Physical therapy clinical education in a 2:1 student-instructor education model.

[Triggs Nemshick M, Shepard KF. Physical therapy clinical education in a 2:1 student-instructor education model. Phys Ther. 1996;76:968 -981.]

Key Words: Clinical education, Collaborative learning, Education, Education model, Physical therapist.

Sussman,[1] in a monograph, has identified a number of effects of staff shortages in physical therapy clinics on clinical education, including decreased experience levels of clinical instructors (CIs), a need to cancel clinical rotations at the last minute, decreased availability of positions in general acute care and rehabilitation settings, ineffective clinical education due to higher CI patient care expectations, and decreased time spent on CI preparation. Good clinical placements are difficult to obtain, in part, because of the numbers of physical therapist and physical therapist assistant students from the 148 accredited physical therapist programs and 178 accredited physical therapist assistant programs as well as the 55 developing physical therapist programs and the 69 developing physical therapist assistant programs that require a variety of clinical placements.[2] Physical therapists, therefore, need to explore alternatives to the one-CI-to-one-student (1:1) model that is currently prevalent.

Clinical Education Models in Physical Therapy

Sussman[1] suggested that a model that can be explored is the two-students-to-one-CI model. Lopopolo[3] discussed the financial benefit and the benefit to staffing shortages of a 2:1 ratio by increasing the productivity of the "team" versus the CI alone, especially in final rotations. Gandy,[4] in another monograph, suggested that an alternative 2:1 ratio for first-year affiliates may also be more effective because it addresses staffing shortages and builds in a peer-support system that does not exist in the traditional 1:1 student-instructor model. Lopopolo and Gandy suggested that the alternative model of 2:1 ratio in both early and final rotations may allow academic faculty who manage clinical placements to place a greater number of students and allow CIs to educate a greater number of students. As a result, this model may assist in increased productivity without additional cost, and it exposes more students, potential employees, to the facility. The students could also benefit from the experience of the peer-support system that could carry over into their professional caree

Emery[5] detailed a model of a 3:1 student-staff ratio in a limited setting for short time periods. Three students supervised by one CI worked primarily with outpatients with musculoskeletal conditions twice weekly for one semester. Their tasks included discussing and treating and completing documentation for two patients within a 2.5-hour time frame.[5(pp8,9)] Clinical instructors had the advantage in this model in acting in a supervisory role without patient care responsibilities. Emery reported the CIs' comments of "feeling greater control of the environment and flexibility in moving between individual instruction and supervision."[5(p9)] There was also increased productivity in patient care above the productivity expected for the CI alone.[5(pp9,10)] Emery stated that students rated the experience positively and believed it had the following advantages over the traditional experiences: It increased note-writing experience, it increased autonomy, and it provided a challenge to assume more responsibility. This model also increased the students' motivation to read about and discuss patient issues. The students commented positively on the cooperative peer-like atmosphere in this model as opposed to the competitive atmosphere they perceived students developing at some other settings.[5(p10)]

Ladyshewsky,[6] in a study of models of clinical education, assessed the effectiveness of the 2:1 model as a means of supervising students. The feedback offered by the students and CIs suggested that the 2:1 model was a viable alternative to a 1:1 placement in some environments, in particular, inpatient and outpatient orthopedic settings. Ladyshewsky recommended further evaluation of models of clinical education to identify factors needed for successful learning while efficiently utilizing CI resources.[6(p35)]

Peer Collaboration and Professional Socialization 

Edwards et al, studying public health nurse students, indicated other educational benefits of peer collaboration such as the sharing of alternative interventions, expertise, and constructive feedback.[7(p221), Peer collaboration, therefore, is another area of interest pertinent to the 2:1 student-instructor ratio in education. Some concerns exist when utilizing peer collaboration. Baker and Srivastaba,[8] who studied nursing students, commented that there is the potential for inaccurate information to be shared, especially in the beginning of an early clinical experience. Students may also be reluctant to be critical of their peers. These comments suggest that the CI should be aware of these possibilities, identify inconsistencies early, and assist the students in improvement to ensure an effective collaboration.(8(p22)] Baker and Srivastaba also comment on the positive aspect of the student collaborative experience for the instructor: "This experience for the clinical instructor maintains motivation and objectivity, and assists the instructor in increasing insight into their own professional and personal values."[3(p22)]

DeClute and Ladyshewsky[9] suggested that collaborative learning enhances students' level of clinical competence in the areas of patient evaluation, planning, professional behavior, and program documentation. They advocated learning in new clinical education models, such as the 2:1 model, in order to enhance clinical competence, meet the growing demands for clinical placements, and reinforce the use of a team approach in health care delivery.[9(pp47,48)]

Peer collaboration is closely linked with professional socialization. A model including collaboration, such as the 2:1 student-CI model, fosters independence because it challenges students to be less reliant on their supervisors. Students are challenged to work independently, consulting a supervisor with new ideas and well-thought-out questions, and to collaborate in problem solving. Gerace and Silibano[10(p207)] suggest that fostering dependence in a 1:1 student-CI model may cause students to feel that seeking help and advice from peers, and eventually coworkers, is a sign of inadequacy. We believe that in this 1:1 model, students are socialized into a superior-inferior role, encouraging them to seek assistance only from someone of a higher status.

Physical therapists seldom work in isolated clinical environments, but rather in environments that involve peer review, collaboration for treatment ideas, peer support in staffing shortages or special projects, and discussions with other treatment team members to achieve patient goals. In striving to attain the goal of professional socialization during a physical therapy clinical rotation, we postulate that a student collaborative clinical education model might be more effective because it approximates a physical therapy model of practice more closely than a 1:1 student-preceptor model.

Current nursing and physical therapy literature that examines clinical education and peer collaboration suggests that a variety of clinical education models need to be explored. Henry recommended to physical therapists, "Before conclusively changing clinical education, it appears necessary to investigate more substantiative data about the feasibility and effectiveness of different student-instructor ratios on student learning and instructor time."[11(p76)] Thus, the purpose of our study was to explore the experience of a physical therapy clinical rotation using a 2:1 student-instructor model and identify factors that promote or interfere with a successful clinical education experience.

