delivery of CE programs.

Analysis of the differences between regions demonstrated that physical therapists from northern Ontario were more interested in teleconferencing as a learning method than were their southern Ontario counterparts. Conversely, physical therapists from southern Ontario indicated greater interest in using short lectures or in-services. The northern physical therapists' apparent interest in teleconferencing may be due to the wider availability to them of this learning method, as previously discussed. The southern physical therapists, however, preferred short lectures or in-services, possibly due to their greater accessibility to (1) experts in the field, (2) academic resources, and (3) a variety of speakers. With larger hospitals located in southern Ontario, there may be more physical therapists participating in CE opportunities and then returning to share this information with colleagues in the in-service format.

Computer-assisted instruction was ranked as the least interesting method of learning. This is a relatively new method of instruction, quite different from traditional learning methods encountered in a university or practice setting. The physical therapists may not yet have had enough exposure to this new learning method to appreciate its potential value. Computer-assisted learning modules experienced by most respondents also may be first-generation and may not have taken advantage of recent advances in multimedia applications, "user-friendly" interfaces, and built-in evaluations providing immediate feedback.

Factors Influencing Participation

Physical therapists from both geographical regions rated content pertinent to current practice and courses available in the respondent's area of interest as the most important factors influencing participation in CE. This was also found for health care professionals who ranked course content items as most important in other CE studies in physical therapy and nursing.[4,6] This finding is interesting in an environment with decreasing fiscal resources, as respondents have basically indicated that content, followed by presentation quality and method of presentation, are more important than cost or timing factors. It appears that the ultimate success of a CE activity may be largely determined by physical therapists' evaluation of its pertinence to their professional practice. Continuing education program planners should therefore focus their efforts on providing educational opportunities in pertinent interest areas and on using presenters who are respected experts in their particular fields.

The results of this study suggest that three program factors should be deemphasized by CE program planners due to their low rankings: type of facility, opportunities for social activities, and the provision of child care. Because participation does not seem to be based on these issues, planners should accord them a lower priority than content and presentation quality.

Principal-component factor analysis resulted in six meaningful factors influencing CE participation: (1) timing, (2) presentation quality, (3) work-related cost, (4) course-related cost, (5) socialization, and (6) program content. Because most of the scale items used in this study have been noted in the nursing literature, it was not surprising that the factors influencing physical therapist participation were similar to those previously identified.[12] Because there was only one item measuring professional growth and there were no items measuring licensure requirements, these two factors were not extracted from the principal-components factor analysis, as they were in the study by Craft et al.[12]

The extracted components together accounted for approximately 50% of the scale variance in measuring influences on CE. Although internal consistency was demonstrated for all subscale items, the survey instrument did not measure all the possible influences on CE. In nursing, motivation accounts for 46% of the variance in CE participation.[15] In our study, we did not attempt to identify what motivates physical therapists to participate in CE because studies across health care professions have shown that practitioners participate primarily for the sake of knowledge itself and not because of external pressures.[8,15-17] Future research should address motivation as an influence on CE participation to determine whether this variable would contribute to the scale variance as measured by factor analysis.

Implications and Conclusions

In general, it appears that specific programming for physical therapists in sparsely settled areas is unnecessary, as the expressed CE needs of physical therapists do not differ vastly between regions. Continuing education, activities, however, should reflect the needs and preferences of both regional groups in terms of program design.

Although it is the responsibility of CE providers to meet these professionally expressed needs, there is an added demand to challenge those needs in relation to the technological, social, political, and professional changes occurring in health care. For example, ongoing technological advances in all likelihood will make access to information regarding novel techniques and procedures, new equipment, and research data more readily available. The use of computer-assisted instruction will almost certainly play a vital role in assisting health care professionals to maintain a high quality of practice in the future. Although physical therapists do not express a great interest in this method of learning, we believe that CE providers should emphasize and encourage the development and evaluation of this method in the delivery of CE opportunities, especially to therapists in remote areas who cannot otherwise easily access academic resources.