Method

This research design is a descriptive qualitative field study,[(12(p5)]

Framework

As suggested by Miles and Huberman,[13(p18)] a conceptual framework was designed to explicate and bound the phenomenon under study. Based on the literature we reviewed and our personal experience, this initial conceptual framework identified student characteristics, CI characteristics, student-CI interactions, and organizational factors that were considered important in clinical education (Fig. 1). These categories and relationships might be used to guide studies about other types of clinical education models. Similar conceptual frameworks have been used in prior qualitative studies concerned with clinical education[14] and expertise in physical therapy clinical practice.[15(p713)]

The initial conceptual framework contained a set of general research questions that were pertinent to this study, including: 1. What personal and professional characteristics of the CI influence the interaction between CI and student in the 2:1 clinical education model and its outcome?

2. What personal and professional characteristics of the students influence the interaction between the students and the CI in the 2:1 clinical education model and its outcome?

3. What types of organizational factors influence the outcome of the 2:1 clinical education model?

4. What factors make the 2:1 clinical education model a positive or successful experience?

Sample

The subjects were selected by deliberative (purposive) sampling. Inclusion criteria for the CIs included having full-time employment in an acute care hospital or outpatient clinic and having been a CI for at least four previous students. The CIs were identified through contacts with local center coordinators of clinical education (CCCEs) and academic coordinators of clinical education (ACCEs). The physical therapy students were from accredited entry-level master's degree physical therapy programs in their first or second full-time clinical rotation. The students were from the same academic program in two cases. In the third case, the students were from two different academic settings. Demographic data are displayed in Table 1.

[TABULAR DATA OMITTED]

Instrumentation 

Two semistructured interview schedules, one for students and one for CIs, were developed. The interview schedule for the students was very similar to the interview schedule for the CIs. Interviews lasted approximately 30 minutes and were audiotaped for transcription and subsequent analysis.

A second type of instrument used in this study was a journal. All subjects were requested to maintain journals for two reasons: to foster self-awareness of the daily events and personal reactions to this type of clinical education experience and to provide data (create an artifact) to increase the researchers' understanding of this 2:1 clinical education model. The journals provided an ongoing introspective account of the situation, person, and event being investigated. According to Sellitz et al,'6 the benefit of using journals in addition to observation and interviews is to reveal to the researcher reflections about the experience as it was lived, the inner experience, as described by the subject without the interference of the researcher.

The first author (MTN) collected the observational and interview data. She has had 8 years of experience as a physical therapist, 7 years of experience as a CI (nine students), and 3 years of experience as a CCCE.

Procedure

Prior to the study, all subjects as well as relevant ACCEs and CCCEs were provided with background information and information about the study's purpose, procedures, and data collection. The CIs and students were asked to sign informed consent forms and fill out demographic data sheets. To ensure anonymity, a case number was assigned to each subject. A data-collection schedule was created to assist with scheduling of interviews and observational data. The interview data and notations were organized by use of an interview transcription log.[17(pp82-85)] The CIs and students participated in the 2:1 clinical rotation experience for 4 to 6 weeks. During the second and fourth weeks of the rotation, the first author observed each student-CI team for 1 to 2 hours.

The purpose of the observation was to become familiarized with the clinical site and to observe the student-CI interactions as well as student-student interactions. The observational data were documented in field notes and transcribed into an observation log for later data analysis. Within 1 week following the rotation, the researcher administered the CI and student interview schedules.

Validity and Reliability

The study purpose and semistructured interview schedules were reviewed by a panel of eight clinical educators for the purpose of determining whether the data from the interviews would be necessary and sufficient to answer the study purpose. The semistructured interview schedules were also given to a panel of three physical therapists who were knowledgeable about the use of qualitative research methods. They were asked to review the questions for content and clarity relative to the purpose of the study. Subsequent to input from these panels, both substantive and editorial changes were made. Thus, input from these two panels was used to enhance the content validity of the interview schedules.

Quotations from interviewees were used as low-inference data. Low-inference data refers to what the subjects actually said, as opposed to the researcher inferring what the subjects meant from what was said. Low-inference data are classically used in qualitative studies to provide credibility (internal validity.)[18] The use of interview schedules, journals, and field observations provided data that could be triangulated. To triangulate, similar types of data gathered from multiple sources using multiple instruments are used to ensure that the data are trustworthy, that is, internally valid (credible) and reliable (dependable and consistent).l920 For example, if the subject describes an event that is important from her or his perspective both in an interview and in a reflective journal and the researcher observes the event during field observations, the researcher can then report with conviction that the event occurred and was perceived as important by the subject (credibility) and that other researchers collecting data from the same sources would get a similar result (dependability and consistency).[20]

An audit trail of the procedural steps in data analysis is documented in the Appendix. This audit trail contains a description of each step, from the development of the initial conceptual framework to the development of a new model describing factors for a successful 2:1 clinical education experience. Raw data from each step are available for review (audit) to confirm the existence and context of the data set and procedural rigor.[20]

Kappa coefficients[21] were calculated on one third of the data set to examine reliability of category coding between the two authors. The data from interview questions about communication (questions 2 and 3), advantages (questions 4 and 5), and disadvantages (questions 6 and 7) were used to calculate the Kappa coefficients. All Kappa coefficients were .85 or higher.

Results

Demographic data summarizing the data-collection sites and the nine subjects in the three cases are presented in Table 1. The students in cases A and B were students from the same physical therapy program and at the same rotation level practicing in inpatient acute care settings. In case A, the complexity of the patients' problems varied; these patients may have had one physical therapy problem or multiple physical therapy as well as medical problems. In case B, many of the patients were evaluated initially at the bedside. These patients also had either a single physical therapy problem or multiple problems. The students in case C were from two different physical therapy programs, and 1 student was participating in his or her first clinical rotation and the other student was participating in his or her second clinical rotation. These students were working in a fast-paced outpatient orthopedic facility and treated a variety of patients with physical therapy problems. The productivity expectation for each team during this experience was as follows: (1) case A: 8 to 10 patients per CI-student group per day, (2) case B: 13 patients per CI-student group per day, and (3) case C: 20 to 22 patients per CI-student group per day.

In Tables 2 and 3, descriptions of the typical day of one successful experience (case A) and the unsuccessful experience (case C) are presented for the beginning of the clinical experience as well as for the end of the experience. A successful experience was defined as a 2:1; model experience that reached completion, and an unsuccessful experience was defined as a 2:1 experience that had to be discontinued and changed back to the 1:1 model. The information in Tables 2 and 3 is provided as a response to the first interview question, "Describe the typical day you experienced in this study." This information is presented to give the reader an idea of the types of organizational factors identified in the initial conceptual framework that could influence the 2:1 clinical education experience and help make it successful or unsuccessful.

The major themes emerging from this study describe important processes and outcomes of the successful 2:1 clinical education experience. The themes are illustrated by qualitative data extracted (and assigned codes) from key informant interviews (eg, Int A, S1, p13), reflective journals (eg, Jn1 A, S1, p14), and observation or researcher field notes (eg, Field Notes B, Obs 1, p2).

In response to the second interview question, "Describe the type of communication that was experienced between the two students," both students and CIs reported that the students experienced social communication that was supportive and enjoyable. This theme of social communication is reflected in the following data:

First of all, because we're from the same school, we have

definite social interaction and we were friends before we

came here. (Int A, S1, p2)

They (the students) socialized, too, because we all eat right

next to each other. (Int B, C1, p5)

The student respondents also reported communicating about patient care: the sharing of ideas about treatments, goals, and plans for their patients as well as joint patient care such as practicing transfers or techniques. Two of the student groups chose to do a joint in-service. The themes of patient care communication and patient care activities are reflected in the following data:

Sometimes we'll talk about plans for treatment with each

other, and I think it helps us to discuss our treatment plans.,

We have more ideas and feel more secure with our rationale 

when we discuss our plans with our CI and the patients. (Jn1

A, S1, p14)

We did bounce a lot of ideas off of each other and our

experiences as far as "I felt nervous doing this" or "I don't

feel comfortable when I do this." It was like thinking out

loud. (Int B, S1, p5)

The only negative response regarding communication between the two students was in reference to sharing the treatment or the evaluation session of one patient. The students preferred treating their own patients and did not find treating the same patient together to be an effective learning experience. The following were responses that represented this problem:

We both had patients together in our first few days. Sometimes,

I liked it, though I felt like I was in the way. If he or

she was treating a patient, I was just standing there watching.

I felt like I wasn't doing anything to help. You know, I

felt kind of like I wasn't learning. (Int C, S2, p4)

When I did have them (the students) share a patient, one

student kind of overwhelmed the other a little bit because

he or she was kind of bold about trying things. I wanted the

other student to feel safe doing things his or her way, and I

wasn't sure he or she did. I didn't have them see a lot of

patients together. (Int A, C1, p4)

In response to the third interview question, "Describe the type of communication between the CIs and the two students," the highest response from eight of the nine subjects was informal communication, as needed throughout the day. Only the CIs commented on the responsibility of formal communication with each student in the form of a midterm and a final evaluation. The following data represent the theme of informal communication:

Pretty informal communication. I didn't block off a lot of

time to sit and question them away from the patient. I spent

most of my time either watching them or being with them

during the day. (Int A, C1, p2,3)

The CIs and students both described the theme of communication content as close guidance in the beginning of the rotation, with a gradual increase in independence near the end of the rotation.

Well, the CI in the beginning while getting to know us, I'm

sure he or she spoon-fed a lot of it to us in a way. But as we

became more comfortable with our surroundings, with how

things worked, and with getting our own patients, then he

or she backed off well. (Int A, S2, p3)

When he or she would ask me questions, especially in the

last half of the rotation, I would encourage him or her to

look things up and then come to me if he or she couldn't

find something. I would say, "Where would you find it?" (Int

A, C1, p3)

Half of the students reported that the negative aspect of their communication with the CI was that they would have liked more organized time periods throughout the day to provide feedback and a wrap-up time at the end of the day.

We met as we needed to . . . The CI at my prior affiliation

would meet me at the end of the day and talk about how

everything went. That didn't happen here. I was waiting for

it to happen, but it never did. (Int C, S1, p3)

One CI and three students reported that students had to wait for the CI's assistance or feedback at times. The students felt that this was both negative and positive, negative because they did not have one-to-one attention but positive because at times it forced them to think more clearly and make decisions on their own. The following examples of data from interviews, journals, and observations describe the theme of time availability of the CI:

I did feel like I had to wait for him or her ... It would be like "CI, CI, CI," and he or she would be with the other student. Then, I would be thinking about what I wanted to ask him or her, and I would say, "OK, I'll do this." And sometimes it would just work out. (Int B, S1, p8)

One thing about waiting for my CI is that it gives me a chance to think about what I'm asking. At times, I answered my own questions. (Jn1 B, S1, p25)

The following is an example of the time availability observed:

The CI is with one student in the gym talking and problem

solving, and the other student is independently exercising

with another patient. (Field Notes, Case B, p6)

In response to the fourth question, "What did you see as the three most significant advantages of the 2:1 student-CI clinical education model for the student?" there were two notable responses from both the CIs and the students. The first was that having a second student present created a comfortable, secure environment for a clinical learning experience. The following is an example of the theme of positive clinical environment:

I felt more comfortable starting the internship because I

had someone connected at my elbow to get through the day

with me. Everything we experienced was together, so there

wasn't so much of that pressure that comes with starting

something new. (Int A, S1, p4)

Having another student there made me less anxious and

nervous .... It was nice to vent my anxieties, frustrations,

insecurities with someone who would really relate to my

situation. (Jn1 B, S1, p1)

The second response was that the students had more opportunity to share different philosophies and ideas as well as to practice new or unfamiliar techniques on each other before approaching the patient. The following data represent the theme of increased opportunity to gain knowledge or collaborate:

Both schools have some totally different philosophies, different

ideas. Listening to where the other student was

coming from, it was fresh, new. (Int C, S1, p6)

If you're teaching shoulder mobilization to the students,

together they have the ability to work with each other. One

can practice on the other before they work on the patients.

(Int C, CI, p8,9)

In response to question 5 in the interview, "What did you see as the three most significant advantages of the 2:1 student-CI clinical education model for the CI?" the most frequent response from all the students and one CI was that the CI had an opportunity to grow in knowledge and management skills. That is, the CI had two different people to learn how to interact with at one time, and more students to get input and questions from to improve or challenge the CI's own knowledge base. Here are examples of some of the data that reflect the theme of CI growth in knowledge and management skills:

I think the CI can learn from the students and the more

students the CI has to learn from at a time teaches them to

interact with two different people in a different manner and

get away from a set protocol. I think it's a hard thing to do.