Added to the explosion of information technology are increased demands by the public for professional accountability based on scientific evidence of efficacy, effectiveness, and efficiency. These demands have implications for CE providers in the design of their educational programs. The physical therapists in this study, for example, indicated that they preferred conferences and workshops as their primary learning method. The majority of the physical therapists from northern Ontario also indicated that they participated in teleconferencing, but that they were relatively uninterested in this method of learning. There is little evidence available on the effectiveness of various formats of CE for physical therapists to change practice or affect health care outcomes. Without this evidence, it is difficult to determine the format that CE activities should take. Addressing this research gap is critical in an era of rapidly advancing knowledge and ever-increasing demands for evidence-based practice behaviors.

Acknowledgments

We thank Dr Linda Pederson and Ms Diane Parker-Taillon for their assistance in the project. We also thank all the volunteers who participated in the pretest, the pilot study, and the main study for their generous donation of time, without which this project could not have been completed.

References

[1] Hoffman AM. Continuing education: a perspective of planning. J Allied Health. 1979;8:29-33.

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[3] Finley C. Mandatory continuing education: a survey of current activity. Phys Ther. 1988;68:374-378.

[4] Seymour RJ, Connelly T, Gardner D. Continuing education: an attitudinal survey of physical therapists. Phys Ther. 1979;59:399-404.

[5] Campbell DD, Pasemko E. Developing Continuing Professional Education in Physical Therapy, Occupational Therapy and Speech-Language Pathology/ Audiology. Edmonton, Alberta, Canada: Faculty of Extension, University of Alberta; 1985.

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[7] Hightower AB. Continuing education in physical therapy. Phys Ther. 1973;53:17-24.

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[9] Harvey LM. Continuing education and the geographically isolated therapist. Canadian Journal of Occupational Therapy. 1983;50:125-132.

[10] Robert S, Scott J. Assessing continuing education needs of five allied health professions in rural California. Journal of Continuing Education in the Health Professions. 1988;8:55-61.

[11] Schaeffer RL, Mendenhall W, Ott L. Elementary Survey Sampling Boston, Mass: PWS-Kent Publishing Co; 1990.

[12] Craft MJ, Heick M, Richards B, et al. Program characteristics influencing nursing selection of CE offerings. Journal of Continuing Education in the Health Professions. 1992;23:245-252.

[13] Goel V. Analysis of Complex Surveys. Toronto, Ontario, Canada: Institute for Clinical Evaluative Sciences; 1993.

[14] Shott S. Statistics for Health Professionals. Philadelphia, Pa: WB Saunders Co; 1990.

[15] Waddell DL. Why do nurses participate in continuing education? A meta-analysis. Journal of Continuing Education in Nursing. 1993;24:52-56.

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[17] O'Connor AB. Reasons nurses participate in self-study continuing education programs. Nurs Res. 1982;31:371-374.

MR Tassone, MSc, BScPT, is Lecturer, Department of Physical Therapy, University Of Toronto, Toronto, Ontario, Canada, and Professional Director of Physiotherapy, Women's College Hospital, 76 Grenville St, Toronto, Ontario, Canada M5S 1B2 ([e-mail]). Address all correspondence to Ms Tassone.

M Speechley, PhD, was Associate Professor, Departments of Physical Therapy and of Epidemiology and Biostatistics, university of western Ontario, London, Ontario, Canada N6G 1H1, at the time of this study.

This study was conducted in partial fulfillment of the requirements of Ms Tassone's master's degree in physical therapy, university of western Ontario.

This article was presented, in part, as a platform presentation at the 12th International congress of the World Confederation for Physical Therapy; Washington, DC; June 25-30, 1995; and at the Ontario Physiotherapy Association Conference; Toronto, Ontario, Canada; March 1995.

This work was supported by an Ontario Ministry of Health Fellowship to Ms Tassone and by funding received from the Ontario Physiotherapy Association and the College of Physiotherapists of Ontario.

This research was approved by the Review Board for Health Science Research Involving Human Subjects, University of Western Ontario.