(Int C, S2, p4,5)

Two of the three CIs and half of the students reported that the CIs had less stress with this model because of decreased paperwork, less personal patient care, and occasionally more time to work on other management responsibilities. Here are some examples of comments about the theme of decreased stress:

I think the CI had a lot less paperwork. At the end of the

rotation, the CI said, "I'm losing my students, that means

I'm going to have paperwork to do." (Int A, S2, p8)

I stayed late a lot less than when I have one student because

I am busy with my own patient care, paperwork, and also

helping the student. This time I split up my patients

between the two students. (Int A, CI, p6,7)

In response to the sixth question, "What did you see as the three most significant disadvantages of the 2:1 student-CI clinical education model for the student?" the majority of the CIs and students reported that students had decreased individual time and attention in this model because there were two students to divide the time between. The students also were disappointed at times because they wanted specific one-to-one feedback and not just generalized feedback directed to both students. Here are some examples of data reflecting the theme of decreased individual time and attention:

I think that more individual feedback would help me to

know how I'm doing. The other student and I have gotten

most feedback directed at both of us in a group. I feel more

a part of a team rather than a single student. Sometimes, I

think I would like to know the positive and not-so-positive

things I am doing. (Jn1 B, S1, p13)

If the student wants one-to-one attention all of the time, he

or she would probably not deal with this well. I could not

just drop everything for one student if I'm working with

another student. (Int A, CI, p12)

The students also reported the disadvantages of comparing their abilities with those of their partner in the 2:1 model. Half of the students felt that if there were two students at different knowledge or skill levels, the experience would not be as effective because of the gradual decrease in confidence in the student with less academic or clinical experience. Here are some examples of data that reflect the theme of negative interpersonal dynamics and difference in knowledge and skill levels:

I need to be sure that the student gets the opportunities to

feel safe trying new things and isn't overshadowed by the

other student's presence. The other student is much more

outgoing initially as compared to this student. (Jn1 A, CI,

p9)

I asked a lot of questions and the other student didn't, and

the other student started to feel personally that there was

something wrong with that. His or her self-confidence went

down the first week. (Int C, S1, p6)

In response to the seventh question, "What did you see as the three most significant disadvantages of the 2:1 student-CI clinical education model for the CI?" both the students and the CIs described the biggest disadvantage to the CIs was that they had to work within time constraints. The CIs had to go back and forth between the two students and were sometimes needed by both students at the same time. The CIs also had to spend extra time doing both the midterm and final evaluations. Here are some examples that reflect the theme of time constraints:

Writing my notes, writing their midterms and finals--a lot

of paperwork involved for me. (Int C, CI, p14)

I'm not so excited about doing two evaluations. I suppose

I'll have to suffer through it. (Jn1 B, CI, p9)

One disadvantage is that the CI may be guiding one student

through a learning experience and then have to pop back

and forth from student to student. The CI could get worn

down. (Int A, S1, p11)

Both the students and the CIs mentioned that it is difficult for the CI to work with two students with different personalities because the CI has to learn how to supervise both of the students and use different approaches. The CIs stated that it would be really difficult with two competitive students or students with large differences in their knowledge or skills. The following examples represent the theme of different student personalities or skill levels:

If it was really competitive students, or a really really poor

student and a good student ... you hope they're not at opposite

extremes. (Int B, CI, p9)

It's difficult dealing with one student, and now you have two.

If you're working with one and there's a personality conflict,

can you imagine having two that you might have a conflict with?

(Int A, S1, p11)

A disadvantage mentioned by half of the students, but not the CIs, was that the CIs had a tremendous amount of responsibility for the safety and effective care of both of the students' patients. An example of the comments mentioned by the students reflects the theme of high responsibility for patient care:

The CI has to keep track of a lot of patients that he or she

isn't treating. He or she had more responsibility; he or she

had to make sure both of us were safe with patients ...

(Int B, S2, p10)

The CI is helping with the setup of one patient's wound care

treatment, preparing the field on the mat, while watching the

student put on his or her sterile gloves. The CI glances over

at the other student to see the responses of his or her patient

about the questions of how the patient feels on the tilt table.

(Field Notes, A Obs 1, p2)

A disadvantage presented by the CIs, but not the students, was that the staff in the department had additional responsibilities due to the need for the CI to initially treat a reduced caseload while orienting the students. One example that reflects the theme of negative effect on physical therapy staff is:

Initially, you really need to increase your attention ... to

answer two different sets of questions and be with both of them.

My caseload was decreased, and the staff was absorbing some of

the patients in the week. (Int B, CI, p8)

In response to the eighth question, "Do you think this model of clinical education is effective and feasible in this clinical setting? Why or why not? How does it compare with the 1:1 model or previous experiences?" five of the six students and all of the CIs thought that the model was effective and feasible. Both students and CIs felt that it was very important to have students with the same level of education as well as students who were beyond their first rotation. Neither of the two teams that followed the 2:1 model through to completion of the study involved students on their first rotation. This theme is presented in the following examples:

I think it would be very hard with first-affiliation students.

I don't know if they would be comfortable ... a first-time

student wants individualized attention. (Int B, CI, p11)

I recommend that there shouldn't be first affiliations involved

in this type of model. (Jnl B, CI, p8)

I think the students have to be from the same school and the

same level of clinical affiliation. The therapist then knows

their skill level and has been exposed to their educational

level. (Int A, S1, P.13)

Clinical Instructor Characteristics: Flexibility and Experience

Four of the six students and one of the three CIs described the need for the CIs to be flexible to make this clinical education model feasible and effective. The students also expressed the opinion that the CIs should be experienced in clinical education.

The CIs have to be flexible. They have to look at the experience

as somewhat of a learning experience in dealing with different

personalities. They should feel confident enough to want to be

challenged that way. (Int C, S1, p10)

Having a CI who was able to balance the two students is what made

this work. I think a beginning therapist wouldn't have been able

to do it and may have been overwhelmed. (Int A, S2, p9)

The CI should be a more low-key, relaxed type. Some people would

be totally frazzled by it. I think the CCCEs would know the CIs

who could handle two students. (Int B, CI, p12)

Student Characteristics: Compatible Personalities; Good Students

Some of the students and CIs also felt that students' personalities needed to be compatible, and the CIs noted that the students needed to be good students.

I think student compatability is something that should be

taken into consideration when assigning two students to

one CI. (Jnl A, S1, p12)

I think it's an important recommendation to make sure the

students' personalities are compatible. It would be difficult

to put two really competitive students together. (Jnl B, CI, p11)

If you had two really poor students, unsafe students, it

would really be a nightmare. (Int A, CI, p12,13)

In response to the ninth question, "Would you participate in another physical therapy clinical affiliation with this type of 2:1 student-CI ratio again? Why or why not?" all of the CIs and five of the six students stated that they would participate in this type of clinical rotation again.

The students noted that they wanted to be assured of a separate caseload.

I think that my CI is great. He or she is really allowing

the other student and me to work on our own. It is allowing

us to become more comfortable on our own. I think this CI

is doing a great job balancing his or her time between us.

(Jnl A, S2 p12)

Half of the students reported they would participate again because it was such a positive environment in which to learn.

We got along so well. The support was big plus because

you know it's always kind of tense when you don't know

who your friends are ... at least you have somebody on

your side. (Int C, S1, p14,15)

The CIs reported they would participate again because it seemed to be less stressful for them as compared with a 1:1 situation.

It seemed nicer than having the one student and your

own caseload, just keeping track of theirs. It's less

stressful. (Int B, CI, p13)

I have not felt overwhelmed having two students the way

I sometimes have with even one student. I haven't needed

to stay late to get my own work done. This model seems

less difficult than I thought. (Jnl A, CI, p11,12)

Discussion

Based on the data obtained in this study, a 2:1 student-CI model appears to be a viable model for clinical education of physical therapists. We believe that physical therapy clinicians prefer to educate students in the clinic in a one-to-one clinical education model. We also contend that it has been difficult to convince clinicians to experiment with alternative models of clinical education. For example, to obtain the sample for this study, CIs and CCCEs in 30 hospitals and outpatient centers were contacted. From these contacts, only three study subject teams were obtained. Both external and internal factors contribute to the reluctance to move outside the 1:1 student education model. The external factors include, for example, a perceived decrease in productivity standards and real staffing shortages. An example of an internal factor could be the stress caused by any change and difficulty in pioneering a new area in which little direction and practical information are available. From the results of this study, it appears that alternative models of clinical education can be effective.

In this study, a new conceptual model that identifies factors of a successful 2:1 clinical education experience was developed as a result of the data analysis (Fig. 2). As compared with the initial conceptual framework that identified components present in any clinical education experience, this new model depicts factors identified by the results of this study that contribute to a successful clinical education experience using the 2:1 model. Beyond identifying specific factors under the categories of student, CI, organization, and student-CI interactions, a major addition to the new model is the identification of student-student interactions, which confirms several positive benefits of peer collaboration identified by Gandy,[4] Emery,[5] and Edwards et al[7]: the creation of a cooperative peer-support system, sharing of knowledge, and sharing of alternative interventions in patient care.

Issues related to student matching and scheduling of the 2:1 clinical education experience became evident from our observations. The cases studied did not involve a specific matching technique. The ACCEs in all of the cases were notified of the plans for the 2:1 experience and approved or altered the selection of the students as they felt appropriate. This process did not involve grade point averages or learning style inventories; instead, it depended on the ACCE putting together two students who were perceived to be compatible. The issue of matching is one that merits further investigation. If the process of matching is made too complicated, however, we believe that it may lead to more frustration for ACCEs during the placement of students. An alternative suggestion is to look at ways of assisting CIs to learn to effectively deal with students who have different levels of experience or different personalities.

The experience in case C that ended in a disbanding of the 2:1 clinical education experience provided information to consider in future studies about the effectiveness and feasibility of 2:1 models. From the CI's perspective, the primary reason that this experience was not successful was that the students were at different levels of experience, especially as related to patient care. The two different educational and clinical backgrounds did not allow the students to feel like there was equality.

Another critical issue that may have affected the students' and CI's ability to succeed in a clinical education experience using the 2:1 model in case C was that they were subjected to very high productivity standards, even during the first day of the rotation. Other staff were not available to absorb some of the caseload and decrease this productivity standard at the beginning of the experience. Although the students had different educational backgrounds and different ages (ie, 21 and 27 years) and gender, it appeared that they were beginning to resolve their differences. As reported by the students in the poststudy interview, they continued to provide each other with a very supportive environment even after they went back to the 1:1 clinical education model. For example, they spent time together practicing techniques, assisting with patient care, and discussing patient problems and ideas. If this team had been given a smaller initial caseload and the opportunity to spend more time together, combined with some intervention by the CI or CCCE to facilitate effective teamwork, this 2:1 experience might also have ended successfully.

Students did not perceive their written evaluations as a form of communication. The students discussed formal evaluations only as a disadvantage to the CI of the 2:1 model due to the time required for the completion of the two evaluation forms for each student at the midterm and final evaluations. Formal evaluations seem to be viewed by students more as paperwork than as a communication tool. This perception, however, may exist regardless of the student-CI ratio. One of the traditional uses of the written evaluation is to communicate to students how they are performing in the many different facets of a physical therapist's role. These formal evaluations are also used to facilitate student self-evaluation as well as discussions about strengths, areas in which the student improved, and areas needing improvement.

One advantage of the 2:1 model, as compared with the 1:1 model, was perceived decreased stress for the CI. Supervising and managing students without the direct responsibility for a separate caseload appeared to be less stressful because the CI can spend time with each student and do concomitant paperwork. Although students perceived that a disadvantage of this model was the CI's responsibility for patient care and safety, this type of responsibility was not seen as stressful by the CIs. One reason may be that the students were aware of safety precautions and consulted with the CI or asked him or her to be present during the treatment session when needed. The ability of the CI to be comfortable in this model could possibly be facilitated through a discussion about safety and specific safety guidelines with the students during the orientation.

Clinical productivity is very important for efficient operation of physical therapy services and is of concern when a physical therapy department participates in clinical education. In case A, the CI reported that the normal productivity expectation for a staff therapist was approximately 10 patients per day. The CI-student team was not able to achieve those expectations initially, but by the last 2 weeks of the 8-week-long rotation, each student was treating 5 patients per day and the CI was treating 1 to 2 patients per day. In case B, the CI reported that the normal productivity expectation for a staff therapist was 13 patients per day. In the final 2 weeks of the 8-week-long rotation, each student was treating approximately 10 patients per day and the therapist was treating 6 to 7 patients per day for therapists who were not available. Thus, this team was able to double its productivity at the end of the clinical education experience. These preliminary findings suggest that although a CI-student team initially may not meet normal productivity standards, the team will likely reach or exceed those standards by approximately the fifth week of the rotation. These data are similar to Lopopolo's findings of increasing productivity of a CI-student team, especially in later rotations.[3]

Recommendations

Pairing two students with the same experience level enhanced their ability to succeed in the 2:1 model. Apparently, it is very important to provide students with a good balance of independent and collaborative experiences. Students thought that this mix of experiences gave them the opportunity to develop the individual and collaborative skills that are needed in professional practice. Clinical instructors who are flexible were identified as ideal instructors because of the need to adapt to changes in activities, personalities, schedule changes, and unforeseen events throughout the day.

One additional suggestion if this method is considered is to ensure the commitment of the departmental staff to assisting with the CI's patient care at the beginning of and following the rotation. During orientation, the CI will require more time to orient two students and gradually introduce them to patient care, and at the end of the experience, the CI may not be able to provide care for the increased caseload. There is a need for a gradual increase in productivity to the required level of the CI, and the amount of patient care should be increased at the discretion of the CI. This clinical education model's success may be reliant on the support of the other staff members.

Limitations

The first author, who collected the data, may have had biases, including a strong desire to improve clinical education experiences, optimistic feelings toward new clinical education models being as effective or more effective than the present model, and a great interest in challenging CIs to try alternative types of clinical experiences. The use of techniques such as collection of low-inference data, providing an audit review, triangulation, and reliability checks were used to mitigate the effects of these biases.

Another limitation of this study was the small number of cases followed due to the difficulty in obtaining volunteer subjects for the sample. As noted in the "Discussion" section, identifying CIs who were willing to participate was problematic. Many reasons were given by CCCEs or CIs for not participating in this study. Reasons included (1) staff shortages and inability to take any students, (2) inexperienced staff, (3) no staff members with prior experience with at least four students who were not involved with other special projects, and (4) lack of interest in this type of study.

With the small sample size, there is limited ability for the information to be generalized to the larger population of CIs and students. A demographic description of the CIs, students, clinical rotation lengths, clinical settings, and levels of clinical rotations has been given. This description presents an example of who the information might apply to so that readers can proceed with caution and make accurate comparisons with their situations.

Although the students' journals provided some useful validation data, the students wrote very broadly about their clinical experience and much of the data was irrelevant to the focus of the study. In future studies, we recommend giving the students a short list of guiding questions to focus their journal writing.

Other areas related to this study that would merit future investigation would be to repeat this study in a variety of physical therapy settings or with students participating in the first rotation. It would also be interesting to interview participants in other 2:1 experiences with the same poststudy interview schedule and to compare their responses to determine whether their clinical education experiences support the new conceptual model of a successful 2:1 experience. The impact of instructor training prior to a 2:1 experience could be explored, and the use of a 2:1 model with physical therapist assistant students could be studied. Further investigation into the 2:1 experience with the more experienced student acting as a mentor to the less experienced student would also be beneficial. Models other than the 2:1 model also warrant study to investigate their effectiveness and feasibility.

Conclusions

This report presented a description of 2:1 clinical education experiences from the CIs' and students' perspectives. Results of the study demonstrated that the alternative model of 2:1 student-CI supervision for physical therapy students can be a successful experience. Factors that promote or interfere with a successful experience have been identified, and suggestions have been given to help initiate the process of trying this alternative model in the clinic.

Further research is needed in similar and related areas to assess the effectiveness and feasibility of a variety of clinical education models. As more information is generated about alternative clinical education models, CIs and clinics may increase their knowledge about educating physical therapy students. In this way, clinical instruction may be provided more readily and effectively in the face of the challenges, such as staffing shortages, inexperienced staff, and high productivity expectations.

Acknowledgments

We acknowledge the generosity and dedication of the CIs and students who participated in this project. Their reflections, openness, and ideas were priceless, and to them, we express great thanks.

[FIGURES 1 to 2 ILLUSTRATION OMITTED]

(a) CIs=Clinical instructors.

References

[1] Sussman B. Effects of staff shortages on clinical education now and in the future. In: Issues in Clinical Education: Present Status/Future Needs. Alexandria, Va: American Physical Therapy Association; 1988:50-55.

[2] APTA Accreditation Update: Newsletter from the Department of Accreditation. Alexandria, Va: American Physical Therapy Association;January 1996.

[3] Lopopolo R. Financial model to determine the effect of clinical education programs on physical therapy departments. Phys Ther. 1984;64:1396-1402.

[4] Gandy JS. Fiscal implications for clinical education. In: Issues in Clinical Education: Present Status/Future Needs. Alexandria, Va: American Physical Therapy Association; 1988:67.

[5] Emery M. Student-staffed clinics: creative clinical education during times of constraint. Clinical Management. 1986;6(2):6-10.

[6] Ladyshewsky R. Clinical teaching and the 2:1 student-Clinical Instructor ratio. Journal of Physical Therapy Education. 1993;7(1):31-35.

[7] Edwards LH, Eyer J, Kahn EH. The use of partners in undergraduate public health nursing. Public Health Nurs. 1985;2:213-221.

[8] Baker P, Srivastaba R. Student facilitators. The Canadian Nurse. 1988;84(6):20-22.

[9] DeClute J, Ladyshewsky R. Enhancing clinical competence using a collaborative clinical education model. Phys Ther. 1993;73:42-56.

[10] Gerace L, Sibilano H. Preparing students for peer collaboration: a clinical teaching model. J Nurs Educ. 1984;23:206-209.

[11] Henry JN. Clinical environment and resources for clinical education. In: Issues in Clinical Education: Present Status/Future Needs. Alexandria, Va: American Physical Therapy Association; 1988:76.

[12] Miller WL, Crabtree BF. Primary care research: a multimethod typology and qualitative road map. In: Crabtree BF, Miller WL, eds. Doing Qualitative research: Research Methods for Primary Care, Volume 3. Newbury Park, Calif: Sage Publications Inc; 1992: chap 1.

[13] Miles M, Huberman AM. Qualitative Data Analysis. 2nd ed. Newbury Park, Calif: Sage Publications Inc; 1994.

[14] Scully RM, Shepard KF. Clinical teaching in physical therapy education: an ethnographic study. Phys Ther. 1983;63:350-357.

[15] Jensen G, Shepard K, Gwyer J, Hack L. Attribute dimensions that distinguish master and novice physical therapy clinicians in orthopedic settings. Phys Ther. 1992;72:711-722.

[16] Sellitz C,Jahoda M, Deutsch M, Cook SW. Research Methods in Social Relations. New York, NY: Holt, Rinehart and Winston Inc; 1959:325.

[17] Merriam SB, Case Study Research in Education: A Qualitative Approach. San Francisco, Calif:Jossey-Bass Inc Publishers; 1988:82-85, 98-101.

[18] Goetz JP, LeCompte MD. Ethnography and Qualitative Design in Educational Research. Orlando, Fla: Academic Press Inc; 1984:184.

[19] Knafl KA, Breitmayer B. Triangulation in qualitative research: issues of conceptual clarity and purpose. In: Morse JM, ed. Qualitative Nursing Research: A Contemporary Dialogue. Rockville, Md: Aspen Publishers Inc; 1989: chap 13.

[20] Lincoln YS, Guba KG. Establishing Trustworthiness. Newbury Park, Calif: Sage Publications Inc; 1985: chap 12.

[21] Haley SM, Osberg JS. Kappa coefficient calculation using multiple ratings per subject: a special communication. Phys Ther. 1989;69:970-974.

Appendix

Audit Trail

1. Designed an initial conceptual framework to guide the study. This initial framework was based on the literature to date and researcher knowledge and experience regarding physical therapy clinical education. 2. Semistructured interview questions were developed and subsequently reviewed by two panels for content validity. 3. One researcher collected data about the experience:

* observations at two sites at the midway point of the affiliation (third site disbanded before the midway point)

* semistructured interviews with CIs(a) and students at three sites

* individual journals from the CIs and students 4. Data from observations (field notes), interviews, and journals were reviewed independently by the two researchers to determine common elements that existed across all three cases. Data were triangulated from these three sources to ensure consistency and trustworthiness of the common elements derived from the data set. Categorical codes were established to identify these common elements. 5. Sections of the data set were coded independently by the two researchers. The codings were compared and decision rules were created to ensure that independent and mutually exclusive categories were established. 6. The entire data set was coded by the primary researcher independently, and one third was coded by the secondary researcher to ensure reliability. Kappa coefficients were calculated. 7. Both researchers reviewed the cases to determine the predominant themes that could be derived from the categories. 8. A new conceptual model was designed to portray the predominant categories on themes that emerged, which represented factors that influenced the 2:1 student-CI clinical education experience.

Invited Commentary

Thank you for the opportunity to comment on this article. The authors are to be commended for sharing the results of their work with the wider physical therapy community. Given the paucity of literature on cooperative learning in health professional education, the authors have made a significant contribution to this growing area of inquiry.

The literature review provides a useful introduction to the benefits and challenges of cooperative learning in clinical education. There are a few important references in the literature outside of the nursing and physical therapy professions that would have added considerable strength to the article.[1,2] There are also recent articles relating to productivity in clinical education, both within a 1:1 model and within a 2:1 model, that would have provided more insight into the productivity dimension.[3-6]

I found the authors' writings on the issue of collaboration and professional socialization to be excellent. This is one of the key features of the cooperative learning model, which the physical therapy profession should embrace. The authors accurately outline how the 1:1 model encourages superior-inferior role status and socializes students into seeking assistance from individuals with higher status (apprenticeship model). This is not how physical therapists practice in real life, and anything we as educators can do to mimic real-life practice in the students' education should be fostered. The cooperative learning model also provides a greater opportunity for students to develop competence in the affective domain of professional practice. Carpenter[7] provides an excellent description of the "cultural" aspects of the physical therapy profession. Although Carpenter addresses the Canadian physical therapy community, her arguments apply directly to the concepts of professional socialization raised by Triggs Nemshick and Shepard. The points that are raised by Carpenter challenge us to reevaluate our cultural traditions of clinical education.

The conceptual framework that was used to guide the study is well developed. Unfortunately, many of the themes that are part of the framework are not explored fully in the report. This is largely due to the small number of participants in the study. This is perhaps the most significant weakness of the work, as there are only two clinical instructor (CI) and four student perspectives that are used to make generalizations about cooperative learning experiences. To increase the sample size, it would have been useful to offer a training workshop for CIs as an incentive to participate in the project. The authors raised this point in their article. It appears from the article that CIs received only administrative and general information about the project. For many CIs, multiple-student supervision is perceived as more work and poses many unknown challenges. An opportunity to explore the model in more detail with other CIs may have increased commitment to the project and boosted the sample size.

The qualitative research method that was used was appropriate for this type of study. The investigators had in place the appropriate safeguards to ensure that the data were valid and reliable by using triangulation procedures. The other aspect of qualitative research that adds rigor and richness to the data-collection process is obtaining multiple perspectives. This was lacking because of the small sample size. Because of this limitation, it is difficult to say whether other researchers would obtain the same data, because the small sample size creates the possibility that the findings are opinion, rather than characteristics of cooperative learning placements. Obtaining multiple perspectives through a larger sample population would have provided more opportunities for common themes to emerge, thus grounding the possibility that the advantage or challenge is truly a component of cooperative learning. The journal experience was not a particularly successful data-collection method, according to the researchers, so their triangulation procedures were weakened by having to rely solely on interviews and 4 hours of field observation.

The authors have also not discussed what sort of preparation the students received in terms of cooperative learning. I raise this argument in light of the discussion concerning students who stated that they would have preferred to work alone with their patients. Working independently contradicts the whole purpose of learning as a team. Cooperative learning skills do not develop naturally. Physical therapy program admission standards in many ways encourage students to be competitive. One of the reasons behind the students' preference to work independently may be that they had poorly developed cooperative skills in the first place. Another reason may be that the CI did not clearly delineate the role expectations of the students when working together. Yet another argument may be that our "educational culture" emphasizes the autonomous practitioner model. To work cooperatively may be perceived as a sign of professional inadequacy. Delineating roles, using jigsaw methods to foster cooperation; having clear cooperative learning expectations; and encouraging students to be peer evaluators may have improved the students' ratings of the joint patient care initiatives.

The productivity gains reported by the authors are consistent with the findings of earlier work examining this same question.[3] Graham et al[4] have also stated that placements of longer duration will produce greater productivity gains for the institution. Both 4-and 6-week placements were part of the current study, and it is not clear whether the group that broke even with respect to productivity was the placement of shorter or longer duration. This is an important piece of information because it may influence a facility's decision to participate in a cooperative learning placement. If, for example, the significant productivity gain occurred in the 6-week cooperative learning placement, academic programs may need to restructure their placement program toward longer placements in order to convince agencies to participate in this teaching model.

The issue of matching students is raised as a concern. I would agree with the authors and support their statement that more research is needed in this area. On a personal note, I have mixed views on the matching-versus-nonmatching argument. When one looks at the reality of the workplace, we do not have the luxury of deciding whether we will work with our co-workers. We learn to respect differences, develop assertiveness skills, and practice conflict management when necessary. Thus, from this perspective, the matching issue is irrelevant, as good supervisors should be able to manage these situations just like managers deal with them among their staff. The nonmatching approach is also supported by Tiberius and Gaiptman,[1] insomuch as they state it is not the differences in students that create the problem but rather the skill of the CI in managing people. This raises the point of CI training once again for successful implementation of cooperative learning models.

On the other hand, one wants to optimize learning and not place too much burden on the CI, who also has patient care responsibilities. Matching by learning style, grade point average, or age may minimize the potential for extreme student differences. These student differences, however, may be a rich resource for joint learning, as they challenge the students to develop their interpersonal communication skills.

The dissolution of case C should not be interpreted as a failure of the cooperative model. In examining the participant mix of case C, there were gender and age influences in this model that were quite different from those of cases A and B. The other problem with case C is that it was not a true cooperative learning arrangement because of the different levels of students. There would have been obvious status differences between the participants in case C. Further, Bruffee[8] has stated that for cooperative learning arrangements to be successful, there must be team rewards, individual accountability, and equal opportunities for success. These factors, particularly the equal opportunities for success, would have been difficult to achieve, given the different levels of the students.

In closing, the authors should be commended for embarking on a challenging project in an environment that appeared to be very closed to new approaches. In spite of my critique, their findings lend support to the growing body of cooperative learning research in health professional education. Their work creates new questions for clinical educators and further validates the use of the qualitative research method as an option for physical therapists looking for answers to difficult questions. I hope that my comments serve to strengthen this article and will foster further research in the area of cooperative learning and clinical education.

References

[1] Tiberius R, Gaiptman B. The supervisor-student ratio: 1:1 versus 2:1. Canadian Journal of Occupational Therapy. 1985;52:179-183.

[2] Johnson DW, Maruyama G, Johnson R, et al. Effects of cooperative, competitive, and individualistic goal structures on achievement: a meta-analysis. Psychol Bull. 1981;89:47-62.

[3] Ladyshewsky R. Enhancing service productivity in acute care inpatient settings using a collaborative clinical education model. Phys Ther. 1995;75:53-60.

[4] 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.

[5] Coulson E, Woeckel D, Copenhaver R, et al. Effects of clinical education on the productivity of private practice facilities. Journal of Physical Therapy Education. 1991;5:29-32.

[6] Ladyshewsky R, Bird N, Finney J. The impact on departmental productivity during physical therapy student placements: an investigation of outpatient physical therapy services. Physiotherapy Canada. 1994;45:94-98.

[7] Carpenter C. The evolving culture of physiotherapy: Barbara Edwardson Lectureship, 1995. Physiotherapy Canada. 1996;48:11-15.

[8] Bruffee KA. Collaborative learning and the conversation of mankind. College English. 1984;46:635-652.

Richard K Ladyshewsky, MHSc, BMR(PT) Lecturer and Clinical Coordinator-Development School of Physiotherapy Curtin University of Technology Perth, Western Australia, Australia 6008 ([e-mail])

Author Response

We are grateful to Mr Ladyshewsky for providing an informative commentary, and we value the additional perspective he has provided on this topic. We certainly agree that clinical education models have received much discussion, with little research regarding what actually happens from the perspectives of the clinical instructors (CIs) or students involved.

We disagree with Mr Ladyshewsky that the small number of participants was a "significant weakness" of the study. Qualitative case studies, by their nature, use in-depth triangulated data from one case or a small number of cases to provide a holistic description of a phenomenon.[1] In this type of research, the intent is not to provide a broad generalization but to provide what has been named "reader generalizability" or "user generalizability."[2] That is, it is up to the reader to determine the extent to which the case can be applied to her or his own situation. This is common practice in law and medicine, where the practitioner determines whether one case applies to another. Certainly, we would advocate the study of additional cases in order to reaffirm or revise the conceptual framework regarding what factors promote a successful 2:1 clinical education experience. The concept of user generalizability rather than the broad notion on "generalizing" to all 2:1 clinical education experiences, however, would still be appropriate.

Mr Ladyshewsky has also raised the point of "preparing" both CIs and students for their participation in a 2:1 model. For the purpose of this research study, such prior preparation would have interfered with the natural setting and with CI and student behaviors that might naturally occur in a 2:1 clinical education experience. Thus, in our study, the CIs as well as the students had the opportunity to cope with this new experience and to determine ways to create a successful experience. We feel the data are even more compelling because the results represent the natural elements of the phenomenon as they happen to participants without influence or prior preparation.[3]

Certainly, if the 2:1 model were to be used by clinicians, we would strongly support prior preparation. Such training might enhance the willingness of both students and CIs to work within this new model. As we have noted, at the time this study was conducted, it was difficult to convince clinicians to participate in this alternative clinical education model. Out of 30 hospitals and outpatient centers contacted, only three cases were realized; that is, only three CIs were willing to participate in this 2.1 clinical education model.

Issues related to productivity are also important if this model is to be accepted by the clinical community. In the two groups that completed the rotation with the 2:1 model, productivity expectations were met or exceeded by the sixth week of an 8-week experience. Because productivity was not the focus of this study, specific information about productivity was not collected. However, we recognize this an important issue with regard to such cooperative learning experiences in the clinical setting.

We are hopeful that this study will encourage other researchers to engage in qualitative research that adds to our understanding of clinical and educational phenomena as well as to present data that add to our knowledge of effective, cost-efficient clinical education programs.

References

[1] Merriam SB. Case Study Research in Education: A Qualitative Approach. San Francisco, Calif:Jossey-Bass Inc Publishers; 1988:5-21.

[2] Walker S. Explorations of case study evaluations. Evaluation Quarterly. 1979;3:446-459.

[3] Lincoln YS, Guba EG. Naturalistic Inquiry. Newbury Park, Calif: Sage Publications Inc; 1985:221-249.

Maureen Triggs Nemshick, PT Katherine F Shepard, PhD, PT, FAPTA 

M Triggs Nemshick, PT, is Academic Coordinator of Clinical Education and Clinical Assistant Professor, Institute for Physical Therapy Education, Widener University, One University Pl, Chester, PA 19013 (USA). Ms Triggs Nemshick was a Master of Science degree candidate, Department of Physical Therapy, College of Allied Health Professions, Temple University, 3307 N Broad St, Philadelphia, PA 19140, and was employed by Prime Professionals, Bala Cynwyd, PA 19004, at the time this research was conducted. Address all correspondence to Ms Triggs Nemshick.

KF Shepard, PhD, PT, FAPTA, is Professor, Department of Physical Therapy, College of Allied Health Professions, Temple University.

This study was approved by Temple University Institutional Review Board Research Review Committee A.

This article was submitted June 12, 1995, and was accepted March 27, 1996.